The Windsor Place

Inspectors wroteBased on staff interview, record review and facility policy review, the facility failed to develop a baseline care plan related to skin integrity concerns for a resident with excoriation to the buttocks. The resident developed a pressure ulcer within four days of admission to the facility. This was for one (1) of 28 care plans reviewed. Resident #39. Cross reference:

Inspectors wroteBased on observation, resident and staff interview, record review and facility policy review, the facility failed to provide necessary treatment and services to promote healing and prevent new ulcers from developing for (1) one of five (5) residents with wounds reviewed.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to label and date open items in the pantry, refrigerator, and freezer for one (1) of two (2) kitchen tours during the survey. Findings Include: Review of the facility policy titled Food Storage undated, revealed under, Policy . Foods will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination . 14. Refrigerated food storage . f. All foods should be covered, labeled and dated. Also revealed under, 15. Frozen Foods: c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to maintain an account of all controlled medications and provide evidence of periodic reconciliation for two (2) of five (5) medication carts reviewed during medication pass. 100 hall and 200 hall.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure a resident had a wheelchair in good repair for one (1) of 86 residents requiring a wheelchair for mobility.

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to implement a care plan for shaving a dependent resident for one (1) of 25 resident care plans reviewed.

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to shave a resident that was dependent on staff for care for one (1) of three (3) residents reviewed for Activities of Daily Living (ADL).

Inspectors wroteBased on observation, resident and staff interview, and record review the facility failed to ensure the residents had a environment free of potential hazards as evidenced by cleaning chemicals not being securely locked in a janitors storage closet for two (2) of five (5) units in the building. 400 Hall and Dementia Unit.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure an informed consent was obtained for the application of bed rails for one (1) of 25 sampled residents. Resident #30 Findings Include: Review of the facility policy titled Side Rails Policy with a revision date of 10/19 revealed under, Policy: it is the policy of this facility to keep residents as safe as possible while they are in the bed, as well as enable them to be as active in their care physically as they are able. An observation of Resident #30 on 10/7/24 at 4:05 PM revealed he was lying in bed. The left side of the bed was against the wall, and one-half (1/2) side rails were raised on both sides of the bed. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed 1) to ensure a medication order, medication administration record, and narcotic record label were all labeled correctly for one (1) of five (5) medication carts reviewed during medication pass, (100 hall medication cart) and; 2) the facility failed to securely store medications when two medication capsules were found sitting in a clear medication cup in a resident's room for 1 of 124 residents observed on initial tour. (Resident #28).

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were initiated for one (1) of five (5) residents reviewed for EBP.

Inspectors wroteBased on staff and Resident Representative (RR) interviews, record review, and facility policy review, the facility failed to notify the physician of a significant change in a resident's physical status for one (1) of three (3) residents samples.

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to resolve a grievance in a timely manner for four of five residents in Resident Council. Resident # 14, Resident #64, Resident #96, and Resident #101. Findings Include: Record review of the Facility's Grievance Policy dated February 8, 2023, revealed, Policy: It is the policy of (facility name) to investigate all concerns/grievances and provide the results of the investigation to the party filing the concern/grievance .Standard: .The facility will make prompt efforts to resolve all grievances .Policy Explanation and Compliance Guidelines: Process 5. All staff involved in a grievance investigation shall take steps to preserve the confidentiality of files and records relating to grievances and share only with those who have a need to know. 6. [...]

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to update Advance Directives for code status to ensure the residents' preferences were honored for three (3) of 32 residents in the initial pool. Resident #16, Resident #81 and Resident #99.

Inspectors wroteBased on resident and staff interviews, record review and facility policy review, the facility failed to ensure a resident was free from verbal abuse for one (1) of 32 residents reviewed. Resident #84.

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to report an allegation of abuse to the appropriate state agencies for one (1) of 32 residents reviewed. Resident #84 Findings Include: Record review of the facility policy titled Abuse, Neglect, Exploitation, and the Vulnerable Adults Act Policy with a revision date of 2/6/23 revealed, It is the policy of this facility that residents and patients are to be treated with dignity and respect at all times under any circumstance. Mistreatment in the form of verbal or physical abuse of any nature will not be tolerated. Also revealed under, Procedure: . b. Who is responsible for reporting abuse? i. [...]

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to complete a through investigation of alleged abuse for one (1) of 32 residents in initial pool. Resident #84.

Inspectors wroteBased on observations, resident and staff interviews, record review, and facility policy review, the facility failed to maintain adequate staffing to assist residents in getting the care needed for seven (7) of 109 residents upon initial tour. Resident # 14, #64, #84, #87, #96, #98, and #101.

Inspectors wroteBased on staff and pharmacist interviews, record review, and facility policy review, the facility failed to ensure a resident on an as needed (PRN) psychotropic medication had a stop date for one (1) of six (6) medication reviews. Resident #17 Findings Include: Review of the facility policy titled Psychotropic Medication Policy and Procedure revealed under, Standards: 1. The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long-term care facility to include regular review for continued need, appropriate dosage, side effects, risk and /or benefits. Revealed under, Physician/NP/mental health NP (When available to a facility) . 3. Orders for PRN psychotropic medications will be time limited (i.e., times 2 weeks) and only for specific clearly documented circumstances. [...]

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to prevent the likelihood of the spread of infection as evidenced by staff not cleaning and disinfecting a multi-use resident device used to check vital signs between each resident use for one (1) of four (4) survey days.

Inspectors wroteAmendment 1/25/22 Upon secondary review with CMS Regional Office staff and State Quality Assurance, the State Survey Agency (SSA) determined that the scope and severity for F657 has been elevated to an H due to the pattern of numerous falls that occurred. Based on record review, staff and family interview and facility policy review the facility failed to revise a fall care plan for Resident #111 after multiple falls that occurred for 1 of 5 falls reviewed.

Inspectors wroteAmendment 1/25/22 Upon secondary review with CMS Regional Office staff and State Quality Assurance, the State Survey Agency (SSA) determined that the scope and severity for F689 has been elevated to an H due to the pattern of numerous falls that occurred. Based on observation, staff and family interviews, record review and facility policy review, the facility failed to provide increased supervision for a resident who had sustained ten (10) falls with two (2) resulting in major injuries that included a Subarachnoid Hemorrhage and a fractured hip from 8/31/21 to 10/26/21 for one (1) of five (5) residents reviewed for falls, Resident #111.

Inspectors wroteBased on observation, staff interviews and facility policy reviews the facility failed to store food to prevent the likelihood of foodborne illness as evidenced by opened items with no open date and unlabeled food items in the refrigerator for one (1) of two (2) kitchen tours.

Inspectors wroteBased on staff interviews, resident interview and record review, the facility failed to notify the Resident Representatative in writing of a transfer to the hospital for two (2) of four(4) residents reviewed. Resident # 56 and Resident # 111.

Inspectors wroteBased on record review, staff interview and facility policy review, the facility failed to complete a discharge assessment for the Minimum Data Set (MDS) for one ( 1) of two (2) residents identified for resident assessments. Resident 1.

Inspectors wroteBased on staff interviews, record reviews and facility policy review the facility failed to maintain the appropriate staff at the quarterly Quality Assurance (QA) meetings for two( 2) of four(4) quarterly meetings reviewed.