Windsor Calallen

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe environment for residents in 1 of 6 hallways (300 Hall) with 1 of 3(IT room) locked non-residential rooms left unlocked. 1. The facility failed to ensure the safety of the residents in the 300 hall by not closing the door to the IT room, which contained hazardous items. These failures have the potential to result in an injury to residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #6) of 5 residents reviewed for respiratory care. The facility failed to ensure Resident #6's oxygen was administered at the correct setting of 4 liters per minute on 07/20/2026 as ordered by the physician. This deficient practice could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from any significant medication errors for 1 of 8 residents (Resident #49) reviewed for medication errors. The facility failed to administer Resident #49's metoprolol tartrate (medication that lowers blood pressure) when Resident #1's blood pressure was inside the physician's parameters on 07/17/26 and 07/20/26. These failures could place residents at risk for complications such as increased blood pressure, exacerbation of symptoms, and potential hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles for medications stored in 1 of 5 medication carts (400-Hall Nurse Cart) reviewed for storage. The facility failed to ensure the Lispro Insulin pen (short acting insulin used to lower blood glucose) for Resident #97 in the 400-Hall Nurse Cart was labeled with the date it was opened. This failure could place residents at risk of receiving expired medications and not receiving the therapeutic benefit of the medication from staff.

Inspectors wroteBased on observation, interviews and record review, the facility failed to wear hair restrains correctly, ensure food preparation and service area was clean and storage of food in accordance with professional standards for food service safety for 1 of 1-refrigerator (1 of 1 facility refrigerator) and 1 of 1 freezer (1 of 1 resident freezer reviewed for storage, preparation and sanitation. The facility failed to ensure food items in the refrigerators were sealed correctly preventing exposure to air and cross contamination The facility failed to ensure items in the freezers were sealed correctly preventing exposure to air and cross contamination. The facility failed to ensure steam table wells were clean and free from debris to ensure proper working condition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #11) reviewed for infection control practices. The facility failed to ensure LVN-E performed proper and adequate tracheostomy care and hand hygiene for Resident #11 on 07/21/2026. The facility failed to ensure RN-B performed adequate hand hygiene during a medication pass on 07/21/2026 and tracheostomy care on 07/21/2026. The facility failed to ensure Resident #11 had one accurate physician order for EBP. These failures could place residents at risk for cross-contamination and infection due to inadequate care and hygiene being used.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide or obtain laboratory services to meet the needs of its residents for of 1 of 5 residents (Resident #1) reviewed for laboratory services. The facility failed to ensure Resident #1's Keppra (a medication used to treat seizures) level was drawn every three months to ensure Resident #1 was at a therapeutic level. This failure could place residents at risk of not receiving needed laboratory services and not having medications managed at a therapeutic level.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for storage, preparation, and sanitation. The facility failed to ensure all kitchen staff wore hair and beard covers while assisting in the kitchen during lunch on 06/24/2026. This failure could place residents at risk for food contamination and food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained and accurately documented for 1 of 5 residents (Resident #1) reviewed for accuracy of records. The facility failed to ensure Resident #1's bowel and bladder documentation was charted in PCC (the electronic record and charting system) for the dates of 06/20/2026 and 06/21/2026. This failure could place residents at risk for improper care due to inaccurate or incomplete assessments and records.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident had the right to dignified existence in a manner and an environment which promoted maintenance or enhancement of quality of life for 1 (Resident #1) of 5 residents reviewed for dignity. The facility failed to ensure CNA-A received permission from Resident #1 and/or the Responsible Party prior to completely shaving off Resident #1's facial hair. This failure could place residents at risk of feeling uncomfortable, disrespected, or embarrassed, and could decrease the residents' self-esteem and/or diminish their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive assessment within 14 calendar days after admission as required for 1 (Resident #1) of 5 residents reviewed for comprehensive assessment accuracy and timing. The facility failed to complete Resident #1's comprehensive admission assessment by 03/08/2026 after admission to the facility. This failure could result in newly admitted residents not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for comprehensive care plans. The facility did not include Resident #1's mechanically altered diet (modified texture and consistency of food and liquids such as mechanical soft or purred diet) on her care plan. This failure could place residents at risk for not receiving a safe and appropriate care.

Inspectors wroteBased on interview and record reviews the facility failed to ensure that drugs and biologicals for Resident #1 were received and counted appropriately for 1 of 4 residents. A narcotic medication for Resident #1 was not received and counted appropriately by RN A when Resident #1 admitted to the facility. The narcotic count for medication Oxycodone-Acetaminophen Oral Tablet 10-325 MG was short by 15 pills. This failure could result in being in pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: 1. The facility failed to ensure all food was labeled, dated, and not expired in refrigerators #1 and #2. 2. The facility failed to ensure all food was labeled, dated, and not expired in freezers #1 and #2. 3. The facility failed to ensure all refrigerators and freezers had internal thermometers. 4. The facility failed to ensure the chest-type milk refrigerator was clean and sanitized. 5. The facility failed to ensure rotted tomatoes were not stored with fresh tomatoes. 6. The facility failed to ensure dry goods were dated, labeled, sealed, and not expired. 7. The facility failed to ensure the meat slicer and roasting pans were clean and sanitized. 8. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to a PASRR evaluation was completed on newly admitted residents prior to admission or after admission for 1 of 5 residents (Resident #83) reviewed for Preadmission Screening and Resident Review screenings. The facility failed to ensure Resident #83's PASRR L1 screening dated 08/26/21 accurately reflected his diagnoses of mental illness. There was no evidence that Resident #83 was referred to a Level 2 PASRR Screening and Evaluation. This failure could affect residents by placing them at risk for not receiving needed treatments and services.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 5 residents (Resident #50) reviewed for nutritional status. The facility failed to recognize, evaluate, and address timely interventions such as continued weekly weights to identify and prevent weight loss when Resident #1 experienced significant weight loss of 21% (47 pounds) between the dates of 03/10/25 and 05/07/25. This failure could place residents at risk for improper care, weight loss, malnutrition, and overall health decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label and include the expiration date for 2 of 4 medication carts (Hall #3 med-cart and Hall #5 med-cart) reviewed for storage and 1 of 1 medication room (med-room [ROOM NUMBER]) reviewed for labeling and storage. The facility failed to properly label from hall #3 med-cart a bottle of saline nasal spray that had been opened and used. The bottle was approximately half full. The facility failed to dispose of the medication from hall #3 med-cart Morphine (a narcotic pain medication) 30 MG tablets belonging to Resident #17 that expired on 04/11/24. The facility failed to dispose of the medication from hall #3 med-cart Pravastatin (a drug used to lower cholesterol) 20 MG tablets belonging to Resident #44 that expired on 04/08/2025. [...]

Inspectors wroteThe facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases. The facility failed to handle, store, process, and transport all linens to prevent the spread of infection for 2 of 2 (Bin #1 and Bin #2) laundry bins reviewed for infection control. The facility failed to ensure LA H and LA I properly washed and stored wet linen according to facility procedures. The facility failed to ensure LA H and LA I dried wet linen and resident clothing after washing them. These failures could place residents at risk for cross contamination and infection.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a person-centered comprehensive care plan to include measureable objectives and timeframes to attain or maintain the resident's highest practical physical, mental and psychosocial well-being for 1 of 5 residents (Resident #8) reviewed for comprehensive care plans in that: The facility failed to revise or update Resident #8's care plan to reflect the habitual losing or misplacing of items and accusing others of theft. This failure could affect the resident by placing him at risk for not receiving appropriate interventions to meet his current needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one Resident (Resident #1) of five residents reviewed for infection control practices, in that: The facility failed to ensure CNA C performed hand hygiene after removing gloves during incontinent care. This failure could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, and comfortable environment for 1 of 10 residents (Resident #1) reviewed for safe environment. The facility failed to ensure Resident #1's room temperature was maintained at or below 81 degrees. This failure could place residents at risk of living in an uncomfortable and unsafe environment and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 1 (Resident #2) of 5 residents reviewed for care plans. The facility failed to develop a baseline care plan, or a comprehensive care plan in place of a baseline care plan, in place of a baseline care plan, for Resident #2 during the 20 days Resident #2 was at the facility. This failure could place residents at risk of not receiving effective person- centered care to achieve their highest practicable level of physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one (Resident #1) of two residents reviewed for quality of care. The facility failed to ensure the Wound Care Nurse followed doctor's orders (pat dry wound) during wound care for Resident #1. This failure could place residents at risk for not receiving the appropriate care and treatment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that drugs and biologicals were stored in locked compartments for 1 of 9 medication carts observed for compliance. One medication cart in the 600 hall was left unlocked and unattended by LVN C. This failure could place residents at risk of access and ingestion of non-narcotic medications.

Inspectors wroteBased on observation interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 4 of 10 residents (Resident #24, Resident #58, Resident #55, and Resident #68), staff, and the public; in that: 1.)The facility failed to ensure bathroom sinks hot water temperatures were below 110 degrees Fahrenheit in occupied rooms for Resident #24 and Resident #58 on 3/4/24 through 3/6/24. 2.)The facility failed to ensure bathroom sinks hot water temperatures were below 110 degrees Fahrenheit in occupied rooms for Resident #55 and Resident #68 on 3/4/24 through 3/6/24. This failure could affect residents by placing them at risk for diminished quality of life due to the lack of a well-kept environment and water temperatures over 110 degrees Fahrenheit, placing residents at risk of being in an unsafe environment and at risk for burn injuries. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure he accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on one of four medication carts (hall 100 nurse's cart) reviewed for pharmacy services. 1. The facility failed to account for 2 of Resident #81's 0.5mg Lorazepam (medication to treat anxiety) tablets. 2. RN A and RN B failed to accurately document Resident #81's 0.5mg Lorazepam drug count on 03/04/24. This failure could place residents at risk for drug diversion and delay in medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen and 1 of 1 nutrition room reviewed for sanitation in that: 1. The facility failed to ensure juice dispenser guns were sanitary 2. The facility failed to ensure equipment was clean and sanitized 3. The facility failed to ensure dishwasher temperatures were at a safe temperature to sanitize dishes 4. The facility failed to ensure chemical logs were accurate and at safe sanitation levels 5. The facility failed to ensure dry goods were dated, labeled, sealed, and not expired 6. The facility failed to ensure spices were not left open to air 7. The facility failed to ensure items in the nutrition room refrigerator were not expired 8. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for two of six Residents (Resident #89, and Resident #70) that were reviewed for infection control and transmission-based precautions policies and practices, in that: 1.) The facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling Legionella (bacteria that grows and multiplies in moist areas that can cause respiratory illness) through a program that identifies areas in the water system where Legionella bacteria can grow and spread. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents have the right to personal privacy and confidentiality of his or her personal and medical records for 1 (Residents # 27) of 6 residents for personal privacy and confidentiality in that: On 03/04/2024, MA A did not lock the nurse's station computer that contained sensitive resident information such as medication administered, name, room numbers, and advance directives for Resident # 27. This failure could place residents at risk for having their personal and medical information exposed.

Inspectors wroteBased on observation, record review and interview the facility failed to develop and implement written policies and procedures that Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for one resident (Resident#70) of four residents reviewed for abuse, neglect, and exploitation. The facility failed to conduct an investigation of Resident#70 injury of unknown origin. Resident #70 sustained a skin tear approximately 5.5cm X 0.1 cm to his left wrist. These deficient practices could place residents at risk for abuse, neglect, and not having their needs met. Findings Included: Record review of Resident #70's electronic face sheet dated 03/05/2024 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, for one resident (Resident #18) of 16 residents reviewed for quality of care, in that: The facility did not implement the use of Prevalon Boots (heel protectors that help reduce the risk of bedsores by keeping the heel floated, relieving pressure) for Resident #18, as ordered by her physician to maintain skin integrity on 3/5/24. This deficient practice could affect residents receiving preventative skin care at risk for pressure ulcer development or a deterioration of a current pressure ulcer.

Inspectors wroteBased on interview and record review, the facility failed to ensure the drug regimen of 1 out of 1 resident (Resident #4) was reviewed at least once a month by a licensed pharmacist, in that: Resident #4 was missing monthly medication reviews documented for the months of January 2024 and February 2024. This deficient practice could place resident at risk from harm related to unnecessary medications or dosages, could place them at risk for adverse consequences related to medication therapy, and impact residents' ability to achieve or maintain their highest practicable level of physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents on psychotropic drugs received a gradual dose reduction for 1 of 1 resident (Resident #4) reviewed for psychotropic drugs. The facility failed to ensure Resident #4 received a gradual dose reduction for Prozac (antidepressant), Xanax (anxiolytic), and Temazepam (sedative/hypnotic) since 09/2023. These failures placed residents at risk of unnecessary psychotropic drug use. Finings included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments for one hall (Hall 300) of eight medication carts. On 03/05/2024, The facility failed to keep one medication cart locked on Hall 300 . These failures placed 24 residents on Hall 300 at risk of drug diversions or misuse of medications.

Inspectors wroteBased on interviews and record review the facility failed to notify the resident, resident's representative, and ombudsman of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood before transferring or discharging the resident for 1 of 5 residents (Resident #1) reviewed for transfer and discharge. 1. Resident #1, Resident #1's responsible party and the ombudsman were not notified in writing of the effective date of transfer on or discharge for Resident #1, the reason for the transfer/discharge, the location to which the resident would be transferred, or the right of appeal. Resident #1 was discharged on 9/1/23 to an acute behavioral hospital. This deficient practice could affect residents who are transferred or discharged from the facility at risk of having their discharge rights violated.

Inspectors wroteBased on interview and record review, the facility failed to complete a discharge summary for 1 of 1 resident (Resident #1) reviewed for discharge summaries. The facility did not complete a discharge summary for Resident #1 on the discharge date of 09/07/2023. This failure could affect residents who are discharged from the facility by not providing a recapitulation of the residents stay and a final summary of the residents' status for any continuation of care that may be required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments of 1 (100 hall medication cart) of 6 of the medication carts reviewed for storage, in that: On 11/19/2023,the facility failed to ensure the 100 hall medication cart was not left unlocked and unattended at the nurses station. This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations.