Windsor Care Center of Sacramento

Inspectors wroteBased on interview and record review, the facility failed to have sufficient nurse staffing for a census of 111 residents, when the facility's Actual Direct Care Service Hours Per Patient Day (DHPPD- use to measure the total number of hours dedicated to direct care provided by caregivers, like nurses and certified nurse assistants to each patient in a facility over a 24-hour period) were below the required minimum standard of 3.5 DHPPD and 2.4 hours per patient day for certified nurse assistants (CNA DHPPD) from 11/1/24 to 11/7/24. This failures resulted to 10 recorded resident falls from 11/1/24 to 11/7/24 and had the potential for facility residents to not receive needed health treatment and personal care, and to not achieve their highest physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility compromised resident personal privacy and confidentiality when the shred box containing meal tickets was overfilled, exposing resident information. This had the potential of exposing resident information to non-staff individuals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of 26 sampled residents (Resident 72 and Resident 59) was assisted with their activities of daily living (ADLs- normal daily functions required to meet basic needs) when: 1. Resident 72 had blackish substance underneath the fingernails; and, 2. Resident 59 was not provided with oral care as indicated. These failures had the potential for Resident 72 and Resident 59 to acquire an infection and not achieve their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 26 sampled residents (Resident 35 and Resident 30) were offered activities that meet their interests and preferences when; 1) Resident 35 did not receive activities that met her preferences and was only offered activities once a week; and 2) The facility did not provide Resident 30 any activity that meets his psychosocial needs from 11/12/24 to 12/16/24; These failures had the potential for Resident 30 and Resident 35 to not achieve their highest mental, emotional, spiritual, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 111 residents, when: 1. A shared blood pressure cuff equipment was not cleaned and sanitized in between resident use; 2. Staff did not wear required personal protective equipment (PPE) while providing care for Resident 96, who was on Enhanced Barrier Precautions (EBP); 3. Certified Nursing Assistant 9 (CNA 9) did not perform hand hygiene when feeding multiple residents during lunch; and 4. Two facility staff and a hospice staff did not wear PPE when provided care to Resident 79 and Resident 117 who were both on EBP. These failures resulted in increased risk for cross-contamination (transfer of bacteria from one person, object, or place to another) and may cause transmission of infection to a vulnerable population.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe, sanitary and comfortable environment for 29 residents (Residents 53, 29, 54, 40, 83, 28, 22, 16, 71, 73, 59, 103, 20, 272, 47, 104, 98, 101, 95, 67, 56, 39, 27, 70, 273, 51, 24, 26, 92) for a census of 111 when their bathroom exhaust fans were not properly cleaned leading to dust buildup. This failure had the potential to pose a fire hazard and expose the residents to breathe in mold and bacteria from the dust buildup.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity and respect for three out of 26 sampled residents (Resident 1, Resident 14 and Resident 33) when: 1. Certified Nursing Assistant 9 (CNA 9) remained standing while assisting Resident 1 and Resident 33 with lunch; and, 2. Resident 14 was served her lunch tray late while other residents in the table were already eating. These failures had the potential to impact the three residents' self-esteem and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident needs were accommodated for one of 26 sampled residents (Resident 89) when Resident 89 did not have their call light within reach. This failure had the potential to result in Resident 89 further falls with injury.

Inspectors wroteBased on interview and record review, the facility failed to have an accurate Minimum Data Set (MDS-a federally mandated assessment) assessment for one of 26 sampled residents (Resident 49), when Resident 49's comprehensive MDS behavioral assessment was inaccurate. This failure placed the facility to not have an accurate health status data of Resident 49, and had the potential for Resident 49 to not achieve his highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician's orders were followed in accordance with professional standards of care for one of 26 sampled residents (Resident 91), when: 1. Resident 91 did not receive spironolactone (medication used for high blood pressure) for four days (four scheduled doses) due to the medication not being re-ordered timely (Within 3-5 days of medications running out), and the licensed nurse (LN) did not notify the physician for Resident 91's missed medications; and 2. Resident 91 did not receive a full dose of antidepressant medication (medication used for depression) for four days due to the medication not being re-ordered timely, and the physician was not notified for the missed medications. These failures had the potential for not meeting the resident's treatment needs or worsening of her medical conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of 26 sampled residents (Resident 102) received trauma-informed care (a framework of care for helping people who have experienced trauma) in accordance with professional standards of practice and accounting for residents' experiences when Resident 102's trauma trigger(s) was not identified and her Post-traumatic stress disorder (PTSD-a mental health condition that can develop after a person experiences or witnesses a traumatic event) diagnosis was not care planned. This failure placed Resident 102 at risk for re-traumatization (re-experience/relives a traumatic event or experiences causing similar stress reactions to a new event), and to not achieve her highest physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services to meet the needs of one of 26 sampled residents (Resident 91), when: 1. Resident 91 did not receive spironolactone (medication used for high blood pressure) for four days (four scheduled doses) due to the medication not being re-ordered timely (Within 3-5 days of medications running out); and, 2. Resident 91 did not receive the full dose of the antidepressant medication (medication used for depression) for four days due to medication not being ordered timely. These failures had the potential for not meeting the resident's therapeutic needs or worsening of her medical conditions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 26 sampled residents (Resident 6) was free of unnecessary medications, when Resident 6 was prescribed a psychotropic (any drug that affects behavior, mood, thoughts, or perception) medication without adequate indication or a target behavior. This failure resulted in the use of unnecessary psychotropic medication that could potentially cause adverse reactions and consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored and labeled correctly for a census of 111, when: 1. One opened vial and three bottles of perishable medications were not labeled with an open or use by date in the medication room; and, 2. One bottle of glucose strips, one inhaler and one insulin pen were not labeled with an open or use by date in the medication cart. These failures had the potential for residents to receive expired medications with reduced potency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store supplies in accordance with professional standards for food service safety for the 110 residents eating facility prepared meals, when: 1. Three large steam table pans were found stored wet; and 2. A bag of frozen spinach was not closed, exposing the spinach to the environment. These failures had the potential to result in food-borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to protect the right to be free from physical abuse for one out of 26 sampled residents (Resident 49) by another resident (Resident 112), when Resident 112 grabbed Resident 49 by the hair, pulled her down and hit her. This failure resulted in Resident 49 getting hurt, and had the potential for Resident 49 and all residents in the facility to experience physical and/or psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sample residents (Resident 2) when Certified Nursing Assistant (CNA) 4 slapped the face, aggressively pulled the arm, and used a gown to cover the face of Resident 2. This failure had the potential for Resident 2 to suffer physical and emotional injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect two of five sampled residents (Resident 2 and Resident 3) from abuse when Resident 1 punched Resident 2 on the face and bit Resident 3 on the right hand. These failures resulted in Resident 2 sustaining a scratch on the left lower lip and Resident 3 sustaining a skin tear on the right hand.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plan for one of five sampled residents (Resident 1) when there was no care plan developed for Resident 1 ' s use of Trazodone (medication used to treat depression). This failure had the potential to result in Resident 1 not maintaining the highest practicable well-being and preventing avoidable decline.

Inspectors wroteBased on interviews, and record review, the facility failed to protect one of three sampled residents' (Resident 1) right to be free from physical abuse when Resident 2 kicked Resident 1 on the right side of his torso. This failure had the potential to result in serious physical injury to the Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their Policy and Procedure, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, and report an alleged abuse for one of four sampled residents (Resident 2) when Resident 3 physically harmed Resident 2. This deficient practice placed Resident 2 and other residents in the facility for potential injury from Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from physical abuse when Resident 1 was forced into the chair, shoved down on the chest to be seated, and got hit in the hand and arm by a Certified Nursing Assistant 1 (CNA 1). This failure had the potential to result in serious physical injury for Resident 1.

Inspectors wroteBased on interview and record review, the facility ' s dietary services failed to recognize a food allergy for one resident (Resident 1) of three sampled residents when Resident 1 was served fish for lunch and was allergic to it. This failure resulted in Resident 1 having to take medication to prevent a severe, life-threatening allergic reaction.

Inspectors wroteBased on interview and record review, the facility failed to complete annual performance evaluations for eight of eight sampled certified nursing assistants (CNAs), CNA 2, CNA 3, CNA 4, CNA 5, CNA 6, CNA 7, CNA 8, and CNA 9 for a census of 109. This failure increased the risk for residents to receive poor quality of care from the CNAs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was prepared in a form to meet individual needs for 24 of 109 residents when Minced and Moist (MM) diets received bowtie pasta and green beans that were not modified to ¼ inch or less, and Soft and Bite-size (SB) diets received regular size bow-tie pasta that were not cut to ½ inch or smaller size. This failure had the potential to create a choking hazard for 24 residents (including Resident 14, Resident 460, Resident 83, Resident 84, Resident 161, Resident 103, Resident 54, Resident 25, Resident 3, Resident 5, Resident 49, Resident 213, Resident 210, Resident 106, Resident 63, Resident 52, Resident 40, Resident 63, Resident 1, Resident 91, Resident 58, Resident 6, Resident 33, and Resident 59) eating facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was stored and distributed in accordance with professional standards for food service safety, when the facility failed to: 1. Prevent a build-up of ice around the freezer door and on the floor; and 2. Provide tray tickets with the lunch meals when the tray was delivered to the resident. These failures had the potential to compromise the safety of frozen food served to the 109 residents eating facility prepared meals, as well as to provide the wrong meal tray to the 34 residents on hallway two.

Inspectors wroteBased on observation, interview, and record review, foods brought to the facility for residents were not kept safe for consumption when resident food was labeled only with a room number. This failure had the potential of leading to foods being given to the wrong resident (who may be allergic to or unable to safely consume) as well as staff not throwing out foods that were no longer safe to eat.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, clean and homelike environment was promoted for two of 33 sampled residents (Resident 61 and Resident 102), when: 1. Resident 61's room had a broken closet door, two missing drawers, and trash in the bottom drawer; and 2. Resident 102's immediate environment was empty and the walls were bare, and the resident had food particles in bed. These failures had the potential for the residents not attaining their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) accurately reflected the residents' current status and health conditions for three of 33 sampled residents (Resident 107, Resident 15, and Resident 30), when: 1. Resident 107's discharge MDS indicated the resident was discharged to an acute hospital; 2. Resident 15's MDS assessments indicated an active diagnosis of pneumonia (PNA, infection in the lungs) on six different occasions; and 3. Resident 30's MDS assessment indicated the resident received insulin (medication used to lower blood sugar) injections. These failures resulted in the MDS data and records submitted to CMS (Centers for Medicare-Medicaid Services) being inaccurate, and had the potential to result in the residents not receiving appropriate treatment and care to maintain their highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were reviewed and revised timely for one of 33 sampled residents (Resident 93) when his indwelling urinary catheter (a tube inserted into the bladder) and acute pain due to catheter placement care plans had not been updated at least quarterly. This failure had the potential to result in Resident 93 having unmet nursing needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain nail care for one Resident (Resident 8) of 33 sampled residents, when Resident 8's fingernails were long and packed with a brownish-black substance. This failure decreased the facility's potential to maintain Resident 8's nail care and prevent infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to post the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for residents' care per shift on a daily basis, for a census of 109. This failure resulted in staffing information not being provided to visitors and staff.

Inspectors wroteBased on observation and interview, the facility failed to properly secure the expired or discontinued controlled medications (medications with high potential for abuse or addiction), when the storage file cabinet was not permanently affixed to a permanent structure. This failure had the potential to increase risk of drug diversion and misuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication administration error rate of five percent or below was maintained for a census of 109, when three medication errors were observed during medication pass out of 32 medication pass opportunities. This failure resulted in medication error rate of 9.38%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure wheelchairs for two out of 33 sampled residents (Resident 20 and Resident 32) were in good repair, when Resident 20's wheelchair had a broken brake handle on the right handle, and Resident 32's wheelchair had a torn right arm rest. This failure had the potential to compromise the health and safety of the two residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for four out of 33 sampled residents (Resident 93, Resident 96, Resident 106, and Resident 217). This failure decreased the potential for the residents to get assistance from staff in a timely manner when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, functional, sanitary, clean and comfortable environment was provided for one of 33 sampled residents (Resident 61), when Resident 61's room had a broken closet door, two missing drawers, trash in the bottom drawer, and an unclean bathroom. This failure had the potential to result in Resident 61 not attaining his highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to submit the results of an abuse allegation investigation involving two of four sampled residents (Resident 1 and Resident 2) to the Department of Public Health within 5 working days of the incident. This failure decreased the potential for the facility to protect residents from abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in accordance with professional standards of practice for one of 21 sampled residents (Resident 67) when: 1. Showers were not provided, as scheduled; 2. Food preferences and dislikes were not honored, and not included on the meal ticket; and 3. Physician's order for diet was not followed. These failures resulted in resident's unmet needs, and had the potential to result in the resident not attaining the highest practicable physical, psychosocial, and mental well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nursing staff were able to describe the safe storage of medication pass supplements for a census of 101. This failure had the potential to place residents at risk for for foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices for a census of 101, when: 1. Staff were unable to demonstrate how to effectively check for the concentration of sanitizing solution in the red buckets; 2. Staff were unable to verbalize how to properly sanitize the beverage dispenser system (BDS); 3. Health shakes were thawed in refrigerator but not discarded after two weeks per manufacturer guidelines; 4. Peanut butter and jelly sandwiches were not refrigerated per the grape jelly manufacturer guidelines; 5. Steam table pans were stored wet in the ready-for-use area, and a spatula was found wet in a drawer indicating it was ready to use; 6. A strainer was found ready to use but contained embedded rice in the rim of the strainer; 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect privacy rights for one of 21 sampled residents (Resident 61), when Certified Assistant Nurse (CNA) 3 sat on Resident 61's bed while assisting the resident with eating. This failure had the potential to be seen by Resident 61 as an invasion of personal space.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat one of 21 sampled residents (Resident 61) with dignity and respect, when a staff member referred to Resident 61 as a feeder in a public area. This failure had the potential to affect the emotional well-being of Resident 61, along with other residents who overheard the comment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident needs were accommodated for four of 21 sampled residents (Resident 8, Resident 10, Resident 21, and Resident 67) when: 1. Call light was not in reach for Resident 8, 2. Showers were not provided as scheduled for Resident 10 and Resident 67, and 3. Staff did not allow Resident 21 to participate in the social dining program despite his request. These failures had the potential to result in residents' decreased independence, risks for falls, and risks for unmet needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure privacy during personal care for two of 21 sampled residents (Resident 95 and Resident 48) when curtains were missing or did not cover the window area of the bedroom. This failure had the potential to result in residents' embarrassment and humiliation.

Inspectors wroteBased on interview and record review, the facility failed to ensure that an accurate assessment was completed for 1 of 21 sampled residents (Resident 121). This failure resulted in Resident 121 having an inaccurate medical record.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a desirable body weight for one of 21 sampled residents (Resident 7), when the weight loss was not documented. This failure resulted in a severe undesirable weight loss for Resident 7, and had the potential to result in further decline in the resident's nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and secure labeling and storage of medications and biological's for a census of 101, when: 1. Expired glucose monitoring test strips were found in the medication storage room; 2. Sterile needles were found in a box labeled with an expired date, in the medication storage room; 3. Refrigerated medications and vaccines were stored below acceptable temperature ranges; and 4. Two expired emergency medication kits (e-kits) were found in the refrigerator. These failures had the potential to negatively affect the health and well-being of the facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident preferences were accommodated for two of 21 sampled residents (Resident 67 and Resident 21), when: 1. Resident 67's food dislikes were included in the meal tray; and 2. Resident 21 was not provided with a beverage of choice with a meal. This failure resulted in residents' emotional distress, and had the potential to result in residents' health complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program for a census of 101, when: 1. A bench used by multiple residents was split and missing pieces of upholstery with an exposed padding; 2. Certified Nursing Assistant (CNA) 3, sat on Resident 61's bed while assisting the resident with eating; 3. Proper wearing of face masks by staff was not enforced; and 4. A nursing staff member wore a torn and soiled face mask while around residents. These failures had the potential risks to result in transmission of communicable diseases and infections.