Windsor Gardens

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for two (Residents #1 and #2) of eight residents reviewed for resident rights. A) 1. The facility failed to ensure Resident #1 was adequately dressed, on Monday 07/20/26 at 9:35 am. He was sitting in a wheelchair with only a blue hospital gown on, at the north end of the 600 hall. 2. The facility failed to ensure Resident #1 was adequately dressed, on Monday 07/20/26 at 10:39 am. As he was being rolled down the 600 hall and taken to the therapy room, he was seen with a blue hospital gown and a beige blanket tied around his neck. 3. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #7, Resident #98, and Resident #104) of twenty-one residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #7, Resident #98, and Resident #104's rooms were in a position that was accessible to the resident on 01/13/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy and confidentiality of his or her personal and medical records for eleven (Residents #2, #5, #33, #40, #44, #49, #53, #91, #100, #116, and #117) of twenty-eight residents reviewed for resident rights. 1. The facility failed to ensure LVN B secured Resident #5's medical information before leaving her cart on 01/13/2026.2. The facility failed to ensure MA C secured Residents #2, #33, #40, #44, #49, #53, #91, #100, #116, and #117's medical information before leaving her cart on 01/14/2026. These failures could place the residents at risk of not having their personal and medical information confidential and exposed to unauthorized individuals.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights 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 a resident for three (Residents #2, #100, and #111) of twelve residents reviewed for care plans. 1. The facility failed to ensure Resident #2's care plan, dated 01/09/2026, included a care plan for pulmonary embolism. 2. The facility failed to ensure Resident #100's care plan, dated 01/09/2026, included a care plan for hypertension. 3. The facility failed to ensure Resident #111's Comprehensive Care Plan reflected the use of a BiPAP machine (noninvasive ventilation that helps you breathe) on 01/13/2026. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team after each assessment for seven (Residents #33, #44, #91, #98, #100, #104 and #116) of twelve residents reviewed for care plans revision. The facility failed to complete a quarterly care plan for Residents #33, #44, #91, #98, #100, #104, and #116. This failure could place the residents at risk of care and needs not being met.

Inspectors wroteBased on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for three (Residents #5, #17, and #111) of eighteen residents reviewed for medication storage. 1. The facility failed to ensure that Resident #5's carbonate powder used by the resident before dialysis was not inside the room on 01/13/2026.2. The facility failed to ensure that LVN B did not leave Resident #5's carbonate on top of her cart unattended on 01/13/2026.3. The facility failed to ensure that there were no medications inside Resident #17's room on 01/13/2026.4. The facility failed ensure Tums (treats indigestion) tablets were not left in a medicine cup on Resident #111's dresser on 01/13/2026. [...]

Inspectors wroteBased 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 three (Residents #24, #77, and #128) of fifteen residents reviewed for infection control. 1. The facility failed to ensure CNA D and the ABOM wore gowns when Resident #24, who had a catheter, was transferred to his wheelchair on 01/14/2026. 2. The facility failed to ensure CNA E performed hand hygiene and changed her gloves during Resident #77's incontinent care on 01/14/2026.3. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care that was developed within 48 hours of resident's admission and failed to provide the resident and their representative with a summary of the baseline care plan for two (Resident #127 and Resident #128) of four residents reviewed for baseline care plans. The facility failed to complete in its entirety the baseline care plan for Resident #127 and Resident #128 within 48 hours of admission. [...]

Inspectors wroteBased observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection for one (Resident #77) of four residents reviewed for incontinent care. The facility failed to ensure that CNA E performed the right technique during Resident #77's incontinent care on 01/15/2026. This failure could place the residents at risk for urinary tract infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #96 and Resident #111) of twelve residents reviewed for respiratory care.1. The facility failed to ensure Resident #96 's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was stored properly when not in use on 01/13/2026.2. The facility failed to ensure Resident #111 's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) and BiPAP mask was stored properly when not in use on 01/13/2026. The facility failed to ensure Resident #111 had a physician's order for a BiPAP machine on 01/13/2026. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident was provided with pharmaceutical services, including procedures that assure the accurate administration of drugs, to meet the needs of each resident for 1 of 7 residents (Resident #1) reviewed for pharmacy services. The facility failed to check Resident #1's BS on six different occasions between the dates of October 1, 2025, through October 23, 2025. This failure has the potential for the resident being placed in a hypoglycemic state or not receiving the therapeutic dosage.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the comprehensive care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of seven residents reviewed for Comprehensive Care Plans. The facility identified Resident #1 with redness/excoriation around her perineum (genital area) and buttocks area on 08/04/2025 but was not detailed on her Comprehensive Care Plan. This failure could place residents at risk of injury, infection, and a decreased quality of life. Findings Included:Review of Resident #1's face sheet dated 08/21/2025 revealed was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted from an acute care hospital 07/30/2025. [...]

Inspectors wroteBased on observation, interview and record review, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Resident #1 and Resident #2) of seven residents reviewed for skin integrity. 1. The facility failed to ensure Resident #1 received accurate skin assessments that included change of condition around her genital area on 08/04/2025, 08/13/2025, and 08/20/20252. The facility failed to ensure Resident #1 received medication and treatment per provider orders related to her genital area on 08/16/2025, 08/17/2025, and 08/21/2025. 3. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received parenteral fluids consistent with professional standards of practice in accordance to physician's orders, the comprehensive person-centered care plan, and the resident's goals and preferences for (Resident #1) of five residents reviewed for parenteral fluids. The facility failed to ensure Resident #1 who had intravenous access present upon observation on 08/21/2025 at 9:44 AM had physician's orders for assessment, care, monitoring, and treatment. This failure could place residents at risk of injury, infection, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received the necessary treatment and services, to promote healing, prevent infection for two ( Resident #3, and Resident #4) of five residents reviewed for pressure ulcers. 1. The facility failed to ensure that Resident #3 had a dressing that covered the wound on Resident #3's lateral right ankle on 5/20/2025. 2. The facility failed to ensure that Resident #4 had a dressing that covered the wound on Resident #4's sacrum on 5/20/2025. These failures could place residents with wounds at risk for infection, a decline in health, and reduce wound healing.

Inspectors wroteBased on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of five residents reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #1 had a comprehensive person-centered care plan for Resident #1 during their stay from 2/23/2025 to 3/30/2025 (35 days ). This deficient practice could place residents at risk of not being provided with the necessary care or services to address their specific needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals were labeled properly for one ([NAME] medication room) of three medication rooms and two (300 hall and 500hall) of five medication carts reviewed for medication storage and labeling. 1. The [NAME] medication room contained one open multi-dose vial of tuberculin without an open date. 2. The 300-hall cart contained seven open eye drop medications without an open date. 3. The 500-hall cart contained one open eye drop medication without an open date and one bottle of liquid protein without an open date. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications and having possible adverse effects.

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 in the facility's main kitchen reviewed for food safety. 1. The facility failed to ensure the ice machine filters and vent was free from dirt and dust. 2. The facility failed to ensure food items in the refrigerator, freezer and dry storage room were labeled and stored in accordance with the professional standards for food service. 3. The facility failed to discard items stored in refrigerator, freezers or dry storage that were not past the 'best buy', consume by or expiration dates. 4. The facility failed to have Dietary staff wash hands or change gloves when they touched other surfaces while handling food or upon re-entering the kitchen. [...]

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 one of three (CNA C) staff members and nine of nine residents (Resident #16, #41, #50, #74, #104, #265, #266, #267, & #268) reviewed for infection control procedures. CNA C failed to perform hand hygiene after direct contact with residents #16, #41, #50, #74, #104, #265, #266, 267, and #268 while serving meals on the rehabilitation hallways. This failure could place residents at risk for healthcare associated cross contamination and infections.

Inspectors wroteBased on interview and record review the facility failed to ensure one (Resident #1) of six residents reviewed, received treatment with respect and dignity that promoted maintenance of his or her quality of life. The facility failed to ensure CNA H preserved Resident #1's dignity by not providing her with good customer service on 09/09/2024, evidenced by CNA H stating oh, I sure would like to hit you on that big old booty. This failure places the residents at risk for harm by not protecting and promoting their rights to be treated with respect and dignity and have good customer serviced rendered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for one (satellite kitchen on the rehabilitation halls) of one satellite kitchen observed for physical environment. The facility failed to ensure floors, cabinets, walls, sink, and refrigerator were clean, safe, and in good repair in the satellite kitchen on Halls 500, 600, 700, and 800, that were rehabilitation hallways. These failures could place residents at risk for diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 5 residents (Resident #3) reviewed for resident records. 1. The facility failed to ensure LVN A documented emergency medical services notification when Resident #3's family member requested Resident #3 be sent to the hospital because she had not responded to verbal stimuli and looked lethargic. 2. The facility failed to complete an assessment of the resident. 3. The facility failed to ensure physician orders for resident to go to the hospital were in electronic health record. This failure could place residents at risk for not receiving appropriate care due to incomplete/inaccurate information being documented.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one of two residents (Residents #01) reviewed for feeding tubes. LVN A failed to monitor and addressed error message of FLOW ERROR: Clog in line downstream of pump for Resident #01 eternal feeding pump on 08/24/26 from 10:50 AM to 11:44 AM. LVN A used a plunger and pushed 10cc of air and 60cc of water in Resident #01 G-Tube without checking for placement. These failures could place residents at risk of tube obstruction and a decrease in hydration.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs in order attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of eight residents reviewed for care plans. The facility failed to ensure CNA A followed Resident #1's comprehensive care plan to ensure safe mechanical lift transfers. The facility failed to ensure CNA A followed Resident #1's comprehensive care plan which required two-person shower assists, which caused Resident #1 to fall from the shower bed and sustained a frontal scalp hematoma and laceration on her forehead which required 3 stitches. An Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 06/21/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible; and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of eight residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 was transferred by two people using a mechanical lift as indicated in the comprehensive care plan. The facility failed to ensure two people assisted Resident #1 during showers as indicated in the comprehensive care plan. Resident #1 fell from the shower bed and sustained a frontal scalp hematoma and laceration on her forehead which required 3 stitches. The facility failed to ensure they had a system in place to monitor equipment (shower beds) for safe working order and log audits on a regular basis. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of significant medication errors for 1 (Resident #33) of 9 residents reviewed for medication accuracy. The facility failed to discontinue hydrocodone (pain medication) after it was ordered to be discontinued by the physician on 5/29/24. This failure placed residents at risk for confusion, respiratory depression, kidney damage, and medication interactions.

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 in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure food items in the refrigerators (3), freezer and dry storage room were labeled and stored in accordance with the professional standards for food service. 2. The facility failed to discard items stored in the dry storage that were not properly labeled or past the 'best buy', consume by or expiration dates. 3. The facility failed to ensure the ice machine's vent/grate and outer surface were free from dirt and dust. 4. The facility failed to ensure handwashing sink #1's trash receptacle was in good repair with a secure fitting lid. 5. The facility failed to empty handwashing sink #1's trash receptacle once it was full. [...]