Windsor Grove Health and Rehabilitation

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure sufficient staffing to meet the needs of the 106 of 106 residents in the facility. The facility failed to ensure there was one nurse on each the Blue Unit and the Pink Unit during the night shift on 04/29/25 and failed to ensure enough staff to implement the care plan intervention of one-to-one supervision for five residents who required one-to-one-supervision.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure Certified Nurse Aides (CNA) received performance reviews at least once every 12 months and regular in-service education based on the outcome of the reviews for four of five CNAs (CNA6, CNA9, CNA10, and CNA12) whose personnel files were reviewed. This had the potential to have a negative impact on resident care.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free from significant medication errors for 2 Residents (#87 & #94) in a survey sample of 55 Residents.

Inspectors wroteBased on observation, Resident interview, staff interview and clinical record review, the facility staff failed to provide services in the facility with reasonable accommodation of resident needs and preferences, for 1 Residents (# 362) in a survey sample of 55 Residents. 1. For Resident # 362, the facility staff failed to ensure the bed was an appropriate size for a resident with morbid obesity (Body mass index greater than 40).

Inspectors wroteBased on interviews, record reviews, and facility policy reviews, the facility failed to notify the Responsible Party (RP) of a change in condition for one resident (Resident (R)71) investigated for changes in condition out of a total sample of 55 residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to timely report an injury of unknown origin for one of one residents (Resident) (R71) reviewed for reporting of alleged violations out of a total sample of 55 residents. This had the potential for further abuse.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to thoroughly investigate an injury of unknown origin for one of one residents (Resident (R)71) reviewed for abuse out of a total sample of 55 residents. This had the potential for further abuse to the resident.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility staff failed to develop and implement a comprehensive person-centered care plan for 1 Resident (# 38) in a survey sample of 55 Residents.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to review and revise the care plan for 1 resident (#43) and invite the interdisciplinary team to the care plan meeting for 2 residents (Resident #59 and 71), of 55 residents in the survey sample.

Inspectors wroteBased on interview, clinical record review and facility documentation, the facility staff failed to ensure services were provided to meet professional standards of quality for 1 Resident (55) in a survey sample of 55 Residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to ensure that activities of daily living (ADL) care related to toenail care was provided to one resident (Resident (R)80) out of a total sample of 55 residents. This failure had the potential to cause the resident foot problems.

Inspectors wrote3. For Resident #55 the facility staff failed to have a signed copy of the DNR available in the clinical record. Resident # 55 was admitted to the facility on [DATE] with diagnoses that included, but we're not limited to hypertension, high cholesterol, dementia, depression, major depressive disorder, muscle, weakness, cognitive, communication, deficit, insomnia, and presence of a pacemaker. Resident # 55's most recent MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 3/3 25, scored the resident as having a BIMS (Brief Interview of Mental Status) score of 4 out of 15 indicating severe cognitive impairment. During the survey Resident #55 was observed to be unable to follow simple instructions by staff, feed herself or engage in meaningful conversations. [...]

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure that physician's orders were followed for one of 55 residents (Resident (R) 116) whose records were reviewed. This failure has the potential to negatively impact R116 and others that have similar orders that currently reside at the facility.

Inspectors wrote2. For Resident #87 the facility staff failed to schedule vision services for a resident with visual impairment. Resident # 87 was admitted to the facility on [DATE] with diagnoses that included, but we're not limited to dementia, schizophrenia, anemia, hypertension, psychotic disorder with delusions due to unknown physiological condition, and cognitive communication deficit. Resident number 87's most recent minimum data set with an ARD (Assessment Reference Date) of 4/16/25 coded Resident # 87 as having a BIMS (Brief Interview of Mental Status) score of 6 out of 15 indicating severe cognitive impairment. Resident number 87 could follow simple conversation. On 4/29/25 Resident #87 stated I need glasses, I can't see. When asked if she had an eye examination, she stated that she could not remember when the last time she had an eye examination. [...]

Inspectors wroteBased on observation, clinical record review and staff interviews, the facility staff failed to provide foot care for two (2) Residents (#65 and #90) of 55 residents, in the sample survey.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to 1.) provide supervision for one of five residents (Resident (R) 35) identified as requiring one-to-one supervision for aggressive behaviors, 2) ensure potential hazardous items were not left unattended in the room of one (R) 2 and provide supervision for a resident (R) 114 with a known balance/gait issues, of 55 sampled residents. These failures had the potential for injury to other residents from R35's aggressive behavior and for injury related to exposure to unknown substances.

Inspectors wroteBased on observation, interview, clinical record review, and facility documentation the facility staff failed to ensure Residents received adequate nutrition to prevent weight loss for 1 Resident (#55) in a survey sample of 55 Residents.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure medications were stored and labeled for three of four medication carts observed and one of two medication rooms observed. This had the potential for misappropriation of medications and possible unsafe medication administration.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure a resident visually impaired resident received training and assistance on infection prevention measures were followed while providing urinary catheter care self care for 1 of 55 residents (Resident #43), in the survey sample.

Inspectors wroteBased on clinical record review and staff interviews, the facility staff failed to maintain an effective pest control program for 1 of 55 residents (Resident #65), in the survey sample. Resident #65 was admitted to the facility on [DATE] with diagnoses of but not limited to hemiplegia and hemiparesis of right-side cerebral infarct, dysphagia, chronic congestive heart failure, and dementia. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 04/24/25. Resident # 65's BIMS (Brief Interview for Mental Status) Score was a 15 out of 15, indicating no cognitive impairment. Resident #65 required assistance with all ADL's (Activities of Daily Living). [...]

Inspectors wroteBased observation and Resident interviews the facility failed to ensure residents are adequately equipped to allow residents to call for staff through a communication system for 2 of 7 residents in the survey sample, R#6 and R#7.

Inspectors wroteBased on observations and Residents interviews the facility fail to ensure a safe, comfortable, and homelike for 3 residents out of 7 in the survey sample: Resident #1, Resident #2, and Resident #3 environment .

Inspectors wroteBased on observations and Residents interviews the facility fail to ensure a safe, comfortable, and homelike for 3 out of 7 residents in the survey sample (R#1, #2 and #3) .

Inspectors wroteBased on resident interview the facility failed to ensure a resident with colostomy received care consistent with professional standards of practice for 1 out of 7 residents in the survey sample, Resident #4.

Inspectors wroteBased on observation and Resident interview the facility failed to ensure sufficient fluid intake to maintain proper hydration and health for 2 out 7 residents in the survey sample, R#2 and R#3.

Inspectors wroteBased on observations, clinical record review, staff interview, and facility documentation, the facility staff failed to provide dignity and respect for 1 Resident (Resident #47) of 35 residents in the survey sample. The facility staff failed to provide Resident #47 dignity and respect during wound care as evidenced by writing on the resident's wound dressing after applying it to the resident's right upper buttock.

Inspectors wroteBased on a facility reported incident, resident personal funds review, resident interviews, staff interviews and facility document review the facility staff failed to ensure that 2 of 35 residents in the survey sample were allowed to manage their own financial affairs/facility personal funds account in regards to a Covid Stimulus Check, Resident #14 and Resident #100.

Inspectors wroteBased on responses from six residents during a group interview and general observations, the facility staff failed to ensure the residents were aware of the contact information for all State regulatory and informational agencies to include email, mailing addresses and telephone numbers in a font large enough to be read by residents.

Inspectors wroteBased on a facility reported incident, resident personal funds review, resident interviews, staff interviews and facility document review the facility staff failed to prevent the misappropriation of resident federal stimulus check funds for 2 of 35 residents in the survey sample, Resident #14 and Resident #100.

Inspectors wroteBased on staff interviews, clinical record review and facility documentation review the facility staff failed to send a copy of the Resident's Care Plan to include their goals after being transferred and admitted to the hospital for two residents (Resident #91 and #94) in survey sample of 35 residents.

Inspectors wroteBased on resident record review, staff interviews and facility document reviews, the facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of discharges for two residents (Resident #43 and #94) in the sample of 35 residents.

Inspectors wrote2. The facility staff failed to ensure that Resident #91 was provided a written copy of the facility's bed-hold and reserve bed payment policy upon transfer/discharge to the hospital on [DATE]. Resident #91 was originally admitted to the facility on [DATE]. Diagnosis for Resident #91 included but not limited to Chronic Obstructive Pulmonary Disease (COPD.) The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 03/01/21 coded the resident with a 06 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The Discharge MDS assessments was dated for 08/09/20 - discharged with return anticipated. [...]

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility's staff failed to accurately code the 2/18/21 quarterly MDS assessment at sections H0100 Bowel and Bladder Appliances and H0300 Urinary continence for 1 of 35 residents (Resident #70), in the survey sample.

Inspectors wroteBased on clinical record review, staff interview and facility documentation, the facility staff failed to provide supervision and implement interventions to reduce environmental hazards for one resident (Resident #4) in the survey sample of 35 residents.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility's staff failed to ensure appropriate care and services were provided to prevent/reduce trauma to the urethra and bladder, and other complications while utilizing an indwelling catheter for 1 of 35 residents (Resident #70), in the survey sample.

Inspectors wroteBased on resident record record review, staff interviews and facility document review the facility staff failed to ensure a gradual dose reduction for Trazadone was followed through for 1 of 35 Resident's in the survey sample, Resident #88.

Inspectors wroteBased on the observation of 3 medication carts and 2 medication rooms; the facility staff failed to dispose of expired medications for two units. The facility staff failed to dispose of expired medications on the Peach Unit and The [NAME] 300 Unit.

Inspectors wroteBased on clinical record review and staff interviews, the facility's staff failed to promptly notify the physician of laboratory results which fell outside of the clinical range for administration of an antibiotic for 1 of 35 residents (Resident #36), in the survey sample.

Inspectors wroteBased on clinical record review and staff interviews, the facility's staff failed to have laboratory results obtained 1/30/21, on the clinical record for 1 of 35 residents (Resident #36), in the survey sample.

Inspectors wroteBased on clinical record review and staff interviews, the facility's staff failed to ensure unnecessary administration of an antibiotic for seven days (use of an antibiotic when an infection wasn't diagnosed) for 1 of 35 residents (Resident #36), in the survey sample.

Inspectors wroteBased on observations, record review, staff interviews, resident interview, and facility document review the facility staff failed to ensure that shower preferences were followed for one of 57 residents in the survey sample, Resident #108. The facility staff failed to ensure that Resident #108's shower preferences were followed as indicated in the comprehensive care plan.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to conduct an investigation and keep residents free from further abuse for two of 57 residents in the survey sample, Resident #5 and Resident #82. 1. Facility staff failed to investigate a sexual encounter between Resident #5 and Resident #107 on 3/6/19; and failed to protect Resident #5 from a second sexual encounter with Resident #107 on 3/20/19. 2. For Resident #82, facility staff failed to investigate a resident to resident altercation between Resident #82 and Resident #107; and failed to prevent further potential abuse from Resident #107.

Inspectors wroteBased on staff interviews, clinical record review and facility documentation review the facility staff failed to send a copy of the Resident's care plan to include their goals for six of 57 residents (Resident #317, #32, #41, #265, #65 and #108) after being transferred to the hospital.

Inspectors wroteBased on staff interviews, facility documentation review and clinical record review the facility staff failed send a copy of the Bed-Hold Policy upon discharge/transfer for five of 57 resident's (Resident #317, 32, 41, 65 and 108) after being transferred to the local hospital.

Inspectors wroteBased on complainant investigation, observation, resident interviews, staff interviews, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for three out of 57 residents (Residents #55, #32 and #465) in the survey sample. 1. The facility staff failed to follow the physician orders for the treatment of the following wounds: right below the knee *amputation site (surgical incision) and skin tear to right elbow for Resident #55. 2. The facility staff failed to follow physician orders and administer treatments to a right BKA (Below the Knee Amputation) for Resident #32. 3. The facility failed to justify treatment with elimite cream for Resident #465.

Inspectors wroteBased on record review and staff interviews, the facility staff failed to provide physician ordered medications and treatments for 3 of 57 residents in the survey sample, Resident #6, #465, & #265. 1. The facility staff failed to provide Resident #6 with medications as ordered by the physician. 2. The facility staff failed to provide wound care for Resident #465. 3. The facility staff failed to provide treatment for a venous stasis ulcer wound for Resident #265.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to notify the responsible party and physician after a resident to resident abuse incident for two of 57 residents in the sample, Resident #5 and #107; and failed to notify the physician of medications not administered per order for Resident #6. 1. For Resident #5 and Resident #107, facility staff failed to notify the responsible parties and physician after a sexual encounter had occurred on 3/6/19. 2. For Resident #6, facility staff failed to notify the physician of missed doses of insulin.

Inspectors wroteBased on a medical record review, facility document review and staff interviews the facility staff failed to ensure a Notice of Medicare Non-Coverage was given timely prior to the last covered skilled day of 1/23/19 for one of 57 residents in the survey sample, Resident # 92. This is cited as Past Non-Compliance.

Inspectors wroteBased on observation and staff interviews the facility staff failed for one resident (Resident #55), in the survey sample of 57, to ensure privacy was maintained during a wound care dressing change for Resident #55.

Inspectors wroteBased on observation and staff interview, the facility staff failed to provide a homelike environment during the dining observation from 06/24/19 to 06/27/19 on the Peach Unit (Memory Care Unit). Facility staff served resident meals on trays during the dining observation on the Peach Unit.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that facility staff failed to ensure a resident was free from abuse for one of 57 residents in the survey sample, Resident #5. Facility staff failed to ensure Resident #5 was separated and protected from Resident #107 after a sexual encounter on 3/6/19 between the two residents; another sexual encounter occurred on 3/20/19.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to implement abuse policies and report and investigate allegations of abuse; and failed to ensure resident safety after abuse had occurred for four of 57 residents in the survey sample, Resident #5, #82, #107 and #41. 1. For Resident #5, facility staff failed to implement abuse policies and report, investigate and ensure Resident safety after a sexual encounter with Resident #107 on 3/6/19. 2. For Resident #82, facility staff failed to implement abuse policies and report, investigate and ensure Resident safety after a physical altercation with Resident #107 on 6/24/19. 3. The facility staff failed to implement the written policy and procedure to report allegation of abuse to the Administrator in a timely manner for Resident #41.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to report an allegation of abuse to the appropriate state agencies for four of 57 residents in the survey sample, Resident #5, #82, #107 and #41. 1. Facility staff failed to report a sexual encounter that had occurred between Resident #5 and Resident #107 on 3/6/19 to the appropriate state agencies. 2. Facility staff failed to report a resident to resident altercation that had occurred between Resident #82 and Resident #107 on 6/24/19 to the appropriate state agencies. 3. The facility staff failed to report allegation of abuse in a timely manner for Resident #41.

Inspectors wroteBased on medical record review, facility document review and staff interviews the facility staff failed to ensure that a Comprehensive Minimum Data Set, dated [DATE] was accurately coded to include a Level II PASRR (Preadmission Screening and Resident Review for one of 57 residents in the survey sample, Resident #108. The facility staff failed to ensure that Resident #108's Annual Minimum Data Set, dated [DATE] was accurately coded to include a Level II PASRR (Preadmission Screening and Resident Review).

Inspectors wroteBased on observations, resident interview, staff interview and clinical record review the facility staff failed to develop a comprehensive care plan for one of 57 residents in the survey sample, Resident #97. The facility staff failed to include care area 'falls on the comprehensive care plan when Resident #97 was identified as a fall risk.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to revise the care plan after resident to resident altercations for three of 57 residents in the survey sample, Residents #5, #107 and #7. 1. Facility staff failed to revise the care plan after a sexual encounter had occurred between Resident #5 and Resident #107 on 3/6/19. 2. Facility staff failed to revise the care plan after a resident to resident physical altercation had occurred between Resident #7 and Resident #107.

Inspectors wroteBased on staff interviews, and clinical record reviews the facility staff failed to provide a nutritional supplement per physician orders for one of 57 Residents in the survey sample (Resident #63). The facility staff failed to provide the nutritional supplement, Mighty Shake, on 6/25/19.

Inspectors wroteBased on facility information obtained during the Complaint investigation, Sufficient and Competent Nurse Staffing task, and staff interviews, the facility staff failed to staff an Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. 1. The facility staff failed to staff an RN , for at least 8 consecutive hours on 06/16/19 and utilized the Director of Nursing as a charge nurse with a resident census greater than 60. 2. The facility staff failed to ensure RN coverage eight hours in a twenty-four hour period on 4/14/18, 4/15/18 and 6/24/18.

Inspectors wroteBased on record review and staff interviews, the facility staff failed to provide pharmaceutical services for one resident (Resident #6) in the survey sample of 57 residents. For Resident #6, facility staff failed to ensure medications were available for administration per physician's order.

Inspectors wroteBased on record review and staff interviews, the facility staff failed to ensure two of 57 residents were free from significant medication errors. 1. The facility staff failed to ensure Resident #6 received insulin per physician's order. 2. The facility staff failed to ensure that Resident #32 received his insulin per physician's order.

Inspectors wroteBased on observation, staff interview, and facility document review, it was determined that facility staff failed to secure medications on one of four medications carts; a medication cart on the blue unit. And failed to ensure one of two medication rooms were free from expired biologicals; the green unit medication storage room. 1. Facility staff failed to ensure the medication cart on the Blue Unit was locked when it was left unattended. 2. The facility staff failed to dispose of multiple expired influenza vials stored in the refrigerator in the medication room located on the [NAME] Unit.

Inspectors wroteBased on observations and staff interviews the facility staff failed to follow infection control practices, increasing the chances of infection, illnesse and disease for one of 57 residents in the survey sample (Resident #10.) The facility staff failed to cover an open wound on Resident #10's left lower extremity in a timely manner.