Windsor Healthcare Residence

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the residents right to be free from abuse for three (Residents #10, #52, and #32) of five residents reviewed for abuse, in that:On 7/28/25, Resident #10 was pushed by Resident #62 after the resident attempted to enter Resident #62's room without permission. On 8/07/25, Resident #52 and Resident #62 were engaged in a pushing match. Resident #62 pushed Resident #52. Resident #52 fell to the floor and hit her head. Resident #52 was sent to ER for evaluation and sustained no injuries. On 08/25/25, Resident #32 was pushed Resident #62 after the resident entered Resident #62's room without permission. Resident #32 fell to the floor and hit her head. Resident #32 was sent to ER for evaluation and sustained no injuries. On 8/26/25 at 6:45 PM, an IJ was identified. The facility was notified of the IJ on 8/26/2025. [...]

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. The facility failed to ensure the food served was fresh and in an edible condition. The facility failed to ensure food was served in a sanitary manner. This failure could place residents at risk of foodborne illness by serving them expired food and food in unsanitary conditions.

Inspectors wroteBased on interviews and record review, the facility failed to provide pharmaceutical services including the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 1 (Resident #62) of 4 residents reviewed for pharmacy servicesThe facility failed to ensure Resident #62 received Risperdal 2mg by mouth twice daily and Risperdal 0.5mg by mouth twice daily between 8/20/2025 and 8/26/2025. This omission could place residents at risk for exacerbation of psychotic symptoms.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 residents (Resident #1) reviewed for quality of care, in that:The facility failed to conduct a weekly skin assessment for Resident #1 on due on 08/13/25 but not completed. These failures placed residents at risk of physical harm, pain, and a decreased quality of life.

Inspectors wroteBased on observations, interviews and record review, the facility failed to have a policy to ensure safe and sanitary storage of residents' food items for 3 of 7 residents' (Residents #2, #3, and #4) reviewed for food policy, in that: Residents #2, #3, and #4's personal in-room refrigerator was not monitored for safe temperatures. These failures could place residents at risk of food borne illnesses.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 1 of 11 residents (Residents #1) reviewed for resident rights in that: The facility failed to ensure Residents #1's call light was within reach on 12/04/24. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 4 residents (Resident #1) reviewed for a clean and homelike environment. The facility failed to ensure Resident #1's urinal was emptied appropriately on 12/04/24. This failure placed residents at risk of decreased feelings of self-worth and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area, for 1 of 11 residents (Resident #1) reviewed for physical environment. The facility failed to ensure Resident #1 had a working call light in his room on 12/04/24. This failure could place residents at risk of not being able to get assistance when needed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the residents' right to privacy for 1 of 8 residents (Resident #8) reviewed for privacy. The facility failed to ensure LVN provided privacy by closing Resident #8's door when performing wound care on Resident 8's right heel on 07/25/24 at 9:16 AM. This failure could place residents at risk of having their bodies exposed to the public, resulting in low self-esteem, and a diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 8 residents (Residents #25) reviewed for resident assessments. The facility failed to ensure Resident #25's most recent quarterly MDS dated [DATE] reflected that Resident #25 did not have a urinary catheter. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate supervision and assistive devices to prevent accidents for 1 (Resident # 1) of 9 reviewed for falls. The facility failed to provide adequate supervision for Resident # 1 , by ensuring all staff were awake while on duty, which resulted in Resident # 1 falling on 11/14/2023 and sustaining a right superior and inferior pubic rami fracture. This failure could resulted in Resident # 1 with a fracture of the right superior and inferior pubic rami fracture and the other residents at risk from injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personnel provided basic life support, which included CPR, to a Resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the Resident's advance directives for 1 of 6 Residents (Resident #1) reviewed for cardio-pulmonary resuscitation. RN A and LVN B failed to continue to perform CPR, until the arrival of emergency medical personnel, to Resident #1 who was a full code status. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 5:05 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope identified as isolated with actual harm, due to the facility's need to evaluate the effectiveness of the corrective systems. [...]