Windsor House at Champion

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, facility policy review and interview, the facility failed to ensure Resident #88 was provided with necessary and adequate care and services to prevent accidents with injury during staff assisted care. This affected one resident (#88) of three residents who were investigated for accidents. The facility census was 87. Actual Harm occurred on 08/30/25 when Resident #88, who had severe cognitive impairment and was dependent on staff for activities of daily living sustained a fractured distal medial femoral metadiaphysis when staff failed to ensure the resident's foot was not caught under her wheelchair while being transported by staff. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure Quality Assurance Performance Improvement (QAPI) meetings were held at least quarterly. This had the potential to affect all residents in the facility. The facility census was 80.

Inspectors wroteBased on observation, interview and policy review the facility failed to provide a clean shower room on the north hall unit. This had the potential to affect 40 residents identified as utilizing the shower room (Residents #1, #4, #5, #6, #8, #11, #13, #14, #15, #18, #20, #22, #23, #24, #27, #29, #30, #31, #32, #36, #40, #41, #42, #43, #44, #46, #47, #49, #51, #57, #59, #61, #62, #70, #72, #74, #77, #133, #183, and #184). The facility also failed to maintain clean Hoyer (mechanical) lifts on the north hall unit. This had the potential to affect 12 residents (Residents #4, #8, #11, #20, #29, #32, #36, #44, #47, #70, #77, and #183) identified as utilizing the Hoyer lift on the north hall. The facility census was 80.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview, observation, record review, review of social media post, review of Self-Reported Incident (SRI) #254779 and review of the facility abuse policy revealed the facility failed to ensure Resident #67 was free from abuse. This affected one resident (#67) out of two residents reviewed for abuse. The facility census was 80.

Inspectors wroteBased on record review, policy review, and interview the facility failed to send written notice to Residents #18 and #81 or the resident's representatives after the resident transferred from the facility was and admitted to the hospital. This affected two of two residents whose records were reviewed for discharge to hospital.

Inspectors wroteBased on observation, interview and policy review the facility failed to provide meaningful activities as scheduled. This affected one resident ( #70) of two residents (#70 and #78) who were reviewed for activities. The facility census was 80.

Inspectors wroteBased on interview, record review, review of Centers for Disease Control and Prevention (CDC) guidelines and review of facility policy, the facility to ensure residents were up to date with their influenza and pneumococcal vaccinations. This affected three residents (Resident #2, #64 and #67) out of five residents reviewed for vaccinations. The facility census was 80.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview and review of the facility policy, the facility failed to ensure the resident and/or resident representative received the Notice of Medicare Non-Coverage (NOMNC) timely and as required. This affected one resident (#86) of three residents reviewed for billing. The facility census was 82.

Inspectors wroteBased on closed medical record review, interview and policy review the facility failed to ensure physician ordered laboratory testing was completed to monitor medication use. This affected one resident (Resident #90) of three residents reviewed for unnecessary medications. The facility census was 93.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to implement a comprehensive and individualized pressure ulcer prevention program, including turning and repositioning to prevent the development of in-house pressure ulcers for Resident #19. The facility also failed to timely identify and treat pressure ulcers for the resident. Actual Harm occurred on 01/20/23 when Resident #19, who was cognitively impaired and required extensive assistance from two staff for bed mobility and transfers, identified to have developed two in-house acquired unstageable (full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough [yellow, tan, gray, green or brown] and/or eschar [tan, brown or black] in the wound bed) pressure ulcers to the left buttock. [...]

Inspectors wroteBased on observation, interview, and facility policy, the facility failed to ensure the kitchen area was maintained in a clean and sanitary condition and food items were properly dated. This had the potential to affect all 82 of 82 residents who consumed food items from the kitchen.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure Resident's #15 and #25 were monitored for antipsychotic medication side effects. This affected two residents (Resident's #15 and #25) and had the potential to affect all 13 residents (Resident #15, #22, #24, #25, #29, #34, #49, #52, #61, #65, #71, #72, and #134) on antipsychotic medications. The facility census was 82.

Inspectors wroteBased on interview and record review, the facility failed to ensure notification of a weight change was provided to Resident #5's physician and notification of falls was provided to the family of Resident #71. This affected two residents (Resident #5 and Resident #71) of two residents reviewed for notification.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Residents #65 and #134's comprehensive care plans included goals and interventions to address all behaviors. This affected two residents (Resident #65 and Resident #134) of four residents reviewed for behaviors. The census was 82.

Inspectors wroteBased on observation, record review and interview the facility failed to provide comprehensive assessment (including weight monitoring), monitoring and physician notification for Resident #5 related to a diagnosis of congestive heart failure to prevent hospitalization. In addition, the facility failed to ensure non-pressure related wound care was provided timely for Resident #44. This affected one resident (Resident #5) of two residents reviewed for hospitalization, and one resident (Resident #44) of three residents reviewed for wound care. The census was 82.

Inspectors wroteBased on observation, interviews and record review, the facility to ensure Resident #1's cervical collar was in place as ordered to help prevent further contracture, comfort while in a chair, and position for proper swallowing. This affected one (Resident #1) of one resident reviewed for position and mobility. The facility census was 82.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the environment was free from accidental hazards, and Residents #2, #4, and #65 received adequate supervision and services to prevent accidents. This affected three residents (Residents #2, #4, and #65) of four residents reviewed for accidents. The census was 82.

Inspectors wroteBased on observation, interview and record review, the facility failed ensure effective treatment and services were in place to ensure residents with dementia maintained their highest practical well-being. This affected two residents (Resident #65 and Resident #134) of four residents reviewed for behavior. The census was 82.

Inspectors wroteBased on interviews and record review the facility failed to adequately and promptly resolve Resident Council grievances regarding cold food. This affected two Residents (#55 and #127) of the 5 residents (#17, #25, #30, #32, #55 and #127) who attended the resident council meeting during the survey.

Inspectors wroteBased on interview and record review the facility failed to ensure pressure ulcer treatments were implemented promptly per physician orders and failed to complete and document assessment of the pressure ulcer on Resident #61's right heel when it re-opened. This affected one of two residents reviewed for pressure ulcers.

Inspectors wroteBased on interview and record review the facility did not ensure a consistent system for completion and documentation of pre-dialysis and post-dialysis assessments and did not ensure all assessments were accurately completed for Resident #47. This affected one of one resident reviewed for dialysis. The census was 84.