Windsor Nursing and Rehabilitation Center of Alice

Inspectors wroteBased on observation, interviews and record review, the facility failed to store food in accordance with professional standards for food service safety in the facility kitchen for 2 of 3 facility refrigerators, and 1 of 2 facility freezers reviewed for storage, preparation and sanitation. -The facility failed to ensure containers of tuna, corn, chocolate pudding, vanilla pudding, chilled fruit, and jello that were dated past the 72-hour used by date were thrown away.-The facility failed to ensure the safe storage of a bag of onions sitting next to the pail with cleaning chemical solution and a rag for cleaning purposes.-The facility failed to ensure 2 boxes of hashbrowns, and 1 box of bread dough were sealed and protected from cross contamination and exposure to splash, dust, or other contamination. [...]

Inspectors wroteBased on interview and record review, the facility failed to review and revise the comprehensive care plan after each assessment, including both the comprehensive and quarterly review assessments for 1 (Resident #5) of 5 residents reviewed for care plans. The facility failed to review and revise Resident #5's care plan with the current code status. This failure could place residents at risk of not receiving adequate or required care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 of 3 residents (Resident#33) reviewed for indwelling catheters. The facility failed to prevent Resident#33's urinary catheter bag from touching the floor. This failure could place residents at risk for cross contamination and urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided with such care, consistent with professional standards of practice, for 2 (Resident #56 and Resident #8) of 5 residents reviewed for respiratory care. 1. The facility failed to ensure Resident #56's oxygen was administered at the correct setting of 3 liters per minute on 03/30/2026 as ordered by the physician. 2. The facility failed to ensure Resident #8 had an emergency tracheostomy kit at the resident's bedside on 03/30/2026. These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications, a decreased quality of care, and a delayed lifesaving intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were secured and stored in accordance with currently accepted professional principles and standards for 1 of 2 medication storage rooms (C Hall Medication Storage Room) reviewed for medication storage. The facility failed to ensure the C Hall Discontinued Medication cabinet was locked and secured. This failure could place the residents at risk of gaining access to unlocked medications that were not prescribed to them and place the facility at risk of drug diversion.

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 3 (Resident #38, #14, and #66) of 8 residents reviewed for infection control practices.1. The facility failed to ensure MA A changed gloves after touching multiple surfaces during administration of eye drops on 03/31/2026 for Resident #38.2. The facility failed to ensure Resident #14 had EBP orders.3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free of unnecessary drugs for 1 (Resident #2) of 3 residents reviewed for medications. The facility failed to have an adequate indication for the use of the medication Risperidone (an antipsychotic with black box warning) for Resident #2 before administering the medication. This failure could put residents at risk of harm from adverse reactions or harmful side effects.

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 1 of 5 residents (Resident #1) reviewed for infection control practices. The facility failed to ensure LVN-A donned gloves and performed proper hand hygiene when dealing with secretions and body fluids. These failures could place residents at risk for cross contamination and infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident had the right to be free from abuse for seven residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident#15, Resident #20 and Resident #23) of 7 residents reviewed for abuse/neglect. 1. The facility failed to ensure Resident #2 was free from abuse, Resident #2 sustained a right hip fracture from being pushed by Resident #3 on 04/22/25. 2. The facility failed to ensure Residents #2 and #5 were free from abuse, Resident #4 hit Resident #3 in the back of the head causing a bump to her head and pushed Resident #5 that caused him to fall on top of another resident on 06/07/25 at 4:50 PM. 3. The facility failed to ensure Resident #15, Resident #20, and Resident #23 were free from abuse when Resident #15 struck Resident #20 on the back of his head with her phone causing an abrasion; [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure residents received adequate supervision to prevent accidents and/or hazards as possible for 1 of 12 residents (Resident #1) reviewed for supervision and accident hazards. The facility failed to ensure Resident #1 received adequate supervision in allowing Resident #1 to exit the facility without the knowledge of staff sometime between 6:30 PM and 7:00 PM on 05/16/25. An IJ was identified on 07/01/25. The IJ template was provided to the facility on [DATE] at 8:15 PM. While the IJ was removed on 07/03/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because new polices implemented to prevent future errors were still in process. This failure could place residents at risk for injuries and a decline in health. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 3 Residents (Resident #4, Resident #15, and Resident #3) out of 4 investigated for abuse in the facility, in that: The facility failed to enforce the abuse policy correctly during investigations of abuse for Resident #'s 3, 4 and 15. Investigations were found to be inconclusive based on an incorrect interpretation of the definition of abuse and willful. The ADM and DON were not able to define abuse or willful correctly, making them incapable of determining whether abuse occurred at the facility or not. The ADM was the abuse prevention coordinator at the facility in charge of investigating abuse allegations. [...]

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 reviewed for storage, preparation, and sanitation. The facility failed to ensure kitchen equipment was in good condition. This failures could place residents at risk for complications from food contamination.

Inspectors wroteBased on interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident#36 and Resident#27) of 12 residents reviewed for accuracy of assessments. 1. The facility failed to ensure Resident#36's MDS assessment accurately reflected the use of oxygen. 2. The facility failed to ensure Resident#27's MDS assessment accurately reflected the use of oxygen. These failures could place residents at risk for receiving inadequate care and services due to inaccurate assessments.

Inspectors wroteBased on observation, interview 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 includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 9 residents (Resident #9 and Resident 31) reviewed for care plans. 1. The facility failed to ensure Resident #9's care plan revised on 12/26/24 reflected she was non-compliant with her no added salt diet. 2. The facility failed to ensure Resident #31's care plan revised on 02/06/25 reflected she was non-compliant with her order to wear a palm protector on her left hand. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory was provided such care, consistent with professional standards of practice for 2 of 9 residents (Resident # 9 and Resident #49) reviewed for respiratory care. 1. The facility failed to ensure Resident #9's oxygen was administered at 3 lmp instead of 2 lpm via nasal cannula as ordered by physician. 2. The facility failed to ensure an oxygen sign was hung outside of Resident's #49's room, who received oxygen. These failures could place resident at risk of developing respiratory complications, having a decreased quality of care and expose residents to hazards such as explosions which could lead to physical harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 1 of 9 residents (Resident #117) reviewed for pharmacy services. The Facility failed ensure Resident #117's controlled medication was signed off on the MAR on 02/23/25 after being administered. This failure could place residents at risk of not receiving their narcotic medications and drug diversion.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection 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 4 residents (Resident #28) reviewed for infection control. CNA B failed to wash her hands or use hand sanitizer between gloves changes while providing catheter care and perineal care for Resident #28. This failure could place residents at risk for spread of infection and cross contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to post nurse staffing information on a daily basis to include the facility name, the current date, the total number, and the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift for 3 of 3 days reviewed (02/22/25, 02/23/25, and 02/24/25) for nurse staffing. The facility failed to post the daily staffing information in a prominent place on 02/22/25, 02/23/25, and 02/24/25. This failure could place residents at risk of not being informed of the census and the number of staff working each day to provide care on all shifts.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one (Resident #1) of 4 residents reviewed for supervision. The facility failed to ensure Resident #1 received adequate supervision while Resident #1 was unaccounted for approximately 29 minutes from 4:46 PM to 5:15 PM on 08/17/24 before a 3rd party notified CNA A that Resident #1 was in her wheelchair outside the facility. The noncompliance was identified as PNC. The PNC began on 08/17/24 and ended on 09/04/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents requiring supervision at risk for injury and accidents with potential for more than minimal harm.

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 reviewed for sanitation in that: 1. The facility failed to ensure the juice dispenser guns were sanitary 2. The facility failed to ensure the dishes were clean and sanitized 3. The facility failed to ensure equipment was clean and sanitized 4. The facility failed to remove a dented can from service 5. The facility failed to discard and replace unsanitary cooking utensils 6. The facility failed to refrain from having personal items in the prep areas 7. The facility failed to maintain cleanliness of the floor in the nutrition room 8. The facility failed to label and date items in the nutrition room refrigerator 9. [...]

Inspectors wroteBased on observation, record reviews, and interviews, the facility failed to maintain essential equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating equipment: 1. The dish washer machine was not operating correctly. 2. The vent hood filters were not being cleaned. These failures could place residents and staff at risk of foodborne illnesses and injury.

Inspectors wroteBased on interview and record review 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 2 of 24 residents (Resident #31 and Resident #209), reviewed for care plans. - Resident #31's and Resident #209's care plan did not reflect their code status. The deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and implementing personalized plans developed to address their specific needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biological were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 (Hall C nurse medication cart) of 5 of the medication carts reviewed for storage: The facility failed to ensure the C hall medication was not left unlocked and unattended at the nurses station. This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations.