Windsor Nursing and Rehabilitation Center of Bastr

Inspectors wroteBased on 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 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 one of six residents (Resident # 5) reviewed for care plans. The facility failed to develop a comprehensive care plan to reflect Resident #5 needed in room activities. These failures could place residents at risk of not receiving appropriate interventions to meet their psychosocial needs.

Inspectors wroteBased on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one of five residents (Resident # 9) reviewed for activities. The facility failed to provide Resident #5 in room activities three times per week from May 2026 through June 18, 2026. This failure could place residents at risk for boredom, depression, and a diminished quality of life.

Inspectors wroteBased on interview, observations and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 6 residents ( Resident #1) reviewed for pharmacy services. The facility failed to follow protocol of administering medications for Resident #1 resulting in postponing a surgical procedure. This failure could place residents at risk of not receiving the correct medications and a resident physical needs not being met.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to 1 of 3 medication carts (Medication Cart #1) reviewed for drug storage. The facility failed to ensure LVN A did not leave Medication Cart #1, unlocked leaving , medications unsecured, and accessible to other staff, residents, or visitors on 06/23/2026 at 6:49 a.m. and 7:30 a.m. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents were free of any significant medication errors for 1 of 5 residents (Resident #1) reviewed for significant medication errors. The facility failed to ensure processes were in place for accurate verification and reconciliation of physician orders and medications upon admission. The DON did not enter the complete medication allergy list into Resident #1's electronic medical record and the facility's NP prescribed an antibiotic that Resident # 1 had a known allergy to. This resulted in Resident #1 having an allergic reaction that led to significant rash over her body. Resident #1 was administered the medication Bactrim DS: Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) a total of 12 different times on: [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for storage, preparation and sanitation. The facility failed to ensure the kitchen dry pantry shelves were clean. The facility failed to ensure frozen foods were properly labeled and dated. These failures could place residents who received prepared meals from the kitchen at risk for food borne illness and cross-contamination.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to serve foods that were palatable and attractive and prepare food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchen observed. 1. The Regular diet kitchen test tray of the lunch meal foods were unappealing and lacked flavor. The regular diet lunch test tray revealed a tray with a Resident's adaptive aide ( spoon and fork) provided, and the food item of Arroz Con [NAME] which tasted mushy in texture, and salty in taste . The main ingredients in the dish could not be identified visually as it was formed in in round / ball shape on the plate. The plate provided was a divided plate with Arroz Con [NAME], broccoli and corn; however, the corn and broccoli was mixed together . The test tray did not have a dessert or a beverage. [...]

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 and follow accepted national standards for one of five residents (Resident #48). reviewed for infection control practices. The facility failed to ensure that staff wore a gown during medication administration via g-tube (a tube inserted into the stomach) for Resident #48. This failure could place the resident at risk for cross contamination. Findings Included: Review of Resident #48's Face sheet reflected a [AGE] year-old female, admitted on [DATE]. [...]

Inspectors wroteBased on 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 one(Resident #1) of 5 residents reviewed for care plans. The facility failed to revise Resident #1's care plan to reflect the most recent fall on 03/25/2025. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings Included: [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure the kitchen floors, food preparation surfaces, pantry shelves and refrigerator shelves were clean. The facility failed to ensure frozen meat was thawed and stored properly prior to preparation. The facility failed to ensure stored foods were properly stored, labeled, and dated. These failures could place residents who received prepared meals from the kitchen at risk for food borne illness and cross-contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a comfortable and homelike environment for 1 of 151 resident rooms (Resident # 38), and 1 of 1 dining rooms whose environment was reviewed. A) The facility failed to ensure Resident # 38's room was free of trash and debris on the floor on 06/09/2024 at 10:12 AM. B) The facility failed to ensure the dining room floor was free of dead and dying insects during the meal service on 06/09/2024 at 12:03 PM. These failures could place residents at risk of living in an unsanitary, uncomfortable environment, and lead to a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs are limited to 14 days unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for 1 (Resident #23) 10 residents reviewed for pharmacy services. The facility failed to ensure Resident #23 had a stop date for PRN Ativan (a medicine used to treat the symptoms of anxiety). This failure could place residents at risk of being overmedicated or receiving unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #37) of 14 residents reviewed for infection control. LVN A failed to perform hand hygiene after removing her gloves and before putting on clean gloves while performing wound care to Resident #37 on 06/11/24. This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post required nurse staffing information in a prominent place readily accessible to resident and visitors. The facility failed to ensure nurse staffing information was posted on 06/08/24 and 06/09/24. This failure could put residents, resident representatives, and visitors at risk of being unaware of actual staffing levels and available staff.

Inspectors wroteBased on interview, and record review the facility failed to ensure the required 80 square feet per resident for 47 of 47 rooms licensed for double occupancy. The facility failed to ensure resident rooms had the required 80 square feet per resident. This deficient practice placed residents at risk for having a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the menu for four (Resident #12, Resident #25, Resident #97, and Resident #9) of eight residents reviewed for menu accuracy. 1. The FSD failed to ensure the pureed recipe was accurately followed for Residents #12, #25, #97, and #9. 2. The [NAME] failed to use the correct scoop size to serve residents. This failure placed residents at risk of decreased intake and weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the required 80 square feet per resident for 48 of 48 rooms licensed for double occupancy. The facility failed to ensure resident rooms had the required 80 square feet per resident. This deficient practice placed residents at risk for having a diminished quality of life.