Windsor Nursing and Rehabilitation Center of Edinb

Inspectors wroteBased on interview and record review and observation, the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 3 residents (Resident #1) reviewed for change in condition. The facility failed to notify Residentnotify Resident #1's MD when she fell on 6/17/26 at around 12:00am. Resident #1 did not sustain any injury due to fall. This failure could place residents at risk of not receiving the appropriate care and services to maintain their health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 1 (Resident #1) of 3 residents reviewed for care plans. The facility did not develop and implement a comprehensive person-centered care plan to address Resident #1's order and non compliance with use with a sling to left arm due to an acute fracture to left humerus head/neck after a fall on 06/17/26 at 05:30 a.m. This failure could place residents at risk for their needs not being met.

Inspectors wroteBased on observation and interview, the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles reviewed for medications stored in 1 (B hall cart) of 4 medication carts reviewed for storage. The facility failed to ensure that the nurses medication cart for B hall was secured by a lock when it was left unattended by RN A. This failure could place residents at risk of injury if medication left unsecured were consumed.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records that were complete and accurate in accordance with accepted professional standards and practices for 1 of 3 residents (Resident #1) reviewed for accuracy. The facility failed to add a physician's order for a sling to Resident #1's left shoulder after she returned from the hospital on [DATE]. This failure could place residents at risk for errors in care.

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. 1. The facility failed on 08/26/2025 to ensure foods were properly labeled and dated.2. The facility failed on 08/26/2025 to ensure the cook's hands were washed and gloves were worn during food preparation. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings Include: Observation of the kitchen counter on 08/26/25 at 8:27 AM revealed the following: [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain medical records on each resident that are accurately documented for 3 of 5 residents (Resident #51 and Resident # 34 and Resident # 10) reviewed for medical records. 1. Facility failed on 8/26/2025 to ensure physician orders were written for IV (intravenous) access and maintenance of IV site for Resident # 34. 2. Facility failed on 08/26/2025 to ensure physician orders were written for IV (intravenous) access and maintenance of IV site for Resident #10. On 09/08/25, record review of August's order summary revealed resident obtained an order for IV hydration, thus revealing resident already had an IV lock in place. No orders were found to indicate the date, time and location the IV lock was initially placed. No orders were found to indicate maintenance on IV lock such as flushes or IV lock replacements. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for 1 of 3 residents (Resident # 11) reviewed for accidents and supervision. The facility failed to ensure Resident # 11's door handle remained unlocked from the outside when the door was closed. This failure could place residents at risk for accidents and injuries.

Inspectors wroteBased on observations, interviews, 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 for 1 of 5 residents (Resident # 15) reviewed for quality of care. The facility failed on 08/27/2025 to ensure Residents # 15's indwelling catheters (drains urine from your bladder into a bag outside your body) had a securement device to anchor their catheters. This failure could place residents at risk for urinary tract infections and catheter related injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure parenteral care and services were administered consistent with professional standards of practice for 2 of 2 residents reviewed for intravenous fluids. (Resident #10 and #34) 1) The facility failed on 8/26/2025 to ensure the dressing on Resident # 34's peripheral intravenous line (a short flexible tube inserted into the vein to administer fluids and medications) was dated and initialed. 2) The facility failed on 08/26/2025 to ensure the dressing on Resident #10's peripheral intravenous line (a short flexible tube inserted into a vein to administer fluids and medications [IV]) was dated and initialed. Dressing on Resident's hand revealed a clear dressing over IV line site with no date of insertion and no initials indicating which nurse had inserted IV line. [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete, accurately documented, readily accessible, and systematically organized for 3 of 5 residents (Resident #51 and Resident # 34 and Resident # 10) reviewed for resident record 1. Facility failed on 8/26/2025 to ensure physician orders were written for IV (intravenous) access and maintenance of IV site for Resident # 34.2. Facility failed on 08/26/2025 to ensure physician orders were written for IV (intravenous) access and maintenance of IV site for Resident #10. On 09/08/25, record review of August's order summary revealed resident obtained an order for IV hydration, thus revealing resident already had an IV lock in place. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection 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 #3, Resident #11, Resident #12) of 5 residents reviewed for infection control practices, in that: 1) The facility failed on 8/26/205 to ensure maintenance A, ADON/RN B, Houskeeper C did not don (put on) PPE before entering Resident #11, Resident #3, Resident #12 room. Residents were under contact precautions as per physician orders. This failure could place residents who resided in the facility, as well as employees and visitors, at risk of communicable diseases.

Inspectors wroteBased on record review and interview the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet the residents psychosocial needs for one (Resident#11) of two residents reviewed for comprehensive person centered care plan. The facility did not have interventions in place for Resident #11's behavior of removing peg tube. Resident #11 had removed his peg tube on 2 separate occasions and was sent to hospital. This failure could affect residents and place them at risk of not receiving appropriate interventions.

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals in 1 of 1 medication room review for medication storage . The facility failed to ensure that all medical supplies in the main medication storage room located in the in the front of the building were not past their expiration date. The facility's failure could result in residents receiving expired medical supplies, such as formula, as well as those supplies not being maintained at their best therapeutic level.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preference for one (Resident #23) of four residents reviewed for call light. The facility failed to ensure Resident #23 had a padded call light as indicated on his care plan. This failure could place residents at risk of not having their needs met.

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 are identified in the comprehensive assessment for 1 of 4 residents (Resident #23) reviewed for care plans, in that: The facility failed to ensure Resident #23's comprehensive care plan dated 06/06/24 identified him as a one or two person assist for ADL's. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and no having personalized plans developed to address their specific needs.

Inspectors wroteBased on interview and record review the facility failed to ensure resident who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for two Residents (R#46, R#16) of 5 residents reviewed for unnecessary medications. The facility failed to ensure that: 1) Resident #46 had an appropriate diagnosis for Risperidone (an antipsychotic used to treat schizophrenia and bipolar disorder). 2) Resident # 16, with a diagnosis of unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety received antipsychotic medication Lurasidone without an additional diagnosis indicating the use for antipsychotic medication. [...]

Inspectors wroteBased on observation, interview and record review the facility must ensure that a resident with pressure ulcers receives necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing for 1 of 2 residents (Resident #20) reviewed for pressure sores in that: LVN C failed to utilize appropriate wound care treatment during wound care to Resident #20 This failure could affect residents with pressure injuries and wounds and could place the residents at risk for worsening of pressure ulcers.

Inspectors wroteBased on observation, interview 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 3 residents (Resident #57) and 1 of 4 medication carts (200 hall medication cart) reviewed for medication administration and storage, in that: 1. Certified Medication Aide (CMA) D used her ungloved right index finger to take a pill from a medication bottle intended for Resident #57 2. LVN C had a loose pill in a medication cup inside the top drawer of the medication cart intended for Resident #14 These deficient practices could affect residents who received medication and place them at risk of infection, not receiving the appropriate amount of medication and drug diversion.

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 2 residents (Resident #20) reviewed for infection control practices, in that: LVN C failed to utilize appropriate hand hygiene during wound care and skin treatment to Resident #20 This failure could place residents at risk for infection, slow wound healing and or a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly, for 2 of 2 dumpsters in that: 1. Dumpster #1 did not have a drain plug. 2. Dumpster #2 did not have a drain plug. These failures posed a sanitary and safety hazard that could result in the attraction of vermin and affect all resident residing in the facility by exposing them to germs and diseases carried by vermin and rodents.