Windsor Nursing and Rehabilitation Center of Harli

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 (Residents #1), reviewed for pharmaceutical services, in that: The facility failed to ensure Resident #1's Morphine orders included pain parameters for when the medication should be given. This failure could place residents at risk for not receiving medication as ordered.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that a medication was properly labeled for 1 of 2 residents (Resident #1) that were reviewed for pharmacy services. The facility failed to ensure that a tube of Permethrin External Cream 5% (a topical medication primarily used to treat scabies (skin rash)) was labeled with Resident #1's name. This failure could place residents at risk of not receiving prescribed medications as ordered and adverse effects of medications due to incorrect labeling.

Inspectors wroteBased on record review and interviews, the facility failed to maintain clinical records on each resident that were complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for administration. The facility failed to document skin integrity findings into the skin assessments for continued monitoring. This deficient practice could affect residents who require care and monitoring and place them at risk of not receiving the care to meet their needs.

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 13 of 13 residents reviewed for infection control practices. The facility failed to ensure all EBP residents in the facility had PPE available immediately near the residents' rooms. This failure could place residents at risk for cross contamination and infection.

Inspectors wroteBased on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provided jurisdiction in long-term care facilities) in accordance with state law through established procedures for 1 of 5 residents (Resident #1) reviewed for abuse and neglect. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care of 1 (Resident #123) of 6 residents reviewed for baseline care plan completion. The facility failed to complete the advance directive section in the baseline care plan dated [DATE] for Resident #123 within the required 48-hour timeframe when the physician order was dated [DATE]. This deficient practice could place the residents at risk of not having their end of life wishes honored, such as receiving unwanted resuscitative measures.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 3 (Resident #63, Resident #345) residents reviewed for respiratory care. 1. The facility failed to ensure Resident #63's oxygen was administered at the correct setting of 3 liters per minute on 06/10/2025 as ordered by the physician. 2. The facility failed to ensure Resident #345's oxygen was administered at the correct setting of 2 liters per minute on 06/10/2025 as ordered by the physician. These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, including the opened date on over the counter (OTC) medications in 1 of 23 medication carts (700 hallway Medication Cart) and one of two residents Resident#106. reviewed for medication storage in that: 1. The OTCs in the 700 hallway Medication Cart did not have an opened date written on the bottle. 2. On 06-12-2025 LVN G failed to administer Resident #106's medications and left a cup containing Resident #106's medication on her bedside table. These deficient practices could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication or treatment.

Inspectors wroteBased on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #123) of 6 residents reviewed for accuracy and completeness of clinical records. The facility failed to obtain the physician's signature on the OOH-DNR form for Resident #123 dated [DATE]. This deficient practice could affect residents who require care and monitoring and place them at risk of receiving or not receiving advanced directives to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of disease and infection for 1 (Resident #346) of 3 residents reviewed who were in isolation. CNA F did not don PPE before entering Resident #346's. Resident #346 was under contact isolations 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 observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care received such care consistent with professional standards of practice and the comprehensive person-centered care plan for 2 of 6 residents (Residents #84 and Resident #90) reviewed for respiratory care. The facility failed to ensure Resident #84 received oxygen at the prescribed rate. He received oxygen at a rate less than prescribed. The facility failed to ensure Resident #90 received oxygen at the prescribed rate. He received oxygen at a rate higher than prescribed. This failure could place residents receiving oxygen at risk for respiratory distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen must be free of unnecessary drugs for one (Resident #74) of six resident reviewed for medications. The facility failed to have an adequate indication for the use of the medication Rexulti (brexpiprazole- atypical antipsychotic) for Resident #74. 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 maintain medical records in accordance with accepted professional standards and practices that were complete, accurately documented, readily accessible, and systematically organized for 1 (Resident #83) of 8 residents reviewed for accurate medical records. The facility failed to correctly transcribe the physician orders for Resident #83 related to oxygen setting. This deficient practice could place residents at risk of having incomplete or inaccurate records and residents receiving inadequate treatment or care.

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 and to help prevent the development and transmission of communicable disease and infection for 1 of 3 residents (Resident #49) reviewed for infection control, in that: The facility did not provide Resident#49's contact precaution room with a clinical waste covered cart to properly dispose of PPE. This deficient practice could place residents, staff, and visitors at risk and contribute to the spread of infection due to improper disposal of contaminated PPE.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for accuracy of records. 1)The facility failed to accurately document in Resident #1's clinical records the dark discolorations on bilateral upper and lower extremities. 2) The facility failed to document in Resident #1's clinical records her diagnosis of bullous pemphigoid (a rare skin condition that causes, large, fluid filled blisters.) 3) The facility failed to properly assess Resident #1's skin conditions. These failures could place residents at risk of not receiving appropriate care resulting in deterioration in condition and exacerbation of disease process due to inaccuracy of the residents' records.

Inspectors wroteBased on observation, interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' mental and psychosocial needs, for two Residents (R#10 and R#317) of 22 residents reviewed for care plans. 1) The facility did not develop and implement a comprehensive person-centered care plan for Resident #10 to address the use of the drug Ambien. 2) The facility failed to implement a comprehensive person-centered care plan for Resident #317's antibiotic treatment. These failures could place all residents at risk for not getting their medical, physical, and psychosocial needs being met and not being provided with the necessary care or services and having personalized plans developed to address their specific needs.

Inspectors wroteFACILITY Infection Control Based 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 and to help prevent the development and transmission of communicable disease and infection for 1 of 4 residents (Resident # 87) reviewed for infection control, in that: 1. The facility failed to ensure LVN H followed proper hand hygiene before and after wound care of Resident # 87. LVN H failed to wash her hands for at least 20 seconds per facility policy. These deficient practices could place this and other residents at risk for infection.