Windsor Nursing and Rehabilitation Center of McAll

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that a resident who was incontinent of bladder with a suprapubic catheter (flexible tube inserted into the bladder through the abdomen to drain urine) received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #27) of 1 resident reviewed for urinary catheters (a flexible tube used to empty the bladder and collect urine in a drainage bag). The facility failed to place Resident #27's urinary catheter drainage bag below the bladder. This failure could place residents with urinary catheters at risk for urinary tract infections. Record review of Resident #27's face sheet dated 12/03/25 revealed a [AGE] year-old male admitted on [DATE] with an original admission date of 02/02/25. [...]

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 foods were properly labeled and dated. This failure placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Observation of the kitchen wall on 12/01/25 at 8:25 AM revealed a jar of spice that was not labeled or dated when opened. Observation of the kitchen preparation counter on 12/01/25 at 8:26 AM revealed a loaf of bread was not labeled or dated when opened. Observation of the freezer on 12/01/25 at 8:27 AM revealed 3 packages of hot dog buns not labeled or dated when opened. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one of four residents (Resident#1) reviewed for accidents and supervision. The facility failed to provide adequate supervision to Resident#1. Resident #1 fell from the shower chair while care was being provided by CNA A and CNA B and sustained a fracture to right hip. This failure could place residents who require supervision at risk of accidents or injury. [...]

Inspectors wroteBased on interviews and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated and failed to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress for 1 of 4 residents (Resident #1) reviewed for neglect. The facility failed to thoroughly investigate a reported fall which could have led to a correlation of a fracture which was confirmed on 09/29/25. This failure could place residents at risk of further abuse, physical harm, mental anguish and emotional distress. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure the residents had the right to be free from abuse, neglect and misappropriation of property for 8 of 16 residents (Resident #4, Resident #9, Resident #12, Resident #15, Resident #20, Resident #23, Resident #27, and Resident #31) reviewed for abuse, in that: [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, were reported immediately to the State Survey Agency, within two hours if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 2 of 16 (Resident #15 and Resident #4) residents reviewed for abuse/neglect, in that: The facility failed to report allegations of resident abuse for Resident #15 and Resident #4 to the State Survey Agency within the allotted time frame of 2 hours on 04/24/25 when Resident #15 pulled Resident #4's hair. This failure could place all residents at increased risk for potential abuse due to unreported allegations of abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident was not given a psychotropic drug unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 3 ( Resident #34, Resident# 59, and Resident #25) of 4 residents reviewed for unnecessary medications, in that: 1. Resident #34 was receiving Prozac (an antidepressant) without adequate indication for its use or an appropriate diagnosis. 2. The facility failed to have an adequate diagnosis or indication for the use of the medication Gabapentin (anti-epileptic drug, used for seizures and some types of pain, with off-label use of anxiety, insomnia, and bipolar disorder) for Resident #59. 3. Resident #25 was prescribed a psychotropic drug for anxiety without a documented diagnosis of anxiety in the clinical record. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the resident's right to formulate advance directives for 1 (Resident #72) of 8 residents reviewed for advance directives. The facility failed to ensure that Resident #72's Advance Directive was signed by the family representative and code status was entered as DNR in the records at the facility. This failure could place the residents at risk of not having their end of life wishes honored, such as receiving unwanted resuscitative measures.

Inspectors wroteBased on interview and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 1 of 3 residents (Resident #28) reviewed for preadmission screenings. The facility failed to refer Resident #28 for PASRR Evaluation after a positive PASRR 1 screening. This failure could place residents at risk of receiving inadequate care.

Inspectors wroteBased on record review and interview the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for one (Resident #53) of five residents whose medications were reviewed. The facility's Pharmacy Consultant recommended the physician consider a GDR for the Keppra and the Trazodone on 05/30/24. The facility failed to ensure the physician documented his rationale for not making any changes to Resident #53's medication therapy. This failure could place residents receiving psychotropic medications at risk for adverse consequences and could cause a decline in their physical, mental, and psychosocial condition.

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 help prevent the development and transmission of communicable disease and infection for 2 (Resident #16 and Resident #45) of 16 residents reviewed for infection control, in that: 1. The facility failed to ensure LVN A changed his gloves when moving from a dirty to clean task during wound care on Resident #16. 2. The facility failed to ensure LVN D cleaned the stethoscope prior to checking placement of peg tube during the task of medication administration on Resident #45. These failures could place resident at risk for infection due to improper care practices.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the resident physician regarding a change in resident's condition for one (Resident #11) of three residents reviewed for changes in condition in that: The facility failed to inform the physician of Resident #11's swelling to his right leg. This failure could place residents' representative/physician at risk of not being aware of any changes in their conditions and could result in delay in treatment and decline in residents' health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to periodically review and revise the comprehensive person-centered care plan by a team of qualified persons after each assessment, including both the comprehensive and quarterly review assessments for 2 of 3 residents (Resident #1 and Resident #2) reviewed for care plans, in that: 1. The facility failed to ensure Resident #1's most recent care plan reflected a witnessed fall with injury on 12/21/2023. 2. The facility failed to ensure Resident #2's most recent care plan reflected an unwitnessed fall with serious injury on 12/12/2023. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 4 Residents (Residents #3 and #4) reviewed for medical records accuracy, in that: 1. Resident #3's [DATE] Medication Administration Records documentation was incomplete. Staff did not document or sign off on the administration of physician ordered anxiety medication, Lorazepam. 2. Resident #4's [DATE] Medication Administration Records documentation was incomplete. Staff did not document or sign off on the administration of physician ordered pain medication, Gabapentin. These failures could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 of 7 Residents (Resident #3, Resident #4 and Resident #6) reviewed for medical records accuracy, in that: 1. Resident #3's October 2023 Medication Administration Record documentation record was incomplete as it did not include dates for physician ordered Haloperidol (medication for mental/mood disorders) was given. 2. Resident #4's February 2024 Medication Administration documentation was incomplete for physician orders related to his indwelling (left within a bodily organ) suprapubic (area above pubic bone) catheter (a tube inserted into bladder to drain urine). Staff did not document catheter care, irrigation, and urine output on each shift 5 times in February 2024 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident who entered the facility with an indwelling catheter or subsequently recieves one is assessed for removal of catheter as soon as possible unless the resident's clinical condition demonstates that catheterization is necessary for 1 of 7 residents (Resident #1) reviewed for incontinent care and catheter care, in that: The facility failed to document upon readmission on [DATE] MD orders for an indwelling urinary catheter including indication for use; the MD orders for removal of Resident #1's indwelling urinary catheter on 01/04/2024 and the MD order for the reinsertion of an indwelling urinary catheter on 01/06/2024 without a documented physician order which included catheter size and balloon inflation parameter. [...]

Inspectors wroteBased on interview, and record review, the facility failed to providecare included but was not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs for 1 of 7 residents (Resident #1) reviewed for incontinent care and catheter care, in that: The facility LVN A failed to document orders for the removal (01/04/24) and insertion (01/06/24) of R#1's indwelling urinary catheter. LVN B did not obtain catheter size before inserting R#1's indwelling urinary catheter. This deficient practice could place residents at-risk for infection due to improper care practices, injury, leakage and decreased quality of life.

Inspectors wrote1. Based on interviews, and record review, the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team after there was an update for 3 of 24 residents (Resident #39, Resident #44, and Resident #54) whose care plan were reviewed, in that: -The facility failed to ensure Resident #44's care plan reflected DNR instead of CPR. - The facility failed to ensure Resident #54's care plan reflected DNR instead of CPR. -The facility failed to develop a comprehensive person-centered care plan for Resident #39, use of anticoagulant medication. This failure could place residents at risk of receiving incorrect care and cause health complications with subsequent illnesses.