Windsor Nursing and Rehabilitation Center of Morga

Inspectors wroteBased on interviews and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1 was treated with respect and dignity when CNA A used foul language towards her on 07/01/26. This failure could place residents at risk for decreased quality of life, quality of care, and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse and neglect for of 5 residents (Resident #2) reviewed for abuse, neglect, and exploitation. The facility failed to protect Resident #2 from physical abuse when Resident #1 hit Resident #2 multiple times in the head and fell to the floor with him on 03/29/2026. These failures could place residents at risk for physical and/or psychological harm or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet the residents' medical, nursing, and psychosocial needs for 1 (Resident #1) of 5 residents reviewed for person-centered care plans:The facility failed to recognize, develop, and implement a care plan and care plan interventions with measurable timeframes and objectives to address Resident #1's aggressive behaviors prior to his physical aggression incident on 03/29/2026. These failures could affect residents by placing them at risk of not being provided with the necessary care and services to address their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' environment remains as free of accidents and hazards as possible for 1 of 5 residents (Resident #3) reviewed for abuse, neglect, and exploitation. The facility failed to protect Resident #3 from neglect when the AA failed to apply her smoking apron, and Resident #3 received a cigarette burn on 03/19/2026. These failures could place residents at risk for physical and/or psychological harm or injury.

Inspectors wroteBased on interview and record review, the facility failed to manage the personal funds deposited by residents for 1 (Resident #4) of 5 residents reviewed for residents' rights. The facility failed to ensure Resident #4 had access to his personal funds upon request in a timely manner on 04/03/2026. This failure could place residents whose funds were managed by the facility without access to their funds deposited within the facility. The findings Included: Record review of Resident #4's face sheet dated 04/10/2026 revealed a [AGE] year-old male who was originally admitted to the facility on [DATE] with a readmission on [DATE]. Resident #4's admitting diagnosis was Transient Cerebral Ischemic Attack (a mini stroke which occurred when there was a temporary interruption of blood flow to the brain). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of significant medication errors for 5 of 10 residents (Resident #23, Resident #47, Resident #66, Resident #74, and Resident #82) reviewed for medication errors. 1. The facility failed to ensure LVN C did not document NA in place of Resident #23's blood pressure and pulse when her blood pressure altering medication was administered on 06/03/25, 06/06/25, 06/07/25, 06/08/25, 06/16/25, 06/25/25, 06/26/26, 07/06/25, 07/07/25, and 07/08/25. The facility failed to ensure LVN C did not document NA in place of Resident #23's BP, temp, pulse, resp, and O2 sats on 06/07/25, 06/16/25, 06/25/25, 06/26/25, 07/04/25, 07/05/25, and 07/06/25 when vital signs were to be documented on every day shift on Saturday (04/12/25 to 06/09/25) then every shift (began 06/13/25) per the two physician's orders. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one (Resident #70) of one resident the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed. The facility did not provide Resident #70 with a written notice prior to a room change or the right to refuse on 03/27/25. This deficient practice could place residents at risk for being displaced without notice and/or reason to accommodate other individuals. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who required dialysis received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #47) reviewed for Dialysis fistula assessment and care. The facility failed to ensure the nurses knew how and were performing the proper technique for assessing Resident #47's dialysis fistula (vascular access used in hemodialysis, which was a treatment for patients with kidney failure) for thrill (a vibration felt over the fistula or shunt) and bruit (swooshing sound cause by blood flow through the fistula or shunt). This deficient practice and failure could place residents at risk for a blockage and/or stenosis (narrowing of the veins and/or arteries) of the fistula site. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological were labeled and stored in accordance with currently accepted professional principles for 3 of 6 medication carts (2nd Floor Nurse Med-Cart A, 2nd Floor Treatment Cart, 3rd Floor Nurse Med-Cart B, and 3rd Floor Treatment Cart) reviewed for labeling and storage. The facility failed to properly label from 2nd Floor Nurse-Med-Cart-A a vial of insulin Glargine (a long-acting insulin used to treat Type 1 or Type 2 Diabetes), with an open or expiration date. The facility failed to dispose of the medication from 2nd Floor Treatment Cart a container of Hemorrhoidal Pads (a pad used to treat hemorrhoids) 50% which had expired on 03/22/2025. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents, staff and public in 2 (Elevator 1 and Elevator 2) of 3 elevators reviewed for environment. The facility failed to maintain 2 elevators used by residents, staff, and visitors free from offensive odors. This failure could affect all residents that used common areas and place them at risk for diminished quality of life due to the lack of a well-kept environment. During an observation throughout the day beginning on 07/07/25 08:33 AM, this surveyor smelled a strong foul odor on both Elevator 1 and Elevator 2 most of the day. During an observation throughout the day beginning on 07/08/25 08:10 AM this surveyor smelled a strong foul odor on both Elevator 1 and Elevator 2. [...]

Inspectors wroteBased on observations, interview, and record reviews, the facility failed to provide the required 80 square feet per resident in 89 of 89 resident rooms (Room numbers: 200, 201, 202, 203, 204, 205, 206, 207, 208, 209, 210, 211, 216, 217, 218, 219, 220, 221, 222, 223, 224, 225, 226, 227, 228, 229, 230, 300, 301, 302, 303, 304, 305, 306, 307, 308, 309, 310, 311, 312, 313, 314, 315, 316, 317, 318, 319, 320, 321, 322, 323, 324, 325, 326, 327, 328, 329, 330, 331, 401, 402, 403, 404, 405, 406, 407, 408, 409, 410, 411, 412, 413, 414, 415, 416, 417, 418, 419, 420, 421, 422, 423, 425, 426, 427, 428, 429, 430, 431) observed for room size requirement. All 89 rooms did not account for 80 square feet per resident. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents' environment remained as free of accident hazards as is possible; and residents received adequate supervision and assistance devices to prevent accidents for one 1 of 5 residents (Resident #9) reviewed for accident hazards. The facility failed to ensure that on 12/16/24 the PTA supervised and did not leave Resident #9 unattended in her wheelchair which allowed Resident #9 to fall out of the wheelchair onto the floor where she sustained a hematoma (a closed wound where blood collects and causes swelling because it cannot drain out) above and a laceration (cut) next to her left eyebrow. This failure could result in residents not receiving appropriate supervision leading to falls, injuries, or hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the right to be free from abuse for one (Resident #62) of two residents reviewed for abuse. The facility failed to ensure Resident #62 was free from abuse. On 10/24/24, Resident #60 hit Resident #62 in the head with a grabber because Resident #62 would not stop touching it. This failure could place residents at risk for abuse and psychological harm.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources, are reported immediately but not later than 2 hours after the allegation is made 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, to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures for 2 of 3 Residents (Residents #62 and #61) reviewed for Abuse, and Injury of unknown source. 1. The facility did not report an allegation of abuse per facility policy to the Administrator regarding Resident #62 on 02/24/25 until 02/28/25. 2. [...]

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure that the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, for two residents (Resident #3 and Resident #61) of 20 residents whose care plans were reviewed, in that: 1) Resident #3's comprehensive care plan was not revised to reflect Resident #3 had a history of trying to give money to residents and staff. 2) Resident #61's comprehensive care plan was not revised to reflect interventions for Resident #61 who had a history of falls. These failures could place residents at risk for inadequate care, accidents, and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and under proper temperature controls on 2 of 6 treatment/medication carts and 3 of 3 medication storage rooms reviewed for storage of drugs. 1. The 200-floor treatment/medication cart was left unlocked by the nurse's station with the drawers facing outward. 2. 300 floor treatment/medication cart was left unlocked outside room [ROOM NUMBER] with its back against the wall and drawers facing the hallway. 3. The temperature log for the medication storage refrigerator in the 400 floor medication storage room did not have a temperature recorded for 06/15/24 or 06/16/24 and the refrigerator was not clean. 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident receives care, consistent with professional standards of practice, to prevent deterioration of existing pressure ulcers, promote healing, and prevent development of new pressure ulcers, for one (Resident #46) of three residents reviewed for pressure ulcers, in that: -Wound care nurse did not pat dry Resident #46's pressure ulcer after cleaning the wound with wound cleanser as ordered. This failure could place residents with existing pressure ulcers receiving preventive skin care at risk for developing new pressure ulcers and/or a deterioration in existing pressure ulcers.

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. 1. The facility failed to ensure juice dispenser guns were sanitary. 2. The facility failed to ensure equipment was clean and sanitized. 3. The facility failed to ensure dry goods were sealed. 4. The facility failed to ensure spices and a freezer item were not left open to air. 6. The facility failed to ensure personal items were not in the prep area or refrigerator 7. The facility failed to ensure the kitchen was following their policies These failures could place residents at risk of foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have sufficient staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one (Resident #272) of eight residents reviewed for medication administration. The facility failed to ensure that four nurses (LVN A, LVN H, LVN I, and LVN J) admistered medication that was ordered for Resident #272 as documented. This failure could place residents at risk for not receiving their medications, not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 20 residents r(Resident #273), staff, and the public. -A facility staff member left an empty covered needle syringe on top of Resident #273's drawer in his room. This failure could place 20 residents who reside on the 200 floor at risk for injury or illness due to an unsafe environment.

Inspectors wroteBased on observation and record review, the facility failed to provide the required 80 square feet per resident in 46 multiple resident rooms (201, 203, 205, 207, 209, 211, 216, 218, 220, 222, 225, 227, 229, 231, 301, 303, 305, 307, 309, 311, 312, 314, 316, 318, 320, 322, 325, 327, 329, 331, 401, 403, 405, 407, 409, 411, 412, 414, 418, 420, 422, 424, 425, 427,429, and 431) out of a total of 90 resident rooms. Rooms measured between 120 and 132.3 square feet instead of the 80 square feet per resident required. This failure could impede the ability or residents living in these rooms to attain their highest practicable well-being.

Inspectors wroteA complaint and incident investigation (490830, 490679) entrance date was conducted on 03/19/24. The census was 119. Acronyms: MDS-Minimum Data Set BIMS-Brief Interview for Mental Status Tag: F623 S/S= B Surveyor Name(s): [NAME] Immediate Supervisor: [NAME] Based on interviews and record review the facility failed to ensure the notice of transfer or discharge was made by the facility at least 30 days before the resident was transferred or discharged and record the reasons for the transfer or discharge in the resident's medical record and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman, for 1 of 4 residents (Resident #1) reviewed for transfer and discharge. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents 1 (Resident #1) of 5 reviewed for elopement. The facility failed to ensure Resident #1 was supervised for elopement, Resident #1 eloped on 12/09/2023 and was found approximately 1.3 miles from facility. Failed to care plan Resident #1's wandering, pacing, trash digging, schizophrenia behaviors, and drug seeking behaviors. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 12/09/2023 and ended on 12/11/2023. The facility corrected the non-compliance before the investigation began. This failure could place residents at risk of not receiving individualized interventions to promote appropriate supervision that could cause injury/serious injury/ or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments of two medication carts (200, 300, 400 Hall 2nd floor Medication Cart ) reviewed for storage, in that: The facility failed to ensure, halls 200, 300, and 400 medication carts were locked when unattended. This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations.