Windsor Nursing & Retirement Home

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to properly label and date thickened liquids, by not indicating open dates, in one of one nourishment kitchenettes and two of two resident unit refrigerators and failed to ensure one opened thickened liquid was refrigerated after opening in one of one nourishment kitchenettes.

Inspectors wroteBased on interview and record review, the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws. Specifically, the facility failed to ensure a nurse assigned to direct resident care had an active license as a Registered Nurse.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement safe smoking strategies for one Resident (#1), out of two sampled residents who smoked cigarettes. Specifically, the facility failed to ensure the safe smoking strategy of wearing a smoking apron (flame-resistant protective garment designed for individuals, often in wheelchairs, to shield themselves and their clothing from hot ashes) was implemented for Resident #1 while smoking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one Resident (#10), out of a total of sample of 19 residents, was provided with a therapeutic diet based on his/her comprehensive assessment and as ordered by the physician. Specifically, the facility failed to ensure he/she was administered the correct enteral feeding (delivering nutrition directly into the gastrointestinal tract for individuals unable to consume enough food by mouth) formula based on their nutritional needs.

Inspectors wroteBased on interview and personnel record review, the facility failed to ensure the new hire employee records maintained documentation to indicate staff were provided education and offered information on obtaining the 2025-2026 COVID-19 vaccination for two out of five newly hired employees.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN/ CMS-10055) was completed and signed to ensure the Resident/Resident Representative was fully informed of the services being discontinued and a determination was made to continue or discontinue services at a skilled level of care for two Residents (#10, #52), out of three sampled residents who received beneficiary notification, as required by Centers for Medicare & Medicaid Services (CMS).

Inspectors wroteBased on observation and interview, the facility failed to ensure residents in two of three dining rooms had a comfortable and homelike dining experience.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure audiology services were offered to ensure the highest practicable level of care for one Resident (#76), out of a total sample of 19 residents. Specifically, for Resident #76, when their hearing aids went missing, the facility failed to offer/provide alternative treatment, and/or to assist in arranging audiology services to obtain new hearing aids, resulting in a 98-day delay in services.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure all medications used in the facility were stored and labeled in accordance with currently accepted professional standards in two of two medication carts reviewed.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another). In addition, to ensure the use of gloves was limited to a single use task.

Inspectors wroteBased on record review and interview, the facility failed to ensure an accurate medical record for one Resident (#84), out of a total sample of 19 residents. Specifically, the facility failed to ensure the medical record indicated the dietary recommendation for Mirtazapine (antidepressant used for an appetite stimulant) had been reviewed by the provider timely.

Inspectors wroteBased on observation, record review, and interview, the facility failed to initiate the grievance process on behalf of one Resident (#76), out of a total sample of 19 residents. Specifically, for Resident #76, the facility failed to initiate an investigation when his/her hearing aids were determined to be missing, file a grievance for the missing hearing aids, and follow the grievance process, resulting in a 98-day delay in offering and/or providing alternative audiology services.

Inspectors wroteBased on record review, interview, and observation, the facility failed to follow professional standards of practice for one Resident (#197), out of a total sample of 19 residents. Specifically, the facility failed to follow and provide care in accordance with the physician's order for management of the Resident's right upper extremity Peripherally Inserted Central Catheter (PICC-a thin flexible tube inserted into a vein in the upper arm and guided into a large vein above the right side of the heart called the superior vena cava) which included dressing changes, measurement of the external length of the catheter and upper arm, and monitoring of the insertion site for signs/symptoms of infection.

Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure post-fall interventions were developed and implemented to mitigate the risk of future falls resulting in two falls in three months, one of which resulted in a head strike causing bruising for one Resident (#78), out of a total sample of 19 residents.

Inspectors wroteBased on record review, policy review, observation, and interview, the facility failed for one Resident (#88), out of a total sample of 19 residents, to provide care and implement pressure prevention interventions resulting in the development of facility acquired pressure ulcers (injuries to the skin and underlying tissue resulting from prolonged pressure exerted over areas of the body) on both the left and right buttocks and right heel of Resident #88.

Inspectors wroteBased on interviews, policy review, and review of Resident Council Minutes, the facility failed to ensure that grievances brought forward through Resident Council from 4/27/23 through 9/26/23 were addressed and promptly resolved as required.

Inspectors wroteBased on policy review, review of Resident Council Minutes, grievance review, and resident and staff interviews, the facility failed to ensure that staff: 1. Addressed and promptly resolved several grievances brought forward during Resident Council Meetings held on 4/27/23 through 9/26/23; and 2. For Resident #88, the facility failed to ensure the grievance process was implemented and concerns resolved in a timely manner.

Inspectors wroteBased on record review, observations, policy review, and interviews, the facility failed to assist one Resident (#43) and their family, out of a total sample of 19 residents, in sourcing a replacement hearing device after the loss of the Resident's hearing aids.

Inspectors wroteBased on record review and interview, the facility failed to ensure that individualized, resident-centered, comprehensive care plans were developed and consistently implemented for one Resident (#32), out of a total sample of 23 residents. Specifically, the facility failed to ensure a care plan was developed for the use of psychotropic medications that included individualized, resident-centered, targeted signs/symptoms or behaviors.

Inspectors wroteBased on observation, interview, and policy review, the facility failed for two Residents (#82 and #302) to ensure respiratory equipment and tubing was managed and stored in a sanitary way to prevent the potential of contamination from environmental debris and germs.

Inspectors wroteBased on policy review, interview, and record review, the facility failed to ensure for one Resident (#17), of one resident receiving hemodialysis, that treatment, care and services were consistent with professional standards of practice. Specifically, the facility failed to ensure the medical record reflected ongoing communication and collaboration with the Dialysis Center regarding the exchange of pertinent information before and after dialysis treatment.

Inspectors wroteBased on record review, hospice contract review, and staff interview, the facility failed to ensure for one Resident (#44), out of a total sample of 19 residents, that hospice services were provided in accordance with the agreement between the hospice and the facility. Specifically, the facility failed to ensure a current signed recertification statement for hospice eligibility and ongoing documentation of hospice staff visits were available in the medical record to ensure prompt and effective communication and continuity of care for the Resident.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure written notice for transfer and discharge was provided to Residents and/or Resident Representatives prior to hospital transfers for one Resident (#17), out of a total sample of 19 residents, and one Resident (#100), out of a total of three closed records.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to provide written notification of the bed hold policy to the Resident or Resident Representative prior to discharge to the hospital for two Residents (#91 and #17), in a total sample of 19 residents and one Resident (#100), out of a total of three closed records.