Windsor Park Rehab & Nursing Center

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification Survey from 09/26/2024 to 10/03/2024, the facility did not ensure the residents' right to a safe, clean, comfortable, and homelike environment was maintained. This was evident in 1 (West Side) of 2 units observed. Specifically, 1.) A resident's wheelchair has been observed with torn cushion on the left arm rest, 2.) The Hoyer lift was rusty with dark yellow and blackish stains on the metal frame, 3.) The wooden door frame on the whirlpool room had chipped paint, and 4.) The elevator was observed with layers of mismatched black colored paint.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 09/26/2024 to 10/03/2024, the facility did not ensure infection control practices and procedures were maintained. This was evident in 3 (Resident #159,#35, and #22) of 18 total sampled residents. Specifically, Licensed Practical Nurse #1 was observed using the same blood pressure cuff for Residents #159 and #22 without cleaning and disinfecting the blood pressure cuff in between each resident use. Licensed Practical Nurse #1 also failed to clean and disinfect the blood pressure machine after each usage.

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification Survey from 09/26/2024 to 10/03/2024, the facility did not ensure that the nurse staffing information was posted in a prominent place readily accessible to residents and visitors. Specifically, there was no available posting of daily nurse staffing information.

Inspectors wroteBased on record reviews and interviews conducted during an Abbreviated Survey (NY00342374), the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. This was evident for 13 out of 13 Justice Involved Residents. Specifically, 13 Justice Involved Residents were not allowed to exercise their rights while residing in the facility. Based on interviews with facility staff, residents and representatives of the Federal Bureau of Prison Services while residing in the facility, the residents remain in the custody and under the authority of the Bureau of Prisons. [...]

Inspectors wroteBased on observation, record reviews, and interviews, conducted during an abbreviated survey (NY00342374), the facility failed to ensure that thirteen Justice Involved Residents (Residents 1-13) had the right to, and that the facility promoted and facilitated the residents self-determination through support of residents choices. The facility did not ensure that Justice Involved Residents had the right to make choices about aspects of their life that were significant to them. This was evident in 13 of 13 Justice Involved Residents sampled for self-determination. Specifically, observations made on 06/06/2024, 06/26/2024 and 06/27/2024, during various times throughout the day revealed 13 Justice Involved Residents wearing two-foot-long shackles around their ankles which limited their movement throughout the facility. [...]

Inspectors wroteBased on record reviews and interviews conducted during an Abbreviated Survey (NY00342374), the facility failed to ensure residents were afforded the right to formulate advance directives while residing in the skilled nursing facility. This was evident for 13 out of 13 Justice Involved Residents (Resident #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13) sampled. Specifically, a review of the medical record revealed that 13 Justice Involved Residents were designated as Full Code. The medical record did not document that the residents were provided written information that included their right to formulate advance directives in accordance with their wishes. During interviews with the Director of Social Work it was revealed the Justice Involved Residents were assigned full code status by the Federal Bureau of Prisons. [...]

Inspectors wroteBased on record reviews and interviews conducted during an Abbreviated Survey (NY00342374), the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality. This was evident for 13 out of 13 Justice Involved Residents. Specifically, 13 Justice Involved Residents were not allowed to exercise their rights while residing in the facility. Based on interviews with facility staff, residents and representatives of the Federal Bureau of Prison Services while residing in the facility, the residents remain in the custody and under the authority of the Bureau of Prisons. [...]

Inspectors wroteBased on observation, record review, and staff interviews conducted during an Abbreviated Survey (NY00342374), the facility failed to ensure the residents were free from physical or chemical restraints imposed for purposes of discipline or convenience and are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. This was evident for 13 out of 13 (Residents 1-13) sampled residents. Specifically, observations made at various times throughout the days on 06/06/2024, 06/26/2024, and 06/27/2024-06/28/2024 revealed that 11 Justice Involved Residents were wearing two-foot-long shackles around their ankles. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during an Abbreviated Survey (Complaint Intake #NY00342374), the facility failed to ensure that resident assessment accurately reflected the residents' status. This was evident for 13 of 13 Justice Involved Residents who were sampled (Residents 1-13). Specifically, observations made on 06/06/2024, 06/26/2024, 06/27/2024, and 06/28/2024 during various times through the day revealed 12 Justice Involved Residents wearing two-foot-long restraints around their ankles, one resident left wrist cuffed to their bed rail. Review of Section P of the residents' Minimum Data Set (MDS, an assessment tool) did not identify that Justice Involved Residents (1-13) had restraints in use. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during an Abbreviated Survey (Complaint Intake #NY00342374), the facility failed to ensure that resident assessment accurately reflected the residents' status. This was evident for 13 of 13 Justice Involved Residents who were sampled (Residents 1-13). Specifically, observations made on 06/06/2024, 06/26/2024, 06/27/2024, and 06/28/2024 during various times through the day revealed 12 Justice Involved Residents wearing two-foot-long restraints around their ankles, 1 resident left wrist cuffed to their bed rail. Review of Section P of the residents' Minimum Data Set (MDS, an assessment tool) did not identify that Justice Involved Residents (1-13) had restraints in use. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during an Abbreviated Survey (NY00342374), the Medical Director failed to ensure resident care policies were implemented and the rights of individual were respected. This was evident for 13 Justice Involved Residents sampled (Justice Involved Residents #1-13). Specifically, on 06/06/2024, 06/26/2024, 06/27/2024, and 06/28/2024 during observations made various times throughout the day 11 Justice Involved Residents were observed wearing shackles around their ankles and 1 Justice Involved Residents were observed with their left wrist cuffed to the bed. During observations on 06/06/2024, 06/26/2024, 06/27/2024, and 06/28/2024 confirmed all Justice Involved Residents eating in their room. [...]

Inspectors wroteBased on observation, interviews, and record review conducted during an abbreviated survey (NY00324912), the facility failed to protect resident's rights to be free from physical abuse. The facility did not ensure that each resident was free from physical abuse. This was evident for 1 out of 6 residents (Resident #4) sampled for Abuse. Specifically, the facility surveillance camera, dated 09/26/23, showed Resident #4 hit Certified Nursing Assistant (CNA) #4 as CNA #4 was escorting Resident #4 from the dining room to Resident #4's room. CNA #4 then pulled Resident #4's hair.

Inspectors wroteBased on observation, interviews, and record review conducted during an abbreviated survey (NY00324912), the facility failed to ensure that a reasonable suspicion of a crime against a resident or an individual receiving care from the facility was reported to the local law enforcement. This was evident for 1 out of 6 residents (Resident #4) sampled. Specifically, the facility surveillance camera dated 09/26/2023 showed Resident #4 hit Certified Nursing Assistant (CNA) #4 as CNA #4 was escorting Resident #4 from the dining room to Resident #4's room. CNA #4 then pulled on Resident #4's hair. The facility did not report the alleged allegation of abuse within 2 hours on 09/25/23 to local law enforcement. The facility reported the abuse to local law enforcement on 10/04/23 while the Department of Health (DOH) surveyors were onsite investigating the allegation of abuse.

Inspectors wroteBased on observation, interviews, and record review conducted during an abbreviated survey (NY00321418), the facility did not ensure that a resident drug regimen was free from unnecessary medication. This was evident for one out of six residents (Resident #1) reviewed for antipsychotic medication. Specifically, Resident #1, who was not initially receiving an antipsychotic medication, was administered Haloperidol (an antipsychotic medication use used to treat certain mental/mood disorder such as schizophrenia, schizoaffective disorder) 2miligrams (mg) as a onetime dose on 08/02/23 for diagnosis of Anxiety. There was no documented evidence that non-pharmacological interventions were attempted prior to the administration of the anti-psychotic medication.