Windsor Rehabilitation & Health Care Center

Inspectors wroteBased on interview and record review, facility staff failed to ensure three residents (Resident #6, #21, and #90) had access to their trust fund account which included evenings and weekends. The facility census was 37. 1. Review of the policies provided showed staff did not provide a policy for the availability of funds. Review of the facility's admission Packet, undated, showed in the personal property of resident section, upon execution of this agreement the facility shall provide the resident or his/her authorized representative with a copy of a policy discussing the resident's rights regarding his or her own personal funds, which may be kept on deposit in the facility's resident trust account. Review of the facility's policy titled, Resident Rights, showed the resident rights include but are not limited to if resident wishes, have community manage personal funds. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide a clean, comfortable and homelike environment when staff failed to maintain resident rooms and common areas in good repair. The facility census was 37. 1. Review of the policies provided showed staff did not provide a policy for environmental concerns. 2. Observation on 06/23/25 at 10:55 A.M., showed resident occupied room [ROOM NUMBER], bed two, with a white stain to the top of the nightstand and the fall mat next to the bed with build up of brown debris. 3. Observation on 06/23/25 at 11:05 A.M., showed resident occupied room [ROOM NUMBER] floor sticky. Observation on 06/23/25 at 2:00 P.M., showed the resident room floor sticky. 4. Observation on 06/23/25 at 1:45 P.M., showed resident occupied room [ROOM NUMBER] with linens and trash on the floor, a strong odor and multiple flies. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan to meet the medical, nursing, mental and psychosocial needs for four residents (Resident #9, #18, #21 and #27) out of sixteen sampled residents. The facility census was 37. 1. Review of the facility's policy titled Care Planning, dated December 2014, showed every resident will be assessed using the Minimum Data Set (MDS), a federally mandated assessment tool, according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual. Staff are directed to use this assessment data to develop a comprehensive plan of care for each resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning and well being as possible. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to serve food items to residents in accordance with the nutritionally calculated recipes. The facility census was 37. 1. Review of the facility's policy titled Pureed Food Preparation, dated 2016, showed pureed food will be prepared using standardized recipes to ensure maximum nutritive value. Serve with appropriate scoop number or divide equally to provide an equal number of portions. All of the pureed food must be used in order to deliver the correct nutrient density to each resident. The number of pureed servings obtained from the pureed recipe must equal the number of servings from which started. Review of the facility's Pureed Breaded Pork Chop recipe, dated 2025, showed: -Remove portions needed from regular prepared recipe and place in a sanitized food processor; -Add broth; blend until smooth; [...]

Inspectors wroteBased on interview and record review, facility staff failed to document the administration or refusal of the pneumococcal (lung inflammation caused by bacteria or viral infection) vaccine for four residents (Resident #1, #6, #7, and #10) out of five sampled residents. The facility census was 37. 1. Review of the facility's Infection Control and Prevention program, dated 2019, showed the program defines and manages appropriate resident health initiatives such as the immunization program (influenza, pneumococcal, etc.). The program is under the direction of the Quality Assessment and Assurance (QAA) committee. The committee functions to review pneumococcal vaccine compliance. Review of the Centers for Disease Control (CDC), Adult Immunization Schedule by Age | Vaccines & Immunizations | CDC, dated 05/29/25, showed vaccines are recommended for those age [AGE] years or older who have: [...]

Inspectors wroteBased on interview and record review, facility staff failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment tool, for three residents (Resident #6, #21, and #32) of six sampled. The facility census was 37. 1. Review of the policies provided by facility staff showed staff did not provide a policy for the completion of MDS assessments. Review of the Resident Assessment Instrument (RAI) manual, used to facilitate accurate and effective resident assessment practices, version 1.19.1, dated October 2024, showed the manual instructed staff to not code antiplatelet medications such as clopidogrel (antiplatelet) or aspirin as an anticoagulant. 2. Review of Resident #6's Significant Change in Status (SCSA) MDS, dated [DATE], showed staff documented the resident received an anticoagulant medication in the look-back period. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to post the required nurse staffing information with all the required components when the staff failed to document and update the actual hours worked. The facility census was 37. 1. Review of the facility's policy titled Posting Direct Care Daily Staffing, dated December 2024, showed facility staff will post the staffing on a daily basis at the beginning of each shift. The actual hours worked per position, and the total number of hours worked will be posted. Review of the facility's Staff hour posting, dated 06/01/25 through 06/23/25, showed the nurse staff posting did not contain documentation of actual hours worked for the entire 24-hour period for 06/01/25, 06/03/25 through 06/09/25, 06/16/25 through 06/18/25, and 06/20/25 through 06/22/25. [...]

Inspectors wroteBased on interview and record review, facility staff failed to send a copy of the notice of transfer and/or discharge for four (Resident #6, #27, #32 and #35) of four sampled residents to the representative of the Office of the State Long-Term Care (LTC) Ombudsman from January 2025 to May 2025. The facility census was 37. 1. Review of the facility's admission and Discharge report, dated 01/01/25 through 05/31/25, showed 25 residents transferred or discharged from the facility. 2. Review of Resident #6's medical record showed staff documented the resident discharged on 04/07/25. The record did not contain documentation the Ombudsman was notified. 3. Review of Resident #27's medical record showed staff documented the resident discharged on 03/07/25 and 04/15/25. The record did not contain documentation the Ombudsman was notified. 4. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure the activities program was directed by a qualified professional. The census was 37. 1. Review of the facility's Activity Director (AD) Job Description, undated, showed the employee must have successfully completed all educational requirements for licensure and certification as required by federal and state regulations. During an interview on 06/25/25 09:02 A.M., the administrator said he/she thought the activity director had a certification but he/she did not. During an interview on 06/25/25 at 11:40 A.M., the AD said he/she did not have certification and had been in the role since November of last year. He/She did not know he/she should be certified until recently.

Inspectors wroteBased on observation, interview, and records review, the facility failed to implement an effective pest control program to control flies within the facility. The facility census was 34. Review showed the facility did not provide a policy regarding pest control. 1. Review of the pest control company's summary of service, dated 04/24/24, showed the following facility recommendations: -Insect Light 001- Insect light trap is not working properly. Please schedule service to ensure effective flying insect control; -Insect Light 4- Insect light trap is not working properly. Please schedule service to ensure effective flying insect control; -Insect Light 003- Insect light trap is not working properly. Please schedule service to ensure effective flying insect control; -Needs new bulb. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a system in placed to ensure nurse aides (NA) completed their training, competencies, and testing in a timely manner when four NAs (NA D, NA F, NA G, and NA H) failed to complete a state approved certified nursing assistant (CNA) training program, competency evaluation, and certification test timely and continued to work providing direct care to residents. The facility's census was 34. Review showed the facility did not provide a policy related to training and certification of NAs/CNAs. 1. Review of NA D's personnel file showed the NA hired to work at the facility on 12/28/23 in the nursing department as a NA. During an interview on 07/25/24, at 11:15 A.M., NA D said he/she worked full-time at the facility for approximately six to seven months continuously as a NA. [...]

Inspectors wroteBased on interview and record review, the facility failed thoroughly investigate all allegations of possible misappropriation and failed to take steps protect all residents during an investigation process when staff failed to document a thorough investigation of an allegation of possible misappropriation of resident's (Resident #2) property and when the alleged involved staff members (Nurse Assistant (NA) D, NA F, and NA G) continued to work independently with all residents. The facility census was 34. Review of the facility policy titled, Abuse Policy, undated, showed the following: -It is the policy of this facility that each resident will be free from abuse. Abuse can include verbal, mental, sexual, physical abuse, misappropriation of resident property and exploitation, and corporal punishment or involuntary seclusion; [...]

Inspectors wroteBased on interview and record review, the facility to provide care for all residents consistent with standards of practice when staff failed to implement physician ordered changes for one resident's (Resident #1's) treatment order for affected areas on his/her bilateral (both sides) lower extremities. The facility census was 34. Review of the facility policy titled, Physician Orders, dated March 2015, showed the following: -Current lists of orders must be maintained in the clinical record of each resident to avoid confusion and errors; -Treatment orders should specify what is to be done, location and frequency, and duration of the treatment. Review of the facility policy titled, Wound Care and Treatment, dated July 2015, showed the physician will specifically order the treatment to be provided (including cleansing, ointments, gauze, dressing type, and frequency of treatments). 1. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least eight consecutive hours a day for three of the 14 days reviewed for November and December 2023 (12/02/23, 12/03/23, and 12/09/23). The facility census was 32. 1. Review of the daily staffing for the period of 11/27/23 thru 12/09/23 showed a RN was not scheduled in the facility on 12/02/23, 12/03/23, and 12/09/23. During an interview on 12/14/23, at 9:21 A.M., the Administrator said the staffing coordinator was not present and he/she would be the person to talk to about staffing. The administrator was aware the facility had days when there was no RN coverage during a 24-hour period. Those days were most likely on weekends since the Director of Nursing (DON) was the only RN the facility had. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that it stored, prepared, and distributed food in accordance with professional standards for food safety when staff failed to perform hand hygiene prior to handling clean dishes, failed to follow manufacture directions for storage/dispose of supplements, and failed to keep the ice machine clean. The deficiency had the potential to affect 35 residents. 1. Review of the facility's untitled policy provided by the dietary manager from the computer, dated April 2011, showed after the first tray of dishes is washed, pull the rack out of machine to air dry. Sanitize hands between handling of soiled and clean dishes. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide the Advance Beneficiary Notice (ABN) and Notice for Medicare Non Coverage (NOMNC) to three residents (Residents #10, #141 and #142) of three sampled residents who received Medicare part A services. The facility census was 32. 1. Review of Resident #10's Electronic Medical Record (EMR), under the census tab, showed the following: -admission date of 07/20/18 on Medicare Part A services; -On 06/26/23, the resident was discharged from Medicare Part A services by the facility. The resident remained in the facility. Review of the resident's record showed the facility failed to provide the resident and/or their representative with ABN and NOMNC notices. 2. Review of Resident #141's EMR, under the census tab, showed the following: -admission date of 07/21/23 on Medicare Part A services; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to perform hand hygiene during one resident (Resident #20), of one resident observed, during a dressing change, and staff failed to perform hand hygiene and disinfect the glucometer when completing blood glucose monitoring for two residents (Resident #2 and #12). The facility census was 32. 1. Review of the facility policy titled, Handwashing, undated, did not address when hand hygiene is to be performed. Review of the facility policy titled, Standard and Transmission Based Precautions, undated, showed staff to wash hands after removing gloves. Review of Resident #20's Electronic Medical Record (EMR), under the census tab, showed the following: -admission date of 11/12/21; -Diagnoses included diabetes, non-pressure ulcer on the left leg, and a skin disorder. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that one resident (Resident #34) of 13 sampled residents maintained acceptable parameters of nutritional status when staff failed to identify and address the resident's weight loss for four months. The facility census was 32. Review of the facility policy titled, Weight Monitoring, original date of May 2015, showed the following: -Monthly weights will be obtained by the 7th of each month; -Weights will be monitored at least monthly; -Weight reports will be provided to the Director of Nursing (DON) within two days of weight; -Weekly weights will be completed for those with significant weight change. 1. Review of Resident #34's Profile tab in the electronic medical record (EMR) showed the following: -admission date of 02/20/23; [...]

Inspectors wroteBased on interview and record review, the facility failed to document treatments of ordered wound care in accordance with professional standards for one resident (Resident #1) out of a sample of eight. The facility census was 40. Review of the facility's policy, titled Wound Care and Treatment, undated, showed the following: -It is the purpose of the facility to prevent and treat all wounds; -Documentation of the treatment should be done immediately after the treatment. (The policy did not address documention of resident refusals of treatment.) 1. Review of Resident #1's face sheet showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff treated five residents (Resident #4, #7, #10, #11, and #17) with dignity and respect when staff members spoke to or about the residents in a manner that could be considered demeaning or embarrassing to the residents. The facility census was 39. Record review of the facility's policy entitled, Resident Rights (Revised 4/21/16), showed the following information: -It is the intent of the facility to promote and ensure that highest standards of conduct and reliability by its employees and consultants to in turn produce environments in the facility that promote the highest standards of care and security for our residents and the families we serve. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders prior to use of side rails for five residents (Resident #19, #26, #33, #37, and #38). The facility failed to complete a safety assessment regarding use side rails, failed to obtain informed consent for the use of side rails for six residents, and failed to care plan the use of side rails for six residents (Resident #6, #19, #26, #33, #37, and #38). The facility census was 39. Record review of the facility's policy, titled Physical Restraints, dated March 2015, showed the following information: -Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body; -Equipment: Side rails (bed rails). [...]

Inspectors wroteBased on record review and interview, the facility failed to consistently document completion of wound care and failed to complete full and accurate wound assessments (including measurements and a full description of the wound) for one resident's (Resident #26) surgical incision. The facility census was 39. Record review of the facility's policy, titled Wound Care and Treatment, dated July 2015, showed the following information: -The purpose of the facility is to prevent and heal all wounds; -There must be a specific order for the treatment (including cleansing, ointments, gauze, dressing type and frequency of the treatment); -Complete documentation; -Documentation should be done immediately after the treatment; -Prevention strategies included ongoing skin assessment with weekly documentation of status; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were free of significant medication errors when staff failed to prime an insulin pen for one resident (Resident #27) during random medication pass observation. The facility had a census of 39. According to the manufacturer's guidelines, a Novolog insulin (insulin Aspart; rapid acting insulin) pre-filled pen should be primed with each use by expelling two units of insulin prior to the administration of the ordered units for the dose. Record review of a facility's policy and procedure, entitled Injection -Subcutaneous (SQ) (Nursing Guidelines Manual, March, 2015), showed the following information: -Expel air from the syringe. (The policy did not specifically address use of insulin pre-filled pens.) 1. [...]