Windsor Rehabilitation and Healthcare

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs, for 4 of 6 (Resident 's#12, #64, #7 and #38) residents reviewed for care plans.1. The facility did not ensure that Residents #12, #64, and #7's care plan included significant weight loss. 2. The facility failed to follow Resident #38's care plan for health shakes. These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that the resident environment remains as free of accident hazards as possible for 3 of 6 residents (Resident #8, #38, and #58) reviewed for accidents. 1. The facility failed to ensure Resident #8 wander guard was functioning properly on 02/26/26. 2. The facility failed to ensure Resident #38 had a fall mat when he fell out of bed on 02/19/26. 3. The facility failed to ensure Resident #58's fall mat was beside her bed on 02/23/26 and 02/24/26. These failures could place residents at risk of elopement, injury, or harm.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this was not possible or resident preferences indicate otherwise for 5 of 8 residents (Resident's #7, #12, #56, #64 and #72) reviewed for nutrition. 1. The facility did not ensure Resident #7, #12, #56, #64, and#72, received their health shake on 02/23/26. 2. The facility did not ensure 4 oz of glazed ham was given to residents who received a regular diet on 02/23/26. 3. The facility did not ensure the #12 scoop was used for the mechanical soft glazed ham on 02/23/26. 4. The facility did not ensure 2 #8 scoops were used for the pureed glazed ham on 02/23/26. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the meals served met the nutritional needs of residents for 1 of 1 meal (the lunch meal) and 1 of 1 resident (Resident #40) reviewed for nutritional adequacy. 1. The facility did not ensure 4 oz of glazed ham was given to residents who received a regular diet on 02/23/26. 2. The facility did not ensure the #12 scoop was used for the mechanical soft glazed ham on 02/23/26. 3. The facility did not ensure two #8 scoops were used for the pureed glazed ham on 02/23/26. These failures could put residents at risk of a decrease in resident choices, diminished interest in meals, and weight loss.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received and the facility provided food that was palatable, attractive, and at a safe and appetizing temperature for 8 of 8 confidential residents, and 1 of 1 meal reviewed for palatability, attractiveness, and appetizing. The dietary staff failed to provide food that was palatable and at an appetizing temperature for 8 confidential residents. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss. Record review of a Resident Council Meeting Form, dated 2/19/2026, indicated the group council voiced their food being cold. The form failed to address how the grievances would be managed. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 3 of 6 residents (Resident's #85, #7 and #56) reviewed for food and drinks. 1. The facility failed to ensure Resident #85 was not given cornbread on 02/23/26, as ordered by the physician. 2. The facility failed to ensure Resident #7 and Resident #56, received their health shake on 02/23/26. These failures could place residents at risk for choking, weight loss, and unmet nutritional needs. Findings Include: 1. Record review of Resident #85's face sheet, dated 02/27/26, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. [...]

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 in the facility's only kitchen reviewed for food safety requirements. The facility failed to ensure the sanitation bucket was checked for chlorine level and logged according to manufacture guidelines. The facility failed to ensure the three-compartment sink was checked for chlorine level and logged according to manufacture guidelines. The facility failed to ensure the high heat dishwasher was logged daily to ensure it was functioning according to facility policy. The facility failed to ensure employees in the kitchen wore hair nets according to facility policy. The facility failed to ensure employees in the kitchen wore beard guards according to facility policy. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 6 residents (Residents #40, # 100, #56, and #31) reviewed for infection control. 1. The facility did not ensure EBP was put in place for Resident #40. 2. The facility did not ensure CNA B cleaned Resident #100 peri-anal area before placing a clean brief underneath her. 3. The facility failed to ensure CNA M thoroughly cleaned the peri area, changed gloves, and used hand hygiene before going from dirty to clean while providing incontinent care to Resident #56. 4. The facility failed to ensure CNA R did not wear dirty PPE into resident #31's room on 02/24/26. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, clean, and comfortable environment for residents, staff and the public for 3 of 3 residents (Residents #17, 61, and 52) reviewed for environment . The facility failed to ensure adequate lighting along the exterior pathway leading to the designated smoking area. This failure place residents at risk of falls.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the residents have the right to be informed of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers, for 1 of 24 residents (Resident #40) reviewed for consent for antipsychotic medications. The facility did not ensure Resident #40 was prescribed and administered Paxil (antidepressant) without prior consent. This failure could place residents at risk for receiving unnecessary psychotropic medications without informed consent.

Inspectors wroteBased on interview and record review the facility failed to ensure assessments accurately reflected the resident status for 2 of 6 residents (Resident # 38 and Resident # 9) reviewed for MDS assessment accuracy. 1. The facility failed to code Resident #38's hospice accurately. 2. The facility failed to code Resident #9's hospice accurately This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish based on the comprehensive assessment and consistent with the resident's needs and choices for 1 of 2 resident (Resident #100) reviewed for activities of daily living. The facility failed to provide communication assistance to effectively communicate with staff for Resident #100. This failure could place residents at risk for decline and diminishing quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 of 24 (Residents #43) residents reviewed for ADL care. The facility did not ensure Resident #43's fingernails were trimmed and free from a black colored substance routinely. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 2 (Resident #3) residents reviewed for quality of care. The facility failed to ensure LVN T did Resident #3's left inferior lower lateral buttock and left proximal posterior thigh wound treatment as ordered on 02/23/26 and 02/24/26. This failure could result in residents with wounds not having their treatments performed as ordered, wounds becoming infected, and decreased wound healing. Findings Included: [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 24 residents (Residents #100 and #56) reviewed for incontinent care. 1. The facility did not ensure CNA B cleaned Resident #100 peri-anal area before placing a clean brief underneath her. 2. The facility failed to ensure CNA M thoroughly cleaned the peri area, changed gloves, and used hand hygiene before going from dirty to clean while providing incontinent care to Resident #56. These failures could place residents at risk for skin breakdown, urinary tract infections and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 2 (Resident #6) residents reviewed for enteral nutrition. The facility failed to follow physician orders for Resident #6's enteral feeding tube to be administered at 74 ml/hr. This failure could place residents at risk for nutritional deficit.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 5 residents (Residents #85) reviewed for respiratory care. 1. The facility failed to ensure Resident #85's oxygen was set at 2 liters per nasal cannula as ordered on 02/25/26. 2. The facility failed to ensure the suction equipment was maintained in working order on 1 of 1 crash carts. These failures could place residents at risk of developing respiratory complications, managing airway emergencies and a decreased quality of care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 1 crash carts (central nurse's station) reviewed for drugs and biologicals. The facility failed to ensure expired medical supplies were not available for resident use on the crash cart. This failure could place residents at risk of reduced germ-killing efficacy, skin irritation, contamination risks, and non-sterile cleaning.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure mediations were secured in a locked medication carts to prevent unauthorized access in 2 of 7 medication carts (300 Hall nurse medication cart and 400 Hall nurse medication cart) reviewed for medication storage. The facility failed to ensure the medication carts were locked and not available for unauthorized access. This failure could place residents at risk for unauthorized access to medications, medical errors, harm to cognitively impaired residents, medication tampering, controlled substance diversion, and regulatory non-compliance.

Inspectors wroteBased on interview and record review the facility failed to collaborate with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services, and communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family for 1 of 1 resident (Resident #9) reviewed for hospice services. The facility did not ensure Resident #9's hospice records were a part of their records in the facility. This deficient practice could place residents at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

Inspectors wroteBased on interview and record review the facility failed to establish an infection prevention and control program (IPCP that included, at a minimum, an antibiotic stewardship by ensuring the propriate that included antibiotic use protocols and a system to monitor antibiotic use for 1 of 5 residents (Resident #50) reviewed for antibiotic stewardship program. The facility failed to ensure Resident #50 obtained appropriate lab work and diagnoses to support the use of prescribed antibiotics. This failure could place residents at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident's drug regimen be free from unnecessary drugs without adequate indications for its use for 1 of 18 (Resident #2) reviewed for unnecessary medications. -The facility failed to have a medical diagnosis for Resident #2 before he was prescribed Lantus Subcutaneous Solution 100 Unit/ML from 05/28/2024 to 06/04/2024. This failure could lead to residents being prescribed medications without indication and place residents at risk of unnecessary side effects and a decline in overall health.

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 food procurement in that: -Food items were found in the kitchen's cooler with expired and beyond the use by date. -Food items in the walk-in cooler and freezer were not sealed. -Cleaned baking sheets, pans, utensils, and divided platesd had food particles on them. -Menu item on the steam table was not at the correct holding temperature. -The facility failed to ensure that the floor of the dry storage room was free of paper and other debris. These failures could affect residents who ate food from the facility kitchen and place them at risk of food borne illness and disease.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or quality of life, recognizing each resident's individuality for 2 of 6 residents (Resident #49 and #18) observed for resident rights. - LVN B failed to provide Resident # 18 and Resident #49 with full privacy while performing blood glucose check with insulin administration on 11/20/2024. This failure could place residents at risk of not being treated with dignity and respect.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of a resident's admission, including initial goals based on admission orders, physician orders, dietary orders, and social services for 1 of 18 (Resident #5) reviewed for baseline care plans. -Resident #5 did not have a baseline care plan completed within 48 hours when they admitted on [DATE]. This failure could lead to residents not receiving individualized services and care upon admission.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop comprehensive care plan within seven days after completion of the comprehensive assessment, for one (Resident #52) of 18 residents reviewed for comprehensive care plans as evident by: The facility failed to ensure that Resident #52's care plan was updated to address her blood pressure medications. This failure could place residents on high blood pressure medication at risk for not getting the therapeutic value of their mediations. Findings Included: Record review of Resident #52's face sheet dated 11/20/2024 revealed she was a 67- year-old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 18 residents (Resident #16) reviewed for pharmacy services. ADON A failed to follow physician's orders when Resident #16's blood pressure was above the prescribed parameters for November 2024. This failure could lead to residents being prescribed medications without indication and placed residents who required blood pressure monitoring at risk of not receiving the care and services ordered by the physician which could lead to a decrease in their overall health.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, dispensing, and administering of all drugs and biologicals) to meet the needs of 2 of 6 residents (Resident #75 and Resident #2) reviewed for pharmacy services with 3 errors out of 30 opportunities from 2 of 2 staff (MA C and MA E) and a medication error rate of 10%. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility must ensure residents were free of any significant medication errors for two (Residents #44, and #52) of eighteen residents reviewed for medications. - The facility failed to follow physician's orders by administering blood pressure medications when Resident #44 and Resident #52's blood pressure were out of the prescribed parameter that it should be held. These failures could place residents at risk of not getting the therapeutic outcomes of their blood pressure medications, that could caused, increased negative side effects, and decline in health status. Findings Included Resident #44 Record review of Resident #44's face sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interviews and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 18 residents (Resident #64) reviewed for medication administration. -The facility failed to ensure that Resident #64's MAR was accurate and complete with no blanks for Levothyroxine (for thyroid dysfunction). This failure could place all resident at risk of not getting medications as ordered by their physicians that could lead to residents not getting the therapeutic effect of their medications. Findings Included: Record review of Resident #64's face sheet dated 11/20/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #10) of 1 resident observed for wound care. RN A failed to properly wash or sanitize his hands after changing his gloves when providing wound care to Resident #10. This deficient practice placed 18 residents who received wound care at risk for cross contamination and/or spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 residents (Residents #326) reviewed for medications. The facility failed to administer medications as prescribed for Resident #326. This failure could place residents at risk of not receiving the therapeutic effects of their medications including a diminished health status.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 3 of 4 residents (Residents #21, #25, and #42) reviewed for hospice services. The facility did not ensure Residents #21, #25, and #42's hospice records were a part of their records in the facility. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

Inspectors wroteBased on interview and record review, the facility failed to provide all necessary information and any other documentation to ensure a safe and effective discharge for 1 of 3 residents reviewed for discharge. (Resident #74) The facility failed to complete a discharge summary which indicated Resident #74 had transferred to the behavioral facility. This deficient practice could affect the safety of residents discharged from the facility due to improper discharge. Findings Include: Record review of Resident #74's face sheet, dated 09/27/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #74 had diagnoses which included metabolic encephalopathy (chemical imbalance in the blood), schizoaffective disorder (mood disorder) and unspecified dementia (memory impairment). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an accurate MDS was completed for 1 of 18 residents reviewed for MDS assessment accuracy. (Resident #55) The facility failed to accurately reflect Resident #55's restraint status on the MDS assessment. This failure could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 6 (Resident #326) residents reviewed for care plans. The facility failed to ensure staff followed Resident #326's care plan by not administrating her prescribed medication as ordered. This failure could place residents at risk of not receiving necessary medication and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for 1 of 2 (Resident #57) residents reviewed for intravenous fluids. The facility failed to ensure Resident #57 received PICC (a soft, flexible catheter inserted into a central vein used for prolonged antibiotic therapy) line dressing changes as ordered. This failure could affect residents by placing them at risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for residents' needs for 1 of 2 licensed staff (LVN D) reviewed. The facility failed to ensure LVN D, was competent in providing care for the peripherally inserted central catheter (PICC - a soft, flexible catheter inserted into a central vein used for prolonged antibiotic therapy) for Resident #57. This failure could potentially affect residents by placing them at an increased and unnecessary risk of exposure to staff who lack the appropriate skills and competencies to provide safe care and minimize infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent infections for 1 of 2 residents reviewed (Resident #51) for infection control practices. The facility failed to ensure CNA F and CNA G changed their gloves or performed hand hygiene appropriately while providing incontinent care for Resident #51. This failure could place any resident at the facility at risk for infection due to improper care practices.