Windsor the Ridge Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to explain the risks and benefits of psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) during the consent process to the responsible party for one of 5 sampled residents (Resident 108). This failure resulted in Resident 108's responsible party not fully informed about the psychotropic medications, including their nature, degree, duration, probability of side effects, significant risks, and potential interactions with other drugs the resident is receiving. Cross reference to F0757.

Inspectors wroteBased on observation, interviews and record review, the facility did not ensure one of 5 residents ( Resident 8) receiving medication to treat a specific diagnosed condition, when Resident 8 has an order for Depakote ER oral tab 250 mg one tab by mouth at bedtime for Dementia in other Diseases Classified Elsewhere, moderate, with other Behavioral Disturbance manifested by verbal sexual disinhibition. This failure has potential for residents receiving unnecessary medication. Review of admission Record of Resident 8, admitted on [DATE] and readmitted [DATE] with diagnoses including: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that restorative care services were provided to one resident (Resident 11) by not applying the resident's Ankle Foot Orthosis (AFO-a brace that you wear on your lower leg and foot to help you walk better and more safely) as ordered by the physician. This failure to implement restorative interventions as ordered had the potential to contribute to functional decline, increased risk of falls, and reduced quality of life for Resident 11.

Inspectors wroteBased on interview and record review, the facility failed to adequately monitor and supervise one of three sampled residents, Resident 23, who repeatedly left the premises without the facility's knowledge. This failure posed risks to Resident 23's health and safety, including heat or cold exposure, being struck by a vehicle, dehydration, and other medical complications, potentially affecting their overall well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a prescribed psychotropic (a medicine that affects your brain and changes how you think, feel, or behave) medication was ordered and available for one of one sampled residents (Resident 34), resulting in a delay in administration. This failure had the potential to compromise Resident 34 mental health stability, disruption of therapeutic treatment, and adverse effects on the resident's psychosocial well-being. During a medication pass observation conducted on 9/24/2025 at 10:20 AM, front of room [ROOM NUMBER], a psychotropic medication Seroquel 25mg was not available for Resident 34. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that the medication for 1 resident (Resident 8), was changed in response to identified irregularities, when during a Medication Regimen Review (MRR) by pharmacist, gave recommendation for approved diagnoses for use of Depakote Extended Release (ER). This failure has potential for residents receiving unnecessary medications. Review of admission Record, admitted on [DATE] and readmitted [DATE] with diagnoses including: Dementia (a brain disorder that causes decline in memory and thinking) in other disease classified elsewhere, moderate with other behavioral disturbances, Anxiety Disorder ( a mental condition like persistent worry, fear and nervousness), Depression( condition with persistent sadness, hopelessness and loss of interest, Urinary Tract Infection ( infection of the urinary tract caused by bacteria). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 5 sampled residents (Resident 108) was free from unnecessary drugs when Quetiapine (also known as Seroquel - a drug used to treat schizophrenia, a serious mental health condition) was administered to treat Resident 108's post-traumatic stress disorder (PTSD - a mental health condition that can develop after a person experiences or witnesses a traumatic event) related delirium (a sudden, temporary state of confusion that can cause a person to have trouble paying attention, thinking clearly, and being aware of their surroundings). Additionally, Quetiapine was not indicated in Resident 108's discharge medication list and physician's assessment and plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of three residents (Resident 1) when the facility did not administer medication as ordered by a physician for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of two residents when the facility did not follow the physician's order to monitor Resident 1's inappropriate behavior. This failure had the potential to compromise residents' safety and health in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to attempt, offer, and document the use of bed rail (adjustable metal or rigid plastic bars that attach to the bed) alternatives for 17 of 67 residents (Resident 6, 10, 15, 19, 24, 29, 31, 40, 43, 54, 61, 62, 66, 80, 81, 84, and 94) , and obtain informed consent for one of 67 residents (Resident 199) prior to installation of the bed rails. These failures had the potential to put the residents at risk for entrapment and serious injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. The recipe for Spinach was followed according to ingredient list for approximately 15 of 96 sampled residents 2. Accurate diets were not served according to resident preferences for two of 96 sampled residents (Resident 36 & Resident 51) These failures had the potential for adverse reactions to foods added to recipes without residents being aware, and for residents to not eat foods according to personal preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices in the kitchen when: 1. Dietary Aide (DA) C did not perform hand hygiene after cleaning the floor and touching dirty surfaces; 2. Multiple food items were kept in the freezer after the use by date; and 3. Canned food with major dents were not identified and removed from dry storage shelf These failures had the potential to spread food-borne illness to residents in the facility.

Inspectors wrote3. Review of Resident 91's admission Record indicated, Resident 91 was admitted to the facility with diagnoses including aphasia (a language disorder wherein the person is unable to communicate effectively to others) following cerebral infarction (also called stroke), hemiplegia (paralysis of one side of the body/a severe or complete loss of strength in the arm, leg, and sometimes face on one side of the body) and hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body) following unspecified cerebrovascular disease (CVA - also referred to as stroke) affecting right dominant side (more skillful side), and benign prostatic hyperplasia (an enlarged prostate [a gland just below the bladder]) with lower urinary tract symptoms (examples include leaking urine, having sudden and frequent urges to pee, having a weak stream or feeling like [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policies on self-administration of medication (resident takes medication without staff assistance) when there were no assessments performed for self-administration of medications, and medications were left at the bedside for 2 of 24 sampled residents (Residents 84 and 3). These failures had the potential for unsafe and improper administration of medications.

Inspectors wroteBased on interview and record review, the facility failed to provide two of three sampled residents (Resident 13 and 83) with the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN, a financial liability notice). This failure could lead to resident unknowingly assume financial liability for receiving services that were not covered by Medicare.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, a clinical assessment tool) for one of 24 sampled residents (Resident 63). Failure to accurately assess the resident had the potential to compromise the facility's ability to provide resident-centered care plan interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Level II PASRR (Pre-admission Screening and Resident Review, a federal requirement to help ensure individuals with mental disorders and intellectual disabilities are not inappropriately placed in nursing homes for long-term care) was completed for two of 24 residents (Residents 41 and 61). This failure had the potential to put the residents at risk for not receiving appropriate care and services for their mental health conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement individualized, resident-centered care plans for 3 of 24 sampled residents (Residents 74, 3 and 18) when care plans for: 1. Resident 74's feeling of sadness was not developed and implemented; 2. Oxygen (a colorless, odorless gas) and anticoagulant (sometimes called blood thinning medications) used for Resident 3 was not developed; and 3. Oxygen used for Resident 18 was not developed. These failures had the potential to result in the residents not receiving the care and services necessary to maintain their health, safety and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents received the necessary care and services for two of six residents (Residents 148 and 15) when licensed nurses did not follow the physician's order for oxygen supplement (a therapy that provides extra air to breathe in) for Residents 148 and 15. These failures had the potential to affect the residents' care and could jeopardize their health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure controlled medications (those with high potential for abuse and addiction) reconciled with the corresponding Medication Administration Records (MAR) for four of nine randomly sampled residents (Residents 7 ,37 ,58, and 76). The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but did not document on the Medication Administration Record (MAR) to indicate the controlled medications were given to the residents. This failure had the potential for misuse or diversion of controlled medications.

Inspectors wroteBased on observation, interview and record review, the facility had an eight percent medication error rate when two medication errors out of 25 opportunities were observed during medication pass for one of six residents (Residents 72). These failures had the potential to compromise the health and safety of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were labeled appropriately when: 1. One opened Refresh Tears lubricant eyedrop without resident's name and an open date was found in medication cart AA; 2. One opened Vyzulta (used to lower intraocular [eye] pressure with open - angle glaucoma [eye condition that can cause blindness] or ocular hypertension) 0.024 % Ophthalmic (used to treat eye infections) Solution was found without an open date; and 3. One opened Brimonidine Tartrate (used to treat open-angle glaucoma or high fluid pressure in the eye) ophthalmic solution was found without an open date. These failures had a potential for residents to receive medications with unsafe and reduced potency from being used past their discard date which could lead to unsafe and ineffective medications for the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve food at an appetizing temperature for one test tray food item out of seven sampled food items. This failure had the potential for residents to not wish to eat the sampled food item due to colder temperature.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the physician- prescribed therapeutic diet (a diet order as part of treatment for a disease or clinical condition to decrease or increase specific nutrients in the diet) to four of 96 sampled residents when: 1. Three residents (Resident 29, Resident 41 & Resident 57) who were ordered a Controlled Carbohydrate Diet (The focus of the diet is eating the same amount of carbohydrates every day in an attempt to keep blood sugar levels stable) were served the wrong dessert item; and 2. One resident (Resident 92) who was ordered a Fortified Diet ( a diet with additional high calorie items to help prevent or treat weight loss), did not receive the fortified food item for noon meal. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control practices were implemented when: 1. Certified nursing assistant O (CNA O) did not perform hand hygiene while serving and setting up lunch trays in between residents (Residents 14, 71 and 58); and 2. Nasal cannula (NC - a device that consists of plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostrils for oxygen administration) was not stored properly when not in use (Resident 44). These failures had the potential to compromise resident's health and safety in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to provide a safe, functional, and comfortable environment for two of 24 sampled Residents: 1. Resident 94's bed controller was not functioning for two days; and 2. Resident 41's toilet paper holder was broken for three days without being reported and fixed. These failures had the potential to affect the comfort of the residents.

Inspectors wroteBased on interview, and record review, the facility failed to update the fall care plan for one of 8 residents (Resident 84) when interdisciplinary team (IDT, team composed of members from different departments involved in resident's care) did not review and revised Resident 84's fall risk care plan with subsequent falls. This failure resulted in Resident 84's two more subsequent falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure fall management policy and procedure were implemented for one of eight residents (Resident 84) when: fall risk assessment was not performed when Resident 84 had a significant change in status and the interdisciplinary team (IDT, team composed of members from different departments involved in resident's care) did not develop and implement appropriate new interventions after a fall. These failures resulted in Resident 84's subsequent falls and had a potential to sustain serious injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from physical abuse for one out of three residents (Resident 1) when Resident 2 (who was of moderate mental capacity) slapped Resident 1 in the mouth causing injury to Resident 1's top lip and first aid being administered. Resident 2's act of slapping Resident 1 in the mouth was a deliberate act to inflict harm or injury, not accidental; therefore, his action was deemed as a willful act and considered abuse. This failure had the potential of both physical and emotional harm to all residents.

Inspectors wrote4. Review of Resident 30's admission Record indicated she was admitted to the facility on [DATE] with anxiety disorder (people with anxiety disorders frequently have intense, excessive and persistent worry and fear about everyday situations) diagnosis. Review of Resident 30's physician order indicated she had an order for buspiron (used to treat anxiety) 15 milligrams (mg, a metric unit of mass) every 12 hours for anxiety started on 5/20/21. Review of Resident 30's medical record indicated there was no side effect monitoring for buspiron. During an interview with the director of nursing (DON) on 8/6/21 at 9:21 a.m., she reviewed Resident 30's clinical record and confirmed there was no side effect monitoring for buspiron. DON stated Resident 30 should have been monitored for the side effects of buspiron. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was served at a palatable temperature for three non-sampled residents (Residents 44, 45, and 77) when the residents complained about the food temperature. This failure had the potential to result in decreased food intake and weight loss, compromising the resident's nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under the sanitary conditions when: 1. An unlabeled big container of sliced bread with cheese dated 7/16/21 was inside the refrigerator; 2. coffee maker machine's daily cleaning was not followed per manufacturer's guidelines; 3. There were three electric fans with grayish black substance; 4. water filter for coffee maker was dated 3/1/2020; 5. undated and unlabeled open bag of chocolate chips; 6. kitchen cook did not perform hand hygiene when changing gloves. These failures had the potential to cause foodborne illness (illness resulting from contaminated food) to the residents who received food from the kitchen.

Inspectors wrote2. During an observation in the dining room on 8/2/21 at 12:44 p.m., certified nursing assistant N (CNA N) put on gloves without washing her hands, picked up the fried chicken leg and thigh on Resident 43's plate, and shredded it for Resident 43 to eat. During a concurrent interview with CNA N, she stated she should wash her hands and put on gloves before touching the resident's food. Review of the facility's policy Food: Preparation, dated 9/2017, indicated All staff will practice proper hand washing techniques and glove use. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 8 residents (37) had informed consent (written permission before implementing a healthcare intervention) prior to initiating psychotropic medication (medication capable of affecting the mind, emotions, and behavior). This failure resulted in the resident receiving psychotropic medications without being informed about their risks and side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate residents' needs for three of 19 sampled residents when: 1. Resident 41 had been waiting 21 minutes for transfer assist in a commode. 2. Resident 64 waited for more than 15 minutes for his perineal care after bowel movement. 3. Resident 74's call light device was not within reach to accomodate his needs. These failures had the potential to result in the residents' needs being unmet and affecting residents' well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean, safe, orderly, and sanitary homelike environment for two of nineteen sampled residents when: 1. Resident 44's toilet was not working and was clogged with stool; 2. The toilet paper dispenser for Resident 26 had no toilet paper because the roller was broken. These failures had the potential to place the residents at risk for an unsafe and uncomfortable environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR, screening for individuals with a mental disorder and individuals with intellectual disability) screening document was accurately completed for one of five residents (27). This failure had the potential for mentally ill residents not to receive the required care and services.

Inspectors wrote2. Review of Resident 64's admission Record indicated he was admitted to the facility with chronic obstructive pulmonary disease (COPD, a lung disease that makes it hard to breathe) diagnosis. Review of Resident 64's physician order, dated 7/30/2020, indicated he had an order for Symbicort Aerosol (an inhaler that is used to treat COPD) 160/4.5 micrograms (mcg, a metric unit of mass) 2 puff inhale orally two times a day related to COPD. During an observation of medication administration on 8/3/21 at 9:40 a.m., after administering 2 puffs of Symbicort Aerosol to Resident 64, licensed vocational nurse I (LVN I) gave Resident 64 a cup of water to rinse his mouth. Resident 64 rinsed his mouth and swallowed the water. During an interview with LVN I on 8/3/21 at 10:19 a.m., she stated she should instruct Resident 64 to spit out the water after he rinsed his mouth. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an on-going activity program to support the resident in her choice of activities for one of 19 sampled residents (Resident 65) when the facility did not provide in-room visits to Resident 65. This failure could potentially affect the physical, mental, and psychosocial well-being of the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate treatment and services for one of 19 sampled residents (Resident 65) when the restorative nursing aide (RNA, helps residents to gain an improved quality of life by increasing their level of strength and mobility) program was not implemented related to contractures (condition of hardening, shortening of muscles and tendons) care plan. This failure had the potential for Resident 65 to decline in activities of daily living (ADL's such as bed mobility, transfer, personal hygiene, toileting, and bathing) and prevent physical deterioration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate care to prevent accidents for one of 19 sampled residents (Resident 67) when certified nursing assistant C (CNA C) transferred Resident 67 with Hoyer lift (lifting machine) by herself. This failure had the potential for accidents and injury to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately monitor intravenous (IV, catheter inserted into blood vessel for administration of fluids and/or medication) access/lines for three of 19 residents (Residents 143, 36, and 64). This failure had the potential of losing IV access for the resident and/or the incorrect amount of fluid being administered to the resident, and affecting the residents' health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two residents (Resident 64), who was physician-ordered to receive respiratory services of continuous positive airway pressure (CPAP, machine uses a hose and mask or nosepiece to deliver constant and steady air pressure) received this service and the care was accurately documented. This failure had the potential to result to impact resident's health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure for two of 19 sampled residents (Resident 84 and Resident 19), were provided with the appropriate and necessary pain management when: 1. Resident 84's left lower back pain was not addressed promptly; 2. The pain medication order for Resident 19 was not followed accurately. These failures had the potential to result in the resident's poor quality of life and discomfort.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate care to one resident (77) on dialysis (process of removing excess water, solutes, and toxins from the blood in people whose kidneys no longer perform these functions naturally) when the access site for bruit (swishing sound that indicates patency heard by auscultating the dialysis shunt) and thrill (vibration that indicates arterial and venous blood flow and patency felt by palpating the dialysis shunt) for post dialysis were left blank on Resident 77's Dialysis Communication Records, and the licensed nurses did not assess Resident 77's vital signs (reflect essential body functions, including the heartbeat, breathing rate, temperature, and blood pressure) after dialysis as ordered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a 14.29% medication error rate when five medication errors of 35 opportunities were observed during the medication administrations for two sampled residents (49 and 64). These failures had the potential to negatively affect the residents' health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ staff with the appropriate competency and skills to carry out functions of the food and nutrition service when the kitchen cook (KC) did not properly dip the test strip in the sanitizer water per manufacturer's recommendation. This failure could affect proper washing and sanitation which could cause foodborne illness to the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the recipe procedure when the cook and kitchen aide did not follow the ingredients for pureed diet. This failure had the potential to decrease food intake and cause weight loss.

Inspectors wrote3. During an observation on 8/2/21 at 1:34 p.m., Resident 390 was sitting in his wheelchair having lunch of sliced bread, noodles, meat, vegetables and a slice of regular cake, by himself and consumed about 20 percent of his meal. Resident 390's dietary menu slip for 8/2/21, indicated he would have pureed dinner roll/bread and pureed chocolate chip cake with white frosting. During a concurrent observation and interview on 8/2/21 at 1:34 p.m., with certified nursing assistant H (CNA H), she verified Resident 390 had a slice of regular cake, not pureed chocolate chip cake and he had no pureed dinner roll, but sliced bread instead. Review of Resident 390's Order Summary Report dated 8/3/21, indicated he had an order of Therapeutic Lifestyle Change (TLC) Diet, Dysphagia Mechanical Soft Texture Diet, Nectar Thick Consistency, and large portion entrée, ordered on 7/29/21. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly dispose the garbage when the garbage container had no lid to cover it. This failure had the potential to attract pests and transfer harmful microorganism to food leading to foodborne illness to the residents.