The Windsor Place

In the surveyor’s words

From the most serious findings on record at The Windsor Place, in the surveyor’s own words.

• Actual harm, isolatedF655Oct 9, 2024

  Based on staff interview, record review and facility policy review, the facility failed to develop a baseline care plan related to skin integrity concerns for a resident with excoriation to the buttocks. The resident developed a pressure ulcer within four days of admission to the facility. This was for one (1) of 28 care plans reviewed. Resident #39. Cross reference: F686 Findings include: A review of the facility policy titled, Care Plan Policy, revealed, on admission a care plan must be completed. A review of the Baseline Care Plan dated 8/23/24 for Resident #39 revealed Skin risk: current skin integrity issues checked.Specific skin integrity issue: Excoriation to buttock Physician orders: see Medication Administration Record (MAR) and Treatment Administration Record (TAR). […]

• Actual harm, isolatedF686Oct 9, 2024

  Based on observation, resident and staff interview, record review and facility policy review, the facility failed to provide necessary treatment and services to promote healing and prevent new ulcers from developing for (1) one of five (5) residents with wounds reviewed. Resident #39 Findings include: A review of the facility policy titled, Overview of Skin and Wound Care Management, revealed, the facility staff strives to prevent/patient skin impairment. The Interdisciplinary team works with the resident and family to identify and implement interventions to prevent and treat potential skin integrity issues.Components of the skin care and wound management program include, but are not limited to, the following: 2.) Implementation of prevention strategies to minimize the potential for… […]

• Actual harm, isolatedF657Oct 28, 2021

  Based on record review, staff and family interview and facility policy review the facility failed to revise a fall care plan for Resident #111 after multiple falls that occurred for 1 of 5 falls reviewed. Findings include: Record review of the facility policy titled Care Plan Policy with revision date 4-2019 revealed Policy It is the policy of this facility that an individualized, interdisciplinary care plan will be developed and maintained for each resident in the facility. Procedure: It is the responsibility of each nurse to update care plans. When an order is written or an incident occurs, it is the responsibility of the nurse taking the order, or the RN desk nurse documenting the incident to: #7 Stop and update the care plan immediately . […]

• Actual harm, isolatedF689Oct 28, 2021

  Based on observation, staff and family interviews, record review and facility policy review, the facility failed to provide increased supervision for a resident who had sustained ten (10) falls with two (2) resulting in major injuries that included a Subarachnoid Hemorrhage and a [CONDITION(S)] from 8/31/21 to 10/26/21 for one (1) of five (5) residents reviewed for falls, Resident #111. Findings include: Review of the facility policy titled, Fall Prevention Policy, with a revision date of 04-01 revealed Policy: It is the policy of this facility that each resident will be assessed upon admission, re-admission, quarterly, and annually or with a significant change for their fall risk potential. […]

• No harm, potential for more than minimal, widespreadF812Oct 9, 2024

  Based on observation, staff interview, and facility policy review, the facility failed to label and date open items in the pantry, refrigerator, and freezer for one (1) of two (2) kitchen tours during the survey. Findings Include: Review of the facility policy titled Food Storage undated, revealed under, Policy . Foods will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination . 14. Refrigerated food storage . f. All foods should be covered, labeled and dated. Also revealed under, 15. Frozen Foods: c. All foods should be covered, labeled and dated. […]