Windsor Care Center of Sacramento

In the surveyor’s words

From the most serious findings on record at Windsor Care Center of Sacramento, in the surveyor’s own words.

• Actual harm, isolatedF600May 8, 2024

  Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from physical abuse when Resident 1 was forced into the chair, shoved down on the chest to be seated, and got hit in the hand and arm by a Certified Nursing Assistant 1 (CNA 1). This failure had the potential to result in serious physical injury for Resident 1. Findings: In a review of Resident 1's Admission Record, Resident 1 was admitted to the facility in 2022 with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and dementia (a condition of progressive loss of memory and abstract thinking, and personality change). […]

• No harm, potential for more than minimal, widespreadF725Dec 20, 2024

  Based on interview and record review, the facility failed to have sufficient nurse staffing for a census of 111 residents, when the facility's Actual Direct Care Service Hours Per Patient Day (DHPPD- use to measure the total number of hours dedicated to direct care provided by caregivers, like nurses and certified nurse assistants to each patient in a facility over a 24-hour period) were below the required minimum standard of 3.5 DHPPD and 2.4 hours per patient day for certified nurse assistants (CNA DHPPD) from 11/1/24 to 11/7/24. This failures resulted to 10 recorded resident falls from 11/1/24 to 11/7/24 and had the potential for facility residents to not receive needed health treatment and personal care, and to not achieve their highest physical, mental, and psychosocial well-being. […]

• No harm, potential for more than minimal, patternF583Dec 20, 2024

  Based on observation, interview, and record review the facility compromised resident personal privacy and confidentiality when the shred box containing meal tickets was overfilled, exposing resident information. This had the potential of exposing resident information to non-staff individuals. Findings: During surveyor initial set-up on 12/17/24 at 7:49 a.m., the survey team was briefly set up in the large dining room off the kitchen. A shred box was located next to the main door with meal tickets coming through the box opening. The survey team was able to read resident information from meal tickets at the box's opening. During the initial kitchen tour on 12/17/24 at 8:03 a.m., the Dietary Manager (DM) was escorted to the shred box. She concurred that the shred box was full to the brim. […]

• No harm, potential for more than minimal, patternF677Dec 20, 2024

  Based on observation, interview, and record review, the facility failed to ensure two out of 26 sampled residents (Resident 72 and Resident 59) was assisted with their activities of daily living (ADLs- normal daily functions required to meet basic needs) when: 1. Resident 72 had blackish substance underneath the fingernails; and, 2. Resident 59 was not provided with oral care as indicated. These failures had the potential for Resident 72 and Resident 59 to acquire an infection and not achieve their highest practicable well-being. Findings: 1. […]

• No harm, potential for more than minimal, patternF679Dec 20, 2024

  Based on observation, interview, and record review, the facility failed to ensure two of 26 sampled residents (Resident 35 and Resident 30) were offered activities that meet their interests and preferences when; 1) Resident 35 did not receive activities that met her preferences and was only offered activities once a week; and 2) The facility did not provide Resident 30 any activity that meets his psychosocial needs from 11/12/24 to 12/16/24; These failures had the potential for Resident 30 and Resident 35 to not achieve their highest mental, emotional, spiritual, and psychosocial well-being. Findings: 1. […]