Windsor Gardens Convalescent Hospital

In the surveyor’s words

From the most serious findings on record at Windsor Gardens Convalescent Hospital, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Oct 18, 2022

  Based on interview and record review, the facility failed to develop and implement a comprehensive, individualized plan of care for one of three sampled residents (Resident 1), who had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did not develop a plan of care with the participation of the interdisciplinary team (IDT- A group of experts from various disciplines working together to treat a person's ailment, injury, or chronic [long term] health condition) including the attending physician addressing Resident 1's multiple absences (out of the facility for appointments) which interfered with the administration of antiseizure medications and did not develop interventions such as evaluating Resident 1 for safe self-administration of medications and/or coordinate the scheduled… […]

• Immediate jeopardy, isolatedF755Oct 18, 2022

  Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had diagnosis of [CONDITION(S)] (sudden, uncontrolled electrical disturbance in the brain that can cause changes in movements [convulsions] and levels of consciousness [alertness]) received medications as ordered to meet the resident's needs. The facility did not administer or make arrange for Resident 1 to receive [MEDICATION(S)] (clonazepan - anti [CONDITION(S)] medication), [MEDICATION(S)] ([MEDICATION(S)] - antiseizure medication) and [MEDICATION(S)] ([MEDICATION(S)] - antiseizure medication) between 8/9/2022 and 9/30/2022, while Resident 1 was absent (gone for medical appointments) from the facility. […]

• Actual harm, isolatedF689Mar 6, 2024

  Based on observation, interview, and record review the facility failed to provide the necessary assessments, care, and services for one of three residents (Resident 1) to prevent falls, by failing to ensure two staff transferred Resident 1 from wheelchair (WC) to bed. On 2/25/2024, certified nurse assistant 1 (CNA 1) attempted to transfer Resident 1 from a WC to a bed without the assistance of another staff member. As a result, on 2/25/2024, Resident 1 fell from the WC onto the floor sustaining right eye injury. Resident 1 required emergent transfer to general acute care hospital 1 (GACH 1) via 911 (emergency response telephone number). […]

• Actual harm, isolatedF600Nov 4, 2023

  Based on interview and record review, the facility failed to protect the resident's right to be free from neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress) for one out of seven sampled residents (Resident 1) after Resident 1 and family members 1 and 2 (FM 1 and FM 2) complained of itching and discomfort since 7/2023. The facility was aware Resident 1 was continuously itching and scratching for four months despite being treated with hydrocortisone (medication used to treat redness, itching, swelling, or other discomfort caused by skin conditions) and Atarax (medication to treat itching). […]

• Actual harm, isolatedF684Nov 4, 2023

  Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) remained comfortable and free of itching by failing to notify a physician and follow up on a dermatology consult after the facility was aware that Resident 1 continued to itch and that family members 1 and 2 (FM 1 and FM 2) had complained that Resident 1 had been scratching and complaining of discomfort since 7/2023. The facility was aware Resident 1 was continuously itching and scratching for four months despite being treated with hydrocortisone (medication used to treat redness, itching, swelling, or other discomfort caused by skin conditions) and Atarax (medication to treat itching). […]