Windsor Grove Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Windsor Grove Health and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF725May 1, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure sufficient staffing to meet the needs of the 106 of 106 residents in the facility. The facility failed to ensure there was one nurse on each the Blue Unit and the Pink Unit during the night shift on 04/29/25 and failed to ensure enough staff to implement the care plan intervention of one-to-one supervision for five residents who required one-to-one-supervision. Findings include: 1. Review of a document provided by the Administrator on 04/30/25 revealed there were five residents (R35, R54, R55, R87, and R98) on the secure unit that required one-to-one supervision. a. […]

• No harm, potential for more than minimal, patternF730May 1, 2025

  Based on interviews and record reviews, the facility failed to ensure Certified Nurse Aides (CNA) received performance reviews at least once every 12 months and regular in-service education based on the outcome of the reviews for four of five CNAs (CNA6, CNA9, CNA10, and CNA12) whose personnel files were reviewed. This had the potential to have a negative impact on resident care. Findings include: Review of CNA 6's personnel file revealed a start date of 02/02/23. There was no documented evidence in the personnel file that CNA6 had a performance evaluation or in-service education based on the outcome of the review. Review of CNA 9's personnel file revealed a start date of 08/01/22. […]

• No harm, potential for more than minimal, patternF760May 1, 2025

  Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free from significant medication errors for 2 Residents (#87 & #94) in a survey sample of 55 Residents. The findings included: 1. For Resident #87 the facility staff failed to ensure she received Risperdal Consta injections every 2 weeks as ordered by physician for Schizophrenia. Resident # 87 was admitted to the facility on [DATE] with diagnoses that included, but we're not limited to dementia, schizophrenia, anemia, hypertension, psychotic disorder with delusions due to unknown physiological condition, and cognitive communication deficit. […]

• No harm, potential for more than minimal, patternF919Nov 14, 2024

  Based observation and Resident interviews the facility failed to ensure residents are adequately equipped to allow residents to call for staff through a communication system for 2 of 7 residents in the survey sample, R#6 and R#7. The findings include: 1. Resident #6 was admitted to the facility on [DATE] with a diagnosis of Obesity, Chronic Respiratory Failure, Chronic Constructive Pulmonary Disease, Anxiety Disease, Congestive Heart Failure, and Dependence for Supplemental Oxygen. Resident #6's Care Plan dated 10/07/2024 documented the resident as having Full Code Status, Resident #6 is at risk for fall related to Gait/Balance problems history of falls. […]

• No harm, potential for more than minimal, patternF925Nov 14, 2024

  Based on observations and Residents interviews the facility fail to ensure a safe, comfortable, and homelike for 3 residents out of 7 in the survey sample: Resident #1, Resident #2, and Resident #3 environment . The findings include: 1. Resident #1 was admitted to the facility on [DATE] with a diagnosis of Diabetes, Encephalopathy, Hematuria, Schizoaffective Disorder, Anxiety, Depression, Muscle Weakness, and Insomnia. Resident #1's Care Plan dated 07/25/2024 documented the resident as being independent for meeting, emotional, physical, and social needs. Resident #1's Minimum Data Set (MDS) assessment dated [DATE], the resident was coded as having no Mood or Behavioral symptoms presence. […]