Windsor House

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Sep 20, 2023

  Based on interviews, record review, review of a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, review of Facility Reported Incidents (FRIs) received by the Alabama State Survey Agency, and review of the facility's investigative file, the facility failed to ensure Resident Identifier (RI) #s 1, 2, and 4 were free from abuse. 1) On [DATE], Employee Identifier (EI) #4, a CNA (Certified Nursing Assistant) and EI #5, a CNA were providing care for RI #2. During the care RI #2 had gotten feces on his/her hands and was trying to touch EI #4. EI #5 witnessed EI #4 telling RI #2 not to touch her, and that RI #2 was nasty. EI #5 said, EI #4 held RI #2's hands down pinning RI #2's arms down by his/her head and said, don't fucking touch me. […]

• Immediate jeopardy, isolatedF607Sep 20, 2023

  Based on interviews, medical record review, review of a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, and review of Facility Reported Incidents (FRIs) received by the State Survey Agency, the facility failed to implement the facility's abuse policies when: 1) Employee Identifier (EI) #8, Licensed Practical Nurse (LPN), Unit Manager failed to report an allegation of sexual abuse to the Administrator and failed to implement immediate protective measures. On 07/28/2023 Resident Identifier (RI) #6's daughter reported to EI #8 that RI #7 had entered RI #6's room and touched his/her breast twice. […]

• Actual harm, isolatedF580May 29, 2021

  Based on interviews, record review, and review of a facility policy titled Weight Loss Interventions, the facility failed to notify Resident Identifier (RI) #36's responsible party when RI #36, a resident with a history of weight loss, lost a severe amount of weight from October 2020 through March 2021. RI #36 went from 169.9 pounds to 132.0 pounds without the family being made aware of the continued weight loss. This deficient practice affected RI #36; one of three residents sampled for weight loss. Findings include: The facility's policy titled Weight Loss Interventions, with an effective date of 3/16/2021, documented PURPOSE To ensure adequate nutrition for those at risk for weight loss, etc. PROCEDURE . 6. If weight has not stabilized or if the resident has lost 5% in one month . […]

• Actual harm, isolatedF658May 29, 2021

  Based on interviews, review of Resident Identifier (RI) #81's medical record, the facility's POSITION DESCRIPTION and the FUNDAMENTALS OF NURSING, the facility failed to ensure Employee Identifier (EI) #4, the Health Information Management Coordinator (HIMC) transcribed RI #81's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The failure to transcribe the order resulted in RI #81's suprapubic catheter not being changed as ordered by the physician for three months. On 5/22/2021, RI #81 was sent to the local hospital's emergency room after complaining of abdominal pain and sediment being noted in the suprapubic catheter tubing. […]

• Actual harm, isolatedF692May 29, 2021

  Based on interviews, review of Resident Identifier (RI) #36's medical record, and the facility's policy titled Weight Loss Interventions, the facility failed to ensure nutritional interventions were implemented when RI #36 experienced a severe weight loss from November 2020 to January 2021. Beginning 11/25/2020, RI #36 experienced a severe weight loss of 7.3% in one month. There were no nutritional interventions to address the resident's weight loss until 1/18/2021. This deficient practice affected RI #36; one of three residents reviewed for weight loss. […]