Windsor Lane Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF689Dec 11, 2024

  Based on observation, medical record review, staff interview, review of a facility investigation including written statements, review of facility camera footage, hospital documentation review, review of a manufacture operating manual, and facility policy review, the facility failed to ensure specialized chairs were utilized in a safe and proper manner to prevent injuries. Actual Harm occurred when Resident #01 was placed in a Broda chair (a supportive positioning chair which allows residents to tilt and recline) equipped with caster type wheels and Resident #01 was left unattended while seated in the chair, which was not assessed for use, with the caster wheels unlocked. […]

• Actual harm, isolatedF687Dec 5, 2022

  Based on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to monitor skin as care planned, complete skin assessments, and monitor a resident's wound. This resulted in actual harm when a diabetic foot ulcer was discovered at an outside podiatrist appointment, which resulted in amputation of the right great toe, eleven days after discovery. This affected one (Resident #47) of three residents reviewed for non-pressure wounds. The facility census was 68. Findings include: Review of the medical record revealed Resident #47 was admitted on [DATE]. […]

• Actual harm, isolatedF689Feb 25, 2021

  Based on medical record review, observation, policy review and staff interviews, the facility failed to provide supervision and implemented the physician ordered safety interventions to prevent falls. This resulted in actual harm when Resident #3 fell from his wheelchair and suffered a left [MEDICAL CONDITION]. This affected one (#3) of three residents reviewed for falls. The facility identified 11 residents at risk for falls. The facility census was 62. Findings include: Review of the medical record for Resident #3 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessments dated 01/07/21 revealed Resident #3 was severely cognitively impaired. […]

• No harm, potential for more than minimal, widespreadF880Jan 27, 2022

  Based on review of the employee COVID-19 testing records, review of employee time cards, review of the COVID screening forms, staff interviews, epidemiologist interview, review of the Center for Disease Control and Prevention (CDC) guidelines, and review of the facility policy, the facility failed to ensure staff followed return to work guidelines and failed to implement additional staffing strategies to prevent the potential spread of [CONDITION(S)]-Co-V-2 (COVID-19). This had the potential to affect 64 of 64 residents who reside in the facility. The facility census was 64. Findings include: Review of employee testing records revealed Dietary Staff (DS) #122 tested positive for [CONDITION(S)]-CoV-2 (COVID-19) on 01/12/22. […]

• No harm, potential for more than minimal, widespreadF880Apr 15, 2021

  Based on observation, staff interview, and facility policy review, review of the COVID-19 Nursing Home data website, Centers for Disease Control and Prevention (CDC) and Healthcare Infection Control Practices Advisory Committee (HICPAC) guidance, the facility failed to implement infection control and prevention measures to prevent the spread of Coronavirus Disease 2019 (COVID-19), the facility failed to ensure staff was wearing eye protection when caring for residents and also failed to wear the proper personal protective equipment (PPE) when entering a droplet isolation room. This had the potential to affect 57 of 57 residents in the facility. The facility census was 57. Findings include: 1) Observation on 04/14/21 at 6:04 A.M. […]