Windsor Nursing and Rehabilitation Center of San D

In the surveyor’s words

From the most serious findings on record at Windsor Nursing and Rehabilitation Center of San D, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Oct 5, 2023

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation: 1. The facility failed to ensure utensils were clean. 2. The facility failed to keep accurate temperature and chemical logs for the dishwasher. 3. The facility failed to dispose of expired foods. These failures could place residents at risk of foodborne illnesses. Findings include: Observation of the kitchen and interview with the DM on [DATE] beginning at 11:30 a.m. revealed a DA pouring coffee into cups on 2 trays. One tray was done, the other cups on the other tray had a removable white residue in them. The DM removed the residue with his thumb. […]

• No harm, potential for more than minimal, widespreadF922Aug 18, 2022

  Based on observation, interview, and record review, the facility failed to ensure that enough water was available in case of a loss of water supply and did not have written procedures defining sources of water, and was unaware of the method for estimating the volume of water required for 1 of 1 facility. There were only 16, 5-gallon jugs of water on hand for a census of 54 residents and employees. This failure could place residents at serious risk for complications from dehydration and sanitation. Findings were: During an observation of the emergency water supply accompanied by the MS on 8/16/22 at 10:58 a.m. revealed 16, 5-gallon jugs of water (80 gallons) for emergency use for a current census of 54. […]

• No harm, potential for more than minimal, patternF880Nov 17, 2023

  Based on observation, interview and record review the facility failed to establish and maintain an Infection Prevention and Control Program designed to help prevent the standard and transmission-based precautions to be followed to prevent the spread of infections or diseases for 2 of 4 units reviewed for laundry services. -Laundry Aide A left the laundry bin with clean linens uncovered on units 100 and 200. These failures could affect residents and staff and place them at risk for healthcare associated cross contamination, infections, and COVID-19 (coronavirus). The findings included: Observation on 11/14/23 at 01:50 PM Laundry Aide A delivered clean linens to the 100 care unit. The bin was left uncovered when Laundry Aide A went into a resident's room to deliver clean linen. […]

• No harm, potential for more than minimal, patternF812Aug 18, 2022

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety for 1 of 1 kitchens and 1 of 1 nutrition room. There were personal food items in the kitchen refrigerator and dry storage areas, contaminated and/or broken equipment, the dishwasher temperature was below requirements, the kitchen handwashing sink temperature was above requirements, and there was expired and unlabeled food in the nutrition room. These failures could place residents at serious risk for complications from food contamination. […]

• No harm, potential for more than minimal, isolatedF656Jul 28, 2026

  Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #1) of 3 residents whose care plans were reviewed. The facility failed to ensure Resident #1's comprehensive care plan was implemented by not providing the required two-person assistance during bathing. Resident #1 received bathing assistance from only one staff member on 07/16/26.This failure could place residents in the facility at risk of not being provided with the necessary care or services, and the implementation of personalized plan of care developed to address their specific needs. The findings include:Record review of Resident #1's face sheet dated 07/28/26 reflected a [AGE] year-old-female with an original admission date of 07/11/26. […]