Windsor Nursing and Rehabilitation Center of Segui

In the surveyor’s words

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

• Immediate jeopardy, patternF689Apr 21, 2024

  Based on observation, interview and record review the facility failed to ensure the resident environment was as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 2 of 9 residents (Residents #1 and #2) reviewed for accidents and hazards. 1. The facility failed to ensure Resident #1 did not elope from the facility. Resident #1 eloped to a busy street on 12/18/23. 2. The facility failed to ensure staff were adequately trained on the elopement process, which included not training the therapy department after 12/18/23 elopement incident. 3. The facility failed to ensure interventions for elopement were updated and appropriate to prevent elopements for Resident #1 and #2. […]

• Actual harm, isolatedF689May 24, 2024

  Based on interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 10 residents (Resident #29) reviewed for quality of care. On 05/17/2024, Resident #29 suffered a broken ankle when CNA C and CNA I used a sheet to transfer Resident #29 from a shower chair to a wheelchair. This failure could place residents at risk for serious injuries. The findings included: A record review of Resident #29's admission record dated 05/23/2024, revealed an admitted [DATE] with diagnoses which included disorder of bone density and structure, pain in knees, and muscle weakness. […]

• No harm, potential for more than minimal, patternF759May 24, 2024

  Based on observation, interview and record review the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 6.9%, based on 2 errors out of 29 opportunities which involved 2 of 6 residents (Resident #16 and #53) reviewed for medication administration and medication errors. 1. Medication Aide J administered Resident #16's clonazepam, a drug used to treat panic disorder, 17 minutes late. 2. Medication Aide J administered Resident #53's gabapentin, a drug used to treat nerve pain, 30 minutes late. These deficient practices could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. […]

• No harm, potential for more than minimal, patternF761May 24, 2024

  Based on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 medication cart and 1 Treatment cart of 2 carts observed for secure biologicals and drugs. 1.LVN F left the medication cart unsecured on 200 Hallway while administering medications. 2.The Treatment Nurse left the treatment cart unsecured on 05/22/2024 on the 100 Hallway, and on 05/23/2024 on the 300 Hallway prior to wound care for a resident. These deficient practices could place residents at risk for misappropriation, misuse or tampering of medications. The findings included: Observation on 05/22/2024 at 08:29 a.m. […]

• No harm, potential for more than minimal, patternF812May 24, 2024

  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. 1. The facility failed to ensure pre-packaged chicken salad was discarded after the use by date. 2. The facility failed to ensure beverage machines dispenser gun with dispenser buttons was clean and properly stored. 3. The facility failed to ensure staff with facial hair was covered by a hair restraint. 4. The facility failed to ensure refrigerated items were dated and properly sealed. 5. The facility failed to ensure puree carrots were prepared in a sanitary fashion. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. […]