Windsor Nursing & Retirement Home

In the surveyor’s words

From the most serious findings on record at Windsor Nursing & Retirement Home, in the surveyor’s own words.

• Actual harm, isolatedF686Oct 12, 2023

  Based on record review, policy review, observation, and interview, the facility failed for one Resident (#88), out of a total sample of 19 residents, to provide care and implement pressure prevention interventions resulting in the development of facility acquired pressure ulcers (injuries to the skin and underlying tissue resulting from prolonged pressure exerted over areas of the body) on both the left and right buttocks and right heel of Resident #88. Findings include: Review of the facility's policy titled Skin Integrity Management, dated as revised on 3/16/22, indicated but was not limited to the following: - Based on assessment the facility will ensure that residents receive the necessary treatment and services consistent with professional standards of practice to prevent the… […]

• Actual harm, isolatedF689Oct 4, 2022

  Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had a history of wandering with no sense of direction or purpose, exhibited exiting seeking behaviors, was assessed by nursing to be at an increased risk for elopement, and required the use of a wander guard bracelet for safety, the Facility failed to ensure Resident #1 was provided with adequate supervision to maintain his/her safety, to prevent an incident/accident (elopement) resulting in injury. On 9/15/22, unbeknownst to staff on his/her unit Resident #1 wandered off the unit, Resident #1 then made his/her way undetected by dietary staff through the kitchen area, and exited a back door of the Facility to the loading dock area. […]

• Actual harm, isolatedF658Apr 14, 2021

  Based on record review and staff interview, the facility failed to ensure that for two Residents (#16, #45), from a total sample of 31 residents, that staff provided care and treatment in accordance with Professional Standards of Practice, resulting in: Residents #16 and #45 being transferred to the hospital for assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: The Practice Principles, Wound Care Essentials, copyright 2020, indicates that: * wound assessment-an appraisal of a patient's condition based on clinical signs and symptoms, laboratory data, and medical history-is an integral part of wound management. *wound documentation essentials .documentation is an essential component of wound assessment. […]

• No harm, potential for more than minimal, widespreadF886Mar 13, 2023

  Based on observation, interview, and document review, the facility failed to ensure staff conducted testing and specimen collection in a manner that was consistent with current standards of practice for conducting COVID-19 tests and per manufacturer's instructions. Specifically, the facility failed to properly perform BinaxNOW COVID-19 Ag Card self-testing for four out of four staff members observed. Findings include: Review of the facility's policy titled, COVID-19 Testing, revised November 2022, indicated but was not limited to the following: -Facilities must conduct testing according to nationally recognized guidelines, outlined by the Centers for Disease Control and Prevention (CDC) and for point of care (POC) testing per the manufacturer's package inserts. […]

• No harm, potential for more than minimal, widespreadF565Apr 14, 2021

  Based on resident and staff interviews, policy review, and review of Resident Council Minutes and the grievance book, the facility failed to ensure that grievances brought forward through Resident Council, regarding long call bell response times, staff cell phone use in unit hallways, and staff speaking a language other than English in resident areas, were acted upon promptly and resolved within seven working days of the grievance filing date, per the facility policy. Findings include: During a resident group meeting on 4/8/21 at 10:00 A.M., nine of eleven residents in attendance said: -Certified Nursing Assistants (CNA) and nurses are on their cell phones while in the hallways on the units; -it takes a long time for staff to answer call bells; and -staff speak a language other than… […]