Windsor Point Continuing Care

In the surveyor’s words

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

• Immediate jeopardy, isolatedF888Jul 15, 2022

  Based on observations, staff interviews and record review, the facility failed to implement their policy for COVID-19 vaccinations and to meet the requirement for staff vaccinations when Nursing Assistant (NA) #1 and NA #2 worked without being fully vaccinated and without an exemption. This was for 2 of 7 staff members reviewed for COVID-19 vaccinations. The facility was in outbreak status from 6/11/22 to 7/9/22 and had 4 resident infections from 6/11/22 through 6/20/22 (Residents #14, #16, #22 and #4) with one of those residents experiencing a hospitalization (Resident #16). […]

• No harm, potential for more than minimal, widespreadF847Oct 26, 2023

  Based on a review of the facility arbitration agreement and staff interview, the facility failed to allow residents/resident representatives the right to choose whether or not to enter into a binding arbitration agreement when they required a binding arbitration agreement to be signed as a condition of admission to the facility and as a requirement to continue to receive care. This agreement was provided in the admission packet and was required to be signed during the admission process and it remained in effect throughout a residents stay at any level of care within the continuing care community. This affected all facility residents. The findings included: A review of the facility's admission packet titled, Resident Agreement Continuing Care Contract 2023/2024 was conducted on 10/23/2023. […]

• No harm, potential for more than minimal, widespreadF848Oct 26, 2023

  Based on record review of the facility arbitration agreement and staff interviews, the facility failed to provide an arbitration agreement that provided for 1) a selection of a neutral arbitrator agreed upon by both parties and 2) the selection of a venue that was convenient to both parties. This agreement was provided in the admission packet and was required to be signed during the admission process and it remained in effect throughout a residents stay at any level of care within the continuing care community. This affected all facility residents. Findings included: A review of the facility's admission packet titled, Resident Agreement Continuing Care Contract 2023/2024 was conducted on 10/23/2023. […]

• No harm, potential for more than minimal, widespreadF851Oct 26, 2023

  Based on record review and staff interviews the facility failed to electronically submit complete and accurate Registered Nurses hours based on payroll data to the Centers for Medicare and Medicaid (CMS) for the third quarter of 2023. Findings included: The payroll-based journal staffing report triggered for no Registered Nurses hours on four or more days. A review of the staffing sheets did not include Registered Nurses who were in the building 16 out of 92 days reviewed. A review of the payroll for those days revealed that there were Registered Nurses in the building for 8 consecutive hours on those days. […]

• No harm, potential for more than minimal, widespreadF812Jul 15, 2022

  Based on observation and staff interviews the facility failed to ensure that food items that had been opened were securely closed, labeled, and dated. The facility also failed to maintain equipment used to prepare, store, and serve food in a sanitary condition. This was evidenced by carts and equipment that had a heavy accumulation of grease and dark matter, items that were stained, and an item with areas that were rusted through the metal surface. This was evident in 2 of 2 kitchen observations. Findings included: An observation of the facility kitchen on 6/27/2022 at 10:03 AM revealed the following: 1. In the reach-in refrigerator, there were two small clear plastic bags of shredded yellow cheese that were opened and not labeled and dated. […]