Windsor the Ridge Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF700Mar 29, 2024

  Based on observation, interview, and record review, the facility failed to attempt, offer, and document the use of bed rail (adjustable metal or rigid plastic bars that attach to the bed) alternatives for 17 of 67 residents (Resident 6, 10, 15, 19, 24, 29, 31, 40, 43, 54, 61, 62, 66, 80, 81, 84, and 94) , and obtain informed consent for one of 67 residents (Resident 199) prior to installation of the bed rails. These failures had the potential to put the residents at risk for entrapment and serious injury. Findings: During the initial tour observation on 3/24/24 at 2:25 p.m., Resident 6, 10, 15, 19, 24, 29, 31, 40, 43, 54, 61, 62, 66, 80, 81, 84, 94, and 199 had upper bed rails elevated and in use. During a concurrent observation and interview on 3/27/24 at 3:02 p.m. […]

• No harm, potential for more than minimal, patternF800Mar 29, 2024

  Based on observation, interview and record review, the facility failed to ensure: 1. The recipe for Spinach was followed according to ingredient list for approximately 15 of 96 sampled residents 2. Accurate diets were not served according to resident preferences for two of 96 sampled residents (Resident 36 & Resident 51) These failures had the potential for adverse reactions to foods added to recipes without residents being aware, and for residents to not eat foods according to personal preferences. Findings: 1. During a concurrent observation and interview on 3/26/24 at 11:59 a.m. with Cook A, Cook A added cooked red bell peppers to the cooked spinach. Cook A stated, I am adding them for some more color. […]

• No harm, potential for more than minimal, patternF812Mar 29, 2024

  Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices in the kitchen when: 1. Dietary Aide (DA) C did not perform hand hygiene after cleaning the floor and touching dirty surfaces; 2. Multiple food items were kept in the freezer after the use by date; and 3. Canned food with major dents were not identified and removed from dry storage shelf These failures had the potential to spread food-borne illness to residents in the facility. Findings: 1. During an observation on 3/26/24, at 11:28 a.m., in the kitchen, DA C cleaned the floors with a broom, then threw trash into the trash can touching the surface of the trash can with his bare hands. […]

• No harm, potential for more than minimal, patternF758Aug 6, 2021

  Based on observation, interview and record review, the facility failed to ensure for four of 19 sampled residents (Residents 82, 67, 29 and 30) were free from unnecessary [CONDITION(S)] medications (drugs that affect brain activities associated with mental processes and behavior when: 1. Resident 82 did not receive a gradual dose reduction (GDR, stepwise tapering of a dose to determine symptoms, conditions or risk can be managed by a lower dose or if the dose or medication can be discontinued) for [MEDICATION(S)] (a medication for depression); 2. Resident 67, there was no specific target behavior to monitor [MEDICATION(S)] (antipsychotic medication); 3. […]

• No harm, potential for more than minimal, patternF804Aug 6, 2021

  Based on observation, interview and record review, the facility failed to ensure food was served at a palatable temperature for three non-sampled residents (Residents 44, 45, and 77) when the residents complained about the food temperature. This failure had the potential to result in decreased food intake and weight loss, compromising the resident's nutritional status. Findings: During an initial tour with Resident 77 on 8/2/21 at 9:41 a.m., Resident 77 stated the hot food was served cold and cold food was served warm. During an initial tour with Resident 45 on 8/2/21 at 10:31 a.m., Resident 45 stated the hot food was cold. During a group meeting on 8/4/21 at 12:54 a.m., Resident 44 stated the hot food was cold when they served the tray. […]