Inspection Reports for
Windsor House

The complaint investigation involved multiple allegations including failure to notify family of room changes (complaint/report number AL00045069), physical and verbal abuse by staff (complaint/report numbers AL00045242, AL00045244, AL00045448), and unsafe environment due to barricades and inadequate behavioral health care for residents exhibiting wandering behaviors.

The facility failed to notify a resident's representative of a room change, failed to prevent and report multiple incidents of abuse by staff against residents, failed to implement abuse policies and protective measures timely, and failed to maintain a safe environment free from accident hazards such as barricades blocking egress. Additionally, the facility failed to adequately assess and address behavioral health needs of a resident with wandering behaviors.

The deficiencies were cited as a result of investigations of complaint/report numbers AL00043510 and AL00044803.

The facility failed to maintain a homelike environment due to maintenance issues such as chipped paint, leaking faucets and toilets, and broken tiles. Medication administration practices were unsafe, including improper preparation and disposal of medications by a nurse. Documentation of resident care activities was incomplete, and infection control practices were inadequate, with a staff member failing to sanitize hands properly during meal delivery.

This deficiency was cited as a result of the investigation of complaint/report numbers AL00043510 and AL00044803.

The facility was found deficient in maintaining a safe, clean, and homelike environment due to unresolved maintenance issues; improper medication preparation and disposal by nursing staff; failure to document resident care activities such as bathing; and inadequate hand hygiene practices by staff, all with potential to affect residents' health and safety.

The facility was found deficient in multiple areas including failure to notify family of significant weight loss, inadequate maintenance of resident environment, failure to provide bed-hold notices for hospital transfers, inaccurate resident assessments, improper pressure ulcer care, failure to implement toileting programs, medication storage issues, failure to investigate dental concerns, inconsistent documentation of meal intake, and improper infection control practices.

The complaint investigation found that the facility did not report an injury of unknown origin involving Resident Identifier #72's bruising and bleeding of the left eye to the State Agency within 24 hours as required. The Administrator confirmed no report was made for January, February, and March 2019 incidents, with the last reportable incident being December 2018.

The facility failed to report Resident Identifier #72's injury of unknown source to the State Agency within the required 24-hour timeframe. The resident had bruising and bleeding around the left eye, which was assessed and sent to the emergency room, but the injury was not reported as required by facility policy and state regulations.

The complaint investigation found that residents were not invited to care plan meetings as required and that medication administration practices did not meet professional standards, including improper insulin injection site and contamination risk from blowing on medical equipment.

The facility failed to ensure that two cognitively intact residents were invited to their care plan meetings, and a licensed nurse administered insulin incorrectly by injecting it into the deltoid muscle instead of a subcutaneous site. Additionally, a nurse blew on the glucometer and insulin pen before placing them back into the medication cart, risking contamination.