Windsor House

The facility failed to administer medication as ordered by the primary care provider for one resident. Specifically, the resident was not receiving required finger stick blood sugar checks four times daily as prescribed for managing elevated blood sugar.

The facility failed to administer medication as ordered by the primary care provider for a resident with type 2 diabetes. Specifically, the facility did not follow orders for finger stick blood sugar checks four times daily and failed to properly monitor blood sugar levels before insulin administration.

The facility failed to provide necessary personal care assistance for 2 of 5 sampled residents who required staff assistance with fingernail care. Specifically, an observation of Resident #1 revealed fingernails that were 1/4 inch long with a dark brown substance underneath all nails.

The facility failed to ensure the Special Care Unit (SCU) was free of hazards in 47 resident rooms. Specifically, various items including toiletries, medication patches, shampoo, and batteries were left accessible to residents, posing an ingestion or safety risk.

The facility failed to ensure the Special Care Unit was free of hazards by allowing various items to be accessible to residents in 47 resident rooms. Specifically, items such as toiletries, batteries, fingernail clippers, and non-prescription pain patches were found in resident areas, posing an ingestion or safety risk.

The facility failed to refer a resident to home health skilled nursing for catheter care as required by the physician's order. This failure resulted in the resident experiencing complications, including a urinary tract infection and multiple emergency department visits for catheter-related trauma.

The facility failed to provide adequate supervision for a resident with dementia in a special care unit. This resulted in the resident eloping from the facility unnoticed and being found sitting in a vehicle in the parking lot.