Windsor Nursing & Retirement Home

Windsor Nursing & Retirement Home

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Windsor Nursing & Retirement Home? Our lawyers can help.

Abuse of the elderly is not acceptable and we fight hard in these types of cases. If you suspect a nursing home or caregiver has caused harm to your loved one in someone elses’ care, contact our law firm today for a free legal consultation.

Talking to us does not obligate you to anything, but we may be able to tell you if you have a claim and the value of your case. If we accept your case, you pay no fee unless we recover for you.

About Windsor Nursing & Retirement Home

Windsor Nursing & Retirement HomeWindsor Nursing & Retirement Home is a non-profit, 120 bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Yarmouth, Brewster, Dennis, Harwich, Mashpee, Sandwich, Bourne, Falmouth, Nantucket, Warehamn, Plymouth, Carver, Kingston, Duxbury, Fairhaven, and the other towns in and surrounding Barnstable County, Massachusetts.

Windsor Nursing & Retirement Home focuses on 24 hour care, respite care, hospice care and rehabilitation services.

Windsor Nursing & Retirement Home
265 N Main Street
South Yarmouth, MA 02664

Phone: (508) 394-3514
Website: https://windsorskillednursing.org/

CMS Star Quality Rating

The Centers for Medicare and Medicaid (CMS) rates all nursing homes that accept medicare or medicaid benefits. CMS created a 5 Star Quality Rating System—1 star is the lowest rating and 5 stars is the highest—that look at three areas.

As of 2017, Windsor Nursing & Retirement Home in South Yarmouth Massachusetts received a rating of 4 out of 5 stars.

Performance Area Rating
Overall Rating 4 out of 5 (Above Average)
State Health Inspections 2 out of 5 (Below Average)
Staffing 4 out of 5 (Above Average)
Quality Measures 5 out of 5 (Much Above Average)

Fines and Penalties

Our Nursing Home Abuse and Neglect Attorneys inspected government records and discovered Windsor Nursing & Retirement Home committed the following offenses:

The nursing home failed to make sure services provided by the nursing facility meet professional standards of quality.

Based on record review and staff interview, the facility failed to ensure that for one resident (#9) of 20 sampled residents, medications were administered as ordered by the physician.

Findings include:

Standard reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and Practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered nurse and practical nurse incorporate into the plan of care, and implement prescribed medical regimens. The rules and regulations 9.03 define standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice.

For Resident #9, the facility failed to ensure that physician’s order for a [MEDICATION NAME] (anti-coagulant medication) flush for an implanted port (intravenous access for antibiotics) was followed, consequently Resident #9 received the incorrect dose of [MEDICATION NAME] flush for 9 days. Resident # 9 was admitted to the facility 2/2014 and his/her [DIAGNOSES REDACTED]. The most recent annual Minimum Data Set (MDS) assessment, dated 12/16/16, indicated that Resident #9 had a brief interview for mental status (BIMS) score of 14 out of 15, meaning Resident #9 was cognitively intact. The MDS indicated that Resident #9 was tired and had symptoms of depression, he/she required assistance of the staff for all of his/her activities of daily living; he/she was incontinent of bowel and bladder, and Resident #9 did not ambulate.

eview of the clinical record included a urinalysis and culture report, dated 1/13/17, which indicated the following: Escherichia Coli greater than 100,000 identified as a drug resistant organism, ESBL (extended spectrum beta lactamase). In addition, the urinalysis indicated that Resident #9’s urine contained Proteus Mirabilis greater than 100,000.

Review of the physician’s order, dated 1/23/17, indicated that Resident #9 was prescribed the antibiotic, [MEDICATION NAME], 1 gram, intravenously, daily for 10 days. Review of the Physician’s order indicated the protocol for the implanted port for intravenous access. The physician order/protocol included for an implanted port: the staff would flush the port before the antibiotic with normal saline 5 cubic centimeters (cc), then administer the antibiotic, then flush with the normal saline after the antibiotic, and then flush the port with a [MEDICATION NAME] flush. The physician’s order indicated that the strength of the [MEDICATION NAME] flush was 100 units/ml (milliliters) and the amount of the flush was 5 ml. Review of the Facility policy for implanted venous port indicated that staff would verify the Physician’s order prior to accessing the site. The Surveyor observed the medication pass on 2/1/17 at 10:00 A.M.

The Surveyor observed Medication Nurse #1 gather supplies to administer Resident #9’s antibiotic medication including the flushes. The Surveyor observed Medication Nurse #1 gather the [MEDICATION NAME] flush that she would use after the antibiotic was finished. The Surveyor observed Medication Nurse #1 hang the antibiotic and place the [MEDICATION NAME] flush on the bedside stand. The Surveyor read the label on the [MEDICATION NAME] flush and observed that the strength was [MEDICATION NAME] 10 units/ml.

The Surveyor asked Medication Nurse #1 about the [MEDICATION NAME] flush strength, and she said the strength was correct. The Surveyor then interviewed Unit Manager #2. The Surveyor and Unit Manager #2 looked in the medication room for the [MEDICATION NAME] flushes and observed a bag of flushes labeled [MEDICATION NAME] 10 units/ml. Unit Manager #2 said the [MEDICATION NAME] was different than the Physician’s order. The Surveyor interviewed the Director of Nurses (DON) on 2/2/17. The DON said after Surveyor intervention on 2/1/17, the staff obtained the correct strength of flush from the emergency kit (Pyxis) for the flush on 2/1/17. The DON said she was not certain that Resident #9 received the correct [MEDICATION NAME] flush from 1/23/17 to 2/1/17. Unit Manager #2 said she notified the Pharmacy, who said they sent the wrong strength of [MEDICATION NAME] flushes.

There was no evidence provided to the Surveyors at the exit conference to ensure that Staff were aware of the medication discrepancy and no evidence that Resident #9 received the correct dose of [MEDICATION NAME] flushes from 1/23/17 to 2/1/17.

The nursing home failed to have a program that investigates, controls and keeps infection from spreading.

Based on record review, observation and interview, the facility failed to ensure for 1 resident (#9) out of a total sample of 20 resident records, that contact precautions were initiated for a resident who had a urinary tract infection with a MDRO (multi drug resistant organism) for 9 days until Surveyor intervention on 1/31/17.

Findings include:

Resident # 9 was admitted to the facility 2/2014 and his/her [DIAGNOSES REDACTED]. The most recent annual Minimum Data Set (MDS) assessment, dated 12/16/16, indicated that Resident #9 had a brief interview for mental status (BIMS) score of 14 out of 15, meaning Resident #9 was cognitively intact. The MDS indicated that Resident #9 was tired and had symptoms of depression, he/she required assistance of the staff for all of his/her activities of daily living; he/she was incontinent of bowel and bladder and Resident #9 did not ambulate.

Review of the clinical record indicated a urinalysis report, dated 1/13/17, indicated that Resident #9’s urine contained Escherichia Coli greater than 100,000 identified as a drug resistant organism, ESBL (extended spectrum beta lactamase). In addition the report indicated that Resident #9 ‘s urine contained the organism Proteus Mirabilis, greater than 100,000. Review of the facility policy for contact precautions, dated 11/7/16, indicated that contact precautions were indicated for any infectious disease that was transmitted through direct contact and recommendations indicated gowns, gloves, private room or cohort.

The Surveyor and Unit Manager #2 toured the unit on 1/31/17 during the morning and observed that Resident #9’s room was not identified as a precaution room. Unit Manager #2 told the Surveyor that Resident #9 was on intravenous antibiotics for a urinary tract infection but the infection was colonized and when Resident #9 had symptoms of nausea and vomiting, the Physician initiated the antibiotic. Unit Manager #2 said no precautions were

The nursing home failed to keep accurate, complete and organized clinical records on each resident that meet professional standards.

Based on record review and staff interview, the facility failed to maintain medical records, for two sampled residents (#6 and #19), that were complete and accurate. The total sample was 20 residents.

Findings include:

1. For Resident #6, the facility failed to accurately document a [MEDICAL CONDITION] event the Resident had on 7/15/17 by not including documentation of the [MEDICAL CONDITION] type and duration of the [MEDICAL CONDITION]. Resident #6 was a long term care resident with multiple [DIAGNOSES REDACTED]. A review of the medical record indicated a nurses’ progress note, dated 7/15/16 written at 12:30 P.M. described the following: at 7:40 A.M., noted that the Resident was found with [MEDICAL CONDITION] activity and unresponsive.

The note documented a Code Blue was called in the facility and the Resident had a pulse and respirations. There was no information of what the pulse and respirations were and no information of the nurse assessing the type of [MEDICAL CONDITION] and the duration of the [MEDICAL CONDITION]. The next nurses’ progress note written at 1:00 P.M. on 7/15/16 documented the Code Blue was called at 7:30 A.M. (ten minutes earlier than previous note) and noted the Resident was being treated by two nurses.

The nurse wrote the Resident had a pulse and respirations and documented a blood pressure of 146/78 and pulse of 99 and no record of respirations. The note continued with the Resident being unresponsive and staff report possible [MEDICAL CONDITION] as reason for Code Blue. At 7:51 A.M. the Resident was transferred to the hospital. The nurse documentation for the two notes had no information of the nursing staff observing the sequence and timing of the [MEDICAL CONDITION] activity. There was no information of the nursing staff noting the type of [MEDICAL CONDITION] (tonic, clonic, staring, blinking); whether more than one type of [MEDICAL CONDITION] occurred. The record had no information of the Resident having the presence of autonomic signs of lip smacking, grimacing or rolling of the eyes. A review of the hospital discharge summary after admission to the hospital, dated 7/18/16 indicated the Resident had a witnessed [MEDICAL CONDITION].

The facility’s medical record had no information of who had witnessed the [MEDICAL CONDITION] and no description written as to what type of [MEDICAL CONDITION], duration or signs of [MEDICAL CONDITION] the Resident may have experienced. Interview on 2/2/17 at 12:30 P.M., the Director of Nurses said she was not working at the facility at that time and would review. The Director said she would speak to the nurses who had written the notes. 2. For Resident #19, the medical record had no information of having received a physician ordered monthly antipsychotic medication. The Resident was admitted on ,[DATE] and transferred to another facility on 12/2016. Resident #19 was a closed record review on 2/3/17. The medical record indicated the Resident had a [DIAGNOSES REDACTED]. IM (Intramuscular) every month.

A review of the medication administration records for 9/2016 and 11/2016 indicated the Resident received the monthly medication. The 10/2016 Medication Administration Record [REDACTED]. During interview on 2/7/17 at 11:00 A.M., the Director of Nurses said the record was incomplete and the nurse should have signed off the monthly [MEDICATION NAME] medication.

Boston Nursing Home Neglect and Elder Abuse Lawyers

In addition to the above reported deficiencies, the nursing home was also cited for the failure to:

  • Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents.  Based on observation, staff interview and review of the facility’s emergency water and disaster plan documentation, the facility failed to ensure sufficient food and portable water supplies to meet the needs of the residents in a potential emergency were monitored to ensure availability, according to the facility’s Disaster Emergency Water and Feeding Plan.
  • Listen to the resident or family groups or act on their complaints or suggestions.  Based on the Resident Council group interview and staff interviews, the facility failed to
    act upon the Council’s concerns and communicate back to the Council answers to the groups grievances, leaving the Residents with a lack of support and feeling that the group was ineffective.
  • Give the right treatment and services to residents who have mental or psychosocial problems adjusting.  Based on record review and interviews, the facility failed to ensure they could provide services for 2 sampled Residents (#3 and #12) with mental health, addictive behaviors and/or substance use disorder care needs, prior to admitting residents with these needs,
    from a total of 20 residents. For Residents #3, the facility failed to ensure psychiatric and addictive behavioral services were developed and included in treatment plans to assist residents admitted with medical histories that included addictive behaviors and substance use disorder. For Resident #12, the facility failed to provide services to treat [DIAGNOSES REDACTED].
  • Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.  Based on observation, interviews with residents and staff, the resident group meeting, and for 4 of 5 test trays, the facility failed to ensure meals served were palatable and at appropriate temperatures.

Windsor Nursing & Retirement Home, Nursing Home Neglect and Elder Abuse Lawyers

If someone you love has suffered neglect or elder abuse by a senior caregiver, nursing home, or other care facility, our lawyers may be able to help. Regardless of whether or not criminal charges are filed against an alleged abuser, you may still be able to pursue compensation in a civil claim. Compensation in elder abuse cases may be awarded if someone in the care of another suffers harm due to intentional or negligent actions (including failure to take action).

Abuse of the elderly is not acceptable and we fight hard in these types of cases. If you suspect a nursing home or caregiver has caused harm to your loved one in someone elses’ care, contact our law firm today for a free legal consultation. Talking to us does not obligate you to anything, but we may be able to tell you if you have a claim and the value of your case. If we accept your case, you pay no fee unless we recover for you.

Oftentimes, victims of abuse either cannot or will not speak up for themselves out of fear. If you notice any warning signs or symptoms of neglect of abuse an an elderly person, it is important you contact an elder abuse lawyer immediately. Not only are there statute of limitations on filing a claim, but the sooner we start helping you, the easier it will be to collect evidence and talk to any witnesses before important details are lost, hidden, or forgotten.

 

Boston Personal Injury Lawyers for Elder Abuse Cases

Cape Cod / South Yarmouth Nursing Home Neglect and Elder Abuse Attorneys

We offer a free, no-obligation legal consultation to help you understand your rights and the value of your case. Our personal injury law firm takes cases involving elder abuse and neglect. We offer legal service to clients in Massachusetts, Rhode Island and New Hampshire.


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Page Last Updated: December 23, 2017

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