Windsor Calallen

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 14, 2023

  Based on record review and interview the facility failed to ensure that each resident recieved adequate supervision and assistance to prevent accidents for one resident (Resident #3) of six resident reviewed for supervision. The facility did not implement Resident #3's comprehensive care plan and did not transfer Resident #3 with a 2-person assisted Hoyer (mechanical lift) transfer as reflected on Resident #3's comprehensive care plan. This deficient practice could place residents at risk for not receiving appropriate treatment and services. […]

• No harm, potential for more than minimal, patternF842Aug 12, 2026

  Based on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 2 of 6 residents (Resident #1 and Resident #2) reviewed for medical records. 1. The facility failed to ensure RN A did not document Resident #1's vital signs as NA on 6 of 6 opportunities between 08/01/26 and 08/11/26.The facility failed to ensure RN A did not document Resident #1's respiratory vital signs as NA on 6 of 6 opportunities between 08/01/26 and 08/11/26.The facility failed to ensure LVN B did not document Resident #1's vital signs as NA on 5 of 5 opportunities between 08/01/26 and 08/11/26.The facility failed to ensure RN C did not document Resident #1's… […]

• No harm, potential for more than minimal, patternF812May 7, 2025

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: 1. The facility failed to ensure all food was labeled, dated, and not expired in refrigerators #1 and #2. 2. The facility failed to ensure all food was labeled, dated, and not expired in freezers #1 and #2. 3. The facility failed to ensure all refrigerators and freezers had internal thermometers. 4. The facility failed to ensure the chest-type milk refrigerator was clean and sanitized. 5. The facility failed to ensure rotted tomatoes were not stored with fresh tomatoes. 6. […]

• No harm, potential for more than minimal, patternF584Mar 6, 2024

  Based on observation interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 4 of 10 residents (Resident #24, Resident #58, Resident #55, and Resident #68), staff, and the public; in that: 1.)The facility failed to ensure bathroom sinks hot water temperatures were below 110 degrees Fahrenheit in occupied rooms for Resident #24 and Resident #58 on 3/4/24 through 3/6/24. 2.)The facility failed to ensure bathroom sinks hot water temperatures were below 110 degrees Fahrenheit in occupied rooms for Resident #55 and Resident #68 on 3/4/24 through 3/6/24. […]

• No harm, potential for more than minimal, patternF755Mar 6, 2024

  Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure he accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on one of four medication carts (hall 100 nurse's cart) reviewed for pharmacy services. 1. The facility failed to account for 2 of Resident #81's 0.5mg Lorazepam (medication to treat anxiety) tablets. 2. RN A and RN B failed to accurately document Resident #81's 0.5mg Lorazepam drug count on 03/04/24. This failure could place residents at risk for drug diversion and delay in medication administration. Findings included: Record review of Resident #81's face sheet revealed a [AGE] year-old female admitted on [DATE]. […]