Windsor Gardens

In the surveyor’s words

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

• Immediate jeopardy, isolatedF656Jun 22, 2024

  Based on observation, interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs in order attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of eight residents reviewed for care plans. The facility failed to ensure CNA A followed Resident #1's comprehensive care plan to ensure safe mechanical lift transfers. The facility failed to ensure CNA A followed Resident #1's comprehensive care plan which required two-person shower assists, which caused Resident #1 to fall from the shower bed and sustained a frontal scalp hematoma and laceration on her forehead which required 3 stitches. […]

• Immediate jeopardy, isolatedF689Jun 22, 2024

  Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible; and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of eight residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 was transferred by two people using a mechanical lift as indicated in the comprehensive care plan. The facility failed to ensure two people assisted Resident #1 during showers as indicated in the comprehensive care plan. Resident #1 fell from the shower bed and sustained a frontal scalp hematoma and laceration on her forehead which required 3 stitches. […]

• No harm, potential for more than minimal, patternF550Jul 20, 2026

  Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for two (Residents #1 and #2) of eight residents reviewed for resident rights. A) 1.The facility failed to ensure Resident #1 was adequately dressed, on Monday 07/20/26 at 9:35 am. He was sitting in a wheelchair with only a blue hospital gown on, at the north end of the 600 hall. 2. The facility failed to ensure Resident #1 was adequately dressed, on Monday 07/20/26 at 10:39 am. […]

• No harm, potential for more than minimal, patternF558Jan 15, 2026

  Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #7, Resident #98, and Resident #104) of twenty-one residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #7, Resident #98, and Resident #104's rooms were in a position that was accessible to the resident on 01/13/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Resident #98Review of Resident #98's Face Sheet, dated 01/14/2026, reflected an [AGE] year-old female admitted on [DATE]. […]

• No harm, potential for more than minimal, patternF583Jan 15, 2026

  Based on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy and confidentiality of his or her personal and medical records for eleven (Residents #2, #5, #33, #40, #44, #49, #53, #91, #100, #116, and #117) of twenty-eight residents reviewed for resident rights. 1. The facility failed to ensure LVN B secured Resident #5's medical information before leaving her cart on 01/13/2026.2. The facility failed to ensure MA C secured Residents #2, #33, #40, #44, #49, #53, #91, #100, #116, and #117's medical information before leaving her cart on 01/14/2026.These failures could place the residents at risk of not having their personal and medical information confidential and exposed to unauthorized individuals.Findings included: 1. […]