Windsor Health and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Dec 5, 2022

  1. Based on observation, interview, and record review it was determined the facility failed to ensure a resident was assessed and interventions were implemented to prevent aspiration for 1 of 3 sampled residents (#13) reviewed for accidents. This failure resulted in an immediate jeopardy situation. This placed residents at risk for aspiration and death. Findings include: Resident 13 admitted to the facility on [DATE] with diagnoses including pneumonitis (inflammation of lung tissue) due to inhalation of food and vomit, dysphagia (difficulty swallowing), stroke and hemiparesis (weakness to one side of the body). […]

• Actual harm, isolatedF740Jul 13, 2026

  Based on observation, interview and record review it was determined the facility failed to provide necessary behavioral health services for 1 of 1 sampled resident (#32) reviewed for behavior. This failured resulted in Resident 32 continuing to experience untreated mental health symptoms, including expressing statements of wanting to die and socially isolating her/himself. Findings include:Resident 32 admitted to the facility in 4/2026 with diagnoses including anxiety disorder, obsessive-compulsive disorder, attention deficit hyperactivity disorder, post-traumatic stress disorder, major depressive disorder, and bipolar disorder.A 4/30/26 admission MDS revealed Resident 32 had a score of 19 on the Patient Health Questionaire-9 (an assessment of depression symptoms), which indicated she/he… […]

• No harm, potential for more than minimal, widespreadF727Jul 13, 2026

  Based on interview and record review it was determined the facility failed to staff a registered nurse for eight consecutive hours per day, seven days per week, for 18 out of 34 days reviewed for staffing. This placed residents at risk for unmet assessment needs. Findings include:A review of the Direct Care Staff Daily Reports dated 6/3/26 through 7/6/26 revealed there were 18 days without 8 consecutive hours of registered nurse coverage on any shift in a 24 hour period on the following dates: 6/3/26, 6/4/26, 6/8/26, 6/9/26, 6/10/26, 6/15/26, 6/16/26, 6/17/26, 6/18/26, 6/22/26, 6/23/26, 6/24/26, 6/25/26, 6/29/26, 6/30/26, 7/1/26, 7/2/26, and 7/6/26. On 7/7/26 at 5:19 PM, Staff 18 (LPN) stated Staff 2 (DNS) did not work the floor. […]

• No harm, potential for more than minimal, widespreadF812Mar 14, 2025

  Based on observation, interview and record review it was determined the facility failed to ensure kitchen staff wore appropriate hair restraints during meal preparation for 1 of 1 facility kitchen reviewed for sanitation. This placed residents at risk for unsanitary foods. Findings include Review of the US FDA Food Code 2022 revealed: -food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food. On 3/12/25 at 11:43 AM Staff 18 (Cook) was observed plating meals without wearing a hair restraint. […]

• No harm, potential for more than minimal, widespreadF727Sep 1, 2021

  Based on interview and record review it was determined the facility failed to ensure an RN was available for at least eight consecutive hours for 13 days out of 58 days reviewed for RN coverage. This placed residents at risk for delayed nursing assessments. Findings include: A review of Direct Care Staff Daily Reports from 2/1/21 through 2/28/21 and 7/24/21 through 8/22/21 revealed the following dates with no RN coverage: - 2/5/21 - 2/6/21 - 2/12/21 - 2/16/21 - 2/18/21 - 2/19/21 - 2/25/21 - 2/26/21 - 2/27/21 - 7/24/21 - 8/3/21 - 8/4/21 - 8/5/21 On 9/1/21 at 1:08 PM Staff 1 (Administrator) acknowledged the lack of RN coverage on the identified dates.