Windsor Health Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF727Dec 31, 2024

  Based on record review and staff interview, the facility failed to ensure there was a registered nurse ( RN) on duty for at least eight consecutive hours a day and seven days a week as required. This had the potential to affect all 56 residents. The facility census was 56. Findings include: Review of the staff schedule for the week of 12/22/24 to 12/28/24 revealed there was no RN scheduled in the building on 12/22/24, 12/25/24, and 12/28/24. Interview on 12/31/24 at 11:45 A.M. with the Payroll Coordinator (PC) #360 stated an RN was scheduled on 12/22/24 but was pulled to another facility. PC #360 confirmed no RN was scheduled on 12/25/24 or 12/28/24 or present in the facility. Interview on 12/31/24 at 1:00 P.M. […]

• No harm, potential for more than minimal, widespreadF727Feb 27, 2023

  Based on record review and interview, the facility failed to have a Registered Nurse (RN) working in the facility for eight consecutive hours each day of the week. This had to potential to affect all 47 residents in the facility. Findings include: Review of the schedule for 01/22/23 through 02/26/23 revealed the facility did not have an RN working for eight consecutive hours on 01/22/23, 01/28/23, 01/29/23, 02/04/23, 02/05/23, 02/11/23/ 02/12/23, 02/18/23, 02/19/23, 02/25/23 and 02/26/23. Interview on 02/22/23 at 6:52 A.M. with Licensed Practical Nurse (LPN) #409 revealed she had no knowledge of any RN's working for the facility except for the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) #456. Interview on 02/23/23 at 8:09 A.M. […]

• No harm, potential for more than minimal, patternF602Feb 14, 2026

  THIS DEFICIENCY IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, Self-Reported Incident (SRI) review and interview, the facility failed to ensure residents were free from misappropriation. This finding affected four (Residents #49, #55, #56 and #57) of four residents identified during the investigation of diversion of narcotics. Findings include: Review of Resident #49's medical record revealed the resident was admitted on [DATE] with diagnoses including quadriplegia, chronic pain syndrome and anemia. […]

• No harm, potential for more than minimal, patternF881Jun 18, 2025

  Based on record review, interview, and review of the facility policy, the facility failed to utilize an effective antibiotic stewardship program that monitored antibiotic use including reducing the risk of adverse effects of the development of antibiotic resistant organisms from unnecessary or inappropriate antibiotic use. This affected 15 residents (#4, #7, #11, #19, #30, #31, #32, #33, #34, #37, #42, #49, #56, #57 and #61) out of 16 residents who were ordered antibiotics during the months of April 2025 and May 2025. The facility census was 57. Findings include: 1. Review of the Monthly Infection Log for April 2025 revealed the facility tracked residents who received antibiotics during the month. […]

• No harm, potential for more than minimal, isolatedF686Jun 18, 2025

  Based on observation, interview, record review, and facility policy review the facility failed to ensure a low air loss mattress (a specialized therapeutic surface to help redistribute pressure across the body to prevent pressure ulcers) was initiated for Resident #32 as recommended per Wound Nurse Practitioner (NP) #479. This affected one (Resident #32) out of two residents reviewed for wounds. The facility identified 13 residents (#6, #7, #9, #11, #29, #30, #31, #32, #35, #36, #40, #48, #57) with wounds. The facility census was 57. Findings include: Review of medical record for Resident #32 revealed an admission date of 03/27/25 and diagnoses including diabetes, muscle wasting, chronic kidney disease, and peripheral vascular disease. […]