Windsor Healthcare Residence

In the surveyor’s words

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

• Immediate jeopardy, patternF600Aug 28, 2025

  Based on observations, interviews and record reviews, the facility failed to ensure the residents right to be free from abuse for three (Residents #10, #52, and #32) of five residents reviewed for abuse, in that:On 7/28/25, Resident #10 was pushed by Resident #62 after the resident attempted to enter Resident #62's room without permission.On 8/07/25, Resident #52 and Resident #62 were engaged in a pushing match. Resident #62 pushed Resident #52. Resident #52 fell to the floor and hit her head. Resident #52 was sent to ER for evaluation and sustained no injuries.On 08/25/25, Resident #32 was pushed Resident #62 after the resident entered Resident #62's room without permission. Resident #32 fell to the floor and hit her head. […]

• Immediate jeopardy, isolatedF678Sep 15, 2023

  Based on observation, interview, and record review, the facility failed to ensure personnel provided basic life support, which included CPR, to a Resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the Resident's advance directives for 1 of 6 Residents (Resident #1) reviewed for cardio-pulmonary resuscitation. RN A and LVN B failed to continue to perform CPR, until the arrival of emergency medical personnel, to Resident #1 who was a full code status. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 5:05 PM. […]

• Actual harm, isolatedF689Nov 20, 2023

  Based on observation, interview, and record review the facility failed to provide adequate supervision and assistive devices to prevent accidents for 1 (Resident # 1) of 9 reviewed for falls. The facility failed to provide adequate supervision for Resident # 1 , by ensuring all staff were awake while on duty, which resulted in Resident # 1 falling on 11/14/2023 and sustaining a right superior and inferior pubic rami fracture. This failure could resulted in Resident # 1 with a fracture of the right superior and inferior pubic rami fracture and the other residents at risk from injuries. Findings include: Review of Resident # 1's face sheet dated 11/14/2023 revealed a [AGE] year-old female admitted on [DATE]. […]

• No harm, potential for more than minimal, widespreadF908Apr 14, 2022

  Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for two of two laundry washers, reviewed for essential equipment, in that: One of the facility laundry washers was completely inoperable, and the other was leaking water from several areas. This deficient practice could result in residents not having access to hygienically clean laundry. Having safe functional equipment to provide facility related services. Findings included: Observation on 4/12/2022 at 8:21 a.m. revealed two commercial laundry washers in the dirty side of the facility laundry building. The machine on the left was not in operation at all. […]

• No harm, potential for more than minimal, patternF812Aug 28, 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. The facility failed to ensure the food served was fresh and in an edible condition. The facility failed to ensure food was served in a sanitary manner.This failure could place residents at risk of foodborne illness by serving them expired food and food in unsanitary conditions. Findings included: Observation on 8/26/2025 at 8:33 AM of the cooler revealed the following: - Moldy tomatoes were in a box with no date. - Moldy cucumbers were in a box with no date. […]