Windsor House at Champion

In the surveyor’s words

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

• Actual harm, isolatedF689Oct 21, 2025

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, facility policy review and interview, the facility failed to ensure Resident #88 was provided with necessary and adequate care and services to prevent accidents with injury during staff assisted care. This affected one resident (#88) of three residents who were investigated for accidents. The facility census was 87. […]

• Actual harm, isolatedF686Feb 23, 2023

  Based on observation, interview, record review and review of the facility policy, the facility failed to implement a comprehensive and individualized pressure ulcer prevention program, including turning and repositioning to prevent the development of in-house pressure ulcers for Resident #19. The facility also failed to timely identify and treat pressure ulcers for the resident. Actual Harm occurred on 01/20/23 when Resident #19, who was cognitively impaired and required extensive assistance from two staff for bed mobility and transfers, identified to have developed two in-house acquired unstageable (full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough [yellow, tan, gray, green or brown] and/or eschar [tan, brown or black] in the wound bed)… […]

• No harm, potential for more than minimal, widespreadF868Jan 9, 2025

  Based on record review and interview, the facility did not ensure Quality Assurance Performance Improvement (QAPI) meetings were held at least quarterly. This had the potential to affect all residents in the facility. The facility census was 80. Findings include: A review of the facility documents titled QA Signature Sheet revealed QAPI meetings were held on 04/12/23, 05/17/23, 06/07/23, 08/16/23, 10/11/23, 04/17/24, 05/08/24, 06/05/24, 07/10/24, 11/13/24, and 12/18/24. There was no evidence a QAPI meeting had been held during the first quarter of 2024. An interview was conducted on 01/09/25 at 2:48 P.M. with the Director of Nursing who verified there was no QAPI meeting held in the first quarter of 2024 and verified the QA Signature Sheets reflected accurate dates of the QAPI meetings.

• No harm, potential for more than minimal, widespreadF812Feb 23, 2023

  Based on observation, interview, and facility policy, the facility failed to ensure the kitchen area was maintained in a clean and sanitary condition and food items were properly dated. This had the potential to affect all 82 of 82 residents who consumed food items from the kitchen. Findings include: Observation of the kitchen on 02/12/23 from 6:26 P.M. to 6:48 P.M. with Dietary #518 revealed: The stand mixer was observed to uncovered and had five spots of dried brown debris on the base and underside of the unit. […]

• No harm, potential for more than minimal, patternF921Jan 9, 2025

  Based on observation, interview and policy review the facility failed to provide a clean shower room on the north hall unit. This had the potential to affect 40 residents identified as utilizing the shower room (Residents #1, #4, #5, #6, #8, #11, #13, #14, #15, #18, #20, #22, #23, #24, #27, #29, #30, #31, #32, #36, #40, #41, #42, #43, #44, #46, #47, #49, #51, #57, #59, #61, #62, #70, #72, #74, #77, #133, #183, and #184). The facility also failed to maintain clean Hoyer (mechanical) lifts on the north hall unit. This had the potential to affect 12 residents (Residents #4, #8, #11, #20, #29, #32, #36, #44, #47, #70, #77, and #183) identified as utilizing the Hoyer lift on the north hall. The facility census was 80. Findings include: Observation on 01/06/25 at 9:00 A.M. […]