Windsor Medical Center Inc

In the surveyor’s words

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

• Immediate jeopardy, widespreadF607Mar 14, 2023

  Based on record review, review of facility self-reported incidents, review of the facility policy and procedure related to Abuse and staff interview the facility failed to ensure allegations of staff to resident physical and verbal abuse that occurred on 02/22/23 were reported timely to ensure all facility residents were protected. This resulted in Immediate Jeopardy on 02/22/23 at approximately 1:30 A.M. when State tested Nursing Assistant (STNA) #374 witnessed STNA #370 potentially physically and verbally abuse Resident #26, a resident who resided in a facility licensed only bed but failed to immediately report the incident. On 02/22/23 at approximately 4:45 A.M. […]

• No harm, potential for more than minimal, widespreadF880Mar 2, 2026

  Based on closed record review, facility policy review, and interview the facility failed to effectively and timely communicate and provide information as requested to State and local public health authorities to mitigate the potential spread of legionella. This had the potential to affect 3 of 3 residents residing in the facility. Findings include:Review of an undated facility policy titled Water Management Policy revealed when a suspected or confirmed outbreak occurred, the Water Management Team would initiate a thorough investigation to identify the source, assess the extent of exposure, and implement control measures. […]

• No harm, potential for more than minimal, widespreadF812Jun 23, 2022

  Based on observation and staff interview the facility failed to ensure an ice scoop was properly stored in a clean and sanitary manner to prevent contamination. This had the potential to affect 16 of 16 residents residing in the facility. Findings include: On 06/22/2 at 7:19 A.M. Stated tested Nursing Assistant (STNA) #800 was observed to retrieve an ice scoop from inside the ice machine. The ice scoop was observed directly on top of the ice. The STNA proceeded to fill a glass up with ice for a resident and then placed the ice scoop back into the ice machine directly on top of the ice without any type of protective barrier. On 06/22/22 at 7:19 A.M. […]

• No harm, potential for more than minimal, isolatedF628May 8, 2025

  Based on record review, interview, and review of facility policies, the facility failed to provide written transfer and bed hold notices to Residents #1 and #114 at the time of transfer to the hospital. This affected two residents (#1 and #114) of two reviewed for hospitalization. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 04/03/25 with diagnosis including, sepsis, diabetes type 2, hypertension, UTI, pneumonia, kidney stones, low potassium, and anemia. Resident #1 was discharged to the hospital 05/03/25. Review of progress note dated 05/03/25 at 1:15 P.M. revealed abnormal lab results were reported to the Certified Nurse Practitioner (CNP) and the response was to send Resident #1 to the hospital for further evaluation. […]

• No harm, potential for more than minimal, isolatedF641May 8, 2025

  Based on record review and interview, the facility failed to ensure resident assessments were completed accurately. This affected two (Residents #116 and #117) of 11 residents reviewed for accuracy of assessments. Findings include: 1. Review of the medical record for Resident #116 revealed an admission date of 03/10/25 with diagnoses including adult failure to thrive, congestive heart failure and hypertension. Resident #116 remained in the facility as of the survey on 05/08/25. Review of Resident #116's Minimum Data Set (MDS) 3.0 assessments the facility had completed revealed the facility had submitted a discharge return not anticipated assessment on 04/17/25. Interview on 05/08/25 at 2:18 P.M. […]