Windsor Nursing and Rehabilitation Center of Alice

In the surveyor’s words

From the most serious findings on record at Windsor Nursing and Rehabilitation Center of Alice, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jul 3, 2025

  Based on observation, interview, and record review the facility failed to ensure each resident had the right to be free from abuse for seven residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident#15, Resident #20 and Resident #23) of 7 residents reviewed for abuse/neglect. 1. The facility failed to ensure Resident #2 was free from abuse, Resident #2 sustained a right hip fracture from being pushed by Resident #3 on 04/22/25. 2. The facility failed to ensure Residents #2 and #5 were free from abuse, Resident #4 hit Resident #3 in the back of the head causing a bump to her head and pushed Resident #5 that caused him to fall on top of another resident on 06/07/25 at 4:50 PM. 3. […]

• Immediate jeopardy, isolatedF689Jul 3, 2025

  Based on observation, interviews, and record reviews the facility failed to ensure residents received adequate supervision to prevent accidents and/or hazards as possible for 1 of 12 residents (Resident #1) reviewed for supervision and accident hazards. The facility failed to ensure Resident #1 received adequate supervision in allowing Resident #1 to exit the facility without the knowledge of staff sometime between 6:30 PM and 7:00 PM on 05/16/25. An IJ was identified on 07/01/25. The IJ template was provided to the facility on [DATE] at 8:15 PM. While the IJ was removed on 07/03/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because new polices implemented to prevent future errors were still in process. […]

• Immediate jeopardy, isolatedF689Jan 3, 2025

  Based on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one (Resident #1) of 4 residents reviewed for supervision. The facility failed to ensure Resident #1 received adequate supervision while Resident #1 was unaccounted for approximately 29 minutes from 4:46 PM to 5:15 PM on 08/17/24 before a 3rd party notified CNA A that Resident #1 was in her wheelchair outside the facility. The noncompliance was identified as PNC. The PNC began on 08/17/24 and ended on 09/04/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents requiring supervision at risk for injury and accidents with potential for more than minimal harm. […]

• No harm, potential for more than minimal, widespreadF812Feb 26, 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 reviewed for storage, preparation, and sanitation. The facility failed to ensure kitchen equipment was in good condition. This failures could place residents at risk for complications from food contamination. The findings included: Observation of the kitchen during initial tour on 02/24/25 at 10:20 AM revealed a 3-door refrigerator and a 2-door refrigerator. The temperature in both refrigerator was below 41 degrees Fahrenheit. It was noted that on both refrigerator's when one door was closed the other door(s) opened. […]

• No harm, potential for more than minimal, widespreadF812Dec 7, 2023

  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 reviewed for sanitation in that: 1. The facility failed to ensure the juice dispenser guns were sanitary 2. The facility failed to ensure the dishes were clean and sanitized 3. The facility failed to ensure equipment was clean and sanitized 4. The facility failed to remove a dented can from service 5. The facility failed to discard and replace unsanitary cooking utensils 6. The facility failed to refrain from having personal items in the prep areas 7. The facility failed to maintain cleanliness of the floor in the nutrition room 8. […]