Windsor Nursing and Rehabilitation Center of Duval

In the surveyor’s words

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

• Immediate jeopardy, widespreadF921Jan 27, 2024

  Based on observations, interviews, and record reviews, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible for 1 of 1 facility reviewed for physical environment, in that: The facility failed to ensure no open flames are near oxygen cylinders, store cylinders in the upright position, and secure the cylinders from residents and the public. An Immediate Jeopardy (IJ) was identified on 01/26/24 at 10:25 AM While the IJ was removed on 01/27/24 at 10:27 AM, the facility remained out of compliance at a scope of widespread and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to monitor their corrective actions. […]

• Actual harm, isolatedF600Sep 9, 2024

  Based on interview and record review, the facility failed to keep residents free from abuse for 1 (Resident # 1) of 9 residents reviewed for abuse. The facility failed to ensure Resident # 1 was not physically assaulted by Hospitality Aide A. The noncompliance was identified as PNC. The IJ began on 08/02/2024 and ended on 08/06/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of physical harm, mental anguish, or emotional distress. […]

• No harm, potential for more than minimal, patternF605May 22, 2026

  Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity, including the right to be free from unnecessary drugs used in excessive dose including duplicated drug therapy, excessive duration, without adequate monitoring, and without adequate indications for it for 1 of 5 residents (Resident #14) reviewed for pharmacy services and unnecessary drugs. The facility did not prevent Resident #14 from receiving 13 doses of unnecessary psychotropic drug, Ativan 1ml/mg, discontinued on [DATE]. This failure could place residents at risk for overdosing, delayed healing, and other adverse consequences. […]

• No harm, potential for more than minimal, patternF755May 22, 2026

  Based on observation, interview, and record review, the facility failed to establish a system of accurate reconciliation and determine that drug records were in order, and that an account of all controlled drugs were maintained and periodically reconciled for 3 of 11 medication carts (Medication Cart #1, Medication Cart #2, and Medication Cart #3) in the facility effecting 5 of 11 residents (Resident #91, Resident #201, Resident #122, Resident #14, and Resident #73) reviewed for pharmacy services.The facility failed to ensure:1. RN A accurately reconciled Resident #91's narcotic medication log on medication cart #1 when he administered Resident #91's Lorazepam 0.5 mg (controlled medication used for anxiety). […]

• No harm, potential for more than minimal, patternF760May 22, 2026

  Based on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors and failed to report drug errors to the resident's physician in a timely manner and record them in the resident's record for 1 of 5 residents (Resident #91) reviewed for drug administration. The facility failed to ensure that RN A administered a correct dose of Lorazepam 0.5 mg (controlled medication used for anxiety) to Resident #91 for a week without obtaining a correct dose of medication according to the physician order. This failure could place residents at risk for overdosing, delayed healing, and other adverse consequences. […]