Windsor Nursing and Rehabilitation Center of Harli

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF812Aug 12, 2026

  Number of residents sampled: Number of residents cited: Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation and for two of two nutritional storage rooms. 1.The facility failed to ensure 1 one-gallon bottle of corn syrup with vanilla was labeled and dated in the dry food storage. 2. The facility failed to ensure expired nutritional supplement drinks in the nourishment rooms were disposed of. These failures could place residents who consumed food from the kitchen at risk for food borne illness. Findings included: 1. […]

• No harm, potential for more than minimal, patternF880Aug 12, 2026

  Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 16 (Resident #149, Resident #99, and Resident #5) residents reviewed for infection control, 1.The facility failed to ensure Resident #149's IV dressing was labeled on 08/10/2026. 2. The facility failed to ensure CNA G and CNA H performed proper hand hygiene, bed bath procedure, and proper doffing of PPE after exiting Resident 99's room. 3. The facility failed to ensure Resident #5's oxygen tubing was changed. […]

• No harm, potential for more than minimal, patternF880Nov 20, 2025

  Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 13 of 13 residents reviewed for infection control practices. The facility failed to ensure all EBP residents in the facility had PPE available immediately near the residents' rooms. This failure could place residents at risk for cross contamination and infection.Findings included: Record review of the list of residents on precautions, from the ICN, dated 08/20/2025, revealed 13 residents in the facility were on EBP, and 4 residents were on contact precautions. […]

• No harm, potential for more than minimal, isolatedF605Aug 12, 2026

  Based on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the residents' medical symptoms for 1 of 7 residents (Resident #14) reviewed for unnecessary medications. The facility failed to ensure LVN B correctly documented Resident #14's behavior monitoring for Klonopin on 08/01/26, 08/04/26, 08/07/26, 08/08/26, and 08/11/26; Olanzapine on 08/03/26, 08/08/26, and 08/10/26; Lurasidone on 08/01/26, 08/08/26, 08/11/26, and 08/12/26. During the 6:00 a.m. to 2:00 p.m. shift. This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication and dependence on unnecessary medications. […]

• No harm, potential for more than minimal, isolatedF628Aug 12, 2026

  Number of residents sampled: Number of residents cited: Based on record reviews and interviews, the facility failed to send a copy of the residents' discharge notice, prior to discharge, to the representative of the Office of State Long-Term Care (LTC) Ombudsman of the residents' transfer or discharge and the reasons for the move for 1 of 4 (Resident #145) reviewed for notifying the LTC Ombudsman of the residents' discharge.Resident #145 was discharged home on [DATE] without a notice to the LTC state ombudsman.This failure could place residents at risk of not knowing their rights and receiving the services of the state LTC Ombudsman.Findings were:Record review of Resident #145's admission Record dated 08/12/26 revealed a [AGE] year old female with an admission date of 05/15/26. […]