Windsor Nursing and Rehabilitation Center of Mcall

In the surveyor’s words

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

• Actual harm, isolatedF689Nov 21, 2025

  Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one of four residents (Resident#1) reviewed for accidents and supervision. The facility failed to provide adequate supervision to Resident#1. Resident #1 fell from the shower chair while care was being provided by CNA A and CNA B and sustained a fracture to right hip. This failure could place residents who require supervision at risk of accidents or injury. […]

• Actual harm, isolatedF689Feb 19, 2021

  Based on interview and record review, the facility failed to provide adequate supervision for one Resident (Resident #1) of one resident reviewed for accidents, supervision and elopement, in that: Resident #1 eloped from the facility and was found four blocks away, an hour and 15 minutes later, in 40-degree weather. He was taken to the hospital and diagnosed with [REDACTED]. This failure could affect any resident and place them at risk of elopement and injury. The findings included: Review of Resident #1's February 2020 Medication Review Report revealed he was a [AGE] year-old man who was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF600Jul 9, 2025

  Based on observations, interview and record review, the facility failed to ensure the residents had the right to be free from abuse, neglect and misappropriation of property for 8 of 16 residents (Resident #4, Resident #9, Resident #12, Resident #15, Resident #20, Resident #23, Resident #27, and Resident #31) reviewed for abuse, in that: The facility failed to ensure Resident #4, Resident #9, Resident #12, Resident #15, Resident #20, Resident #23, Resident #27, and Resident #31 were free from abuse when:-Resident #9 touched/rubbed Resident #4's private area with his hand on 10/19/24.-Resident #12 kissed Resident #20 on her mouth and forehead on 04/03/25.-Resident #12 kissed Resident #4 on her mouth on 04/05/25.-Resident #23 kissed Resident #4 on her mouth on 05/02/25.-Resident #31 punched… […]

• No harm, potential for more than minimal, patternF758Sep 12, 2024

  Based on interview and record review, the facility failed to ensure the resident was not given a psychotropic drug unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 3 ( Resident #34, Resident# 59, and Resident #25) of 4 residents reviewed for unnecessary medications, in that: 1.Resident #34 was receiving Prozac (an antidepressant) without adequate indication for its use or an appropriate diagnosis. 2. The facility failed to have an adequate diagnosis or indication for the use of the medication Gabapentin (anti-epileptic drug, used for seizures and some types of pain, with off-label use of anxiety, insomnia, and bipolar disorder) for Resident #59. 3. […]

• No harm, potential for more than minimal, patternF842Mar 1, 2024

  Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 of 7 Residents (Resident #3, Resident #4 and Resident #6) reviewed for medical records accuracy, in that: 1.Resident #3's October 2023 Medication Administration Record documentation record was incomplete as it did not include dates for physician ordered Haloperidol (medication for mental/mood disorders) was given. 2.Resident #4's February 2024 Medication Administration documentation was incomplete for physician orders related to his indwelling (left within a bodily organ) suprapubic (area above pubic bone) catheter (a tube inserted into bladder to drain urine). […]