Windsor Nursing and Rehabilitation Center of Wesla

In the surveyor’s words

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

• Immediate jeopardy, isolatedF760May 29, 2026

  Based on interview and record review, the facility failed to ensure that residents were free of significant medication errors for 1 of 4 residents (Resident #1) reviewed for pharmacy services. Facility failed to acquire and administer physician ordered anti-seizure medication phenytoin (Dilantin) to treat Resident #1's seizure disorder. Resident #1 suffered a seizure and was sent to hospital on [DATE] with impression of Status Epilepticus, Subtherapeutic phenytoin (Dilantin) levels, Active infection (UTI/Sepsis/Pneumonia). The noncompliance was identified as PNC. The IJ began on 3/12/26 and ended on 4/9/26. The facility had corrected the noncompliance before the survey began.These failures could place residents at risk of complications, as well as jeopardize their health and safety. […]

• Immediate jeopardy, isolatedF689Mar 12, 2024

  Based on observations, interviews, and record review, the facility failed to ensure each resident recieved adequate supervision for one resident (Resident#44) of 2 residents whose records were reviewed for elopements. Resident #44 eloped from the facility undetected on 05/05/23. Resident #44 was able to remove her wanderguard bracelet and exit the facility on 06/24/23. Resident #44 eloped from the facility undetected after removing wanderguard bracelet for a second time 06/26/23. The non-compliance was identified at PNC (Past non-compliance). The Immediate Jeopardy (IJ) situation began on 06/26/23 and ended 06/27/23 The facility had corrected the noncompliance before the survey began. This failure could place the residents with exit seeking behaviors at risk for injury or death. […]

• No harm, potential for more than minimal, patternF812Jul 16, 2026

  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.1.The facility failed to ensure that there were no personal items belonging to staff stored in refrigerator #2.2.The facility failed to ensure 15 juice bags were stored without being dated in the dry food storage.3 The facility failed to ensure expired nutritional drinks were stored in the nourishment room. These failures could place residents at risk for food borne illness.Findings included: During an observation on 07/14/26 at 8:37 a.m. […]

• No harm, potential for more than minimal, patternF880Jul 16, 2026

  Based on observation, interviews, 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 3 of 4 residents (Resident #61, Resident #37 and Resident #57) reviewed for infection control. 1.The facility failed to ensure CNA A performed proper hand hygiene and indwelling catheter care during peri care (incontinent care) for Resident #61. 2.The facility failed to ensure Resident #37's white pillowcases were clean. 3.The facility failed to ensure Resident #57's portable urinal was hanging from his wheelchair's backrest. […]

• No harm, potential for more than minimal, patternF680May 20, 2025

  Based on interview and record review the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activity professional for 61 of 61 residents. The facility did not have a qualified Activities Professional to direct their activities program. This deficient practice could affect any resident and could result in residents not receiving activities that were individualized to match the skills, abilities, and interests/preferences of each resident. The findings were: Record review on 05/20/25 at 10:30 a.m. […]