Windsor Rehabilitation and Healthcare

In the surveyor’s words

From the most serious findings on record at Windsor Rehabilitation and Healthcare, in the surveyor’s own words.

• Immediate jeopardy, patternF686Jan 28, 2021

  Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure injuries from developing was provided for 1 of 3 residents reviewed for pressure injuries. (Resident #1) The facility did not: *Assess and treat Resident #1's sacral (area at the bottom of the spine) pressure injury when it was identified and reported by multiple staff. The sacral wound was first documented and reported on 12/26/20 and was not assessed and treated by the treatment nurse until 10 days later. *Identify Resident #1's sacral wound was infected when the wound had a foul odor, heavy brownish colored drainage and bleeding. […]

• No harm, potential for more than minimal, widespreadF812Jul 27, 2022

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: Resident #26's sunny side eggs were prepared with pasteurized eggs. food items were dated, labeled, and sealed appropriately. hair restraints were worn by dietary staff. expired food item was discarded. the toaster and microwave clean and free of food debris. ice machine filter clean and free from debris the cooking grease in the deep fryer was kept clean. the deep fryer was free of grease build up. This failure could place residents at risk for foodborne illness. […]

• No harm, potential for more than minimal, widespreadF812May 26, 2021

  Based on observation, interview and record review, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure the air vent, air return vents and ice machine were clean. These failures could place residents who ate meals prepared in the kitchen at risk of food being served in unsanitary conditions and for food-borne illnesses. The findings include: During an observation of the kitchen environment during lunch service on 05/24/21 at 12:10 p.m., there was an air vent, directly above the right side of the steam table, blowing cool air out. The air vent had dust and black debris on the grate. […]

• No harm, potential for more than minimal, patternF656Feb 27, 2026

  Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs, for 4 of 6 (Resident 's#12, #64, #7 and #38) residents reviewed for care plans.1. The facility did not ensure that Residents #12, #64, and #7's care plan included significant weight loss. 2. The facility failed to follow Resident #38's care plan for health shakes. These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings included: 1. […]

• No harm, potential for more than minimal, patternF689Feb 27, 2026

  Based on observations, interviews and record reviews, the facility failed to ensure that the resident environment remains as free of accident hazards as possible for 3 of 6 residents (Resident #8, #38, and #58) reviewed for accidents. 1.The facility failed to ensure Resident #8 wander guard was functioning properly on 02/26/26. 2. The facility failed to ensure Resident #38 had a fall mat when he fell out of bed on 02/19/26. 3.The facility failed to ensure Resident #58's fall mat was beside her bed on 02/23/26 and 02/24/26. These failures could place residents at risk of elopement, injury, or harm. Findings included: 1. […]