Windsor Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF760Nov 26, 2024

  Based on observation, record review, resident interview, staff interview, nurse practitioner interview, physician interview, pharmacist, and psychiatry nurse practitioner interview the facility failed to administer 6 doses of a required antipsychotic medication for one (Resident #11) of one resident reviewed for significant medication errors. Resident #11 had an acute psychotic event after missing 6 doses of his antipsychotic medication resulting in a fall with a broken shoulder and hip that required surgical repair, acute blood loss and acute pain. Resident #11 has been bedbound since the incident. Findings included: Resident #11 was admitted to the facility on [DATE] with a diagnosis of paranoid schizophrenia. […]

• Immediate jeopardy, isolatedF770Nov 26, 2024

  Based on observation, record review, resident interview, staff interview, nurse practitioner interview, physician interview, pharmacist interview, and psychiatry nurse practitioner interview the facility failed to obtain laboratory tests as ordered and provide laboratory results to the pharmacy as required for antipsychotic medication monitoring for one (Resident #11) of one resident reviewed for laboratory services. Resident #11 had an acute psychotic event after laboratory results were not obtained and faxed to the pharmacy for the renewal of his antipsychotic medication. Resident #11 suffered a fall with a broken shoulder and hip that required surgical repair, acute blood loss and acute pain. Resident #11 has been bedbound since the incident. […]

• Immediate jeopardy, isolatedF600Oct 15, 2024

  Based on record review, observations, and interviews with resident, staff and the Physician, the facility failed to protect the residents' right to be free from resident to resident abuse for 3 of 5 residents reviewed for abuse (Resident #222, Resident #61, and Resident #41). On 10/19/23 Resident #2, a male resident, entered Resident #222's room (a female resident) and punched her in her legs multiple times with a closed fist as she was sitting on her bed. On 6/22/24 Resident #2 punched Resident #61 (a female resident) in the face multiple times with a closed fist at the nurse's station due to the belief that she was cheating on him. Resident #222 and Resident #61 were vulnerable and were unable to protect themselves. […]

• Actual harm, isolatedF600May 6, 2025

  Based on record review, staff interview, and family interview, the facility failed to protect the resident's right to be free from abuse for one (Resident #1) of three residents reviewed for physical abuse. Resident #1, a severely cognitively impaired resident, was hit with a belt by a family member resulting in three whip-like marks on her left upper thigh and abdomen. A reasonable person would be traumatized by being hit with a belt. Findings included: Resident #1 was admitted to the facility on [DATE] and had diagnoses of a genetic-related intellectual disability and a neurological condition. Documentation on a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and was dependent on staff for all activities of daily living. […]

• Actual harm, isolatedF607May 6, 2025

  Based on record review, and staff and family interviews, the facility failed to immediately identify abuse and respond to intervene to protect a resident from physical abuse. Facility staff delayed intervention when Resident #1, a severely cognitively impaired resident, was hit with a belt by a family member resulting in three whip-like marks on her left upper thigh and abdomen and a visit to the emergency room . The facility also failed to notify the state agency within two hours of physical abuse that occurred in the facility. This occurred for 1 (Resident #1) of 3 residents reviewed for adherence to abuse policies and procedures during physical abuse investigations. Findings included: a. […]