Windsor Woods Rehab and Healthcare Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF842Apr 24, 2025

  Based on interview and record review the facility failed to ensure accurate and complete documentation related to Activities of Daily Living (ADLs) for toileting hygiene for four (#2, #4, #5, #6) out of four sampled residents. Findings included: During an interview on 04/24/2025 at 1:08 p.m. the Director of Nursing (DON) stated the aide staff works 8-hour shifts. The DON verified after reviewing the toilet hygiene documentation that the aides were not documenting every day, every shift they were providing incontinence care / toileting hygiene. The DON confirmed documentation was missing. The DON verified the incontinence care was to be documented under the toileting hygiene. 1. […]

• No harm, potential for more than minimal, patternF550Jun 6, 2024

  Based on record review, interview, and record review, the facility failed to provide incontinent supplies to meet resident needs for five (Residents #73, #35, #22, #49, #61) of 47 residents sampled. Findings Included: 1. An interview was conducted on 06/03/24 at 11:45 a.m. with Resident # 61. She stated staff ran out of incontinent briefs yesterday evening and she was not able to be changed. She stated staff only had a size small, and she wears an extra-large and/or extra extra-large and a small would not fit. She stated staff had to run to [local store] to pick up briefs for residents. […]

• No harm, potential for more than minimal, patternF761Aug 4, 2022

  Based on observations, interviews and record review, the facility failed to store medications in a safe and secure manner 1) in four medication carts (two A Wing and two C Wing) of four medication carts observed, and 2) for three residents (#16, #63, and #82) of forty one residents sampled. Findings included: 1) A review of the facility provided policy titled 4.1 Storage of Medications, dated 09/18 revealed the following: Policy: Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations to maintain their integrity and to support safe effective drug administration. […]

• No harm, potential for more than minimal, patternF908Aug 4, 2022

  Based on observations, staff interview and facility record review, the facility failed to ensure one of one walk in freezers were operating appropriately during two of four days observed (08/01/2022 and 8/4/2022). It was determined the freezer door would not latch closed in order to keep warm air from getting in, and as a result, there was ice build up inside the freezer compartment. Findings included: On 8/1/2022 at 9:45 a.m. the kitchen was toured with the Dietary Manager. During the tour, it was noted the kitchen had a walk in refrigerator and within the walk in refrigerator was the walk in freezer. Once the walk in refrigerator was approached, the door was opened and the inside temperature revealed 38 degrees F., per the inside analog thermometer. […]

• No harm, potential for more than minimal, isolatedF656Apr 24, 2025

  Based on observation, interviews and record reviews, the facility failed to follow the comprehensive person-centered care plan related to providing toileting care with a two-person assist for one (#2) of eight sampled residents. Findings included: During an interview on 04/24/25 at 1:08 p.m. the Nursing Home Administrator (NHA) and the Director of Nursing (DON) stated Resident #2 initially told the 7 a.m. to 3 p.m. shift aide on 02/26/2025 about her finger hurting. The DON stated she went to Resident #2s room, and Resident #2 alleged a person (unknown at the time) came into her room the night before and hit her hand a couple hundred times. The NHA and the DON stated during their investigation Staff A, Certified Nursing Assistant (CNA) who cared for Resident #2 on the 11 p.m. to 7 a.m. […]