Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Windsor Woods Rehab And Healthcare Center during CMS and state inspections, most recent first.
Aides did not consistently document toileting hygiene or incontinence care for several dependent residents with complex medical needs, as confirmed by the DON and review of records, resulting in incomplete ADL documentation.
A resident with multiple complex medical conditions and moderate cognitive impairment did not receive care in accordance with their comprehensive care plan, which required a two-person assist for toileting and incontinence care. Instead, a CNA provided care alone, contrary to documented requirements for total dependence and two-person assistance for all ADLs, as confirmed by facility leadership.
A resident with severe cognitive impairment and significant ADL needs experienced skin tears when a hospice CNA provided a shower without following the facility's care plan, which required use of a mechanical lift. The hospice aide was not informed of the resident's specific assistance needs, and there was no documentation of care coordination or communication between facility and hospice staff regarding ADL support.
A facility failed to provide adequate incontinent supplies, affecting five residents' dignity and comfort. Residents reported shortages of appropriately sized briefs, with some having to wait or use ill-fitting ones. The issue arose from a missed supply order due to staff absence, leading to low stock over a weekend. Staff confirmed occasional shortages, and a grievance was filed regarding the issue.
The facility failed to ensure accurate PASRR documentation for several residents, leading to deficiencies in identifying mental health conditions. A resident with depression and dementia did not have these diagnoses marked on their PASRR, and another resident's schizophrenia was initially unmarked. An incomplete PASRR for a resident missed a Major Depressive Disorder diagnosis, and another resident with multiple mental health diagnoses did not have a Level II evaluation completed. The DON confirmed these inaccuracies.
A resident with chronic right lower leg swelling did not receive appropriately sized compression stockings from the facility, leading to constant swelling and difficulty walking. The resident's medical records indicated issues with muscle weakness and mobility, and despite awareness of the edema by occupational therapy, the correct size stockings were not ordered until after the survey identified the deficiency.
The facility failed to identify and address PTSD triggers for two residents, resulting in a deficiency in trauma-informed care. One resident's care plan lacked specific interventions for PTSD, and staff were unaware of his diagnosis and triggers. Another resident's care plan did not identify specific PTSD events or triggers, despite the facility's policy emphasizing the importance of mitigating such triggers.
A resident with encephalopathy experienced a delay in receiving appropriate antibiotics due to expired collection supplies and incorrect initial medication orders. The resident's wound culture was rejected, and ciprofloxacin was administered despite resistance. The correct antibiotic, linezolid, was delayed by 29 hours after lab results were received, indicating a deficiency in pharmaceutical services.
The facility exceeded the acceptable medication error rate, with a 7.14% error rate observed. An LPN administered incorrect aspirin to a resident and failed to prepare MiraLAX for another, contrary to the facility's medication administration policy.
Failure to Document Toileting Hygiene for Dependent Residents
Penalty
Summary
The facility failed to ensure accurate and complete documentation of Activities of Daily Living (ADLs), specifically regarding toileting hygiene, for four sampled residents. Interviews and record reviews revealed that aide staff did not consistently document incontinence care or toileting hygiene every day and every shift as required. The Director of Nursing (DON) confirmed that documentation was missing and that aides were expected to record perineal hygiene under toileting hygiene for each shift. The residents involved had significant medical histories and were all dependent on staff for toileting hygiene. One resident had multiple diagnoses including osteoarthritis, dementia, and neuromuscular dysfunction of the bladder, and was described as poorly motivated and frequently refusing care. Another resident had quadriplegia and required total assistance for all ADLs. Additional residents had conditions such as COPD, heart failure, traumatic brain injury, and developmental disorders, all necessitating full staff support for toileting and hygiene. Review of the toileting hygiene documentation for these residents showed inconsistent entries, with some days missing documentation of care provided. The DON verified during interviews that documentation was lacking for several residents and that aides should have been documenting perineal hygiene at least every shift. The facility was unable to provide a policy outlining documentation expectations when requested.
Failure to Follow Two-Person Assist Care Plan for Dependent Resident
Penalty
Summary
The facility failed to follow the comprehensive, person-centered care plan for a resident who required a two-person assist for toileting and incontinence care. On the night in question, a CNA provided incontinence care alone, despite the care plan specifying that the resident was dependent on two staff members for bed mobility, turning, repositioning, and toileting. The CNA reported that the resident was combative during care, and the incident was later confirmed by the Nursing Home Administrator (NHA) and Director of Nursing (DON) during their investigation. The care plan, which had been updated and reviewed multiple times, clearly indicated the need for two-person assistance due to the resident's total dependence for activities of daily living (ADLs) and her frequent refusal of care. The resident involved had a complex medical history, including generalized osteoarthritis, dysphagia, COPD, diabetes, anemia, seizures, pressure ulcers, dementia, mood disorders, osteoporosis, neuromuscular dysfunction of the bladder, psychosis, major depressive disorder, anxiety, and hypertension. At the time of the incident, the resident was moderately cognitively impaired, as indicated by a BIMS score of 10, and was observed to be confused and unable to answer questions about her care needs. The facility's policy required that care and services be provided in accordance with the comprehensive assessment and care plan, but this was not followed in this instance.
Failure to Coordinate Hospice and Facility Care Plans for ADL Assistance
Penalty
Summary
The facility failed to ensure that a hospice plan of care was properly developed and coordinated for a resident receiving hospice services, specifically regarding communication between the facility and the hospice provider about activities of daily living (ADLs). The resident, who had severe cognitive impairment and multiple diagnoses including dementia, encephalopathy, and a history of falls, required substantial to maximal assistance with ADLs and was dependent on a wheelchair. The care plan indicated the need for a mechanical lift for transfers and detailed the level of assistance required for various activities. An incident occurred when a hospice CNA provided a shower to the resident and, during the process, caused skin tears on the resident's left elbow, right forearm, and right ankle. The CNA did not follow the facility's care plan, which required the use of a mechanical lift for transfers, and instead transferred the resident to the shower chair alone. There was no documentation of communication between facility staff and the hospice aide regarding the resident's specific ADL care needs, nor was there documentation of the frequency or nature of care provided by the hospice aide. Interviews with the Nursing Home Administrator and Director of Nursing revealed that the hospice provider maintained its own care plan, which did not specify the level of assistance required for the resident, only the tasks to be performed. The facility staff did not communicate the resident's assistance needs to the hospice aides, and there was no policy in place to guide coordination of care between the facility and hospice provider. The service agreement between the facility and hospice required coordination and inclusion of both plans of care, but this was not implemented in practice.
Inadequate Incontinent Supplies Lead to Resident Discomfort
Penalty
Summary
The facility failed to provide adequate incontinent supplies to meet the needs of five residents, leading to a deficiency in maintaining residents' rights to a dignified existence and self-determination. Interviews with residents revealed that they experienced a shortage of appropriately sized incontinent briefs, with some residents having to wait for supplies or use ill-fitting briefs. For instance, one resident reported that staff ran out of extra-large briefs, and only small sizes were available, which did not fit. Another resident mentioned not receiving a clean pull-up on a particular day due to the shortage. The facility's supply management process contributed to the deficiency. The Central Supply Coordinator, who was responsible for ordering supplies twice a week, had an emergency and was absent, leading to a missed order. The Nursing Home Administrator, who covered for the coordinator, did not approve the order, resulting in no delivery on a critical day. Consequently, the facility ran low on supplies over the weekend, and staff had to purchase briefs from a local store to meet immediate needs. Interviews with staff confirmed the inconsistency in supply availability, with some staff noting that the facility occasionally ran out of briefs. The facility's grievance report indicated that a concern about brief availability was raised, highlighting the ongoing issue. The report also showed that the facility ordered supplies multiple times in May, but the missed order and delivery schedule contributed to the shortage experienced by residents.
Inaccurate PASRR Documentation for Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Level I Preadmission Screening and Resident Review (PASRR) for four residents, leading to deficiencies in identifying and documenting mental health conditions. Resident #68 was admitted with diagnoses of depression and unspecified dementia, but the PASRR did not indicate these qualifying diagnoses, and a Level II PASRR was not completed as required. Similarly, Resident #98's PASRR initially failed to mark schizophrenia, a diagnosis present in the resident's medical record, although this was later corrected. Resident #18's PASRR was incomplete, missing the qualifying diagnosis of Major Depressive Disorder, which was confirmed to be on the resident's facesheet. Resident #15 was admitted with multiple diagnoses, including major depressive disorder, unspecified dementia, and PTSD, yet the PASRR Level I Screen did not indicate any suspicion of serious mental illness or intellectual disability, nor was a Level II PASRR evaluation completed. The facility's policy requires the screening to identify serious mental illness or intellectual disability to ensure appropriate placement and the provision of specialized services. The Director of Nursing confirmed the inaccuracies in the PASRR documentation for these residents, acknowledging the need for corrections.
Failure to Provide Correct Compression Stockings
Penalty
Summary
The facility failed to ensure that appropriate compression stockings were ordered and provided for a resident experiencing chronic right lower leg swelling. During an interview and observation, the resident reported that the compression stockings provided by the facility were too small, which contributed to constant swelling in his left leg, making it difficult for him to walk. Photographic evidence confirmed the size discrepancy and the noticeable swelling in the resident's right lower leg and foot. The resident's admission record indicated diagnoses of generalized muscle weakness, abnormalities of gait and mobility, and fatigue. Further review of the occupational therapy daily treatment note revealed that the resident had left lower extremity edema, which was noted by the occupational therapist, with nursing staff being made aware. Despite this, the appropriate size compression stockings were not ordered until after the issue was raised during the survey. The physical therapy daily treatment note also documented the resident's report of edema in the left lower extremity and his request for lighter weights during therapy. The deficiency was identified as the facility's failure to provide the correct size compression stockings in a timely manner, as per the resident's needs and medical condition.
Deficiency in Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to identify and address triggers related to Post Traumatic Stress Disorder (PTSD) for two residents, leading to a deficiency in providing trauma-informed care. Resident #15, who was admitted with diagnoses including PTSD, had a care plan that lacked specific interventions related to his triggers. Despite being followed by a psychologist and psychiatrist, the care plan only included general interventions such as coordinating psychological services and encouraging expression of feelings. Interviews with staff revealed a lack of awareness about the resident's PTSD diagnosis and specific triggers, indicating a gap in communication and care planning. Similarly, Resident #12, who had a chronic PTSD diagnosis, also had a care plan that did not identify specific PTSD events or triggers. The facility's policy on trauma-informed care emphasizes the importance of identifying and mitigating triggers to prevent re-traumatization. However, the care plans for both residents did not reflect this policy, as they failed to include individualized interventions based on the residents' specific trauma histories. This oversight highlights a deficiency in the facility's approach to trauma-informed care, as staff were not adequately informed or prepared to manage the residents' PTSD-related needs.
Delayed Antibiotic Administration for Resident with VRE Infection
Penalty
Summary
The facility failed to ensure timely administration of antibiotics for a resident diagnosed with encephalopathy, who was reviewed for unnecessary medications. The resident's wound culture was rejected due to expired collection supplies, leading to a delay in obtaining accurate lab results. The urinalysis indicated a vancomycin-resistant Enterococcus faecium infection, but the resident was initially started on ciprofloxacin, which was resistant according to the sensitivity analysis. The appropriate antibiotic, linezolid, was not administered until 29 hours after the lab results were received, indicating a significant delay in treatment. The Director of Nursing (DON) confirmed that the delay was due to the use of expired vials for specimen collection, which required a new order and subsequent culture. The initial order for doxycycline was placed but not administered, and the order was later changed to linezolid. The facility's failure to administer the correct antibiotic promptly after receiving lab results highlights a deficiency in pharmaceutical services, impacting the resident's care and treatment timeline.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by observations and record reviews. During the survey, 42 medication administration opportunities were observed, resulting in three errors, leading to a 7.14% medication error rate. The errors involved two residents. For one resident, the LPN administered aspirin low dose 81 mg instead of the prescribed aspirin EC tablet delayed release 81 mg. This discrepancy was confirmed through a review of the physician's orders. For another resident, the LPN administered several medications but failed to prepare and administer MiraLAX 17 grams, which was scheduled for 8:00 a.m. The medication was not discussed with the resident, and the Medication Administration Record (MAR) indicated that MiraLAX was refused. The facility's policy on medication administration requires verification of medication orders and administration within 60 minutes of the scheduled time, which was not adhered to in these instances.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hudson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bayonet Point Health Center By Harborview | 0.6 mi | — | 0 | 0 |
| Solaris Healthcare Bayonet Point | 1.3 mi | — | 9 | 2 |
| Bear Creek Nursing Center | 1.9 mi | — | 0 | 0 |
| Heather Hill Healthcare Center | 6.9 mi | — | 0 | 0 |
| Madison Pointe Care Center | 7.3 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.