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 Gardens during CMS and state inspections, most recent first.
A resident with diabetes and other serious health conditions did not have blood sugar checks performed or documented on six occasions as ordered for insulin administration. Interviews with an LPN, the DON, and the Administrator confirmed that blank entries in the MAR meant the checks were not done, and no alternative documentation was found. Facility policy required all procedures and results to be recorded, but this was not followed.
Two residents with wounds did not have required dressings in place as ordered, resulting in open wounds being left uncovered. Staff interviews confirmed that dressings are essential for healing and infection prevention, and that all staff are responsible for monitoring and replacing dressings when missing. The facility's wound management policy requires appropriate dressing of wounds, but this was not followed for these residents.
A resident with multiple medical conditions, including diabetes and seizure disorder, did not have a comprehensive person-centered care plan developed or implemented during their stay. Despite identified care needs and standard procedures for care plan completion, staff confirmed that no care plan was created or maintained for this individual.
The facility failed to properly label medications in one medication room and two medication carts, with open vials and bottles lacking open dates. Staff interviews revealed a lack of adherence to the facility's policy on medication labeling, which requires open dates to ensure effectiveness and safety. The responsibility for labeling was acknowledged to fall on the administering MA or nurse, with oversight by unit managers and the pharmacy.
A CNA failed to perform hand hygiene after direct contact with multiple residents while serving meals, despite being trained and aware of the facility's infection control policy. This deficiency involved residents with various medical conditions, potentially risking cross-contamination and infections.
The facility's main kitchen was found to have several deficiencies related to food safety and hygiene. Observations revealed dirty ice machine filters, improperly labeled and stored food items, and poor hand hygiene practices among dietary staff. Additionally, unsanitary conditions such as unclean floors and cracked food container lids were noted, posing a risk to food safety.
The facility failed to maintain a clean and functional environment in the rehabilitation satellite kitchen, with issues such as dirty sinks, cabinets, and floors, and missing cabinet handles. Staff interviews revealed a lack of awareness and communication regarding the kitchen's condition and use, with no documentation of needed repairs in the maintenance logbook. The Administrator acknowledged the area should be cleaned daily, while the Medical Director highlighted its potential use for rehabilitation.
A resident with a complex medical history was subjected to an inappropriate comment by a CNA, compromising her dignity and quality of life. The comment, made in a joking manner, led to discomfort for the resident's family, who decided to discharge her the same night. The facility's policy on residents' rights was not upheld, and the incident was investigated.
A facility failed to document emergency medical services notification and physician orders for a resident who was lethargic and unresponsive. The resident, with multiple health conditions, was sent to the hospital at the family's request, but necessary documentation, including assessments and times of emergency service calls, was missing. Interviews with staff highlighted the lack of adherence to documentation policies.
A resident with a G-tube experienced a feeding tube error that was not promptly addressed by an LVN, who failed to check tube placement before attempting to clear a clog. This resulted in the resident not receiving her prescribed formula for nearly an hour. Interviews revealed that proper procedures were not followed, which could have prevented potential complications.
A resident with quadriplegia and total dependence for care was injured after a CNA failed to follow the care plan requiring a two-person assist for transfers and showers. The CNA attempted to shower the resident alone, resulting in a fall and head injury. The facility identified this as an Immediate Jeopardy situation due to the failure to adhere to the care plan.
A resident in a persistent vegetative state, requiring total care, was injured after being transferred and showered by a single CNA, contrary to the care plan's requirement for a two-person assist. The resident fell from a shower bed, sustaining a head injury, due to inadequate supervision and failure to ensure equipment safety. The facility lacked a system to monitor equipment functionality, contributing to the incident.
A resident with chronic kidney disease was administered hydrocodone after it was ordered to be discontinued, leading to a significant medication error. Interviews with staff revealed that the medication administration process failed to prevent this error, as the medication was given twice post-discontinuation. The facility's policy defines this as a medication error, emphasizing the need for adherence to physician's orders.
Failure to Document and Perform Ordered Blood Sugar Checks for Diabetic Resident
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of drugs for a resident with multiple complex diagnoses, including end stage renal disease, heart disease, heart failure, and type 2 diabetes mellitus with hyperglycemia. The resident was admitted with orders for NovoLOG insulin to be administered according to a sliding scale, with blood sugar (BS) checks required four times daily. Record review revealed that on six separate occasions within a specified period, the resident's BS was not checked as ordered, and there was no documentation indicating that the procedure was attempted or any reason for omission. Interviews with an LPN, the DON, and the Administrator confirmed that all BS checks and medication administrations should be documented in the medical record, and that blank entries on the Medication Administration Record (MAR) indicated the procedure was not performed. The facility's policy required detailed documentation for each BS check, including the result, the person performing the procedure, and any reasons for not completing it. The DON was unable to locate any alternative documentation for the missing BS checks, and all staff interviewed acknowledged the importance of following physician orders and documenting all procedures as required.
Failure to Maintain Wound Dressings for Two Residents
Penalty
Summary
The facility failed to ensure that two residents with wounds received the necessary treatment and services to promote healing and prevent infection. For one male resident with a history of intellectual disabilities, anemia, and hypertension, the care plan and physician orders required a dressing to be applied to a venous or arterial ulcer on his right lateral ankle. On the day of observation, the resident was found without a dressing on the wound, which was open and missing the top layer of skin. The resident reported discomfort without the dressing, and the treatment nurse confirmed that the dressing was missing, possibly due to it falling off during a shower. The nurse acknowledged that staff were responsible for monitoring dressings and that a new dressing should have been applied if it was found missing. A second resident, a female with pressure ulcer of the sacral region, chronic kidney disease, and dysphagia, was also found without a required dressing on her sacral wound. The care plan and physician orders specified the use of a gauze-soaked Dakin's Solution and a dry dressing. During observation, a CNA discovered the wound was uncovered and stated that the nurse should have been notified to apply a new dressing. The treatment nurse and LVN both confirmed that they were not aware the dressing was missing and would have applied a new one if notified. The wound was described as large and uncovered at the time of observation. Interviews with staff, including the treatment nurse, LVN, physician, and DON, confirmed that dressings are essential for wound protection and healing, and that staff are expected to monitor and replace dressings as needed. The facility's policy on wound management also requires wounds to be managed and dressed appropriately to maximize healing. The failure to ensure dressings were present and maintained as ordered led to the deficiency for both residents.
Failure to Develop and Implement Comprehensive Person-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one resident during their 35-day stay. Despite the resident having multiple medical diagnoses, including hypertension, diabetes, seizure disorder, bacterial infection, and anxiety, and requiring several medications and interventions, no comprehensive care plan was created or maintained during their admission. The Minimum Data Set (MDS) assessment identified several care areas that required attention, such as ADL function, urinary incontinence, nutritional status, and pressure ulcer risk, but these were not addressed in a formal care plan. Interviews with facility staff confirmed that the comprehensive care plan was not completed or entered into the system while the resident was present. The MDS nurse acknowledged responsibility for care plan entry and stated that the plan was typically completed within 14 days, but admitted that it was not done for this resident. The DON and other staff also confirmed that care plans are expected for all residents and are monitored by multiple team members, but in this case, no care plan was in place. No facility policy for care plans was provided during the survey.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure proper labeling of drugs and biologicals in one medication room and two medication carts. Specifically, the [NAME] medication room contained an open multi-dose vial of tuberculin without an open date. Additionally, the 300-hall medication cart had seven open eye drop medications without open dates, and the 500-hall cart contained one open eye drop medication and one bottle of liquid protein, both without open dates. These labeling deficiencies were identified during observations and interviews with staff, who acknowledged the importance of open dates for ensuring the medications' effectiveness and safety. Interviews with staff, including Medication Aides (MAs), Assistant Directors of Nursing (ADONs), and the Director of Nursing (DON), revealed a lack of awareness and adherence to the facility's policy on medication labeling and storage. The policy, revised in February 2023, requires that multi-dose vials be dated when opened and discarded within 28 days unless otherwise specified by the manufacturer. The staff admitted that the responsibility for labeling fell on the MA or nurse administering the medication, and that unit managers and the pharmacy were responsible for monitoring compliance. The failure to label medications properly could potentially lead to medication errors and reduced therapeutic effects, as noted by the DON.
Inadequate Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of CNA C, who did not perform hand hygiene after direct contact with residents while serving meals. This deficiency was observed during meal service on the rehabilitation hallways, where CNA C interacted with nine residents without using hand sanitizer or washing hands between contacts. The lack of hand hygiene could potentially lead to healthcare-associated cross-contamination and infections among residents. The residents involved in this deficiency included individuals with various medical conditions such as anemia, hypertension, heart failure, renal insufficiency, diabetes, and other health issues. These residents required assistance with activities of daily living and were either cognitively able to make decisions or moderately impaired. The failure to perform hand hygiene occurred despite the availability of hand sanitizer in the hallway and the facility's policy requiring hand hygiene before and after direct contact with residents. Interviews with CNA C and the Director of Nursing (DON) revealed that CNA C was aware of the hand hygiene requirements but did not comply due to nervousness and the urgency to serve lunch trays. The DON confirmed that all staff are trained to perform hand hygiene and that failure to do so can spread germs to residents and staff. The facility's policy emphasizes hand hygiene as the primary means to prevent the spread of infections, and CNA C had previously received training on this procedure.
Food Safety and Hygiene Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain food safety standards in its main kitchen, as observed during a survey. The ice machine filters and vents were found to be dirty and dusty, which could lead to contamination. Additionally, food items in the refrigerator, freezer, and dry storage room were not properly labeled or stored according to professional standards. This included items without discard dates and some past their expiration dates, which were not discarded as required. The survey also revealed poor hand hygiene practices among dietary staff. Staff members were observed not washing their hands or changing gloves after touching other surfaces or upon re-entering the kitchen. This lack of proper hand hygiene could lead to cross-contamination and increase the risk of food-borne illnesses among residents. Further observations noted unsanitary conditions in the kitchen, such as unclean floors with debris and slippery residues, as well as cracked lids on food containers that prevented airtight seals. These conditions, combined with the improper storage and labeling of food, posed a significant risk to the safety and quality of food served to residents.
Deficient Maintenance and Cleanliness in Rehabilitation Satellite Kitchen
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the satellite kitchen located on the rehabilitation halls. Observations revealed several issues, including a sink with dried dark particles and a dark slime area around the drain, cabinets with dried dark gooey stains and missing handles, and a chipped decorative wood area above the sink. Additionally, the wall next to the portable steam table had dried fluid stains, and the kitchen floor was sticky. A dirty refrigerator shelf was found on the floor, and the refrigerator contained a pitcher of orange juice with no food present. Interviews with staff members, including the Director of Rehabilitation, Maintenance Man A, Housekeeper B, LVN D, the Administrator, the Medical Director, and the Housekeeper Supervisor, revealed a lack of awareness and communication regarding the condition and use of the satellite kitchen. Maintenance and housekeeping staff were unaware of the need for repairs and cleaning, and there was no documentation in the maintenance logbook for necessary repairs. The Administrator acknowledged the area should be cleaned daily and expressed dissatisfaction with the current state, while the Medical Director emphasized the potential positive use of the space for rehabilitation purposes.
Resident's Dignity Compromised by Inappropriate CNA Comment
Penalty
Summary
The facility failed to ensure that a resident received treatment with respect and dignity, which compromised the maintenance of her quality of life. The incident involved a certified nursing assistant (CNA H) who made an inappropriate comment to the resident, stating, "oh, I sure would like to hit you on that big old booty," in what was perceived to be a joking manner. This comment was made in the presence of the resident's family, who initially laughed but later lodged a complaint, indicating that the comment was in poor taste and not reflective of good customer service. The resident, an elderly female with a complex medical history including unspecified encephalopathy, hypertension, hyperlipidemia, type II diabetes mellitus, breast cancer, and unspecified dementia, was admitted to the facility for rehabilitation. She required assistance with transfers and needed step-by-step cues for safe movement. The incident occurred shortly after her admission, and she was discharged the same night following the family's decision to take her home due to discomfort with the situation. Attempts to interview the involved CNA and the resident's family were unsuccessful, but the Executive Director and Director of Nursing provided insights into the incident. The Executive Director confirmed that the family felt uncomfortable with the CNA's comment, and despite efforts to address the family's concerns, the resident was taken home. The Director of Nursing noted that the family had been joking with the CNAs initially, but the situation was later perceived differently. The facility's policy on residents' rights emphasizes the right to be free from abuse and neglect, and the incident was investigated as per the facility's procedures.
Incomplete Documentation of Emergency Medical Services for a Resident
Penalty
Summary
The facility failed to ensure the medical record was complete and accurately documented for a resident who was reviewed for resident records. Specifically, the facility did not document the notification of emergency medical services when the resident's family requested that she be sent to the hospital due to lethargy and unresponsiveness to verbal stimuli. Additionally, there was no assessment completed for the resident, and physician orders for the hospital transfer were not recorded in the electronic health record. The resident in question was an elderly female with multiple diagnoses, including dementia, chronic kidney disease, insomnia, and other significant health conditions. On the day of the incident, the resident's family requested emergency medical services due to her lethargic state and inability to respond to verbal stimuli. Despite this request, the necessary documentation, including the time emergency services were called and the time they arrived, was missing from the resident's medical record. Interviews with facility staff, including LVNs and the ADON, revealed that there were expectations for documenting such incidents, including the use of nurses' notes or SBAR forms. However, these were not completed in this case. The facility's policy on changes in a resident's condition required detailed observations and documentation, which were not adhered to, resulting in incomplete records for the resident's emergency situation.
Failure to Monitor and Address Feeding Tube Error
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for a resident with a feeding tube. The resident, a severely cognitively impaired female with multiple diagnoses including gastrostomy status, experienced a feeding tube issue when the enteral feeding pump displayed a 'FLOW ERROR: Clog in line downstream of pump' message. LVN A did not address the error message promptly and failed to check the placement of the G-tube before attempting to clear the clog by injecting air and water into the tube. This oversight occurred over a period of nearly an hour, during which the resident did not receive her prescribed formula. Interviews with LVN A, LVN B, and the DON revealed that LVN A did not follow proper procedures, such as checking the G-tube placement, which could have prevented potential complications like aspiration or dislodgement of the tube. The DON confirmed that the issue was due to a kink in the line rather than a clog, and emphasized the importance of following facility policies to ensure resident safety. The facility's policy and the operating manual for the feeding pump both highlight the necessity of checking tube placement and using appropriate methods to restore patency, which were not adhered to in this instance.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, leading to a significant incident. The resident, who was quadriplegic and in a persistent vegetative state, required total dependence for all activities of daily living, including transfers and showers. The care plan specified that the resident needed a two-person assist for mechanical lift transfers and showers. However, CNA A did not follow this care plan and attempted to transfer and shower the resident alone, resulting in the resident falling from the shower bed and sustaining a frontal scalp hematoma and laceration on her forehead, which required stitches. The incident occurred when CNA A was giving the resident a shower and turned the resident over, causing her to slide off the shower bed. The facility's incident report and subsequent investigation revealed that CNA A did not adhere to the care plan's requirement for a two-person assist, which was a critical safety measure for the resident's condition. Interviews with facility staff, including the Executive Director and DON, confirmed that CNA A acted alone during the transfer and shower, contrary to the established care plan and facility policy. The failure to follow the care plan placed the resident at risk of injury, as evidenced by the fall and subsequent head injury. The facility's policy required that all mechanical lifts and transfers be conducted with two staff members to ensure resident safety. Despite the availability of the care guide and training provided to staff, CNA A did not seek assistance, leading to the incident. The facility identified this as an Immediate Jeopardy situation, highlighting the severity of the deficiency in adhering to the resident's care plan.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not adhere to the comprehensive care plan for a resident who required a two-person assist with a mechanical lift for transfers and showers. This oversight led to the resident being transferred and showered by a single CNA, contrary to the care plan's requirements. The resident, who was quadriplegic and in a persistent vegetative state, was entirely dependent on staff for all activities of daily living, including hygiene and transfers. During a shower, the resident fell from the shower bed, resulting in a frontal scalp hematoma and a laceration on the forehead that required stitches. The incident occurred because the CNA attempted to turn the resident over on the shower bed without the assistance of another staff member, as mandated by the care plan. Additionally, the facility lacked a system to monitor the safety and functionality of equipment, such as shower beds. The investigation revealed that the shower bed's side rail was not properly secured, which may have contributed to the fall. The facility's maintenance records did not show regular checks or documentation of equipment safety, and staff were not formally trained to report maintenance issues, leading to a breakdown in communication and safety protocols.
Medication Error Due to Failure to Discontinue Hydrocodone
Penalty
Summary
The facility failed to ensure that residents were free of significant medication errors, specifically in the case of a male resident with a history of cellulitis and chronic kidney disease. The resident was prescribed hydrocodone for pain management, which was ordered to be discontinued by the physician. However, the medication was administered twice after the discontinuation order, on two separate occasions. This oversight placed the resident at risk for adverse effects such as confusion, respiratory depression, and potential kidney damage. Interviews with facility staff, including the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs), revealed discrepancies in the medication administration process. The DON stated that discontinued medications should not appear in the system for administration, and any administration post-discontinuation is considered a medication error. The facility's policy on medication errors, revised in April 2014, defines such errors as the administration of drugs not in accordance with physician's orders, highlighting the unauthorized administration of the hydrocodone as a clear violation.
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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 Lancaster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Millbrook Healthcare And Rehabilitation Center | 0.8 mi | — | 5 | 0 |
| Avir At Lancaster | 2.5 mi | — | 14 | 1 |
| Desoto Nursing & Rehabilitation Center | 2.7 mi | — | 12 | 1 |
| Lancaster Nursing & Rehabilitation | 2.7 mi | — | 2 | 0 |
| Five Points Nursing And Rehabilitation | 3.1 mi | — | 6 | 0 |
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