Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Windsor Healthcare & Rehab Center during CMS and state inspections, most recent first.
The facility failed to manage a fly infestation due to malfunctioning insect light traps and corporate denial of replacement requests. Residents were disturbed by flies, and staff attributed the issue to frequent use of external doors. Despite regular pest control visits, the problem persisted, affecting residents' comfort.
The facility failed to ensure timely completion of CNA training and certification for four nurse aides, resulting in them working without proper certification. The NAs were employed for over four months without completing necessary training and competency evaluations. The facility lacked a policy and system to track CNA class progress, and the interim DON and Administrator were aware but did not ensure timely completion.
A facility failed to investigate allegations of misappropriation of a resident's property and did not suspend involved staff members. The resident's family reported that a staff member renting the resident's property was not paying rent and had moved other staff into the home. Despite the facility's policy requiring suspension and investigation, the staff continued working, and no thorough investigation was conducted.
A resident with cellulitis and other conditions did not receive updated treatment as per physician orders due to staff oversight. The initial treatment order was not updated in the system, leading to continued use of an outdated treatment plan. Interviews revealed that the nurse failed to update the treatment flowsheet, resulting in a deficiency.
Facility Fails to Address Fly Infestation Due to Inadequate Pest Control Measures
Penalty
Summary
The facility failed to implement an effective pest control program to manage a fly infestation, as evidenced by multiple observations and interviews with residents and staff. The pest control company's service summaries from April to June 2024 indicated that several insect light traps were not functioning properly and required new bulbs, yet these issues were not addressed. The Maintenance Director confirmed that the pest control company recommended replacing the bug lights, but the facility's corporate office denied the requests for replacement. Residents reported being disturbed by flies buzzing around their faces and landing on their skin, with some residents claiming to kill numerous flies daily. Staff interviews revealed that the fly issue was attributed to frequent use of external doors by both staff and residents, which allowed flies to enter the building. Despite the pest control company visiting the facility regularly, the problem persisted, and staff resorted to using flyswatters to manage the situation. The Administrator acknowledged the fly issue and stated that multiple requests to the corporate office for bug light repairs or replacements were denied. The interim DON claimed not to have observed a fly problem, and staff had not reported it to them. The facility's failure to address the malfunctioning insect light traps and the corporate office's refusal to approve necessary replacements contributed to the ongoing fly infestation, affecting the residents' comfort and well-being.
Failure to Ensure Timely CNA Certification for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides (NAs) completed their training, competencies, and testing in a timely manner, resulting in four NAs working without proper certification. NA D, NA F, NA G, and NA H were all employed for more than four months without completing a state-approved certified nursing assistant (CNA) training program, competency evaluation, and certification test. NA D and NA F were still in the process of completing their online CNA classes, while NA G had finished the class tests but was waiting for the facility to complete competency checks. NA H had been working as a NA since January 2024 without certification. The facility lacked a policy related to the training and certification of NAs/CNAs, and there was no system in place to track the progress of NAs in their CNA classes. Interviews revealed that the interim Director of Nursing (DON) and the Administrator were aware of the issue but had not ensured timely completion of the necessary requirements. The Licensed Practical Nurse (LPN) B, who volunteered to help with competencies, noted that the NAs did not consistently bring their competency sheets to work. The interim DON had contacted the online CNA instructor to inquire about the NAs' testing status, but no further actions were taken to address the deficiency at the time of the report.
Failure to Investigate Misappropriation Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of possible misappropriation of a resident's property and did not take adequate steps to protect all residents during the investigation process. The issue arose when a resident's family reported that a Nurse Assistant (NA) employed by the facility, who was renting the resident's property, was not paying rent and had allegedly moved other staff members into the property. Despite these allegations, the involved staff members continued to work independently with all residents, and no documented investigation was completed. The resident involved was cognitively intact and had a history of depression, muscle weakness, diabetes mellitus, and high blood pressure. The resident's family member reported that the staff members living in the resident's home were not paying rent and were causing damage to the property. The facility's Administrator was aware of the situation but did not suspend the staff members or conduct a thorough investigation, as advised by the corporate director of operations, who considered it a community issue rather than a facility issue. Interviews with the involved staff members revealed that they were unaware of the misappropriation of property and believed they had verbal agreements to live in the resident's home. The facility's policy required that all alleged violations be thoroughly investigated and that employees alleged to have committed abuse be suspended immediately pending investigation. However, these procedures were not followed, and the facility did not prevent further potential abuse or mistreatment while the investigation was in progress.
Failure to Implement Updated Treatment Orders
Penalty
Summary
The facility failed to provide care consistent with standards of practice when staff did not implement physician-ordered changes for a resident's treatment. The resident, who was cognitively intact, had a history of cellulitis, schizophrenia, osteoarthritis, muscle weakness, edema, and pain. The physician had initially ordered a specific treatment for the resident's bilateral lower extremities, which included cleansing with Hibiclens and applying a baking soda paste, to be changed daily. This order was later updated to a different treatment involving soap and water cleansing and the application of A&D ointment, but the change was not implemented by the nursing staff. The treatment flowsheet continued to reflect the outdated treatment order, and nurses continued to perform the old treatment from July 1 to July 21, despite the new order being issued on July 8. Interviews with facility staff revealed that the nurse who received the updated order failed to update the treatment flowsheet and discontinue the previous order. The interim DON and the Administrator both expected that new orders should be entered into the computer system and documented appropriately, but this was not done, leading to the deficiency.
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Illustrative
What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Windsor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lincoln Community Care Center | 14.7 mi | ★★★★★ | 7 | 0 |
| Adair Village | 16.7 mi | ★★★★★ | 12 | 0 |
| Clinton Healthcare And Rehabilitation Center | 17.2 mi | ★★★★★ | 0 | 0 |
| E W Thompson Health & Rehabilitation Center | 17.9 mi | ★★★★★ | 2 | 0 |
| Sylvia G Thompson Residence Center, Inc | 18 mi | ★★★★★ | 13 | 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 July 2026) and official state health department websites.