Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 The Windsor Place during CMS and state inspections, most recent first.
A facility failed to develop a baseline care plan for a resident with skin integrity issues upon admission, leading to the development of a Stage 2 pressure ulcer. Despite a new treatment order for excoriation, the order was not entered into the system, and no treatment was initiated. The MDS Coordinator confirmed the oversight in developing the care plan and implementing skin orders.
A resident developed a pressure sore on her lower buttocks while in the facility, and the facility failed to implement the physician's order for Calmoseptine treatment. The order was not entered into the system, and the treatment was not initiated, leading to the development of a stage 2 pressure ulcer. Interviews with staff confirmed the oversight, which may have contributed to the deterioration of the resident's condition.
The facility failed to label and date open food items in the pantry, refrigerator, and freezer, as observed during a kitchen tour. Unlabeled and undated items included shredded mozzarella cheese, low-fat cottage cheese, chicken broth, pork fritters, and breaded squash. The Dietary Manager confirmed the oversight, and the Administrator emphasized the importance of labeling to prevent foodborne illness.
The facility failed to maintain accurate records and reconciliation of controlled medications for two medication carts. A resident's Hydrocodone/APAP prescription was not updated to reflect a new order, leading to discrepancies in the narcotic count. Interviews revealed missing doses were not noted upon receipt, and there was no record of waste or missing doses. The Consultant Pharmacist performed random audits but lacked evidence, and the DON confirmed secure storage and destruction of discontinued narcotics.
A resident's wheelchair was found in disrepair, with torn armrests exposing sharp edges and foam, posing a risk of injury. Facility staff interviews revealed a lack of communication and procedure for reporting maintenance issues, as the maintenance staff was unaware of the problem due to not receiving a work order. The facility lacked a formal policy to ensure resident equipment was maintained properly.
A resident with moderate cognitive impairment and self-care deficits related to congestive heart failure and diabetes mellitus was not shaved as per his care plan, despite expressing a preference to be clean-shaven. The facility's staff failed to follow the care plan, which included grooming as part of the resident's bathing routine. The DON and MDS Coordinator confirmed the oversight, acknowledging that the care plan was not adhered to.
A resident dependent on staff for ADLs was not shaved despite expressing a preference to be clean-shaven. Observations over multiple days showed the resident with significant facial hair, contrary to the facility's policy that includes grooming as part of ADL care. The DON acknowledged the oversight, confirming that shaving was part of the resident's scheduled bathing routine.
The facility failed to secure cleaning chemicals in janitors' closets on the 400 Hall and Dementia Unit, posing potential hazards to residents. Observations revealed unlocked closets with broken coded locks containing disinfectants. Staff confirmed the closets should be locked, but maintenance was not informed of the issues. The administrator acknowledged the requirement for locked closets to prevent resident access to hazardous materials.
A facility failed to obtain informed consent for the use of bed rails for a resident with hemiplegia. Despite the facility's policy requiring informed consent, the resident had side rails applied without a signed consent form. Staff interviews confirmed the oversight, highlighting a deficiency in the facility's adherence to its own policies.
The facility failed to properly label and store medications, leading to discrepancies in medication management. A resident's Hydrocodone/APAP prescription was not updated to reflect a dosage change, and wastage was not documented. Additionally, Gabapentin capsules were found unsecured in a resident's room, who was not authorized to self-administer medications. The resident, with dementia and anxiety, did not take the medication as prescribed, highlighting a lapse in staff oversight.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a PICC line, as required by their policy. An RN accessed the PICC line using only standard precautions, and no EBP sign was posted on the resident's room door. The RN was unaware of the need for EBP, and the facility's policy requires EBP for central lines.
The facility failed to notify the physician of a significant change in a resident's condition, including a decrease in blood pressure and a urinary tract infection. The urine culture results were delayed over the weekend, leading to a delay in starting antibiotics. The facility's policy on timely notification was not followed.
Failure to Implement Baseline Care Plan for Skin Integrity
Penalty
Summary
The facility failed to develop a baseline care plan for a resident with skin integrity concerns, specifically excoriation to the buttocks, upon admission. Despite the facility's policy requiring a care plan to be completed on admission, the baseline care plan for the resident only noted a skin risk without detailing specific interventions for the excoriation. The resident was admitted with a diagnosis related to orthopedic aftercare following surgical amputation, and a new treatment order for Calmoseptine was issued for the excoriation. However, the physician's order for the treatment was not entered into the computer system, and no treatment was initiated on the day of admission. This oversight was confirmed by the Infection Control Nurse during a record review, who noted that the resident subsequently developed a Stage 2 pressure ulcer. The Minimum Data Set (MDS) Coordinator acknowledged the failure to develop the baseline care plan and implement the new skin orders, which are intended to guide staff in providing necessary care until a comprehensive care plan is developed.
Failure to Implement Pressure Ulcer Prevention and Treatment
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing and prevent new ulcers from developing for a resident with wounds. The resident, who was admitted with a diagnosis of orthopedic aftercare following surgical amputation, developed a pressure sore on her lower buttocks while in the facility. A review of the facility's policy on skin and wound care management indicated that prevention strategies should be implemented to minimize the potential for developing pressure ulcers. However, the facility did not follow through with the physician's order for Calmoseptine treatment to the excoriation on the buttocks, as the order was not entered into the computer system, and the treatment was not initiated. The resident was later assessed to have a new stage 2 pressure ulcer on the right buttock. Despite obtaining an order for collagen treatment, the facility's records did not show that the initial treatment for the excoriation was ever started. Interviews with the Infection Control Nurse, Director of Nursing, and Assistant Director of Nursing confirmed that the physician's order for the Calmoseptine treatment was missed, which may have contributed to the deterioration of the area. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status score of 15.
Failure to Label and Date Open Food Items
Penalty
Summary
The facility failed to adhere to its food storage policy by not labeling and dating open food items in the pantry, refrigerator, and freezer. During a kitchen tour, surveyors observed several instances of non-compliance, including an unlabeled and undated 5-pound bag of shredded mozzarella cheese and a 5-pound container of low-fat cottage cheese in the walk-in refrigerator. Additionally, a 32-ounce box of chicken broth was found open and undated in the pantry, and it was not stored properly as required after opening. In the walk-in freezer, a blue bag containing six meat-like patties, identified as pork fritters, and another bag with breaded squash were both found opened and without labels or dates. The Dietary Manager confirmed these observations and acknowledged that the kitchen staff had been educated on the importance of labeling and dating foods to ensure proper usage. The Administrator also confirmed that the expectation was for kitchen staff to label and date opened items to prevent foodborne illness.
Controlled Medication Reconciliation Deficiency
Penalty
Summary
The facility failed to maintain an accurate account of controlled medications and provide evidence of periodic reconciliation for two of the five medication carts reviewed. Specifically, the facility did not update the medication label for a resident's Hydrocodone/APAP prescription to reflect a new order of administering 1/2 tablet every 4 hours as needed for pain. During the medication pass, it was observed that the Controlled Substance Record still instructed to give 1 tablet, and there were discrepancies in the narcotic count, with a missing dose not accounted for on the record. Interviews with staff revealed that the missing dose was not noted upon receipt from the pharmacy, and there was no record of the missing dose or waste on the narcotic count records. The facility's Consultant Pharmacist stated that random audits were performed but did not provide evidence of these audits. The Director of Nurses confirmed that discontinued narcotics are stored securely and destroyed monthly with the pharmacist, but the facility lacked proper documentation for the receipt and reconciliation of controlled substances.
Failure to Maintain Resident Wheelchair in Good Repair
Penalty
Summary
The facility failed to ensure that a resident's wheelchair was in good repair, compromising the resident's right to a safe and comfortable environment. Observations on two consecutive days revealed that the wheelchair of Resident #51 had armrests that were torn and tattered, with sharp plastic edges and exposed yellow foam. This condition posed a risk of injury to the resident, as confirmed by an LPN who noted that the resident could scratch the skin on his arms due to the disrepair. Interviews with facility staff revealed a lack of communication and procedure regarding the maintenance of resident equipment. The LPN confirmed the need for repair and explained that staff are responsible for notifying maintenance through a work order. However, the maintenance staff member interviewed stated that he had not received any work order for the wheelchair and was unaware of its poor condition. The facility did not have a formal written policy to ensure resident equipment was maintained in good condition, relying instead on staff to report issues as they arise.
Failure to Implement Care Plan for Resident Grooming
Penalty
Summary
The facility failed to implement a care plan for a dependent resident who preferred to be clean-shaven. The resident, who had a self-care performance deficit related to congestive heart failure and diabetes mellitus, expressed a desire to be shaved as part of his bathing routine. Despite being scheduled for bathing and showering on specific days, the resident was observed to have unshaven facial hair over multiple days, indicating that the care plan was not followed. The Director of Nursing confirmed that grooming and shaving were part of the bathing activities of daily living (ADL) care plan, which was not adhered to by the staff. The resident, who had moderate cognitive impairment, was admitted to the facility with diagnoses including Type 2 Diabetes Mellitus and Osteoarthritis. The Minimum Data Set (MDS) Coordinator, responsible for developing care plans, acknowledged that the care plan for ADL bathing care, which included grooming and shaving, was not followed. The facility's policy required individualized care plans to be developed and maintained for each resident, but in this case, the care plan was not effectively implemented, leading to the deficiency.
Failure to Provide Grooming Care for Resident
Penalty
Summary
The facility failed to provide adequate grooming care for a resident who was dependent on staff for activities of daily living (ADL). The resident expressed a desire to be shaved, particularly on shower days, but was observed with significant facial hair stubble over multiple days. Despite the resident's requests and the facility's policy that includes grooming as part of ADL care, the staff did not fulfill this need. The Director of Nursing acknowledged the oversight and confirmed that shaving was part of the resident's scheduled bathing routine. The resident, who has been at the facility since June 2022, has a diagnosis of Type 2 Diabetes Mellitus and Osteoarthritis and was noted to have moderate cognitive impairment with a BIMS score of 10. The facility's policy emphasizes encouraging resident choice and participation in ADLs, yet the resident's preference to be clean-shaven was not honored. This deficiency was identified through observations, interviews, and record reviews, highlighting a lapse in the facility's adherence to its own policies regarding resident care and grooming.
Unsecured Cleaning Chemicals in Janitors' Closets
Penalty
Summary
The facility failed to ensure a safe environment free from potential hazards for residents, as evidenced by unsecured cleaning chemicals in janitors' closets on two of the five units in the building, specifically the 400 Hall and Dementia Unit. Observations revealed that the janitors' closets on these units were unlocked, with full bottles of disinfectant accessible. The janitors' closet on the Dementia Unit was observed to be unlocked, with a broken coded lock, and contained three full bottles of disinfectant. A Certified Nurse Assistant (CNA) confirmed the lock was broken and had not informed maintenance, although the closet was in view of staff due to the unit's open layout. Similarly, the janitors' closet on the 400 Hall was found unlocked, with four bottles of liquid disinfectant inside. A Licensed Practical Nurse (LPN) confirmed the closet should be locked to prevent resident access to chemicals. Housekeeping staff acknowledged the broken lock on the 400 Hall closet, and maintenance staff confirmed the locks on both units were broken, with an attempt to fix the 400 Hall lock previously made. The facility administrator confirmed that janitors' closets should always be locked to prevent resident access to hazardous materials.
Failure to Obtain Informed Consent for Bed Rails
Penalty
Summary
The facility failed to obtain informed consent for the application of bed rails for one of the residents, identified as Resident #30. The facility's policy requires that residents be assessed for safety risks, and informed consent must be obtained before bed rails are applied. However, during an observation, it was noted that Resident #30 had one-half side rails raised on both sides of the bed without a signed consent form. The resident was admitted with a medical diagnosis of hemiplegia following a cerebral infarction affecting the left non-dominant side, and the physician's orders indicated the use of side rails for increased bed mobility and independence. Interviews with facility staff, including the MDS Nurse and the ADON, revealed that bed rail assessments were completed on admission and quarterly, and the risks and benefits were explained to the family. However, the ADON confirmed that a consent form was not signed for Resident #30, which should have been done to ensure the family was notified of the risks associated with bed rails. This oversight led to the deficiency noted in the report.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, leading to deficiencies in medication management. During a review of the medication carts, it was found that the medication order, medication administration record, and narcotic record label for a resident's Hydrocodone/APAP prescription were not updated to reflect a change in dosage from 1 tablet to 1/2 tablet. This discrepancy was confirmed by an LPN, who noted that the wastage of the unused half-tablet was not documented, and a missing tablet was reported. This indicates a failure in maintaining accurate medication records and accountability. Additionally, during an initial tour, two medication capsules were found unsecured in a resident's room, which were identified as Gabapentin 300 mg. The resident did not have an order to self-administer medications, and the presence of these capsules in the room suggests that the staff did not ensure the resident took their medication as prescribed. Interviews with nursing staff and the DON confirmed that medications should not be left in residents' rooms, as this poses a risk of accidental ingestion or misuse. The resident involved was moderately cognitively impaired, with a diagnosis of unspecified dementia and anxiety, further emphasizing the need for careful medication management.
Failure to Implement Enhanced Barrier Precautions for Resident with PICC Line
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a Peripheral Inserted Central Catheter (PICC) line, as required by their policy. During an observation, a Registered Nurse (RN) performed hand hygiene and used a barrier on the overbed table for supplies but accessed the PICC line using only standard precautions, without implementing EBP. Additionally, there was no EBP sign posted on the resident's room door. An interview with the RN revealed she was unaware of the need to implement EBP for a resident with a PICC line. The facility's Training Coordinator and Director of Nurses confirmed that the policy requires EBP for central lines, which includes the resident in question. The resident was admitted to the facility the day before the observation.
Failure to Notify Physician of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to notify the physician of a significant change in a resident's physical status. Specifically, the facility did not inform the physician about a decrease in blood pressure and a urinary tract infection in a timely manner. The urine culture was obtained on a Wednesday, and the results were available by Friday night. However, the facility did not retrieve the results until the following Monday, delaying the start of antibiotics. Interviews with the Resident Representative, Assistant Director of Nursing, and the facility's physician confirmed that the physician was not notified until Monday, which delayed the necessary treatment for the resident's well-being. The resident involved had a history of Type 2 diabetes mellitus and cystitis. The Assistant Director of Nursing acknowledged that the staff should have contacted the lab over the weekend to obtain the results and notify the physician promptly. The facility's policy mandates notifying the physician of any significant changes in a resident's condition, which was not adhered to in this case. The Administrator was also unaware that the staff had failed to contact the hospital lab to obtain the culture results in a timely manner, confirming the deficiency in the facility's notification process.
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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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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Columbus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aurora Health And Rehabilitation | 1 mi | ★★★★★ | 12 | 0 |
| Trinity Healthcare Center | 1.4 mi | ★★★★★ | 2 | 0 |
| Vineyard Court Nursing Center | 3.4 mi | ★★★★★ | 3 | 0 |
| Baptist Memorial Hospital Gt | 3.6 mi | — | 0 | 0 |
| West Point Community Living Center | 16.9 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 July 2026) and official state health department websites.