Above 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 Health Care Center during CMS and state inspections, most recent first.
An agency LPN misappropriated oxycodone from four residents with conditions including quadriplegia, chronic pain, cancer, COPD, and other comorbidities, all of whom had physician orders for oxycodone for moderate to severe pain. The LPN diverted narcotics by forging other nursing staff signatures on narcotic flow records, removing oxycodone cards and associated documentation, and causing multiple residents to be missing known and unknown quantities of oxycodone tablets. The facility’s internal investigation confirmed the diversion and misappropriation of these controlled medications, in violation of its abuse and misappropriation prevention policy.
The facility did not consistently apply McGeer criteria or communicate findings to physicians when antibiotics were prescribed for infections that did not meet established surveillance definitions. Multiple residents received antibiotics without proper assessment or documentation of necessity, and some received prolonged antibiotic therapy without evidence of ongoing physician review. Facility leadership confirmed gaps in policy review, staff training, and communication with outside providers regarding antibiotic use.
A resident with multiple risk factors and existing pressure ulcers was not provided with a low air loss mattress, despite repeated recommendations from a wound NP. Instead, only a standard pressure reducing mattress was used, and the care plan did not specify the recommended intervention. The resident developed a new deep tissue injury that progressed to an unstageable pressure ulcer, and staff confirmed the low air loss mattress was never implemented.
Two residents with significant contractures and impaired mobility did not consistently receive passive range of motion (PROM) and splinting programs as recommended by therapy. Therapy discharge summaries and care plans called for restorative interventions, but there were missing physician orders, incomplete care plans, and inconsistent documentation of splint use. Staff interviews confirmed that restorative programs were not reliably implemented or documented, resulting in a failure to maintain or improve the residents' range of motion.
A resident with multiple medical conditions did not have weekly weights consistently obtained as ordered, and significant weight changes were not always reported to the physician. Staff interviews and record reviews confirmed missed weight documentation, unclear responsibility for physician notification, and care plans lacking required details, resulting in failure to follow physician orders and facility policy.
A resident with dementia and PTSD, who had a history of traumatic experiences and behavioral symptoms, did not receive trauma-informed care as required. The care plan, Kardex, and nursing notes lacked references to trauma or related interventions, and staff were unaware of specific trauma triggers or care needs. Facility policy required trauma assessments and care planning, but these were not completed or reflected in the resident's documentation.
A resident with multiple comorbidities and an open pressure ulcer did not receive enhanced barrier precautions (EBP) during wound care, as required by facility policy and federal guidelines. The RN/Wound Nurse performed wound care using gloves but did not wear a gown, and there was no EBP signage or physician order in place. The infection control preventionist observed the procedure but did not intervene. Staff interviews confirmed that EBP should have been implemented once the wound was open.
The facility did not have an RN on duty for at least eight consecutive hours a day, seven days a week, affecting all 56 residents. During a specific week, no RN was scheduled or present on three days. An RN was pulled to another facility on one of these days, and an LPN covered the absence, leaving no RN in the facility.
Misappropriation and Diversion of Resident Narcotic Medications by Agency LPN
Penalty
Summary
The deficiency involves misappropriation of residents' narcotic medications by an agency LPN, resulting in missing oxycodone tablets and related narcotic documentation for four residents. One resident with quadriplegia, chronic pain syndrome, and anemia, who had intact cognition, had an order for oxycodone 10 mg every four hours as needed for pain; this resident was found to be missing an unknown amount of oxycodone tablets after the LPN forged other nursing staff signatures on the narcotic flow record. A second resident with malignant neoplasm of the left breast, morbid obesity, and generalized anxiety disorder, also cognitively intact, had an order for oxycodone 4 mg every four hours as needed for moderate to severe pain and was determined to be missing seven oxycodone tablets. A third resident, who had malignant neoplasm of the bronchus, bipolar disorder, and a brain disorder, with documented memory problems, had standing and as-needed oxycodone orders (5 mg four times daily and 10 mg every four hours as needed for increased pain) and was found to be missing 30 oxycodone tablets. A fourth resident with COPD, essential hypertension, and muscle wasting, cognitively intact and ordered oxycodone 5 mg one to two tablets every four hours as needed for pain, was missing an unknown amount of oxycodone because the LPN removed the remaining oxycodone card and narcotic flow record from the facility. The facility’s own investigation, as reflected in the misappropriation self-reported incident, substantiated that the agency LPN diverted narcotics from these four residents, contrary to the facility’s abuse prevention policy that requires protection from misappropriation of resident property.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program to monitor and ensure appropriate antibiotic use, as evidenced by record reviews, interviews, and policy review. Specifically, the facility did not consistently utilize McGeer criteria to assess the necessity and appropriateness of antibiotic prescriptions for residents, including those with chronic infections or those admitted from hospitals. In multiple cases, antibiotics were administered to residents for infections that did not meet McGeer criteria, and there was no documentation that physicians were informed of these findings to reconsider or evaluate the need for antibiotic therapy. Medical record reviews revealed that several residents received antibiotics for various infections, such as UTIs, pneumonia, and chronic wounds, without meeting the established criteria for infection surveillance. In some instances, antibiotics were prescribed without a documented stop date or duration, and there was no evidence of ongoing physician review or evaluation of the continued necessity for these medications. For example, one resident received cephalexin for an extended period without documented reassessment, and the facility was unable to provide evidence that the appropriateness of this ongoing antibiotic use was reviewed by a physician. Interviews with facility leadership, including the infection preventionist and the DON, confirmed that McGeer criteria were not applied to all residents, particularly those with chronic infections or those under the care of outside physicians. The facility's policy required annual review and staff education on antibiotic stewardship, but there was no evidence of recent policy review or staff training. The infection preventionist reported challenges in communicating with non-facility physicians and indicated that the facility did not intervene in antibiotic management unless the infection originated within the facility.
Failure to Provide Low Air Loss Mattress for High-Risk Resident with Pressure Ulcers
Penalty
Summary
The facility failed to implement a low air loss mattress for a resident with significant risk factors and existing pressure ulcers, despite repeated recommendations from the Wound Nurse Practitioner (NP). The resident, who had diagnoses including diabetes, muscle wasting, chronic kidney disease, and peripheral vascular disease, was admitted with pressure ulcers and was assessed as being at high risk for further skin breakdown due to immobility, malnutrition, and atrophy. The Wound NP consistently recommended a low air loss mattress from admission onward, and this recommendation was documented in multiple progress notes over several months. Despite these recommendations, the resident was only provided with a standard pressure reducing mattress, not a low air loss mattress, as confirmed by observations and staff interviews. The care plan and physician orders referenced pressure reducing surfaces and other interventions such as heel protectors and offloading, but did not specifically address the use of a low air loss mattress as recommended by the Wound NP. The resident subsequently developed a new deep tissue injury (DTI) on the left heel, which later declined to an unstageable pressure ulcer with slough and drainage, as documented in wound tracking and progress notes. Interviews with nursing staff and the Wound NP confirmed that the low air loss mattress was never provided, despite ongoing recommendations and the resident's continued risk and wound deterioration. Facility policy indicated that specialized surfaces, including low air loss mattresses, should be selected based on risk assessment and specialist recommendations, but this was not followed in this case. The failure to implement the recommended intervention contributed to the resident's ongoing wound issues and the development of a new pressure injury.
Failure to Implement and Document Restorative ROM and Splinting Programs
Penalty
Summary
The facility failed to ensure that passive range of motion (PROM) and splinting restorative programs were completed according to therapy recommendations for two residents with impaired range of motion. For one resident with hemiplegia, hemiparesis, and contractures in both hands and wrists, occupational therapy recommended a restorative PROM program and a splint-wearing schedule upon discharge from therapy. However, there were no physician orders or documentation for restorative ROM or splints, and the care plan did not address contractures, PROM, or splinting. Multiple observations confirmed that the resident's hands remained in a contracted position without splints, and interviews with therapy and nursing staff verified that the recommended restorative program and splinting had not been implemented since therapy discharge. Another resident with a history of cerebral infarction, muscle wasting, and contractures was also identified as requiring a PROM restorative program and a splinting program for contracture prevention. The care plan and therapy discharge summary recommended a restorative PROM program and daily use of hand and elbow splints. However, electronic records showed inconsistent documentation of splint application, with several days lacking any record of the splint being applied or refused. Interviews with staff revealed that the facility had recently shifted responsibility for restorative programs from dedicated restorative CNAs to floor CNAs, resulting in issues with program completion and documentation. The facility's policy required that residents at risk for functional limitations receive active or passive ROM to prevent further decline and that staff document all activities, participation, and refusals. Despite these requirements, both residents did not consistently receive the recommended restorative interventions, and documentation was incomplete or missing, leading to a failure to maintain or improve their range of motion as required.
Failure to Obtain Weekly Weights and Notify Physician of Significant Weight Changes
Penalty
Summary
The facility failed to ensure that a resident's weights were obtained as ordered and that the physician was notified of significant weight changes, as required by physician orders and facility policy. The resident, who had diagnoses including dysphagia, dementia, gastro-esophageal reflux disease, and hypertension, was admitted with an order for weekly weights and physician notification if her weight changed by more than three pounds from her admission weight. Despite this, there were multiple instances where weights were not recorded weekly, and significant fluctuations in weight were not consistently communicated to the physician. Review of the resident's weight records showed irregularities, including periods where no weights were documented for several weeks, and instances where reweights were requested but not completed in a timely manner. Notably, there was no weight recorded between early May and late May, despite a request for a reweight. The resident experienced both significant weight gains and losses over short periods, but documentation did not show that the physician was notified each time the weight change exceeded the threshold specified in the order. Interviews with facility staff, including the dietitian and nursing leadership, confirmed that the weekly weights and required notifications were not consistently performed. Staff were unclear about who was responsible for notifying the physician and could not provide evidence that notifications occurred as ordered. The care plan also did not reflect the specific order for weekly weights and physician notification for significant weight changes, further contributing to the deficiency.
Failure to Provide Trauma-Informed Care for Resident with PTSD and Dementia
Penalty
Summary
The facility failed to provide trauma-informed care to a resident with a history of dementia, major depressive disorder, anxiety disorder, intermittent explosive disorder, alcohol abuse, and post-traumatic stress disorder (PTSD). The resident had documented traumatic experiences, including being assaulted and serving in the Vietnam War, which were noted in psychosocial assessments and family interviews. Despite these documented traumas and ongoing behavioral symptoms such as paranoia, hallucinations, resistance to care, and combativeness, there was no evidence that trauma-specific assessments were completed after admission. The resident's care plan, last reviewed in April 2025, did not reference trauma, trauma triggers, or trauma-informed interventions, even though the resident was dependent on staff for emotional, intellectual, physical, and social needs due to cognitive deficits. The Kardex for nursing assistants and nursing progress notes from June 2024 to June 2025 also lacked any information or documentation relevant to trauma or trauma-informed care. Staff interviews confirmed a lack of knowledge regarding specific trauma-related care or triggers for the resident, and the social services staff reported that no specific trauma assessment was used beyond an initial screening at admission. The facility's policy required assessment and care planning for trauma and behavioral health issues on admission and quarterly, including identification of triggers and non-pharmacological interventions. However, the care plan and supporting documentation did not reflect these requirements for the resident in question, and staff were not able to identify or implement trauma-informed care practices as outlined in the policy.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement and use enhanced barrier precautions (EBP) for a resident with an open pressure ulcer, as required by both facility policy and federal guidelines. The resident, who had multiple diagnoses including diabetes, chronic kidney disease, and peripheral vascular disease, was admitted with pressure ulcers and later developed an unstageable wound with drainage and slough. Despite these conditions, there was no physician order for EBP, no EBP signage in the resident's room, and the care plan did not address EBP. During wound care, the RN/Wound Nurse performed hand hygiene and wore gloves but did not don a gown, which is required for high-contact care activities under EBP protocols. The infection control preventionist was present during the procedure but did not intervene or provide hands-on care. Interviews with nursing staff and the Director of Nursing confirmed that EBP should have been implemented, including the use of a gown during wound care. The oversight was attributed to the initial status of the wound, which was not open, but staff acknowledged that EBP should have been initiated once the wound opened. Review of facility policy and the CMS memorandum confirmed that EBP is indicated for residents with wounds, regardless of known infection or colonization status. The failure to implement EBP was observed in one resident out of two reviewed for EBP, despite the facility identifying multiple residents requiring such precautions.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, as required. This deficiency had the potential to affect all 56 residents of the facility. A review of the staff schedule for the week of December 22 to December 28, 2024, revealed that no RN was scheduled in the building on December 22, December 25, and December 28, 2024. An interview with the Payroll Coordinator confirmed that an RN scheduled for December 22 was pulled to another facility, and no RN was scheduled or present on December 25 and December 28. The Director of Nursing verified that a Licensed Practical Nurse (LPN) was called in to cover the RN's absence on December 22, resulting in no RN being present on that day, as well as on December 25 and December 28.
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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 Youngstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Vista Nursing And Rehab | 0.7 mi | ★★★★★ | 5 | 0 |
| Heritage Manor Jewish Hm For | 0.8 mi | ★★★★★ | 2 | 0 |
| Omni Manor Nursing Home | 2.4 mi | ★★★★★ | 1 | 0 |
| Liberty Health Care Center Inc | 3 mi | ★★★★★ | 9 | 0 |
| Austintown Healthcare Center | 3.2 mi | ★★★★★ | 11 | 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.