All citations for Windsor Calallen

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Windsor Calallen

Last standard health inspection on record

July 22, 2026

Showing 1 to 19 of 19 citations

  1. No harm, with potential for more than minimal harm

    Have approved installation, maintenance and testing program for fire alarm systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0345, Smoke Deficiencies. Inspection of May 7, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 28, 2025).

  2. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of May 7, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 28, 2025).

  3. No harm, with potential for more than minimal harm

    Have restrictions on the use of highly flammable decorations.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0753, Miscellaneous Deficiencies. Inspection of May 7, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 28, 2025).

  4. No harm, with potential for more than minimal harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of May 7, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 8, 2025).

  5. No harm, with potential for more than minimal harm

    Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0222, Egress Deficiencies. Inspection of May 7, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 28, 2025).

  6. No harm, with potential for more than minimal harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0321, Smoke Deficiencies. Inspection of May 7, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 28, 2025).

  7. No harm, with potential for more than minimal harm

    Install smoke barrier doors that can resist smoke for at least 20 minutes.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0374, Smoke Deficiencies. Inspection of May 7, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 28, 2025).

  8. No harm, with potential for more than minimal harm

    To conduct inspection, testing and maintenance of fire doors by qualified individuals.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0761, Miscellaneous Deficiencies. Inspection of May 7, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 28, 2025).

  9. No harm, with potential for more than minimal harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of August 21, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (August 22, 2025).

  10. No harm, with potential for more than minimal harm

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0755, Pharmacy Service Deficiencies. Inspection of August 8, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (August 9, 2025).

  11. No harm, with potential for more than minimal harm

    PASARR screening for Mental disorders or Intellectual Disabilities

    Isolated (one or a few residents). CMS level D.

    Health citation F-0645, Resident Assessment and Care Planning Deficiencies. Inspection of May 7, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 8, 2025).

  12. No harm, with potential for more than minimal harm

    Provide enough food/fluids to maintain a resident's health.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0692, Quality of Life and Care Deficiencies. Inspection of May 7, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 8, 2025).

  13. No harm, with potential for more than minimal harm

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0761, Pharmacy Service Deficiencies. Inspection of May 7, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 8, 2025).

  14. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0880, Infection Control Deficiencies. Inspection of May 7, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 8, 2025).

  15. No harm, with potential for more than minimal harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of April 9, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (April 10, 2025).

  16. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0880, Infection Control Deficiencies. Inspection of April 9, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (April 11, 2025).

  17. No harm, with potential for more than minimal harm

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0584, Resident Rights Deficiencies. Inspection of April 4, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (April 5, 2025).

  18. No harm, with potential for more than minimal harm

    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

    Isolated (one or a few residents). CMS level D.

    Health citation F-0655, Resident Assessment and Care Planning Deficiencies. Inspection of February 20, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (March 14, 2025).

  19. No harm, with potential for more than minimal harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0684, Quality of Life and Care Deficiencies. Inspection of February 20, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (March 14, 2025).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.