All citations for Windsor Health and Rehabilitation Center

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 Health and Rehabilitation Center

Last standard health inspection on record

April 17, 2025

Showing 1 to 21 of 21 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 August 11, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 20, 2022).

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

    Conduct risk assessment and an All-Hazards approach.

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

    Emergency preparedness citation E-0006, Emergency Preparedness Deficiencies. Inspection of August 11, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 20, 2022).

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

    Address patient/client population and determine types of services needed.

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

    Emergency preparedness citation E-0007, Emergency Preparedness Deficiencies. Inspection of August 11, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 20, 2022).

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

    Include a process for Emergency Preparedness collaboration.

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

    Emergency preparedness citation E-0009, Emergency Preparedness Deficiencies. Inspection of August 11, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 20, 2022).

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

    Address subsistence needs for staff and patients.

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

    Emergency preparedness citation E-0015, Emergency Preparedness Deficiencies. Inspection of August 11, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 20, 2022).

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

    Establish policies and procedures for sheltering.

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

    Emergency preparedness citation E-0022, Emergency Preparedness Deficiencies. Inspection of August 11, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 20, 2022).

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

    Establish policies and procedures for medical documentation.

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

    Emergency preparedness citation E-0023, Emergency Preparedness Deficiencies. Inspection of August 11, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 20, 2022).

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

    Establish policies and procedures for volunteers.

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

    Emergency preparedness citation E-0024, Emergency Preparedness Deficiencies. Inspection of August 11, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 20, 2022).

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

    Establish roles under a Waiver declared by secretary.

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

    Emergency preparedness citation E-0026, Emergency Preparedness Deficiencies. Inspection of August 11, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 20, 2022).

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

    Develop a communication plan.

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

    Emergency preparedness citation E-0029, Emergency Preparedness Deficiencies. Inspection of August 11, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 20, 2022).

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

    List the names and contact information of those in the facility.

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

    Emergency preparedness citation E-0030, Emergency Preparedness Deficiencies. Inspection of August 11, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 20, 2022).

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

    Provide primary/alternate means for communication.

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

    Emergency preparedness citation E-0032, Emergency Preparedness Deficiencies. Inspection of August 11, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 20, 2022).

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

    Establish methods for sharing information.

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

    Emergency preparedness citation E-0033, Emergency Preparedness Deficiencies. Inspection of August 11, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 20, 2022).

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

    Provide a means of sharing information on occupancy/needs.

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

    Emergency preparedness citation E-0034, Emergency Preparedness Deficiencies. Inspection of August 11, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 20, 2022).

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

    Provide family notifications of emergency plan.

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

    Emergency preparedness citation E-0035, Emergency Preparedness Deficiencies. Inspection of August 11, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 20, 2022).

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

    Inspect, test, and maintain automatic sprinkler systems.

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

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of August 11, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 20, 2022).

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

    Have simulated fire drills held at unexpected times.

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

    Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of August 11, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 20, 2022).

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

    Have proper medical gas storage and administration areas.

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

    Fire safety citation K-0923, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of August 11, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 20, 2022).

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

    Provide hallway or ground-level exits in all residents' rooms.

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

    Fire safety citation K-0254, Egress Deficiencies. Inspection of August 11, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 20, 2022).

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

    Construct fire resistant interior walls.

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

    Fire safety citation K-0331, Smoke Deficiencies. Inspection of August 11, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 20, 2022).

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

    Install corridor and hallway doors that block smoke.

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

    Fire safety citation K-0363, Smoke Deficiencies. Inspection of August 11, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 20, 2022).

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.