Inspection Reports for
Windsor Care Center
125 STERLING WAY, MOUNT STERLING, KY, 40353
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
91% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 14, 2025
Visit Reason
The inspection was conducted following complaints and investigations related to failure to immediately notify a resident's family of injury and failure to ensure safe transfer techniques using a mechanical lift, resulting in resident injuries.
Complaint Details
The complaint investigation involved failure to notify family of bruising to Resident 2 and unsafe transfer resulting in injury to Resident 1. The bruising was reported late to the family, and the mechanical lift incident caused a head injury requiring emergency care. The facility conducted investigations, staff interviews, and implemented mandatory training. One staff member was terminated due to unsafe practices.
Findings
The facility failed to immediately notify the family of a resident's bruising and failed to ensure safe use of a mechanical lift during resident transfers, resulting in a resident head injury. Mandatory staff education and training on mechanical lift use were implemented following the incidents.
Deficiencies (2)
F 0580: The facility failed to immediately notify the resident's representative of an identified injury or significant change in physical status for 1 of 1 sampled resident.
F 0689: The facility failed to ensure safe transfer techniques using a mechanical lift, causing a resident to be struck on the head by the lift bar resulting in a laceration and hematoma.
Report Facts
Residents Affected: 1
Residents Affected: 1
Staff Signatures on Training Attendance: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SRNA4 | State Registered Nurse Aide | Operator of mechanical lift involved in resident injury and terminated for failure to use lift properly |
| SRNA1 | State Registered Nurse Aide | Second staff member involved in mechanical lift incident |
| DON1 | Director of Nursing | Conducted investigation of mechanical lift incident and staff disciplinary actions |
| RN3 | Sterling Unit Manager Registered Nurse | Reported bruising on Resident 2 |
| RN2 | Registered Nurse / Staff Development Specialist | Conducted mechanical lift training and education |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 21, 2025
Visit Reason
The visit was a follow-up revisit to verify the implementation of the acceptable Plan of Correction (POC) received on 04/08/2025.
Findings
Based on the follow-up revisit and implementation of the acceptable Plan of Correction, the facility was deemed to be in substantial compliance on 04/16/2025.
Report Facts
Plan of Correction received date: Plan of Correction received via ePOC on 04/08/2025
Substantial compliance date: Facility deemed in substantial compliance on 04/16/2025
Inspection Report
Routine
Deficiencies: 6
Date: Mar 13, 2025
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements related to resident transfer notifications, care planning, respiratory care, infection prevention, and quality assurance.
Findings
The facility failed to provide timely written notification to residents and their representatives regarding transfers and bed hold policies for 8 of 10 residents reviewed. The facility also failed to develop and implement comprehensive care plans for some residents, ensure proper respiratory care consistent with physician orders, maintain an effective infection prevention and control program, and sustain an effective Quality Assurance Performance Improvement (QAPI) process.
Deficiencies (6)
F0623: Facility failed to provide timely written notification to residents and their representatives before transfer or discharge, including appeal rights, for 8 of 10 residents reviewed.
F0625: Facility failed to notify residents or their representatives in writing how long the nursing home will hold the resident's bed during hospital transfer or therapeutic leave for 8 of 10 residents reviewed.
F0656: Facility failed to develop and implement comprehensive care plans meeting residents' medical and psychosocial needs for 2 of 26 sampled residents, including failure to follow oxygen administration orders and lack of care plan for dialysis catheter.
F0695: Facility failed to provide safe and appropriate respiratory care consistent with professional standards for 1 of 3 residents sampled, including improper oxygen administration and failure to ensure use of bipap device.
F0865: Facility failed to have an effective Quality Assurance Performance Improvement (QAPI) program focused on outcomes of care and quality of life for 1 of 50 sampled residents, evidenced by repeat deficiencies in cleaning shared equipment.
F0880: Facility failed to establish and maintain an effective infection prevention and control program, including failures in hand hygiene, cleaning shared equipment, proper use of PPE, and oxygen tubing maintenance for 5 of 50 sampled residents.
Report Facts
Residents reviewed for transfer notification: 10
Residents reviewed for care planning: 26
Residents sampled for respiratory care: 3
Residents sampled for infection prevention: 50
Residents sampled for QAPI review: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Named in respiratory care and wound care deficiencies related to oxygen administration and hand hygiene |
| RN1 | Unit Manager/Registered Nurse | Named in respiratory care deficiency related to oxygen administration and care plan oversight |
| DON | Director of Nursing | Named in multiple interviews regarding care plan expectations, infection control, and QAPI |
| Administrator | Named in interviews regarding facility policies and oversight of QAPI and infection control | |
| BOM | Business Office Manager | Named in transfer notification and bed hold policy deficiencies |
| IP Nurse | Infection Prevention Nurse | Named in infection prevention deficiencies and education |
| Medical Director | Named in respiratory care deficiency regarding oxygen administration orders |
Inspection Report
Routine
Deficiencies: 10
Date: May 3, 2024
Visit Reason
Routine inspection of Windsor Care Center to assess compliance with healthcare regulations including resident care, infection control, medication management, and facility operations.
Findings
The facility had multiple deficiencies including failure to coordinate PASARR assessments for residents with serious mental illness, incomplete care plans for residents' medical and psychosocial needs, inadequate podiatry services, lack of restorative nursing program, improper care of feeding tubes, medication storage and handling violations, infection prevention and control lapses, and incomplete documentation of COVID-19 vaccination status for staff.
Deficiencies (10)
F0644: Facility failed to refer a resident with a new diagnosis of psychosis for a level II PASARR review as required.
F0656: Facility failed to develop and implement comprehensive care plans addressing medical, nursing, and psychosocial needs for 3 of 30 sampled residents.
F0684: Facility failed to provide appropriate skin care and implement care plan interventions for a resident with skin picking behavior, resulting in skin tears and infections.
F0687: Facility failed to provide podiatry services and foot care for a diabetic resident, increasing risk of infection and complications.
F0688: Facility failed to provide appropriate treatment and services to maintain or improve range of motion for 3 residents and lacked a restorative nursing program.
F0693: Facility failed to prevent complications of enteral feeding by not applying ordered antibiotic ointment to a resident's infected gastric tube site.
F0761: Facility failed to ensure drugs, biologicals, and vaccines were stored according to accepted professional principles, including improper vaccine storage, unlocked medication carts, and failure to discard expired medications.
F0812: Facility failed to store food under sanitary conditions in nourishment unit refrigerators, including ice packs stored in freezers and lack of temperature logs.
F0880: Facility failed to implement an effective infection prevention and control program, including improper cleaning and disinfection of shared equipment, improper medication handling, and expired disinfectant wipes.
F0887: Facility failed to maintain documentation of COVID-19 vaccination education, offering, and status for 2 of 3 sampled staff members.
Report Facts
Residents sampled for care plan deficiency: 3
Residents sampled for ROM deficiency: 3
Residents affected by medication storage issues: 9
Residents affected by infection control issues: 5
Residents affected by COVID-19 vaccination documentation issues: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN5 | Licensed Practical Nurse | Failed to apply antibiotic ointment to gastric tube site; improper medication storage and infection control practices |
| LPN3 | Licensed Practical Nurse | Failed to properly disinfect glucometer and perform hand hygiene |
| KMA2 | Kentucky Medication Aide | Handled medication with bare hands during administration |
| NASR9 | Nurse Aide-State Registered | Failed to disinfect mechanical lift after use |
| KMA4 | Kentucky Medication Aide | Left medication room keys unattended in nurse station drawer |
| LPN11 | Licensed Practical Nurse | Failed to sign controlled substances count sheet at shift start |
| KMA3 | Kentucky Medication Aide | Declined COVID-19 vaccination and filed religious exemption; no documentation of vaccine education |
| DA1 | Dietary Aide | No documentation of COVID-19 vaccination or education; refused vaccination |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 3, 2024
Visit Reason
The inspection was conducted to investigate multiple allegations of resident-to-resident abuse incidents reported at the facility involving several residents.
Complaint Details
The investigation involved 7 allegations of resident-to-resident abuse affecting 5 residents. The facility failed to provide documented evidence of investigations for three reported abuse incidents occurring on 06/30/2023, 07/11/2023, and 09/10/2023. The substantiation status is not explicitly stated.
Findings
The facility failed to protect residents from abuse in multiple incidents involving resident-to-resident altercations and failed to conduct thorough investigations of these abuse allegations. The investigations lacked witness statements, root cause analysis, and sufficient documentation.
Deficiencies (2)
F 0600: The facility failed to protect residents from all types of abuse including physical and verbal abuse in incidents involving three residents who struck or kicked others causing minimal harm or potential for harm.
F 0610: The facility failed to respond appropriately to all alleged violations by not conducting thorough investigations including witness interviews, root cause analysis, and resident assessments for multiple resident-to-resident abuse incidents.
Report Facts
Residents affected: 5
Allegations investigated: 7
BIMS scores: 6
BIMS scores: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) 4 | Signed progress notes and provided limited recollection of an incident involving residents R27 and R168 | |
| Kentucky Medication Aide (KMA) 2 | Reported witnessing verbal abuse and kicking incident involving residents R368 and R87 | |
| Licensed Practical Nurse (LPN) 10 | Reported witnessing resident altercation and initiated neurological checks | |
| Licensed Practical Nurse (LPN) 14 | Signed incident reports and described abuse prevention supervision practices | |
| Social Services Director (SSD) | Conducted resident interviews and described role in abuse investigations | |
| Director of Nursing (DON) | Provided expectations for staff regarding resident safety and reporting of altercations | |
| Administrator | Discussed expectations for thorough investigations and interventions following abuse allegations |
Inspection Report
Routine
Deficiencies: 7
Date: Aug 29, 2019
Visit Reason
The inspection was conducted to assess compliance with federal regulations related to resident rights, care planning, use of restraints, safety, and overall quality of care at Windsor Care Center.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during meal assistance, inadequate accommodation of resident needs such as call light accessibility, improper use and evaluation of restraints and alarms, inaccurate resident assessments, incomplete and unrevised care plans, and failure to prevent accidents related to hot beverage service resulting in a resident burn injury.
Deficiencies (7)
F 0550: The facility failed to treat residents with dignity during meal assistance by standing rather than sitting beside residents requiring extensive physical assistance.
F 0558: The facility failed to reasonably accommodate the needs of Resident #105 by not ensuring the call light was within reach, resulting in delayed assistance.
F 0604: The facility failed to ensure residents were free from physical restraints or alarms used for convenience without proper evaluation and documentation for Residents #67 and #77.
F 0641: The facility failed to ensure accurate Minimum Data Set (MDS) assessments for Residents #28 and #77, missing pain management and functional limitations.
F 0656: The facility failed to implement the comprehensive care plan for Resident #105, specifically related to call light accessibility and assistance.
F 0657: The facility failed to ensure comprehensive care plans were reviewed, revised, and developed with interdisciplinary team involvement and resident or representative participation for Residents #67, #68, and #77.
F 0689: The facility failed to ensure adequate supervision and safe serving of hot beverages, resulting in Resident #1 sustaining a second degree burn from hot coffee served in a Styrofoam cup.
Report Facts
Residents sampled: 27
BIMS score: 6
Coffee temperature: 150
Burn wound size: 22
Burn wound width: 5.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SRNA #1 | State Registered Nurse Aide | Named in findings related to meal assistance and hot beverage incident |
| SRNA #2 | State Registered Nurse Aide | Named in findings related to meal assistance and hot beverage incident |
| LPN #1 | Licensed Practical Nurse | Named in findings related to restraint evaluation and hot beverage incident |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for resident dignity, restraint policies, care plan accuracy, and incident response |
| Administrator | Facility Administrator | Interviewed regarding facility policies, care plan meetings, and incident response |
| Dietary Manager | Dietary Manager | Interviewed regarding hot beverage preparation and serving policies |
| Staff Development Coordinator | Staff Development Coordinator | Interviewed regarding staff education on hot beverage safety |
| Weekend Supervisor/RN #1 | Registered Nurse | Responded to hot beverage incident and conducted investigation |
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