Inspection visit
Health inspection
10 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 10 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0563
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Level of Harm - Minimal harm
or potential for actual harm
Based on resident interview, staff interview, review of self-reported incidents (SRIs), review of a facility
employee handbook, and review of a Centers for Medicare and Medicaid (CMS) memorandum, the facility
failed to reasonable allow residents to have visitors of their choosing. This affected one (#4) of one resident
reviewed for visitation. The facility census was 60.
Residents Affected - Few
Findings include:
Review of Resident #4's medical record revealed an admission date of 06/09/21. Diagnoses included
hypertensive heart disease, morbid obesity, muscle weakness, and localized edema. Review of the most
recently completed Minimum Data Set (MDS) assessment, dated 08/26/21, revealed Resident #4 had intact
cognition.
Interview on 11/21/21 at 11:59 A.M. with Resident #4 stated a former dietary staff member (Dietary Aide
(DA) #877) recently quit working in the facility and wanted to come visit him, but the Administrator told her
she was not allowed to enter the facility for visits.
A telephone interview was conducted on 11/22/21 at 10:12 A.M. with Human Resources Manager (HRM)
#725 who verified DA #877 no longer was employed in the facility. HRM #725 stated there were rumors DA
#877 was crossing professional boundaries with Resident #4 but nothing was substantiated. HRM #725
stated DA #877 also displayed poor work habits and was not performing job duties adequately so DA #877
was given a final written warning on either 11/18/21 or 11/19/21. HRM #725 stated after DA #877 was given
her final written warning she was a no call, no show on her next scheduled day of work and did not show up
to work thereafter. HRM #725 stated DA #877's employment was terminated when she did not show up to
work and did not call to say she was not coming into work. HRM #725 stated based on DA #877's no call,
no show she would not be allowed on the facility premises since she left on bad terms.
Interview on 11/23/21 at 2:20 P.M. with Administrator #515 stated he received a telephone call from DA
#877 and she asked about visiting Resident #4. Administrator #515 stated he would not allow DA #877 to
visit Resident #4 in the facility as she left her employment with the facility on bad standing. Administrator
#515 stated he was not refusing to allow Resident #4 and DA #877 to see each other, however, it could not
occur in the facility.
Review of self-reported incidents (SRIs) dated between 12/22/20 and 11/12/21 revealed DA #877 was not
involved in any investigations for abuse, neglect, or misappropriation.
Review of an employee handbook, revised June 2014, on page 39 under the section titled, Visiting,
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 14
Event ID:
365681
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365681
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/24/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Windsor Lane Healthcare Center
355 Windsor Lane
Gibsonburg, OH 43431
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0563
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
revealed former employees of the facility who were terminated must contact the administrator's office prior
to entering the facility and may do so only to visit a resident. At that time the former employee must provide
the date, time, and length of visit and name of resident. Under some circumstances former employee may
not be permitted on the premises depending on the cause of termination. There were no visitation
restrictions in the employee handbook for former staff members who quit their employment with no
advanced notice to the facility.
Review of a CMS memorandum referenced as QSO-20-39-NH and titled Nursing Home Visitation COVID-19, last revised 11/12/21, revealed facilities must allow indoor visitation at all times and for all
residents as permitted under the regulations. While previously accepted during the public health emergency
(PHE), facilities can no longer limit the frequency and length of visits for residents, the number of visitors, or
require advanced scheduling of visits. The effective date of the memorandum was immediately.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365681
If continuation sheet
Page 2 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365681
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/24/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Windsor Lane Healthcare Center
355 Windsor Lane
Gibsonburg, OH 43431
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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.
Based on review of facility's policy, observation and resident and staff interview, the facility failed to maintain
a sanitary and homelike environment. This affected three resident rooms and six residents (#2, #9, #38,
#46, #51, and #56) who resided in the those rooms. The facility census was 60.
Findings include:
Observation on 11/21/21 between 9:00 A.M. and 11:00 A.M. revealed three resident rooms had sticky fly
traps suspended from the ceiling with dead flies noted on each trap. The sticky fly trap in Resident #2 and
#38's room was located on the wall above the television on bed #1's side of the room and contained 10
dead flies. The sticky fly trap in Resident #46 and #51's room was located on the ceiling directly over
Resident #51's bed and contained in excess of 50 dead flies. The sticky fly trap in Resident #9 and #56's
room was located on the ceiling attached to a hook on the privacy curtain track between Resident #9 and
#56's beds and contained approximately 30 dead flies. No active fly activity was observed during these
observations.
Observation on 11/22/21 between 8:00 A.M. and 3:00 P.M. and on 11/23/21 between 8:30 A.M. and 9:30
A.M. revealed the stick fly traps with the dead flies remained in Resident #2, #9, #38, #46, #51 and #56's
rooms unchanged. There was no evidence of any active fly activity during observations on 11/22/21 or
11/23/21.
Interview on 11/23/21 at 8:40 A.M. with Resident #56 stated the facility put the fly trap up in his room
approximately in August 2021 when the flies were really bad in his room and indicated he had not seen any
fly activity for approximately the last six weeks. Resident #56 stated he did not like looking at the dead flies
on the fly trap and wanted it to be changed or taken down.
Interview on 11/23/21 at 9:36 A.M. with Resident #51 stated he did not know how long the fly trap was up in
his room, but stated it was disgusting to have to lay in bed and look up at all the dead flies stuck to the trap
above his bed.
Interview on 11/23/21 at 9:42 A.M. with Licensed Practical Nurse (LPN) #850 stated she was not aware
when the sticky fly traps were put up, but verified she did not see any active fly activity in the facility on
11/22/21 or 11/23/21.
Interview on 11/23/21 at 9:45 A.M., during the observation of the sticky fly traps in Resident #2, #9, #38,
#46, #51 and #56's rooms with LPN #850 verified the dead flies on each trap and LPN #850 confirmed the
traps needed to be changed or removed.
Review of a facility policy titled, Laundry and Housekeeping/Equipment and Utilities Standards of Practice,
dated 2004, revealed the procedures in the policy will clean and disinfect resident rooms and resident
bathrooms thereby providing a clean, safe decontaminated environment for the residents.
This deficiency substantiates Master Complaint Number OH00127329.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365681
If continuation sheet
Page 3 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365681
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/24/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Windsor Lane Healthcare Center
355 Windsor Lane
Gibsonburg, OH 43431
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0603
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, staff interview, resident interview, review of a facility policy, and review
of the Centers for Disease Control and Prevention (CDC) COVID-19 guidance, the facility failed to ensure a
Resident (#57) was not involuntary secluded to their room unnecessarily. Resident #57 was the only
resident in the facility identified as being on COVID-19 quarantine. The facility census was 60.
Residents Affected - Few
Findings include:
Review of Resident #57's medical record revealed an original admission date of 06/11/19 and a most
recent readmission date of 11/19/21. Diagnoses included acute and chronic respiratory failure with
hypercapnia, chronic obstructive pulmonary disease, morbid severe obesity, and unspecified
immunodeficiency.
Review of the Minimum Data Set (MDS) assessment, dated 10/25/21, revealed Resident #57 had intact
cognition.
Review of a document titled, COVID-19 Vaccine Registration Form, revealed Resident #57 received her first
dose of the COVID-19 vaccine on 06/17/21 and her second dose on 07/15/21.
Review of a nursing progress note dated 08/24/21 revealed Resident #57 tested positive for COVID-19.
Review of a nursing progress note dated 11/16/21 revealed Resident #57 was sent to the hospital, and
review of a nursing progress note dated 11/19/21 revealed Resident #57 returned to the facility. The time
between when Resident #57 tested positive for COVID-19 on 08/24/21 and when she returned to the facility
on [DATE] was 88 days.
Review of a physician order dated 11/19/21 revealed Resident #57 was to be quarantined to her room for
three days with a discontinuation date of 11/22/21.
Observation on 11/21/21 at 9:41 A.M. revealed Resident #57 was in a bedroom on the South Hall. Located
on Resident #57's bedroom door was a sign indicating the personal protective equipment (PPE) required to
wear when entering the bedroom and a bin was located in the hallway beside the doorway which contained
appropriate PPE.
Interview on 11/21/21 at 11:36 A.M. with Resident #57 stated she recently went to the hospital, stayed a
few days, and when she returned to the facility she was placed in COVID-19 quarantine. Resident #57
stated the facility told her she would be in quarantine for three days and she would not be able to leave her
room. Resident #57 stated she was fully vaccinated for COVID-19 and tested positive for COVID-19 in the
summer, and did not understand why she was in quarantine at that time.
Interview on 11/21/21 at 12:37 P.M. with Licensed Practical Nurse (LPN) #540 verified Resident #57 was on
quarantine for COVID-19 precautions because she just got back from the hospital. LPN #540 stated it was
facility practice for fully vaccinated residents to be on a three day quarantine when they returned from the
hospital.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365681
If continuation sheet
Page 4 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365681
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/24/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Windsor Lane Healthcare Center
355 Windsor Lane
Gibsonburg, OH 43431
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0603
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Observation on 11/22/21 at 9:43 A.M., 11:12 A.M., and 3:02 P.M. revealed Resident #57 remained in
quarantine in her bedroom.
Interview on 11/22/21 at 11:06 A.M. with Assistant Director of Nursing (ADON) #610 verified all new and
readmissions to the facility were placed on a three day quarantine to their room regardless of the resident's
COVID-19 vaccination status. ADON #610 stated she thought she heard somewhere that residents had to
be placed on quarantine for three days, but she was unsure where she heard the information. In addition,
ADON #610 stated by placing residents on quarantine, they were able to monitor residents for 72 hours to
make sure the resident did not have symptoms of any other infection.
Interview on 11/23/21 at approximately 10:30 A.M. with Director of Nursing (DON) #650 verified Resident
#57 was fully vaccinated when she tested positive for COVID-19 on 08/24/21.
Review of the facility's undated COVID-19 policy revealed no documentation of the current guidance for
new admission and re-admissions for residents that were fully vaccinated and/or had COVID-19 infections
in the last 30 days. An undated addendum to the COVID-19 policy revealed new admissions and residents
who had a hospital stay must be quarantined to their room for 14 days.
Review of the CDC website, at,www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, updated
09/10/21, titled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2
Spread in Nursing Homes, and under the sub-section titled, New Admissions and Residents who Leave the
Facility, revealed in general, all unvaccinated residents who are new admissions and readmissions should
be placed in a 14-day quarantine, even if they have a negative test upon admission. Fully vaccinated
residents and residents within 90 days of a SARS-CoV-2 infection do not need to be placed in quarantine.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365681
If continuation sheet
Page 5 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365681
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/24/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Windsor Lane Healthcare Center
355 Windsor Lane
Gibsonburg, OH 43431
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0604
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, staff interview, medical record review, and review of a facility policy, the facility failed to
evaluate the need for use of a restraint and routinely re-evaluate for continued use of a restraint. This
affected one (Resident #26) of one resident reviewed for restraint use. The facility identified one resident
with a physical restraint. The facility census was 60.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #26 revealed the resident was admitted on [DATE]. Diagnoses
included dementia with behavioral disturbance, schizoaffective disorder, psychotic disorder with
hallucinations, Alzheimer's disease, and abnormal posture.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/10/21, revealed Resident #26 was
severely cognitively impaired. Resident #26 utilized a chair that prevented her from rising and a bed alarm.
Review of the plan of care, initiated 06/29/20, revealed Resident #26 used a geri walker related to a history
of falling, dementia, and inability to keep her head upright when walking. Resident #26 had a diagnosis of
abnormal posture. Interventions included to evaluate the resident quarterly at the care conference. The plan
of care was silent for the use of a bed alarm.
Review of a physician order, dated 06/07/20, revealed Resident #26 was to utilize a geri walker for safety.
Additional review of an order dated 06/11/21 revealed an order for a pad alarm while in bed.
Review of the Interdisciplinary Team (IDT) Care Conference Summaries, dated 06/11/20, 09/20/20,
12/10/20, 03/11/21, 06/10/21, and 09/09/21 revealed the use of the geri chair was reviewed on 09/20/20
and 03/11/21. The use of the bed alarm had not been reviewed by the IDT during the care conference
meeting held after implementation of the device.
Observation on 11/21/21 at 12:34 P.M. revealed Resident #26 was in the dining room of the memory care
unit. Resident #26 was seated in a wheeled chair, made of plastic, that completely surrounded Resident
#26 and limited her movement. Additional observation of Resident #26's room revealed an alarm mat on
her bed.
Interview on 11/22/21 at 10:16 A.M. with State Tested Nurse Aide (STNA) #700 revealed Resident #26
utilized the geri walker because Resident #26 walked hunched over and would fall forward when trying to
ambulate. In addition, the bed alarm alerted staff, if they were providing care to another resident, that
Resident #26 was getting out of bed. STNA #700 stated both the geri chair and the bed alarm were used to
assist with keeping Resident #26 safe because she had a history of falling and harming herself due to her
posture. STNA #700 stated staff were trained on both devices and both were monitored to ensure their safe
use.
Interview on 11/22/21 at 4:05 P.M. with the Director of Nursing (DON) revealed residents should be
assessed prior to restraints being implemented and routinely thereafter. The DON stated assessments
would have been completed and documented in the resident's electronic medical record (EMR). The DON
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365681
If continuation sheet
Page 6 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365681
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/24/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Windsor Lane Healthcare Center
355 Windsor Lane
Gibsonburg, OH 43431
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0604
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
verified Resident #26's EMR was silent for initial assessment and ongoing reevaluation of continued use of
the geri walker and bed alarm.
Subsequent interview on 11/22/21 at 4:09 P.M. with the DON revealed restraint use was reviewed and
re-evaluated during quarterly interdisciplinary team (IDT) care plan meetings and the Social Worker (SW)
likely had those documents.
Interview on 11/22/21 at 4:33 P.M. with SW #520 verified there was no initial assessment to determine
Resident #26's need for a geri walker or bed alarm. In addition, SW #520 verified the IDT care plan meeting
notes reflected the use of the geri chair was only reevaluated on 09/20/20 and on 03/11/21 and the use of
the bed alarm had not been reviewed at the IDT care plan meeting held since the use was implemented.
Review of the facility's undated policy titled Windsor Lane Restraint Policy and Procedure revealed
residents were to be evaluated for use of restraints prior to restraint use. Additionally, restraints were to be
reevaluated quarterly to see if the need for the restraint continued.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365681
If continuation sheet
Page 7 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365681
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/24/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Windsor Lane Healthcare Center
355 Windsor Lane
Gibsonburg, OH 43431
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, and review of the facility's policy, the facility failed to develop a
comprehensive care to include the use of a restraint. This affected one (Resident #26) of 21 residents
reviewed for care plans. The facility census was 60.
Findings include:
Review of the medical record revealed Resident #26 was admitted on [DATE] with diagnoses including
dementia with behavioral disturbance, schizoaffective disorder, psychotic disorder with hallucinations,
Alzheimer's disease, and abnormal posture.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/10/21, revealed Resident #26 was
severely cognitively impaired. Resident #26 utilized a chair that prevented her from rising and a bed alarm.
Review of the plan of care, initiated 06/29/20, revealed Resident #26 used a geri walker related to a history
of falling, dementia, and inability to keep her head upright when walking. The plan of care was silent for any
care planned interventions utilizing the use of a bed alarm.
Review of a physician order, dated 06/07/20, revealed Resident #26 was to utilize a geri walker for safety.
An order, dated 06/11/21, revealed an order for a pad alarm while in bed.
Interview on 11/22/21 at 2:11 P.M. of Assistant Director of Nursing (ADON) #610 verified Resident #26
utilized a bed alarm for safety and the use of the bed alarm was not included in Resident #26's plan of care.
Review of the facility's policy titled Care Planning Process, dated 2004, revealed the plan of care should
identify interventions for the resident.
Review of the facility's undated policy titled Windsor Lane Restraint Policy and Procedure revealed
restraints were to be care planned.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365681
If continuation sheet
Page 8 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365681
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/24/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Windsor Lane Healthcare Center
355 Windsor Lane
Gibsonburg, OH 43431
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, staff interview, and medical record review, the facility failed to ensure Resident #43's
environment was free from accident hazards. This affected one (Resident #43) of four residents reviewed
for accident hazards. The facility census was 60.
Findings include:
Review of the medical record for Resident #43 revealed an admission date of 01/08/21. Diagnoses included
schizophrenia, bipolar disorder, generalized anxiety disorder, agoraphobia with panic disorder, hemiplegia
and hemiparesis following cerebral infarction (stroke), and voice and resonance disorder.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/08/21, revealed Resident #43
had a moderate degree of cognitive impairment. The assessment indicated Resident #43 felt depressed
seven to 11 days during the review period but did not have thoughts he would be better off dead.
Review of the care plan for Resident #43 revealed it identified the presence of behavioral symptoms that
may be harmful to himself, including wrapping the call light (cord) around his neck. The plan also identified
a behavior by Resident #43 of throwing himself out of bed or intentionally rolling out of bed onto the floor.
The plan included a goal for Resident #43 to not harm himself and for staff to anticipate and meet his
needs. Further review of the care plan for Resident #43 revealed two elements of the plan included an
intervention to ensure the call light was within reach.
Review of the progress notes, revealed on 09/23/21, Resident #43 was found to have wrapped the call light
cord around his neck. The documentation indicated that in accordance with an order from the nurse
practitioner, emergency medical services transported Resident #43 to the emergency room for evaluation
following what the document described as suicidal threats. Resident #43 was unharmed and returned to the
facility 09/24/21.
Observation on 11/22/21 at 11:10 A.M. revealed Resident #43 was lying in bed with his eyes open. The left
side of the bed was against the wall and a mattress was on the floor on the right side of the bed. The call
light cord, which was several feet long, was observed to be wrapped loosely around the bed's grab bar on
the right side of Resident #43's head. Observation confirmed there was sufficient length for Resident #43 to
wrap the cord around his neck and still be able to roll or throw himself out of bed (as described in the
medical record) with enough length remaining to create an asphyxiation hazard.
Interview on 11/22 21 at 11:16 A.M. with Licensed Practical Nurse (LPN) #545 confirmed Resident #43 had
a history of attempts at self-strangulation using the call light cord. LPN #545 further confirmed Resident
#43's call light cord was loosely wrapped around the bed's grab bar on the right side.
Interview on 11/22/21 at 11:29 A.M. with Assistant Director of Nursing (ADON) #610 further confirmed
Resident #43 had attempted to self-strangulate in the past, using the call light cord. ADON #610 confirmed
the observation that Resident #43's call light cord was wrapped loosely around the bed's grab bar to the
right of Resident #43's head.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365681
If continuation sheet
Page 9 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365681
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/24/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Windsor Lane Healthcare Center
355 Windsor Lane
Gibsonburg, OH 43431
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Interview on 11/22/21 at 12:14 P.M. with Licensed Social Worker (LSW) #520 further confirmed Resident
#43's history of wrapping the call light around his neck. LSW #520 reported there had been discussion
about using a bell instead, but the facility decided Resident #43 would likely throw the bell.
Interview on 11/23/21 at 2:51 P.M. with the Director of Nursing (DON) further confirmed Resident #43 was
transported to the emergency room on [DATE] for evaluation of a suicidal threat after Resident #43
wrapped the call light cord around this neck. The DON reported the facility was unable to think of an
alternate means for Resident #43 to summon staff, and therefore had not accommodated this need for a
safer alternative.
Event ID:
Facility ID:
365681
If continuation sheet
Page 10 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365681
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/24/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Windsor Lane Healthcare Center
355 Windsor Lane
Gibsonburg, OH 43431
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, and review of the facility's policy, the facility failed to monitor and
timely follow up on a resident's significant weight loss. This affected one (Resident #26) of four residents
reviewed for nutrition. The facility identified four residents with unplanned significant weight gain or loss. The
facility census was 60.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #26 revealed the resident was admitted to the facility on [DATE].
Diagnoses including dementia with behavioral disturbance, schizoaffective disorder, psychotic disorder with
hallucinations, Alzheimer's disease, and abnormal posture.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/10/21, revealed Resident #26 was
severely cognitively impaired.
Review of the plan of care, initiated 07/12/18, revealed Resident #26 had a nutritional problem related to
dementia, dysphasia, and not wanting to eat. Interventions included to monitor weights.
Review of the Mini Nutritional Assessment, dated 09/10/21, revealed Resident #26 was at risk for
malnutrition.
Review of Resident #26's weights revealed on 10/01/21 Resident #26 weighed 127.3 pounds and on
11/03/21 Resident #26 weighed 115.5 pounds. This was a 9.27% significant weight loss in one month.
Resident #26's electronic medical record (EMR) was silent for any weights following the significant weight
loss documented on 11/03/21.
Review of a weight obtained on 11/22/21 revealed Resident #26 weighed 120.2 pounds. This was a 5.6%
significant weight loss in a month.
Interview on 11/22/21 at 2:11 P.M. of Assistant Director of Nursing (ADON) #610 revealed when a
significant weight loss was noted, the resident should be reweighed to verify the weight loss and the family
and physician should be notified. ADON #610 verified Resident #26 was not reweighed following the
significant weight loss documented on 11/03/21 to confirm the weight loss and Resident #26's EMR did not
have documentation the family, physician, or dietician had been notified of the weight loss. ADON #610
stated the facility would typically do weekly weights to monitor weight loss and verified this was not done for
Resident #26. ADON #610 stated the weight documented on 11/03/21 was probably not correct.
Review of the facility's policy titled Patient/Resident Weights, dated 2004, confirmed if the month-to-month
weight showed more than a five percent weight loss, the resident was reweighed within 24 hours.
Additionally, if there was a five percent or more weight loss in one month, the family, physician, and the
Nutritional Services Director were notified by the nursing department.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365681
If continuation sheet
Page 11 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365681
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/24/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Windsor Lane Healthcare Center
355 Windsor Lane
Gibsonburg, OH 43431
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
Based on medical record review, staff interview, and review of the facility's policy, the facility failed to ensure
pharmacy recommendations were followed up with by the physician in a timely manner. This affected one
(Resident #32) of five residents reviewed for unnecessary medications. The facility census was 60.
Findings include:
Review of Resident #32's medical record revealed an admission date of 05/07/21. Diagnoses included
Alzheimer's disease, dementia, and anxiety disorder.
Review of the Minimum Data Set (MDS) assessment, dated 09/14/21, revealed Resident #32 was severely
cognitively impaired. Resident #32 displayed no behaviors during the review period.
Review of Resident #32's physician orders revealed an order with a start date of 05/13/21 and a
discontinuation date of 09/14/21 for Lorazepam Tablet 0.5 milligrams (mg) to be given .25 mg as needed for
anxiety behaviors twice daily. The as needed (PRN) exceeded the 14 day limit for a PRN anti-anxiety
medication.
Review of Resident #32's pharmacy reviews revealed on 06/14/21 a pharmacy review was completed and
the pharmacist recommended Resident #32's as needed (PRN) Lorazepam 0.25 mg for anxiety be
assigned a specific duration for therapy and a rationale for extended use. No physician response was
found.
Interview on 11/22/21 at 3:59 P.M. with the Director of Nursing (DON) verified the physician did not timely
respond to the 06/14/21 pharmacy recommendation to add a duration and rationale for extended treatment
to Resident #32's PRN Lorazepam. The Lorazepam was discontinued 09/14/21 and new order was
received 09/14/21 with a limited duration.
Review of the facility's policy titled Consulting Pharmacist Monthly Drug Review, dated 2016, revealed the
pharmacist was to conduct a monthly drug regimen review in accordance to the policy. Unnecessary
medications included medications in excessive duration. The resident's attending physician must document
in the medical record the identified irregularity was reviewed and what action, if any, was taken to address
it.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365681
If continuation sheet
Page 12 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365681
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/24/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Windsor Lane Healthcare Center
355 Windsor Lane
Gibsonburg, OH 43431
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
Based on medical record review, staff interview, and review of the facility's policy, the facility failed to ensure
resident's as needed (PRN) antianxiety medications were limited to 14 days or had a rationale for
extension. This affected one (Resident #32) of five residents reviewed for unnecessary medications. The
facility census was 60.
Findings include:
Review of Resident #32's medical record revealed an admission date of 05/07/21. Diagnoses included
anxiety disorder. Review of Resident #32's Minimum Data Set (MDS) assessment, dated 09/14/21,
revealed Resident #32 was severely cognitively impaired.
Review of Resident #32's physician orders revealed an order with a start date of 05/13/21 and a
discontinuation date of 09/14/21 for Lorazepam Tablet 0.5 milligrams (mg) to be given .025 mg as needed
for anxiety behaviors twice daily. The as needed (PRN) exceeded the 14 day limit for a PRN anti-anxiety
medication.
Review of Resident #32's Medication Administration Record (MAR) for May 2021 through November 2021
revealed Resident #32 had her PRN Lorazepam available for 124 days. No reason for extended use was
found. Resident #32 received PRN Lorazepam on 08/11/21, 08/27/21, 08/29/21, 09/07/21 and 09/14/21
before the order was discontinued. On 09/14/21, a new order was written for Lorazepam 0.5 mg given at
0.25 mg as needed for anxiety behaviors twice daily until 09/21/21. On 09/21/21, a new order was written
for Lorazepam 0.5 mg given at 0.25 mg as needed for anxiety behaviors twice daily until 10/14/21.
Interview on 11/22/21 at 3:59 P.M. with the Director of Nursing (DON) verified Resident #32 received the
PRN medication longer than 14 days without a rationale.
Review of the facility's policy titled Consulting Pharmacist Monthly Drug Review, dated 2016, revealed the
pharmacist was to conduct a monthly drug regimen review in accordance to the policy. Unnecessary
medications included medications in excessive duration. The resident's attending physician must document
in the medical record the identified irregularity was reviewed and what action, if any, was taken to address
it.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365681
If continuation sheet
Page 13 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365681
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/24/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Windsor Lane Healthcare Center
355 Windsor Lane
Gibsonburg, OH 43431
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual
needs.
Based on observation, staff interview, and medical record review, the facility failed to provide beverage
consistencies in accordance with physician orders and the care plan. This affected one (Resident #43) of
seven residents reviewed for hydration and/or nutrition. The facility census was 60.
Findings include:
Review of the medical record for Resident #43 revealed an admission date of 01/08/21. Diagnoses included
hemiplegia and hemiparesis following cerebral infarction (stroke), Type II diabetes mellitus, and dysphagia.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/08/21, revealed Resident #43
had a moderate degree of cognitive impairment. The assessment indicated Resident #43 required
extensive assistance by one staff person for eating, and experienced coughing or choking during meals.
Review of the physician orders for Resident #43 revealed an order, dated 08/24/21, for nectar-thick liquids.
Review of the care plan for Resident #43 revealed it identified a swallowing problem due to dysphagia, with
a goal to have reduced aspiration. The plan included an intervention to provide thickened liquids as
ordered.
Review of the diet card for Resident #43 revealed it did not indicate the need for thickened liquids.
Observation on 11/22/21 at 11:10 A.M. revealed Resident #43 was lying in bed with his eyes open, with no
staff present in the room. On a table in the room, was a coffee cup containing approximately six ounces of
coffee, that had a plastic straw sticking through the hole in the plastic lid that covered the cup. The coffee
inside the cup was not thickened. The end of the straw sticking out through the lid had dried food debris on
it.
Interview on 11/22/21 at 11:16 A.M. with Licensed Practical Nurse (LPN) #545 confirmed Resident #43 had
a physician order for nectar-thickened liquids. LPN #545 confirmed the coffee on Resident #43's table was
not thickened in accordance with the physician order, and the straw with dried food debris sticking out
through the lid, indicated Resident #43 had used the straw to drink the non-thickened coffee.
This deficiency substantiates Complaint Number OH00127329.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365681
If continuation sheet
Page 14 of 14
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Back to topCitations
10 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F603 - The resident has the right to be free from abuse, neglect, misappropriation
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
F604 - Respect and Dignity
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F563 - The resident has a right to receive visitors of his or her choosing at the time o
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
F584 - Safe Environment
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.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
FAQ · About this visit
Common questions about this visit
What happened during the November 24, 2021 survey of WINDSOR LANE HEALTHCARE CENTER?
This was a inspection survey of WINDSOR LANE HEALTHCARE CENTER on November 24, 2021. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WINDSOR LANE HEALTHCARE CENTER on November 24, 2021?
Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from separation (from other residents, his/her room, or confinement to his/her room)."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.