Windsor The Ridge Rehabilitation Center
Inspection Findings
F-Tag F0552
Federal health inspectors cited WINDSOR THE RIDGE REHABILITATION CENTER in SALINAS, CA for a deficiency under regulatory tag F-F0552 during a standard health inspection conducted on 2025-11-25.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Ensure that residents are fully informed and understand their health status, care and treatments.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 7 deficiencies cited during this inspection of WINDSOR THE RIDGE REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-26.
F-Tag F0605
Federal health inspectors cited WINDSOR THE RIDGE REHABILITATION CENTER in SALINAS, CA for a deficiency under regulatory tag F-F0605 during a standard health inspection conducted on 2025-11-25.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
The facility was found deficient in the following area: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 7 deficiencies cited during this inspection of WINDSOR THE RIDGE REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-26.
F-Tag F0676
Federal health inspectors cited WINDSOR THE RIDGE REHABILITATION CENTER in SALINAS, CA for a deficiency under regulatory tag F-F0676 during a standard health inspection conducted on 2025-11-25.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 7 deficiencies cited during this inspection of WINDSOR THE RIDGE REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-26.
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
(#36) and was placed back onto LW. RP was connected and agreed to pick up resident to run errands in order to decrease exit-seeking behaviors. Resident is on Q 1 hour monitoring location until further notice.Review of Resident 23's Interdisciplinary Care Conference dated 9/5/25 indicated, Resident 23 was observed with exit-seeking behavior during the morning shift, verbalizing wanting to leave the facility to visit his daughter and grandchildren.Recommendations: Increased supervision by staff. Wanderguard, intact, functioning, and location in place.Review of Resident 23's eINTERACT Change in Condition Evaluation - V 5.1 dated 9/13/25 indicated, At approximately 18:30 PM, the resident exited the facility without staff knowledge. Elopement (A situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision) protocol was immediately initiated, staff conducted thorough search in each resident room. outside the facility surrounding and resident was not located, 911 was called and report the elopement incident, all documents and description of resident were provided, MD and RP aware.
Admin and DON notified.During an interview on 9/25/25 at 3:26 PM, Registered Nurse (RN) 1 stated that
on 9/13/25 at 6:30 PM, he noticed Resident 23 was not in his bed nor inside the facility. RN 1 stated they were not able to find Resident 23 so he called 911 (emergency services) and notified the responsible party and the Administrator. During further interview, RN 1 stated that Resident 23 had his wander guard (a technology system used in facilities like hospitals and senior living homes to prevent residents at risk of wandering from leaving a secure area) on his left wrist but nobody heard the alarm when resident left. RN 1 also stated that they did not find Resident 23's wander guard in the facility. RN 1 further stated that Resident 23 was high risk for elopement thus, he was placed on one-on-one (1:1) supervision in July 2025 but was discontinued in mid-August 2025. RN 1 also stated that Resident 23 had episodes of leaving the facility prior to this incident.During an interview on 9/25/25 at 3:58 PM, Certified Nursing Assistant (CNA) 2 stated that Resident 23 had left the facility more than once and placed a designated CNA to provide 1:1 supervision. CNA 2 also stated that an order and intervention to check resident every 15-20 minutes was in place.Review of Resident 23's active orders for September 2025 indicated, Monitor episode of exit seeking
the facility every shift for episode of elopement. Monitor wander guard placement #36 to left wrist for function and location every shift. Monitor wander guard for placement and functioning hourly.Review of Resident 23's elopement care plan revised on 9/11/25 indicated, [Resident 23] has increase supervision-initiated r/t leaving the facility without staff knowledge . [Resident 23] noted removing wander guard using metal utensils. The care plan indicated interventions including, Ensure bedroom screen door is locked at all times. Initiated increased supervision and monitoring . Monitor and document behaviors and triggers that may lead to elopement. Monitor wander guard #36 placement and functioning. Provide plastic utensils in all meals.During a concurrent interview and record review on 9/25/25 at 4:53 PM with the DON Resident 23's care plan was reviewed. The DON stated that the new intervention they added on 9/11/25 was to provide plastic utensils in all meals to resident. The DON also stated that increased supervision and monitoring was continued.Review of the facility's policy and procedure titled, Elopement, revised 2/21/25, indicated, .The facility shall establish and utilize
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F-Tag F0755
Federal health inspectors cited WINDSOR THE RIDGE REHABILITATION CENTER in SALINAS, CA for a deficiency under regulatory tag F-F0755 during a standard health inspection conducted on 2025-11-25.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 7 deficiencies cited during this inspection of WINDSOR THE RIDGE REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-26.
F-Tag F0756
Federal health inspectors cited WINDSOR THE RIDGE REHABILITATION CENTER in SALINAS, CA for a deficiency under regulatory tag F-F0756 during a standard health inspection conducted on 2025-11-25.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 7 deficiencies cited during this inspection of WINDSOR THE RIDGE REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-26.
F-Tag F0757
Federal health inspectors cited WINDSOR THE RIDGE REHABILITATION CENTER in SALINAS, CA for a deficiency under regulatory tag F-F0757 during a standard health inspection conducted on 2025-11-25.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure each resident’s drug regimen must be free from unnecessary drugs.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 7 deficiencies cited during this inspection of WINDSOR THE RIDGE REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-26.
WINDSOR THE RIDGE REHABILITATION CENTER in SALINAS, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SALINAS, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WINDSOR THE RIDGE REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.