Windsor Rehabilitation And Healthcare Center

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, staff interviews, and a resident interview, the facility failed to protect a resident's right to be free from resident-to-resident physical abuse when Resident #3 struck Resident #4, resulting in a bruise to the right side of the face.

This occurred for 1 of 3 residents reviewed for abuse (Resident #4).

Findings included:Resident #3 was readmitted to the facility on [DATE].Documentation on an annual Minimum Data Set assessment dated [DATE] revealed Resident #3 was cognitively intact.Resident #4 was admitted to the facility on [DATE].Documentation on a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #4 had moderately impaired cognition.Documentation in a behavior note for Resident #3 dated 8/27/2025 at 2:45 PM written by the Assistant Director of Nursing (ADON) revealed the following information.

The ADON heard yelling in the dining room area and went to the dining room. Resident #3 indicated to the ADON that Resident #4 needed help getting through the doorway in his wheelchair from the outside. Resident #4 began to curse and call Resident #3 a racially charged name. As the ADON removed Resident #4 from the doorway, both Resident #3 and Resident #4 began to curse at each other. Resident #3 propelled himself in his wheelchair toward Resident #4 with his hand raised to hit him.

The ADON told Resident #3 not to hit Resident #4, but Resident #3 then slapped Resident #4 on the right side of the face. Resident #4 was assisted in his wheelchair to the nursing station.The ADON was interviewed on 10/8/2025 at 12:11 PM.

The ADON confirmed Resident #3 struck Resident #4 as she was attempting to pull Resident #3 out of the way.

The ADON indicated Resident #4 refused to stop calling Resident #3 a racially charged name so Resident #3 slapped him.

The ADON stated afterward the police were called and Resident #4 could not recall the incident.

The ADON confirmed Resident #3 was charged with assault and had already made an initial court appearance.

The ADON confirmed Resident #4 had a small bruise on the right side of his head after being struck by Resident #3.Resident #3 was interviewed on 10/8/2025 at 11:40 AM. Resident #3 explained that Resident #4 was outside and was trying to get into the building but was stuck in the doorway. Resident #3 further explained that he shouted for help until the ADON came into the dining room and he pointed to Resident #4 to let her know he was the one who needed help. Resident #3 stated that Resident #4 started cursing at him and called him a racially charged named that was very disrespectful. Resident #3 revealed he tried to hit Resident #4 but never made contact because the ADON pulled Resident #4 out of the way. Resident #3 confirmed the police were called but the ADON told the police Resident #3 struck Resident #4. Resident #3 confirmed he had already been to court, and the case had a continuation date. Resident #3 explained that Resident #4 had apologized to him and there were no further issues or problems between the two residents.Resident #4 was interviewed on 10/8/2025 at 11:50 AM. Resident #4 did not recall any incident or occasion for which he was slapped or hit at the facility. Resident #4 denied knowledge of any altercations he had involving Resident #3.The Administrator was interviewed on 10/8/2025 at 2:12 PM.

The Administrator stated that after Resident #3 hit Resident #4 the police were called.

The Administrator confirmed Resident #3 was charged with assault.

The Administrator also confirmed Resident #4 was assessed by a provider, ice was applied to his face, and he was moved to a different hallway away from Resident #3.

The Administrator stated Resident #3 and Resident #4 have not had any further issues.

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