Gibsonburg, OH

Windsor Lane Healthcare Center

3-star overall rating with 2-star inspections with abuse icon flag with $21,677 in total fines with 17 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

355 Windsor Lane, Gibsonburg, OH

(419) 637-2104

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1986-06-13

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.41

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

1.08

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.94

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

4.42

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

1.49

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

4.03

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.24

Weekend registered nurse coverage · state 0.41 · national 0.47

Physical therapist

0.04

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.31

CMS adjusted RN staffing hours

Adjusted total hours

3.32

CMS adjusted total nurse staffing hours

Case-mix index

1.82

Higher values indicate more complex resident acuity

RN turnover

44%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

40%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,008

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

14.33

Composite VBP score used to determine payment impact.

Payment multiplier

0.9813

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

0.95

Performance 59.80% · Measure score 0.95 · Achievement 0.95 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

1.92

Baseline 2.85 hours · Performance 3.56 hours · Measure score 1.92 · Achievement 1.69 · Improvement 1.92

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	1.05	1.02 About the same
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 12 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	1.35%	8.2% 6.8 pts worse	Numerator 1 · Denominator 74
Staff flu vaccination coverage	6.67%	42% 35.3 pts worse	Numerator 8 · Denominator 120
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.6	1.8 0.2 pts better	1.9 0.3 pts better	Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.9 · Expected 2.3 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.9	1.8 0.1 pts worse	1.8 0.1 pts worse	Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.9 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	90.4%	92.4% 2 pts worse	93.4% 3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 94.0% · Q2 90.9% · Q3 89.7% · Q4 87.1% · 4Q avg 90.4%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	94.3%	94.5% 0.2 pts worse	95.5% 1.2 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 94.3%
Percentage of long-stay residents experiencing one or more falls with major injury	1.5%	3.3% 1.8 pts better	3.3% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 1.5% · Q4 2.9% · 4Q avg 1.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	6.8%	26.1% 19.3 pts better	11.4% 4.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 13.2% · Q4 14.5% · 4Q avg 6.8%
Percentage of long-stay residents who lose too much weight	6.0%	6.2% 0.2 pts better	5.4% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 4.8% · Q3 10.9% · Q4 4.8% · 4Q avg 6.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	38.0%	25.4% 12.6 pts worse	19.6% 18.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 38.1% · Q2 35.9% · Q3 39.1% · Q4 39.1% · 4Q avg 38.0%
Percentage of long-stay residents who received an antipsychotic medication	9.6%	11.5% 1.9 pts better	16.7% 7.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 11.4% · Q3 7.1% · Q4 6.7% · 4Q avg 9.6% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.4%	0.1% 0.3 pts worse	0.1% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4%
Percentage of long-stay residents whose ability to walk independently worsened	14.6%	7.7% 6.9 pts worse	16.3% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 14.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	4.0%	6.2% 2.2 pts better	14.9% 10.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 4.7% · Q3 0.0% · Q4 3.2% · 4Q avg 4.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.0%	0.2% 0.8 pts worse	1.0% About the same	Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	0.5% 0.5 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	21.1%	21.7% 0.6 pts better	19.8% 1.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 10.3% · Q3 32.2% · Q4 35.3% · 4Q avg 21.1%
Percentage of long-stay residents with pressure ulcers	3.8%	3.7% 0.1 pts worse	5.1% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 2.7% · Q3 4.8% · Q4 3.2% · 4Q avg 3.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	63.6%	78.1% 14.5 pts worse	81.7% 18.1 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 63.6%

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-07-25 · Fire 2024-07-25

17 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2021-11-24 · Fire 2021-11-24

12 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2019-05-22 · Fire 2019-05-22

11 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

2 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-07-25

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2024-09-13

F · Potential for more than minimal harm 2024-07-25

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-09-13

F · Potential for more than minimal harm 2024-07-25

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-09-13

F · Potential for more than minimal harm 2024-07-25

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-09-13

F · Potential for more than minimal harm 2024-07-25

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-09-13

F · Potential for more than minimal harm 2024-07-25

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-09-13

E · Potential for more than minimal harm 2024-07-25

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-09-13

E · Potential for more than minimal harm 2024-07-25

K915 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper power supply for life support equipment.

Corrected 2025-09-10

F · Potential for more than minimal harm 2021-11-24

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2021-12-22

F · Potential for more than minimal harm 2021-11-24

K912 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have power receptacles that are properly grounded.

Corrected 2021-12-22

E · Potential for more than minimal harm 2021-11-24

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2021-12-22

E · Potential for more than minimal harm 2019-05-22

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2019-06-25

E · Potential for more than minimal harm 2019-05-22

K754 · Miscellaneous Deficiencies

Fire Safety

Provide properly sized and located linen or trash receptacles.

Corrected 2019-06-25

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-12-29

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Not marked corrected

D · Potential for more than minimal harm 2025-09-10

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-09-29

D · Potential for more than minimal harm 2025-09-10

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-09-29

D · Potential for more than minimal harm 2025-09-10

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-09-29

G · Actual harm 2024-12-11

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-12-18

D · Potential for more than minimal harm 2024-11-22

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-11-07