Windcrest Health & Rehabilitation

Based on observation and interviews, the facility failed to provide a resident group with private space and prevent staff to attend without the invitation of the group for 1 of 1 group council meeting observed. The facility failed to prevent LVN E from entering a resident council meeting while in progress. This failure placed residents that could participate in a resident council at risk of not having the right to voice their concerns without staff being present or overhearing their concerns and conduct resident council meetings without interference. Findings included: During an observation and interview on 05/12/2026 at 2:05 PM, LVN E entered the resident council meeting. LVN E was informed a resident council meeting was in session and facility staff could not be present during the meeting. LVN E did not leave when requested to do so. LVN E stated she needed to take Resident #18's Blood Pressure and give her medication, before she left and stated she would do it really quick. During an interview on 05/14/2026 at 10:00 a.m., the AD stated resident council should have been private.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 8 of 21 (Resident #4, Resident #5, Resident #7, Resident #9, Resident #21, Resident #24, Resident #44, and Resident #81) residents reviewed for comprehensive person-centered care plans. The facility failed to develop a comprehensive care plan that included the need to reside on a secure unit for Resident #4, Resident #5, Resident #7, Resident #9, Resident #21, Resident #24, Resident #44, and Resident #81. This deficient practice could place residents in the facility at risk of not being provided the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure orders were provided for the resident's immediate care and needs for 4 (Resident #7, Resident #9, Resident #24, and Resident #44) of 16 residents reviewed for care supervised by a physician. The facility failed to ensure a physician order was put into place/received to admit Resident #7, Resident #9, Resident #24, and Resident #44 to an Alzheimer's certified secure care unit. The facility failed to obtain a diagnosis to admit Resident #24 to an Alzheimer's certified secure care unit. These failures could affect residents by not having their medical care supervised by a physician.The findings included the following: Review of Resident #7's electronic face sheet dated 05/14/2026, revealed a [AGE] year-old female initially admitted on [DATE] and most recent admission on [DATE]. Resident #7 was admitted with medical diagnoses of Parkinsonism (a group of neurological conditions characterized by slow movement, muscle stiffness, balance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility must not use any individual working in the facility as a nurse aide for more than four months on a full-time basis unless that individual has completed a training and competency evaluation program for 1 of 8 (NA C) non-certified nurse aides reviewed. The facility failed to ensure full-time NA C was certified within four months of the date of hire.This failure placed residents at risk of receiving inappropriate care from an individual whose skill level was not known. Findings included:Record review of the facility's employee files reflected NA C was hired on 10/29/2025 as a full-time nurse aide.During an interview on 05/14/2026 at 11:43 a.m., the DON stated NA C had been working as a full-time nurse aide in the facility and was taken off of the schedule today. During a telephone interview on 05/14/2026 at 1:29 p.m., NA C stated she started working on the floor providing resident care on 11/3/25, she stated she had already taken the online course to start her NA certification prior to being hired. She stated she was told by LVN D, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure kitchen staff properly secured hair in hair nets when handling and serving food. These failures could place residents who received food from the kitchen at risk of cross contamination and food borne illness.The findings include: During an observation on 05/12/2026 at 9:35 a.m., the Dietary Manager was observed in the kitchen with a thin hair net on covered by a gray headband with approximately one (1) inch of hair exposed above her neck where the hair net had moved up and exposed the hair. During an observation on 05/12/2026 at 9:36 a.m., the Lead [NAME] was observed wearing a thin hair net with approximately two (2) inches of hair that hung out of the hair net and down by both her temples and 1/2 inch was exposed above her forehead where the hair net had moved up and exposed the hair. During an observation on 05/12/2026 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to treat residents with respect, dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 10 residents (Resident #18), observed in the confidential group interview. The facility failed to prevent LVN E from taking Resident #18's blood pressure and administering medication during a resident council meeting on 5/14/26., in front of 9 other residents. This failure could result in a diminished quality of life and a loss of self-esteem for the residents. The findings included: Record review of Resident #18's electronic Face Sheet dated 05/14/2026 revealed the resident was a 93 -year-old female admitted to the FacilityFfacility on 05/31/2024 with the following diagnoses: Dementia ( a loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), dysphagia (difficulty swallowing), lack of coordination, and cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #9) of 21 residents whose assessments were reviewed for accuracy. The facility failed to ensure Resident #9's MDS assessment accurately reflected the use of a walker. This failure placed the residents at risk for unmet care needs.Findings included:Record review of Resident #9's electronic face sheet dated 05/14/2026 reflected a [AGE] year-old female who was admitted on [DATE] with diagnoses that included dementia (changes in the brain that affect memory, thinking, and behavior) and osteoarthritis (joint condition where the cushioning cartilage in your joints gradually wears away, causing pain, stiffness, and difficulty moving).Record review of Resident #9's quarterly MDS dated [DATE] reflected Resident #9 had a BIMS of 05 meaning severe cognitive impairment. Further review reflected she used a walker as a mobility device.Record review of Resident #9's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 2 of 3 medication carts (medication cart for Unit #1 and medication cart for Unit #2) reviewed for pharmacy services. The facility failed to ensure Resident #33, and Resident #71's natural tears eye drops were labeled with an open date on the medication cart for Unit #1. The facility failed to ensure Resident #12, and Resident #81's natural tears eye drops were labeled with an open date on the medication cart for Unit #2. These failures could affect residents prescribed medications in the facility and place them at risk for not receiving the correct medications, medication misuse, or receiving expired medications. Findings Included: During an observation on 03/10/25 at 10:00 AM, the medication cart for Unit #1 contained 2 bottles of natural tears eye drops with no open date for Resident #33 and Resident #71. During an observation on 03/10/25 at 10:10 AM, the medication cart for the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Resident #50 and Resident #48) and 1 of 2 staff (LVN A) reviewed for blood glucose monitoring. The facility failed to ensure that LVN A cleaned the glucometer (capillary-blood sampling devices) after using it for Resident #50 and before using it for Resident #48. This failure could place residents at risk for cross contamination, infections, and a decrease in quality of life. Findings included: Resident #50 Review of Resident #50's electronic Face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of diabetes, pelvis fractures, and heart failure. Review of Resident #50's admission MDS dated [DATE], revealed: BIMS of 10 which indicated moderately impaired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen's reviewed for meal service. Facility kitchen staff failed to discard food after handles touched with bare hands fell into pureed bread pan and roll bin during meal service. These failures could place residents at risk of food borne illness that ate from the kitchen. Findings included: During an observation on 01/29/2024 at 12:33 p.m., [NAME] A picked up scoop handle that was lying in puree bread halfway through meal pass and removed . [NAME] A asked [NAME] B to bring clean scoop over to steam table. [NAME] B brought back a clean scoop and placed into puree bread. [NAME] A started serving pureed bread to two of the pureed meal trays. The pureed bread was taken off the steam table by [NAME] A only after being asked if the food was okay to be served. During an interview on 01/29/2024 at 12:37 p.m., [NAME] A denied knowing that handle of scoop had dropped into ready to serve pureed bread, she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the comprehensive assessment for 2 (Resident #2 and Resident #20) of 4 residents reviewed for care plans. The facility failed to develop and implement a comprehensive person-centered care plan that addressed bed and chair alarms for Resident #2. The facility failed to develop and implement a comprehensive person-centered care plan that addressed a chair alarm for Resident #20. These failures could place residents at risk for falls and/or injury, negatively impact the resident's quality of life, as well as the quality of care and services received. Findings included: 1.Review of Resident #2's face sheet revealed a [AGE] year-old male admitted on [DATE] with medical diagnoses of fracture of the pelvic bone, dementia, type 2 diabetes, heart disease, and osteoporosis. Review of Resident #2's admission MDS dated [DATE] revealed in Section C -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that the resident environment remained as free of accident hazards as possible for one (Resident #20) of three residents reviewed for accident hazards. The facility failed to ensure that Resident #20's fall matt was placed beside her bed as ordered by physician. This failure could put residents at increased risk for accidents and injury. Findings include: Review of Resident #20's Face Sheet revealed an [AGE] year-old female initially admitted on [DATE] with a recent admission date of 12/15/2023. Resident #20's medical diagnoses included psychotic disorder with hallucinations, blood clots in the legs, back pain, difficulty walking, right shoulder pain, weakness, night terrors, and impaired cognition. Review of Resident #20's Annual MDS dated [DATE] revealed in Section C - C0500. BIMS Summary Score a BIMS score of 00 indicating the resident was unable to complete the interview. Review of Resident #20's Comprehensive Care Plan initiated 04/18/2018…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.