Elevate Care Windsor Park

In the surveyor’s words

From the most serious findings on record at Elevate Care Windsor Park, in the surveyor’s own words.

• Actual harm, isolatedF600Aug 6, 2026

  Based on interview and record review, the facility failed to follow its policy to affirm the right of one resident (R2) to be free from abuse. On May 28, 2026, R2 was observed with left periorbital ecchymosis and reddish purple discoloration consistent with a 'black eye,' as well as bruising to the right temple extending toward the hairline, all were of unknown origin. R2 was subsequently admitted to the hospital with diagnoses of closed head injury and contusions to multiple sites of the head and neck. A total of four residents were reviewed for abuse or resident injury. […]

• Actual harm, isolatedF689Jun 12, 2026

  Based on interview and record review the facility failed to safely warm up food in the microwave for one resident (R4) out of four residents reviewed for accidents and supervision. This failure resulted in the resident sustaining a second degree burn measuring 15.0 cm (Centimeter) x 17.0 cm x 0.10 cm after hot noodles were spilled in her lap. Findings include: R4 was admitted to the facility with diagnosis not limited to Essential (Primary) Hypertension, Gastro-Esophageal Reflux Disease, Kyphosis, Cerebral Palsy, Burn of Second Degree of Right Thigh. R4's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. Progress note dated 04/14/26 2:34 PM document in part: Wound Care Note Text: R4 had a recent report of a new skin condition. […]

• Actual harm, isolatedF689Jan 29, 2026

  Based on interview and record review the facility failed to follow their fall prevention policy and safely transfer for one resident (R4). The facility failed to check the mechanical lift sling to ensure that the sling was safe for resident transfers. This failure resulted in R4 falling to the ground from a mechanical lift, causing R4 pain and being frightened every time the staff have to transfer R4. This failure affected one resident (R4) reviewed for falls. This past noncompliance occurred from 10/26/25 to 11/4/25. […]

• Actual harm, isolatedF686Jun 23, 2025

  Based on observation, interview and record review, the facility failed to provide wound care treatment and change wound dressing as ordered by physician to one (R1) resident identified as a high risk for development of pressure ulcer. This failure affected one (R1) out of three residents reviewed for improper nursing care. As a result of this failure, R1 had worsening/deterioration and infection of pressure ulcer. The findings include: R1's admission record showed admission date of 5/12/2025 with diagnoses not limited to Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, Essential (primary) hypertension, Aphasia following cerebral infarction, Dysphagia following cerebral infarction, Acute respiratory failure with hypoxia, Pneumonitis due to inhalation… […]

• Actual harm, isolatedF684Mar 6, 2025

  Based on observation, interviews and record review, the facility failed to make prescribed anticonvulsant medication (Dilantin/ Phenytoin) available for one a resident (R444), who is diagnosed with seizure disorder, had sub- therapeutic (low levels) of Dilantin in his blood according to lab-work, and missed a dose of his anticonvulsant medication; the facility failed to administer medication for one resident (R15) who has seizure disorder. This failure has affected R444, who had two episodes of seizures within five minutes of each other and resulted in R15 having sub- therapeutic levels Dilantin medication in the blood. […]