Healthwin Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Healthwin Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600May 26, 2023

  Based on record review & interview, the facility failed to protect a resident's right to be free from neglect related to lack of timely, appropriate nursing interventions and services in response to a significant change in condition which resulted in the death of a resident for 1 of 3 residents reviewed for abuse/ neglect. (Resident B) The Immediate Jeopardy began on [DATE] at 1:30 A.M., when the facility failed to ensure staff assessed and notified the physician of a resident who was found by a CNA to be exhibiting symptoms of acute distress and failed to initiate cardiopulmonary resuscitation (CPR) timely when found unresponsive.(Resident B) The Administrator and Director of Nursing were notified of the Immediate Jeopardy on [DATE] at 2:45 P.M. […]

• Immediate jeopardy, isolatedF689Nov 17, 2022

  Based on observation, interview and record review, the facility failed to ensure safety their elopement policy was followed for a resident who was deemed at high risk for elopement and displayed exit seeking behaviors, which resulted in a resident exiting the premesis unattended. (Resident B) The immediate jeopardy began, on 10/24/22 at 7:54 A.M., when Resident B was last observed on the facility's video surveillance system exiting the facility, with the Administrator. The Administrator was observed to return inside the facility, leaving the resident unattended in a facility park area, which allowed the resident to proceed to an unlocked gate and exited the facility park, circling around to the front of the facility and ended up in the facility parking lot, before the resident was assisted… […]

• Immediate jeopardy, isolatedF689Dec 13, 2021

  Based on observation, interview and record review, the facility failed to ensure adequate supervision and assistive devices were provided to prevent [CONDITION(S)], from hot coffee, for 2 of 2 residents, reviewed for accidents. Resident B, who was moderately cognitively impaired and required assistance with eating, experienced a 2nd degree burn from hot coffee on 8/28/21, and interventions were not implemented to attempt to prevent further [CONDITION(S)]. Resident D, who was severely cognitively impaired and required supervision, experienced a 2nd degree burn from hot coffee on 9/18/21. Interventions and supervision were not implemented, and the resident experienced 2nd degree [CONDITION(S)] again, on 11/03/21, to her thighs from the hot coffee. […]

• Immediate jeopardy, isolatedF804Dec 13, 2021

  Based on observation, interview and record review, the facility failed to ensure coffee was served at a safe temperature. Resident B, who was moderately cognitively impaired and required assistance with eating, experienced a 2nd degree burn from hot coffee on 8/28/21. Resident D, who was severely cognitively impaired and required supervision with eating, experienced a 2nd degree burn from hot coffee on 9/18/21 and multiple 2nd degree [CONDITION(S)], on 11/03/21. This deficient practice had the potential to affect 34 residents, who drank coffee, out of 94 total residents. The immediate jeopardy began on 8/28/21 when Resident B experienced 2nd degree [CONDITION(S)] from coffee. […]

• Actual harm, isolatedF689Aug 17, 2026

  Based on record review and interview, the facility failed to supervise a resident during a shower that resulted in a fall with the resident sustaining a major injury for 1 of 3 residents reviewed for accidents. (Resident B) Finding includes:A record review for Resident B was completed, on 8/14/2026 at 9:40 A.M. Diagnoses included, but were not limited to: lack of coordination, difficulty walking, collapsed vertebra thoracic region, unsteadiness on feet and a history of transient ischemic attacks (TIAs, mini strokes) and cerebral infarction (stroke).A Quarterly Minimum Data Set (MDS) assessment, dated 3/12/2026, indicated Resident B had moderate cognitive impairment, required partial/moderate assistance for showering and required substantial/maximal assistance for shower transfers.A Fall… […]