Windcrest Health & Rehabilitation

In the surveyor’s words

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

• Actual harm, patternF760Feb 14, 2024

  Based on observation, interview, and record review, the facility failed to prevent significant medication error for 1 of 33 residents (Resident #77) reviewed for pharmacy services. The facility failed to follow physician's order by not administering Lasix 20mg (diuretic medication to reduce swelling) as needed every 24 hours for Resident #77. These failures could place residents at risk for decreased level of functioning and quality of life. Findings included: Review of Resident #77's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: Sepsis, Pneumonia, respiratory failure, and congestive heart failure. […]

• Actual harm, isolatedF684Feb 14, 2024

  Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 6 residents (Resident #77) reviewed for quality of care. The facility failed to follow physician's order for daily weights for Resident #77 for 01/26/2024 and 01/27/2024. These failures could place residents at risk for decreased level of functioning and quality of life. Findings included: Review of Resident #77's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: Sepsis, Pneumonia, respiratory failure, and congestive heart failure. […]

• No harm, potential for more than minimal, widespreadF812Feb 14, 2024

  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., Cook A picked up scoop handle that was lying in puree bread halfway through meal pass and removed . Cook A asked Cook B to bring clean scoop over to steam table. Cook B brought back a clean scoop and placed into puree bread. […]

• No harm, potential for more than minimal, patternF565May 14, 2026

  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. […]

• No harm, potential for more than minimal, patternF656May 14, 2026

  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. […]