Windcrest Nursing and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jul 31, 2025

  Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for 1 of 2 residents (Resident #3) reviewed for quality of care. Resident #3 exited the facility through an alarming secure unit exit door on 5/14/2025. CNA A turned off the alarm without looking for Resident #3. Resident #3 left the facility and went missing for over 1.75 hours. The police found Resident #3 in a parking lot near an interstate highway and highway access roads. The noncompliance was identified as PNC. The IJ began on 5/14/2025 and ended on 6/4/25. The facility had corrected the noncompliance before this investigation survey began. This failure could place residents at risk of injury or death due to lack of supervision. […]

• Immediate jeopardy, isolatedF600Mar 3, 2025

  Based on observation, interviews and record reviews, the facility failed to ensure residents had the right to be free from abuse, neglect, and misappropriation of property for 1 of 6 residents (Resident #2) reviewed for abuse, in that: The facility did not properly monitor or put in place preventative measures for Resident #2, who had a severe cognitive impairment, to prevent an act of sexual abuse by Resident #1 on 02/13/25, when he kissed Resident #2, and 02/14/25, when he fondled Resident #2. An IJ was identified on 02/27/25. The IJ template was provided to the facility on [DATE] at 06:18 PM. […]

• Immediate jeopardy, isolatedF684Mar 3, 2025

  Based on interviews, and record reviews the facility failed to provide treatment and care in accordance with professional standards of practice for 1 of 8 Residents (Resident #4) reviewed for neurological assessments after a fall. 1. On [DATE] at approximately 5:28 AM Resident #4 had an unwitnessed fall and was discovered on the floor in her bedroom, and LVN H failed to perform neurological assessments for Resident #4 at 6:45 AM, and at 7:15 AM, and failed to report to LVN I she had not assessed Resident #4 and at 8:00 AM Resident #4 and discovered deceased . 2. On [DATE] at approximately 7:40 AM LVN I assessed Resident #4 without performing a neurological assessment at 7:45 AM and did not document Resident #4's vital signs. The noncompliance was identified as PNC. […]

• Immediate jeopardy, isolatedF600May 30, 2024

  Based on interviews and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 21 residents (Resident #1) reviewed for abuse. The facility failed to ensure CNA B reported when HA A allegedly abused Resident #1 on [DATE]. The facility failed to ensure HA A was not working after this alleged abuse and had access to residents for her overnight shift. The facility failed to ensure all staff members were properly educated on abuse, neglect, and exploitation after this incident. On [DATE] at 03:52 PM an Immediate Jeopardy (IJ) was identified. […]

• Immediate jeopardy, isolatedF684May 30, 2024

  Based on observations, interviews, and record reviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 (Resident #3) reviewed for quality of care. Resident #3 had signs and symptoms of a stroke and was not sent to the hospital for evaluation for approximately 6 hours after a change of condition was reported. The non-compliance was identified as past non-compliance. The immediate jeopardy began on 2/23/2024 and ended on 2/28/2024. The facility corrected the non-compliance before the investigation began. […]