Windmill Village Rehabilitation & Care Center

In the surveyor’s words

From the most serious findings on record at Windmill Village Rehabilitation & Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF580Mar 24, 2023

  Based on the interview and record review, the facility failed to immediately consult the physician and/or inform the Resident/Responsible Party (RP) when there was a change of condition for 1 of 5 residents reviewed for notification of changes. (Residents #1) The facility failed to consult the physician, emergency services, or responsible party that Resident #1 had a significant drop in oxygen saturation levels of 31% throughout three shifts. This failure could place residents at risk of not having notifications made for health-related issues and could hinder resident treatment, even causing death. An IJ was identified on [DATE] at 5:00 PM. The IJ template was provided to the facility on [DATE] at 5:30 PM. […]

• Immediate jeopardy, patternF684Mar 24, 2023

  Based on interview and record review, 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 5 residents (Resident #1) by failing to contact physician or emergency services, to provide medical attention for Resident #1's declining oxygen saturation levels. 1.) The facility failed to contact the physician or emergency services after Resident #1 was found to have a decrease in oxygen saturation levels and possibly causing death. Resident #1 was only sent to the hospital after family member intervened and requested Resident #1 to seek medical attention because of Resident #1's decrease and unstable oxygen saturation levels. […]

• No harm, potential for more than minimal, widespreadF812Apr 12, 2024

  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 dietary services. 1) The facility failed to protect foods from potential contamination. 2) The facility failed to ensure foods were not expired. These failures could place residents at risk for food contamination and foodborne illness. The findings included: - The following observation was made during a kitchen tour on [DATE] that began at 10:00 AM and concluded at 10:35 AM: -An opened bag of potato chips on the counter, open date [DATE]. -An opened bag od bologna in the fridge, open date [DATE]. -an opened gallon jug of milk in the fridge, best by [DATE]. […]

• No harm, potential for more than minimal, patternF550Jul 9, 2026

  Based on interviews and record reviews, the facility failed to treat residents with respect, dignity, and care in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality for 11 of 11 confidential residents in that: The facility failed to ensure staff were not utilizing their personal cell phones while providing care, which included assisting residents with their showers and performing peri-care. The deficient practice could place residents at risk for diminished quality of life, loss of dignity and self-worth. […]

• No harm, potential for more than minimal, patternF812Jul 9, 2026

  Based on observations, interviews, 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 dietary services, in that: The facility failed to ensure the fryer was free of build up and grime. The facility failed to ensure the toaster was free of build-up and grime. The facility failed to ensure the wall behind the dishwashing station was free of build-up and grime.The facility failed to ensure hot holding pans/cookie sheets were free of build-up and grime.The facility failed to ensure all canned food items had expiration or use-by dates. The facility failed to ensure all pantry food items had expiration or use-by dates. […]