Windsor Nursing and Rehabilitation Center of Morga

In the surveyor’s words

From the most serious findings on record at Windsor Nursing and Rehabilitation Center of Morga, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 16, 2023

  Based on observation, record review, and interview, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents 1 (Resident #1) of 5 reviewed for elopement. The facility failed to ensure Resident #1 was supervised for elopement, Resident #1 eloped on 12/09/2023 and was found approximately 1.3 miles from facility. Failed to care plan Resident #1's wandering, pacing, trash digging, schizophrenia behaviors, and drug seeking behaviors. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 12/09/2023 and ended on 12/11/2023. […]

• Immediate jeopardy, isolatedF600Aug 23, 2023

  Based on interview and record review, the facility failed to ensure the right of the residents to be free from abuse for 1 of 1 residents reviewed for abuse and neglect. The facility failed to ensure Resident #1 did not experience abuse from CNA B. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 07/25/23 and ended on 7/25/23. The facility corrected the non-compliance before the investigation began. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. […]

• Immediate jeopardy, isolatedF607Aug 23, 2023

  Based on observation, interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, for 1 of 3 residents (Resident#1) reviewed for abuse and neglect, in that: The facility failed to ensure CNA A and CNA C immediately reported any alleged incidents of abuse to the abuse prevention coordinator. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 07/25/23 and ended on 7/25/23. The facility corrected the non-compliance before the investigation began. These failures placed residents at risk of further abuse by leaving an alleged perpetrator remain in contact with facility residents. […]

• Actual harm, isolatedF600Apr 14, 2026

  Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse and neglect for of 5 residents (Resident #2) reviewed for abuse, neglect, and exploitation.The facility failed to protect Resident #2 from physical abuse when Resident #1 hit Resident #2 multiple times in the head and fell to the floor with him on 03/29/2026.These failures could place residents at risk for physical and/or psychological harm or injury.The findings included:1. Record review of Resident #1's face sheet, dated 04/09/2026, revealed a [AGE] year-old male with an admission date of 06/28/2024. […]

• Actual harm, isolatedF656Apr 14, 2026

  Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet the residents' medical, nursing, and psychosocial needs for 1 (Resident #1) of 5 residents reviewed for person-centered care plans:The facility failed to recognize, develop, and implement a care plan and care plan interventions with measurable timeframes and objectives to address Resident #1's aggressive behaviors prior to his physical aggression incident on 03/29/2026.These failures could affect residents by placing them at risk of not being provided with the necessary care and services to address their needs. […]