Windcrest Health & Rehabilitation

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure orders were provided for the resident's immediate care and needs for 4 (Resident #7, Resident #9, Resident #24, and Resident #44) of 16 residents reviewed for care supervised by a physician. The facility failed to ensure a physician order was put into place/received to admit Resident #7, Resident #9, Resident #24, and Resident #44 to an Alzheimer's certified secure care unit. The facility failed to obtain a diagnosis to admit Resident #24 to an Alzheimer's certified secure care unit. These failures could affect residents by not having their medical care supervised by a physician.

Inspectors wroteBased on interview and record review, the facility must not use any individual working in the facility as a nurse aide for more than four months on a full-time basis unless that individual has completed a training and competency evaluation program for 1 of 8 (NA C) non-certified nurse aides reviewed. The facility failed to ensure full-time NA C was certified within four months of the date of hire. This failure placed residents at risk of receiving inappropriate care from an individual whose skill level was not known.

Inspectors wroteBased 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 kitchen sanitation. The facility failed to ensure kitchen staff properly secured hair in hair nets when handling and serving food. These failures could place residents who received food from the kitchen at risk of cross contamination and food borne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to treat residents with respect, dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 10 residents (Resident #18), observed in the confidential group interview. The facility failed to prevent LVN E from taking Resident #18's blood pressure and administering medication during a resident council meeting on 5/14/26., in front of 9 other residents. This failure could result in a diminished quality of life and a loss of self-esteem for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #9) of 21 residents whose assessments were reviewed for accuracy. The facility failed to ensure Resident #9's MDS assessment accurately reflected the use of a walker. This failure placed the residents at risk for unmet care needs.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 2 of 3 medication carts (medication cart for Unit #1 and medication cart for Unit #2) reviewed for pharmacy services. The facility failed to ensure Resident #33, and Resident #71's natural tears eye drops were labeled with an open date on the medication cart for Unit #1. The facility failed to ensure Resident #12, and Resident #81's natural tears eye drops were labeled with an open date on the medication cart for Unit #2. These failures could affect residents prescribed medications in the facility and place them at risk for not receiving the correct medications, medication misuse, or receiving expired medications. Findings Included: [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Resident #50 and Resident #48) and 1 of 2 staff (LVN A) reviewed for blood glucose monitoring. The facility failed to ensure that LVN A cleaned the glucometer (capillary-blood sampling devices) after using it for Resident #50 and before using it for Resident #48. This failure could place residents at risk for cross contamination, infections, and a decrease in quality of life.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the comprehensive assessment for 2 (Resident #2 and Resident #20) of 4 residents reviewed for care plans. The facility failed to develop and implement a comprehensive person-centered care plan that addressed bed and chair alarms for Resident #2. The facility failed to develop and implement a comprehensive person-centered care plan that addressed a chair alarm for Resident #20. These failures could place residents at risk for falls and/or injury, negatively impact the resident's quality of life, as well as the quality of care and services received.

Inspectors wroteBased on interview and record review the facility failed to ensure that the resident environment remained as free of accident hazards as possible for one (Resident #20) of three residents reviewed for accident hazards. The facility failed to ensure that Resident #20's fall matt was placed beside her bed as ordered by physician. This failure could put residents at increased risk for accidents and injury.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure staffing information was posted in a prominent place readily accessible to residents and visitors that included: The total number and the actual hours worked by the registered nurses, licensed practical nurses or licensed vocational nurses and certified nurse aides directly responsible for resident care per shift for 1 of 3 days reviewed. The facility failed to ensure the daily staffing information was posted in a prominent location on 01/30/2024. This failure could place residents, their families, and visitors at risk of not knowing how many staff are currently working to provide care on all shifts. Findings Included: During an observation on 01/30/2024 at 9:12 a.m., daily staffing posted in hallways for previous date of 01/29/2024. [...]