Inspection Reports for
Windrose at Weymouth

Food and dietary services: Dietary reviews were missing one six-month review in calendar year 2023 and the second half of 2024 lacked the required nutrition-standards statement (repeat finding).

Memory care unit: Documentation for the bi-annual Special Care Residence operations review was missing for calendar year 2024, chemicals were not secured in the common kitchen, the laundry room door was unlocked, and staff did not respond to door alarms as required.

Resident care plans: Two resident records were missing documentation of reassessment and service plan review every six months (repeat finding).

Quality assurance program: Documentation of target dates, responsible staff, and outcomes for follow-up actions were missing for 2024; evidence-informed falls prevention program review was missing for 2023 and 2024; quarterly medication review summary was missing for the last quarter of 2024 (repeat finding).

Incident reporting: The residence filed 14 incident reports more than 24 hours after the occurrence of the incidents or accidents (repeat finding).

Resident records: Four personnel records lacked signed and dated job descriptions; the correspondence log was incomplete and missing for November 2024 (repeat finding).

Staff health screening: Two personnel records were missing documentation confirming seasonal influenza vaccinations or declination statements for the 2024/2025 flu season (repeat finding).

Staffing: Documentation confirming quarterly staffing level assessments was missing for calendar year 2024.

Staff training: Documentation of training needs assessments for 2023 and 2024 was missing; introductory visits were inconsistently documented; biannual personal care evaluations were missing for 2024; required LGBTQ training documentation was missing for two staff (repeat finding).