Inspection Reports for Windemere Park Assisted Living I

The inspection was conducted due to a complaint alleging that Resident A was left soaked in urine for hours with severe catheter injuries, unmet care needs, a pressure ulcer, and that call lights were not answered for over 90 minutes.

The investigation established violations related to neglect of Resident A, including failure to respond timely to call lights and failure to update the resident's service plan annually. The facility did not maintain a file on the resident and call light response times were sometimes lengthy.

The complaint alleged that Resident A was left soaked in urine for hours with severe catheter injuries, unmet care needs, and a pressure ulcer, highlighting serious neglect and lack of proper hygiene and repositioning. The call light was not answered for over 90 minutes. The complaint was substantiated.

The inspection was conducted in response to a complaint received on July 9, 2025, regarding the death of Resident A who was found deceased in the facility.

The investigation found that Resident A was found deceased on the floor next to her bed after an apparent fall. The facility did not comply with the resident's service plan requiring checks every two hours, as PACE staff failed to perform required rounding. Additionally, the administrator lacked documentation and details regarding the incident.

The complaint alleged that Resident A was found deceased in a pool of blood next to her bed on July 3, 2025. The complaint was substantiated with violations established related to failure to provide care consistent with the service plan and lack of documentation.

The inspection was conducted as a renewal licensing study to evaluate compliance with regulatory requirements and to determine if the facility's license should be renewed.

The facility was found to be noncompliant with medication administration documentation, plumbing maintenance, and general cleanliness and maintenance in several resident rooms. Specific issues included incomplete medication logs, a clogged toilet in Room 154, and unclean resident rooms with bad odors.

The inspection was conducted in response to complaints alleging resident neglect, insufficient staffing, lack of staff training, medication errors, failure to bring residents to meals, and maintenance issues at Windemere Park Assisted Living I.

The investigation substantiated multiple violations including neglect of residents, inadequate staffing, insufficient staff training especially for agency staff, medication administration problems, failure to ensure residents were brought to meals, maintenance deficiencies, unsafe access to cigarettes and lighters, unlocked medication carts, and unsanitary resident rooms.

The investigation was initiated following complaints received on 07/15/2024 and 07/16/2024 alleging neglect, insufficient staffing, lack of staff training, medication errors, failure to bring residents to meals, and maintenance issues. The complaints were substantiated.

The inspection was conducted in response to complaints alleging the facility lacked an organized visitor program, Resident A lacked showers and laundry services, and there was no lunch served on May 11, 2024, with meals being late.

The investigation found that the facility had an organized visitor program, but Resident A did not receive showers and laundry services as scheduled, constituting violations. The allegation regarding no lunch served and late meals was not substantiated.

The complaint was received on 2024-05-23 alleging issues with visitor entry procedures, Resident A's lack of showers and laundry services, and meal service problems. The visitor program allegation was not substantiated. Violations were established for Resident A's lack of showers and laundry services. The meal service allegation was not substantiated.

The investigation was initiated due to a complaint alleging that Resident A had low blood sugar, an abrasion on the elbow, and soiled sheets and clothing during a respite stay at the facility.

The investigation found that the allegation of low blood sugar and soiled clothing was not substantiated; however, the facility did not have a completed service plan for Resident A, which violated the requirement to treat residents with dignity and attend to their personal needs consistent with their service plan.

The complaint alleged Resident A had low blood sugar, an abrasion on the elbow, sheets and clothes covered with red juice, and dirty socks. The violation was not established for these allegations, but additional findings showed a violation due to lack of a completed service plan for Resident A.

The inspection was conducted as a renewal of the facility's license to ensure compliance with public health code and administrative rules regulating home for the aged facilities.

The facility was found to be in substantial compliance with all applicable rules and statutes regulating home for the aged facilities, and an acceptable corrective action plan has been received.

The investigation was initiated due to a complaint alleging that a Resident of Concern (ROC) did not receive appropriate assistance, was not provided her special diet, and was unable to enter or exit the building when needed.

The investigation found violations including failure to provide appropriate assistance to the ROC, failure to provide the ROC's special renal diet, lack of reliable access for residents to enter or exit the building after hours, and failure to maintain proper documentation of important observations regarding the ROC.

The complaint alleged that the ROC, who was physically dependent and on dialysis, experienced long waits for assistance, missed dialysis treatments due to lack of help, was not provided her special diet, and had difficulty entering or exiting the building. The complaint was substantiated in part with violations established for lack of assistance, diet provision, access issues, and documentation failures.

The inspection was conducted in response to a complaint alleging that Resident A's personal hygiene needs were not being met at Windemere Park Assisted Living I.

The investigation found that Resident A's personal hygiene needs were not adequately met, with incomplete documentation of bathing and personal care tasks. Additionally, Resident A's service plan lacked required information regarding medication management and staff assistance with medication refusals.

The complaint alleged that Resident A was observed to be disheveled, wearing dirty clothing, and having body odor, indicating unmet personal hygiene needs. The complaint was substantiated with violations established.

The document serves as a renewal notification for the Home for the Aged license of Windemere Park Assisted Living I, confirming substantial compliance with public health code and administrative rules over the past year.

An administrative review revealed substantial compliance with applicable regulations, resulting in the renewal of the facility's 12-month license effective March 2, 2023.

The investigation was initiated due to a complaint alleging resident abuse on the second floor, inappropriate touching between residents, residents left in urine overnight, unclean residents' rooms, and issues with juice and ice machines.

The investigation found no evidence of abuse, inappropriate touching, residents left in urine overnight, or issues with juice and ice machines. However, residents' rooms on the second floor were found to be unclean with sticky floors and urine odors. Additionally, incident reports were incomplete and not submitted to the State as required, resulting in violations.

The complaint alleged residents were abused on the second floor, a resident was inappropriately touched by another, residents were left in urine overnight, residents' rooms were not cleaned, and juice and ice machines were not maintained. The abuse and inappropriate touching allegations were not substantiated. The claim of residents left in urine overnight was not substantiated. The claim regarding juice and ice machines was not substantiated. The allegation of unclean residents' rooms was substantiated. Additional findings included incomplete and unsubmitted incident reports.

The inspection was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for Windemere Park Assisted Living I.

The facility was found to be in substantial compliance with licensing requirements, with no rule or statutory violations noted. The report recommends issuance of a temporary license with a maximum capacity of 90.