Deficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
79% worse than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 3
Apr 30, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to therapeutic diets, food storage safety, and call light accessibility in the nursing home.
Findings
The facility failed to ensure one resident received the prescribed therapeutic diet, improperly stored resident food items risking food borne illness for 49 residents, and failed to ensure call light accessibility for one resident out of seven reviewed.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure one resident received the prescribed therapeutic diet. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store resident food items in accordance with professional food service safety standards, risking food borne illness among 49 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure call light accessibility for one resident of seven reviewed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 49
Residents affected: 7
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager B | Certified Dietary Manager | Interviewed regarding food storage deficiencies and therapeutic diet errors |
| Dietary Worker F | Dietary Worker | Confirmed error regarding wrong textured dessert on resident tray |
| Clinical Dietary Manager D | Clinical Dietary Manager | Interviewed about therapeutic diet order and food storage issues |
| Nursing Home Administrator | NHA | Interviewed regarding therapeutic diet order and call light accessibility expectations |
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 1, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of narcotic medications involving multiple residents at the facility.
Findings
The facility failed to prevent incidents of misappropriation of narcotic pain medication for three residents and failed to properly report and investigate these allegations to the State Agency. Multiple interviews and record reviews revealed missing medications, incomplete destruction logs, and inconsistent procedures for medication destruction. The Director of Nursing was suspended pending investigation.
Complaint Details
The complaint investigation was substantiated by findings that the Director of Nursing mishandled narcotic medications, resulting in missing controlled substances for residents R604, R605, and R606. The facility failed to report and investigate the misappropriation allegations properly, despite awareness of the issue by the Nursing Home Administrator.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to protect residents from wrongful use of their belongings or money, specifically narcotic medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Missing Lorazepam tablets: 30
Missing Hydrocodone pills: 17
Number of residents reviewed for misappropriation: 5
Number of residents affected: 3
Number of medication cards handed to DON: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN F | Licensed Practical Nurse | Handed off controlled substances to DON and signed narcotic count sheet |
| RN G | Registered Nurse | Witnessed medication handoff and reported missing medications |
| LPN I | Licensed Practical Nurse | Signed some narcotic sheets but refused to sign sheets missing medications |
| RN E | Minimum Data Set Assessment Nurse | Involved once in medication destruction with DON; name on incomplete documents |
| Pharmacist K | Pharmacist | Interviewed regarding narcotic delivery and storage procedures |
| Nursing Home Administrator | Nursing Home Administrator | Aware of missing medication concerns but did not investigate or report to State Agency |
| Director of Nursing | Director of Nursing | Suspended pending investigation for misappropriation of narcotic medications |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 16, 2024
Visit Reason
The inspection was conducted due to an intake complaint (MI00145241) regarding the facility's failure to schedule a follow-up appointment for a resident (R701) with lung cancer requiring a CT scan with contrast.
Findings
The facility failed to schedule a follow-up appointment and necessary CT scan for resident R701 despite multiple physician progress notes documenting attempts to obtain the prescription and schedule the scan. The appointment clerk and Nursing Home Administrator confirmed no appointments were made, and the facility's policy on outside appointments was reviewed.
Complaint Details
This citation pertains to Intake MI00145241. The complaint was substantiated based on interviews and record review showing the facility did not schedule required follow-up care for resident R701.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to schedule a follow-up appointment and CT scan for resident R701 as ordered. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents Affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator (NHA) | Interviewed regarding why appointments were not made for resident R701 | |
| Appointment Clerk | Interviewed about resident R701's outside appointments and scheduling process |
Inspection Report
Routine
Deficiencies: 4
Apr 4, 2024
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with healthcare facility standards including resident environment safety, pharmaceutical services, food service sanitation, and physical plant maintenance.
Findings
The facility was found deficient in maintaining a safe and homelike environment for residents, ensuring monthly pharmacy consultant medication reviews, maintaining sanitary food service equipment and kitchen practices, and keeping the physical plant clean and in good repair. Multiple issues were observed including a large hole in a resident's room wall, lack of monthly medication reviews for several residents, unsanitary kitchen equipment and food storage, and extensive physical plant maintenance deficiencies such as damaged flooring, soiled ventilation grills, and broken furniture.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide a safe, clean, comfortable and homelike environment including a large hole in the wall behind a resident's bed with visible wiring. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure monthly Pharmacy Consultant Medication Regimen Reviews for five residents, with no reviews completed since 06/27/23. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to clean and maintain food service equipment and maintain sanitary kitchen practices, including soiled transport cart handles, ice and water dispensing machines, and food residue on multiple kitchen appliances. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain the physical plant clean and in good repair, including missing vinyl tiles in laundry room, non-functional overhead lights, damaged flooring, soiled ventilation grills, damaged furniture, and loose faucet assemblies. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 5
Residents affected: 45
Residents affected: 45
Medication orders: 20
Medication orders: 18
Damaged flooring surface: 240
Damaged flooring surface: 20
Damaged laminate surface: 26
Damaged drywall surface: 10
Damaged windowpane: 15
Inspection Report
Routine
Deficiencies: 5
Apr 4, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident safety, pharmaceutical services, food service sanitation, infection control, and physical plant maintenance at Windemere Park Health and Rehabilitation Center.
Findings
The facility was found deficient in maintaining a safe and homelike environment, ensuring monthly pharmacy consultant medication reviews, cleaning and maintaining food service equipment, implementing an effective infection prevention and control program, and maintaining the physical plant in good repair. Multiple observations and record reviews revealed issues such as unsafe room conditions, lack of medication regimen reviews, unsanitary food service equipment, incomplete infection control documentation, and damaged or soiled facility infrastructure.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide a safe environment for one resident due to a large hole in the wall behind the bed with visible wiring. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Pharmacy Consultant Medication Regimen reviews were completed monthly for five residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to clean and maintain food service equipment and maintain sanitary kitchen practices affecting 45 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide and implement an infection prevention and control program with all required elements documented. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to clean and maintain the physical plant, resulting in cross-contamination, bacterial harborage, and reduced air quality. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 45
Residents affected: 5
Residents affected: 1
Facility acquired infection rate: 7.68
Temperature: 22
Temperature: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager B | Dietary Manager | Noted multiple food service sanitation issues and planned corrective actions |
| Director of Maintenance A | Director of Maintenance | Observed and reported multiple physical plant deficiencies and planned repairs |
| Infection Control Preventionist Nurse | Infection Control Preventionist Nurse | Reported on infection control program elements and deficiencies |
| Nursing Home Administrator | Administrator | Reviewed infection control findings and confirmed missing documentation |
Inspection Report
Routine
Deficiencies: 13
Jan 11, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, food service, and quality assurance at Windemere Park Health and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to maintain call lights within resident reach, lack of documentation for bed hold policy, medication administration errors, inadequate supervision of psychotropic medications, insufficient dietary staffing leading to use of disposable dining ware, serving food at improper temperatures, ineffective QAPI meetings, lack of medical director attendance at QAPI, and deficiencies in infection prevention and control practices including improper PPE use and inadequate disinfectant for C. difficile.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 13
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to maintain call lights within resident reach for three residents, risking unmet care needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide documentation of bed hold policy for one resident transferred to hospital, risking denial of readmission or financial liability. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to supervise medications left at bedside, notify physicians of held medications, and instruct mouth rinse after steroid inhaler use for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure adequate indication and documentation for psychotropic medication use beyond 14 days for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Medication error rate exceeded 5% due to incorrect doses and wrong drug administered to two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to date or discard expired insulin pens, risking decreased medication efficacy. | Level of Harm - Minimal harm or potential for actual harm |
| Insufficient dietary staff resulted in use of disposable dishes, plastic utensils, and foam cups for all residents' meals. | Level of Harm - Minimal harm or potential for actual harm |
| Food served at unpalatable temperatures, often cold, causing dissatisfaction and potential nutritional risk for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| QAPI meetings failed to effectively identify and address ongoing deficiencies including staffing and use of disposable dining ware. | Level of Harm - Minimal harm or potential for actual harm |
| Medical Director or designee did not attend QAPI meetings at least quarterly, risking decreased oversight of infection control and resident care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement active water management plan to reduce risk of legionella and other pathogens in plumbing system. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure proper donning and doffing of PPE and hand hygiene for residents on contact precautions, risking infection spread. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate disinfectant (bleach-based) for room of resident with C. difficile infection. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 9.38
Residents affected by call light deficiency: 3
Residents affected by bed hold documentation deficiency: 1
Residents affected by medication supervision deficiency: 1
Residents affected by psychotropic medication documentation deficiency: 2
Residents affected by medication errors: 2
Residents affected by insulin pen labeling deficiency: 1
Residents affected by dietary staffing deficiency: Many
Residents affected by food palatability deficiency: 4
Residents affected by infection control PPE deficiency: 3
Residents affected by disinfectant deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN E | Licensed Practical Nurse | Named in medication administration and mouth rinse deficiency for resident R14 |
| LPN F | Licensed Practical Nurse | Named in medication error deficiency for residents R37 and R248 |
| LPN G | Licensed Practical Nurse | Named in medication error and infection control PPE deficiencies for residents R248 and R249 |
| LPN H | Licensed Practical Nurse | Named in infection control PPE deficiency for resident R148 |
| Director of Nursing | Interim Director of Nursing | Interviewed regarding medication administration and infection control deficiencies |
| Administrator | Facility Administrator | Interviewed regarding call light, bed hold, dietary staffing, food palatability, QAPI, and infection control deficiencies |
| Social Worker | Social Worker | Interviewed regarding psychotropic medication orders for residents R21 and R248 |
| Dietary Manager A | Dietary Manager | Interviewed regarding dietary staffing and food palatability deficiencies |
| Kitchen staff/Cook B | Kitchen Staff/Cook | Interviewed regarding dietary staffing deficiency |
| Dietary Aide C | Dietary Aide | Interviewed regarding dietary staffing deficiency |
| Supervisor D | Supervisor | Interviewed regarding dietary staffing deficiency |
| Nurse F | Nurse | Interviewed regarding disinfectant use for C. diff |
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