Inspection Reports for
Windemere Park of Warren

F 0808 Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. The facility failed to ensure one resident (R35) received the prescribed therapeutic diet, including errors with food texture and diet orders.

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. The facility failed to store resident food items in accordance with professional standards, including expired and undated food items in resident refrigerators.

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. The facility failed to ensure call light accessibility for one resident (R13), with the call light observed out of reach multiple times.

F 0602 Protect each resident from the wrongful use of the resident's belongings or money: the facility failed to prevent incidents of misappropriation of narcotic pain medication for three residents (R604, R605, R606).

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to report and investigate an allegation of misappropriation of narcotic medications to the State Agency for two residents (R605 and R606).

F 0684 Provide appropriate treatment and care according to orders, resident's preferences and goals: the facility failed to schedule a follow-up appointment for one resident with lung cancer despite multiple documented attempts to obtain the necessary prescription and schedule the appointment.

F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: a large hole with visible wiring was observed in a resident's room and was not repaired, creating an unsafe environment.

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review: the facility failed to ensure monthly pharmacy consultant medication reviews were completed for five residents since 06/27/23.

F 0812 Procure food from sources approved or considered satisfactory and maintain sanitary kitchen practices: multiple food service equipment and areas were heavily soiled with accumulated and encrusted food residue and mineral deposits, and food storage temperatures were not maintained, increasing risk of contamination.

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable: multiple areas including laundry, central supply, nursing stations, staff restrooms, resident rooms, and common areas were observed with damaged flooring, soiled ventilation grills, loose fixtures, damaged furniture, and missing or damaged windowpanes, increasing risk of cross-contamination and reduced air quality.

F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: a large hole with visible wiring behind Resident 1's bed was observed and not repaired, posing a safety hazard.

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review: pharmacy consultant medication reviews were not completed monthly since 06/27/23 for five residents (R12, R10, R13, R17, and R19).

F 0812 Procure food from approved sources and maintain sanitary kitchen practices: multiple food service equipment and areas were heavily soiled with accumulated and encrusted food residue and mineral deposits, damaged equipment was observed, and food storage temperatures were not maintained properly.

F 0880 Provide and implement an infection prevention and control program: the facility failed to ensure all elements of the infection control program were implemented and documented, with missing documentation for multiple months in 2023.

F 0921 Make sure the nursing home area is safe, easy to use, clean and comfortable: multiple areas including laundry room, central supply, nursing stations, staff restrooms, resident rooms, and common areas had damaged flooring, soiled ventilation grills, loose fixtures, missing curtain hooks, and damaged windowpanes, increasing risk for cross-contamination and reduced air quality.

F 0558 Reasonably accommodate the needs and preferences of each resident: call lights were not maintained within resident reach for three residents (R250, R21, R27).

F 0625 Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave: failed to provide documentation of bed hold notification for one resident (R45).

F 0658 Ensure services provided by the nursing facility meet professional standards of quality: failed to supervise medications left at bedside, notify physicians of held medications, and instruct resident (R14) to rinse mouth after steroid inhaler use.

F 0758 Implement gradual dose reductions and non-pharmacological interventions for psychotropic medications: failed to ensure adequate indication and documentation for PRN psychotropic medication use beyond 14 days for two residents (R21, R248).

F 0759 Ensure medication error rates are not 5 percent or greater: three medication errors observed involving incorrect doses and wrong drug forms for two residents (R37, R248).

F 0761 Ensure drugs and biologicals used in the facility are labeled and stored properly: insulin pens were open and not dated, risking decreased efficacy.

F 0802 Provide sufficient support personnel to safely and effectively carry out food and nutrition service: insufficient dietary staff resulted in meals served with disposable dishes, plastic utensils, and foam cups, affecting all residents.

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature: multiple residents (R20, R12, R30, R8) reported food was cold and unappetizing; observations confirmed food temperatures below recommended levels.

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities: failed to effectively identify and address ongoing deficiencies including staffing and use of disposable food service items in QAPI meetings.

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly: Medical Director or designee did not attend QAPI meetings in the last four months of 2022, risking decreased oversight of infection control and resident care.

F 0880 Provide and implement an infection prevention and control program: failed to maintain an active water management plan for legionella risk; failed to ensure proper PPE donning/doffing and hand hygiene for residents on contact precautions (R148, R248, R249); failed to provide appropriate bleach-based disinfectant wipes for C. difficile room.