Inspection Report Summary
The most recent inspection on December 30, 2025, identified deficiencies related to medication availability and administration, resulting in missed doses of critical antirejection medications. Earlier inspections showed a pattern of deficiencies involving medication management, resident safety including supervision and use of assistive devices, and food safety practices. Several complaint investigations were substantiated, including issues with care plan implementation, timely assessments, and resident rights, but enforcement actions such as fines or license suspensions were not listed in the available reports. Prior inspections also noted failures in reporting major injuries and maintaining quality assurance programs. The facility has shown some correction of deficiencies on re-inspections, but recent findings indicate ongoing challenges in medication administration and resident safety.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
10.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
141% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
105 residents
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 1
Date: Dec 30, 2025
Visit Reason
The inspection was conducted as a result of investigations into complaints #2688634-C, #2695788-C, and #2698415-C between December 29 and December 30, 2025, with complaint #2688634-C resulting in a deficiency.
Complaint Details
The investigation was triggered by complaints #2688634-C, #2695788-C, and #2698415-C. Complaint #2688634-C was substantiated and resulted in a deficiency related to medication errors.
Findings
The facility failed to ensure that medications were available and administered as ordered for one resident, resulting in four missed doses of critical antirejection medications. Documentation and communication failures regarding unavailable medications and physician notification were identified, along with inadequate follow-up on medication delivery issues.
Deficiencies (1)
Facility failed to ensure medications were available and administered as ordered for Resident #3, resulting in four missed doses of antirejection medications.
Report Facts
Census: 105
Missed medication doses: 4
Medication delivery quantities: 14
Medication delivery quantities: 14
Medication delivery quantities: 56
Medication delivery quantities: 14
Medication delivery quantities: 14
Medication delivery quantities: 56
Medication delivery quantities: 14
Missed doses: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse (RN) | Confirmed working morning shift on 11/14/25 and reported actions taken regarding missing medication |
| Staff A | Registered Nurse (RN) | Worked evening shifts on 11/12/25 and 11/14/25; reported medication unavailability and pharmacy communication |
| Staff C | Certified Medication Assistant (CMA) | Notified Staff A about missing medication on 11/14/25 |
| Staff D | Licensed Practical Nurse (LPN) | Reported inservice education provided to nursing staff on medication availability procedures |
| Staff E | Pharmacist | Provided information on medication delivery and refill issues |
| Director of Nursing (DON) | Director of Nursing | Reported notification of missed doses, pharmacy communication issues, and corrective education provided |
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 1
Date: Dec 30, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding medication errors at Windmill Manor, specifically focusing on ensuring residents are free from significant medication errors.
Complaint Details
The complaint investigation found that Resident #3 missed four doses of medications due to unavailability. The facility did not document attempts to obtain the medications or notify the physician. The issue was substantiated with corrective actions including staff education and improved communication with the pharmacy.
Findings
The facility failed to ensure medications were available and administered as ordered for Resident #3, who missed four doses of antirejection medications due to unavailability. Documentation lacked evidence of attempts to obtain medications or physician notification. The facility provided in-service education to nursing staff on medication ordering and delivery following the incident.
Deficiencies (1)
Failed to ensure medications were available and administered as ordered for Resident #3, resulting in missed doses of antirejection medications.
Report Facts
Resident census: 105
Missed medication doses: 4
Medication deliveries: 14
Medication deliveries: 14
Medication deliveries: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse (RN) | Confirmed medication unavailability and called pharmacy for STAT delivery on 11/14/25 |
| Staff A | Registered Nurse (RN) | Worked evening shifts on 11/12/25 and 11/14/25; reported medication unavailability but did not follow up with pharmacy |
| Staff C | Certified Medication Assistant (CMA) | Notified Staff A about missing Tacrolimus medication on 11/14/25 |
| Staff D | Licensed Practical Nurse (LPN) | Reported in-service education on medication unavailability procedures |
| Staff E | Pharmacist | Explained medication refill and delivery issues, confirmed lack of reorder for Tacrolimus 1mg capsules |
| Director of Nursing | Director of Nursing (DON) | Notified of missed doses on 11/21/25, called pharmacy and lung transplant clinic, provided staff education |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Called liver transplant team and reported missed doses of Tacrolimus |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 4, 2025
Visit Reason
A revisit of the survey ending September 17, 2025 was conducted to verify correction of previous deficiencies.
Findings
All deficiencies identified in the prior survey were corrected and the facility was found to be in substantial compliance effective September 18, 2025.
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 1
Date: Sep 17, 2025
Visit Reason
The inspection was conducted as a result of complaints #2589557-C and #2613888-C received between September 11 and September 17, 2025, focusing on investigation of alleged deficiencies.
Complaint Details
Complaint #2589557-C resulted in a deficiency related to failure in supervision and use of gait belts during resident transfers, leading to a fall and injury.
Findings
The facility failed to provide appropriate supervision and use of gait belts during resident transfers, resulting in a resident fall with fractures. The investigation revealed staff did not use gait belts as required, violating safety policies.
Deficiencies (1)
Failure to provide appropriate supervision and assistance devices to prevent accidents, resulting in a resident fall and injury.
Report Facts
Resident census: 109
Dates of complaint investigation: September 11, 2025 to September 17, 2025
Dates of staff in-service training: 7/16/2025 and 9/18/2025
Sample monitoring frequency: 3
Sample size for monitoring: 4
Monitoring duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Named in findings for failure to use gait belt and involvement in resident fall |
| Staff B | Registered Nurse (RN) | Reported Staff A's failure to use gait belt prior to resident fall |
| Director of Nursing | Provided policy expectations and monitoring plan related to gait belt use |
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 1
Date: Sep 17, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a fall incident involving Resident #1, where staff failed to use a gait belt during transfer, resulting in injury.
Complaint Details
The complaint investigation found that Resident #1 fell during transfer without the use of a gait belt, resulting in a closed nondisplaced fracture of the left radius. The CNA admitted not using the gait belt due to unavailability at the moment. The facility policy mandates gait belt use unless contraindicated. The Director of Nursing confirmed this expectation.
Findings
The facility failed to provide appropriate supervision and use of a gait belt during a resident transfer, leading to Resident #1 falling and sustaining a left arm and wrist fracture. Staff interviews and policy reviews confirmed the expectation to use gait belts, which was not followed by the involved CNA.
Deficiencies (1)
Failure to use a gait belt to ensure resident safety during transfer, resulting in a fall and injury.
Report Facts
Census: 109
Dates of in-service training: Gait belt training completed on 9/30/24 and 7/16/25
Resident admission date: Resident #1 admitted 7/21/25
Resident discharge date: Resident #1 discharged 7/30/25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Named in fall incident and failure to use gait belt |
| Staff B | Registered Nurse (RN) | Reported Staff A's confession of not using gait belt |
| Director of Nursing | Director of Nursing (DON) | Confirmed policy expectation for gait belt use |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 6, 2025
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey ending on April 17, 2025, to address compliance issues at the facility.
Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction submitted, resulting in certification of compliance effective April 28, 2025.
Inspection Report
Annual Inspection
Census: 88
Deficiencies: 1
Date: Apr 17, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #127481-C from April 14, 2025 to April 17, 2025.
Complaint Details
The inspection included investigation of complaints #127481-C.
Findings
The facility failed to re-submit a Pre-Admission Screening and Resident Review (PASARR) for a stay longer than 60 days for one of three residents reviewed. The Social Services Director was unaware of the time-limited PASARR resubmission requirement. The facility policy was reviewed and updated to ensure timely PASARR submissions for residents with mental disorders and intellectual disability.
Deficiencies (1)
Failure to re-submit a Pre-Admission Screening and Resident Review (PASARR) for a stay longer than 60 days for residents with mental disorders and intellectual disability.
Report Facts
Resident census: 88
Residents reviewed for PASARR compliance: 3
Residents with PASARR deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director | Named in interview regarding PASARR processing and deficiency |
| Administrator | Administrator | Named in interview regarding PASARR expectations and compliance |
Inspection Report
Annual Inspection
Census: 88
Deficiencies: 1
Date: Apr 17, 2025
Visit Reason
The inspection was conducted to assess compliance with Pre-admission Screening and Resident Review (PASARR) requirements, specifically regarding the resubmission of PASARR for residents staying longer than 60 days.
Findings
The facility failed to re-submit a PASARR for a resident who stayed longer than 60 days, as required by policy and regulations. Interviews with staff revealed a lack of awareness about the need to resubmit time-limited PASARRs, and the facility policy mandates resubmission upon completion of short term approval time frames.
Deficiencies (1)
Failure to re-submit a Pre-admission Screening and Resident Review (PASARR) for a stay longer than 60 days for 1 of 3 residents reviewed.
Report Facts
Census: 88
Residents reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Interviewed regarding PASARR processing and lack of awareness about resubmission requirements | |
| Administrator | Interviewed regarding expectations for timely completion of PASARRs |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 1, 2025
Visit Reason
The document serves as a Plan of Correction following a survey ending on 2025-03-18, addressing the facility's compliance status.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective 2025-03-19.
Report Facts
Survey end date: Mar 18, 2025
Certification effective date: Mar 19, 2025
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 2
Date: Mar 18, 2025
Visit Reason
The inspection was conducted based on complaints regarding failure to implement care plans and failure to follow physician orders for multiple residents.
Complaint Details
The complaint investigation found substantiated medication errors and care plan deficiencies affecting multiple residents, including increased anxiety and emergency room transfer due to missed medication.
Findings
The facility failed to implement complete care plans for two of three residents reviewed and failed to follow physician orders for three residents, resulting in medication errors including missed doses and incorrect dosages, some causing increased anxiety and emergency room transfer.
Deficiencies (2)
Failed to implement care plans for two of three residents reviewed.
Failed to follow physician orders for three residents, including missed administration of Clonazepam and incorrect dosages of Lyrica and other medications.
Report Facts
Residents reviewed: 3
Residents affected: 2
Residents affected: 3
Medication dosage: 1
Medication dosage: 150
Medication dosage: 100
Medication dosage: 80
Medication dosage: 8.6
Medication dosage: 0.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Interim Administrator | Confirmed expectation that staff follow physician orders as written during interview on 3/18/25 | |
| Resident's provider | Confirmed expectation that staff follow physician orders as written during interview on 3/18/25 |
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 2
Date: Mar 18, 2025
Visit Reason
The inspection was conducted as a result of complaint #125849-C received by the facility, with the investigation focusing on deficiencies related to the development and implementation of comprehensive care plans and adherence to physician orders.
Complaint Details
Complaint #125849-C was substantiated based on clinical record review, resident interviews, and facility policy review. Deficiencies were related to failure to follow physician orders and implement care plans for residents #1, #2, and #3.
Findings
The facility was found to have failed to implement comprehensive, person-centered care plans for residents, including measurable objectives and timeframes, and failed to follow physician orders for medication administration, resulting in increased anxiety and emergency room transfer for one resident. The complaint was substantiated.
Deficiencies (2)
Failure to develop and implement a comprehensive person-centered care plan for residents, including measurable objectives and timeframes.
Failure to provide services that meet professional standards, including following physician orders for medication administration.
Report Facts
Resident census: 101
Medication dosage: 1
Medication dosage: 150
Medication dosage: 80
Medication dosage: 8.6
Medication dosage: 0.4
Sample size for monitoring: 3
Timeframe: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 24, 2024
Visit Reason
A complaint investigation was conducted for complaints #122727-C, #122779-C and a facility reported incident #122954-I from August 23, 2024 to August 24, 2024.
Complaint Details
Complaint investigation for complaints #122727-C, #122779-C and facility reported incident #122954-I; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 19, 2024
Visit Reason
The document is a plan of correction submitted following a prior deficiency statement, indicating the facility's acceptance of compliance and corrective actions.
Findings
The facility was found to be in compliance based on acceptance of a credible allegation of compliance and plan of correction, with certification effective July 29, 2024.
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 2
Date: Jul 2, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to respect a resident's right to request transfer to the emergency room for evaluation related to blood in stool and failure to provide timely assessment and intervention for the resident's condition.
Complaint Details
The complaint investigation found substantiated failures in honoring the resident's right to hospital transfer and timely medical intervention. Staff and family interviews revealed the resident repeatedly requested hospital transfer due to bleeding and pain, which was initially denied by nursing staff. The resident was eventually transported to the hospital where significant medical issues were identified.
Findings
The facility failed to honor Resident #7's repeated requests to be transported to the hospital despite multiple episodes of bloody bowel movements and pain. Staff interviews, clinical record reviews, and family statements confirmed delays and inadequate responses to the resident's condition, resulting in eventual hospital transport with significant findings including rectal bleeding and anemia.
Deficiencies (2)
Failed to respect a resident's right to request transfer to the emergency room for evaluation related to blood in stool.
Failed to provide timely assessment and intervention for a resident taking anti-coagulant medication with multiple episodes of diarrhea and blood in an incontinent brief.
Report Facts
Resident census: 81
Vital signs: 96.5
Vital signs: 98
Vital signs: 56
Vital signs: 76
Vital signs: 97
Vital signs: 97.6
Vital signs: 145
Vital signs: 79
Vital signs: 119
Vital signs: 18
Vital signs: 98
Medication dosage: 650
Blood pressure: 160
Blood pressure: 80
Pulse: 104
Hemoglobin: 11
Hemoglobin: 8.8
Hemoglobin: 7.7
Blood count: 10.9
EMS call time: 5.27
EMS arrival time: 5.36
Resident transport time: 5.54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in findings related to failure to send resident to hospital despite requests |
| Staff B | Certified Nursing Assistant (CNA) | Reported resident's condition and requests for hospital transfer |
| Staff C | Certified Nursing Assistant (CNA) | Provided care during night shift and insisted nurse call ambulance |
| Staff D | Licensed Practical Nurse (LPN) | Charge nurse who confirmed resident's right to hospital transfer |
| Staff E | Certified Nursing Assistant (CNA) | Reported resident refusal of shower and condition to nurse |
| Staff F | Medical Doctor (MD) | Received notification about resident's condition |
| Administrator | Facility Administrator | Stated resident should have been transported to hospital when requested |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 2
Date: Jul 2, 2024
Visit Reason
The inspection was conducted as part of an investigation of complaints #121718-C, #121758-C, and a facility reported incident #121795-I. The visit aimed to assess the facility's compliance with resident rights and quality of care regulations.
Complaint Details
Complaint #121758-C was substantiated. Facility reported incident #121795-I was substantiated.
Findings
The facility was found to have failed to respect a resident's right to request a transfer to the emergency room and failed to provide timely assessment and intervention for a resident on anticoagulant medication with multiple episodes of diarrhea and blood in an incontinent brief. The complaint and incident were substantiated.
Deficiencies (2)
Failure to respect a resident's right to request transfer to emergency room for evaluation related to blood in stool.
Failure to provide timely assessment and intervention for a resident on anticoagulant medication with multiple episodes of diarrhea and blood in an incontinent brief.
Report Facts
Resident census: 81
MDS Brief Interview for Mental Status (BIMS) score: 15
Vital signs: 96.5
Blood pressure: 145
Blood pressure: 79
Heart rate: 119
Blood oxygen saturation: 97
Hemoglobin: 11
Hemoglobin: 8.8
Hemoglobin: 7.7
Blood pressure: 160
Pulse: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in findings related to Resident #7 care and hospital transfer requests |
| Staff B | Certified Nursing Assistant (CNA) | Named in findings related to Resident #7 care and observations of symptoms |
| Staff C | Certified Nursing Assistant (CNA) | Named in findings related to Resident #7 care and observations of symptoms |
| Staff D | Licensed Practical Nurse (LPN) | Named in findings related to Resident #7 hospital transfer and symptom assessment |
| Staff E | Certified Nursing Assistant (CNA) | Named in findings related to Resident #7 care and refusal of shower |
| Staff F | Medical Doctor (MD) | Named in findings related to review of Resident #7 condition and hospital transfer |
| Administrator | Named in findings and plan of correction monitoring Resident #7 care |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 25, 2024
Visit Reason
The visit was a revisit survey conducted to verify the facility's plan of correction following previous complaints and reported incidents.
Complaint Details
Complaints #121558-C, #121588-C, and #121608-C were investigated and found not substantiated. Facility Reported Incidents #121596-I and #121599-I were also not substantiated.
Findings
The facility was found to be in substantial compliance with no additional non-compliance identified. Complaints and facility reported incidents investigated during the visit were not substantiated.
Report Facts
Complaint numbers: 3
Facility reported incidents: 2
Inspection Report
Annual Inspection
Census: 94
Deficiencies: 7
Date: May 16, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #120155-C, 120426-C, and 120514-C.
Complaint Details
Complaints #120155-C and #120514-C were substantiated as part of the annual recertification survey and investigation conducted May 13-16, 2024.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity by keeping residents clean, failure to provide adequate supervision and safety measures to prevent falls resulting in fractures, inadequate incontinent care, failure to serve food and drink at safe temperatures, poor kitchen sanitation and food safety practices, and failure to maintain an effective Quality Assurance Performance Improvement (QAPI) program.
Deficiencies (7)
Facility failed to keep resident #51 in clean clothes and with a clean face after every meal to maintain dignity.
Facility failed to implement and modify interventions and provide safety to resident #67 who fell repeatedly and sustained two fractures.
Facility failed to provide adequate incontinent care for residents #49, #71, and #74.
Facility failed to bring foods to correct temperature prior to serving and keep at correct temperature throughout meal service.
Facility failed to maintain kitchen sanitation including presence of flies, uncovered garbage, unclean surfaces, improper food storage and handling, and improper glove use.
Facility failed to ensure an effective QAPI program to address previously identified quality deficiencies.
Facility failed to notify the state of resident falls resulting in major injury leading to admission to higher level of care for resident #67.
Report Facts
Resident census: 94
Deficiency count: 7
Fine amount: 8750
Fine amount: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stacy Clemens | Administrator | Signed inspection report and plan of correction |
| Lynn Gray | Unknown | Mentioned in plan of correction rescinding F609 and F610 deficiencies |
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 3
Date: May 16, 2024
Visit Reason
The inspection was conducted based on complaints and observations regarding failure to maintain resident dignity and provide adequate incontinent care for residents.
Complaint Details
The complaint investigation focused on failure to maintain resident dignity and provide adequate incontinent care. The facility was found to have repeated deficiencies in these areas, with substantiation based on observations, interviews, and policy review.
Findings
The facility failed to maintain cleanliness and dignity for residents by not keeping them in clean clothes and not providing adequate incontinent care for multiple residents. Additionally, the facility's Quality Assurance Performance Improvement (QAPI) process was found ineffective in addressing repeated deficiencies.
Deficiencies (3)
Failed to keep Resident #51 in clean clothes and with a clean face after every meal to maintain dignity.
Failed to provide adequate incontinent care for Residents #49, #71, and #74, including incomplete cleansing after incontinence episodes.
Failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies, resulting in repeated deficiencies.
Report Facts
Residents affected: 1
Residents affected: 3
Census: 94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Certified Nursing Assistant (CNA) | Named in incontinent care deficiency for Resident #71 |
| Staff I | Certified Nursing Assistant (CNA) | Named in incontinent care deficiency for Resident #71 |
| Staff J | Certified Nursing Assistant (CNA) | Named in incontinent care deficiency for Resident #74 |
| Staff K | Certified Nursing Assistant (CNA) | Named in incontinent care deficiency for Resident #49 |
| Staff L | Certified Nursing Assistant (CNA) | Named in incontinent care deficiency for Resident #49 |
| Director of Nursing | Provided expectations for resident care and interviewed regarding deficiencies | |
| Memory Lane Coordinator | Interviewed regarding Resident #51 behavior and care | |
| Assistant Director of Nursing | Reported expectations for incontinent care | |
| Assistant Administrator | Reported expectations for resident care after incontinent episodes | |
| Administrator | Reported monitoring and audits of deficiencies with QAPI |
Inspection Report
Annual Inspection
Census: 94
Deficiencies: 6
Date: May 16, 2024
Visit Reason
The inspection was conducted as part of a recertification, complaint, and survey process to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity by keeping residents clean, inadequate fall prevention and supervision resulting in multiple fractures, insufficient incontinent care, improper food temperature control, unsanitary kitchen conditions, and ineffective Quality Assurance Performance Improvement (QAPI) processes.
Deficiencies (6)
Failed to keep the resident in clean clothes and with a clean face after every meal to maintain dignity for 1 of 3 residents reviewed.
Failed to implement and modify interventions and provide safety to 1 of 3 residents reviewed for falls who fell repeatedly and sustained two fractures.
Failed to provide adequate incontinent cares for 3 out of 3 residents reviewed.
Failed to bring foods to the correct temperature prior to serving and keep it at the correct temperature throughout meal service.
Failed to keep the kitchen free of flies, keep garbage cans covered, keep bare hands off drinking surfaces, keep kitchen surfaces clean, store food at correct temperatures, keep stored foods dated and closed, and use gloves correctly during food preparation.
Failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies, resulting in repeated deficiencies.
Report Facts
Residents Affected: 1
Residents Affected: 1
Residents Affected: 3
Residents Affected: 94
Temperature: 52.5
Temperature: 50
Temperature: 50.1
Temperature: 73.2
Temperature: 48.2
Temperature: 45.3
Temperature: 56.5
Temperature: 55.7
Temperature: 56.5
Temperature: 45.1
Temperature: 42.8
Temperature: 46
Temperature: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Certified Nursing Assistant (CNA) | Named in incontinent care deficiency for failing to wash front peri area |
| Staff I | Certified Nursing Assistant (CNA) | Named in incontinent care deficiency for transferring resident |
| Director of Nursing | Director of Nursing | Explained expectations for resident care and washing soiled areas |
| Memory Lane Coordinator | Memory Lane Coordinator | Reported resident behavior and care challenges |
| Assistant Administrator | Assistant Administrator | Reported expectations for resident care and cleaning |
| Food Service Supervisor | Food Service Supervisor | Explained food temperature and kitchen sanitation expectations |
| Staff A | Dietary Assistant | Observed touching drinking rim of glasses with bare fingers |
| Staff B | Dietary Assistant | Observed touching drinking rim of glasses with bare fingers |
| Staff C | Dietary Assistant | Observed touching drinking rim and inside of glasses with bare fingers |
| Staff D | Head [NAME] | Observed multiple glove use violations during food preparation |
| Staff E | [NAME] | Observed multiple glove use violations during food preparation |
| Staff F | [NAME] | Observed bare hand contact with food and lack of hand hygiene |
| Staff G | [NAME] | Reported broken window causing fly infestation |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 28, 2024
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance for the facility.
Findings
The facility was certified in compliance effective March 28, 2024, based on acceptance of the credible allegation and Plan of Correction. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 1
Date: Mar 27, 2024
Visit Reason
The inspection was conducted as an investigation of complaints #118144-C, #119255-C, #119627-C and facility reported incidents #119438-I and #119657-I from March 20, 2024 to March 27, 2024.
Complaint Details
Complaint #119255-C was substantiated based on observations and staff interviews regarding improper hair restraint during food service.
Findings
The facility failed to restrain hair for 2 of 2 meals observed, with multiple observations of dietary staff not properly wearing hair nets, which is against the facility's food safety policy. The complaint #119255-C was substantiated.
Deficiencies (1)
Failure to procure, store, prepare, and serve food in accordance with professional food safety standards, specifically failure to restrain hair properly during meal service.
Report Facts
Census: 88
Complaints investigated: 4
Employees monitored: 4
Inspection Report
Census: 88
Deficiencies: 1
Date: Mar 27, 2024
Visit Reason
The inspection was conducted to evaluate compliance with food safety standards, specifically regarding proper hair restraint use by dietary staff during meal service.
Findings
The facility failed to ensure that dietary staff properly restrained their hair during meal service on two observed occasions, with multiple staff members having hair outside of their hair nets, posing a risk of food contamination.
Deficiencies (1)
Facility failed to restrain hair for 2 of 2 meals observed, with dietary staff having hair outside of hair nets.
Report Facts
Residents census: 88
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 4, 2024
Visit Reason
The visit was conducted to evaluate the facility's compliance based on a credible allegation and review the submitted Plan of Correction.
Findings
The facility was found to be in substantial compliance and will be certified in compliance effective January 4, 2024, based on acceptance of the credible allegation and Plan of Correction.
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 2
Date: Jan 3, 2024
Visit Reason
Investigation of multiple complaints and a facility self-reported incident conducted between December 7, 2023 and January 3, 2024.
Complaint Details
Complaints #113820-C, #114847-C, #114997-C, #115413-C, #115693-C, #115750-C and #117177-C were substantiated.
Findings
The facility failed to provide timely and appropriate feeding assistance to dependent residents, resulting in substantiated complaints. Additionally, the facility failed to provide accurate and timely assessments, appropriate interventions, and physician notifications for resident condition changes, leading to hospitalizations and other adverse outcomes.
Deficiencies (2)
Facility failed to provide eating assistance in a timely and appropriate manner for residents dependent on staff for feeding assistance during meal observations.
Facility failed to provide accurate and timely assessments, implement appropriate interventions, and notify physicians of resident condition changes, resulting in hospitalizations and adverse events.
Report Facts
Complaints investigated: 7
Residents census: 90
Residents reviewed: 12
Residents dependent on feeding assistance observed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Observed during medication administration and feeding assistance failures |
| Staff B | Licensed Practical Nurse (LPN) | Observed during medication administration and feeding assistance failures |
| Staff C | Certified Medication Aide (CMA) | Observed during medication administration and feeding assistance failures |
| Staff D | Certified Nursing Assistant (CNA) | Observed providing feeding assistance and failing to provide adequate assistance |
| Staff F | Certified Nursing Assistant (CNA) | Observed providing feeding assistance |
| Staff H | Certified Nursing Assistant (CNA) | Observed providing feeding assistance |
| Staff I | Licensed Practical Nurse (LPN) | Documented resident quarantine and refusal of medications |
| Staff J | Registered Nurse (RN) | Documented patient complaints and refusal of insulin |
| Staff K | Registered Nurse (RN) | Documented medication administration and hospital transfer |
| Staff L | Registered Nurse (RN) | Documented hospital communication and medication orders |
| Staff M | Licensed Practical Nurse (LPN) | Documented hospital communication and medication orders |
| Staff O | Certified Medication Aide (CMA) | Documented medication administration and refusals |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 3
Date: Jan 3, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to provide timely and appropriate eating assistance to residents dependent on staff, failure to provide accurate and timely assessments and interventions including notification of physician for condition changes, and failure to provide appropriate neurological assessments after unwitnessed falls.
Complaint Details
The complaint investigation revealed substantiated deficiencies related to failure to provide timely feeding assistance, failure to notify physicians and implement orders related to fecal impaction and weight changes, and failure to conduct neurological assessments after unwitnessed falls.
Findings
The facility failed to provide timely feeding assistance to dependent residents during meal observations, failed to implement physician orders and notify physicians regarding resident condition changes including fecal impaction and refusal of medications, and failed to conduct required neurological assessments after unwitnessed falls. These failures resulted in resident hospitalizations and potential harm.
Deficiencies (3)
Failed to provide eating assistance in a timely and appropriate manner for residents dependent on staff during meal observations.
Failed to provide accurate and timely assessments, failed to implement appropriate interventions, and failed to notify physician of resident condition changes including fecal impaction and refusal of insulin administration.
Failed to provide appropriate neurological assessments after unwitnessed falls for residents.
Report Facts
Resident census: 90
Weight records: 102
Weight records: 214.8
Medication doses refused: 12
Post-fall neuro assessments: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Named in findings related to failure to provide meal assistance and failure to notify physician |
| Staff D | Certified Nursing Assistant (CNA) | Named in observations of feeding assistance to Resident #4 |
| Staff F | Certified Nursing Assistant (CNA) | Named in providing meal assistance and staff interview |
| Staff I | Licensed Practical Nurse (LPN) | Named in nursing progress notes and staff interview regarding notification failures |
| Staff J | Registered Nurse (RN) | Named in nursing progress notes regarding resident condition and refusal of insulin |
| Staff K | Registered Nurse (RN) | Named in nursing progress notes regarding resident condition and refusal of insulin |
| Staff M | Licensed Practical Nurse (LPN) | Named in nursing progress notes regarding physician notification and resident condition |
| Staff L | Registered Nurse (RN) | Named in nursing progress notes regarding resident hospitalization and physician communication |
| Staff N | Registered Nurse (RN) | Named in nursing progress notes regarding resident hospitalization |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 5, 2023
Visit Reason
The document is a plan of correction submitted following a deficiency statement, indicating the facility's acceptance of compliance and corrective actions.
Findings
The facility was found to be in compliance based on acceptance of a credible allegation of compliance and plan of correction, effective June 5, 2023.
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 1
Date: May 17, 2023
Visit Reason
The inspection was conducted as a result of an investigation of multiple complaints (#112726-C, #112808-C, #112972) and facility self-reported incidents (#112809-I, #112868-I) from May 9, 2023 to May 17, 2023.
Complaint Details
Complaint #112808 was not substantiated per Federal Requirements, but a State Rule Violation was cited.
Findings
The facility failed to notify the state of resident falls resulting in major injury leading to admission, as required by regulation. Two residents reviewed had major injuries from falls that were not reported within the required timeframe. Documentation showed delays in reporting and incomplete incident reporting processes.
Deficiencies (1)
Failure to notify the director or designee within 24 hours of any accident causing major injury, specifically related to resident falls resulting in major injury and admission.
Report Facts
Census: 89
Dates of investigation: Investigation conducted from May 9, 2023 to May 17, 2023.
Date of death: Resident #1 death recorded on 2023-04-22.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 22, 2023
Visit Reason
This document is a Plan of Correction related to deficiencies identified during a prior survey event ID #0QIN11.
Findings
No specific deficiencies or findings are detailed in this document; it references another survey event for results.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 22, 2023
Visit Reason
An on-site revisit of the Recertification Survey ending 2023-02-07 and investigation of Complaint #111721-C was conducted from March 20, 2023 to March 22, 2023.
Complaint Details
Complaint #111721-C was investigated and found not substantiated.
Findings
All deficiencies were corrected and the facility was found to be in substantial compliance effective February 23, 2023. The complaint #111721-C was not substantiated and the Denial of Payment for New Admits (DPNA) was not effectuated.
Inspection Report
Routine
Census: 81
Deficiencies: 2
Date: Feb 7, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, medication administration, and use of mechanical lifts following reported incidents.
Findings
The facility failed to prevent staff misappropriation of resident medications for one resident and failed to provide a safe transfer using a mechanical lift which resulted in an arm fracture, hematomas, and pain for another resident. The facility investigation confirmed medication theft by a staff member and identified improper sling use during a mechanical lift transfer causing injury.
Deficiencies (2)
Failed to prevent staff misappropriation of resident medications for one resident.
Failed to provide a safe transfer using a mechanical lift resulting in an arm fracture and hematomas for one resident.
Report Facts
Residents Affected: 1
Residents Affected: 1
Resident Census: 81
Resident Weight: 303.3
Fall Risk Assessment Score: 13
Fracture Healing Timeframe: 4
Fracture Healing Timeframe: 6
Hematoma Size: 20
Hematoma Size: 14
Hematoma Size: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Registered Nurse | Admitted to taking resident medications for personal use |
| Staff B | Medication Aid/Certified Nurses Aid (CMA/CNA) | Reported Staff C's medication misappropriation |
| Staff H | Certified Nurse Aide (CNA) | Witnessed medication misappropriation and involved in mechanical lift incident |
| Staff G | Certified Nurse Aide (CNA) | Involved in mechanical lift incident and interviewed about sling use |
| Staff D | Licensed Practical Nurse (LPN) | Interviewed regarding mechanical lift incident |
| Administrator | Confirmed expectations for medication use and mechanical lift procedures; conducted investigation and staff education |
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 7
Date: Feb 7, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey and included investigation of multiple complaints.
Complaint Details
Complaints investigated were not substantiated regarding resident self-administration of medications. However, other complaint-related deficiencies were identified including misappropriation of medications and failure to report abuse.
Findings
The facility was found to have multiple deficiencies including failure to ensure residents were properly assessed for self-administration of medications, misappropriation of resident medications by staff, failure to report resident-to-resident abuse incidents, incomplete significant change assessments, failure to prevent accidents resulting in injury, and failure to meet food safety requirements.
Deficiencies (7)
Facility failed to ensure residents were assessed to self-administer medications and left medications at bedside improperly.
Facility failed to prevent staff misappropriation of resident medications.
Facility failed to report resident-to-resident abuse incidents to the State Agency.
Facility failed to complete Significant Change Assessments within required timeframe.
Facility failed to provide safe transfers using mechanical lifts resulting in injury to resident.
Facility failed to ensure residents were free from accidents and hazards and failed to provide adequate supervision and assistance devices.
Facility failed to meet professional standards of food service safety and sanitation.
Report Facts
Census: 81
Deficiencies cited: 7
Resident sample size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Acknowledged medication administration practices and resident self-administration |
| Staff B | Certified Medication Aide (CMA) | Observed and reported medication misappropriation by Staff C |
| Staff C | Registered Nurse (RN) | Involved in medication misappropriation incident |
| Staff D | Licensed Practical Nurse (LPN) | Reported on resident incident involving Hoyer lift and interviewed regarding policies |
| Staff E | Certified Nurse Aide (CNA) | Reported resident behaviors and incidents |
| Director of Nursing | Director of Nursing | Monitors compliance and involved in incident reporting and corrective actions |
| Administrator | Facility Administrator | Acknowledged deficiencies and failed to complete incident reports |
Inspection Report
Routine
Census: 81
Deficiencies: 6
Date: Feb 7, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, prevention of medication misappropriation, abuse reporting, significant change assessments, safe mechanical lift transfers, and food service safety at Windmill Manor nursing home.
Findings
The facility was found deficient in multiple areas including failure to assess residents for self-administration of medications, staff misappropriation of resident medications, failure to timely report resident-to-resident abuse incidents, failure to complete significant change assessments, unsafe mechanical lift transfers resulting in resident injury, and unsanitary food preparation and kitchen conditions.
Deficiencies (6)
Failed to ensure residents were assessed to self-administer medications prior to medications being left at bedside for two residents.
Failed to prevent staff misappropriation of resident medications for one resident.
Failed to timely report suspected abuse and neglect related to resident-to-resident biting incidents for two residents.
Failed to complete a Significant Change Assessment for one resident after a significant change in condition.
Failed to provide safe mechanical lift transfers resulting in a resident falling from the lift, causing an arm fracture, hematomas, and pain.
Failed to maintain sanitary conditions in the kitchen and food preparation areas, including contaminated equipment, dirty surfaces, and inadequate cleaning.
Report Facts
Residents Affected: 2
Residents Affected: 1
Residents Affected: 2
Residents Affected: 1
Residents Affected: 1
Facility Census: 81
Resident Weight: 303.3
Fall Risk Score: 13
Pain Score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Acknowledged medications were not to be left at bedside and confirmed medication cups at Resident #36's bedside |
| Staff B | Certified Medication Aide (CMA) | Reported seeing Staff C take medications for personal use and described medication administration practices for Resident #11 |
| Staff C | Registered Nurse (RN) | Admitted to taking resident medications for personal use |
| Staff H | Certified Nurse Aide (CNA) | Reported witnessing Staff C taking medications and described use of Hoyer slings for Resident #24 |
| Staff G | Certified Nurse Aide (CNA) | Described Hoyer sling use and incident with Resident #24 |
| Staff D | Licensed Practical Nurse (LPN) | Reported on Hoyer lift incident and facility policies |
| Staff I | Registered Nurse (RN) | Directed Staff B to report Staff C's medication misappropriation |
| Administrator | Acknowledged failures in documentation, reporting, and investigated Hoyer lift incident | |
| Dietary Manager | Acknowledged unsanitary kitchen conditions and staffing issues |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 6, 2022
Visit Reason
The annual recertification survey was conducted from January 3 to January 6, 2022, including investigations of multiple complaints and intakes.
Complaint Details
Complaints #97680-C, #99322-C, and #100904-C and intakes #98351-I and #101424-I were investigated and found not substantiated.
Findings
The facility was found to be in substantial compliance at the time of the survey. None of the complaints or intakes investigated were substantiated.
Report Facts
Complaint investigations: 3
Intake investigations: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 20, 2020
Visit Reason
Investigation of Complaints #88182, #91428, #91484, and #92680 and a Facility Self-Reported Incident #88175-I conducted from 8/17/20 to 8/20/20.
Complaint Details
Complaints #88182, #91428, #91484, and #92680 and Facility Self-Reported Incident #88175-I were investigated and found not substantiated.
Findings
All investigations related to the complaints and the self-reported incident were not substantiated.
Inspection Report
Routine
Census: 71
Deficiencies: 0
Date: Jun 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total Census: 71
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