Inspection Reports for Windmill Manor

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.

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.

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.

A revisit of the survey ending September 17, 2025 was conducted to verify correction of previous deficiencies.

All deficiencies identified in the prior survey were corrected and the facility was found to be in substantial compliance effective September 18, 2025.

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.

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.

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.

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.

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.

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.

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.

The inspection included investigation of complaints #127481-C.

The document serves as a Plan of Correction following a survey ending on 2025-03-18, addressing the facility's compliance status.

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.

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.

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.

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.

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.

The facility was found to be in substantial compliance following the complaint investigation.

Complaint investigation for complaints #122727-C, #122779-C and facility reported incident #122954-I; facility found in substantial compliance.

The document is a plan of correction submitted following a prior deficiency statement, indicating the facility's acceptance of compliance and corrective actions.

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.

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.

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.

Complaint #121758-C was substantiated. Facility reported incident #121795-I was substantiated.

The visit was a revisit survey conducted to verify the facility's plan of correction following previous complaints and reported incidents.

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.

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.

The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #120155-C, 120426-C, and 120514-C.

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.

Complaints #120155-C and #120514-C were substantiated as part of the annual recertification survey and investigation conducted May 13-16, 2024.

The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance for the facility.

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.

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.

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.

Complaint #119255-C was substantiated based on observations and staff interviews regarding improper hair restraint during food service.

The visit was conducted to evaluate the facility's compliance based on a credible allegation and review the submitted Plan of Correction.

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.

Investigation of multiple complaints and a facility self-reported incident conducted between December 7, 2023 and January 3, 2024.

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.

Complaints #113820-C, #114847-C, #114997-C, #115413-C, #115693-C, #115750-C and #117177-C were substantiated.

The document is a plan of correction submitted following a deficiency statement, indicating the facility's acceptance of compliance and corrective actions.

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.

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.

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.

Complaint #112808 was not substantiated per Federal Requirements, but a State Rule Violation was cited.

This document is a Plan of Correction related to deficiencies identified during a prior survey event ID #0QIN11.

No specific deficiencies or findings are detailed in this document; it references another survey event for results.

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.

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.

Complaint #111721-C was investigated and found not substantiated.

The inspection was conducted as the facility's annual recertification survey and included investigation of multiple complaints.

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.

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.

The annual recertification survey was conducted from January 3 to January 6, 2022, including investigations of multiple complaints and intakes.

The facility was found to be in substantial compliance at the time of the survey. None of the complaints or intakes investigated were substantiated.

Complaints #97680-C, #99322-C, and #100904-C and intakes #98351-I and #101424-I were investigated and found not substantiated.

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.

All investigations related to the complaints and the self-reported incident were not substantiated.

Complaints #88182, #91428, #91484, and #92680 and Facility Self-Reported Incident #88175-I were investigated and found not substantiated.

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.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.