Inspection Reports for
Windmill Manor

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.

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 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.

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.

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 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.

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.

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.

The inspection included investigation of complaints #127481-C.

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 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.

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.

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.

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.

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.

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.

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.

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

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.

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

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.

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.

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.

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.

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

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.

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.

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

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.

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.

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.

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

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.

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.

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 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.

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.