Inspection Reports for Windsor Manor Nevada

Investigation of Incident #130455-I at an assisted living program serving people with dementia.

No regulatory insufficiencies were cited during the investigation.

Investigation of Incident #130455-I; no regulatory insufficiencies found.

The inspection was conducted as an investigation of Incident #128041-C at the assisted living program for people with dementia.

No regulatory insufficiencies were cited during the investigation of Incident #128041-C.

Investigation of Incident #128041-C with no regulatory insufficiencies cited.

Investigation of Incident #127418-I at the assisted living program for people with dementia.

No regulatory insufficiencies were cited during the investigation.

Investigation of Incident #127418-I; no regulatory insufficiencies found.

The visit was conducted as a recertification visit to determine compliance with certification rules for an Assisted Living Program and included investigation of two complaints.

No regulatory insufficiencies were cited during the investigation of Complaints #121443-C and #121982-C, nor during the recertification visit for the Assisted Living Program.

Investigation of Complaints #121443-C and #121982-C found no regulatory insufficiencies.

The visit was conducted as a recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.

No regulatory insufficiencies were cited during the investigation of two complaints. However, during the recertification visit, regulatory insufficiencies were cited related to evaluation of tenants, service plans, and dementia-specific education for personnel.

No regulatory insufficiencies were cited during the investigation of Complaint #100155-C and #106168-C.

Investigation of Complaint #90640-C and an onsite infection control survey.

No regulatory insufficiencies were cited during the investigation of the complaint or the onsite infection control survey.

Complaint #90640-C was investigated and found to have no regulatory insufficiencies.

The inspection was conducted as an investigation of Complaint #87586-C regarding the admission and retention criteria for tenants requiring assistance with standing, transfer, or evacuation.

The program failed to ensure that two of three tenants reviewed did not exceed the level of care criteria requiring routine two-person assistance for transfers. Observations and interviews confirmed that tenants required two staff for transfers, but this was not consistently provided.

Investigation of Complaint #87586-C found regulatory insufficiency related to admission and retention criteria for tenants requiring two-person assistance. The complaint was substantiated with observations and staff interviews confirming the issue.

Recertification visit conducted to determine compliance with certification of an Assisted Living Program for People with Dementia.

No regulatory insufficiencies were cited during the recertification visit for the Assisted Living Program for People with Dementia.

The inspection was conducted as an investigation of Complaint #77779-C regarding regulatory insufficiencies at the assisted living program.

The program failed to report all incidents affecting tenants as required by policy, specifically an injury to Tenant #2 that was not reported. Additionally, a medication error occurred when a Universal Worker administered another tenant's Lovenox injection to Tenant #1, contrary to policy.

Investigation of Complaint #77779-C. The complaint was substantiated by findings of unreported incidents and medication administration errors.

The inspection was conducted as an investigation of Incident #75357-I and Complaint #75351-C at the assisted living facility.

No regulatory insufficiencies were cited during the investigation of the incident and complaint.

Investigation of Incident #75357-I and Complaint #75351-C found no regulatory insufficiencies.

Investigation of Incident #73321-I at the assisted living program for people with dementia.

No regulatory insufficiencies were cited during the investigation.

Investigation of Incident #73321-I with no regulatory insufficiencies cited.

Recertification conducted to determine compliance with certification for an Assisted Living Program.

No regulatory insufficiencies were cited during the recertification inspection for the Assisted Living Program.

The visit was a Final Recertification Monitoring Evaluation conducted by the Department of Inspections and Appeals (DIA) on October 12 and 15, 2015, to determine compliance with certification for an Assisted Living Program at Windsor Manor Nevada.

The report identified a regulatory insufficiency related to Food Service where the staff did not provide 100% of the daily recommended dietary allowances as portions of food were not supplied as written in the menu. Specific observations noted inadequate serving sizes in the dementia unit.

The visit was a Final Recertification Monitoring Evaluation conducted to review recertification documents and evaluate compliance with regulatory requirements for the Assisted Living Program at Windsor Manor.

No regulatory insufficiencies were found during this evaluation. The program did not receive any regulatory insufficiencies during this certification period, and the on-site monitoring evaluation noted no regulatory insufficiencies.

The inspection was conducted as a complaint/incident investigation regarding allegations of lack of nursing coverage, improper medication administration, inaccurate nurse review of blood pressures, and failure to follow directives from a tenant's power of attorney.

The investigation found no regulatory insufficiency related to nursing coverage, nurse review, or administration directives. However, regulatory insufficiency was noted related to medication administration, specifically that medications were sometimes not given as ordered or not available, and administration was not always performed by qualified nursing personnel as required.

The complaint investigation addressed allegations that the program did not have nursing coverage, tenants were not receiving medications as ordered, staff did not obtain accurate blood pressures using a pediatric cuff, and program administration did not follow directives from a tenant's power of attorney. The investigation found the nursing coverage allegation unsubstantiated, medication administration deficiencies substantiated with regulatory insufficiency noted, no regulatory insufficiency related to nurse review or administration directives.

The inspection was conducted as a Final Complaint/Incident Investigation Report for Windsor Manor Nevada, Iowa, following complaints about tenant behaviors and regulatory insufficiencies.

The program was assessed a $1,000 civil penalty for failing to comply with regulatory requirements, resulting in imminent danger or substantial probability of death or physical harm to tenants. The program retained two tenants despite patterns of behavior placing staff and tenants at risk for injury.

The complaint involved tenant #1 exhibiting aggressive physical and sexual behaviors, wandering into other tenant rooms, and tenant #2 exhibiting hallucinations, exit-seeking, and aggressive behaviors. The program retained tenants despite these behaviors placing staff and others at risk. Law enforcement was involved on multiple occasions. The program failed to adequately address these behaviors and maintain safety.

An on-site monitoring evaluation was conducted to assess compliance with regulatory requirements and to evaluate the Assisted Living Program at Windsor Manor Nevada.

The report found that the facility had a total census of 28 residents, including 24 in the general population program and 4 in the dementia-specific program. A regulatory insufficiency was noted regarding delayed completion of criminal and abuse record checks for a staff member hired on 4-20-11, which was later cleared by the Department of Human Services.