Inspection Report
Complaint Investigation
Deficiencies: 4
May 20, 2025
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the facility on 05/20/2025.
Findings
Deficiencies were identified related to personnel records, resident assessment/service plans, medication services, and fire safety requirements. Specific issues included incomplete personnel documentation, failure to document resident service plans accurately, medication storage and labeling problems, and inadequate fire drill documentation.
Complaint Details
The visit included a complaint/incident investigation survey (YZMJ11) conducted on 05/20/2025. Deficiencies were identified relative to the complaint investigation.
Deficiencies (4)
| Description |
|---|
| Personnel records failed to reveal evidence of a signed copy of the employee's awareness of resident's rights for 6 sample staff. |
| Residence failed to document a description of the services and interventions needed on the service plan for 6 sample residents reviewed. |
| Residence failed to ensure medications were stored securely and in a manner to prevent spoilage, dosage errors, administration errors, and/or inappropriate access for 2 of 3 medication carts observed. |
| Fire drills documentation failed to include all necessary components and drills were obstructed or not conducted as required. |
Report Facts
Sample staff reviewed: 6
Sample residents reviewed: 6
Medication carts observed: 3
Fire drills required per year: 6
Fire drills obstructed: 2
Fire drills conducted: 1
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 3, 2025
Visit Reason
An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was related to complaint/incident ACTS reference numbers 100028 and 100163. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 8, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The visit was triggered by a complaint/incident investigation with ACTS reference numbers 97624. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 4, 2024
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was unannounced and complaint/incident based; no deficiencies were found, indicating no substantiated issues.
Inspection Report
Renewal
Deficiencies: 1
Jul 28, 2023
Visit Reason
An unannounced biennial State Licensure survey was conducted at Winslow Gardens to assess compliance with State Licensure requirements.
Findings
The survey identified a deficiency related to medication services, specifically the failure to ensure all medications were administered in accordance with written physician orders for two of three residents reviewed. Issues included unavailable medications and inaccurate medication packaging.
Deficiencies (1)
| Description |
|---|
| Failure to ensure all medication were administered in accordance with written physician orders for two of three residents reviewed. |
Report Facts
Deficiencies cited: 1
Date survey completed: Jul 28, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sandra M. Cullen | Administrator | Signed the report on 8/21/2023 |
| Director of Wellness | Acknowledged medication order issues during surveyor interviews |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 31, 2023
Visit Reason
An unannounced complaint/incident investigation survey was conducted at this residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The investigation was unannounced and no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 28, 2022
Visit Reason
An unannounced complaint/incident investigation survey was conducted at the residence.
Findings
No deficiencies were identified during the investigation.
Complaint Details
The visit was complaint-related and no deficiencies were found, indicating no substantiated issues.
Inspection Report
Complaint Investigation
Deficiencies: 3
Aug 12, 2021
Visit Reason
An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the facility on 08/12/2021.
Findings
Deficiencies were identified related to medication services, including failure to ensure medications were stored securely and properly labeled, and residents not using locked drawers for self-medication as required.
Complaint Details
The complaint/incident investigation was substantiated by surveyor observation, record review, and staff interview, confirming medication storage and administration issues.
Deficiencies (3)
| Description |
|---|
| Medications lacked direction for administration on the bottle for multiple residents. |
| Medications were not stored securely, risking spoilage, dosage errors, and unauthorized access for 6 out of 9 residents observed. |
| Resident did not use the locked drawer provided for self-medication storage. |
Report Facts
Resident medication storage issues: 6
Resident IDs with medication issues: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Medication Technician | Observed administering medications lacking directions on the bottle. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 12, 2021
Visit Reason
An unannounced complaint/incident investigation survey and a biennial State licensure survey were conducted at this residence on 08/12/2021.
Findings
No deficiencies were identified under the complaint investigation survey.
Complaint Details
The complaint investigation was unannounced and no deficiencies were found.
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