Windemere at Westover Hills

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 3 of 5 medication carts (the 100/300 hall medication aide cart, the 100/300/400 hall nurse cart, and the 700 hall nurse cart) assessed for medication storage and labeling. The facility failed to ensure medications located inside the 100/300 hall medication aide cart, the 100/300/400 hall nurse cart, and the 700 hall nurse cart were stored in properly labeled containers. This failure could place residents at risk of receiving inadequate treatments or ingesting medications for which they were not prescribed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 2 of 8 residents (Resident #113, and Resident #16) reviewed for accidents and hazards: 1. The facility failed to ensure Resident #113 did not have a can of disinfectant spray and a plastic pump spray bottle of air freshener in her room. 2. The facility failed to ensure Resident #16 did not have two pairs of scissors in her room. These failures could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care is provided with such care, consistent with professional standards of practice for 2 of 4 residents (Resident #7, and #29) reviewed for respiratory care.1. The facility failed to ensure Resident #7's oxygen concentrator filter was cleaned and free of debris.2. The facility failed to ensure Resident #29's oxygen concentrator filter was cleaned and free of debris, the oxygen tubing was touching the floor, and the oxygen flow rate was set according to the physician's ordersThese deficient practices could place residents at risk for an increase in respiratory complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 5 carts (500 hall nurse cart) reviewed for pharmacy services. The facility failed to ensure the controlled substance reconciliation log was signed for accuracy of medication quantities during shift change. This failure could place residents at risk of not receiving their prescribed medications, experiencing untreated pain and anxiety, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' clinical record was complete and accurate for 1 (Resident #130) of 25 residents reviewed, in that: Resident #130's diagnoses of Insomnia and Dementia were not present on the resident's diagnoses list. This deficient practice could result in delayed or improper care due to inaccurate clinical records.

Inspectors wroteBased on and interview and record review, the facility failed to immediately inform the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 4 residents (Resident #1) reviewed for physician notification of changes. The facility failed to inform Resident #1's physician on 3/11/25 when a BP of 80/42 was obtained by LVN A before Resident #1 was transported to dialysis. Resident #1 was treated for hypotension at the hospital after being sent there from dialysis. An Immediate Jeopardy (IJ) was identified on 4/11/25. The IJ template was presented to the facility ED and DON on 4/11/25 at 6:30 pm. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 4 residents (Resident #1) reviewed for quality of care. The facility failed to immediately intervene when Resident #1 was found to have a BP of 80/42, complained of generalized pain, and requested to go to the hospital on 3/11/25. An Immediate Jeopardy (IJ) was identified on 4/14/25. The IJ template was presented to the facility ED, DON, RDCS, and VPO (via telephone) on 4/14/25 at 1:58 pm. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure all Pre-admission Screening and Resident Review (PASARR) Level 1 residents with mental illness were provided with a PASARR Level II Evaluation and Assessment for 3 of 3 residents (#9, #27 and #38) reviewed for PASARR services. 1. The facility failed to identify Resident #9 as having several diagnoses related to Mental Illness including paranoid schizophrenia, manor depressive disorder, panic disorder, unspecified mood [affective] disorder and anxiety disorder, on the PASARR screening which would require a PASARR Level II assessment. 2. The facility failed to identify Resident #27 as having a diagnosis of unspecified Psychosis, a mental illness, which would require a PASARR Level II assessment. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: Clean utensils and dishware had food particles from previous meals. This deficient practice could place residents who consumed meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to promote the residents' right to receive mail, for all facility residents, in that: Facility staff did not distribute mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for 1 of 5 Residents (Resident #45) whose records were reviewed. MDS Staff failed to ensure Resident #45's quarterly MDS assessment, dated 9/13/24m was completed within 120 days of the annual MDS assessment, dated 5/6/24 This deficient practice could affect any resident and result in resident's not receiving the needed services.

Inspectors wroteBased on interview and record review the facility failed to ensure each assessment must accurately reflect the resident's status for 2 of 13 Residents (Resident #27 and Resident #45) reviewed for accuracy of assessments. 1. MDS staff failed to ensure Resident #27's quarterly MDS, 6/10/24, reflected she had a range of motion impairment on her upper extremity. 2. MDS staff coded Resident #45's quarterly MDS assessment, dated 9/13/24, having a significant weight loss. Resident #45 did not experience a significant weight loss during the look back period. These deficient practicers could affect residents by inaccurately reflecting their status which could contribute to residents not receiving necessary care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure a registered nurse signed and certified the assessment was completed for 1 of 5 Residents (Resident #45) reviewed for assessment certification. An RN did not sign Resident #45's quarterly assessment when it was completed on 9/13/24. This deficient practice could affect any resident and result in the residents' assessment not being valid.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the interdisciplinary team reviewed and revised each resident's Care Plan after each assessment, including both the comprehensive and quarterly review assessments for 2 of 5 Residents (Resident #45 and Resident #70) whose records were reviewed. 1. MDS staff failed to revise Resident #45's Care Plan to reflect she did not experience significant weight loss. 2. MDS staff failed to revise Resident #70's Care Plan to reflect she used side rails for bed mobility. These deficient practices could contribute to residents not receiving the care and services as needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 11 resident rooms (Resident #206) reviewed for storage of drugs. The facility failed to ensure medications were not left at the bedside for Resident #206. This deficient practice could place residents at risk of medication misuse or drug diversion.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain medical records on each resident that were accurately documented in accordance with accepted professional standards and practices for 3 of 10 Residents (Resident #41, Resident #32 and Resident #45) whose records were reviewed. 1. LVN C failed to document an assessment after Resident #41 had a fall. 2. Nursing staff failed to sign and date the assist rail/enabler evaluation for Resident #32 which made the evaluation invalid. 3. Nursing staff failed to obtain a consent from Resident 45's family representative for the use of an assist rail/enabler. These deficient practices could affect any residents who have medical records and could result in misinformation about professional care provided.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys, for 1 of 1 medication aide medication cart, reviewed for security. The nurse medication cart was unattended and unlocked. This failure could place residents at risk for harm by misappropriation of property and not receiving the therapeutic effects of their medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. The facility failed to maintain the cleanliness of the ice maker found within the kitchen. 2. The facility failed to maintain the cleanliness of the juice dispensers found within the kitchen. 3. The facility failed to remove expired and past dated items from the dry food storage. 4. The facility failed to complete daily temperature logs of reach-in refrigerators and freezers found within the kitchen and nourishment room. 5. The facility failed to ensure the chemical dishwasher operated at or above 120 degrees Fahrenheit. These failures could place residents at risk for cross-contamination and foodborne illnesses.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals, and preferences for 2 of 3 residents (Resident #50 and #62) reviewed for oxygen therapy in that: 1. Resident #50's oxygen concentrator filter was covered in a thick white substance. 2. Resident #62's oxygen was provided oxygen inconsistent with the physician's order. These failures could affect residents who received respiratory therapy and put them at risk for inadequate or inappropriate amounts of oxygen delivery.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to prevent complications for 1 of 1 resident (Resident #18) reviewed for feeding tubes. The facility failed to ensure LVN A properly administered crushed medications into Resident #18's feeding tube. This failure could place residents who received medications via a feeding tube at risk for medical complications or a decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 28%, based on 7 errors out of 28 opportunities, which involved 1 of 6 residents (Resident #18) reviewed for medication administration in that: The facility failed to ensure LVN A properly administered crushed medications into Resident #18's feeding tube. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 of 24 residents (Resident #62) reviewed for care plans in that: Resident #62's comprehensive person-centered care plan did not reflect the resident receiving respiratory care. This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs.