Windemere Park Health and Rehabilitation Center

Inspectors wroteThis citation pertains to Intake number 3003145. Based on observation, interview, and record review, the facility failed to maintain resident's right to privacy for five residents (R6, R5, and anonymous resident (AR B) of five reviewed for privacy.

Inspectors wroteThis citation pertains to intake 2800927:Based on observation, interview, and record review, the facility failed to implement fall care plan interventions for one resident (R902) of three residents reviewed for falls.

Inspectors wroteThis citation pertains to Intake number 2716304. Based on interview and record review, the facility failed to provide scheduled showers for one resident (R700) of four residents reviewed for Activities of Daily Living (ADL's).

Inspectors wroteBased on observation, interview, and record review, the facility failed to store resident food items in accordance with professional standards for food service safety. This deficient practice had the potential to result in food borne illness among all 49 residents that potentially store food in the resident refrigerators.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (R35) of two residents reviewed for altered diet consistency, received the prescribed therapeutic diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call light accessibility for one (R13) of seven residents reviewed for call light accessibility.

Inspectors wroteThis citation pertains to Intake: MI00147215. Based on observation, interview, and record review the facility failed to prevent incidents of misappropriation of narcotic pain medication for three residents (R604, R605, R606) of five residents reviewed for misappropriation of property.

Inspectors wroteThis citation pertains to Intake: MI00147215 Based on interview and record review, the facility failed to report and investigate an allegation of misappropriation of narcotic medicaitons to the State Agency for two residents, (R605 and R606) of five residents reviewed for misappropriation of property.

Inspectors wroteThis citation pertains to Intake MI00145241. Based on interview and record review, the facility failed to schedule a follow up appointment for one resident (R701) of three reveiwed for quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to clean and maintain food service equipment and maintain sanitary kitchen practices effecting 45 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on interview and record review the facility failed to ensure all elements of the facility infection control program (ICP) were implemented and documented potentially affecting all 45 residents of the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Pharmacy Consultant Medication Regimen reviews were completed monthly for five residents (R12, R10, R13, R17, and R19) of five residents reviewed for pharmaceutical services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to clean and maintain the physical plant effecting 45 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and reduced air quality.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment for one resident (R1) of two residents reviewed for homelike environment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure insulin pens were dated or discarded when expired in one of three medications care reviewed, resulting in the potential for decreased efficacy of the medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a sufficient number of dietary staff, resulting in resident meals being served with plastic utensils, disposable dishware, and disposable foam drinking cups, affecting all residents that eat meals from the kitchen, resulting in the potential for dissatisfaction with the dining experience.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) meetings were effective and identified ongoing deficiencies, resulting in the decreased over sight of facility staffing practices and ongoing use of disposable services items for resident's meals.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medical Director or their designee attended the Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly, resulting in the and or the potential for decreased over sight of facility infection control practices, medical coordination and resident care.

Inspectors wroteThis citation has three deficient practices. Deficient Practice Statement #1. Based on interview and record review, the facility failed to implement an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all of the 48 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide food at a palatable temperature for four (R20, R12, R30, and R8) of 16 sampled residents resulting in dissatisfaction with meals and the potential for decreased quality of life and inadequate nutritional intake.

Inspectors wroteBased upon observation, interview and record review the facility failed to maintain call lights within resident reach for three (R250, R21, and R27) of 16 sampled residents resulting in the potential for residents not being able to request or receive assistance in a timely manner and the potential for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of a resident or resident representative bed hold for one resident (R45) of one resident reviewed for hospitalizations, resulting in the potential for denial of readmission or the unexpected incurrence of financial liability.

Inspectors wroteBased on observation, interview and record review the facility failed to provide care and services according to facility policy and standards of clinical practice, by not 1) supervising medications left at the bedside, 2) ensuring physicians were notified of medications held, and 3) offering mouth rinse after use of a steroid inhaler for one resident (R14) of six residents observed during medication pass, resulting in the potential for resident not to received recommended doses of medications and physician unaware of changes in resident care needs.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident's who were prescribed psychotropic medication had adequate indication for use, and had adequate documentation to justify use beyond 14 days for PRN (as needed) medication for two residents (R21, R248) of five reviewed for unnecessary medications, resulting in the potential for decreased oversight for psychotropic use, decreased use of non-pharmacological interventions, inappropriate use and unnecessary medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5% when an incorrect medication dose (Risperdal 1.5 tablets and Sertraline 1.5 tablets) and drug (Asprin EC-enteric coated-to decrease stomach irritation) was administered for two residents (R37, R248) of six reviewed during medication pass observation, resulting in three medication errors and a medication error rate of 9.38%.