Windflower Health Center

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 2 of 2 kitchens reviewed for kitchen sanitation. 1. The facility failed to ensure food was properly stored, labeled, and dated.2. The facility failed to ensure a safe and sanitary environment.3. The facility failed to ensure 1 of 1 dishwasher reached appropriate temperatures. These failures could place residents who ate food served by the kitchen at risk of food-borne illness, cross contamination, and loss of nutrition.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 (Residents #10 and #89) of 18 residents reviewed for accommodation of needs. The facility failed to ensure Resident #10 and Resident #89's call lights were in reach on 06/16/2026 and 06/17/2026. This failure could place residents at risk of unmet needs, injury, and/or feelings of helplessness and frustration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a baseline care plan within 48 hours of being admitted for 1 of 18 Residents (Resident #104) that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care Resident #44 did not have a baseline care plan that reflected bed being in the lowest position and a fall mat for safety within 48 hours of being admitted to the facility. This failure could place all newly admitted patients at risk for lack of care, needs not being met, and resident safety. Findings Included: Record review of Resident #104's face sheet, dated 06/16/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet residents' medical, nursing, and mental and psychosocial needs for 1 of 18 residents (Resident #64) whose care plans were reviewed. The facility failed to care plan Resident #64 for utilizing a stand to lift assist for activities of daily living. This failure could place residents at risk of receiving inadequate care and increased safety risks.

Inspectors wroteBased on interview and record review, the facility failed to review and revise the comprehensive care plan after each assessment, including both the comprehensive and quarterly review assessments for 2 (Resident #5, Resident #14) of 18 residents reviewed for comprehensive care plans. The facility failed to update the comprehensive person-centered care plans to address Resident # 5 and Resident #14's needs within 7 days after MDS assessment was completed. The failure could affect residents by delaying treatment, care, and services that could result in residents not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record review the facility failed to assess residents for risk of entrapment from bed rails prior to installation and reviewed the risks and benefits of bed rails with 2 (Residents #38 and #89) of 18 residents or their resident representatives and obtain informed consent prior to installation of bed rails. Resident #38 had (1) one-quarter bed rail, located on right side of bed with no documentation of consent or current safety assessment prior to installation. Resident #89 had (1) one-quarter bed rail, located on left side of bed with no documentation of consent or current safety assessment prior to installation. These failures could place residents at risk of injury, hinder residents from getting out of bed, and/or cause a decline in residents' ability to engage in activities of daily living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical service to include accurate dispensing and administering of drugs for 1 (Resident #43) of 12 residents reviewed to meet the needs of each resident. The facility failed to administer the prescribed anticoagulant (Coumadin) to Resident #43. The facility failed to administer the prescribed anticoagulant (Pradaxa) correctly to Resident #43. This failure could result in ineffective treatment resulting in exacerbation of residents' disease processes.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to ensure residents were free of any significant medication errors for 1 of (Resident #43) 12 residents reviewed for anticoagulant therapy. Resident #43 did not receive her Pradaxa (anticoagulant medication) correctly or her Coumadin (anticoagulant medication) as ordered. The facility's failure could exacerbate the residents' condition resulting in complications to include increased pain, wounds, amputation, extended recovery time, and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure parenteral fluids and central venous catheter care were provided in accordance with professional standards of practice and in accordance with physician's orders and the resident's goals and preferences for 1 (Resident #1) of 8 residents reviewed for parenteral therapy services. The facility failed to ensure timely PICC (external access line for medication) line dressing changes were completed as ordered and failed to ensure ongoing assessment and monitoring of the PICC line dressing for integrity and signs of infection for Resident #1. This failure could place residents at risk of harm due to infection. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 2 of 2 kitchens when they failed to: A. Ensure stored food was properly labeled, dated and covered. B. Ensure general cleanliness was maintained. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, administering, and documentation of all drugs and biologicals) to meet the needs of 1 out of 5 residents (Residents #8) who was observed for medication administration. -RN I administered medication to Resident #8 via nebulizer and left Resident #8 unattended. These deficient practices can affect residents that receive medications resulting in adverse reactions to medication, deterioration in their health, exacerbation of their disease process, and/or hospitalization.

Inspectors wroteBased on observation and record review, the facility failed to store and label drugs and biologics in accordance with professional principles, and include the appropriate accessory and cautionary instructions and the expiration date when applicable to meet the needs of for 1 of 17 (Resident #6,) and 1 of 5 medication carts (LTC Side B medication cart), and 2 of 2 (rehab side and LTC/MC side)medication storage rooms under review. -Medication cart for B side of LTC had a box of anti-diarrheal with an expiration date of 02/2025. -Resident #6's Albuterol inhaler had an expiration date of 01/2025, and a Breo Ellipta inhaler with no open date on medication. -Medication cart for A side of LTC had a box of acid reducer with an expiration date of 12/2024. -Medication cart for A side of LTC had bottle of Geri-Tussin with an expiration date of 03/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 6 (LVN C, CNA F, CNA G, and RNI) staff observed for resident care. -LVN C did not perform hand hygiene, use PPE or sterile technique (to minimize the number of microbes present to as few as possible) to flush Resident #27's suprapubic catheter. -CNA F did not change gloves or perform hand hygiene during incontinent care of Resident #60. -CNA G did not change gloves or perform hand hygiene during incontinent care of Resident #60. -EBP signage or PPE for EBP was in place for Resident #319, who has a PICC line. -RN I did not use PPE while administering IV medications via PICC line for Resident #319. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASRR) to the maximum extent practicable to avoid duplicative testing and effort for 1 of 17 (Resident #60) residents reviewed for PASRR. Resident #60 was not referred for PASRR Level II Assessment when a diagnosis of Mental Illness was identified on 07/03/2024. This failure could affect residents with mental illnesses and placed them at risk of not being assessed to receive needed services.

Inspectors wroteBased on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #114) of 17 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan based on assessed needs to address Resident #114's pain and the appropriate interventions. This failure could place residents at risk of not receiving desired and necessary care and treatment. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #39) of 17 residents reviewed for oxygen thearpy. The facility failed to ensure Resident #39 had physician's order in his chart for oxygen. This failure could place residents at risk of having records that do not reflect their current status or needs. Findings Included: [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to assess residents for risk of entrapment from bed rails prior to installation. The facility failed to review the risks and benefits of bed rails with 1 (Resident #319) of 17 residents or their resident representatives and obtain informed consent prior to installation of bed rails. Resident #319 had (2) one-quarter bed rails, one on each side of his bed with no documentation of consent or safety assessment prior to installation. This failure could place residents at risk of injury, hinder residents from getting out of bed, and/or cause a decline in resident's ability to engage in activities of daily living.

Inspectors wroteBased on interview and record review the facility failed to establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintatined periodically reconciled for 3 of 10 residents (Resident #2, Resident #5, and Resident #6) reviewed for pharmacy services. 1. The facility failed to prevent LVN B from misplacing narcotics for Resident #2, Resident #5, and Resident #6. 2. The facility failed to ensure Resident #2, #5, and #6's narcotics medications were accounted for: 2 out of the 3 narcotics that were missing. These failures could place residents at risk of not receiving medication therapy that would be effective for their treatment, resulting in the exacerbation of conditions and disease processes.

Inspectors wroteBased on interview, and record review, the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have acess to the keys for 3 of 10 residents (Resident #2, Resident #5, and Resident #6) reviewed for medication storage. -The facility failed to ensure LVN B stayed with Resident #6 until narcotic medications were taken. -The facility failed to ensure LVN B did not place narcotics in the nightstand table of Resident #5 and Resident #6's meal tray. -The facility failed to ensure LVN B did not destroy narcotic medications for Resident #2, by throwing them away in the medication cart trash can. These failures could place residents at risk for drug diversion, lack of drug efficacy, and adverse reactions.

Inspectors wroteBased on interview, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by the resident assessments and infividual plans of care considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 1 of 5 (LVN B) staff reviewed for nursing services. The facility failed to ensure that LVN B distributed and destroyed narcotic medications in accordance with professional standards and facility policy. This failure could place residents at risk for drug diversion, lack of drug efficacy, and adverse reactions.

Inspectors wroteBased on interview and record review the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representatives when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention or a significant change in the resident's physical, mental, psychosocial status for 1 (Resident #1) of 6 residents reviewed for notification. The facility failed to ensure Resident #1's resident representative was immediately notified when the resident had a change in condition that required her to be transported via ambulance to the hospital. This failure could result in residents not having the comfort and company of their families during traumatic times.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident has a right to a dignified existence and to treat each resident with respect and dignity for 1 (Resident #324) of 27 residents reviewed for resident's rights. The facility failed to keep Resident #324's catheter bag covered with a privacy bag. This failure could lead to residents at risk of experiencing feelings of shame and/or embarrassment as well as having their right to privacy violated.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknow source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one (Resident # 126) of 18 residents reviewed for abuse. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must be developed within 48 hours of a resident's admission, include the minimum healthcare information necessary to properly care for a resident including, but not limited to initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and PASRR recommendation for 1 (Resident #73) of 3 closed resident records reviewed for baseline care plans. The facility failed to develop a baseline care plan for Resident #73 that addressed his diagnoses and physician's orders. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 18 Residents (Resident #55 and #65) reviewed for comprehensive care plans. - The facility failed to update the code status in the comprehensive person-centered care plan for Resident #55. - The facility failed to include code status in the comprehensive person-centered care plan for Resident #65. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail, assess the resident for risk of entrapment from bed rails prior to installation, and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for one (Resident #126) of 18 residents reviewed for bed rails. Resident #126 had quarter bed rails on both sides of her bed with an assessment that indicated no use of bed rails and no consent in the EHR. This failure could place residents at risk of entrapment or injury. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 2 of 3 Medication Carts (East side cart #1 and East side cart #2) in that: 1 expired medication found in Medication Cart #1 on East side of building. 23 expired oral (buccal) dose of medication, 1 packaged medication without an expiration date, 1 box of expired medication, and 6 loose pills were found in Medication Cart #2 on East side of building. [...]

Inspectors wroteBased on interview, and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 (Resident #324) of 27 residents reviewed for accurate medical records. The facility failed to correctly transcribe the Nurse Practitioner orders for Resident #324 related to blood sugar. This failure could place resident at risk of not receiving needed care or treatments by misleading care providers regarding what care or treatment resident should receive.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors for one of 6 (Resident #1) residents reviewed for medication administration. -Resident #1 received Propranolol HCl oral tablet 20mg, over the course of 8 days, without an order. This failure could place residents who receive blood pressure medications at an increased risk for complications such as decreased blood pressure, decrease pulse, and an exacerbation of symptoms and disease process.