Windemere at Westover Hills

In the surveyor’s words

From the most serious findings on record at Windemere at Westover Hills, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Apr 16, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF684Apr 16, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Aug 18, 2023

  Based 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. […]

• No harm, potential for more than minimal, patternF761Dec 19, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF644Sep 13, 2024

  Based 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. […]