Windemere Park Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Windemere Park Health and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF686Sep 15, 2021

  Based on observation, interview and record review, the facility failed to reposition/offload pressure per standard of care, and/or treat for pain prior to wound care for three residents (Resident #22, #27 and #33) of five reviewed for pressure ulcers (a wound caused by prolonged pressure on the skin over a bony prominence), resulting in the development of a facility acquired unstageable pressure ulcer and unnecessary pain. Findings include: Resident #22 (R22) On 09/13/2021 at 09:38 AM, during an initial tour, Resident #22 was observed laying in bed on their back. Resident #22 was awake and had clear speech. Resident #22 was interviewed about the care at the facility and expressed that they had no concerns regarding the care they were receiving. […]

• No harm, potential for more than minimal, widespreadF813Apr 30, 2025

  Based 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. Findings include: On [DATE] at 10:20 AM, the 4th floor resident refrigerator was observed with Certified Dietary Manager (CDM) B. There were 4 expired cartons of milk, an undated deli sandwich, an undated brown bag lunch, 2 undated bowls of cooked oatmeal, an undated bowl of chili, and a moldy container of raspberries. On [DATE] at 10:30 AM, the 5th floor resident refrigerator was observed with CDM B. There was an undated foam container with chicken and rice. […]

• No harm, potential for more than minimal, widespreadF812Apr 4, 2024

  Based 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. Findings include: On 04/02/24 at 12:40 P.M., An environmental tour of the 5th Floor Dining Room was conducted by this surveyor. The following items were noted: The stainless steel non-insulated transport cart steering handles were observed bent and curved. 1 of 2 handles were also observed covered with black electrical tape. […]

• No harm, potential for more than minimal, widespreadF880Apr 4, 2024

  Based 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. Findings include: On 04/03/24 at 3:07 PM, a review of the infection control program was initiated with the Infection Control Preventionist Nurse. The ICP reported they had started in their role for the facility in Novembers of 2023. A review of the elements included a monthly summary of facility infections, the facility acquired rate of infection, the line list of resident infection, mapping the location of resident infections, documentation of the use of McGreer's Criteria, radiology reports, labs for culture and sensitivity for antibiotic use, a pharmacy report on the… […]

• No harm, potential for more than minimal, widespreadF761Jan 11, 2023

  Based 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. Findings include: On [DATE] at 10:15 AM, a review of the medications in cart one on the fourth floor was conducted with Nurse H. A Novolog pen was open and not dated. A second Novolog pen for the same resident was dated [DATE]. Nurse H reported the resident had moved to the fifth floor and the pen would be discarded as it was past 30 days. A Humalog insulin pen was also open and not dated. […]