Windmere

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF640Mar 3, 2026

  Based on interview and record review, it was determined that the facility failed to complete and transmit Minimum Data Sets (MDS) in accordance with federal guidelines. This deficient practice was identified for 17 of 17 residents reviewed for resident assessment (Resident #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 16, 19, 20, and 21). This deficient practice was evidenced by the following:On 2/25/26 at 1:06 PM, the surveyor reviewed the MDS submissions for Resident #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 16, 19, 20, 21. The MDS's were completed yet they were not submitted/transmitted to CMS as required. The facility had submitted the MDS' exclusively as state-only assessments and did not the MDS's. […]

• No harm, potential for more than minimal, widespreadF812Mar 3, 2026

  Based on observation, interview, record review and policy review, it was determined that the facility failed to sanitize and air dry steam table pans in a manner to prevent microbial growth. This deficient practice was evidenced by the following:On 2/26/26 at 10:32 AM, in the presence of the Executive Sous Chef (ESC) and the Senior Director of Dining and Nutrition Services (DNS), the surveyor observed the following:On a shelf, in the area of the dishwashing area, near the 3 compartment sink, the surveyor observed 4 deep full sheet sized steam table pans, stacked with water between them, 5 deep half sized steam table pans stacked with water between them, and 2 shallow full size steam table pans stacked with water between them. […]

• No harm, potential for more than minimal, widespreadF881Aug 8, 2024

  Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure: a) the Antibiotic Stewardship Program (ASP) Policy and Procedure, part of the facility Infection Prevention Control Program (IPCP) was reviewed at least annually and included a procedure for the reporting of multidrug- resistant organisms (MDRO), and communicable diseases to local/state public health authorities, b) a standardized infection assessment tool or management algorithm (IST) was consistently utilized for prescribed antibiotics (Resident #2), c) residents with chronic urinary tract infection with multiple prescribed antibiotics were tracked to prevent development and/or transmission of MDRO, d) staff were educated when a Multidrug-Resistant… […]

• No harm, potential for more than minimal, widespreadF940Aug 8, 2024

  Based on observation, interview, and document review, it was determined that the facility failed to ensure that all licensed staff received training and competencies in accordance with the Facility Assessment, and to ensure facility policies and procedures for wound care competencies were met. This deficient practice was identified during an Initial Certification Survey for 1 of 7 Residents sampled for wound care (Resident #1) and one closed medical record (Resident #2). The deficient practice effected 2 of 2 Resident Units and was evidenced by the following: On 08/07/24 at 9:09 AM, during the facility entrance conference the surveyors requested a list of all the residents who received wound care. […]

• No harm, potential for more than minimal, isolatedF836Mar 3, 2026

  Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive authorization for a change in facility name in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following:According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program:(a) Certifying compliance. […]