Windmill Manor

In the surveyor’s words

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

• Actual harm, isolatedF689Sep 17, 2025

  Based on clinical record review, staff interviews, and policy review, the facility failed to provide appropriate supervision when a staff failed to use a gait belt to ensure each resident safety during a transfer for 1 of 3 residents reviewed (Resident #1) for safety. Resident #1 fell during the transfer which resulted in a left arm and wrist fracture. The facility reported a census of 109 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated moderate cognitive impairment. The MDS further indicated that the resident received partial/moderate assistance with transfers. […]

• Actual harm, isolatedF689May 16, 2024

  Based on clinical record review, staff interviews, and policy review the facility failed to implement and modify interventions, and provide safety to 1 of 3 residents reviewed for falls (Resident #67) who fell repeatedly at the facility and sustained two (2) fractures. The facility reported a census of 94 residents. Findings included: The Minimum Data Set (MDS) dated [DATE] for Resident #67 documented a Brief Interview of Mental Status (BIMS) score of 4 indicating he has severely impaired cognition. The MDS documented he does not walk, stand, or use the toilet and he is dependent on staff for toilet hygiene, and changing positions from lying to sitting and for transfers. The MDS also documented his primary diagnosis of fractures and other multiple traumas, Alzheimer's, and hip fracture. […]

• Actual harm, isolatedF689Feb 7, 2023

  Based on observation, interview, record review, and facility policy review, the facility failed to provide a safe transfer while using a mechanical lift which resulted in an arm fracture, hematomas, and pain for 1 of 2 residents reviewed for mechanical lift transfers. (Resident#24) The facility reported a census of 81. Findings include: The Annual Minimum Data Set (MDS) assessment set dated 11/1/22 revealed the resident scored 14 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognitively intact. The MDS documented that the Resident required two staff for total dependence for transfers. The MDS revealed that the Resident required total dependence of staff for the following transfers; chair/bed-to-chair, toilet transfer, and car transfer. […]

• No harm, potential for more than minimal, widespreadF812May 16, 2024

  Based on observations, policy review, and staff interviews the facility failed to keep the kitchen free of flies, keep garbage cans covered, keep bare hands off the drinking surface of the glass, keep the kitchen surfaces clean, store food items at the correct temperatures, keep stored foods dated and closed, keep bare hands off of food, and use gloves correctly during food preparation. The facility reported a census of 94 residents. Findings include: During the initial tour of the kitchen on 5/13/24 at 10:29 AM the following items were found soiled: a. Food and paper particles on the floor; sticky substance on the floor. b. Orange appearing leak pooled and dripping onto the surface under the juice machine. c. Milk splatters inside the front refrigerator. d. […]

• No harm, potential for more than minimal, patternF804Apr 9, 2026

  Based on observation, resident and staff interviews, and facility policy review, the facility failed to serve food at a safe, preferred temperature and palatable. The facility reported a census of 111 residents. Findings include: 1. During the observation of the noon meal on 04/07/2026 at 12:05 PM, Staff N, took the temperature of the pork entree with a result of 171 degrees Fahrenheit (F). The pureed pork had a temperature of 166 F. At 1:35 PM, Staff O, [NAME] took the temperatures of a test tray for the State Agency. The pureed pork had a temperature of 113 F, and the pork entrée had a temperature of 135 F. The pork entrée lukewarm upon the taste test. 2. […]