A list of the most recent deficiencies for Windemere at Westover Hills. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-18 | 2023-09-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-18 | 2023-09-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-18 | 2023-09-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-08-18 | 2023-09-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-18 | 2023-09-07 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-08-16 | 2023-09-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-16 | 2023-09-07 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2023-08-16 | 2023-09-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-16 | 2023-09-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-08 | 2022-07-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-08 | 2022-07-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-08 | 2022-07-29 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-07-08 | 2022-07-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-08 | 2022-07-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-08 | 2022-07-29 | Y |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-04-16 | 2021-05-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-16 | 2021-05-31 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-04-16 | 2021-05-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-16 | 2021-05-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-16 | 2021-05-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-16 | 2021-05-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-04-13 | 2021-05-20 | N |
| Respond appropriately to all alleged violations. | Health | 2021-03-11 | 2021-04-09 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-03-11 | 2021-04-09 | Y |
