Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Windemere Park Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, muscle weakness, and moderate cognitive impairment had a care plan specifying that the bed be kept in the lowest position when occupied and that bilateral fall mats be used when in bed, including after a prior fall from the bed. On multiple observations, the resident was found in bed with the mattress surface at a high position and without fall mats in place, while the mats were seen folded in the corner of the room. An LPN confirmed the bed functioned properly and could be lowered, and the DON stated the bed and fall mats should be used as care planned, consistent with the facility’s fall management policy for residents at risk for falls.
A resident with CHF and emphysema, admitted with a care plan specifying showers on certain days of the week, did not receive all scheduled showers over a 30‑day period. Documentation showed only four showers or bed baths were provided, with three scheduled showers missed. A complaint alleged the resident had not been provided appropriate showers since admission. The NHA confirmed missing shower days without explanation and stated residents were to receive showers as scheduled. Review of the facility’s bath, shower, and tub policy showed it only described the procedure for giving a bath and did not address ensuring scheduled showers were provided.
Surveyors found that perishable food items in resident refrigerators, such as milk, sandwiches, oatmeal, chili, and fruit, were expired, undated, or moldy. The Certified Dietary Manager stated that nursing staff were responsible for labeling and discarding these items, but the facility's policy requiring proper labeling and timely disposal was not followed.
A resident with Alzheimer's Disease and dysphagia, who was dependent on staff and rarely understood, was observed receiving both pureed and regular textured foods despite an order for a pureed diet with thin liquids. Staff interviews and record review revealed conflicting dietary orders and a lack of communication among dietary and nursing staff, resulting in the resident not consistently receiving the prescribed therapeutic diet.
A resident with moderate cognitive impairment and a history of falls was repeatedly observed without access to their call light, which was found on the floor or wrapped around the bed hardware out of reach. The resident reported frequent difficulty locating the call light, resulting in delays in care. Staff failed to reposition the call light during room checks, despite facility policy and care plan requirements for call light accessibility.
A long-term care facility failed to prevent the misappropriation of narcotic medications for three residents. The Director of Nursing (DON) misplaced a pack of Lorazepam tablets intended for destruction, and inconsistencies were found in the handling of medications. The facility's procedures for medication destruction were disorganized, with incomplete and unsigned records, leading to missing Hydrocodone pills for two other residents. The investigation revealed a lack of secure handling and destruction of controlled substances.
The facility failed to report and investigate missing narcotic medications for two residents. An RN observed the DON mishandling medications, leading to the discovery of 17 missing Hydrocodone pills. Despite being informed, the NHA did not report the incident to the State Agency, violating the facility's policy.
A resident with a history of lung cancer and recent COPD treatment did not have a follow-up CT scan scheduled as required. Despite physician progress notes indicating communication with the oncology clinic for a CT scan prescription, the facility failed to schedule the appointment. The appointment clerk was unaware of any orders, and the facility's policy for scheduling external appointments was not followed, leading to the deficiency.
Failure to Implement Care-Planned Fall Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for a resident identified as being at risk for falls. The resident, admitted with diagnoses including dementia and muscle weakness and assessed with moderate cognitive impairment on a BIMS, had a baseline care plan that included keeping the bed in the lowest position when occupied and using bilateral fall mats when in bed. These interventions were initiated following admission and, in the case of the fall mats, after a prior fall from the bed. A concern reported to the State Agency specifically referenced the resident’s bed height, the mechanical functioning of the bed, and the facility’s management of the resident’s fall risk. On multiple observations on the same day, the resident was seen in bed with the mattress surface approximately three feet from the floor, not in a lowered or lowest position, and without fall mats in place on either side of the bed, despite the care plan requirements. When an LPN demonstrated the bed’s mechanical functions, the bed was shown to be working properly, confirming that it could be raised and lowered, yet it had been left at the higher position. The fall mats were observed folded and stored in the corner of the room rather than on the floor next to the bed. The resident stated they did not mind if staff lowered the bed and could not recall whether fall mats were usually kept on the floor. The DON confirmed that the bed should be in the lowest position and fall mats should be in place when the resident is in bed, consistent with the facility’s fall management policy, which requires that residents at risk for falls have care plans developed and fall prevention interventions implemented based on assessment.
Failure to Provide Scheduled Showers as Care Planned
Penalty
Summary
Surveyors found that the facility failed to provide scheduled showers for one resident identified as R700. A complaint to the state agency alleged that this resident had not been provided appropriate showers since admission. Record review on 2/18/26 showed that R700 was admitted on 1/07/26 with diagnoses including congestive heart failure and emphysema, and the resident’s care plan documented a bathing schedule of showers on Tuesdays and Fridays. Review of the shower record for the last 30 days showed that the resident only received a shower or bed bath on four dates (1/8/26, 1/13/26, 1/19/26, and 1/26/26), indicating three missed scheduled showers. In interview, the Nursing Home Administrator acknowledged awareness of the concern, stated they had reviewed the charting for refusals, confirmed that shower days were missing, and could not provide an explanation, reiterating that residents are to receive showers as scheduled. Review of the facility’s Bath, Shower and Tub policy showed it only addressed the procedure for giving a bath and did not address ensuring scheduled showers were provided.
Failure to Properly Store and Label Resident Food Items
Penalty
Summary
Surveyors observed that the facility failed to store resident food items in accordance with professional standards for food service safety. During inspections of the 4th and 5th floor resident refrigerators with the Certified Dietary Manager, multiple perishable food items were found to be expired, undated, or moldy, including cartons of milk, a deli sandwich, a brown bag lunch, bowls of cooked oatmeal, a bowl of chili, a container of raspberries, and a foam container with chicken and rice. When questioned, the Certified Dietary Manager indicated that nursing staff were responsible for ensuring food items in resident refrigerators were properly dated and discarded when expired. Review of the facility's policy confirmed that perishable foods brought by family or visitors must be labeled with the resident's name, item, and use by date, and that nursing staff are responsible for discarding perishable foods on or before the use by date.
Failure to Provide Prescribed Therapeutic Diet Consistency
Penalty
Summary
A resident with diagnoses of Alzheimer's Disease and dysphagia, who was dependent on staff for all activities of daily living and had a BIMS score indicating they were rarely or never understood, did not consistently receive the prescribed therapeutic diet. Observations showed the resident was served pureed main course foods as ordered, but also received regular textured fruit cocktail and pineapple chunks, as well as a half peanut butter and jelly sandwich. The presence of regular textured foods on the tray was inconsistent with the resident's order for a regular diet with pureed texture and thin liquids. Review of the electronic medical record revealed an active order for daily peanut butter and jelly sandwiches to increase caloric intake, and a separate order for a pureed diet. Interviews with dietary and administrative staff confirmed that the dietary worker failed to identify the incorrect food texture on the tray, and that there was a lack of awareness among dietary management regarding the peanut butter and jelly order. The hospice nurse who wrote the pureed diet order may not have been aware of the existing order for the sandwich, leading to conflicting dietary instructions.
Failure to Ensure Call Light Accessibility for Resident with Cognitive Impairment
Penalty
Summary
A deficiency was identified when a resident with a history of falls, chronic heel ulcers, and moderate cognitive impairment was repeatedly observed without access to their call light. On multiple occasions, the call light was found on the floor under the bed or wrapped around the headboard hardware, out of the resident's reach. The resident was alert and able to communicate, and their care plan specifically required that the call light be kept within reach to accommodate their dependence on staff for care needs. Despite these documented needs and facility policy requiring call lights to be accessible at all times, staff failed to ensure the call light was within the resident's reach during several observations. The resident reported frequent difficulty locating the call light and confirmed that this resulted in delays in receiving care. Staff entered the room during one observation but did not reposition the call light to make it accessible. Facility policy and administrator expectations both require call lights to be within reach, but this was not consistently implemented for this resident.
Misappropriation of Narcotic Medications in LTC Facility
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic pain medication for three residents, leading to a deficiency in protecting residents' belongings. The incident involved the disappearance of a pack of Lorazepam tablets that was supposed to be destroyed by the Director of Nursing (DON). The Licensed Practical Nurse (LPN) F handed over five cards of controlled substances, including Lorazepam and Tramadol, to the DON for destruction. However, the DON did not sign the Controlled Substance Proof of Use sheet, and the Lorazepam tablets went missing from the DON's possession. Further investigation revealed inconsistencies in the DON's handling of the medications. Registered Nurse (RN) G witnessed the DON taking the medications to the fourth floor, where the DON left them unattended on a resident's nightstand while assisting with feeding. Upon returning, RN G noticed that one card of medication was missing, which the DON attributed to LPN F not providing it or possibly dropping it. Additionally, RN G reported another incident where the DON was seen punching medications out of blister packets at the nurses' station, resulting in missing Hydrocodone pills for two other residents. The facility's procedures for medication destruction were found to be disorganized and lacking consistency. Interviews with staff revealed confusion about the process, with multiple incomplete and unsigned documents related to controlled substance records. The facility's policy on discarding and destroying medications was not followed, as evidenced by the lack of proper documentation and witness signatures. The investigation highlighted the facility's failure to maintain secure handling and destruction of controlled substances, leading to the misappropriation of medications intended for residents with significant medical needs.
Failure to Report and Investigate Misappropriation of Narcotics
Penalty
Summary
The facility failed to report and investigate an allegation of misappropriation of narcotic medications involving two residents. A Registered Nurse (RN) observed the Director of Nursing (DON) handling medications that needed to be destroyed at the nurses' station. The DON was seen punching medications out of blister packets, making it difficult to identify the source of the medications. Upon organizing and counting the medications, the RN discovered that 17 Hydrocodone pills were missing for two residents. The RN reported the missing medications to the Nursing Home Administrator (NHA), but the incident was not reported to the State Agency as required. The two residents involved had significant medical histories. One resident was admitted with Alzheimer's Disease, Diabetes, and Hypertension and was prescribed Hydrocodone-Acetaminophen for moderate pain. The other resident was under hospice care with Chronic Pain and Malignant Neoplasm of the Esophagus, also prescribed Hydrocodone-Acetaminophen for pain management. Despite the RN's report to the NHA, the facility did not investigate or report the missing narcotics to the State Agency, violating their policy on reporting unusual occurrences.
Failure to Schedule Follow-Up Appointment for Resident
Penalty
Summary
The facility failed to schedule a follow-up appointment for a resident who had been in the facility for approximately 2.5 weeks. The resident, who had a history of lung cancer and was recently treated for COPD, required a follow-up CT scan with contrast of the left lung as recommended by their physician. Despite multiple progress notes indicating that the physician had communicated with the oncology clinic to arrange for the necessary prescription for the CT scan, the appointment was not scheduled. The resident was agreeable to have the CT scan done at a local hospital, but the facility did not follow through with the scheduling. The appointment clerk, when interviewed, stated that they were unaware of any outside appointments for the resident and did not see any orders from the doctor. The facility's policy required a physician's order before scheduling external appointments, and the order was supposed to be forwarded to the Medical Records Department for scheduling. However, this process was not followed, leading to the failure in scheduling the necessary follow-up appointment for the resident. The Nursing Home Administrator was also unsure why the appointments were not made, indicating a breakdown in communication and adherence to the facility's policy.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Nursing homes near Warren
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Woods Residential Health | 1.5 mi | ★★★★★ | 28 | 0 |
| St. Anthony Healthcare Center | 2 mi | ★★★★★ | 2 | 0 |
| The Orchards At Warren | 2 mi | ★★★★★ | 22 | 0 |
| Harmony Village Of Warren | 2.5 mi | ★★★★★ | 1 | 0 |
| The Villa At City Center | 2.5 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.