Windemere At Westover Hills

Penalties

• Apr 16, 2025 — Fine ($8,281)

Inspection findings

1. Dec 19, 2025 Health · 6 findings
   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Dec 26, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Dec 26, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Dec 26, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     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.

     Corrected Dec 26, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Dec 26, 2025 · CMS health inspection

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Dec 26, 2025 · CMS fire safety

2. Apr 16, 2025 Health · 2 findings
   • Serious Scope/severity J Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Apr 17, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Apr 17, 2025 · CMS health inspection

3. Sep 13, 2024 Health · 10 findings
   • Not serious Scope/severity D Complaint

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Oct 28, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0638 Resident Assessment and Care Planning Deficiencies

     Assure that each resident’s assessment is updated at least once every 3 months.

     Corrected Oct 28, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Oct 28, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0642 Resident Assessment and Care Planning Deficiencies

     Ensure a qualified health professional conducts resident assessments.

     Corrected Oct 28, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0644 Resident Assessment and Care Planning Deficiencies

     Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

     Corrected Oct 28, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Oct 28, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     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.

     Corrected Oct 28, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Oct 28, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Oct 28, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0911 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the installation and maintenance of electrical systems.

     Corrected Oct 28, 2024 · CMS fire safety

4. Aug 23, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0761 Pharmacy Service Deficiencies

     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.

     Corrected Oct 4, 2024 · CMS health inspection

5. Aug 18, 2023 Health · 9 findings
   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Sep 7, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Sep 7, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Sep 7, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Sep 7, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Sep 7, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0325 Smoke Deficiencies

     Have properly installed hallway dispensers for alcohol-based hand rub.

     Corrected Sep 7, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Sep 7, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0700 Miscellaneous Deficiencies

     Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.

     Corrected Sep 7, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Sep 7, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• DYSON, JESSICA — adp of the snf, NOT APPLICABLE, since 06/26/2023
• DYSON, JESSICA — operational/managerial control, NOT APPLICABLE, since 06/26/2023
• FIAZUDDIN, FARAZ — adp of the snf, NOT APPLICABLE, since 01/01/2025
• HOOPER, GRADY — corporate officer, NOT APPLICABLE, since 12/01/2015
• HOOPER, GRADY — corporate director, NOT APPLICABLE, since 12/01/2015
• FIRST WESTOVER CAPITAL FUNDING LLC — 5% or greater indirect ownership interest, 100%, since 12/08/2014
• WESTOVER CONTINUING CARE CENTER LTD. CO. — operational/managerial control, NOT APPLICABLE, since 03/01/2023
• WESTOVER CONTINUING CARE CENTER LTD. CO. — adp of the snf, NOT APPLICABLE, since 03/26/2025