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Deficiency Records for Windsor House

A list of the most recent deficiencies for Windsor House. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Windsor House. 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?
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-09-20 2023-10-19 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-09-20 2023-10-19 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2023-09-20 2023-10-19 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-09-20 2023-10-19 Y
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Health 2023-09-20 2023-10-19 Y
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2023-08-24 2023-09-28 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-08-24 2023-09-28 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-08-24 2023-09-28 Y
Provide and implement an infection prevention and control program. Health 2023-08-24 2023-09-28 Y
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Health 2022-08-25 2022-09-29 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-08-25 2022-09-29 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2022-05-06 2022-06-10 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2022-05-06 2022-06-10 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2022-05-06 2022-06-10 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2021-05-29 2021-07-02 N
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2021-05-29 2021-07-02 N
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. Health 2021-05-29 2021-07-02 N
Ensure each resident receives an accurate assessment. Health 2021-05-29 2021-07-02 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2021-05-29 2021-07-02 N
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2021-05-29 2021-07-02 N
Provide enough food/fluids to maintain a resident's health. Health 2021-05-29 2021-07-02 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 2021-05-29 2021-07-02 N
Provide routine and 24-hour emergency dental care for each resident. Health 2021-05-29 2021-07-02 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2021-05-29 2021-07-02 N
Provide and implement an infection prevention and control program. Health 2021-05-29 2021-07-02 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2019-03-13 2019-04-17 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2019-03-07 2019-04-11 N
Allow resident to participate in the development and implementation of his or her person-centered plan of care. Health 2018-04-05 2018-05-10 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2018-04-05 2018-05-10 N
Provide and implement an infection prevention and control program. Health 2018-04-05 2018-05-10 N
Install proper backup exit lighting. Fire Safety 2018-04-10 2018-05-10 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2018-04-10 2018-05-10 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2018-04-10 2018-05-10 N

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