A list of the most recent deficiencies for Windcrest Health and Rehab Inc. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-03 | 2023-12-03 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-11-03 | 2023-12-02 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-11-02 | 2023-12-02 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-03-30 | 2023-04-29 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-29 | 2022-08-26 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-07-29 | 2022-08-26 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-07-29 | 2022-08-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-29 | 2022-08-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-29 | 2022-08-26 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-07-29 | 2022-08-26 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-07-29 | 2022-08-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-29 | 2022-08-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-29 | 2022-08-26 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-07-29 | 2022-08-26 | 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 | 2022-07-29 | 2022-08-26 | N |
| Provide or obtain dental services for each resident. | Health | 2022-07-29 | 2022-08-26 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-07-29 | 2022-08-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-29 | 2022-08-26 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-07-29 | 2022-08-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-29 | 2021-10-22 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-05-07 | 2021-06-05 | 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 | 2021-05-07 | 2021-06-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-05-07 | 2021-06-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-07 | 2021-06-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-07 | 2021-06-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-05-07 | 2021-06-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-07 | 2021-06-05 | Y |
| Install proper backup exit lighting. | Fire Safety | 2021-05-03 | 2021-06-05 | 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 | 2021-05-03 | 2021-06-05 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2021-05-03 | 2021-06-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-05-03 | 2021-06-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-03 | 2021-06-05 | N |
