Deficiency Records for Windsor Gardens Rehabilitation Center of Salinas
Updated as of March 01, 2024
A list of the most recent deficiencies for Windsor Gardens Rehabilitation Center of Salinas. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-11 | 2023-09-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-11 | 2023-09-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-11 | 2023-09-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-11 | 2023-09-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-11 | 2023-09-06 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-08-11 | 2023-09-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-11 | 2023-09-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-11 | 2023-09-06 | 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 | 2023-08-11 | 2023-09-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-08-11 | 2023-09-06 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-08-11 | 2023-09-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-08-11 | 2023-09-06 | 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 | 2023-08-11 | 2023-09-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-11 | 2023-09-06 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-08-11 | 2023-09-06 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-14 | 2023-08-31 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-08-14 | 2023-08-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-14 | 2023-08-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-14 | 2023-08-31 | 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 | 2023-08-14 | 2023-08-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-14 | 2023-08-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-14 | 2023-08-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-14 | 2023-08-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-11 | 2023-05-26 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-04-28 | 2023-05-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-20 | 2023-05-19 | Y |
| 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 | 2023-04-27 | 2023-05-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-11 | 2023-01-21 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-08-03 | 2022-10-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-08 | 2022-09-01 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-08-08 | 2022-09-01 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-03-30 | 2022-04-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-30 | 2022-04-29 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-16 | 2022-03-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-29 | 2021-11-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-14 | 2021-10-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-14 | 2021-10-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-30 | 2021-07-16 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-06-30 | 2021-07-16 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-06-30 | 2021-07-16 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-06-30 | 2021-07-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-15 | 2021-07-15 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-03-10 | 2021-03-26 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-03-10 | 2021-03-26 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-12-18 | 2020-01-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-12-18 | 2020-01-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-12-18 | 2020-01-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-12-18 | 2020-01-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-18 | 2020-01-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-12-18 | 2020-01-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-18 | 2020-01-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-18 | 2020-01-13 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2019-12-18 | 2020-01-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-18 | 2020-01-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-18 | 2020-01-13 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-10-17 | 2019-11-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-10-17 | 2019-11-13 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2019-10-17 | 2019-11-13 | 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 | 2019-10-17 | 2019-11-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-17 | 2019-11-13 | N |
| Provide activities to meet all resident's needs. | Health | 2019-10-17 | 2019-11-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-17 | 2019-11-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-17 | 2019-11-13 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-10-17 | 2019-11-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-10-17 | 2019-11-13 | 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 | 2019-10-17 | 2019-11-13 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-10-17 | 2019-11-13 | 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 | 2019-10-17 | 2019-11-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-17 | 2019-11-13 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-10-17 | 2019-11-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-17 | 2019-11-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-11-29 | 2019-01-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-29 | 2019-01-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-11-29 | 2019-01-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-11-29 | 2019-01-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-29 | 2019-01-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-21 | 2018-10-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-21 | 2018-10-26 | 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 | 2018-09-21 | 2018-10-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-09-21 | 2018-10-26 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-09-21 | 2018-10-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-09-21 | 2018-10-26 | 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 | 2018-09-21 | 2018-10-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-21 | 2018-10-26 | N |
