A list of the most recent deficiencies for Windsor Country Drive Care Center. 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 each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-07-25 | 2023-08-14 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-23 | 2023-06-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-23 | 2023-06-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-05-23 | 2023-06-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-23 | 2023-06-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-23 | 2023-06-28 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-05-23 | 2023-06-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-23 | 2023-06-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-23 | 2023-06-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-23 | 2023-06-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-23 | 2023-06-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-23 | 2023-06-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-23 | 2023-06-28 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-05-18 | 2023-06-14 | 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 | 2023-05-18 | 2023-06-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-18 | 2023-06-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-18 | 2023-06-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-05-18 | 2023-06-14 | 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 | 2023-05-18 | 2023-06-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-18 | 2023-06-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-18 | 2023-06-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-18 | 2023-06-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-28 | 2022-09-09 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-03-30 | 2021-04-10 | Y |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-05-30 | 2019-06-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-05-30 | 2019-06-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-05-30 | 2019-06-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-05-30 | 2019-06-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-03-21 | 2019-04-30 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-03-21 | 2019-04-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-21 | 2019-04-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-21 | 2019-04-30 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-03-21 | 2019-04-30 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-03-21 | 2019-04-30 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-03-21 | 2019-04-30 | 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 | 2019-03-21 | 2019-04-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-21 | 2019-04-30 | 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 | 2019-03-21 | 2019-04-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-03-21 | 2019-04-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-03-21 | 2019-04-30 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2019-03-21 | 2019-04-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-21 | 2019-04-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-21 | 2019-04-30 | N |
| Keep all essential equipment working safely. | Health | 2019-03-21 | 2019-04-30 | 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 | 2018-07-20 | 2018-08-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-07-20 | 2018-08-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-07-20 | 2018-08-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-07-20 | 2018-08-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-05-17 | 2018-06-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-17 | 2018-06-17 | N |
| Provide appropriate foot care. | Health | 2018-05-17 | 2018-06-17 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-05-17 | 2018-06-17 | N |
