A list of the most recent deficiencies for Windsor Monterey 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-30 | 2023-07-27 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-30 | 2023-07-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-06-30 | 2023-07-27 | 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 | 2023-06-30 | 2023-07-27 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-06-30 | 2023-07-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-30 | 2023-07-27 | 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 | 2023-06-30 | 2023-07-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-30 | 2023-07-27 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-06-30 | 2023-07-27 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-06-30 | 2023-07-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-30 | 2023-07-27 | 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 | 2023-06-30 | 2023-07-27 | 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 | 2023-06-30 | 2023-07-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-06-30 | 2023-07-27 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-06-30 | 2023-07-27 | 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 | 2023-06-30 | 2023-07-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-30 | 2023-07-27 | N |
| Keep all essential equipment working safely. | Health | 2023-06-30 | 2023-07-27 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-06-30 | 2023-07-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-30 | 2023-07-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-30 | 2023-07-27 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-07-06 | 2023-07-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-06 | 2023-07-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-06 | 2023-07-24 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-07-06 | 2023-07-24 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-07-06 | 2023-07-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-07-06 | 2023-07-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-06 | 2023-07-24 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-07-06 | 2023-07-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-06 | 2023-07-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-06 | 2023-07-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-19 | 2023-07-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-19 | 2023-07-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-22 | 2023-07-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-15 | 2023-06-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-30 | 2023-01-31 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-27 | 2023-01-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-20 | 2022-12-26 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-07-27 | 2022-08-17 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-10-01 | 2021-10-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-14 | 2021-07-23 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-04-15 | 2021-05-04 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2019-07-11 | 2019-09-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-11 | 2019-09-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-07-11 | 2019-09-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-11 | 2019-09-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-07-11 | 2019-09-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-11 | 2019-09-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-11 | 2019-09-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-05-03 | 2019-06-07 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-05-03 | 2019-06-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-03 | 2019-06-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-03 | 2019-06-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-03 | 2019-06-07 | 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 | 2019-05-03 | 2019-06-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-03 | 2019-06-07 | 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 | 2019-05-03 | 2019-06-07 | 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 | 2019-05-03 | 2019-06-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-03 | 2019-06-07 | 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 | 2019-05-03 | 2019-06-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-05-08 | 2018-05-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-05-08 | 2018-05-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-05-08 | 2018-05-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-05-08 | 2018-05-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-05-08 | 2018-05-29 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-03-30 | 2018-04-20 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-03-30 | 2018-04-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-30 | 2018-04-20 | 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 | 2018-03-30 | 2018-04-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-03-30 | 2018-04-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-03-30 | 2018-04-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-03-30 | 2018-04-20 | 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 | 2018-03-30 | 2018-04-20 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-03-30 | 2018-04-20 | N |
