CONTACT INFORMATION REVIEWS & MORE DATA
Deficiency Records for Windsor Gardens Convalescent Hospital
View the most recent health deficiencies and inspection results for Windsor Gardens Convalescent Hospital. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Windsor Gardens Convalescent Hospital. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2025-08-14 | 2025-08-18 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-08-14 | 2025-08-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-07-29 | 2025-07-30 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2025-03-02 | 2025-03-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-03-02 | 2025-03-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-03-02 | 2025-03-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-03-02 | 2025-03-07 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2025-03-02 | 2025-03-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2025-03-02 | 2025-03-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2025-03-02 | 2025-03-07 | 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 | 2025-03-02 | 2025-03-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2025-03-02 | 2025-03-07 | 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 | 2025-03-02 | 2025-03-07 | 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 | 2025-03-02 | 2025-03-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-03-02 | 2025-03-07 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2025-03-02 | 2025-03-07 | 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 | 2025-03-02 | 2025-03-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-03-02 | 2025-03-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-03-02 | 2025-03-07 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2025-03-02 | 2025-03-07 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2025-03-02 | 2025-03-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-03-02 | 2025-03-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2025-03-02 | 2025-03-07 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2025-03-02 | 2025-03-07 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2025-02-12 | 2025-02-27 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2025-01-24 | 2025-01-27 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-11-05 | 2024-11-06 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2024-10-30 | 2024-10-31 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-08-15 | 2024-08-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-08-01 | 2024-08-05 | Y |
| 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 | 2024-07-18 | 2024-07-25 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-18 | 2024-07-25 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-07-18 | 2024-07-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-18 | 2024-07-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-18 | 2024-07-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-07-02 | 2024-07-22 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-07-02 | 2024-07-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-06-07 | 2024-07-06 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-06-07 | 2024-07-06 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-04-22 | 2024-05-10 | 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 | 2024-04-22 | 2024-05-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-04-22 | 2024-05-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-22 | 2024-05-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-08 | 2024-03-29 | 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 | 2024-03-08 | 2024-03-29 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-03-08 | 2024-03-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-06 | 2024-03-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-03-06 | 2024-03-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-23 | 2024-03-15 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-02-08 | 2024-03-07 | Y |
| Post nurse staffing information every day. | Health | 2024-02-08 | 2024-03-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-08 | 2024-03-07 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-02-08 | 2024-03-07 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-02-08 | 2024-03-07 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-02-08 | 2024-03-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-08 | 2024-03-07 | 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 | 2024-02-08 | 2024-03-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-08 | 2024-03-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-08 | 2024-03-07 | Y |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-02-08 | 2024-03-07 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2024-02-08 | 2024-03-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-02-08 | 2024-03-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-01-23 | 2024-02-20 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-01-23 | 2024-02-20 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-01-23 | 2024-02-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-23 | 2024-02-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-05 | 2024-01-20 | 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 | 2024-01-05 | 2024-01-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-04 | 2024-01-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-04 | 2023-12-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-04 | 2023-12-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-25 | 2023-09-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-09 | 2023-07-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-09 | 2023-07-09 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-06-09 | 2023-07-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-05 | 2023-07-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-07 | 2021-06-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-07 | 2021-06-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-07 | 2021-06-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-07 | 2021-06-03 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-05-07 | 2021-06-03 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-05-07 | 2021-06-03 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-05-07 | 2021-06-03 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-05-07 | 2021-06-03 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-05-07 | 2021-06-03 | N |
| Post nurse staffing information every day. | Health | 2021-05-07 | 2021-06-03 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-05-07 | 2021-06-03 | 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 | 2021-05-07 | 2021-06-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-05-07 | 2021-06-03 | 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 | 2021-05-07 | 2021-06-03 | 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 | 2021-05-07 | 2021-06-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-07 | 2021-06-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-07 | 2021-06-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-05-07 | 2021-06-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-05-07 | 2021-06-03 | 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 | 2021-06-03 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-05-07 | 2021-06-03 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-05-07 | 2021-06-03 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2021-05-07 | 2021-06-03 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2021-05-07 | 2021-06-03 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-07 | 2021-06-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-07 | 2021-06-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-07 | 2021-06-01 | N |