Deficiency Records for Windsor Gardens Convalescent Hospital
Updated as of March 01, 2024
A list of the most recent deficiencies for Windsor Gardens Convalescent Hospital. 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 services provided by the nursing facility meet professional standards of quality. | 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 |
| 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 |
| 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 |
| 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 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 |
| Provide and implement an infection prevention and control program. | 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 |
| 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 | 2023-04-17 | 2023-05-17 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-12 | 2023-05-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-28 | 2023-04-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-28 | 2023-04-27 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-03-28 | 2023-04-27 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-23 | 2022-12-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-18 | 2022-12-07 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-10-18 | 2022-12-07 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-18 | 2022-12-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-27 | 2022-11-27 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-10-14 | 2022-10-23 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-07-11 | 2022-08-10 | Y |
| Implement a program that monitors antibiotic use. | Health | 2022-07-11 | 2022-08-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-08 | 2022-07-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-05 | 2022-05-17 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-03-15 | 2022-04-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-02 | 2022-02-14 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-24 | 2021-12-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-13 | 2021-10-26 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-09 | 2021-09-21 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-08-16 | 2021-08-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-16 | 2021-08-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-05 | 2021-08-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-06-29 | 2021-07-09 | Y |
| Reasonably accommodate the needs and preferences of each resident. | 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 |
| 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 |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | 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 |
| 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 |
| Ensure each resident receives an accurate assessment. | 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 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | 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 |
| 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 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 enough food/fluids to maintain a resident's health. | 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 for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-05-07 | 2021-06-03 | N |
| Post nurse staffing information every day. | 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 |
| 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 |
| 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 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 |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | 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 |
| 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 |
| Provide and implement an infection prevention and control program. | 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 | Y |
| 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 |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-11-27 | 2019-12-31 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-11-27 | 2019-12-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-27 | 2019-12-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-27 | 2019-12-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-27 | 2019-12-31 | 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 | 2019-12-03 | 2019-12-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-12-03 | 2019-12-30 | 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 | 2019-12-03 | 2019-12-30 | N |
| Post nurse staffing information every day. | Health | 2019-12-03 | 2019-12-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-03 | 2019-12-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-03 | 2019-12-30 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-12-04 | 2019-01-02 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2018-12-04 | 2019-01-02 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2018-12-04 | 2019-01-02 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-12-04 | 2019-01-02 | N |
| Establish methods for sharing information. | Fire Safety | 2018-12-04 | 2019-01-02 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-12-04 | 2019-01-02 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-12-04 | 2019-01-02 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-12-04 | 2019-01-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-12-04 | 2019-01-02 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-12-04 | 2019-01-02 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-12-04 | 2019-01-02 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-11-16 | 2018-12-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-16 | 2018-12-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-11-16 | 2018-12-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-16 | 2018-12-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-11-16 | 2018-12-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-16 | 2018-12-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-16 | 2018-12-15 | N |
