Deficiency Records for Windsor Vallejo Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Windsor Vallejo Nursing and Rehabilitation 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-05 | 2024-01-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-09 | 2023-12-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-09 | 2023-12-19 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-11-09 | 2023-12-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-09 | 2023-12-07 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-11-09 | 2023-12-07 | Y |
| 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 | 2023-11-14 | 2023-12-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-14 | 2023-12-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-19 | 2023-10-05 | Y |
| 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 | 2023-09-19 | 2023-10-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-19 | 2023-10-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-06 | 2023-07-24 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-06 | 2023-07-24 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-06-06 | 2023-07-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-06 | 2023-07-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-02 | 2023-06-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-13 | 2023-04-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-13 | 2023-04-27 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-23 | 2023-04-13 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-10-03 | 2022-11-02 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-10-03 | 2022-11-02 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-10-03 | 2022-11-02 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-10-03 | 2022-11-02 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-10-03 | 2022-11-02 | Y |
| Report COVID19 data to residents and families. | Health | 2022-10-03 | 2022-11-02 | Y |
| 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 | 2022-09-28 | 2022-11-02 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-09-28 | 2022-11-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-28 | 2022-11-02 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-11 | 2022-10-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-09 | 2022-09-28 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-08 | 2022-07-28 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-06-08 | 2022-07-28 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-15 | 2022-07-12 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-06-15 | 2022-07-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-12 | 2022-07-07 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-04-12 | 2022-07-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-12 | 2022-07-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-12 | 2022-07-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-12 | 2022-06-08 | Y |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-04-21 | 2022-05-17 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-04-21 | 2022-05-17 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-04-21 | 2022-05-17 | N |
| Use approved construction type or materials. | Fire Safety | 2022-04-21 | 2022-05-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-21 | 2022-05-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-21 | 2022-05-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-21 | 2022-05-17 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-04-21 | 2022-05-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-21 | 2022-05-17 | 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 | 2022-04-12 | 2022-05-13 | 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 | 2022-04-12 | 2022-05-13 | 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 | 2022-04-12 | 2022-05-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-04-12 | 2022-05-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-12 | 2022-05-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-22 | 2022-03-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-13 | 2022-03-10 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-10-18 | 2021-11-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-18 | 2021-11-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-18 | 2021-11-30 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-10-18 | 2021-11-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-10 | 2021-10-18 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-08-20 | 2021-10-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-13 | 2021-10-18 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-11 | 2021-06-18 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-05-25 | 2021-06-14 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-04-21 | 2021-05-19 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-03-30 | 2021-05-11 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-26 | 2019-07-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-26 | 2019-07-30 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2019-06-26 | 2019-07-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-26 | 2019-07-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-06-26 | 2019-07-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-12 | 2019-06-12 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2019-04-12 | 2019-06-12 | 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 | 2019-04-12 | 2019-06-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-12 | 2019-06-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-12 | 2019-06-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-04-12 | 2019-06-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-12 | 2019-06-12 | 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 | 2019-04-12 | 2019-06-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-04-12 | 2019-06-12 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2019-04-12 | 2019-06-12 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-04-12 | 2019-06-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-04-12 | 2019-06-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-04-12 | 2019-06-12 | 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 | 2019-04-12 | 2019-06-12 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-04-12 | 2019-06-12 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-04-12 | 2019-06-12 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2019-04-12 | 2019-06-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-12 | 2019-06-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-12 | 2019-06-12 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-04-12 | 2019-06-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-12 | 2019-06-12 | 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 | 2018-03-14 | 2018-07-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-03-14 | 2018-07-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-03-14 | 2018-07-03 | 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 | 2018-03-14 | 2018-07-03 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-03-14 | 2018-07-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-03-14 | 2018-07-03 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-03-14 | 2018-07-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-14 | 2018-07-03 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-03-28 | 2018-04-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-03-28 | 2018-04-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-03-28 | 2018-04-16 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2018-03-28 | 2018-04-16 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-03-28 | 2018-04-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-28 | 2018-04-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-03-28 | 2018-04-16 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-03-28 | 2018-04-16 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2018-03-28 | 2018-04-16 | N |
