Deficiency Records for Windsor Health and Rehabilitation Center, LLC
Updated as of April 01, 2024
A list of the most recent deficiencies for Windsor Health and Rehabilitation Center, LLC. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-25 | 2023-04-25 | 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 | 2022-07-11 | 2022-08-08 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-07-11 | 2022-08-08 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-07-11 | 2022-07-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-10 | 2022-05-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-10 | 2022-05-13 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-03-10 | 2022-05-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-10 | 2022-05-13 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-10 | 2022-05-13 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-03-10 | 2022-05-13 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-03-10 | 2022-05-13 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-03-10 | 2022-05-13 | Y |
| 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 | 2022-03-10 | 2022-05-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-10 | 2022-05-13 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-12-07 | 2022-02-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-07 | 2022-02-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-07 | 2022-02-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-12-07 | 2022-02-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-07 | 2022-02-17 | Y |
| 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 | 2021-12-03 | 2022-01-28 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-12-03 | 2022-01-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-03 | 2022-01-28 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-12-03 | 2022-01-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-12-03 | 2022-01-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-03 | 2022-01-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-02 | 2022-01-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-07 | 2021-09-08 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-07-11 | 2019-08-22 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-07-11 | 2019-08-22 | 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 | 2019-07-11 | 2019-08-22 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-07-11 | 2019-08-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-07-11 | 2019-08-20 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-07-11 | 2019-08-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-07-11 | 2019-08-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-07-11 | 2019-08-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-07-11 | 2019-08-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-11 | 2019-08-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-07-11 | 2019-08-20 | 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 | 2019-07-11 | 2019-08-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-11 | 2019-08-20 | N |
| Dispose of garbage and refuse properly. | Health | 2019-07-11 | 2019-08-20 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-07-11 | 2019-08-20 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-05-17 | 2018-07-17 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2018-05-17 | 2018-07-17 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-05-17 | 2018-07-17 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-05-17 | 2018-07-17 | 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 | 2018-05-17 | 2018-07-17 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-05-17 | 2018-07-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-05-17 | 2018-07-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-05-17 | 2018-07-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-05-17 | 2018-07-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-05-18 | 2018-06-29 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2018-05-18 | 2018-06-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-05-18 | 2018-06-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-18 | 2018-06-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-18 | 2018-06-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-18 | 2018-06-29 | N |
