Deficiency Records for Windsor Health and Rehabilitation Center, LLC
Updated as of May 01, 2024
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Deficiency Records for Windsor Health and Rehabilitation Center, LLC
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.
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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-03-12 | 2024-03-15 | 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 | 2024-03-12 | 2024-03-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-12 | 2024-03-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-03-12 | 2024-03-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-12 | 2024-03-15 | N |
| Respond appropriately to all alleged violations. | Health | 2024-03-12 | 2024-03-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-03-12 | 2024-03-15 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-03-12 | 2024-03-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-12 | 2024-03-15 | 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 | 2024-03-12 | 2024-03-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-12 | 2024-03-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-12 | 2024-03-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-12 | 2024-03-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-12 | 2024-03-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-12 | 2024-03-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-03-12 | 2024-03-15 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-03-12 | 2024-03-15 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-03-12 | 2024-03-15 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2024-03-12 | 2024-03-15 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-03-12 | 2024-03-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-12 | 2024-03-15 | N |
| Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor. | Health | 2024-03-12 | 2024-03-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-12 | 2024-03-15 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2024-03-12 | 2024-03-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-12 | 2024-03-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-27 | 2024-03-14 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-02-27 | 2024-03-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-27 | 2024-02-28 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-02-27 | 2024-02-27 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-02-27 | 2024-02-27 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-02-27 | 2024-02-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-02-27 | 2024-02-27 | 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 | 2024-02-27 | 2024-02-27 | 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 | 2024-02-27 | 2024-02-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-02-27 | 2024-02-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-27 | 2024-02-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-02-27 | 2024-02-27 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-02-27 | 2024-02-27 | 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 | 2024-02-27 | 2024-02-27 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-02-27 | 2024-02-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-02-27 | 2024-02-27 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-02-27 | 2024-02-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-27 | 2024-02-27 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2024-02-27 | 2024-02-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-25 | 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 |
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