Deficiency Records for Windsor Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Windsor Health 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? |
|---|---|---|---|---|
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-08-11 | 2022-09-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-11 | 2022-09-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-11 | 2022-09-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-11 | 2022-09-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-11 | 2022-09-20 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Develop a communication plan. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Establish methods for sharing information. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Provide hallway or ground-level exits in all residents' rooms. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-04-08 | 2022-02-18 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-04-08 | 2022-02-18 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2022-04-08 | 2022-02-18 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-02-11 | 2021-03-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-02-11 | 2021-03-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-02-11 | 2021-03-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-02-11 | 2021-03-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-02-11 | 2021-03-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-02-11 | 2021-03-16 | N |
| 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 | 2021-02-11 | 2021-03-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-02-11 | 2021-03-16 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-07-18 | 2019-09-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-18 | 2019-09-09 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-07-18 | 2019-09-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-18 | 2019-09-09 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2019-07-15 | 2019-09-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-15 | 2019-09-09 | N |
