Deficiency Records for Windsor Place Senior Living Campus
Updated as of January 01, 2021
This is not the most recent data for Windsor Place Senior Living Campus. For the most recent information, click here.
A list of the most recent deficiencies for Windsor Place Senior Living Campus. 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? |
---|---|---|---|---|
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2020-07-13 | 2020-07-31 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-02-20 | 2019-04-07 | N |
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-02-20 | 2019-04-07 | N |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-02-20 | 2019-04-07 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-02-20 | 2019-04-07 | N |
Implement a program that monitors antibiotic use. | Health | 2019-02-20 | 2019-04-07 | N |
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-02-20 | 2019-04-07 | Y |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-02-20 | 2019-04-07 | Y |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-02-20 | 2019-04-07 | Y |
Provide properly protected cooking facilities. | Fire Safety | 2019-02-25 | 2019-03-27 | N |
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2019-02-25 | 2019-03-27 | N |
Provide a written emergency evacuation plan. | Fire Safety | 2019-02-25 | 2019-03-27 | N |
Be properly staffed | Fire Safety | 2019-02-25 | 2019-03-27 | N |
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-02-25 | 2019-03-27 | N |
Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-11-15 | 2017-12-06 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-11-15 | 2017-12-06 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-11-15 | 2017-12-06 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2017-11-15 | 2017-12-06 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-11-15 | 2017-12-06 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-11-15 | 2017-12-06 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-11-15 | 2017-12-06 | N |
Give residents a notice of rights, rules, services and charges. | Health | 2017-11-09 | 2017-12-01 | N |
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-11-09 | 2017-12-01 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-11-09 | 2017-12-01 | N |
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-11-09 | 2017-12-01 | N |
Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2016-10-21 | 2016-11-21 | N |
Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2016-10-21 | 2016-11-21 | N |
Properly installed electrical wiring and equipment. | Fire Safety | 2016-10-21 | 2016-11-21 | N |
Give residents a notice of rights, rules, services and charges. | Health | 2016-10-20 | 2016-11-20 | N |
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-10-20 | 2016-11-20 | N |
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-10-20 | 2016-11-20 | N |
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-10-20 | 2016-11-20 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2016-10-20 | 2016-11-20 | N |
Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. | Health | 2016-10-20 | 2016-11-20 | N |
Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2016-10-20 | 2016-11-20 | N |
Ensure residents maintain acceptable nutritional status. | Health | 2016-10-20 | 2016-11-20 | N |
1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours of dinner; and 3) offer a snack at bedtime each day. | Health | 2016-10-20 | 2016-11-20 | N |
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2016-10-20 | 2016-11-20 | N |
Weekly inspections and monthly testing of generators. | Fire Safety | 2016-10-21 | 2016-11-15 | N |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2016-10-20 | 2016-11-03 | N |
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-10-26 | Not Fixed | 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 | 2020-10-26 | Not Fixed | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-10-26 | Not Fixed | Y |
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2020-10-26 | Not Fixed | Y |
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2020-10-26 | Not Fixed | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-10-26 | Not Fixed | Y |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-10-26 | Not Fixed | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-10-26 | Not Fixed | Y |
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2020-10-26 | Not Fixed | 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 | 2020-10-26 | Not Fixed | Y |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2020-10-26 | Not Fixed | Y |
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2020-10-26 | Not Fixed | Y |
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2020-10-26 | Not Fixed | Y |
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 | 2020-10-26 | Not Fixed | Y |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-10-26 | Not Fixed | Y |
Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2020-10-26 | Not Fixed | Y |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-26 | Not Fixed | Y |
Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2020-10-26 | Not Fixed | Y |