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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-29 | 2023-07-30 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-06-29 | 2023-07-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-29 | 2023-07-30 | N |
| Respond appropriately to all alleged violations. | Health | 2023-06-29 | 2023-07-30 | 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 | 2023-06-29 | 2023-07-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-29 | 2023-07-30 | N |
| Post nurse staffing information every day. | Health | 2023-06-29 | 2023-07-30 | 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 | 2023-06-29 | 2023-07-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-29 | 2023-07-30 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-06-29 | 2023-07-30 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-06-29 | 2023-07-30 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-06-29 | 2023-07-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-29 | 2023-07-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-29 | 2023-07-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-29 | 2023-07-29 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-06-29 | 2023-07-29 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-06-29 | 2023-07-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-29 | 2023-07-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-29 | 2023-07-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-29 | 2023-07-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-06-29 | 2023-07-10 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-06-29 | 2023-07-10 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-06-29 | 2023-07-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-06-29 | 2023-07-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-29 | 2023-03-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-29 | 2023-01-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-29 | 2023-01-30 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-12-29 | 2023-01-30 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-12-29 | 2023-01-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-29 | 2023-01-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-07 | 2022-06-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-07 | 2022-06-21 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-04-07 | 2022-05-07 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-04-07 | 2022-05-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-04-07 | 2022-05-07 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-04-07 | 2022-05-07 | 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 | 2022-04-07 | 2022-05-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-07 | 2022-05-07 | N |
| 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 | 2022-04-07 | 2022-05-07 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-04-07 | 2022-05-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-07 | 2022-05-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-07 | 2022-05-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-07 | 2022-05-07 | Y |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-04-04 | 2022-04-22 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-04-04 | 2022-04-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-04 | 2022-04-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-04 | 2022-04-22 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-04-04 | 2022-04-19 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-04-04 | 2022-04-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-04 | 2022-04-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-04 | 2022-04-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-04-04 | 2022-04-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-04-04 | 2022-04-11 | 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 | 2022-04-04 | 2022-04-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-04-04 | 2022-04-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-04 | 2022-04-05 | 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 | 2020-12-28 | 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 | 2020-10-26 | 2020-12-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-10-26 | 2020-12-28 | N |
| 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 | 2020-12-28 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2020-10-26 | 2020-12-28 | N |
| 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 | 2020-12-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-10-26 | 2020-12-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-10-26 | 2020-12-28 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2020-10-26 | 2020-12-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-10-26 | 2020-12-28 | N |
| 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 | 2020-12-28 | 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 | 2020-10-26 | 2020-12-28 | N |
| 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 | 2020-12-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-10-26 | 2020-12-28 | N |
| 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 | 2020-12-28 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2020-10-26 | 2020-12-28 | N |
| 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 | 2020-12-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-10-26 | 2020-12-28 | N |
| 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 | 2020-12-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-26 | 2020-12-28 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2020-10-26 | 2020-12-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-10-19 | 2020-11-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-10-19 | 2020-11-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-10-19 | 2020-10-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-10-19 | 2020-10-28 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2020-10-19 | 2020-10-19 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-01-25 | 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 | 2024-01-25 | Not Fixed | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-01-25 | Not Fixed | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-25 | 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 | 2024-01-25 | 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 | 2024-01-25 | Not Fixed | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-01-10 | Not Fixed | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-01-10 | 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 | 2024-01-10 | 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 | 2024-01-10 | 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 | 2024-01-10 | Not Fixed | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-10 | Not Fixed | Y |
| Have policies on smoking. | Health | 2024-01-10 | Not Fixed | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-30 | Not Fixed | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-30 | Not Fixed | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-30 | Not Fixed | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-25 | Not Fixed | Y |
