Deficiency Records for Windsor Place Senior Living Campus
Updated as of March 01, 2022
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? |
|---|---|---|---|---|
| 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 medication error rates are not 5 percent or greater. | Health | 2020-10-26 | 2020-12-28 | 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 | 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 | 2020-12-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-10-26 | 2020-12-28 | 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 | 2020-12-28 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2020-10-26 | 2020-12-28 | 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 | 2020-12-28 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-10-26 | 2020-12-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-10-26 | 2020-12-28 | 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 | 2020-12-28 | 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 | 2020-12-28 | 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 | 2020-12-28 | 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 | 2020-12-28 | Y |
| 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 | 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 | 2020-12-28 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-10-26 | 2020-12-28 | 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 | 2020-12-28 | 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 | 2020-12-28 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2020-10-26 | 2020-12-28 | Y |
| 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 |
| 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 |
| 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 | N |
| 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 |
| 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 | 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 |
| Ensure services provided by the nursing facility meet professional standards of quality. | 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 |
| 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 |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 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 |
