A list of the most recent deficiencies for Windsor Nursing and Retirement Home. 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 organize and participate in resident/family groups in the facility. | Health | 2023-10-12 | 2023-11-22 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-10-12 | 2023-11-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-10-12 | 2023-11-22 | 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 | 2023-10-12 | 2023-11-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-12 | 2023-11-22 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-10-12 | 2023-11-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-12 | 2023-11-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-12 | 2023-11-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-10-12 | 2023-11-22 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-10-12 | 2023-11-22 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-10-30 | 2023-11-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-30 | 2023-11-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-30 | 2023-11-13 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-06-01 | 2023-06-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-13 | 2023-03-22 | N |
| Perform COVID19 testing on residents and staff. | Health | 2023-03-13 | 2023-03-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-04 | 2022-10-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-04 | 2022-10-03 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-04-14 | 2021-06-15 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-04-14 | 2021-06-15 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-04-14 | 2021-06-11 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-04-14 | 2021-06-01 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-04-14 | 2021-06-01 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-04-14 | 2021-06-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-14 | 2021-06-01 | N |
| Respond appropriately to all alleged violations. | Health | 2021-04-14 | 2021-06-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-04-14 | 2021-06-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-14 | 2021-06-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-14 | 2021-06-01 | N |
| Provide appropriate foot care. | Health | 2021-04-14 | 2021-06-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-14 | 2021-06-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-04-14 | 2021-06-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-04-14 | 2021-06-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-14 | 2021-06-01 | 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 | 2021-04-14 | 2021-06-01 | 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 | 2021-04-14 | 2021-06-01 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-04-14 | 2021-06-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-14 | 2021-06-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-04-14 | 2021-06-01 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-04-21 | 2021-05-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-04-21 | 2021-05-31 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-04-21 | 2021-05-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-21 | 2021-05-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-04-21 | 2021-05-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-21 | 2021-05-31 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-09-25 | 2019-11-09 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-09-25 | 2019-11-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-09-25 | 2019-11-09 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-09-25 | 2019-11-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-25 | 2019-11-09 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-09-25 | 2019-10-31 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2019-08-08 | 2019-10-07 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-08-08 | 2019-10-07 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2019-08-08 | 2019-10-07 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-08-08 | 2019-10-07 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-08-08 | 2019-10-07 | 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 | 2019-08-08 | 2019-10-07 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-08-08 | 2019-10-07 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-08-08 | 2019-10-07 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-08-08 | 2019-10-07 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-08-08 | 2019-10-07 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-08-08 | 2019-10-07 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-08-08 | 2019-10-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-08 | 2019-10-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-08 | 2019-10-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-08 | 2019-10-07 | N |
| Provide appropriate foot care. | Health | 2019-08-08 | 2019-10-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-08 | 2019-10-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-08-08 | 2019-10-07 | 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 | 2019-08-08 | 2019-10-07 | 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 | 2019-08-08 | 2019-10-07 | 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 | 2019-08-08 | 2019-10-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-08 | 2019-10-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-08 | 2019-10-07 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-08-08 | 2019-10-07 | N |
