Deficiency Records for Windemere Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Windemere Nursing 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? |
|---|---|---|---|---|
| Ensure each resident receives an accurate assessment. | Health | 2022-10-20 | 2022-12-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-20 | 2022-12-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-20 | 2022-11-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-20 | 2022-11-18 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-10-20 | 2022-11-11 | N |
| Provide activities to meet all resident's needs. | Health | 2022-10-20 | 2022-11-11 | 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 | 2022-10-20 | 2022-11-11 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-10-20 | 2022-11-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-10-20 | 2022-11-04 | 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 | 2022-10-20 | 2022-11-04 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-09-25 | 2019-11-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-09-25 | 2019-11-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-25 | 2019-11-19 | 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 | 2019-09-25 | 2019-11-19 | N |
