Deficiency Records for Windemere Park Health and Rehab Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Windemere Park Health and Rehab 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-11 | 2023-02-20 | 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 | 2023-01-11 | 2023-02-20 | 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 | 2023-01-11 | 2023-02-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-11 | 2023-02-20 | 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 | 2023-01-11 | 2023-02-20 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-01-11 | 2023-02-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-01-11 | 2023-02-20 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-01-11 | 2023-02-20 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-01-11 | 2023-02-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-11 | 2023-02-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-11 | 2023-02-20 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-01-18 | 2023-02-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-01-18 | 2023-02-20 | N |
| Meet other general requirements. | Fire Safety | 2023-01-18 | 2023-02-20 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-01-18 | 2023-02-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-18 | 2023-02-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-18 | 2023-02-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-18 | 2023-02-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-01-18 | 2023-02-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-18 | 2023-02-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-18 | 2023-02-20 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-01-18 | 2023-02-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-18 | 2023-02-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-18 | 2023-02-20 | 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 | 2022-09-29 | 2022-11-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-29 | 2022-11-08 | Y |
| Report COVID19 data to residents and families. | Health | 2022-06-01 | 2022-06-21 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-06-01 | 2022-06-21 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-09-15 | 2021-10-13 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-09-15 | 2021-10-13 | 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 | 2021-09-15 | 2021-10-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-15 | 2021-10-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-15 | 2021-10-13 | 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 | 2021-09-15 | 2021-10-13 | N |
| Dispose of garbage and refuse properly. | Health | 2021-09-15 | 2021-10-13 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-09-15 | 2021-10-13 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-09-15 | 2021-10-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-09-15 | 2021-10-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-09-15 | 2021-10-13 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-09-15 | 2021-10-13 | 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 | 2021-09-15 | 2021-10-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-09-15 | 2021-10-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-15 | 2021-10-13 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-09-15 | 2021-10-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-15 | 2021-10-13 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-09-15 | 2021-10-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-09-15 | 2021-10-13 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-09-15 | 2021-10-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-15 | 2021-10-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-09-15 | 2021-10-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-09-15 | 2021-10-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-15 | 2021-10-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-09-15 | 2021-10-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-09-24 | 2020-02-03 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-09-24 | 2020-01-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-24 | 2020-01-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-24 | 2020-01-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-24 | 2020-01-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-09-24 | 2020-01-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-24 | 2020-01-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-24 | 2020-01-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-09-24 | 2020-01-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-24 | 2020-01-20 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-09-24 | 2019-11-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-09-24 | 2019-11-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-24 | 2019-11-15 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-09-25 | 2019-10-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-25 | 2019-10-31 | N |
| Provide activities to meet all resident's needs. | Health | 2019-09-25 | 2019-10-31 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-09-25 | 2019-10-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-25 | 2019-10-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-25 | 2019-10-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-09-25 | 2019-10-31 | N |
