Deficiency Records for Windemere Park Health and Rehab Center
Updated as of August 01, 2021
This is not the most recent data for Windemere Park Health and Rehab Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2020-10-09 | 2020-11-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-07-08 | 2020-08-13 | Y |
| 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 |
| 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 |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-09-25 | 2019-10-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-09-04 | 2019-09-30 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-12-12 | 2019-01-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-12-12 | 2019-01-15 | 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 | 2018-12-12 | 2019-01-15 | 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 | 2018-12-12 | 2019-01-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-12-12 | 2019-01-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-12 | 2019-01-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-12-12 | 2019-01-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-12 | 2019-01-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-12-12 | 2019-01-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-12-12 | 2019-01-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-12-12 | 2019-01-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-12-12 | 2019-01-15 | 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 | 2018-12-13 | 2019-01-15 | 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 | 2018-12-13 | 2019-01-15 | 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 | 2018-12-13 | 2019-01-15 | 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 | 2018-12-13 | 2019-01-15 | N |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2018-12-13 | 2019-01-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-13 | 2019-01-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-09-14 | 2018-10-02 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2017-10-12 | 2017-11-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-10-12 | 2017-11-10 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2017-10-12 | 2017-11-10 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2017-10-12 | 2017-11-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-10-12 | 2017-11-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-10-12 | 2017-11-10 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-10-11 | 2017-11-10 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-10-11 | 2017-11-10 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2017-10-11 | 2017-11-10 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2017-10-11 | 2017-11-10 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-10-11 | 2017-11-10 | N |
| 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. | Health | 2017-10-11 | 2017-11-10 | N |
