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Deficiency Records for Windsor Rehabilitation and Healthcare Center

View the most recent health deficiencies and inspection results for Windsor Rehabilitation and Healthcare Center. Stay informed about quality of care issues.

View the most recent health deficiencies and inspection results for Windsor Rehabilitation and Healthcare Center. Stay informed about quality of care issues.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2026-01-13 2026-02-04 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2026-01-13 2026-02-04 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2026-01-13 2026-02-04 N
Provide and implement an infection prevention and control program. Health 2026-01-13 2026-02-04 Y
Ensure that residents are free from significant medication errors. Health 2026-01-13 2026-02-04 Y
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2026-01-13 2026-02-03 N
Ensure that residents are fully informed and understand their health status, care and treatments. Health 2026-01-13 2026-02-03 N
Ensure residents have reasonable access to and privacy in their use of communication methods. Health 2026-01-13 2026-02-02 Y
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 2026-01-13 2026-02-02 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2026-01-13 2026-02-02 N
Ensure each resident receives an accurate assessment. Health 2026-01-13 2026-02-02 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2026-01-13 2026-02-02 Y
Protect each resident from the wrongful use of the resident's belongings or money. Health 2026-01-13 2026-02-02 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2025-11-14 2025-11-20 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2025-11-14 2025-11-20 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2025-05-28 2025-06-13 Y
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 2025-05-28 2025-06-13 Y
Provide and implement an infection prevention and control program. Health 2025-05-28 2025-06-13 Y
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Health 2025-05-28 2025-06-13 Y
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Health 2025-05-28 2025-06-13 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2025-05-06 2025-05-28 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2025-05-06 2025-05-28 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2025-04-10 2025-04-24 Y
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2024-10-15 2024-11-26 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-10-15 2024-11-26 N
Ensure that residents are free from significant medication errors. Health 2024-11-26 2024-11-14 Y
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2024-10-15 2024-11-14 Y
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2024-10-15 2024-11-14 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-10-15 2024-11-14 Y
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2024-10-15 2024-11-14 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 2024-10-15 2024-11-14 N
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 2024-10-15 2024-11-14 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 2024-10-15 2024-11-14 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-10-15 2024-11-14 N
Ensure each resident receives an accurate assessment. Health 2024-10-15 2024-11-14 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-10-15 2024-11-14 N
Provide timely, quality laboratory services/tests to meet the needs of residents. Health 2024-11-26 2024-11-14 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-10-15 2024-11-14 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-10-15 2024-11-14 Y
Provide medically-related social services to help each resident achieve the highest possible quality of life. Health 2024-10-15 2024-11-14 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2024-08-06 2024-08-16 Y
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. Fire Safety 2023-08-10 2023-10-06 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2023-08-10 2023-10-06 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-08-10 2023-10-06 N
Have proper medical gas storage and administration areas. Fire Safety 2023-08-10 2023-10-06 N
Provide medically-related social services to help each resident achieve the highest possible quality of life. Health 2023-08-10 2023-08-30 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2023-08-10 2023-08-30 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 2023-08-10 2023-08-30 N
Provide and implement an infection prevention and control program. Health 2023-08-10 2023-08-30 Y
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2023-08-10 2023-08-30 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-08-10 2023-08-30 Y
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2023-08-10 2023-08-30 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-08-10 2023-08-30 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-08-10 2023-08-30 Y
Ensure that residents are free from significant medication errors. Health 2023-08-10 2023-08-30 Y
Post nurse staffing information every day. Health 2023-08-10 2023-08-30 N
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 2023-08-10 2023-08-30 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2023-08-10 2023-08-30 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-08-10 2023-08-30 N
Use approved construction type or materials. Fire Safety 2022-05-19 2022-08-31 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 2022-05-19 2022-08-31 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2022-05-19 2022-08-31 N
Install corridor and hallway doors that block smoke. Fire Safety 2022-05-19 2022-08-31 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2022-05-19 2022-08-31 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2022-05-19 2022-08-31 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-05-19 2022-08-31 N

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