Deficiency Records for Windsor Rehabilitation and Healthcare Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Windsor Rehabilitation and Healthcare 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? |
|---|---|---|---|---|
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-09-19 | 2023-10-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-09-19 | 2023-10-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-19 | 2023-10-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-19 | 2023-10-06 | N |
| Post nurse staffing information every day. | 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 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-10 | 2023-08-30 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-10 | 2023-08-30 | Y |
| 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 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | 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 |
| 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 | Y |
| 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 | Y |
| 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 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-08 | 2023-03-21 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-10-19 | 2022-11-15 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-06-15 | 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 | 2022-06-15 | 2022-08-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-15 | 2022-08-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-15 | 2022-08-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-06-15 | 2022-08-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-15 | 2022-08-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-15 | 2022-08-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-19 | 2022-06-16 | 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 | 2022-05-19 | 2022-06-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-05-19 | 2022-06-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-19 | 2022-06-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-19 | 2022-06-16 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-05 | 2021-05-24 | Y |
| Use approved construction type or materials. | Fire Safety | 2019-10-17 | 2020-01-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-10-17 | 2020-01-03 | 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 | 2019-10-17 | 2020-01-03 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2019-10-17 | 2020-01-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-17 | 2020-01-03 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2019-10-17 | 2020-01-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-17 | 2020-01-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-17 | 2020-01-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-10-17 | 2020-01-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-17 | 2020-01-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-11 | 2019-11-08 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2019-10-11 | 2019-11-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-11 | 2019-11-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-11 | 2019-11-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-11 | 2019-11-08 | 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 | 2019-10-11 | 2019-11-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-10-11 | 2019-11-08 | N |
