A list of the most recent deficiencies for Windsor Lane 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? |
|---|---|---|---|---|
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-02-27 | 2024-03-05 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-24 | 2023-09-15 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-24 | 2023-09-15 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-01-19 | 2023-01-23 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-12-05 | 2023-01-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-12-05 | 2023-01-23 | Y |
| Provide appropriate foot care. | Health | 2022-12-05 | 2023-01-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-05 | 2023-01-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-27 | 2022-02-24 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-11-24 | 2021-12-22 | N |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2021-11-24 | 2021-12-22 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-11-24 | 2021-12-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-24 | 2021-12-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-24 | 2021-12-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-24 | 2021-12-22 | 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 | 2021-11-24 | 2021-12-22 | 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 | 2021-11-24 | 2021-12-22 | 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 | 2021-11-24 | 2021-12-22 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-11-24 | 2021-12-22 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-23 | 2021-12-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-23 | 2021-12-22 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-11-23 | 2021-12-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-08-31 | 2021-09-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-31 | 2021-09-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-01 | 2021-07-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-10 | 2021-05-21 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-05-10 | 2021-05-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-10 | 2021-05-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-10 | 2021-05-21 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-04-15 | 2021-05-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-15 | 2021-05-21 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-22 | 2019-06-25 | 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 | 2019-05-22 | 2019-06-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-22 | 2019-06-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-22 | 2019-06-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-22 | 2019-06-25 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-05-22 | 2019-06-25 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-05-22 | 2019-06-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-22 | 2019-06-25 | 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 | 2019-05-21 | 2019-06-25 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2019-05-21 | 2019-06-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-05-17 | 2018-06-29 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2018-05-17 | 2018-06-29 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-05-17 | 2018-06-29 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-05-17 | 2018-06-29 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-05-17 | 2018-06-29 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-05-17 | 2018-06-29 | N |
| Respond appropriately to all alleged violations. | Health | 2018-05-17 | 2018-06-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-05-17 | 2018-06-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-05-17 | 2018-06-29 | 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 | 2018-05-17 | 2018-06-29 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-05-17 | 2018-06-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-17 | 2018-06-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-05-15 | 2018-06-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-05-15 | 2018-06-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-05-15 | 2018-06-29 | N |
