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Deficiency Records for Windsor Hills Nursing Center

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

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

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Have simulated fire drills held at unexpected times. Fire Safety 2025-09-11 2026-01-16 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2025-09-11 2026-01-16 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2025-09-11 2026-01-16 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2025-09-11 2026-01-16 N
Make sure that a working call system is available in each resident's bathroom and bathing area. Health 2025-09-11 2025-10-03 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2025-09-11 2025-10-03 Y
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Health 2025-09-11 2025-10-03 N
Provide and implement an infection prevention and control program. Health 2025-09-11 2025-10-03 N
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Health 2025-09-11 2025-10-03 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2025-09-11 2025-10-03 N
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Health 2025-09-11 2025-10-03 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 2025-09-11 2025-10-03 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 2025-05-09 2025-05-13 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2025-05-09 2025-05-06 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-09-27 2024-10-29 Y
Ensure each resident receives an accurate assessment. Health 2024-09-27 2024-10-29 Y
Provide and implement an infection prevention and control program. Health 2024-09-27 2024-10-29 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 2024-09-27 2024-10-29 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 2024-09-27 2024-10-29 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 2024-09-27 2024-10-29 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-09-27 2024-10-29 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 2024-09-27 2024-10-29 Y
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2024-09-27 2024-10-29 Y
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 2024-09-27 2024-10-29 Y
Provide enough food/fluids to maintain a resident's health. Health 2024-09-27 2024-10-29 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2024-07-26 2024-08-01 Y
Provide medically-related social services to help each resident achieve the highest possible quality of life. Health 2024-07-26 2024-08-01 Y
Have restrictions on the use of portable space heaters. Fire Safety 2023-08-09 2024-01-19 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2023-08-09 2024-01-19 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 2023-08-09 2024-01-19 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2023-08-09 2023-08-25 N
Assess the resident when there is a significant change in condition Health 2023-08-09 2023-08-25 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-08-09 2023-08-25 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-08-09 2023-08-25 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2023-08-09 2023-08-25 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-07-25 2023-08-02 Y
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2023-07-25 2023-08-02 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-07-25 2023-08-02 Y

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