A list of the most recent deficiencies for Windsor Hills Nursing 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? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-01-18 | 2024-01-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-01-18 | 2024-01-19 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-01-18 | 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 |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-18 | 2023-01-13 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-17 | 2022-09-26 | 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 | 2022-08-23 | 2022-09-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-23 | 2022-09-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-08-23 | 2022-09-23 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-23 | 2022-09-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-23 | 2022-09-23 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-08-23 | 2022-09-23 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-08-17 | 2022-09-23 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-08-17 | 2022-09-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-17 | 2022-09-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-17 | 2022-09-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-17 | 2022-09-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-08-17 | 2022-09-23 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-05-13 | 2021-06-15 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-05-13 | 2021-06-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-13 | 2021-06-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-05-13 | 2021-06-15 | Y |
| 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 | 2019-04-01 | 2019-05-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-01 | 2019-05-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-01 | 2019-04-25 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2019-04-01 | 2019-04-25 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-04-01 | 2019-04-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-04-01 | 2019-04-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-04-01 | 2019-04-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-04-01 | 2019-04-25 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-04-01 | 2019-04-25 | N |
| Post nurse staffing information every day. | Health | 2019-04-01 | 2019-04-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-01 | 2019-04-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-01 | 2019-04-25 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-04-01 | 2019-04-25 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-03-26 | 2019-04-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-03-26 | 2019-04-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-03-26 | 2019-04-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-03-26 | 2019-04-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-03-26 | 2019-04-25 | N |
