Deficiency Records for Windsor Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Windsor Health and Rehabilitation 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 and implement an infection prevention and control program. | Health | 2023-11-16 | 2023-12-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-02 | 2023-06-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-02 | 2023-06-21 | 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 | 2023-06-02 | 2023-06-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-08 | 2023-06-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-05 | 2023-01-12 | Y |
| 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 | 2022-12-05 | 2023-01-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-05 | 2023-01-12 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-05 | 2023-01-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-05 | 2023-01-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-05 | 2023-01-12 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-12-05 | 2023-01-12 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-12-05 | 2023-01-12 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-12-05 | 2023-01-12 | 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 | 2023-01-12 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-12-05 | 2023-01-12 | Y |
| 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 | 2022-12-05 | 2023-01-12 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-12-05 | 2023-01-12 | 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 | 2022-12-05 | 2023-01-12 | Y |
| Provide or obtain dental services for each resident. | Health | 2022-12-05 | 2023-01-12 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-12-05 | 2023-01-12 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-12-05 | 2023-01-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-05 | 2023-01-12 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-30 | 2023-01-10 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-11-30 | 2023-01-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-30 | 2023-01-10 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-01-07 | 2022-02-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-01 | 2021-10-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-01 | 2021-10-12 | 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 | 2021-09-01 | 2021-10-12 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-09-01 | 2021-10-12 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-03-15 | 2021-04-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-01 | 2020-08-01 | Y |
