Deficiency Records for Windsor Health and Rehabilitation Center
Updated as of February 01, 2019
This is not the most recent data for Windsor Health and Rehabilitation Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 | 2018-08-22 | 2018-09-14 | 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 | 2018-08-22 | 2018-09-14 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install | Health | 2018-08-22 | 2018-09-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-05-10 | 2018-06-15 | Y |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2018-05-10 | 2018-06-15 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-05-10 | 2018-06-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-10 | 2018-06-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-10 | 2018-06-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-05-10 | 2018-06-15 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-05-10 | 2018-06-15 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-05-10 | 2018-06-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2018-05-10 | 2018-06-15 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2018-05-10 | 2018-06-15 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2018-05-10 | 2018-06-15 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2017-10-10 | 2017-11-29 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-10-10 | 2017-11-29 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-10-10 | 2017-11-29 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2017-10-10 | 2017-11-29 | Y |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2017-10-10 | 2017-11-29 | Y |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-10-10 | 2017-11-29 | Y |
| Assess in a timely manner the resident when the resident enters the nursing home. | Health | 2017-10-10 | 2017-11-29 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2017-10-10 | 2017-11-29 | Y |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-10-10 | 2017-11-29 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-10-10 | 2017-11-29 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-10-10 | 2017-11-29 | Y |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-10-10 | 2017-11-29 | Y |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-10-10 | 2017-11-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-10-10 | 2017-11-29 | Y |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-10-10 | 2017-11-29 | Y |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-10-10 | 2017-11-29 | Y |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2017-10-10 | 2017-11-29 | Y |
| Use a registered nurse at least 8 hours a day, 7 days a week. | Health | 2017-10-10 | 2017-11-29 | Y |
| Post nurse staffing information/data on a daily basis. | Health | 2017-10-10 | 2017-11-29 | Y |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-10-10 | 2017-11-29 | Y |
| Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. | Health | 2017-10-10 | 2017-11-29 | Y |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-10-10 | 2017-11-29 | Y |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-10-10 | 2017-11-29 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-10-10 | 2017-11-29 | Y |
| Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. | Health | 2017-10-10 | 2017-11-29 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-10-10 | 2017-11-29 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-10-10 | 2017-11-29 | Y |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2017-03-15 | 2017-04-14 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2017-03-15 | 2017-04-14 | Y |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-03-15 | 2017-04-14 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-03-15 | 2017-04-14 | Y |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-03-15 | 2017-04-14 | Y |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-03-15 | 2017-04-14 | Y |
| Quickly tell the resident's doctor the results of laboratory tests. | Health | 2017-03-15 | 2017-04-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2016-12-22 | 2017-01-19 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2016-12-22 | 2017-01-19 | Y |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-12-22 | 2017-01-19 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-12-22 | 2017-01-19 | Y |
| Ensure residents maintain acceptable nutritional status. | Health | 2016-12-22 | 2017-01-19 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-12-22 | 2017-01-19 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-10-04 | 2016-11-05 | Y |
| Approved construction type or materials. | Fire Safety | 2016-08-04 | 2016-09-09 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2016-08-02 | 2016-09-09 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-08-02 | 2016-09-09 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-08-02 | 2016-09-09 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2016-08-02 | 2016-09-09 | Y |
| Assess in a timely manner the resident when the resident enters the nursing home. | Health | 2016-08-02 | 2016-09-09 | Y |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2016-08-02 | 2016-09-09 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-08-02 | 2016-09-09 | Y |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-08-02 | 2016-09-09 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-08-02 | 2016-09-09 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-08-02 | 2016-09-09 | Y |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2016-08-02 | 2016-09-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-08-02 | 2016-09-09 | Y |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-08-02 | 2016-09-09 | Y |
| Use a registered nurse at least 8 hours a day, 7 days a week. | Health | 2016-08-02 | 2016-09-09 | Y |
| Post nurse staffing information/data on a daily basis. | Health | 2016-08-02 | 2016-09-09 | Y |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2016-08-02 | 2016-09-09 | Y |
| Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . | Health | 2016-08-02 | 2016-09-09 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2016-03-31 | 2016-04-23 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2016-03-31 | 2016-04-23 | Y |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-03-31 | 2016-04-23 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-03-31 | 2016-04-23 | Y |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2016-03-31 | 2016-04-23 | Y |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2016-03-31 | 2016-04-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-03-31 | 2016-04-23 | Y |
| Ensure residents maintain acceptable nutritional status. | Health | 2016-03-31 | 2016-04-23 | Y |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2016-03-31 | 2016-04-23 | Y |
| Smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2015-06-15 | 2015-07-15 | N |
| Exits that are accessible at all times. | Fire Safety | 2015-06-15 | 2015-07-15 | N |
| Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2015-06-15 | 2015-07-15 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2015-06-12 | 2015-07-15 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2015-06-12 | 2015-07-15 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2015-06-12 | 2015-07-15 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2015-06-12 | 2015-07-15 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2015-06-12 | 2015-07-15 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2015-06-12 | 2015-07-15 | N |
