Deficiency Records for Windcrest Nursing and Rehabilitation
Updated as of January 01, 2019
This is not the most recent data for Windcrest Nursing and Rehabilitation. For the most recent information, click here.
A list of the most recent deficiencies for Windcrest Nursing and Rehabilitation. 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 | 2018-08-15 | 2018-08-29 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-08-15 | 2018-08-16 | 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 | 2018-05-25 | 2018-06-06 | Y |
| 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 | 2018-02-16 | 2018-04-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-02-16 | 2018-04-14 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-02-16 | 2018-04-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-02-16 | 2018-04-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-02-16 | 2018-04-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-02-16 | 2018-03-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-02-16 | 2018-03-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-02-16 | 2018-03-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-02-16 | 2018-03-13 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-02-16 | 2018-03-13 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-02-16 | 2018-03-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-02-16 | 2018-03-13 | 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 | 2018-02-16 | 2018-03-13 | N |
| Provide appropriate foot care. | Health | 2018-02-16 | 2018-03-13 | 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 | 2018-02-16 | 2018-03-13 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2018-02-16 | 2018-03-13 | 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 | 2018-02-16 | 2018-03-13 | N |
| Provide or obtain dental services for each resident. | Health | 2018-02-16 | 2018-03-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-02-16 | 2018-03-13 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-02-16 | 2018-03-13 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-02-16 | 2018-03-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-02-16 | 2018-03-12 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-02-16 | 2018-03-09 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-02-27 | 2018-02-28 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-02-27 | 2018-02-28 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-02-27 | 2018-02-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-02-27 | 2018-02-28 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-02-16 | 2018-02-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-02-16 | 2018-02-20 | 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 | 2018-02-16 | 2018-02-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-02-16 | 2018-02-19 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-02-16 | 2018-02-19 | N |
| 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 | 2017-09-15 | 2017-10-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-09-15 | 2017-10-02 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-12-15 | 2017-01-10 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2016-12-15 | 2017-01-10 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-12-15 | 2017-01-10 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2016-12-15 | 2017-01-10 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-12-15 | 2017-01-10 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2016-12-15 | 2017-01-10 | N |
| Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. | Health | 2016-12-15 | 2017-01-10 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-12-15 | 2017-01-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2016-12-14 | 2017-01-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2016-12-14 | 2016-12-15 | N |
| Provide food in a way that meets a resident's needs. | Health | 2015-11-20 | 2015-12-23 | N |
| Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. | Health | 2015-11-20 | 2015-12-23 | N |
| Quickly tell the resident's doctor the results of laboratory tests. | Health | 2015-11-20 | 2015-12-23 | N |
| Keep complete, dated laboratory records in the resident's file. | Health | 2015-11-20 | 2015-12-23 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2015-11-20 | 2015-12-20 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2015-11-20 | 2015-12-20 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2015-11-20 | 2015-12-20 | N |
| Posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2015-11-18 | 2015-12-18 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2015-11-20 | 2015-12-18 | N |
| Provide proper discharge planning and communication, of the resident's health status and summary of the resident's nursing home stay. | Health | 2015-11-20 | 2015-12-15 | N |
| Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. | Health | 2015-11-20 | 2015-12-15 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2015-11-20 | 2015-12-15 | N |
| Keep clinical record information safe. | Health | 2015-11-20 | 2015-12-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2015-11-20 | 2015-12-14 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2015-11-20 | 2015-12-10 | N |
| Properly protected cooking facilities. | Fire Safety | 2015-11-18 | 2015-11-26 | N |
| Dispose of garbage and refuse properly. | Health | 2015-11-20 | 2015-11-25 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2015-11-18 | 2015-11-24 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2015-11-20 | 2015-11-21 | N |
