Deficiency Records for Windcrest Nursing and Rehabilitation
Updated as of July 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 enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-04-18 | 2019-05-09 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-02-08 | 2019-03-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-02-08 | 2019-03-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-08 | 2019-03-15 | 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 | 2019-02-08 | 2019-03-15 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-02-08 | 2019-03-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-02-08 | 2019-03-11 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-02-08 | 2019-03-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-06 | 2019-03-06 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-02-08 | 2019-02-28 | 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 | 2019-02-08 | 2019-02-28 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2019-02-08 | 2019-02-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-02-08 | 2019-02-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-08 | 2019-02-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-08 | 2019-02-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-02-08 | 2019-02-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-02-08 | 2019-02-28 | 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 | 2019-02-08 | 2019-02-28 | N |
| Provide or obtain dental services for each resident. | Health | 2019-02-08 | 2019-02-28 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-02-08 | 2019-02-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-08 | 2019-02-28 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-02-08 | 2019-02-28 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-02-08 | 2019-02-15 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-02-08 | 2019-02-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-02-08 | 2019-02-15 | 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 | 2019-02-08 | 2019-02-15 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2019-02-08 | 2019-02-15 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-02-08 | 2019-02-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-06 | 2019-02-12 | 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 | 2019-02-08 | 2019-02-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-02-08 | 2019-02-09 | 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 | 2019-02-08 | 2019-02-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-02-08 | 2019-02-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-08 | 2019-02-09 | N |
| 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 |
| Provide and implement an infection prevention and control program. | Health | 2018-01-18 | 2018-02-09 | 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 | 2017-09-15 | 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 |
