A list of the most recent deficiencies for Consulate Health Care of Windsor. 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? |
|---|---|---|---|---|
| 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 | 2021-04-14 | 2021-06-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-04-14 | 2021-06-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-04-14 | 2021-06-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-14 | 2021-06-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-14 | 2021-06-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-04-14 | 2021-06-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-04-14 | 2021-06-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-04-14 | 2021-06-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-03-26 | 2021-05-07 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2021-03-26 | 2021-05-07 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2021-03-26 | 2021-05-07 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-03-26 | 2021-05-07 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-03-26 | 2021-05-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-03-26 | 2021-05-07 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-03-26 | 2021-05-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-03-26 | 2021-05-07 | 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 | 2021-03-26 | 2021-05-07 | N |
| 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 | 2021-03-26 | 2021-05-07 | 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 | 2021-03-26 | 2021-05-07 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-03-26 | 2021-05-07 | N |
| Keep complete, dated laboratory records in the resident's record. | Health | 2021-03-26 | 2021-05-07 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-03-26 | 2021-05-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-26 | 2020-07-26 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-07-11 | 2019-08-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-11 | 2019-08-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-07-11 | 2019-08-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-07-11 | 2019-08-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-11 | 2019-08-12 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-06-27 | 2019-08-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-06-27 | 2019-08-06 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-06-27 | 2019-08-06 | 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 | 2019-06-27 | 2019-08-06 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-06-27 | 2019-08-06 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-06-27 | 2019-08-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-06-27 | 2019-08-06 | N |
| Respond appropriately to all alleged violations. | Health | 2019-06-27 | 2019-08-06 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-06-27 | 2019-08-06 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-06-27 | 2019-08-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-27 | 2019-08-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-27 | 2019-08-06 | 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 | 2019-06-27 | 2019-08-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-06-27 | 2019-08-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-27 | 2019-08-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-06-27 | 2019-08-06 | N |
| 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 | 2019-06-27 | 2019-08-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-06-27 | 2019-08-06 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-06-27 | 2019-08-06 | 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 | 2019-06-27 | 2019-08-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-27 | 2019-08-06 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-06-27 | 2019-08-06 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-06-27 | 2019-08-06 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-06-27 | 2019-02-26 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2017-10-26 | 2018-01-09 | N |
| Provide housekeeping and maintenance services. | Health | 2017-10-26 | 2018-01-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-10-26 | 2018-01-09 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-10-26 | 2018-01-09 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-10-26 | 2018-01-09 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-10-26 | 2018-01-09 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2017-10-26 | 2017-12-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-10-26 | 2017-12-14 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-10-26 | 2017-12-14 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-10-26 | 2017-12-14 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2017-10-26 | 2017-12-14 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-10-26 | 2017-12-14 | N |
| 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 | 2017-10-26 | 2017-12-14 | N |
| Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. | Health | 2017-10-26 | 2017-12-14 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2017-10-26 | 2017-12-14 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2017-10-26 | 2017-12-14 | N |
| Make sure that doctors visit residents regularly, as required. | Health | 2017-10-26 | 2017-12-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-10-26 | 2017-12-14 | N |
