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Deficiency Records for Windsor Grove Health and Rehabilitation
View the most recent health deficiencies and inspection results for Windsor Grove Health and Rehabilitation. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Windsor Grove Health and Rehabilitation. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2025-05-01 | 2025-10-17 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2025-05-01 | 2025-10-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2025-05-01 | 2025-10-17 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2025-05-01 | 2025-06-26 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2025-05-01 | 2025-06-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-05-01 | 2025-06-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-05-01 | 2025-06-26 | 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 | 2025-05-01 | 2025-06-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-05-01 | 2025-06-26 | N |
| Respond appropriately to all alleged violations. | Health | 2025-05-01 | 2025-06-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-05-01 | 2025-06-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2025-05-01 | 2025-06-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2025-05-01 | 2025-06-26 | N |
| Provide appropriate foot care. | Health | 2025-05-01 | 2025-06-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-05-01 | 2025-06-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2025-05-01 | 2025-06-26 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2025-05-01 | 2025-06-26 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2025-05-01 | 2025-06-26 | N |
| Ensure that residents are free from significant medication errors. | Health | 2025-05-01 | 2025-06-26 | 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 | 2025-05-01 | 2025-06-26 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2025-05-01 | 2025-06-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-05-01 | 2025-06-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-05-01 | 2025-06-26 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2025-05-01 | 2025-06-26 | 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 | 2024-11-14 | 2025-01-04 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-11-14 | 2025-01-04 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-11-14 | 2025-01-04 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-11-14 | 2025-01-04 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2024-11-14 | 2025-01-04 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-03-26 | 2021-06-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-03-26 | 2021-06-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-03-26 | 2021-06-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-03-26 | 2021-06-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-26 | 2021-06-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-03-26 | 2021-06-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-03-26 | 2021-06-02 | 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 | 2021-03-26 | 2021-06-02 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-03-26 | 2021-05-07 | N |
| Ensure each resident receives an accurate assessment. | 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 |
| 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 |
| 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 |
| Protect each resident from the wrongful use of the resident's belongings or money. | 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 |
| Honor the resident's right to manage his or her financial affairs. | Health | 2021-03-26 | 2021-05-07 | 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 |
| 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 |
| 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 |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-06-27 | 2019-08-12 | 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 | 2019-06-27 | 2019-08-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-27 | 2019-08-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-06-27 | 2019-08-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-27 | 2019-08-12 | N |
| Respond appropriately to all alleged violations. | 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 |
| 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 |
| Ensure that residents are free from significant medication errors. | 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 |
| 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 enough food/fluids to maintain a resident's health. | 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 |
| Ensure services provided by the nursing facility meet professional standards of quality. | 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 |
| 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 |
| Ensure each resident receives an accurate assessment. | 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 |
| 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 |
| Address subsistence needs for staff and patients. | Fire Safety | 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 |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 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 |
| 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 |
| Keep residents' personal and medical records private and confidential. | 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 |
| 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 |
| 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 |