Deficiency Records for Windsor The Ridge Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Windsor The Ridge 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? |
|---|---|---|---|---|
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-22 | 2023-09-14 | Y |
| 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 | 2023-05-10 | 2023-05-26 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-09-22 | 2021-10-15 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-08-06 | 2021-08-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-06 | 2021-08-26 | 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 | 2021-08-06 | 2021-08-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-06 | 2021-08-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-06 | 2021-08-26 | 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 | 2021-08-06 | 2021-08-25 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-08-06 | 2021-08-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-08-06 | 2021-08-25 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-08-06 | 2021-08-24 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-08-06 | 2021-08-24 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-08-06 | 2021-08-24 | N |
| 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 | 2021-08-06 | 2021-08-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-06 | 2021-08-24 | N |
| Dispose of garbage and refuse properly. | Health | 2021-08-06 | 2021-08-24 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-08-10 | 2021-08-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-10 | 2021-08-24 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-08-06 | 2021-08-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-06 | 2021-08-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-08-06 | 2021-08-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-06 | 2021-08-22 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-08-06 | 2021-08-17 | 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 | 2021-08-06 | 2021-08-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-21 | 2021-08-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-21 | 2021-08-10 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-07-21 | 2021-08-10 | Y |
| 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 | 2021-07-21 | 2021-08-10 | Y |
| Provide activities to meet all resident's needs. | Health | 2021-08-06 | 2021-08-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-24 | 2019-08-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-24 | 2019-08-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-24 | 2019-08-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-24 | 2019-08-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-24 | 2019-08-22 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-06-13 | 2019-07-04 | 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 | 2019-06-13 | 2019-07-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-06-13 | 2019-07-04 | 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 | 2019-06-13 | 2019-07-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-06-13 | 2019-07-04 | 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 | 2019-06-13 | 2019-07-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-13 | 2019-07-04 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-08-22 | 2018-09-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-08-22 | 2018-09-19 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2018-08-22 | 2018-09-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-22 | 2018-09-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-08-22 | 2018-09-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-08-22 | 2018-09-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-05-24 | 2018-06-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-24 | 2018-06-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-24 | 2018-06-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-24 | 2018-06-22 | 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 | 2018-05-24 | 2018-06-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-05-24 | 2018-06-22 | 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 | 2018-05-24 | 2018-06-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-24 | 2018-06-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-24 | 2018-06-22 | N |
