A list of the most recent deficiencies for Windsor Terrace Health Care. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-01 | 2024-02-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-01 | 2024-02-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-01 | 2024-02-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-01 | 2024-02-12 | 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 | 2023-12-01 | 2024-02-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-01 | 2024-02-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-01 | 2024-02-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-12-08 | 2024-01-05 | 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 | 2023-12-08 | 2024-01-05 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-12-08 | 2024-01-05 | 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 | 2023-12-08 | 2024-01-05 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-12-08 | 2024-01-05 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-12-08 | 2024-01-05 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-12-08 | 2024-01-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-08 | 2024-01-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-08 | 2024-01-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-12-08 | 2024-01-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-08 | 2024-01-05 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-12-01 | 2023-12-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-01 | 2023-12-26 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-12-01 | 2023-12-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-01 | 2023-12-26 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-12-01 | 2023-12-26 | N |
| Provide appropriate foot care. | Health | 2023-12-01 | 2023-12-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-01 | 2023-12-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-12-01 | 2023-12-26 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-12-01 | 2023-12-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-12-01 | 2023-12-26 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-01 | 2023-12-26 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-12-01 | 2023-12-26 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-12-01 | 2023-12-26 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-12-01 | 2023-12-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-12-01 | 2023-12-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-22 | 2023-12-13 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-18 | 2023-11-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-18 | 2023-11-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-18 | 2023-11-13 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-18 | 2023-11-13 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-31 | 2023-10-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-31 | 2023-10-02 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-08-17 | 2023-09-14 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-17 | 2023-09-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-31 | 2023-08-29 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-31 | 2023-08-29 | Y |
| 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 | 2023-06-28 | 2023-07-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-06-06 | 2023-07-05 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-05-15 | 2023-06-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-15 | 2023-06-14 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-12 | 2023-05-09 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-12 | 2023-05-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-05 | 2023-04-27 | Y |
| 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 | 2023-04-05 | 2023-04-27 | Y |
| 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 | 2023-04-05 | 2023-04-27 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-05 | 2023-04-27 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-24 | 2023-04-12 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-03-20 | 2023-04-04 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-10 | 2023-03-27 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-10 | 2023-03-27 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-02-23 | 2023-03-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-23 | 2023-03-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-12 | 2023-01-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-08 | 2022-12-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-14 | 2022-12-14 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-12-14 | 2022-12-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-14 | 2022-12-14 | Y |
| 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 | 2022-12-14 | 2022-12-14 | Y |
| 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 | 2022-12-14 | 2022-12-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-10 | 2022-12-08 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-10 | 2022-12-08 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-11-10 | 2022-12-08 | 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 | 2022-11-10 | 2022-12-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-11-10 | 2022-12-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-10 | 2022-12-08 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-11-10 | 2022-12-08 | 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 | 2022-11-10 | 2022-12-08 | 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 | 2022-11-10 | 2022-12-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-10 | 2022-12-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-10 | 2022-12-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-10 | 2022-12-08 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-11-25 | 2022-12-02 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-11-08 | 2022-11-23 | 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 | 2022-11-08 | 2022-11-23 | 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 | 2022-11-08 | 2022-11-23 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-11-08 | 2022-11-23 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-11-08 | 2022-11-23 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2022-11-08 | 2022-11-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-08 | 2022-11-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-08 | 2022-11-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-08 | 2022-11-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-01 | 2022-11-15 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-11-01 | 2022-11-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-04 | 2022-10-31 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-09-24 | 2022-10-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-24 | 2022-10-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-23 | 2022-10-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-09 | 2022-08-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-09 | 2022-08-30 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-08-04 | 2022-08-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-04 | 2022-08-29 | Y |
| 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 | 2022-08-04 | 2022-08-29 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-01 | 2022-08-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-17 | 2022-08-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-28 | 2022-08-14 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-07-15 | 2022-08-09 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-15 | 2022-08-09 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-15 | 2022-08-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-15 | 2022-08-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-10 | 2022-06-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-22 | 2022-06-06 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-04-13 | 2022-04-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-13 | 2022-04-25 | Y |
| Post nurse staffing information every day. | Health | 2022-04-07 | 2022-04-22 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-03-16 | 2022-03-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-05 | 2022-03-14 | 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 | 2022-02-07 | 2022-03-04 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-07 | 2022-03-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-07 | 2022-03-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-09 | 2022-02-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-02-09 | 2022-02-22 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-02-09 | 2022-02-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-01 | 2022-02-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-13 | 2021-12-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-22 | 2021-12-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-22 | 2021-12-06 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-11-22 | 2021-12-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-19 | 2021-10-26 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-10-19 | 2021-10-26 | Y |
| Construct fire resistant interior walls. | Fire Safety | 2021-09-24 | 2021-10-11 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-09-24 | 2021-10-11 | Y |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-09-24 | 2021-10-11 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-09-24 | 2021-10-11 | Y |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-09-24 | 2021-10-11 | Y |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-09-24 | 2021-10-11 | Y |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-09-24 | 2021-10-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-13 | 2021-07-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-13 | 2021-07-22 | Y |
| 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 | 2021-05-12 | 2021-05-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-15 | 2021-05-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-15 | 2021-05-12 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-15 | 2021-05-12 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-15 | 2021-05-12 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-05-03 | 2019-06-03 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-05-03 | 2019-06-03 | 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 | 2019-05-03 | 2019-06-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-03 | 2019-06-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-05-03 | 2019-06-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-03 | 2019-06-03 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-05-03 | 2019-06-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-05-03 | 2019-06-03 | 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 | 2019-05-03 | 2019-06-03 | 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 | 2019-05-03 | 2019-06-03 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-05-03 | 2019-06-03 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-05-03 | 2019-06-03 | 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 | 2019-05-03 | 2019-06-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-05-03 | 2019-06-03 | 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 | 2019-05-03 | 2019-06-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-03 | 2019-06-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-05-02 | 2019-05-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-02 | 2019-05-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-02 | 2019-05-22 | N |
