A list of the most recent deficiencies for Windsor Healthcare Residence. 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 that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-20 | 2023-11-21 | Y |
| 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 | 2023-09-15 | 2023-09-16 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-07-20 | 2023-07-21 | Y |
| Keep all essential equipment working safely. | Health | 2022-04-14 | 2022-06-30 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-05-04 | 2022-06-15 | 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 | 2022-04-14 | 2022-05-27 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-05-04 | 2022-05-27 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-04-14 | 2022-05-20 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-04-14 | 2022-05-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-14 | 2022-05-13 | 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 | 2022-04-14 | 2022-05-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-08 | 2022-02-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-08 | 2022-02-28 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-05-26 | 2021-06-16 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-09-16 | 2019-10-27 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2019-09-16 | 2019-10-11 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-09-16 | 2019-10-11 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-09-10 | 2019-10-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-10 | 2019-10-11 | 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 | 2019-09-10 | 2019-10-11 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-09-16 | 2019-10-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-09-16 | 2019-10-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-16 | 2019-10-08 | 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 | 2019-09-16 | 2019-10-08 | 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 | 2019-09-16 | 2019-10-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-10 | 2019-10-08 | 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 | 2019-09-10 | 2019-09-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-07-19 | 2018-08-29 | 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 | 2018-07-19 | 2018-08-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-07-19 | 2018-08-29 | 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 | 2018-07-19 | 2018-08-29 | 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 | 2018-07-19 | 2018-08-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-19 | 2018-08-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-19 | 2018-08-29 | 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 | 2018-07-19 | 2018-08-08 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2018-07-19 | 2018-08-08 | N |
