Deficiency Records for Windsor Healthcare Residence
Updated as of January 01, 2023
This is not the most recent data for Windsor Healthcare Residence. For the most recent information, click here.
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? |
---|---|---|---|---|
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 |
Provide and implement an infection prevention and control program. | Health | 2020-11-13 | 2020-12-21 | Y |
Provide and implement an infection prevention and control program. | Health | 2020-04-08 | 2020-05-15 | Y |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-03-10 | 2020-04-05 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-02-26 | 2020-03-27 | Y |
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 | 2020-02-26 | 2020-03-27 | 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 |