A list of the most recent deficiencies for Windsor Place. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-28 | 2023-12-29 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-12-28 | 2023-12-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-28 | 2023-12-29 | Y |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-12-22 | 2023-02-03 | 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 | 2022-12-22 | 2023-01-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-22 | 2023-01-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-22 | 2022-12-27 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-11-30 | 2022-12-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-30 | 2022-12-23 | N |
| Respond appropriately to all alleged violations. | Health | 2022-11-30 | 2022-12-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-11-30 | 2022-12-23 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-11-30 | 2022-12-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-30 | 2022-12-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-30 | 2022-12-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-11-30 | 2022-12-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-30 | 2022-12-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-30 | 2022-12-23 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-11-30 | 2022-12-22 | 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 | 2022-11-30 | 2022-12-22 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-11-30 | 2022-12-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-30 | 2022-12-19 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-09-21 | 2021-10-13 | 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 | 2021-09-21 | 2021-10-08 | N |
| Provide activities to meet all resident's needs. | Health | 2021-09-21 | 2021-10-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-21 | 2021-10-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-21 | 2021-10-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-21 | 2021-10-08 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-21 | 2021-10-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-04 | 2021-10-08 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-09-21 | 2021-10-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-09-21 | 2021-10-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-19 | 2021-08-20 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-08-19 | 2021-08-20 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-07-18 | 2019-08-15 | 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 | 2019-07-18 | 2019-08-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-07-18 | 2019-08-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-07-17 | 2019-07-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-07-17 | 2019-07-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-12-22 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-07-18 | Not Fixed | N |
