Deficiency Records for Windsor Place
Updated as of October 01, 2018
This is not the most recent data for Windsor Place. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-08-07 | 2018-09-10 | 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 | 2018-08-07 | 2018-09-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-08-07 | 2018-09-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-08-07 | 2018-09-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-08-07 | 2018-09-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-08-08 | 2018-09-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-08-08 | 2018-09-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-08 | 2018-09-10 | 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 | 2018-08-08 | 2018-09-10 | N |
| Provide activities to meet all resident's needs. | Health | 2018-08-08 | 2018-09-10 | 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 | 2018-08-08 | 2018-09-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-08 | 2018-09-10 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-11-06 | 2017-11-09 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-11-06 | 2017-11-09 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-08-08 | 2017-09-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-08-08 | 2017-09-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-08-08 | 2017-09-22 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2017-08-08 | 2017-09-22 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-08-09 | 2017-09-15 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-08-09 | 2017-09-15 | Y |
| Provide care for each resident in a way that maintains or improves their quality of life. | Health | 2017-08-09 | 2017-09-15 | Y |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-07-05 | 2017-07-07 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-07-05 | 2017-07-07 | Y |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2016-07-07 | 2016-08-31 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2016-07-07 | 2016-08-31 | N |
| Properly protected cooking facilities. | Fire Safety | 2016-07-07 | 2016-08-31 | N |
| Have other fire safety features required by fire safety codes. | Fire Safety | 2016-07-07 | 2016-08-31 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2016-07-07 | 2016-08-31 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2016-07-07 | 2016-08-31 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-07-07 | 2016-08-08 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-07-07 | 2016-08-08 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2016-07-07 | 2016-08-08 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2016-07-07 | 2016-08-08 | N |
| Provide food in a way that meets a resident's needs. | Health | 2016-07-07 | 2016-08-08 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-07-07 | 2016-08-08 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2016-07-07 | 2016-08-08 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-07-07 | 2016-08-08 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2016-07-07 | 2016-08-08 | N |
| Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. | Health | 2016-07-07 | 2016-08-08 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-07-07 | 2016-08-08 | N |
| An approved automatic sprinkler system connected to the fire alarm system. | Fire Safety | 2016-07-07 | 2016-08-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-08-07 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2017-08-08 | Not Fixed | N |
