A list of the most recent deficiencies for Windflower Health Center. 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 residents are free from significant medication errors. | Health | 2023-11-20 | 2023-12-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-21 | 2023-09-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-08 | 2023-05-15 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-02-03 | 2023-02-23 | 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 | 2023-02-03 | 2023-02-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-03 | 2023-02-04 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-12-07 | 2023-01-16 | 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 | 2022-12-07 | 2023-01-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-12-07 | 2023-01-16 | 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 | 2022-12-07 | 2023-01-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-07 | 2023-01-16 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-12-07 | 2023-01-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-01 | 2023-01-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-06 | 2022-05-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-21 | 2021-12-03 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-07 | 2021-11-19 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-10-07 | 2021-11-19 | N |
| 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 | 2021-10-07 | 2021-11-19 | 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 | 2021-10-07 | 2021-11-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-07 | 2021-11-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-07 | 2021-11-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-10-07 | 2021-11-19 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-05-27 | 2021-07-05 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-05-27 | 2021-07-05 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-14 | 2021-05-21 | 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 | 2019-12-19 | 2020-02-02 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-12-19 | 2020-02-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-12-19 | 2020-02-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-19 | 2020-02-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-19 | 2020-02-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-19 | 2020-02-02 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-12-19 | 2020-02-02 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-12-19 | 2020-02-02 | 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 | 2019-12-19 | 2020-02-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-19 | 2020-02-02 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2019-12-19 | 2020-02-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-12-19 | 2020-02-02 | N |
