Deficiency Records for Windsor Atrium
Updated as of April 01, 2020
This is not the most recent data for Windsor Atrium. For the most recent information, click here.
A list of the most recent deficiencies for Windsor Atrium. 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 | 2019-05-10 | 2019-05-13 | Y |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-05-10 | 2019-05-13 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-10 | 2019-05-13 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-10 | 2019-05-13 | 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 | 2019-05-10 | 2019-05-13 | Y |
Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-01-31 | 2019-02-05 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2019-02-01 | 2019-02-05 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-02-01 | 2019-02-05 | N |
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-02-01 | 2019-02-05 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-01 | 2019-02-05 | N |
Ensure the activities program is directed by a qualified professional. | Health | 2019-02-01 | 2019-02-05 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-01 | 2019-02-05 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-02-01 | 2019-02-05 | 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 | Health | 2019-02-01 | 2019-02-05 | 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 | 2019-02-01 | 2019-02-05 | 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 | 2019-02-01 | 2019-02-05 | 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 ne | Health | 2019-02-01 | 2019-02-05 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2019-02-01 | 2019-02-05 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-01 | 2019-02-05 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-02-01 | 2019-02-05 | N |
Provide and implement an infection prevention and control program. | Health | 2019-02-01 | 2019-02-05 | N |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-02-01 | 2019-02-05 | N |
Provide primary/alternate means for communication. | Fire Safety | 2019-01-31 | 2019-02-01 | N |
Provide and implement an infection prevention and control program. | Health | 2018-12-03 | 2018-12-04 | Y |
Reasonably accommodate the needs and preferences of each resident. | Health | 2018-02-16 | 2018-03-16 | N |
Keep residents' personal and medical records private and confidential. | Health | 2018-02-16 | 2018-03-16 | N |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-02-16 | 2018-03-16 | N |
Ensure each resident receives an accurate assessment. | Health | 2018-02-16 | 2018-03-16 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-02-16 | 2018-03-16 | N |
Provide care by qualified persons according to each resident's written plan of care. | Health | 2018-02-16 | 2018-03-16 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-02-16 | 2018-03-16 | N |
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-02-16 | 2018-03-16 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-02-16 | 2018-03-16 | N |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-02-16 | 2018-03-16 | N |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2018-02-16 | 2018-03-16 | N |
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-02-16 | 2018-03-16 | 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 | 2018-02-16 | 2018-03-16 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-02-16 | 2018-03-16 | N |
Implement a program that monitors antibiotic use. | Health | 2018-02-16 | 2018-03-16 | N |
Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2018-02-16 | 2018-03-16 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-01-25 | 2018-02-02 | Y |
Provide care by qualified persons according to each resident's written plan of care. | Health | 2018-01-25 | 2018-02-02 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-01-25 | 2018-02-02 | Y |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-01-25 | 2018-02-02 | Y |
Respond appropriately to all alleged violations. | Health | 2018-01-04 | 2018-01-16 | Y |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2017-12-14 | 2017-12-20 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2017-12-14 | 2017-12-20 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2017-12-14 | 2017-12-20 | Y |
Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-10-19 | 2017-11-10 | Y |
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-10-19 | 2017-11-10 | Y |
Reasonably accommodate the needs and preferences of each resident. | Health | 2017-09-19 | 2017-09-22 | Y |
Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-09-19 | 2017-09-22 | Y |
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-09-19 | 2017-09-22 | Y |
Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-08-02 | 2017-08-15 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-01-26 | 2017-02-16 | N |
Provide housekeeping and maintenance services. | Health | 2017-01-26 | 2017-02-16 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-01-26 | 2017-02-16 | N |
Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-01-26 | 2017-02-16 | N |
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-01-26 | 2017-02-16 | N |
Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2017-01-26 | 2017-02-16 | N |
Store, cook, and serve food in a safe and clean way. | Health | 2017-01-26 | 2017-02-16 | N |
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-01-26 | 2017-02-16 | N |
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-01-26 | 2017-02-16 | N |
Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-01-26 | 2017-02-16 | N |