Deficiency Records for Windsor Atrium

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Updated as of February 01, 2021

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?
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2020-07-31 2020-08-21 Y
Provide and implement an infection prevention and control program. Health 2020-07-31 2020-08-21 Y
Reasonably accommodate the needs and preferences of each resident. Health 2020-02-27 2020-02-28 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2020-02-27 2020-02-28 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2020-02-27 2020-02-28 N
Provide and implement an infection prevention and control program. Health 2020-02-27 2020-02-28 N
Keep residents' personal and medical records private and confidential. Health 2020-01-21 2020-01-31 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2020-01-21 2020-01-31 Y
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 and maintain the bed rail. 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 necessary and PRN use is limited. 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