A list of the most recent deficiencies for Windsor Houston. 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 | 2023-04-06 | 2023-04-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-06 | 2023-04-20 | 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 | 2023-04-06 | 2023-04-20 | Y |
| Dispose of garbage and refuse properly. | Health | 2023-04-06 | 2023-04-20 | Y |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2023-04-06 | 2023-04-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-09 | 2023-03-31 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-09 | 2023-03-31 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-03 | 2022-03-07 | 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 | 2022-02-03 | 2022-03-07 | 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 | 2022-02-03 | 2022-03-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-02-03 | 2022-02-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-28 | 2022-01-15 | Y |
| 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 | 2020-10-05 | 2020-11-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-05 | 2020-11-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-10-05 | 2020-10-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-10-05 | 2020-10-30 | 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 | 2020-10-05 | 2020-10-30 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2020-10-05 | 2020-10-30 | N |
| Keep all essential equipment working safely. | Health | 2020-10-05 | 2020-10-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-10-05 | 2020-10-19 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-10-05 | 2020-10-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-09-30 | 2020-10-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-09-30 | 2020-10-01 | N |
