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Deficiency Records for Windsor Calallen
View the most recent health deficiencies and inspection results for Windsor Calallen. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Windsor Calallen. Stay informed about quality of care issues.
| 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 | 2025-08-21 | 2025-08-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-08-08 | 2025-08-09 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2025-05-07 | 2025-05-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-05-07 | 2025-05-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-05-07 | 2025-05-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2025-05-07 | 2025-05-28 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2025-05-07 | 2025-05-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2025-05-07 | 2025-05-28 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2025-05-07 | 2025-05-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-05-07 | 2025-05-08 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2025-05-07 | 2025-05-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2025-05-07 | 2025-05-08 | 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 | 2025-05-07 | 2025-05-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-05-07 | 2025-05-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-04-09 | 2025-04-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-04-09 | 2025-04-10 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2025-04-04 | 2025-04-05 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2025-02-20 | 2025-03-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-02-20 | 2025-03-14 | 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 | 2024-07-01 | 2024-07-03 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-06 | 2024-03-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-06 | 2024-03-30 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-03-06 | 2024-03-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-03-06 | 2024-03-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-06 | 2024-03-30 | 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 | 2024-03-06 | 2024-03-30 | 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 | 2024-03-06 | 2024-03-30 | 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 | 2024-03-06 | 2024-03-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-06 | 2024-03-30 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-03-06 | 2024-03-30 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-03-06 | 2024-03-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-25 | 2024-01-26 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-01-25 | 2024-01-26 | 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 | 2023-11-19 | 2023-11-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-16 | 2023-05-17 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-01-20 | 2023-02-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-20 | 2023-01-24 | N |