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Deficiency Records for Windsor Gardens Convalescent Hospital
A list of the most recent deficiencies for Windsor Gardens Convalescent Hospital. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Windsor Gardens Convalescent Hospital. 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? |
|---|---|---|---|---|
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-08-15 | 2024-08-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-08-01 | 2024-08-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-18 | 2024-07-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-18 | 2024-07-25 | 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 | 2024-07-18 | 2024-07-25 | Y |
| 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 | 2024-07-18 | 2024-07-25 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-18 | 2024-07-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-07-02 | 2024-07-22 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-07-02 | 2024-07-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-06-07 | 2024-07-06 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-06-07 | 2024-07-06 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-04-22 | 2024-05-10 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-04-22 | 2024-05-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-22 | 2024-05-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-04-22 | 2024-05-10 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-03-08 | 2024-03-29 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-08 | 2024-03-29 | Y |
| 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 | 2024-03-08 | 2024-03-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-06 | 2024-03-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-03-06 | 2024-03-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-23 | 2024-03-15 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-08 | 2024-03-07 | 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 | 2024-02-08 | 2024-03-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-08 | 2024-03-07 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-02-08 | 2024-03-07 | 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 | 2024-02-08 | 2024-03-07 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-02-08 | 2024-03-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-08 | 2024-03-07 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-02-08 | 2024-03-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-08 | 2024-03-07 | Y |
| Post nurse staffing information every day. | Health | 2024-02-08 | 2024-03-07 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2024-02-08 | 2024-03-07 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2024-02-08 | 2024-03-07 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-02-08 | 2024-03-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-01-23 | 2024-02-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-23 | 2024-02-20 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-01-23 | 2024-02-20 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-01-23 | 2024-02-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-05 | 2024-01-20 | 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 | 2024-01-05 | 2024-01-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-04 | 2024-01-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-04 | 2023-12-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-04 | 2023-12-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-25 | 2023-09-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-09 | 2023-07-09 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-06-09 | 2023-07-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-09 | 2023-07-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-05 | 2023-07-05 | 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 | 2023-04-17 | 2023-05-17 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-12 | 2023-05-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-28 | 2023-04-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-28 | 2023-04-27 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-03-28 | 2023-04-27 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-23 | 2022-12-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-18 | 2022-12-07 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-10-18 | 2022-12-07 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-18 | 2022-12-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-27 | 2022-11-27 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-10-14 | 2022-10-23 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-07-11 | 2022-08-05 | Y |
| Implement a program that monitors antibiotic use. | Health | 2022-07-11 | 2022-08-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-08 | 2022-07-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-23 | 2022-06-22 | 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 | 2022-05-23 | 2022-06-22 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-05-23 | 2022-06-22 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-05-23 | 2022-06-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-05 | 2022-05-17 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-03-15 | 2022-04-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-02 | 2022-02-14 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-24 | 2021-12-03 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-07 | 2021-06-03 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2021-05-07 | 2021-06-03 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2021-05-07 | 2021-06-03 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-05-07 | 2021-06-03 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-05-07 | 2021-06-03 | 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 | 2021-05-07 | 2021-06-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-05-07 | 2021-06-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-05-07 | 2021-06-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-07 | 2021-06-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-07 | 2021-06-03 | 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 | 2021-05-07 | 2021-06-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-07 | 2021-06-03 | 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 | 2021-05-07 | 2021-06-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-05-07 | 2021-06-03 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-05-07 | 2021-06-03 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-05-07 | 2021-06-03 | N |
| Post nurse staffing information every day. | Health | 2021-05-07 | 2021-06-03 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-05-07 | 2021-06-03 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-05-07 | 2021-06-03 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-05-07 | 2021-06-03 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-05-07 | 2021-06-03 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-05-07 | 2021-06-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-07 | 2021-06-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-07 | 2021-06-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-07 | 2021-06-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-07 | 2021-06-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-07 | 2021-06-01 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-11-27 | 2019-12-31 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-11-27 | 2019-12-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-27 | 2019-12-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-27 | 2019-12-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-27 | 2019-12-31 | 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 | 2019-12-03 | 2019-12-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-12-03 | 2019-12-30 | 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 | 2019-12-03 | 2019-12-30 | N |
| Post nurse staffing information every day. | Health | 2019-12-03 | 2019-12-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-03 | 2019-12-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-03 | 2019-12-30 | N |
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