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Deficiency Records for Windsor Vallejo Nursing and Rehabilitation Center

A list of the most recent deficiencies for Windsor Vallejo Nursing and Rehabilitation Center. 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 Vallejo Nursing and Rehabilitation Center. 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?
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-07-15 2024-07-16 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 2024-07-15 2024-07-16 Y
Have policies on smoking. Health 2024-07-15 2024-07-16 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-06-05 2024-07-02 Y
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. Health 2024-05-01 2024-05-21 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-05-06 2024-05-06 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2024-04-10 2024-05-03 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-04-10 2024-05-03 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-04-12 2024-04-15 Y
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Health 2024-02-06 2024-02-29 Y
Respond appropriately to all alleged violations. Health 2024-02-06 2024-02-29 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-02-06 2024-02-29 Y
Provide enough food/fluids to maintain a resident's health. Health 2024-02-06 2024-02-29 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2024-02-06 2024-02-29 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-01-19 2024-02-12 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-01-19 2024-02-12 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-01-05 2024-01-26 Y
Respond appropriately to all alleged violations. Health 2023-11-09 2023-12-19 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-11-09 2023-12-19 Y
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2023-11-09 2023-12-07 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-11-09 2023-12-07 Y
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2023-11-09 2023-12-07 Y
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Health 2023-11-14 2023-12-05 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-11-14 2023-12-05 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-09-19 2023-10-05 Y
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 2023-09-19 2023-10-05 Y
Provide and implement an infection prevention and control program. Health 2023-09-19 2023-10-05 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-06-06 2023-07-24 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-06-06 2023-07-24 Y
Provide safe, appropriate pain management for a resident who requires such services. Health 2023-06-06 2023-07-24 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-06-06 2023-07-24 Y
Respond appropriately to all alleged violations. Health 2023-05-02 2023-06-21 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-03-13 2023-04-27 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-03-13 2023-04-27 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-02-23 2023-04-13 Y
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2022-10-03 2022-11-02 Y
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2022-10-03 2022-11-02 Y
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2022-10-03 2022-11-02 Y
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2022-10-03 2022-11-02 Y
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2022-10-03 2022-11-02 Y
Report COVID19 data to residents and families. Health 2022-10-03 2022-11-02 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 2022-09-28 2022-11-02 Y
Prepare residents for a safe transfer or discharge from the nursing home. Health 2022-09-28 2022-11-02 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-09-28 2022-11-02 Y
Ensure each resident receives an accurate assessment. Health 2022-10-11 2022-10-21 Y
Ensure that residents are free from significant medication errors. Health 2022-09-09 2022-09-28 Y
Provide enough food/fluids to maintain a resident's health. Health 2022-06-08 2022-07-28 Y
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Health 2022-06-08 2022-07-28 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2022-06-15 2022-07-12 Y
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2022-06-15 2022-07-12 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-04-12 2022-07-07 N
Observe each nurse aide's job performance and give regular training. Health 2022-04-12 2022-07-07 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2022-04-12 2022-07-07 N
Provide and implement an infection prevention and control program. Health 2022-04-12 2022-07-07 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-04-12 2022-06-08 Y
Establish policies and procedures for medical documentation. Fire Safety 2022-04-21 2022-05-17 N
List the names and contact information of those in the facility. Fire Safety 2022-04-21 2022-05-17 N
Provide emergency officials' contact information. Fire Safety 2022-04-21 2022-05-17 N
Use approved construction type or materials. Fire Safety 2022-04-21 2022-05-17 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-04-21 2022-05-17 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2022-04-21 2022-05-17 N
Install corridor and hallway doors that block smoke. Fire Safety 2022-04-21 2022-05-17 N
Meet requirements for the use of electrical equipment. Fire Safety 2022-04-21 2022-05-17 N
Ensure proper usage of power strips and extension cords. Fire Safety 2022-04-21 2022-05-17 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 2022-04-12 2022-05-13 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 2022-04-12 2022-05-13 N
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Health 2022-04-12 2022-05-10 N
Ensure medication error rates are not 5 percent or greater. Health 2022-04-12 2022-05-10 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2022-04-12 2022-05-10 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-02-22 2022-03-16 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-01-13 2022-03-10 Y
Prepare residents for a safe transfer or discharge from the nursing home. Health 2021-10-18 2021-11-30 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-10-18 2021-11-30 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2021-10-18 2021-11-30 Y
Provide safe, appropriate pain management for a resident who requires such services. Health 2021-10-18 2021-11-30 Y
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2019-06-26 2019-07-30 N
Install corridor and hallway doors that block smoke. Fire Safety 2019-06-26 2019-07-30 N
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. Fire Safety 2019-06-26 2019-07-30 N
Ensure proper usage of power strips and extension cords. Fire Safety 2019-06-26 2019-07-30 N
Have proper medical gas storage and administration areas. Fire Safety 2019-06-26 2019-07-30 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2019-04-12 2019-06-12 N
The resident has the right to receive notices in a format and a language he or she understands. Health 2019-04-12 2019-06-12 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 2019-04-12 2019-06-12 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2019-04-12 2019-06-12 N
Ensure each resident receives an accurate assessment. Health 2019-04-12 2019-06-12 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2019-04-12 2019-06-12 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2019-04-12 2019-06-12 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 2019-04-12 2019-06-12 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2019-04-12 2019-06-12 N
Honor each resident's preferences, choices, values and beliefs. Health 2019-04-12 2019-06-12 N
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2019-04-12 2019-06-12 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2019-04-12 2019-06-12 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2019-04-12 2019-06-12 N
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2019-04-12 2019-06-12 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2019-04-12 2019-06-12 N
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Health 2019-04-12 2019-06-12 N
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Health 2019-04-12 2019-06-12 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2019-04-12 2019-06-12 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2019-04-12 2019-06-12 N
Have a plan that describes the process for conducting QAPI and QAA activities. Health 2019-04-12 2019-06-12 N
Provide and implement an infection prevention and control program. Health 2019-04-12 2019-06-12 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 2018-03-14 2018-07-03 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2018-03-14 2018-07-03 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2018-03-14 2018-07-03 N
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2018-03-14 2018-07-03 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2018-03-14 2018-07-03 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2018-03-14 2018-07-03 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2018-03-14 2018-07-03 N
Provide and implement an infection prevention and control program. Health 2018-03-14 2018-07-03 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2018-03-28 2018-04-16 N
Have properly located and lighted "Exit" signs. Fire Safety 2018-03-28 2018-04-16 N
Provide properly protected cooking facilities. Fire Safety 2018-03-28 2018-04-16 N
Have properly installed hallway dispensers for alcohol-based hand rub. Fire Safety 2018-03-28 2018-04-16 N
Properly provide smoke detection systems in areas open to corridors. Fire Safety 2018-03-28 2018-04-16 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2018-03-28 2018-04-16 N
Install corridor and hallway doors that block smoke. Fire Safety 2018-03-28 2018-04-16 N
Provide a written emergency evacuation plan. Fire Safety 2018-03-28 2018-04-16 N
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. Fire Safety 2018-03-28 2018-04-16 N

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