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Deficiency Records for Windsor Cypress Gardens
A list of the most recent deficiencies for Windsor Cypress Gardens. 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 Cypress Gardens. 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? |
|---|---|---|---|---|
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2024-07-23 | 2024-08-19 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2024-07-23 | 2024-07-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-16 | 2024-01-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-07 | 2023-11-23 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-11-20 | 2023-11-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-26 | 2023-11-02 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-04 | 2023-10-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-12 | 2023-08-09 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-07-12 | 2023-08-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-07-12 | 2023-08-09 | N |
| Provide activities to meet all resident's needs. | Health | 2023-07-12 | 2023-08-09 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-07-12 | 2023-08-09 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-07-12 | 2023-08-09 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-07-12 | 2023-08-09 | 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 | 2023-07-12 | 2023-08-09 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-07-12 | 2023-08-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-12 | 2023-08-09 | N |
| Dispose of garbage and refuse properly. | Health | 2023-07-12 | 2023-08-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-12 | 2023-08-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-12 | 2023-08-09 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2023-07-12 | 2023-08-09 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-07-17 | 2023-07-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-07-17 | 2023-07-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-07-17 | 2023-07-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-17 | 2023-07-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-17 | 2023-07-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-27 | 2023-07-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-06 | 2023-07-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-05 | 2023-07-05 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-24 | 2023-06-24 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-05-22 | 2023-06-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-05 | 2023-05-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-05 | 2023-05-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-14 | 2023-04-28 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-03-16 | 2023-03-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-16 | 2023-03-29 | 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 | 2023-03-15 | 2023-03-29 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-15 | 2023-03-29 | Y |
| 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 | 2023-03-15 | 2023-03-29 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-21 | 2023-03-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-10 | 2023-03-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-17 | 2023-02-17 | 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 | 2023-01-17 | 2023-02-17 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-12-22 | 2023-01-17 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-11-29 | 2022-12-17 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-29 | 2022-12-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-29 | 2022-12-17 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-29 | 2022-12-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-29 | 2022-12-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-29 | 2022-12-17 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-11-10 | 2022-12-10 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-19 | 2022-09-19 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-05 | 2022-09-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-05 | 2022-09-05 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-18 | 2022-06-18 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-05-18 | 2022-06-18 | Y |
| Use approved construction type or materials. | Fire Safety | 2019-11-14 | 2019-12-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-14 | 2019-12-30 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-11-14 | 2019-12-30 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-11-14 | 2019-12-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-14 | 2019-12-30 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-11-14 | 2019-12-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-14 | 2019-12-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-11-14 | 2019-12-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-14 | 2019-12-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-11-14 | 2019-12-30 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-11-14 | 2019-12-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-14 | 2019-12-30 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-11-14 | 2019-12-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-14 | 2019-12-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-14 | 2019-12-30 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2019-11-14 | 2019-12-30 | 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 | 2019-10-25 | 2019-12-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-25 | 2019-12-04 | 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 | 2019-10-25 | 2019-12-04 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-10-25 | 2019-12-04 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2019-10-25 | 2019-12-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-12-18 | 2018-12-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-12-18 | 2018-12-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-18 | 2018-12-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-18 | 2018-12-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-12-18 | 2018-12-31 | N |
| 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 | 2018-10-12 | 2018-11-19 | 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 | 2018-10-12 | 2018-11-19 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-10-12 | 2018-11-19 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-10-12 | 2018-11-19 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-10-12 | 2018-11-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-12 | 2018-11-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-12 | 2018-11-19 | 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 | 2018-10-12 | 2018-11-19 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-10-12 | 2018-11-19 | 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 | 2018-10-12 | 2018-11-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-10-12 | 2018-11-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-12 | 2018-11-19 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2018-10-12 | 2018-11-19 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2018-10-12 | 2018-11-19 | N |
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