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Deficiency Records for Windsor Health and Rehabilitation Center, LLC

A list of the most recent deficiencies for Windsor Health and Rehabilitation Center, LLC. 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 Health and Rehabilitation Center, LLC. 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 2024-03-12 2024-05-07 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-03-12 2024-05-07 N
Plan the resident's discharge to meet the resident's goals and needs. Health 2024-03-12 2024-05-07 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-03-12 2024-05-07 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 2024-03-12 2024-05-07 N
Provide and implement an infection prevention and control program. Health 2024-03-12 2024-05-07 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2024-03-12 2024-03-15 N
Ensure each resident receives an accurate assessment. Health 2024-03-12 2024-03-15 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 2024-03-12 2024-03-15 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-03-12 2024-03-15 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-03-12 2024-03-15 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2024-03-12 2024-03-15 N
Provide routine and 24-hour emergency dental care for each resident. Health 2024-03-12 2024-03-15 N
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Health 2024-03-12 2024-03-15 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-03-12 2024-03-15 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2024-03-12 2024-03-15 N
Hire a qualified full-time social worker in a facility with more than 120 beds. Health 2024-03-12 2024-03-15 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-02-27 2024-03-14 N
Have stairways and smokeproof enclosures used as exits that meet safety requirements. Fire Safety 2024-02-27 2024-03-07 N
Install corridor and hallway doors that block smoke. Fire Safety 2024-02-27 2024-02-28 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2024-02-27 2024-02-27 N
Establish emergency prep training and testing. Fire Safety 2024-02-27 2024-02-27 N
Establish staff and initial training requirements. Fire Safety 2024-02-27 2024-02-27 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2024-02-27 2024-02-27 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 2024-02-27 2024-02-27 N
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2024-02-27 2024-02-27 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2024-02-27 2024-02-27 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2024-02-27 2024-02-27 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2024-02-27 2024-02-27 N
Meet other general requirements that are deficient. Fire Safety 2024-02-27 2024-02-27 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 2024-02-27 2024-02-27 N
Provide a written emergency evacuation plan. Fire Safety 2024-02-27 2024-02-27 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2024-02-27 2024-02-27 N
Meet requirements for the installation and maintenance of electrical systems. Fire Safety 2024-02-27 2024-02-27 N
Ensure proper usage of power strips and extension cords. Fire Safety 2024-02-27 2024-02-27 N
Ensure proper storage of liquid oxygen. Fire Safety 2024-02-27 2024-02-27 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-04-25 2023-04-25 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 2022-07-11 2022-08-08 Y
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. Health 2022-07-11 2022-08-08 Y
Protect each resident from the wrongful use of the resident's belongings or money. Health 2022-07-11 2022-07-11 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-03-10 2022-05-13 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-03-10 2022-05-13 Y
Assure that each resident?s assessment is updated at least once every 3 months. Health 2022-03-10 2022-05-13 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-03-10 2022-05-13 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2022-03-10 2022-05-13 Y
Provide safe, appropriate pain management for a resident who requires such services. Health 2022-03-10 2022-05-13 Y
Provide medically-related social services to help each resident achieve the highest possible quality of life. Health 2022-03-10 2022-05-13 Y
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Health 2022-03-10 2022-05-13 Y
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 2022-03-10 2022-05-13 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2022-03-10 2022-05-13 Y
Ensure each resident receives an accurate assessment. Health 2021-12-07 2022-02-17 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2021-12-07 2022-02-17 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-12-07 2022-02-17 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2021-12-07 2022-02-17 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2021-12-07 2022-02-17 Y
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2021-12-03 2022-01-28 N
Properly provide smoke detection systems in areas open to corridors. Fire Safety 2021-12-03 2022-01-28 N
Install corridor and hallway doors that block smoke. Fire Safety 2021-12-03 2022-01-28 N
Meet other general requirements that are deficient. Fire Safety 2021-12-03 2022-01-28 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2021-12-03 2022-01-28 N
Ensure proper usage of power strips and extension cords. Fire Safety 2021-12-03 2022-01-28 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-08-02 2022-01-24 Y
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2019-07-11 2019-08-22 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 2019-07-11 2019-08-22 N
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2019-07-11 2019-08-22 N
Have an enclosure around a vertical opening shaft. Fire Safety 2019-07-11 2019-08-22 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2019-07-11 2019-08-20 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2019-07-11 2019-08-20 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2019-07-11 2019-08-20 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2019-07-11 2019-08-20 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2019-07-11 2019-08-20 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2019-07-11 2019-08-20 N
Provide enough food/fluids to maintain a resident's health. Health 2019-07-11 2019-08-20 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 2019-07-11 2019-08-20 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2019-07-11 2019-08-20 N
Dispose of garbage and refuse properly. Health 2019-07-11 2019-08-20 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2019-07-11 2019-08-20 N

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