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Deficiency Records for Windsor Place Senior Living Campus

A list of the most recent deficiencies for Windsor Place Senior Living Campus. 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 Place Senior Living Campus. 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 2024-05-22 2024-06-15 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-05-22 2024-06-15 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-05-22 2024-06-15 Y
Respond appropriately to all alleged violations. Health 2024-05-22 2024-06-15 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-05-22 2024-06-15 Y
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. Health 2024-05-22 2024-06-15 Y
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2024-05-22 2024-06-15 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 2024-01-25 2024-02-20 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 2024-01-25 2024-02-20 Y
Honor the resident's right to organize and participate in resident/family groups in the facility. Health 2024-01-10 2024-02-20 Y
Honor the resident's right to manage his or her financial affairs. Health 2024-01-10 2024-02-20 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 2024-01-10 2024-02-20 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 2024-01-10 2024-02-20 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 2024-01-10 2024-02-20 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-01-10 2024-02-20 Y
Have policies on smoking. Health 2024-01-10 2024-02-20 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-11-30 2024-02-20 Y
PASARR screening for Mental disorders or Intellectual Disabilities Health 2024-01-25 2024-02-16 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-01-25 2024-02-16 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-01-25 2024-02-16 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-01-25 2024-02-16 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-11-30 2024-02-16 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-09-25 2024-02-16 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-11-30 2023-12-06 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-06-29 2023-07-30 N
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2023-06-29 2023-07-30 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-06-29 2023-07-30 N
Respond appropriately to all alleged violations. Health 2023-06-29 2023-07-30 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 2023-06-29 2023-07-30 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-06-29 2023-07-30 N
Post nurse staffing information every day. Health 2023-06-29 2023-07-30 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 2023-06-29 2023-07-30 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-06-29 2023-07-30 N
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Health 2023-06-29 2023-07-30 N
Have a plan that describes the process for conducting QAPI and QAA activities. Health 2023-06-29 2023-07-30 N
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2023-06-29 2023-07-30 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-06-29 2023-07-29 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-06-29 2023-07-29 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-06-29 2023-07-29 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2023-06-29 2023-07-29 N
Ensure that testing and maintenance of electrical equipment is performed. Fire Safety 2023-06-29 2023-07-28 N
Provide properly protected cooking facilities. Fire Safety 2023-06-29 2023-07-24 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2023-06-29 2023-07-24 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-06-29 2023-07-14 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2023-06-29 2023-07-10 N
Follow proper procedures when the fire alarm was out of service for more than 4 hours. Fire Safety 2023-06-29 2023-07-10 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2023-06-29 2023-07-10 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2023-06-29 2023-07-10 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-12-29 2023-03-13 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2022-12-29 2023-01-30 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2022-12-29 2023-01-30 Y
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Health 2022-12-29 2023-01-30 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2022-12-29 2023-01-30 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-12-29 2023-01-30 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-04-07 2022-06-21 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2022-04-07 2022-06-21 Y
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2022-04-07 2022-05-07 N
Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Health 2022-04-07 2022-05-07 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2022-04-07 2022-05-07 N
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Health 2022-04-07 2022-05-07 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 2022-04-07 2022-05-07 N
Provide enough food/fluids to maintain a resident's health. Health 2022-04-07 2022-05-07 N
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 2022-04-07 2022-05-07 N
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Health 2022-04-07 2022-05-07 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-04-07 2022-05-07 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-04-07 2022-05-07 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-04-07 2022-05-07 Y
Follow proper procedures when the fire alarm was out of service for more than 4 hours. Fire Safety 2022-04-04 2022-04-22 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2022-04-04 2022-04-22 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2022-04-04 2022-04-22 N
Have proper medical gas storage and administration areas. Fire Safety 2022-04-04 2022-04-22 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2022-04-04 2022-04-19 N
Establish procedures for tracking staff and patients during an emergency. Fire Safety 2022-04-04 2022-04-19 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-04-04 2022-04-15 N
Install corridor and hallway doors that block smoke. Fire Safety 2022-04-04 2022-04-12 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2022-04-04 2022-04-11 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2022-04-04 2022-04-11 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2022-04-04 2022-04-10 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2022-04-04 2022-04-08 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-04-04 2022-04-05 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 2020-10-26 2020-12-28 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 2020-10-26 2020-12-28 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2020-10-26 2020-12-28 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 2020-10-26 2020-12-28 N
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Health 2020-10-26 2020-12-28 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2020-10-26 2020-12-28 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2020-10-26 2020-12-28 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2020-10-26 2020-12-28 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 2020-10-26 2020-12-28 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2020-10-26 2020-12-28 N
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Health 2020-10-26 2020-12-28 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 2020-10-26 2020-12-28 N
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 2020-10-26 2020-12-28 N
Ensure medication error rates are not 5 percent or greater. Health 2020-10-26 2020-12-28 N
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Health 2020-10-26 2020-12-28 N
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Health 2020-10-26 2020-12-28 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 2020-10-26 2020-12-28 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2020-10-26 2020-12-28 N
Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Health 2020-10-26 2020-12-28 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2020-10-26 2020-12-28 N
Make sure that a working call system is available in each resident's bathroom and bathing area. Health 2020-10-26 2020-12-28 N
Have simulated fire drills held at unexpected times. Fire Safety 2020-10-19 2020-11-04 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2020-10-19 2020-11-04 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2020-10-19 2020-10-28 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2020-10-19 2020-10-28 N
Have power receptacles that are properly grounded. Fire Safety 2020-10-19 2020-10-19 N

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