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Deficiency Records for Windward Gardens
A list of the most recent deficiencies for Windward 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 Windward 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? |
|---|---|---|---|---|
| Ensure each resident receives an accurate assessment. | Health | 2024-06-03 | 2024-07-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-06-03 | 2024-07-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-03 | 2024-07-01 | 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 | 2024-04-25 | 2024-05-31 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-04-25 | 2024-05-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-04-25 | 2024-05-31 | 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 | 2024-04-25 | 2024-05-31 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-04-25 | 2024-05-31 | N |
| Provide activities to meet all resident's needs. | Health | 2024-04-25 | 2024-05-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-04-25 | 2024-05-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-25 | 2024-05-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-04-25 | 2024-05-31 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-04-25 | 2024-05-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-04-25 | 2024-05-31 | 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 | 2024-04-25 | 2024-05-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-25 | 2024-05-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-04-25 | 2024-05-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-25 | 2024-05-31 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-04-25 | 2024-05-31 | 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 | 2024-04-25 | 2024-05-31 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-25 | 2024-05-31 | 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 | 2024-04-25 | 2024-05-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-25 | 2024-05-31 | 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 | 2024-04-25 | 2024-05-31 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2024-04-23 | 2024-05-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-04-23 | 2024-05-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-04-23 | 2024-05-24 | 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 | 2024-04-23 | 2024-05-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-23 | 2024-05-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-04-23 | 2024-05-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-04-23 | 2024-05-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-04-23 | 2024-05-24 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2024-04-23 | 2024-05-24 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2024-04-23 | 2024-05-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-04-23 | 2024-05-24 | 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 | 2024-01-09 | 2024-02-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-09 | 2024-02-12 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-09 | 2024-02-12 | Y |
| 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 | 2024-01-09 | 2024-02-12 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-01-09 | 2024-02-12 | 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 | 2024-01-09 | 2024-02-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-09 | 2024-02-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-09 | 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 | 2024-01-09 | 2024-02-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-09 | 2024-02-12 | Y |
| Post nurse staffing information every day. | Health | 2023-09-06 | 2023-10-09 | 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 | 2023-09-06 | 2023-10-09 | 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 | 2023-07-26 | 2023-08-29 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-07-26 | 2023-08-29 | 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 | 2023-07-26 | 2023-08-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-18 | 2023-05-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-18 | 2023-05-23 | 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 | 2023-02-21 | 2023-03-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-21 | 2023-03-14 | 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 | 2023-01-31 | 2023-03-01 | Y |
| 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 | 2023-01-31 | 2023-03-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-31 | 2023-03-01 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-04-25 | 2022-05-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-25 | 2022-05-24 | Y |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2022-02-28 | 2022-04-20 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-02-28 | 2022-04-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-03 | 2022-04-13 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-03-03 | 2022-04-13 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-03-03 | 2022-04-13 | 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 | 2022-03-03 | 2022-04-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-03 | 2022-04-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-03 | 2022-04-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-03 | 2022-04-13 | 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 | 2022-03-03 | 2022-04-13 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-02-28 | 2022-04-12 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-02-28 | 2022-04-12 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-02-28 | 2022-04-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-02-28 | 2022-04-12 | N |
| Meet other general requirements. | Fire Safety | 2022-02-28 | 2022-04-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-02-28 | 2022-04-12 | 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 | 2022-02-28 | 2022-04-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-02-28 | 2022-04-12 | 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 | 2022-02-28 | 2022-04-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-28 | 2022-04-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-28 | 2022-04-12 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-02-28 | 2022-04-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-28 | 2022-04-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-02-28 | 2022-04-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-28 | 2022-04-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-02-28 | 2022-04-12 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-02-28 | 2022-03-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-21 | 2022-01-25 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-12-21 | 2022-01-25 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-09 | 2020-02-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-09 | 2020-02-05 | 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 | 2020-01-09 | 2020-02-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-09 | 2020-02-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-07 | 2020-01-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-07 | 2020-01-22 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2020-01-07 | 2020-01-08 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2020-01-07 | 2020-01-07 | N |
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