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Deficiency Records for Windsor Park Rehab and Nursing Center
A list of the most recent deficiencies for Windsor Park Rehab and Nursing 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 Park Rehab and Nursing 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 | 2024-06-30 | 2024-07-05 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-06-30 | 2024-07-05 | 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 | 2024-06-30 | 2024-07-05 | Y |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2024-06-30 | 2024-07-05 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-06-30 | 2024-07-05 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2024-06-30 | 2024-07-05 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-06-30 | 2024-07-05 | Y |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2024-06-30 | 2024-07-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-24 | 2023-12-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-24 | 2023-12-11 | 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 | 2023-10-24 | 2023-12-11 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-09-01 | 2022-10-07 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-09-01 | 2022-10-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-01 | 2022-10-07 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-09-01 | 2022-10-07 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-10-29 | 2019-11-11 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-04-10 | 2018-07-03 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-04-10 | 2018-07-03 | N |
| Use approved construction type or materials. | Fire Safety | 2018-04-10 | 2018-07-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-04-10 | 2018-07-03 | 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 | 2018-04-10 | 2018-07-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-04-10 | 2018-07-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-04-10 | 2018-07-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-27 | 2018-03-27 | N |
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