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Deficiency Records for Windsor Lane Healthcare Center
A list of the most recent deficiencies for Windsor Lane Healthcare 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 Lane Healthcare 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-25 | 2024-09-13 | 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 | 2024-07-25 | 2024-09-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-25 | 2024-09-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-25 | 2024-09-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-07-25 | 2024-09-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-07-25 | 2024-09-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-25 | 2024-09-13 | N |
| Provide or obtain dental services for each resident. | Health | 2024-07-25 | 2024-09-13 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2024-07-25 | 2024-09-13 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-07-25 | 2024-09-13 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-07-24 | 2024-09-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-07-24 | 2024-09-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-24 | 2024-09-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-07-24 | 2024-09-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-07-24 | 2024-09-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-07-24 | 2024-09-13 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2024-07-24 | 2024-09-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-07-24 | 2024-09-13 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-07-25 | 2024-08-23 | N |
| Have enough backup water supply for essential areas of the nursing home. | Health | 2024-07-25 | 2024-08-23 | 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 | 2024-07-25 | 2024-08-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-02-27 | 2024-03-05 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-24 | 2023-09-15 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-24 | 2023-09-15 | Y |
| 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 | 2023-01-19 | 2023-01-23 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-12-05 | 2023-01-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-12-05 | 2023-01-23 | Y |
| Provide appropriate foot care. | Health | 2022-12-05 | 2023-01-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-05 | 2023-01-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-27 | 2022-02-24 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-11-24 | 2021-12-22 | N |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2021-11-24 | 2021-12-22 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-11-24 | 2021-12-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-24 | 2021-12-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-24 | 2021-12-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-24 | 2021-12-22 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-11-24 | 2021-12-22 | 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 | 2021-11-24 | 2021-12-22 | 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 | 2021-11-24 | 2021-12-22 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-11-24 | 2021-12-22 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-23 | 2021-12-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-23 | 2021-12-22 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-11-23 | 2021-12-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-22 | 2019-06-25 | 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 | 2019-05-22 | 2019-06-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-22 | 2019-06-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-22 | 2019-06-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-22 | 2019-06-25 | 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 | 2019-05-22 | 2019-06-25 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-05-22 | 2019-06-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-22 | 2019-06-25 | 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 | 2019-05-21 | 2019-06-25 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2019-05-21 | 2019-06-25 | N |
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