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Deficiency Records for Windsor Calallen
A list of the most recent deficiencies for Windsor Calallen. 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 Calallen. 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 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 | 2024-07-01 | 2024-07-03 | Y |
Keep residents' personal and medical records private and confidential. | Health | 2024-03-06 | 2024-03-30 | 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 | 2024-03-06 | 2024-03-30 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-06 | 2024-03-30 | 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 | 2024-03-06 | 2024-03-30 | 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 | 2024-03-06 | 2024-03-30 | 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 | 2024-03-06 | 2024-03-30 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-06 | 2024-03-30 | N |
Provide and implement an infection prevention and control program. | Health | 2024-03-06 | 2024-03-30 | N |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-03-06 | 2024-03-30 | Y |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-06 | 2024-03-30 | Y |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-06 | 2024-03-30 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-25 | 2024-01-26 | Y |
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-01-25 | 2024-01-26 | 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 | 2023-11-19 | 2023-11-22 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-14 | 2023-05-22 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-14 | 2023-05-22 | Y |
Provide and implement an infection prevention and control program. | Health | 2023-05-16 | 2023-05-17 | Y |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-01-25 | 2023-02-07 | N |
Ensure that residents are free from significant medication errors. | Health | 2023-01-20 | 2023-01-24 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-05 | 2022-05-23 | 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 | 2021-10-14 | 2021-11-05 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-14 | 2021-11-05 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-10-12 | 2021-11-05 | N |
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