Inspection Results » Windsor Health & Rehabilitation Center

Health Inspection on April 2, 2019 ^[1]

1. Isolated: Immediate jeopardy to the resident health or safety

   • Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. (Corrected 2019-05-07)

2. Pattern: Actual harm that is not immediate jeopardy

   • Administer the facility in a manner that enables it to use its resources effectively and efficiently. (Corrected 2019-05-07)
   • Ensure services provided by the nursing facility meet professional standards of quality. (Corrected 2019-05-07)
   • Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (Corrected 2019-05-07)
   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2019-05-07)

3. Isolated: Actual harm that is not immediate jeopardy

   • Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Corrected 2019-05-07)
   • Provide care and assistance to perform activities of daily living for any resident who is unable. (Corrected 2019-05-07)
   • Provide safe, appropriate pain management for a resident who requires such services. (Corrected 2019-05-07)
   • Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. (Corrected 2019-05-07)
   • Provide medically-related social services to help each resident achieve the highest possible quality of life. (Corrected 2019-05-07)
   • Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. (Corrected 2019-05-07)
   • Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (Corrected 2019-05-07)
   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2019-05-07)

4. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • 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. (Corrected 2019-05-07)
   • Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. (Corrected 2019-05-07)
   • Post nurse staffing information every day. (Corrected 2019-05-07)
   • Have the Quality Assessment and Assurance group have the required members and meet at least quarterly (Corrected 2019-05-07)
   • 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. (Corrected 2019-05-07)

5. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (Corrected 2019-05-07)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2019-05-07)
   • Notify the resident or the residentÂ’s representative in writing how long the nursing home will hold the residentÂ’s bed in cases of transfer to a hospital or therapeutic leave. (Corrected 2019-05-07)
   • Provide and implement an infection prevention and control program. (Corrected 2019-05-07)
   • Provide safe and appropriate respiratory care for a resident when needed. (Corrected 2019-05-07)
   • Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. (Corrected 2019-05-07)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2019-05-07)
   • Respond appropriately to all alleged violations. (Corrected 2019-05-07)
   • Develop and implement policies and procedures to prevent abuse, neglect, and theft. (Corrected 2019-05-07)
   • Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (Corrected 2019-05-07)
   • Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (Corrected 2019-05-07)
   • 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. (Corrected 2019-05-07)

6. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • 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. (Corrected 2019-05-07)
   • Keep residents' personal and medical records private and confidential. (Corrected 2019-05-07)
   • Provide enough food/fluids to maintain a resident's health. (Corrected 2019-05-07)
   • Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (Corrected 2019-05-07)
   • Provide or get specialized rehabilitative services as required for a resident. (Corrected 2019-05-07)
   • Reasonably accommodate the needs and preferences of each resident. (Corrected 2019-05-07)
   • Ensure each residentÂ’s drug regimen must be free from unnecessary drugs. (Corrected 2019-05-07)
   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2019-05-07)
   • Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (Corrected 2019-05-07)
   • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2019-05-07)
   • Ensure medication error rates are not 5 percent or greater. (Corrected 2019-05-07)
   • Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. (Corrected 2019-05-07)
   • Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. (Corrected 2019-05-07)
   • Ensure that the resident and his/her doctor meet face-to-face at all required visits. (Corrected 2019-05-07)
   • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected 2019-05-07)
   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2019-05-07)
   • 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 ne (Corrected 2019-05-07)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2019-05-07)
   • Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. (Corrected 2019-05-07)
   • Ensure each resident receives an accurate assessment. (Corrected 2019-05-07)
   • Develop and implement policies and procedures for flu and pneumonia vaccinations. (Corrected 2019-05-07)