Windsor Grove Health and Rehabilitation

EMake sure that a working call system is available in each resident's bathroom and bathing area.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0919 · Complaint inspection · Deficient, Provider has date of correction (Jan 4, 2025)

EMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0925 · Complaint inspection · Deficient, Provider has date of correction (Jan 4, 2025)

DHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Complaint inspection · Deficient, Provider has date of correction (Jan 4, 2025)

DProvide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0691 · Complaint inspection · Deficient, Provider has date of correction (Jan 4, 2025)

DProvide enough food/fluids to maintain a resident's health.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0692 · Complaint inspection · Deficient, Provider has date of correction (Jan 4, 2025)

DHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0550 · Deficient, Provider has date of correction (May 7, 2021)

DHonor the resident's right to manage his or her financial affairs.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0567 · Deficient, Provider has date of correction (May 7, 2021)

DThe resident has the right to receive notices in a format and a language he or she understands.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0574 · Deficient, Provider has date of correction (May 7, 2021)

DProtect each resident from the wrongful use of the resident's belongings or money.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0602 · Deficient, Provider has date of correction (May 7, 2021)

DNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0622 · Deficient, Provider has date of correction (May 7, 2021)

DProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0623 · Deficient, Provider has date of correction (May 7, 2021)

DNotify 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0625 · Deficient, Provider has date of correction (May 7, 2021)

DEnsure each resident receives an accurate assessment.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0641 · Deficient, Provider has date of correction (May 7, 2021)

DEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Past Non-Compliance (Jul 26, 2020)

DProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0690 · Deficient, Provider has date of correction (May 7, 2021)

DImplement 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0758 · Deficient, Provider has date of correction (May 7, 2021)

DEnsure 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0761 · Deficient, Provider has date of correction (May 7, 2021)

DProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Potential for more than minimal harm · Administration Deficiencies · Tag F0773 · Deficient, Provider has date of correction (May 7, 2021)

DKeep complete, dated laboratory records in the resident's record.

Potential for more than minimal harm · Administration Deficiencies · Tag F0775 · Deficient, Provider has date of correction (May 7, 2021)

DImplement a program that monitors antibiotic use.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0881 · Deficient, Provider has date of correction (May 7, 2021)

EHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0561 · Deficient, Provider has date of correction (Aug 6, 2019)

ERespond appropriately to all alleged violations.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 · Deficient, Provider has date of correction (Aug 6, 2019)

ENot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0622 · Deficient, Provider has date of correction (Aug 6, 2019)

ENotify 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0625 · Deficient, Provider has date of correction (Aug 6, 2019)

EEnsure services provided by the nursing facility meet professional standards of quality.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0658 · Deficient, Provider has date of correction (Aug 6, 2019)

EProvide appropriate treatment and care according to orders, resident’s preferences and goals.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Deficient, Provider has date of correction (Aug 6, 2019)

DImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0580 · Deficient, Provider has date of correction (Aug 6, 2019)

DGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0582 · Past Non-Compliance (Feb 26, 2019)

DKeep residents' personal and medical records private and confidential.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0583 · Deficient, Provider has date of correction (Aug 6, 2019)

DHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Deficient, Provider has date of correction (Aug 6, 2019)

DProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 · Deficient, Provider has date of correction (Aug 6, 2019)

DDevelop and implement policies and procedures to prevent abuse, neglect, and theft.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0607 · Deficient, Provider has date of correction (Aug 6, 2019)

DTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 · Deficient, Provider has date of correction (Aug 6, 2019)

DEnsure each resident receives an accurate assessment.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0641 · Deficient, Provider has date of correction (Aug 6, 2019)

DDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Deficient, Provider has date of correction (Aug 6, 2019)

DDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0657 · Deficient, Provider has date of correction (Aug 6, 2019)

DProvide enough food/fluids to maintain a resident's health.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0692 · Deficient, Provider has date of correction (Aug 6, 2019)

DHave 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.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0727 · Deficient, Provider has date of correction (Aug 6, 2019)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Deficient, Provider has date of correction (Aug 6, 2019)

DEnsure that residents are free from significant medication errors.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0760 · Deficient, Provider has date of correction (Aug 6, 2019)

DEnsure 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0761 · Deficient, Provider has date of correction (Aug 6, 2019)

DProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (Aug 6, 2019)