Windsor Manor Rehabilitation Center

Inspection Results

Nursing Homes California Concord Windsor Manor Rehabilitation Center

Windsor Manor Rehabilitation Center has been cited for a total of 52 deficiencies since we began saving each survey. We believe it is worthwhile to show how things are and were. Some improve and some get worse. Rather than a snapshot, we take s longer view than most. A longer view, we believe, paints a better and more worthwhile picture. We start from them most recent and go back as you scroll down.

Tip: Surveys happen throughout the year and you may want to check with the location or here to see if more recent data is available for Windsor Manor Rehabilitation Center.

Since we bagan longer term (multi year tracking, numbers will naturally be higher than 3 (or so surverys).
There are 1244 nursing homes in California with a total of 104,457 deficiencies resulting in an average of 83.97 deficiencies per nursing home.

The following table describes how deficiencies are scored. An easy way to remember the severity of a deficiency's scope is that the further along in the alphabet (A through L) the scope value is, the more severe the deficiency is.
Additionally, A through F means no actual harm has happened.

Table describing the severity and scope of deficiencies

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Deficiency Cited, Scope, survery date, stems from a complaint, and Date of Correction

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

Category:

Resident Rights Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2023-09-14

Corrected:

2023-10-14

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Category:

Quality of Life and Care Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2023-09-14

Corrected:

2023-10-14

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Category:

Quality of Life and Care Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2023-09-14

Corrected:

2023-10-14

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.

Category:

Pharmacy Service Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2023-09-14

Corrected:

2023-10-14

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.

Category:

Administration Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2023-09-14

Corrected:

2023-10-14

Provide care and assistance to perform activities of daily living for any resident who is unable.

Category:

Quality of Life and Care Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2023-08-31

Corrected:

2023-09-29

Have policies on smoking.

Category:

Environmental Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2023-08-31

Corrected:

2023-09-29

Ensure that residents are free from significant medication errors.

Category:

Pharmacy Service Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2020-09-21

Corrected:

2020-11-02

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.

Category:

Pharmacy Service Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2020-07-01

Corrected:

2020-09-28

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

Category:

Resident Rights Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2019-08-29

Corrected:

2019-09-29

Ensure each resident receives an accurate assessment.

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2019-08-29

Corrected:

2019-09-29

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

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2019-08-29

Corrected:

2019-09-29

Provide care and assistance to perform activities of daily living for any resident who is unable.

Category:

Quality of Life and Care Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2019-08-29

Corrected:

2019-09-29

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Category:

Quality of Life and Care Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2019-08-29

Corrected:

2019-09-29

Ensure medication error rates are not 5 percent or greater.

Category:

Pharmacy Service Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2019-08-29

Corrected:

2019-09-29

Ensure that residents are free from significant medication errors.

Category:

Pharmacy Service Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2019-08-29

Corrected:

2019-09-29

Provide and implement an infection prevention and control program.

Category:

Infection Control Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2019-08-29

Corrected:

2019-09-29

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

Category:

Resident Rights Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2019-08-29

Corrected:

2019-09-29

Ensure each resident receives an accurate assessment.

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2019-08-29

Corrected:

2019-09-29

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

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2019-08-29

Corrected:

2019-09-29

Provide care and assistance to perform activities of daily living for any resident who is unable.

Category:

Quality of Life and Care Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2019-08-29

Corrected:

2019-09-29

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Category:

Quality of Life and Care Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2019-08-29

Corrected:

2019-09-29

Ensure medication error rates are not 5 percent or greater.

Category:

Pharmacy Service Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2019-08-29

Corrected:

2019-09-29

Ensure that residents are free from significant medication errors.

Category:

Pharmacy Service Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2019-08-29

Corrected:

2019-09-29

Provide and implement an infection prevention and control program.

Category:

Infection Control Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2019-08-29

Corrected:

2019-09-29

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

Category:

Resident Rights Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2018-09-27

Corrected:

2018-10-27

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2018-09-27

Corrected:

2018-10-27

PASARR screening for Mental disorders or Intellectual Disabilities

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2018-09-27

Corrected:

2018-10-27

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

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2018-09-27

Corrected:

2018-10-27

Provide activities to meet all resident's needs.

Category:

Quality of Life and Care Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2018-09-27

Corrected:

2018-10-27

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

Category:

Quality of Life and Care Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2018-09-27

Corrected:

2018-10-27

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

Category:

Quality of Life and Care Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2018-09-27

Corrected:

2018-10-27

Ensure each resident�s drug regimen must be free from unnecessary drugs.

Category:

Pharmacy Service Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2018-09-27

Corrected:

2018-10-27

Hire a qualified full-time social worker in a facility with more than 120 beds.

Category:

Administration Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2018-09-27

Corrected:

2018-10-27

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

Category:

Environmental Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2018-09-27

Corrected:

2018-10-27

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

Category:

Resident Rights Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2018-09-27

Corrected:

2018-10-27

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2018-09-27

Corrected:

2018-10-27

PASARR screening for Mental disorders or Intellectual Disabilities

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2018-09-27

Corrected:

2018-10-27

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

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2018-09-27

Corrected:

2018-10-27

Provide activities to meet all resident's needs.

Category:

Quality of Life and Care Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2018-09-27

Corrected:

2018-10-27

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

Category:

Quality of Life and Care Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2018-09-27

Corrected:

2018-10-27

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

Category:

Quality of Life and Care Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2018-09-27

Corrected:

2018-10-27

Ensure each resident�s drug regimen must be free from unnecessary drugs.

Category:

Pharmacy Service Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2018-09-27

Corrected:

2018-10-27

Hire a qualified full-time social worker in a facility with more than 120 beds.

Category:

Administration Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2018-09-27

Corrected:

2018-10-27

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

Category:

Environmental Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2018-09-27

Corrected:

2018-10-27

Provide necessary care and services to maintain or improve the highest well being of each resident .

Category:

Quality of Life and Care Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2017-09-08

Corrected:

2017-09-28

Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.

Category:

Pharmacy Service Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2017-09-08

Corrected:

2017-09-28

Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed.

Category:

Nutrition and Dietary Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2017-09-08

Corrected:

2017-09-28

Store, cook, and serve food in a safe and clean way.

Category:

Nutrition and Dietary Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2017-09-08

Corrected:

2017-09-28

At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.

Category:

Pharmacy Service Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2017-09-08

Corrected:

2017-09-28

Have a program that investigates, controls and keeps infection from spreading.

Category:

Environmental Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2017-09-08

Corrected:

2017-09-28

Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents.

Category:

Administration Deficiencies

Scope:

From Complaint:

Standard:

Survey Date:

2017-09-08

Corrected:

2017-09-28

Learn more about Windsor Manor Rehabilitation Center at the following resources

Inspection Results Penalty Enforcements Maps and Directions
Staff Size Medicare Ratings Ratings Comparison
or return to the main profile page for
Windsor Manor Rehabilitation Center

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