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Inspection visit

Health inspection

WINDCREST HEALTH AND REHAB INCCMS #04536715 citations on this visit
15 citations recorded

Citations

15 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0636GeneralS&S Epotential for harm

    F636 - Resident Assessment

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

  • 0638GeneralS&S Dpotential for harm

    F638 - Quarterly Review Assessment

    Assure that each resident’s assessment is updated at least once every 3 months.

  • 0641GeneralS&S Epotential for harm

    F641 - Accuracy of Assessments

    Ensure each resident receives an accurate assessment.

  • 0660GeneralS&S Epotential for harm

    F660 - Quality of life

    Plan the resident's discharge to meet the resident's goals and needs.

  • 0677GeneralS&S Dpotential for harm

    F677 - A resident who is unable to carry out activities of daily living receives

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

  • 0791GeneralS&S Dpotential for harm

    F791 - Dental Services

    Provide or obtain dental services for each resident.

  • 0865GeneralS&S Fpotential for harm

    F865 - Quality assurance and performance improvement (QAPI) program

    Have a plan that describes the process for conducting QAPI and QAA activities.

  • 0656GeneralS&S Dpotential for harm

    F656 - Comprehensive Care Plans

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

  • 0657GeneralS&S Epotential for harm

    F657 - Comprehensive Care Plans

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

  • 0689GeneralS&S Epotential for harm

    F689 - Accidents

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

  • 0756GeneralS&S Epotential for harm

    F756 - Drug Regimen Review

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  • 0761GeneralS&S Epotential for harm

    F761 - Labeling of Drugs and Biologicals

    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.

  • 0805GeneralS&S Epotential for harm

    F805 - Food and drink

    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

  • 0812GeneralS&S Fpotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0623GeneralS&S Epotential for harm

    F623 - Transfer and discharge-

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

FAQ · About this visit

Common questions about this visit

What happened during the July 29, 2022 survey of WINDCREST HEALTH AND REHAB INC?

This was a inspection survey of WINDCREST HEALTH AND REHAB INC on July 29, 2022. The surveyor cited 15 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at WINDCREST HEALTH AND REHAB INC on July 29, 2022?

Yes, 15 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.