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Inspection visit

Inspection

ENCORE AT WINDSOR HILLSCMS #08506015 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.

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

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

  • 0131GeneralS&S Fpotential for harm

    Meet requirements for sections of health care facilities separated by fire resistive construction.

  • 0623GeneralS&S Dpotential 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.

  • 0644GeneralS&S Dpotential for harm

    F644 - Coordination

    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

  • 0689SeriousS&S Gactual harm

    F689 - Accidents

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

  • 0712GeneralS&S Dpotential for harm

    F712 - Frequency of physician visits

    Ensure that the resident and his/her doctor meet face-to-face at all required visits.

  • 0761GeneralS&S Dpotential 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.

  • 0804GeneralS&S Dpotential for harm

    F804 - Food and drink

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  • 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.

  • 0225GeneralS&S Epotential for harm

    Have stairways and smokeproof enclosures used as exits that meet safety requirements.

  • 0232GeneralS&S Epotential for harm

    Have corridors or aisles that are unobstructed and are at least 8 feet in width.

  • 0363GeneralS&S Epotential for harm

    Install corridor and hallway doors that block smoke.

  • 0372GeneralS&S Epotential for harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  • 0511GeneralS&S Epotential for harm

    Have properly installed electrical wiring and gas equipment.

  • 0911GeneralS&S Epotential for harm

    F911 - Accommodate no more than four residents

    Meet requirements for the installation and maintenance of electrical systems.

FAQ · About this visit

Common questions about this visit

What happened during the February 26, 2024 survey of ENCORE AT WINDSOR HILLS?

This was a inspection survey of ENCORE AT WINDSOR HILLS on February 26, 2024. The surveyor cited 15 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at ENCORE AT WINDSOR HILLS on February 26, 2024?

Yes, 15 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."

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.