Inspection visit
Fire Safety inspection
Citations
21 citations recorded*CMS
This is a Fire Safety survey. CMS cites these findings under the Life Safety Code and Emergency Preparedness rules, a separate set from the health (F-tag) deficiencies. The codes and grading differ, so these do not link to the health violation pages.
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.
- 0007GeneralS&S Epotential for harm
Address patient/client population and determine types of services needed.
- 0009GeneralS&S Epotential for harm
Include a process for Emergency Preparedness collaboration.
- 0015GeneralS&S Epotential for harm
Address subsistence needs for staff and patients.
- 0022GeneralS&S Epotential for harm
Establish policies and procedures for sheltering.
- 0023GeneralS&S Epotential for harm
Establish policies and procedures for medical documentation.
- 0024GeneralS&S Epotential for harm
Establish policies and procedures for volunteers.
- 0026GeneralS&S Epotential for harm
Establish roles under a Waiver declared by secretary.
- 0029GeneralS&S Epotential for harm
Develop a communication plan.
- 0030GeneralS&S Epotential for harm
List the names and contact information of those in the facility.
- 0032GeneralS&S Epotential for harm
Provide primary/alternate means for communication.
- 0033GeneralS&S Epotential for harm
Establish methods for sharing information.
- 0034GeneralS&S Epotential for harm
Provide a means of sharing information on occupancy/needs.
- 0035GeneralS&S Epotential for harm
Provide family notifications of emergency plan.
- 0254GeneralS&S Dpotential for harm
Provide hallway or ground-level exits in all residents' rooms.
- 0331GeneralS&S Dpotential for harm
Construct fire resistant interior walls.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Dpotential for harm
Install corridor and hallway doors that block smoke.
- 0712GeneralS&S Epotential for harm
Have simulated fire drills held at unexpected times.
- 0923GeneralS&S Epotential for harm
Have proper medical gas storage and administration areas.
- 0006GeneralS&S Epotential for harm
Conduct risk assessment and an All-Hazards approach.
FAQ · About this visit
Common questions about this visit
What happened during the August 11, 2022 survey of WINDSOR HEALTH AND REHABILITATION CENTER?
This was a inspection survey of WINDSOR HEALTH AND REHABILITATION CENTER on August 11, 2022. The surveyor cited 21 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WINDSOR HEALTH AND REHABILITATION CENTER on August 11, 2022?
Yes, 21 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Address patient/client population and determine types of services needed."
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.
SourceView on CMS Care Compare
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.