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Windsor Estates Health And Rehabilitation Center
429 WEST LINCOLN ROAD
Kokomo, IN 46902
(765) 453-5600
General
Ratings
Deficiencies
Resident Stats
Staff Stats
| Certified Beds: | 131 |
| Number of Residents: | 102 |
| Percent of Occupied Beds: | 78% |
| Sprinkler Status: | Fully Sprinklered |
| Program Participation: | Medicare and Medicaid |
| Type of Ownership: | For profit - Corporation |
| Located Within a Hospital? | No |
| Multi Nursing Home Ownership? | Yes |
| Resident and Family Councils? | Resident |
| Continuing Care Retirement Community? | No |
| Quality Indicator Survey? | No |
| Special Focus Facility? | No |
| Overall: |  |
| Health Inspection: |  |
| Nurse Staffing: |  |
| Quality Measures: |  |
| RN Only: | |
| Date | Type | Category | Deficiency | Scope | Level of Harm | Date of Correction |
| 20070906 | Health | Resident Rights Deficiencies | Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged. | Pattern | Minimal harm or potential for actual harm | 20071005 |
| 20070906 | Health | Resident Rights Deficiencies | Provide enough notice before discharging or transferring a resident. | Isolated | Minimal harm or potential for actual harm | 20071005 |
| 20070906 | Health | Resident Rights Deficiencies | Tell the resident or the resident's representative in writing how long the nursing home will hold the resident's bed when the resident temporarily leaves the facility. | Isolated | Minimal harm or potential for actual harm | 20071005 |
| 20070906 | Health | Mistreatment Deficiencies | Keep each resident free from drugs that restrain them, unless needed for medical treatment. | Isolated | Minimal harm or potential for actual harm | 20071005 |
| 20070906 | Health | Mistreatment Deficiencies | 1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Isolated | Minimal harm or potential for actual harm | 20071005 |
| 20070906 | Health | Resident Assessment Deficiencies | Make a complete assessment that covers all questions for areas that are listed in official regulations. | Pattern | Minimal harm or potential for actual harm | 20071005 |
| 20070906 | Health | Resident Assessment Deficiencies | Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured. | Isolated | Minimal harm or potential for actual harm | 20071005 |
| 20070906 | Health | Resident Assessment Deficiencies | 1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan. | Pattern | Minimal harm or potential for actual harm | 20071005 |
| 20070906 | Health | Quality Care Deficiencies | Give professional services that meet a professional standard of quality. | Isolated | Actual harm | 20071005 |
| 20070906 | Health | Resident Assessment Deficiencies | Provide a final summary of the resident's health status and a summary of the resident's stay, when the resident is ready to leave the nursing home. | Isolated | Minimal harm or potential for actual harm | 20071005 |
| 20070906 | Health | Resident Assessment Deficiencies | Develop a plan with the resident and family for the resident's care after leaving the nursing home. | Isolated | Minimal harm or potential for actual harm | 20071005 |
| 20070906 | Health | Quality Care Deficiencies | Give each resident care and services to get or keep the highest quality of life possible. | Isolated | Minimal harm or potential for actual harm | 20071005 |
| 20070906 | Health | Quality Care Deficiencies | Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary. | Isolated | Actual harm | 20071005 |
| 20070906 | Health | Quality Care Deficiencies | Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion. | Isolated | Minimal harm or potential for actual harm | 20071005 |
| 20070906 | Health | Quality Care Deficiencies | Make sure that a resident who has been able to eat enough alone or with help is not fed by a feeding tube, if possible. | Isolated | Minimal harm or potential for actual harm | 20071005 |
| 20070906 | Health | Environmental Deficiencies | Make sure that the nursing home area is free of dangers that cause accidents. | Isolated | Minimal harm or potential for actual harm | 20071005 |
| 20070906 | Health | Administration Deficiencies | Keep accurate and appropriate medical records. | Pattern | Minimal harm or potential for actual harm | 20071005 |
| 20070906 | Health | Administration Deficiencies | Keep clinical information safe, so that it will not be lost, destroyed or used by the wrong person. | Widespread | Minimal harm or potential for actual harm | 20071005 |
| 20070906 | Health | Quality Care Deficiencies | Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Isolated | Actual harm | 20071005 |
| 20070906 | Health | Pharmacy Service Deficiencies | 1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects. | Isolated | Minimal harm or potential for actual harm | 20071005 |
| 20070906 | Health | Pharmacy Service Deficiencies | Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly. | Isolated | Minimal harm or potential for actual harm | 20071005 |
| 20070906 | Health | Pharmacy Service Deficiencies | Properly mark drugs and other similar products. | Pattern | Minimal harm or potential for actual harm | 20071005 |
| 20070906 | Health | Environmental Deficiencies | Have a program to keep infection from spreading. | Pattern | Minimal harm or potential for actual harm | 20071005 |
| 20070906 | Health | Administration Deficiencies | Give or get lab tests to meet the needs of residents. | Isolated | Minimal harm or potential for actual harm | 20071005 |
| 20070906 | Health | Administration Deficiencies | Quickly tell the resident's doctor the results of lab tests. | Isolated | Minimal harm or potential for actual harm | 20071005 |
| 20080227 | Health | Administration Deficiencies | Give or get lab tests to meet the needs of residents. | Isolated | Minimal harm or potential for actual harm | 20080502 |
| 20080227 | Health | Pharmacy Service Deficiencies | 1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects. | Isolated | Minimal harm or potential for actual harm | 20080502 |
| 20080227 | Health | Administration Deficiencies | Keep accurate and appropriate medical records. | Pattern | Minimal harm or potential for actual harm | 20080502 |
| 20080227 | Health | Quality Care Deficiencies | Give professional services that follow each resident's written care plan. | Isolated | Minimal harm or potential for actual harm | 20080502 |
| 20080227 | Health | Resident Assessment Deficiencies | Make a complete assessment that covers all questions for areas that are listed in official regulations. | Isolated | Minimal harm or potential for actual harm | 20080502 |
| 20080227 | Health | Mistreatment Deficiencies | 1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Isolated | Minimal harm or potential for actual harm | 20080502 |
| 20080402 | Health | Nutrition and Dietary Deficiencies | Make sure that residents are well nourished. | Pattern | Minimal harm or potential for actual harm | 20080502 |
| 20080402 | Health | Nutrition and Dietary Deficiencies | Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Pattern | Minimal harm or potential for actual harm | 20080502 |
| 20080402 | Health | Nutrition and Dietary Deficiencies | Offer other nutritional food to each resident who will not eat the food served. | Isolated | Minimal harm or potential for actual harm | 20080502 |
| 20080402 | Health | Nutrition and Dietary Deficiencies | 1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day. | Isolated | Minimal harm or potential for actual harm | 20080502 |
| 20080402 | Health | Nutrition and Dietary Deficiencies | Store, cook, and give out food in a safe and clean way. | Pattern | Minimal harm or potential for actual harm | 20080502 |
| 20080904 | Health | Environmental Deficiencies | Have a program to keep infection from spreading. | Isolated | Minimal harm or potential for actual harm | 20080926 |
| 20080904 | Health | Administration Deficiencies | Keep accurate and appropriate medical records. | Isolated | Minimal harm or potential for actual harm | 20080926 |
| 20080904 | Health | Resident Rights Deficiencies | Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged. | Isolated | Minimal harm or potential for actual harm | 20080926 |
| 20080904 | Health | Resident Assessment Deficiencies | Make a complete assessment that covers all questions for areas that are listed in official regulations. | Isolated | Minimal harm or potential for actual harm | 20080926 |
| 20080904 | Health | Quality Care Deficiencies | Give professional services that follow each resident's written care plan. | Isolated | Minimal harm or potential for actual harm | 20080926 |
| 20080904 | Health | Environmental Deficiencies | Make sure that the nursing home area is free of dangers that cause accidents. | Isolated | Minimal harm or potential for actual harm | 20080926 |
| 20080904 | Health | Quality Care Deficiencies | Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Isolated | Minimal harm or potential for actual harm | 20080926 |
| 20090901 | Health | Quality Care Deficiencies | Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Isolated | Actual harm | 20090925 |
| 20090901 | Health | Administration Deficiencies | Keep accurate and appropriate medical records. | Isolated | Minimal harm or potential for actual harm | 20090925 |
| 20100602 | Health | Administration Deficiencies | Keep accurate and appropriate medical records. | Isolated | Minimal harm or potential for actual harm | 20100624 |
| 20100610 | Health | Administration Deficiencies | Keep accurate and appropriate medical records. | Pattern | Minimal harm or potential for actual harm | 20100624 |
| 20100610 | Health | Quality Care Deficiencies | Provide social services for related medical problems to help each resident achieve the highest possible quality of life. | Isolated | Minimal harm or potential for actual harm | 20100624 |
| Value | Notes | |
| Percent of long-stay residents given influenza vaccination during the flu season: | 93 | |
| Percent of long-stay residents who were assessed and given pneumococcal vaccination: | 97 | |
| Percent of long-stay residents whose need for help with daily activities has increased: | 20 | |
| Percent of long-stay residents who have moderate to severe pain: | 3 | |
| Percent of high-risk long-stay residents who have pressure sores: | 21 | |
| Percent of low-risk long-stay residents who have pressure sores: | 2 | |
| Percent of long-stay residents who were physically restrained: | 2 | |
| Percent of long-stay residents who are more depressed or anxious: | 21 | |
| Percent of low-risk long-stay residents who lose control of their bowels or bladder: | 38 | |
| Percent of long-stay residents who have/had a catheter inserted and left in their bladder: | 10 | |
| Percent of long-stay residents who spend most of their time in bed or in a chair: | 4 | |
| Percent of long-stay residents whose ability to move about in and around their room got worse: | 7 | |
| Percent of long-stay residents who had a urinary tract infection: | 5 | |
| Percent of long-stay residents who lose too much weight: | 11 | |
| Percent of short-stay residents given influenza vaccination during the flu season: | 93 | |
| Percent of short-stay residents who were assessed and given pneumococcal vaccination: | 99 | |
| Percent of short-stay residents who have delirium: | 0 | |
| Percent of short-stay residents who had moderate to severe pain: | 25 | |
| Percent of short-stay residents who have pressure sores: | 14 | |
| # of Residents: | 102 |
| # RN Hours per Resident: | 0.69 |
| # LPN Hours per Resident: | 1.34 |
| # CNA Hours per Resident: | 2.22 |
| Total Staff Hours per Resident: | 2.03 |
