Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Windsor The Ridge Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of exit-seeking behavior repeatedly left the facility without staff knowledge, despite being identified as at risk for elopement and having interventions such as a wander guard and increased supervision in place. Staff interviews and documentation revealed inconsistencies and lack of clarity in the implementation of monitoring and supervision, leading to multiple incidents where the resident exited the premises undetected.
Failure to Explain Risks and Benefits for Psychotropic Medication Consent: A resident with cervical spinal stenosis, bacteremia, depression, and PTSD was started on quetiapine, ramelteon, and sertraline, but the consent process did not include explanation of the risks and benefits. The ADON stated verbal consent was obtained by phone from the resident’s RP, yet the form did not identify the physician or document that material information was reviewed, and the RP stated she was not contacted, was not given written information, and did not sign informed consent.
Psychotropic Medication Used for Dementia-Related Behaviors: A resident with dementia, anxiety, depression, and severe cognitive impairment was ordered Depakote ER 250 mg at bedtime for behavioral disturbance manifested by verbal sexual disinhibition. Records showed the medication was treated as a mood stabilizer/anti-manic drug, the pharmacist had flagged the FDA-approved use issue, and the DON said the physician was notified but no change had been made. Staff described the resident as verbally and physically aggressive and needing two-person assistance during care.
Failure to Apply Ordered AFO Splint: A resident with left foot contracture, muscle weakness, and Alzheimer’s disease was observed in bed without the ordered AFO on the left foot. The resident said staff had not been putting it on for weeks. An RNA confirmed the splint was not applied and said they only worked certain days and did not know who would do it when they were absent. The ADON stated there was no system monitoring to confirm splint application, and the last documented application was months earlier. The physician order required bilateral AFOs 6 times per week for 8 hours as tolerated with skin checks, and the care plan called for daily use of the left resting splint.
Psychotropic Medication Not Available for A Resident A resident’s Seroquel 25 mg was not available during a med pass, delaying administration. An LVN said the refill had been faxed but could not produce documentation, while the ADON stated staff were expected to request refills when medication was running low and that the order had been entered in the system. The resident’s MAR showed quetiapine fumarate 25 mg ordered for physical and verbal aggression related to unspecified psychosis, and the resident’s record listed Alzheimer’s disease and unspecified psychosis.
A resident with dementia and behavioral disturbances was receiving Depakote ER for off-label use related to verbal sexual disinhibition. The pharmacist’s MRR identified that Depakote’s FDA-approved uses did not include dementia and requested clarification of the diagnosis or documentation of risk versus benefit, but the DON noted the MD was notified and no change had been made, and no physician documentation of risks and benefits was found.
A resident with PTSD, depression, and recent delirium was given Quetiapine for PTSD-related delirium even though the acute hospital discharge med list did not include it and the H&P did not mention continuing it. The LVN reported no behavioral symptoms since admission, and the DON verified the MAR showed no behaviors while the facility policy required documented indications and targeted behaviors before use of psychotropic meds.
A resident with essential hypertension did not receive Norvasc as prescribed, as the facility failed to document blood pressure and heart rate checks before administration. Additionally, there was no care plan addressing the resident's hypertension, contrary to facility policies. The DON confirmed these oversights during interviews and record reviews.
The facility failed to follow a physician's order to monitor a resident's inappropriate behavior every shift. Despite the resident's diagnoses of parkinsonism, mood disorder, and mild cognitive impairment, and a care plan that included monitoring for inappropriate touching, there was no documentation of such monitoring from 2/19/24 to 5/6/24. The Director of Nursing confirmed this lapse, which was against the facility's policies for documentation and implementing physician orders.
The facility failed to document the use of bed rail alternatives for 17 residents and did not obtain informed consent for one resident prior to the installation of bed rails. The Director of Staff Development confirmed the use of bed rails for turning and repositioning, but there was no documentation of alternatives being attempted. Additionally, the bed rail consent for one resident was obtained after the bed rails were already in use.
The facility failed to follow the standardized recipe for spinach and did not adhere to residents' dietary preferences, resulting in residents being served food items they disliked. Cook A added red bell peppers to spinach, which was not in the recipe, and two residents were served meals that did not align with their documented dislikes.
The facility failed to follow proper sanitation and food handling practices. A dietary aide did not perform proper hand hygiene after cleaning and handling dirty surfaces, and multiple food items were found in the freezer past their use-by dates. Additionally, a dented can of black beans was improperly stored on the dry storage shelf.
The facility failed to update the fall care plan for a resident with a history of falls and high fall risk due to conditions like Alzheimer's disease and a femur fracture. Despite multiple falls, the interdisciplinary team did not review and revise the care plan after each incident, leading to further falls.
The facility failed to implement its fall management policy for a resident with Alzheimer's disease and a history of falls. The resident did not receive a fall risk assessment upon readmission or after a significant change in condition, and the interdisciplinary team did not develop or implement new interventions after multiple falls. This resulted in subsequent falls and potential for serious injury.
The facility failed to ensure respect and dignity for five residents by not providing privacy sleeves for their indwelling catheter urinary bags. Observations and interviews confirmed that the urinary bags of these residents were visible and uncovered, contrary to the facility's policy on privacy and dignity.
The facility failed to follow policies on self-administration of medication for two residents, resulting in medications being left at the bedside without proper assessments or physician orders. One resident with moderately impaired cognition had antidiarrheal medication at their bedside, and another resident with intact cognition had eye drops at their bedside, both without necessary orders.
The facility failed to provide two residents with the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) when their Medicare benefits ended. The Business Office Manager was unaware of the requirement until recently, and the facility's policy was not followed, potentially leading to residents unknowingly assuming financial liability for non-covered services.
The facility failed to accurately complete the MDS for a resident with bipolar disorder, incorrectly marking the PASRR status as 'No' instead of 'Yes'. This error was confirmed by the MDS Coordinator and compromised the facility's ability to provide appropriate care plan interventions.
The facility failed to complete a Level II PASRR for two residents, one with paraplegia, schizophrenia, and morbid obesity, and another who was in isolation due to an infectious disease. The Minimum Data Set Coordinator acknowledged the oversight, and the facility's policy indicated that PASRR should be completed within 24 hours for new admissions.
The facility failed to develop and implement individualized care plans for three residents. One resident with mild depression had no care plan addressing his mood, another resident using oxygen and anticoagulant medication lacked care plans for both, and a third resident using oxygen also had no care plan. Staff confirmed these omissions, which were against the facility's policy.
The facility failed to follow physician's orders for oxygen supplementation for two residents. One resident with chronic respiratory failure and COPD received 2.5 liters per minute instead of the ordered 2 liters, and another resident with respiratory failure and heart failure received 2 liters per minute instead of the ordered 3 liters. LVN confirmed the discrepancies.
The facility failed to ensure that controlled medications were properly reconciled with the corresponding MAR for four residents. Medications were signed out of the CDR but not documented on the MAR, as confirmed through interviews and record reviews with LVNs and the PC.
The facility had an eight percent medication error rate when an LVN failed to administer Zyrtec and MiraLAX to a resident as per the physician's order, due to not checking the next page of the MAR.
The facility failed to label medications appropriately, as observed during a medication cart inspection. An opened bottle of Refresh Tears lubricant eyedrop, Vyzulta 0.024% Ophthalmic Solution, and Brimonidine Tartrate ophthalmic solution were found without open dates. The Pharmacy Consultant confirmed that ophthalmic solutions are good for 28 days after being opened and should be labeled with the resident's name and an open date.
The facility failed to serve food at an appetizing temperature for one test tray food item. The Dietary Manager found that the regular texture Club Spinach had an internal temperature of 125 degrees Fahrenheit, below the required 140 degrees Fahrenheit, after all residents were served the noon meal.
The facility failed to provide physician-prescribed therapeutic diets to four residents. Three residents on a Controlled Carbohydrate Diet were served the wrong dessert, and one resident on a Fortified Diet did not receive the fortified food item. The Dietary Manager confirmed these errors during the noon meal service.
The facility failed to ensure proper infection control practices when a CNA did not perform hand hygiene between assisting multiple residents with meals, and a nasal cannula was improperly stored on the floor in a resident's room. The CNA admitted to not using hand sanitizer due to skin dryness, and an LVN confirmed the improper storage of the nasal cannula.
The facility failed to maintain a safe and comfortable environment for two residents. One resident's bed controller was disconnected for two days, causing discomfort, while another resident's toilet paper holder was broken for three days without being reported or fixed. Staff were either unaware of the issues or did not follow the facility's maintenance reporting procedures.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
A deficiency occurred when the facility failed to adequately monitor and supervise a resident with severe cognitive impairment and a known history of exit-seeking behavior. The resident, who had diagnoses including type 2 diabetes mellitus, hypertension, alcohol dependence, depression, muscle weakness, and impaired mobility, was assessed as being at risk for elopement. Despite this, the resident was able to leave the facility on multiple occasions without staff knowledge. Documentation showed that the resident's care plan identified the risk and included interventions such as a wander guard device, increased supervision, and ensuring the resident's bedroom screen door was locked. On several occasions, the resident was found outside the facility or attempting to leave, sometimes without the wander guard in place or with the device removed. Staff interviews revealed inconsistencies in the implementation and documentation of increased supervision and 1:1 monitoring. There was also a lack of clarity and evidence regarding how these interventions were carried out. Orders were in place for frequent monitoring and checking the wander guard, but the resident was still able to exit the facility undetected, and staff did not always hear the wander guard alarm or find the device after incidents. The facility's failure to consistently implement and document the required supervision and monitoring interventions, as well as to ensure the effectiveness of the wander guard system, resulted in repeated incidents where the resident left the premises without staff awareness. This lack of adequate supervision and monitoring directly contributed to the deficiency cited in the report.
Failure to Explain Risks and Benefits for Psychotropic Medication Consent
Penalty
Summary
The facility failed to explain the risks and benefits of psychotropic medications during the consent process for one resident, who was admitted with diagnoses including cervical spinal stenosis, bacteremia, depression, and PTSD. Review of the resident’s September 2025 order summary showed orders for quetiapine fumarate 25 mg at bedtime related to PTSD manifested by delirium, ramelteon 8 mg at bedtime related to depression manifested by inability to sleep, and sertraline HCl 100 mg daily related to depression manifested by verbalization of feeling sad. During interview and record review, the LVN stated the ADON obtained verbal consent from the resident’s responsible party for ramelteon, sertraline, and quetiapine. The informed consent document showed verbal consent was obtained, but it did not identify the physician who obtained the consent or document that the risks and benefits were explained. The ADON stated she obtained verbal consent by telephone and that the risks and benefits were not explained during the consent process, adding that if the order came from the hospital, she did not do the risk and benefits unless it was a new order in the facility. The DON stated the physician should explain the risks and benefits when obtaining consent for psychotropic medications. The resident’s responsible party stated she did not receive a call from the facility to obtain consent, was not told the risks and benefits, and did not receive written information or sign an informed consent for these medications.
Psychotropic Medication Used for Dementia-Related Behaviors
Penalty
Summary
The facility did not ensure that one of five residents, Resident 8, was receiving medication for a specific diagnosed condition in a manner supported by the documentation reviewed. Resident 8 was admitted and readmitted with diagnoses including dementia with other behavioral disturbances, anxiety disorder, depression, and urinary tract infection. During observation, Resident 8 was alert and smiling, had a Foley catheter, and was noted to have enhanced barrier precautions on the door. The resident’s MDS showed a BIMS score of 3, indicating cognitive impairment. Record review showed an order for Depakote ER 250 mg by mouth at bedtime for dementia with behavioral disturbance manifested by verbal sexual disinhibition. The MAR also listed monitoring for episodes of verbal sexual disinhibition every shift, and facility documents identified Depakote as a mood stabilizer/anti-manic drug for dementia with behavioral disturbance. The pharmacist stated awareness that Depakote ER was ordered for dementia and had recommended review of FDA-approved diagnoses for use. The DON stated the physician had been notified of the pharmacist’s recommendation, but no changes had been made. Staff interviews described the resident as verbally and physically aggressive, grabbing and touching staff, and needing two-person assistance during care.
Failure to Apply Ordered AFO Splint
Penalty
Summary
The facility failed to ensure restorative care services were provided to Resident 11 by not applying the physician-ordered ankle foot orthosis (AFO) as directed. Resident 11’s admission record noted left foot contracture, muscle weakness, and Alzheimer’s disease. A rehabilitation screen documented severe bilateral ankle plantar flexion contractures and stated that therapist provided AFO splints for both ankles, with caregiver education done for CNA and nursing and an on-and-off schedule initiated for the splints. During observation, Resident 11 was lying in bed watching television without the AFO on the left foot. The resident stated that it was fine if staff put it on, but that it had been weeks since they had done so. The restorative nursing assistant confirmed the splint was not on and said it had not been applied that morning, adding that they only worked as RNA on Friday, Saturday, and Sunday and did not know who would do it when they were not there. The ADON stated there was no monitoring in the system to confirm whether the splint was applied and that the last documented application was on 06/27/2025. The physician order directed RNA to apply bilateral AFOs 6 times per week for 8 hours as tolerated with skin checks, and the care plan directed that the resident wear the left resting splint daily.
Psychotropic Medication Not Available for Resident
Penalty
Summary
The facility failed to ensure that a prescribed psychotropic medication was ordered and available for Resident 34, resulting in a delay in administration. During a medication pass observation on 9/24/2025 at 10:20 AM in front of room [ROOM NUMBER], Seroquel 25 mg was not available for the resident. When interviewed immediately afterward, the LVN stated that Seroquel was not available, did not know what happened, believed it had been ordered the prior Saturday, and said the refill order had been faxed to the pharmacy, but could not produce the documentation. A concurrent interview with the ADON and record review showed that staff were expected to request refills when medication was running low, with a sticker in the bubble pack serving as a reorder reminder. The ADON stated that the Seroquel 25 mg was ordered in the system on Monday, 9/22/2025, and that if the medication was not received, staff should follow up with the pharmacy to ensure timely delivery. Resident 34’s MAR showed quetiapine fumarate 25 mg ordered one time only for physical and verbal aggression related to unspecified psychosis, and the MAR also noted the medication was placed on hold. The resident’s admission record listed Alzheimer’s disease and unspecified psychosis not due to a substance or known physiological condition.
Pharmacist MRR Recommendation for Depakote Not Addressed
Penalty
Summary
The facility did not ensure that a licensed pharmacist’s monthly drug regimen review was acted upon for a resident receiving Depakote ER. The resident was admitted and readmitted with diagnoses including dementia with other behavioral disturbances, anxiety disorder, depression, and urinary tract infection. The order summary dated 9/25/25 showed Depakote ER 250 mg at bedtime for dementia with behavioral disturbances manifested by verbal sexual disinhibition, and the MAR for 9/1/25 through 9/30/25 listed anti-convulsant monitoring for episodes of verbal sexual disinhibition each shift. The pharmacist’s MRR dated 4/18/25 stated the resident was receiving Depakote for dementia and noted that the FDA-approved diagnoses for Depakote are absence seizures, migraine prophylaxis, myoclonic seizures, partial seizures, bipolar disorder, and mania, requesting clarification of the diagnosis or documentation of risk versus benefit for off-label use. Facility documentation showed the DON was aware of the issue and had notified the MD, but no change had been made. Nursing progress notes entered by the DON on 4/28/25 stated the MRR review related to Depakote off-label use and to notify the MD to document risk and benefits, but no physician documentation of risks and benefits was found. The facility policy required resident-specific irregularities and clinically significant medication risks to be reported and for recommendations to be acted upon and documented by facility staff and the prescriber.
Unnecessary Quetiapine Given Without Documented Indication
Penalty
Summary
The facility failed to ensure that one sampled resident was free from unnecessary drugs when Quetiapine (Seroquel) was administered for PTSD-related delirium. Resident 108 was admitted with diagnoses including cervical spinal stenosis, bacteremia, depression, and PTSD. During observation, the resident was sleeping in bed with the television on, and the LVN later stated she had not observed any behavioral symptoms since admission. Record review showed that the resident’s 9/2025 order summary included Quetiapine 25 mg, 0.5 tablet at bedtime related to PTSD manifested by delirium, with an active start date of 9/17/25. The acute hospital discharge summary dated 9/15/25 documented that delirium developed during the hospital course and that the resident received Seroquel 12.5 mg at bedtime as needed for agitation and insomnia, but Seroquel was not included in the discharge medication list. The resident’s H&P dated 9/16/25 listed PTSD with depression and insomnia and indicated continuation of Ramelteon, Sertraline, and trazodone as needed, with no mention of Quetiapine. During interviews, the ADON stated the hospital order was to continue Quetiapine for delirium, while the DON later verified that the physician’s progress notes and H&P did not mention continuing Quetiapine and that the discharge medication list did not include it. The DON also stated the resident’s MAR from 9/15/25 through 9/26/25 showed no behaviors and that a resident exhibiting behaviors for 72 hours should be evaluated for a true behavior prior to ordering and starting a psychotropic medication. The facility policy stated residents should only receive antipsychotic/psychotropic medications when necessary, that diagnoses alone do not warrant use, and that indications and targeted behaviors must be documented.
Failure to Administer Medication According to Physician Orders
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident diagnosed with essential hypertension. The resident was prescribed Norvasc, a hypertension medication, to be administered daily with specific instructions to hold the medication if the systolic blood pressure (SBP) was less than 110 or the heart rate (HR) was less than 60. However, from November 1 to November 11, the medication was administered without documented checks of the resident's blood pressure or heart rate, except on November 3 when the resident was noted as sleeping. This oversight was confirmed by the Director of Nursing (DON) during an interview and record review. Additionally, the facility did not have a care plan in place to address the resident's hypertension, which was acknowledged by the DON during a telephone interview. The facility's policies and procedures for administering medications and developing comprehensive care plans were not followed, as they require verification of vital signs before medication administration and the creation of a person-centered care plan to meet the resident's medical needs. The lack of adherence to these policies contributed to the deficiency identified in the care of the resident.
Failure to Monitor Resident's Inappropriate Behavior
Penalty
Summary
The facility failed to ensure care and services were provided in accordance with professional standards of practice for a resident when it did not follow the physician's order to monitor the resident's inappropriate behavior. The resident, who had diagnoses of parkinsonism, mood disorder, and mild cognitive impairment, was admitted with a care plan that included monitoring for episodes of inappropriate touching towards staff. Despite a physician's order to monitor the resident's inappropriate behaviors every shift, there was no documentation indicating that staff monitored these behaviors from the specified period of 2/19/24 to 5/6/24. During an interview and record review, the Director of Nursing confirmed the absence of documentation for monitoring the resident's inappropriate behavior as ordered. The facility's policies and procedures for accepting, transcribing, and implementing physician orders, as well as for documentation, were reviewed and indicated that all documentation should be completed as required for each resident. However, the facility did not adhere to these policies, resulting in a failure to monitor the resident's behavior as mandated by the physician's order.
Failure to Document Bed Rail Alternatives and Obtain Informed Consent
Penalty
Summary
The facility failed to attempt, offer, and document the use of bed rail alternatives for 17 residents and did not obtain informed consent for one resident prior to the installation of bed rails. During the initial tour observation, it was noted that these residents had upper bed rails elevated and in use. The Director of Staff Development confirmed that the bed rails were used for turning and repositioning. However, there was no documentation indicating that alternatives were attempted or offered for these residents. Additionally, the Medical Record Director confirmed that the bed rail consent for one resident was obtained after the bed rails were already installed and in use. The facility's policy and procedure on side-rail safety, revised in 2012, states that bed rails should only be used to facilitate mobility and that alternatives should be attempted before using side rails as a restraint. The policy also requires a side-rail safety assessment by a licensed nurse or the interdisciplinary team upon admission, when side rails are implemented, and at least quarterly. The administrator confirmed that there was no documentation of bed rail evaluations or the use of alternatives for the 17 residents and that the bed rail consent for one resident was obtained post-installation.
Failure to Follow Recipe and Resident Dietary Preferences
Penalty
Summary
The facility failed to ensure that the recipe for spinach was followed according to the ingredient list and that accurate diets were served according to resident preferences. During an observation, Cook A added cooked red bell peppers to the spinach, which was not listed in the recipe. The Dietary Manager confirmed that red bell peppers were not part of the recipe and acknowledged that the cook was instructed to add them for extra color. This deviation from the standardized recipe was observed during meal preparation for approximately 15 residents. Additionally, the facility did not adhere to residents' dietary preferences. Resident 36, who had a documented dislike for bell peppers, was served spinach with red bell peppers. Similarly, Resident 51, who had a documented dislike for gravy, was served turkey with gravy. The Dietary Manager confirmed that residents' food preferences should always be followed, including their dislikes. The facility's policy and procedure on standardized recipes and resident food preferences were not followed, leading to these deficiencies.
Improper Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to follow proper sanitation and food handling practices in the kitchen. Dietary Aide (DA) C was observed cleaning the floor and touching dirty surfaces without performing proper hand hygiene. DA C washed his hands with only water for approximately 15 seconds and then proceeded to unload clean utensils with his bare hands. During an interview, DA C acknowledged that he did not use soap and should have done so before handling clean dishes. This failure to follow hand hygiene protocols was observed during a kitchen inspection and confirmed through an interview with DA C. Additionally, multiple food items were found in the freezer past their use-by dates, including packages of hot dog and hamburger buns. Cook A confirmed that these items should have been discarded. Furthermore, a dented can of black beans was found on the dry storage shelf instead of being placed in the designated box for dented cans. The Dietary Manager (DM) confirmed that the can should not have been on the shelf for use. These observations indicate a failure to adhere to proper food storage and handling practices, which could potentially spread food-borne illnesses to residents.
Failure to Update Fall Care Plan
Penalty
Summary
The facility failed to update the fall care plan for Resident 84, who had a history of falls and was at high risk due to conditions such as a displaced intertrochanteric fracture of the right femur, Alzheimer's disease, and cognitive communication deficit. Despite the resident experiencing multiple falls, the interdisciplinary team did not review and revise the fall risk care plan after each incident. Specifically, after an unwitnessed fall on 2/3/2024 that resulted in hospitalization, there was no documentation of the care plan being updated upon the resident's return. Additionally, after another unwitnessed fall on 2/13/2024 and a witnessed fall on 3/19/2024, the care plan was noted to be updated, but no new fall risk interventions were implemented to prevent further falls. During an interview and record review on 3/28/2024, the Director of Staff Development confirmed that Resident 84's fall risk care plan was not updated following the falls on 2/3/2024 and 3/19/2024. The facility's policy on falls management, revised in 11/2012, mandates that recent falls be reviewed daily by a designated fall team to evaluate the cause and determine additional strategies to prevent recurrence. This policy was not adhered to, resulting in the failure to update and revise the care plan appropriately, leading to subsequent falls for Resident 84.
Failure to Implement Fall Management Policy for Resident
Penalty
Summary
The facility failed to implement its fall management policy and procedure for Resident 84, who had multiple falls. Resident 84, who had diagnoses including a displaced intertrochanteric fracture of the right femur, Alzheimer's disease, and cognitive communication deficit, was readmitted to the facility but did not receive a fall risk assessment upon readmission or after a significant change in condition. Despite having a history of falls and a recent fracture, the interdisciplinary team (IDT) did not develop or implement new interventions after Resident 84's falls on 2/3/2024, 2/13/2024, and 3/19/2024. This lack of action resulted in subsequent falls for Resident 84, who was observed with the bed not in the lowest position and floor mats that could be trip hazards in her room. Licensed vocational nurse K confirmed that fall risk assessments were only done upon admission, and not when there was a significant change in condition. The minimum data set coordinator (MDSC) and the director of staff development (DSD) both confirmed that no fall risk assessments were completed when Resident 84 was readmitted or when there was a significant change in condition. The physical therapist (PT) also confirmed that no post-fall screens were completed after Resident 84's falls, despite the resident being on therapy. The facility's policy on falls management, revised in 2012, indicated that residents should be assessed for fall risk and interventions should be implemented to reduce the risk of falls. The policy also stated that fall risk should be reassessed with each significant change of condition. However, this policy was not followed for Resident 84, leading to multiple falls and the potential for serious injury. The IDT failed to review and update the fall risk care plan and did not implement appropriate new interventions after each fall, as required by the facility's policy.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure respect and dignity for five residents by not providing privacy sleeves for their indwelling catheter urinary bags. Certified Nursing Assistant (CNA) N was observed preparing to empty Resident 94's urinary bag, which was visible from outside the room. Subsequent observations confirmed that Resident 94's urinary bag was not covered with a privacy sleeve. Similarly, Resident 199's urinary bag was visible from outside the room without a privacy sleeve. The Administrator confirmed that urinary bags should be covered with privacy sleeves. Resident 91, who has severe cognitive impairment and multiple medical conditions, was observed on two occasions with an uncovered urinary bag hanging under his wheelchair. During these observations, Resident 91's roommate had visitors in the room, making the uncovered urinary bag visible to them. Resident 3, who has intact cognition and multiple medical diagnoses, was also observed with an uncovered urinary bag that was easily visible to passersby in the hallway. Both a CNA and a Licensed Vocational Nurse (LVN) confirmed that Resident 3's urinary bag was not covered and acknowledged the importance of covering it for privacy. Resident 44 was observed lying in bed with his urinary bag hanging on a portable commode next to his bed, and the bag was not covered. An LVN verified that the urinary bag should be covered even when hanging on the commode. The facility's policy and procedure on privacy and dignity, revised on 10/24/17, indicated that residents' privacy and dignity should always be respected. However, the observations and interviews revealed that this policy was not followed, leading to a deficiency in maintaining residents' dignity and privacy.
Failure to Implement Self-Administration of Medication Policies
Penalty
Summary
The facility failed to implement their policies on self-administration of medication for two residents, leading to medications being left at the bedside without proper assessments or physician orders. Resident 84, who had moderately impaired cognition with a BIMS score of 9, was found with a bottle of antidiarrheal medication at their bedside, which they had brought from home. There was no physician order for this medication, and the resident had not been assessed for the ability to self-administer medications. The registered nurse confirmed the absence of such orders and acknowledged that the medication should not have been at the bedside. Similarly, Resident 3, who had an intact cognition with a BIMS score of 15, was observed with a bottle of eye drop medication on their overbed table. The resident stated they used the eye drops for dry eyes, but there was no physician order for this medication, nor an order allowing the resident to keep it at the bedside. The licensed vocational nurse confirmed the lack of orders and stated that the medication should not have been at the bedside. The facility's policy requires a self-administration assessment and physician order before allowing residents to self-administer medications, which was not followed in these cases.
Failure to Provide SNFABN to Residents
Penalty
Summary
The facility failed to provide two residents with the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), which is a financial liability notice. Resident 13 was admitted to the facility and had their stay covered by Medicare until 12/19/23, while Resident 83 had their Medicare benefits from 12/2/23 until 1/12/24. Both residents continued to reside at the facility after their Medicare benefits ended. During an interview, the Business Office Manager (BOM) confirmed that she had never issued an SNFABN before and was unaware of the requirement until she received training on 3/11/24. The Administrator also confirmed that the residents were supposed to receive the SNFABN when their Medicare benefits ended. The facility's policy and procedure, revised in August 2021, indicated that the SNFABN should be delivered with the Notice of Medicare Non-Coverage (NOMNC) to ensure timely delivery when a Part A covered stay ends. However, this procedure was not followed for Residents 13 and 83. The failure to provide the SNFABN could lead to residents unknowingly assuming financial liability for services not covered by Medicare.
Inaccurate MDS Completion for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for one of the sampled residents, Resident 63. Resident 63 was admitted with a diagnosis of bipolar disorder, a serious mental illness. The Preadmission Screening and Resident Review (PASRR) for Resident 63 indicated a 'Yes' for having a serious mental illness. However, during a review of Resident 63's MDS, it was found that section A1500, which pertains to the PASRR status, was incorrectly marked as 'No'. The MDS Coordinator confirmed that this section should have been coded as 'Yes'. The facility's policy and procedure for the Resident Assessment Instrument (RAI/MDS) requires that the MDS be completed timely and accurately according to federal guidelines. The failure to accurately assess Resident 63's mental health status compromised the facility's ability to provide appropriate, resident-centered care plan interventions. This discrepancy was identified during an interview and record review with the MDS Coordinator, who acknowledged the error in the MDS documentation.
Failure to Complete Level II PASRR for Two Residents
Penalty
Summary
The facility failed to ensure a Level II PASRR was completed for two residents, which is a federal requirement to ensure individuals with mental disorders and intellectual disabilities are not inappropriately placed in nursing homes for long-term care. Resident 41, who had diagnoses including paraplegia, schizophrenia, and morbid obesity, had a positive Level I PASRR screen completed but did not have a Level II PASRR completed due to being isolated as a health and safety precaution. The Minimum Data Set Coordinator (MDSC) acknowledged that the Level I PASRR was done either on admission or prior to admission and that all PASRR letters were uploaded into the electronic health record. However, the state portal website for PASRR does not trigger if a Level II was not done, leading to the oversight. Similarly, Resident 61, who had a positive Level I PASRR screen, did not have a Level II PASRR completed because they were in isolation due to an infectious disease when the Level II PASRR was scheduled. The MDSC admitted that the Level II PASRR was closed and never followed through to complete a new one. The facility's policy indicated that a PASRR should be completed and submitted online for new admissions within 24 hours, and recommendations from the Determination Letter should be included in the individual's Plan of Care. This failure had the potential to put the residents at risk for not receiving appropriate care and services for their mental health conditions.
Failure to Develop and Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized, resident-centered care plans for three residents. Resident 74, who was admitted with multiple diagnoses including depression, did not have a care plan addressing his mild depression despite showing signs of sadness and lack of motivation. The Social Service Director confirmed that no mood interventions were implemented after the initial assessment, and no care plan was developed to address Resident 74's mild depression. Resident 3, who was admitted with conditions requiring supplemental oxygen and anticoagulant medication, did not have care plans for either the use of oxygen or the anticoagulant medication. Observations confirmed that Resident 3 was using oxygen, and the MDS Coordinator verified that a care plan for oxygen use was not developed. Additionally, the Director of Staff Development confirmed that Resident 3 was taking Eliquis, an anticoagulant, but no care plan was created to manage its use. Resident 18, who was observed using oxygen, also did not have a care plan for its use. The Interim Director of Nursing confirmed that a care plan should have been developed for Resident 18's oxygen use. The facility's policy and procedure on care plans indicated that comprehensive, person-centered care plans should include measurable objectives and time frames to meet the resident's needs, but this was not followed for the three residents mentioned.
Failure to Follow Physician's Orders for Oxygen Supplementation
Penalty
Summary
The facility failed to ensure that residents received the necessary care and services according to physician's orders for oxygen supplementation. Resident 148, who was admitted with chronic respiratory failure, hypoxia, and COPD, had an order for continuous oxygen administration at 2 liters per minute via nasal cannula. However, observations revealed that Resident 148 was receiving oxygen at 2.5 liters per minute. Licensed Vocational Nurse (LVN) L confirmed the discrepancy and acknowledged that the oxygen administration should follow the physician's order of 2 liters per minute. Similarly, Resident 15, who was admitted with respiratory failure, hypoxia, chronic diastolic heart failure, and unspecified asthma, had an order for continuous oxygen administration at 3 liters per minute via nasal cannula. Observations showed that Resident 15 was receiving oxygen at 2 liters per minute. LVN L confirmed the observation and stated that the oxygen administration should be at 3 liters per minute as ordered by the physician. The facility's policy on oxygen administration emphasizes the importance of verifying the physician's order, including the liter flow rate, which was not adhered to in these cases.
Failure to Reconcile Controlled Medications with MAR
Penalty
Summary
The facility failed to ensure that controlled medications were properly reconciled with the corresponding Medication Administration Records (MAR) for four residents. Specifically, the medications were signed out of the Controlled Drug Record (CDR) but were not documented on the MAR to indicate that the controlled medications were administered to the residents. This discrepancy was identified for four residents who were receiving as-needed controlled medications, including Tramadol and Hydrocodone-Acetaminophen. The failure to document the administration of these medications on the MAR was confirmed through interviews and record reviews with Licensed Vocational Nurses (LVNs) and the Pharmacy Consultant (PC). For Resident 7, a tablet of Tramadol was removed and documented on the CDR but not on the MAR. Similarly, for Resident 37, multiple instances of Hydrocodone-Acetaminophen were documented on the CDR but not on the MAR. Resident 58 also had a tablet of Hydrocodone-Acetaminophen documented on the CDR but not on the MAR. Lastly, for Resident 76, a tablet of Tramadol was documented on the CDR but not on the MAR. The facility's policy and procedure require that controlled medications be documented both on the accountability record and the MAR immediately after administration, which was not followed in these cases.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility had an eight percent medication error rate when two medication errors out of 25 opportunities were observed during a medication pass for one resident. During a medication pass observation, a Licensed Vocational Nurse (LVN) was observed preparing and administering ten medications to a resident. However, the LVN failed to administer Zyrtec 10 mg and MiraLAX Oral Powder 17 grams as per the physician's order. The LVN confirmed that she forgot to go to the next page of the Medication Administration Record (MAR), resulting in the omission of these medications. The facility's policy and procedure indicated that medications should be administered in accordance with the written order of the attending physician.
Failure to Label Medications Appropriately
Penalty
Summary
The facility failed to ensure medications were labeled appropriately, as observed during a medication cart inspection. Specifically, an opened bottle of Refresh Tears lubricant eyedrop was found without a resident's name and an open date in medication cart AA. Additionally, an opened bottle of Vyzulta 0.024% Ophthalmic Solution and an opened bottle of Brimonidine Tartrate ophthalmic solution were also found without open dates. These observations were confirmed by a Licensed Vocational Nurse (LVN) during the inspection. During a phone interview with the Pharmacy Consultant (PC), it was confirmed that ophthalmic solutions are good for 28 days after being opened and should be labeled with the resident's name and an open date. The facility's policy and procedure, dated October 2017, also indicated that medications should be labeled in accordance with facility requirements and state and federal laws, with labels permanently affixed to the outside of the prescription container. The failure to label these medications appropriately could lead to the use of medications past their discard date, potentially resulting in unsafe and ineffective treatments for residents.
Failure to Serve Food at Appetizing Temperature
Penalty
Summary
The facility failed to serve food at an appetizing temperature for one test tray food item out of seven sampled food items. During an observation, Cook A added cooked red bell peppers to the cooked spinach, completing the cooking process at 11:59 a.m. Later, at 1:20 p.m., the Dietary Manager (DM) tested the internal temperature of seven food items on the sampled test tray after all residents were served the noon meal. One food item, the regular texture Club Spinach, had an internal temperature of 125 degrees Fahrenheit. The DM stated that all hot foods on the tray line should be maintained at 140 degrees Fahrenheit. The facility's policy and procedure indicated that hot foods should be held at 140 degrees Fahrenheit prior to service and that vegetables should be served promptly and not held on the steam table for long periods, with a maximum of one hour prior to serving.
Failure to Provide Physician-Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to provide the physician-prescribed therapeutic diet to four of 96 sampled residents. Three residents who were ordered a Controlled Carbohydrate Diet were served the wrong dessert item, Peach Cobbler Trifle, instead of the prescribed Vanilla Yogurt Mousse. This was observed during the noon meal service, and the Dietary Manager confirmed that the wrong dessert item was served to these residents. The meal tickets for these residents clearly indicated the Controlled Carbohydrate diet order, but the dietary aides did not follow the prescribed diet instructions. Additionally, one resident who was ordered a Fortified Diet did not receive the fortified food item, Super Soup, during the noon meal. The dietary aide failed to add the fortified soup to the resident's tray, and this was confirmed by the Dietary Manager. The meal ticket for this resident indicated the Fortified diet order, but the dietary aides did not comply with the prescribed diet. The facility's policy and procedure for therapeutic diets, which requires daily written instructions and proper training for dietary employees, was not followed in these instances.
Infection Control Deficiencies in Hand Hygiene and Equipment Storage
Penalty
Summary
The facility failed to ensure proper infection control practices were implemented in two specific instances. First, a certified nursing assistant (CNA) did not perform hand hygiene while serving and setting up lunch trays for multiple residents. The CNA was observed assisting one resident with drinking, then immediately assisting another resident without performing hand hygiene in between. This pattern continued as the CNA served lunch trays to other residents without sanitizing hands, despite the facility's policy requiring hand hygiene between patient interactions. The CNA admitted to not using hand sanitizer due to concerns about skin dryness, and the infection control preventionist confirmed that hand hygiene should be performed between resident care activities. Second, a nasal cannula used for oxygen administration was found improperly stored on the floor in a resident's room. The resident was lying in bed with an oxygen concentrator at the bedside, and the nasal cannula tubing was observed on the floor. A licensed vocational nurse (LVN) confirmed the improper storage and acknowledged that the nasal cannula should not be on the floor due to infection control concerns. The facility's policy indicated that oxygen tubing and cannulas should be changed weekly and as needed for excessive soiling, but did not specifically address storage practices.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, functional, and comfortable environment for two residents. Resident 94's bed controller was disconnected, leaving the head of the bed elevated for two days, causing discomfort. The Maintenance Director was aware of the issue but did not replace the bed until the following day. The Occupational Therapist was unaware of the problem until informed by the resident, and the facility's policy on accommodation of needs was not followed, as the resident's comfort was compromised for an extended period. Resident 41's toilet paper holder was broken for three days without being reported or fixed. The Maintenance Director could not find a work order for the issue, and staff members, including a CNA and an LVN, were either unaware of the problem or did not notice it. The facility's policy on work orders was not adhered to, as the broken toilet paper holder remained unfixed despite the process for reporting maintenance issues being in place.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 184 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Salinas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Coastal Post Acute | 0 mi | ★★★★★ | 0 | 0 |
| Katherine Healthcare | 2.2 mi | ★★★★★ | 22 | 0 |
| Salinas Valley Post Acute | 2.6 mi | ★★★★★ | 29 | 0 |
| Pacific Coast Post Acute | 2.6 mi | ★★★★★ | 4 | 0 |
| Carmel Hills Care Center | 12.8 mi | ★★★★★ | 31 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.