Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Winslow House Care Center during CMS and state inspections, most recent first.
A resident who required substantial/maximal assistance for transfers and was identified as a fall risk was being moved from bed to a shower chair using a full body mechanical lift operated by two CNAs. After the sling was raised, the CNA operating the lift activated the leg-spreading function, assumed the legs were fully opened based on the usual grinding noise, and then backed and turned the lift. Because the lift legs were not fully spread, the lift became imbalanced, tipped to one side, and the wheels lifted off the floor, causing the resident to be lowered to the ground while still attached to the lift. The lift’s crossbar struck the resident’s eyebrow, resulting in a bruise, and the resident also sustained a small skin tear on the toe, as documented by nursing staff.
The facility failed to maintain an effective QAPI process to identify and correct a previously cited infection control deficiency. A prior survey had found that staff did not use Enhanced Barrier Precautions during care for at-risk residents, and a later complaint and incident survey again cited the same issue under F880. The Administrator reported that she monitors and audits QAPI effectiveness and confirmed the ongoing concern about the repeated infection control deficiency, with 47 residents in the facility at the time.
A resident with multiple comorbidities, severe cognitive impairment, and a Stage III pressure ulcer on the left lateral foot had a physician order for daily evening-shift wound care, including cleansing, betadine application, and foam dressing with gauze wrap. After a visit to a wound provider, the resident’s wound dressing remained dated from that appointment, and the resident reported that wound care had not been done for at least one night. A PT note and incident report documented that the dressing had not been changed as ordered, while an LPN had signed the treatment record indicating wound care was completed on several days, later admitting he had not performed the dressing change and had signed it off because the wound clinic had changed the dressing. An RN subsequently confirmed the outdated dressing and completed the overdue treatment, revealing a failure to provide and accurately document wound care as ordered.
A resident with multiple comorbidities, severe cognitive impairment, and a stage 3 pressure ulcer had a care plan requiring Enhanced Barrier Precautions (EBP), including gown and glove use for high-contact care, PPE availability at the room entrance, and door signage indicating required precautions. During an observed wound dressing change, an RN performed the entire procedure without donning a gown, and the room lacked both PPE signage and available PPE. The RN later stated she forgot to wear the gown and noted the absence of signage after the resident’s recent room change, despite facility policy directing gown and glove use for wound care under EBP.
Staff failed to use EBP during high-contact care for two residents with wounds and failed to use appropriate PPE while handling dirty laundry. One resident had a heel pressure ulcer and another had stage II buttock pressure ulcers, and both had care plans directing EBP. Staff assisted with transfers, repositioning, bed making, wheelchair setup, toileting, and dressing-related care without gowns and gloves as directed by the EBP signs. Laundry staff also handled soiled linen without an apron, despite the facility policy requiring gloves and other appropriate PPE.
A resident with intact cognition and diagnoses including CAD, asthma, and OSA had no CPR/DNR preference documented in the care plan, EHR, or paper chart after returning from the hospital. An LPN searched the chart and could not find the code status form, and the DON and Administrator confirmed the facility was unable to locate the document after the original was sent to the hospital.
A resident with PASRR Level II approval for schizoaffective disorder, bipolar type had MDS assessments that did not reflect the current PASRR status or diagnosis. One MDS marked the PASRR question as “no,” and two MDSs lacked documentation of schizoaffective disorder. The DON stated the resident’s MDSs should have reflected the current PASRR Level II status and diagnosis.
Failure to obtain and implement PASRR requirements for a resident with bipolar disorder and schizoaffective disorder, bipolar type. The facility had the Level I in the record but did not obtain the Level II PASRR, did not resubmit before the short-term approval expired, and the care plan did not address the PASRR recommendations or specialized services. The DON stated she was unaware the Level II PASRR existed and did not know of a PASRR policy or procedure.
A resident with stroke, dementia, depression, severe cognitive impairment, impaired mobility, and incontinence did not receive the ordered bathing support needed for ADLs. The care plan called for whirlpool/shower bathing twice weekly, but the resident was bathed only once during the review period, while repeated observations showed unkempt, stringy, and matted hair. Records showed several shower refusals, but documentation did not show alternate bathing options, additional interventions, or notification of the provider or RP.
Failure to Update Daily Nurse Staffing Posting: The facility did not keep the daily nurse staffing posting current for residents and visitors. The posting at the main entrance was outdated, and review of the Daily Staff Posting records showed no staffing edits or changes for the month. Staff interviews showed confusion about who was responsible for updating the posting, with the RN staff and DON giving different accounts and the DON stating that new night shift nurses were supposed to change it over.
Staff failed to consistently document the administration and inventory of controlled medications, resulting in discrepancies between medication counts, delivery records, and the Medication Administration Record. In several cases, staff administered narcotics without immediate documentation, and incomplete records prevented accurate tracking of controlled substances for multiple residents with pain management needs.
The facility failed to update care plans for two residents, one with schizophrenia and another with hearing impairment. The care plan for the resident with schizophrenia lacked goals and interventions related to the diagnosis, while the resident with hearing impairment reported inadequate staff accommodation for her needs. Staff interviews revealed unclear responsibilities for updating care plans.
A resident requiring gastric tube medication administration experienced deficiencies in care when medications were given late without physician notification, an extended-release tablet was crushed, and Enhanced Barrier Precautions were not followed. The RN failed to wear a protective gown during the process, contrary to facility policy.
Improper Mechanical Lift Use Leads to Resident Fall and Minor Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe use of a full body mechanical lift during a bed-to-chair transfer, resulting in a fall with injury for one resident. The resident had no cognitive impairment, required substantial/maximal assistance for transfers, and had diagnoses including heart failure, diabetes, and a left heel pressure ulcer. The resident was care planned as a fall risk, with directions for staff to use a full body lift with two staff for transfers to a shower chair. On the day of the incident, two CNAs used a brand-name full body mechanical lift to transfer the resident from bed to a shower chair. During the transfer, staff reported that after raising the resident in the sling, the CNA operating the lift pressed the control to separate the lift’s legs and heard the usual grinding noise, then assumed the legs had fully opened. She then backed the lift away from the bed and began to turn it toward the shower chair. As the lift was turned, it began to lean to one side, and the wheels lifted from the floor. Staff accounts and subsequent checks indicated that the legs of the lift had not been fully opened, causing imbalance and tipping of the lift while the resident was suspended. As the lift tipped, one CNA attempted to hold the lift and another attempted to support and lower the resident. The lift’s crossbar struck the resident’s eyebrow, causing a bruise measuring 2.5 cm by 1 cm, and the resident also sustained a skin tear on the lateral side of the right great toe measuring 1 cm by 0.5 cm. The resident was found on the floor on her back with knees bent, still attached to the lift, which was on its side. The resident reported that the machine tipped over while staff were transferring her. Staff and nursing assessments documented the bruise to the forehead and the skin tear to the toe, which healed within a few days, and the resident denied pain, headache, or nausea following the incident.
Repeated Infection Control Deficiency Due to Ineffective QAPI Process
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective Quality Assurance Performance Improvement (QAPI) process to identify and correct a previously cited infection control problem. A prior CMS 2567 dated 9/25/2025 documented a deficiency for staff failure to use Enhanced Barrier Precautions during resident care for residents identified as at risk. During a subsequent complaint and facility-reported incident survey on 1/28/2026, surveyors again identified the same infection control deficiency under F880, indicating that staff continued not to use Enhanced Barrier Precautions as required for at-risk residents. In an interview on 1/28/2026, the Administrator stated that she monitors and audits the effectiveness of the QAPI process and acknowledged the concern about the repeated pattern of the F880 deficiency. The facility had a reported census of 47 residents at the time of the current survey.
Failure to Complete and Accurately Document Ordered Wound Care Treatment
Penalty
Summary
The deficiency involves the facility’s failure to complete ordered wound treatment for a resident with a documented Stage III pressure ulcer on the left lateral foot. The resident’s MDS showed diagnoses including heart failure, diabetes, non-Alzheimer’s dementia, vascular disease, and a Stage III pressure ulcer, with severe cognitive impairment (BIMS score 5/15) and a need for staff assistance with ADLs. The care plan directed staff to assess the pressure ulcer and surrounding skin weekly and to complete treatments as ordered. A physician order dated 11/17/25 specified that staff were to cleanse the foot wound and surrounding skin, paint the callous and wound with betadine, cover with a foam dressing, and secure with gauze wrap and tape, to be completed daily on the evening shift. On 12/16/25, the resident attended a local wound provider appointment and returned without new orders. A progress note from the wound provider on that date documented that the wound appeared worse, with increased dimensions, and described the diabetic left lateral wound as clean, painful, and fragile, present for more than a year. On 12/18/25, a physical therapy treatment note documented that the resident stated wound care had not been completed the previous night and that the wound cover was still dated 12/16 from the wound doctor appointment; the Administrator was notified. An incident report from the same date recorded that the Administrator was informed that the dressing on the resident’s left foot had a past date and had not been changed on the evening shift, and that when the day nurse went to change the dressing, the resident reported that no one had changed the dressing for a couple of days. Review of the December 2025 treatment record showed that an LPN (Staff K) had signed off the wound treatment as completed on 12/15, 12/16, and 12/17, placing his initials with a check mark indicating completion. In a subsequent interview, Staff K admitted he forgot to do the dressing change on the day the resident went to the wound clinic, could not recall the exact date, and stated he had just signed it off because the wound clinic had done the dressing change that day. He further stated that he did not make any progress notes regarding the wound and reported that everyone else did it that way on days a resident went to the wound clinic. The DON and ADON reported becoming aware of the issue when the resident was found on 12/18/25 with a dressing dated 12/16/25, and an RN confirmed observing the dressing dated 12/16 and completing the scheduled dressing change on her shift because it had apparently not been done as ordered on 12/17. The facility’s medication administration policy required staff to administer medications as prescribed and to sign the medication administration record after administration, underscoring that documentation should reflect actual completion of ordered treatments.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not utilizing Enhanced Barrier Precautions (EBP) for a resident requiring wound care. The resident had diagnoses including heart failure, diabetes, non-Alzheimer’s dementia, vascular disease, and a stage 3 pressure ulcer, and required substantial assistance with toileting and bathing and partial assistance with ambulation. The MDS showed a BIMS score of 5/15, indicating severe cognitive impairment. The resident’s care plan, dated 9/8/25, specified the need for EBP due to a wound, with goals to reduce the spread of infectious agents and minimize transmission of infection. Interventions directed staff to wear a gown and gloves for high-contact activities, keep PPE available near the room entrance, maintain signage on the door indicating required precautions and PPE, and practice good hand hygiene. On observation, the resident’s bedroom door lacked PPE signage and the room did not have PPE available for staff use. A RN entered the room to perform a daily dressing change and, contrary to the EBP requirements and facility policy, did not don a disposable gown while assembling supplies, elevating the resident’s foot, removing a soiled dressing with a dark substance, measuring the wound, performing the wound treatment, and re-dressing the wound. The RN acknowledged in interview that she did not wear a gown as required and attributed this to forgetting, noting the absence of a sign on the door and that the resident had recently changed rooms. The Assistant DON later stated that the resident had recently changed rooms and that staff must not have brought the sign and PPE to the new room. Review of the facility’s Transmission Based Precautions policy, updated 4/1/24, confirmed that EBP requires staff to don gowns and gloves prior to high-contact care activities such as wound care for any skin opening requiring a dressing.
Failure to Use EBP and PPE
Penalty
Summary
The facility failed to use Enhanced Barrier Precautions (EBP) for resident care activities involving two residents with wounds. Resident #3 had diagnoses including a pressure ulcer of the left heel and diabetes mellitus, with a BIMS score of 15 out of 15, and her care plan directed EBP related to wound care. Staff entered her room on multiple occasions and assisted with transfers, repositioning in the wheelchair, making the bed, placing wheelchair footrests and arms, and applying her boot without using EBP, even though the EBP sign was posted on the room door and supplies were available. Resident #32 had diagnoses including stroke, hypertension, and anxiety, with a BIMS score of 15 out of 15, and her care plan identified stage II pressure ulcers to both buttocks with a direction for EBP. Staff assisted her to the bathroom and then to her recliner without wearing a gown or gloves, despite the EBP sign on the room door directing staff to use gloves and a gown for high-contact care activities. The facility also failed to use appropriate PPE while handling dirty laundry. In the laundry room, a black water pipe above hanging clean clothes had debris measuring about 1/2 inch thick by 2 feet long, and a wall fan above the folding table had debris on it. The laundry staff reported she did not wear an apron while removing dirty clothes from the basket and placing them in the washer, and stated she only needed a gown with isolation items. The Environmental Supervisor reported gowns, gloves, and goggles were stored in the laundry cabinet and stated staff needed PPE when isolation was used or if the laundry was really dirty, with gloves and a gown otherwise for dirty laundry. The facility policy stated soiled linen should be handled as little as possible and with minimum agitation, and staff should wear gloves and other appropriate PPE when handling soiled linen.
Missing Code Status Documentation After Hospital Return
Penalty
Summary
The facility failed to maintain code status records for 1 of 3 residents reviewed, Resident #21. The Minimum Data Set dated [DATE] showed the resident had a BIMS score of 14 out of 15, indicating intact cognition, and listed diagnoses of coronary artery disease, mild persistent asthma with acute exacerbation, and obstructive sleep apnea. However, the resident’s care plan did not include a preference for CPR or DNR, and neither the EHR nor the paper chart contained documentation of the resident’s code status. During record review and interviews, Staff H, an LPN who worked mostly overnight, searched the paper chart more than two times and could not locate any code status documents. He stated the documents should be in the front of the chart and explained that the resident had returned from the hospital, with the nurse overseeing the return supposed to place the documents back in the chart. The DON confirmed the resident had recently returned from the hospital and said the care coordinator handled the paperwork and signatures, but the facility was unable to locate the code status document. The Administrator stated the nurse sent the original code status form to the hospital without making a copy for the chart.
Inaccurate MDS Coding for PASRR and Diagnosis
Penalty
Summary
The facility failed to accurately code all diagnoses and PASRR information for one resident reviewed for MDS assessments. Resident #7 had a Notice of PASRR Level II Outcome dated 5/22/2024 showing short-term approval through 5/22/2025 and identifying the resident as Level II for serious mental illness, with a diagnosis of schizoaffective disorder, bipolar type. The PASRR also directed the facility to document “yes” on the MDS for whether the resident was currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. However, the resident’s MDS dated [DATE] marked that response as “no” and did not document the diagnosis of schizoaffective disorder, bipolar type. Another MDS dated [DATE] also lacked documentation of schizoaffective disorder. During interview, the DON stated the resident’s MDSs dated 12/30/24 and 6/27/25 should reflect the current PASRR Level II status and diagnosis of schizoaffective disorder, bipolar type.
Failure to Obtain and Implement PASRR Requirements
Penalty
Summary
The facility failed to obtain Resident #7’s Level II PASRR, failed to implement the Level II requirements, and failed to resubmit the Level I after the short-term approval expired. Resident #7’s MDS listed diagnoses of bipolar disorder and cancer, and the BIMS score was 11 out of 15, indicating moderately impaired cognition. The resident’s PASRR paperwork reflected a Level 1 positive determination with no status change and stated that the previous summary of findings remained valid for the resident’s stay at the nursing facility, should accompany the resident if transferred, and that the services in the previous PASRR remained appropriate and should continue to be delivered. The PASRR documentation also directed that the resident’s PASRR condition be documented in the MDS, including marking A1510 for Level II PASRR conditions. The resident’s Level II PASRR, obtained by the facility after the fact, showed approval for a short-term stay that ended on the expiration date and identified schizoaffective disorder, bipolar type, with specialized services required for behavioral health and/or developmental needs. The care plan failed to address the PASRR recommendations. The RNC MDS Coordinator reported the facility had obtained the Level I and placed it in the record but had not obtained a copy of the Level II PASRR and had not completed a resubmission before the short-term approval expired. The DON reported she was unaware the Level II PASRR existed and stated she did not know of a policy or procedure addressing PASRR.
Failure to Provide Needed Bathing and Grooming Assistance
Penalty
Summary
The facility failed to provide adequate bathing and grooming assistance for a resident with stroke, non-Alzheimer's dementia, depression, severe cognitive impairment, impaired mobility, and incontinence. The resident’s MDS documented a need for supervision or touch assistance with bathing, and the care plan identified a decline in ADL ability related to dementia and impaired mobility. The care plan included an intervention for whirlpool/shower bathing two times per week, but it did not address bathing refusals or related interventions. Between admission and the end of the review period, the resident was bathed/showered only once, and observations on multiple days showed the resident’s hair appeared stringy, matted, or clumped against the back of the head and around the ears. Record review showed scheduled bathing attempts on several dates, with documentation that the resident received one bath/shower and refused on three other occasions. The progress notes documented one day when the resident refused a shower three times, but did not document refusals on other days, alternate bathing options such as a bed bath, additional interventions, notification of the provider, or communication with the responsible party. Staff interviews indicated that residents who refused bathing were sometimes offered a bed bath, but if they continued to refuse they were generally left until the next scheduled bathing day. The DON stated bathing schedules were set at admission and that baths were offered Monday, Tuesday, Thursday, and Friday, with refusals reapproached and documented on the Point of Care list, but the documentation reviewed did not show that occurred for this resident.
Failure to Update Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to update and provide current daily nurse staffing information for residents and visitors. During observation on 9/22/2025 at 9:17 AM, the staffing posting at the main entrance was dated 9/19/25. Review of Daily Staff Posting records from September 1 through September 23, 2025 showed no edits or changes in staffing for the month. During interviews, Staff D, RN, and Staff E, RN stated they did not handle the Daily Staff Posting and that the DON completed them. The DON later stated that the night nurses were responsible for changing the posting over, and then stated she was the only one who updated the Daily Staff Posting records. She also said there were new night shift nurses who were supposed to change it over and she thought they had forgotten.
Failure to Accurately Account for and Document Controlled Medications
Penalty
Summary
The facility failed to maintain an accurate inventory and proper documentation of controlled medications for multiple residents. For several residents with significant pain management needs and complex medical histories, staff did not consistently document the administration of controlled substances on the Medication Administration Record (MAR) or the Controlled Substance Shift Count and Usage Record. In several instances, staff signed out medications on the count sheet but failed to record the administration on the MAR, and in some cases, the facility could not provide complete records for medication deliveries and usage. There were also discrepancies between the number of doses delivered, the number remaining, and the documentation provided. Observations revealed that staff did not always sign out narcotics at the time of administration, leading to inconsistencies between the physical count of medications and the documented records. For example, empty medication packs were found when records indicated doses should remain, and staff admitted to administering medications without immediately documenting them. In one case, a medication cassette was found to contain a Tylenol tablet instead of the prescribed controlled substance, and the facility's investigation confirmed the discrepancy. Staff interviews confirmed lapses in documentation and adherence to procedures for handling and recording controlled substances. The facility's policies required immediate documentation of controlled substance administration and mandated that two staff members verify and sign off on narcotic counts at shift changes. However, these procedures were not consistently followed, as evidenced by incomplete records, missing documentation, and staff admissions of failing to sign out medications as required. These failures resulted in an inability to accurately account for controlled medications received, dispensed, and administered to residents.
Care Plan Deficiencies for Residents with Schizophrenia and Hearing Impairment
Penalty
Summary
The facility failed to ensure comprehensive care plans were reviewed and revised in a timely manner for two residents. Resident #27, diagnosed with schizophrenia, had a care plan that lacked goals, triggers, and interventions related to this diagnosis. Despite the resident's confirmation of having schizophrenia for a long time, the care plan only included focus areas for Asperger's Syndrome, schizoid personality disorder, and depression. The resident's progress notes did not document the new diagnosis or any communication with the provider or discussion with the resident for care planning. Staff interviews revealed a lack of clarity on responsibility for updating care plans, with the MDS Nurse Coordinator relying on information from the Director of Nursing. Resident #25, diagnosed with Meniere's disease and unspecified hearing loss, reported that staff did not accommodate her hearing needs adequately. The care plan included an intervention to ensure the resident's glasses were in good repair but lacked documentation related to her hearing, hearing aid care, goals, or interventions. The resident expressed dissatisfaction with the staff's communication regarding her hearing needs. A nurse consultant acknowledged the need for care plans to be reviewed and updated to reflect the residents' needs.
Medication Administration and EBP Failures
Penalty
Summary
The facility failed to adhere to professional standards of medication administration for a resident requiring medications via gastric tube. The resident, who was on NPO status and required tube feeding, had medications scheduled for 8:00 AM. However, these medications were administered late, and the physician was not notified of the delay as required by the facility's policy. Additionally, an extended-release tablet was crushed, which is against standard medical practice, and this error was not questioned or clarified with the physician. During the medication administration process, the registered nurse did not follow Enhanced Barrier Precautions (EBP) as she failed to wear a protective gown, despite being aware of the requirement. This oversight was acknowledged by the nurse and confirmed by the facility's Director of Nursing and Administrator designee. The facility's policy and training materials clearly outlined the necessity of wearing a gown and gloves when caring for residents with gastric tubes, which was not adhered to in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 166 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Marion
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakview Nursing & Rehablitation - Marion | 0.8 mi | ★★★★★ | 5 | 0 |
| Terrace Glen Village | 1.3 mi | ★★★★★ | 5 | 0 |
| Silver Oak Nursing And Rehabilitation Center Llc | 1.7 mi | ★★★★★ | 14 | 0 |
| Linn Manor Care Center | 2.6 mi | ★★★★★ | 10 | 0 |
| Hallmar Village | 2.6 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Winslow House Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.