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 Windsor Hills Nursing Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and dependent on staff for care was found in bed while another cognitively impaired resident was observed making inappropriate sexual contact. The incident was discovered and stopped by staff, but the facility failed to prevent the occurrence of this non-consensual contact, despite policies prohibiting abuse.
The facility failed to have a designated and trained infection preventionist responsible for the infection prevention and control program. The key staff list did not identify an infection preventionist, and the DON stated the facility had been without one since the previous DON resigned. The DON also stated they oversaw wounds but were not trained and certified as an infection preventionist, and the administrator stated the previous DON had served in that role before leaving.
Failure to notify residents of trust account balances: The facility did not document required notices for four residents with Medicaid whose facility-managed trust accounts were at or above the SSI resource limit. The BOM stated the old system did not generate the needed letters, and no proof was provided that the notices were issued.
Failure to care plan for ROM deficits: A resident with hemiplegia/hemiparesis after a CVA was observed with a contracted right hand and inability to move the right side. The record showed severe cognitive impairment and upper/lower ROM deficits, but the care plan only addressed speech difficulty and did not include the resident’s ROM deficit or right-sided weakness, which staff and the MDS coordinator confirmed.
The facility failed to follow infection control practices during wound care for two residents on EBP and failed to manage oxygen tubing for two residents receiving nasal cannula oxygen. An LPN did not consistently wear gowns, change gloves appropriately, or perform hand hygiene between wound care tasks, and residents stated staff did not always use gloves and gowns. Oxygen tubing for two residents was not dated, and staff could not confirm when it had last been changed, despite orders and facility policy requiring weekly changes.
Call lights were not kept within reach for two residents. One resident with no cognitive impairment and dependence for ADLs had the call light on the floor, and another resident with moderate cognitive impairment and max assist needs had the call light at the foot of the bed, out of reach. An LPN and a CMA both confirmed the call lights were not positioned where the residents could reach them.
A resident’s care plan was not updated to reflect that Buspirone and trazodone had been discontinued. The resident had multiple diagnoses including anxiety, depression, insomnia, chronic pain, and cardiac conditions, but the care plan still listed both meds as current even after the orders were stopped. The MDS coordinator confirmed the care plan should have been updated.
A resident with hemiplegia and hemiparesis after a CVA was observed with a contracted right hand and inability to move the right side. The care plan addressed speech issues but not the resident’s ROM deficits, and staff including a CNA, LPN, RA, and MDS coordinator confirmed the resident was not receiving restorative or ROM services despite documented right-sided weakness and stiffness.
A resident with COPD and continuous oxygen use was not properly identified or care planned for vaping or smoking behaviors. Staff were aware the resident vaped in their room and charged the devices, but the care plan did not address vaping. The resident lit a cigarette while on oxygen, resulting in facial burns. Facility records and staff interviews showed a lack of supervision and monitoring for safe smoking and vaping.
A resident who used vaping devices and chewing tobacco did not have their care plan updated to address vaping, despite staff and the DON being aware of the behavior and facility policy requiring documentation of safe smoking measures. The care plan only referenced tobacco use, omitting interventions for vaping, even though the resident was dependent on staff for daily living and used oxygen for COPD.
A resident with an indwelling urinary catheter did not receive timely catheter changes as ordered by a physician, leading to a deficiency in care. The resident, who had acute kidney failure and urine retention, experienced symptoms of a UTI and was placed on antibiotics. Despite this, the catheter was not changed due to supply issues and the resident's refusal, which was not communicated to the physician or DON. The resident was later diagnosed with a bladder stone after hospital transfer.
A resident with communication needs was unable to express pain levels due to the unavailability of picture exchange tools as outlined in their care plan. The ADON noted the resident pointed instead of using an iPad, and the Administrator recognized the need for a consistent communication method for staff.
The facility failed to complete advance directive acknowledgment forms for two residents. One resident admitted in April and another in May did not have the necessary forms in their electronic health records or admission packets. Social services confirmed the absence of these documents, indicating a failure to document the residents' or their representatives' decisions regarding advance directives.
A resident with Congestive Heart Failure was prescribed Buspirone HCL, an anti-anxiety medication, without a documented diagnosis or reason for its use. The medication order and subsequent care plan reviews lacked an anxiety diagnosis, which was confirmed by the ADON and Regional Director of Clinical Systems.
The facility failed to create and implement accurate care plans for three residents, resulting in unmet needs. One resident with vascular dementia lacked a care plan for their condition, another with an ileostomy had no care plan, and a third resident's care plan inaccurately documented their need for assistance. Staff interviews indicated that care plans were not reviewed or updated appropriately.
The facility failed to post and follow accurate menus for three meal services, as required by policy. Meals served did not match the menu guide, and alternatives and weekly menus were not posted. Supply issues and lack of resident preference consideration contributed to the discrepancies. The dietary manager and staff acknowledged these issues, with the administrator confirming the requirement for residents to access menus a week in advance.
The facility failed to maintain appropriate food temperatures and sanitary conditions during meal preparation and service. Observations revealed that food was not kept at the required temperature, with pureed sausage at 113.2°F and a test tray showing eggs at 110°F, sausage patty at 98°F, and hash brown at 94°F. Additionally, a cook used the same gloves to handle different items without changing them, and the prep table was not cleaned as required.
The facility failed to secure the medication room when not in use, as observed when the door was propped open with no staff present. The room was across from the dining room with mobile residents nearby, including one in a wheelchair. An LPN confirmed the policy to keep the door closed and locked, attributing the oversight to staff who forgot to close it. The facility's policy requires all drugs to be stored in locked compartments.
The facility did not ensure proper disinfection of glucometers before and after use on residents. An LPN was observed using a glucometer without cleaning it, despite acknowledging the policy to do so. The administrator and a corporate nurse confirmed the requirement for proper cleansing.
A resident with a history of anxiety and psychotic disorder exhibited frequent behaviors such as yelling for help, which were not accurately documented in their Resident Assessment. Despite multiple progress notes indicating observed behaviors, the quarterly assessment inaccurately reported no behaviors. Staff interviews confirmed the inaccuracy, highlighting a failure to adhere to the facility's policy of accurate MDS coding.
A resident with severe intellectual disabilities and dysphagia experienced significant weight loss due to the facility's failure to implement physician-ordered dietary interventions in a timely manner. Despite recommendations and orders for health shakes and weekly weights, these were not provided or documented as required, leading to continued weight decline.
A facility failed to arrange a physician-ordered psychiatric evaluation for a resident with depression. Despite procedures requiring social services to coordinate such services, the order was not fulfilled. Interviews revealed that the nurse would notify the physician and DON, who would then involve social services to arrange the appointment. However, the facility did not ensure the evaluation and treatment were provided.
A facility failed to administer and ensure the availability of medications for a resident with chronic pain syndrome. The resident's lidocaine patch and gabapentin were not administered on several days, despite physician orders. Staff interviews revealed lapses in medication ordering and administration processes, with the DON confirming the medications were not given as required.
Failure to Prevent Sexual Abuse Between Residents
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. An incident occurred in which one resident, who had severe cognitive impairment and required extensive assistance with daily activities, was found in bed while another resident, also with severe cognitive impairment and a diagnosis of dementia, was observed with their hand underneath the first resident's gown, making a fondling motion. The resident being touched was unable to respond appropriately to the situation or to questions, and the staff member who discovered the incident reported that the resident being touched was unaware of their circumstances or surroundings. Prior to the incident, there were no documented behavioral issues or similar incidents involving the resident who committed the inappropriate touching. Staff interviews indicated that this resident had previously entered another resident's room to use the bathroom but had not exhibited sexually inappropriate behavior before. The staff member who discovered the incident was alerted by a housekeeper and intervened immediately. The resident who was touched had a history of metabolic encephalopathy, severe memory and thinking problems, and was dependent on staff for all personal care needs. The facility's policy prohibits and aims to prevent all forms of abuse, including sexual abuse, and requires the protection of residents' health, welfare, and rights. Despite these policies, the incident occurred, and the resident was subjected to unwanted sexual contact. The event was witnessed and stopped by staff, but the deficiency lies in the facility's failure to prevent the occurrence of this inappropriate and non-consensual contact between residents.
No Designated Infection Preventionist
Penalty
Summary
The facility failed to have a designated and trained infection preventionist responsible for overseeing the infection prevention and control program. The facility policy titled Infection Preventionist, last reviewed 01/18/25, stated that the facility would employ one or more qualified individuals with responsibility for implementing the infection prevention control program. However, an undated Windsor Hills Nursing Center key staff list provided at the entrance conference did not identify any staff member as an infection preventionist. During the entrance conference on 09/08/25, the DON and business office manager were asked to identify the facility infection preventionist, and the DON stated the facility had been without one since the previous DON resigned. The DON also stated they oversaw wounds in the facility and were not trained and certified to be an infection preventionist. On 09/09/25, the administrator stated the previous DON had been the infection preventionist and had left on 08/15/25.
Failure to Notify Residents of Trust Account Balances
Penalty
Summary
The facility failed to ensure that residents with balances within $200 of the $2,000 resource limit received notices of their account balances for 4 of 5 sampled residents reviewed for trust account balances. Residents #3, #12, #34, and #23 each had Medicaid as a payor source and had facility-managed trust accounts with balances above the $2,000 limit, including $4,666.92 for Resident #3, $2,479.44 for Resident #12, $4,699.50 for Resident #34, and $2,620.23 for Resident #23. The facility policy stated that residents must be notified when their account reaches $200 less than the SSI resource limit for one person and when the account, combined with nonexempt resources, reaches the SSI resource limit. During interview, the business office manager stated the resource limit for residents with Medicaid payor source and facility-managed trust accounts was $2,000. The manager said the new system would generate a letter when residents were within $200 of the resource limit, but the old system did not have that function. The manager also stated there was no documentation showing that notices had been provided and would look for any available records, but no further documentation was provided to show the notices had been given.
Failure to Care Plan for ROM Deficits
Penalty
Summary
The facility failed to develop a care plan for the provision of range of motion services for Resident #6. On 09/08/25, Resident #6 was observed in their room with the right hand slightly contracted and unable to move the right side. The resident’s record showed diagnoses of hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, and an annual assessment dated 06/19/25 documented severe cognitive impairment with a BIMS score of five, along with upper and lower range of motion deficits. The care plan last reviewed on 06/02/25 addressed the resident’s difficulty expressing themself because of a stroke affecting speech, but it did not address the documented ROM deficit or right-sided weakness. CNA #2 stated the resident had stiffness to the right arm and limited use of the right side for two years, and CNA #1 stated the resident was weak on the right side due to a stroke. The MDS coordinator stated the resident had right-sided weakness and ROM deficits and that the care plan did not address these issues and should have been developed and addressed.
Infection Control Practices Not Followed During Wound Care and Oxygen Tubing Care
Penalty
Summary
The facility failed to implement infection control practices during wound care for two residents who were on Enhanced Barrier Precautions (EBP). One resident had diagnoses including bilateral above-the-knee amputations, a non-pressure chronic ulcer of the buttock, and a stage III pressure ulcer. During observed wound treatment, an LPN gathered supplies and donned gloves but did not put on a gown. The LPN changed gloves at times but was also observed applying a sterile bordered gauze without washing hands and later applying a band-aide dressing with bare hands. The resident stated staff did not always wear gloves and gowns when performing wound care. A second resident had a stage III pressure ulcer to the right heel and skin integrity impairment to the buttocks. During observed wound care, an LPN washed hands and donned gloves but did not put on a gown. The LPN removed dressings, cleaned wounds, and changed gloves between tasks, but did not sanitize hands before donning new gloves. The LPN again did not wear a gown while continuing wound care. The resident stated staff did not wear gowns when providing wound care or ADL care. The DON stated EBP was to be used for residents with wounds, colostomies, or any port or open area, and that staff were to wear gloves and gowns when providing direct care, but also stated they did not monitor staff to ensure EBP was used during care and wound treatments. The facility also failed to follow oxygen tubing care practices for two residents receiving oxygen by nasal cannula. One resident’s tubing was not labeled with the last change date, and the resident stated the tubing had last been changed the prior week. The resident had diagnoses including COPD, epilepsy, anxiety, and systolic CHF, and had an order for 2 liters of oxygen via nasal cannula with tubing to be changed every Sunday on the 10:00 p.m. to 6:00 a.m. shift. Another resident was observed with a nasal cannula and tubing that had no date on it; the resident had diagnoses including anemia, CKD, depression, and hypertension. Staff stated they did not know when the tubing had last been changed for that resident, and the DON stated the tubing was supposed to be changed weekly on Sundays with initials, date, and time.
Call Lights Not Kept Within Reach
Penalty
Summary
The facility failed to ensure call lights were within reach for 2 of 23 sampled residents reviewed for call light accessibility. On 09/08/25, Resident #19’s call light button was observed on the floor. The resident’s annual assessment dated 08/05/25 showed a BIMS score of 15, indicating no cognitive impairment, and documented dependence on staff for dressing, toileting, bathing, transferring, and bed mobility. An LPN stated the call light should not have been on the floor and was supposed to be within the resident’s reach at all times. Later that same day, Resident #10’s call light was observed at the foot of the bed and out of reach. The resident’s quarterly assessment dated 09/04/25 showed a BIMS score of 11, indicating moderate cognitive impairment, and documented maximum assistance needed for dressing, toileting, bathing, and transferring. A CMA stated the call light was at the foot of the bed where the resident could not reach it.
Care plan not updated after psychotropic medications were discontinued
Penalty
Summary
The facility failed to ensure Resident #53’s care plan was updated to reflect the current status of medications after Buspirone and trazodone were discontinued. Resident #53 had diagnoses including respiratory disorders, chronic pain, constipation, sleep apnea, ventricular fibrillation, atrial fibrillation, insomnia, anxiety, adjustment disorder with mixed anxiety, and depression. The resident’s medication orders showed Buspirone and trazodone were discontinued on 07/13/25, but the care plan, last updated 07/23/25, still stated the resident was currently taking both medications. During interview on 09/09/25, the MDS coordinator stated they were responsible for updating care plans, confirmed the medications had been discontinued, and acknowledged the care plan did not reflect the current medication status and should have been updated.
Failure to Provide ROM Services for Resident With Right-Sided Weakness
Penalty
Summary
The facility failed to provide range of motion services for Resident #6, who was observed with a slightly contracted right hand and inability to move the right side. Resident #6 had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, and an annual assessment dated 06/19/25 showed severe cognitive impairment with a BIMS score of five, along with upper and lower ROM deficits. The facility policy stated that, based on the comprehensive assessment, the facility would provide interventions, exercise, and/or therapy to maintain or improve ROM. Resident #6’s care plan, last reviewed 06/02/25, addressed difficulty expressing self due to a stroke affecting speech, but it did not address the resident’s ROM deficit on the right side. Staff interviews confirmed the resident had right-sided weakness and stiffness, with limited use of the right arm and side since the stroke. A CNA, an LPN, and the RA all stated the resident was not receiving restorative services or ROM services, and the MDS Coordinator stated the resident was not on a restorative program and no ROM services were being provided. The MDS Coordinator also stated they were not sure when the resident had been screened, and no additional documentation was provided.
Failure to Supervise and Monitor Safe Smoking and Vaping Practices
Penalty
Summary
A deficiency occurred when the facility failed to implement a system to ensure residents were properly supervised and monitored for safe smoking and the use of electronic vaping devices. One resident, who was a known user of vaping devices and required continuous oxygen therapy due to COPD and other medical conditions, was not identified on the facility's smoking or vaping user list. The resident's care plan did not address the use of vaping devices, nor did it provide interventions or supervision related to vaping or smoking in the resident's room. Staff were aware that the resident vaped in their room and charged the devices for them, but there was no documentation or care plan intervention addressing this behavior. The resident was observed with multiple vaping devices and chewing tobacco in their room, along with an oxygen concentrator. Despite the facility's policy prohibiting smoking and vaping in non-designated areas and specifically warning against the use of such devices around flammable gases like oxygen, the resident continued to vape in their room. Staff interviews confirmed that the resident was known to vape in their room while on oxygen, and that staff routinely charged the vaping devices for the resident. The resident was not listed as a smoker or vape user on the facility's records, and their care plan only addressed tobacco chewing, not vaping or smoking. The deficiency resulted in a serious incident where the resident, while using oxygen in their room, lit a cigarette, causing a flash burn to their face and nose. The incident report and hospital records confirmed partial thickness burns to the resident's face, requiring emergency evaluation and treatment. Staff and administrative interviews revealed a lack of awareness and oversight regarding the resident's vaping and smoking behaviors, as well as a failure to update care plans and assessments to reflect the resident's actual practices.
Failure to Update Care Plan for Resident's Vaping and Tobacco Use
Penalty
Summary
The facility failed to ensure that care plans were developed and revised to address the use of electronic vaping devices for a resident who used both vaping devices and chewing tobacco. Despite the facility's policy requiring a safe smoking assessment and documentation of all safe smoking measures, the resident's care plan did not include interventions or assessments related to vaping. Observations revealed multiple vaping devices in the resident's room, along with an oxygen concentrator, and staff interviews confirmed that the resident regularly vaped in their room and staff assisted with charging the devices. The care plan only addressed tobacco use and did not mention vaping, even though the resident's smoking assessment indicated vape use. The resident was dependent on staff for all activities of daily living, required oxygen for COPD, and was cognitively intact. Staff and the resident reported that the resident removed their oxygen when vaping, but this practice and the use of vaping devices were not reflected in the care plan. The Director of Nursing confirmed that the care plan did not address the resident's vape use, despite facility policy and staff awareness of the resident's behaviors.
Failure to Follow Catheter Change Orders and Prevent UTI
Penalty
Summary
The facility failed to follow a physician's order for monthly catheter changes for a resident with an indwelling urinary catheter, leading to a deficiency in care. The resident, who was cognitively intact and had diagnoses including acute kidney failure and urine retention, had a physician's order to change the catheter monthly. However, the catheter was not changed as scheduled due to the unavailability of the correct catheter size, and there was no documentation that the physician or Director of Nursing (DON) was notified of this issue. The order was removed from the medication administration record after three days without being fulfilled. The resident experienced symptoms of a urinary tract infection (UTI), including cloudy urine with a foul odor and sediment, and was placed on antibiotics. Despite these symptoms, the catheter was not changed, and the resident refused to allow nurses to change it, insisting on a urologist for the procedure. The refusal was not communicated to the physician or DON, and the catheter remained unchanged for an extended period. Eventually, the resident was diagnosed with a bladder stone after being transferred to the hospital. Throughout the period, the resident continued to refuse catheter changes by facility staff, preferring to wait for a urologist. The facility's protocol for notifying the DON or administrator about supply shortages was not followed, and the resident was not adequately educated on the consequences of not changing the catheter. The facility's failure to ensure timely catheter changes and proper communication with medical staff contributed to the deficiency in care.
Failure to Provide Effective Communication Tools for Resident
Penalty
Summary
The facility failed to provide effective communication tools for a resident who required picture exchange communication to express their needs and perform activities of daily living. The resident, diagnosed with atrial fibrillation, high blood pressure, and chronic pain, had a care plan indicating the use of pictures to communicate. However, during an observation, it was noted that the resident could not effectively communicate their pain location or level because the necessary communication pictures were unavailable. The Assistant Director of Nursing (ADON) reported that the resident did not use an iPad for communication and instead pointed, highlighting a gap in the communication strategy outlined in the care plan. The Administrator acknowledged the need for a consistent communication method for all staff to interact with the resident effectively.
Failure to Complete Advance Directive Acknowledgment Forms
Penalty
Summary
The facility failed to ensure that advance directive acknowledgment forms were completed for two of the three sampled residents reviewed for advance directives. Resident #7, who was admitted on April 11, 2023, did not have an advance directive form in their electronic health record or admission packet, indicating the decision by the resident or their representative. Similarly, Resident #23, admitted on May 6, 2023, also lacked an advance directive form in their electronic health record or admission packet. On September 24, 2024, social services confirmed that there were no advance directives found in the admission packets or electronic health records for these residents, reflecting a failure to document the residents' or their representatives' decisions regarding advance directives.
Lack of Diagnosis for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident receiving an antipsychotic medication had an appropriate diagnosis for its use. Specifically, a resident with a diagnosis of Congestive Heart Failure was prescribed Buspirone HCL, an anti-anxiety medication, without a documented diagnosis or reason for its administration. The medication order, dated from June, lacked an associated diagnosis, and subsequent reviews of the resident's care plan, gradual dose reduction plan, and nursing level of care assessment also did not document an anxiety diagnosis. This oversight was confirmed by the Assistant Director of Nursing and the Regional Director of Clinical Systems, who acknowledged the absence of a necessary diagnosis for the medication's administration.
Deficient Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement accurate comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. One resident, admitted with a diagnosis of vascular dementia with behavioral disturbances, did not have a care plan to address these needs. Another resident, who had an ileostomy, also lacked a care plan to manage their condition. A third resident, who was dependent on staff for incontinent care, had a care plan that inaccurately documented their needs, stating they required assistance with toileting and transferring on/off the toilet, despite being unable to perform these tasks. Interviews with staff revealed that the care plans were not reviewed or updated as necessary, contributing to the oversight in care planning.
Failure to Post and Follow Accurate Menus
Penalty
Summary
The facility failed to ensure that accurate menus were posted and followed for three observed meal services. The facility's policy required menus to be posted at least one week in advance and followed as posted, with any deviations notified as soon as practicable. However, during observations, the meals served did not match the menu guide report. For instance, on one occasion, breakfast served included oatmeal, scrambled eggs, sausage patties, bacon, and toast, while the menu guide indicated a ham egg cheese skillet. Similarly, for lunch, mashed potatoes were served instead of the wild rice listed on the menu guide. The dietary manager admitted to changing the menu due to recent repetition of rice and supply issues. The facility also failed to post alternative meal options and the weekly menu, as required. Cook #1 mentioned that they did not receive supplies to make blueberry pancakes, leading to a substitution without proper notification. The dietary manager acknowledged frequent supply issues and the need to update menus to reflect resident preferences and available supplies. Additionally, a CNA reported that residents were not asked for their breakfast preferences and received what the kitchen provided, with changes made only if residents expressed dissatisfaction. The administrator confirmed that residents should have access to the menu a week in advance.
Failure to Maintain Food Temperature and Sanitary Conditions
Penalty
Summary
The facility failed to maintain appropriate food temperatures and sanitary conditions during meal preparation and service. During observations, it was noted that the food intended for residents was not kept at the required temperature of 135 degrees Fahrenheit or greater. Specifically, pureed sausage was recorded at 113.2 degrees Fahrenheit, and a test tray showed eggs at 110 degrees, sausage patty at 98 degrees, and hash brown at 94 degrees. The facility lacked a steam table, which contributed to the inability to maintain proper food temperatures. Additionally, the facility did not adhere to its policy on maintaining a sanitary tray line. A cook was observed using the same gloves to handle different items, including touching menu cards and food, without changing gloves as required. The prep table was not cleaned as per the facility's policy, and the staff did not consistently monitor food temperatures throughout meal service. The administrator acknowledged that staff are supposed to check food temperatures and change gloves between tasks to prevent foodborne illness.
Medication Room Security Breach
Penalty
Summary
The facility failed to ensure the medication room was secured when not in use, as observed on 09/23/24 at 10:45 a.m. The medication room door was found propped wide open with a trash can, and there were no staff present or in sight. This room was located directly across from the dining room, where multiple mobile residents were present, including one resident in a wheelchair who was within four feet of the open door. LPN #1 acknowledged that the policy is to keep the door closed and locked, attributing the oversight to staff who had just loaded their cart and forgot to close the door. On 09/27/24, during an interview with the administrator and corporate nurse #2, it was confirmed that the policy was to keep medications locked and secured. The facility's Medication Storage policy, dated 01/08/24, mandates that all drugs and biologicals be stored in locked compartments under proper temperature controls.
Failure to Disinfect Glucometers
Penalty
Summary
The facility failed to ensure that glucometers were disinfected appropriately before and after use on residents. The Glucometer Disinfection policy, which was undated, stated that blood glucometers should be cleaned and disinfected after each use and according to the manufacturer's instructions for multi-resident use. On September 25, 2024, at 10:24 a.m., an LPN was observed using a glucometer on a resident without disinfecting it before or after use, despite sanitizing their hands and wearing gloves. The LPN acknowledged that the policy was to clean the glucometer before and after use but admitted to not doing so. On September 27, 2024, at 9:38 a.m., the administrator and a corporate nurse confirmed that the policy required proper cleansing of the glucometer before and after use. The facility housed 58 residents at the time of the observation.
Inaccurate Resident Assessment Coding
Penalty
Summary
The facility failed to ensure accurate coding of Resident Assessments for a resident with a history of generalized anxiety, psychotic disorder with delusions, and sclerosis of the central nervous system. The resident's care plan, initiated in 2019, documented behavior problems related to dementia and psychological causes, including continuously screaming out. However, a quarterly Resident Assessment and Care Screening inaccurately documented that the resident had no behaviors in the previous seven days, despite multiple progress notes indicating observed behaviors during that period. Observations during the survey confirmed that the resident frequently yelled for help, even after staff had just left their room. Interviews with staff, including a corporate nurse, acknowledged the inaccuracy of the Minimum Data Set (MDS) regarding the resident's behaviors. The facility's policy requires that MDS assessments be accurately coded, but this was not adhered to in the case of this resident, leading to the identified deficiency.
Failure to Implement Physician-Ordered Dietary Interventions
Penalty
Summary
The facility failed to provide dietary interventions as ordered by the physician for a resident with severe intellectual disabilities, cerebral palsy, and dysphagia. The resident experienced a significant weight loss, dropping from 176.8 lbs to 164.0 lbs over one month. Despite the dietician's recommendation for health shakes twice a day to prevent further weight loss, the physician's order for weekly weights and health shakes was not implemented in a timely manner. The resident's weight continued to decline, reaching 156.2 lbs by August. The deficiency was further compounded by the lack of documentation indicating that weekly weights were conducted as ordered in June. The health shakes, initially ordered by the physician in early June, were not provided to the resident until August, two months later. Interviews with facility staff revealed that the responsibility for entering physician orders into the computer system was not executed promptly, leading to a delay in the resident receiving the necessary dietary supplements.
Failure to Arrange Psychiatric Evaluation for Resident
Penalty
Summary
The facility failed to ensure that a physician-ordered psychiatric evaluation was arranged for a resident diagnosed with depression. The physician had ordered a psychiatric evaluation and treatment as indicated on 06/11/24, but there was no documentation that this order had been acted upon. The facility's policy required the social services designee to pursue the provision of medically-related services, including making referrals and obtaining needed services from outside entities. However, the social services department was unavailable for an interview, and it was found that the order for the psychiatric evaluation had not been fulfilled. Interviews with facility staff revealed that when a resident's family requested an appointment for psychological services, the nurse would notify the physician and the DON. The physician would then sign the resident up for services, and the nurse would print out the order and give it to social services. The DON confirmed that the facility had a company that provided these services once a month, and social services would have been responsible for coordinating with the company to complete the order. Despite these procedures, the facility did not arrange for the resident to receive the necessary psychiatric evaluation and treatment.
Medication Administration and Availability Deficiency
Penalty
Summary
The facility failed to ensure that medications were administered as ordered and available for a resident with chronic pain syndrome. The resident had a physician's order for a lidocaine patch to be applied daily and gabapentin to be taken orally once a day. However, the facility's records showed that the lidocaine patch was not administered on several days in May, and the gabapentin was not given on multiple days in June. The facility's Medication Administration policy requires medications to be administered as ordered by the physician, but this was not adhered to in the case of this resident. Interviews with staff revealed that there was a schedule for administering medications, and everyone was responsible for ensuring medications were ordered. However, there were lapses in the process, as indicated by the blanks in the administration records. The LPN and DON acknowledged that the medications were on order but not available in the facility, and there was no explanation for the missing administrations. The DON confirmed that the medications were not given on the specified dates, indicating a failure in the facility's medication management system.
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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.
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Nursing homes near Oklahoma City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Manor | 1.1 mi | ★★★★★ | 15 | 0 |
| Heritage Park | 1.4 mi | ★★★★★ | 0 | 0 |
| The Grand At Bethany Skilled Nursing And Therapy | 1.5 mi | ★★★★★ | 9 | 0 |
| North Winds Living Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Fairmont Skilled Nursing And Therapy | 2.3 mi | ★★★★★ | 7 | 0 |
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