Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Windsor Arbor View during CMS and state inspections, most recent first.
A resident with a toe amputation, DM, PVD, and impaired lower extremities had a care plan that did not include his WB status until discharge, even though he was ordered NWB on admission and later had updated WB orders with a toe wedge shoe. Staff stated the WB intervention should have been on the care plan from admission or when the MDS was completed, but it was not added until the resident was leaving.
Failure to Provide Written Notice Before Room Changes: A resident with diabetes, AKF, and dementia was moved between rooms multiple times, but the resident and family member said no written notice was provided. Staff said room changes were handled by the DON and communicated by phone or in person, and the record contained no documentation of the room changes. The facility policy required prior notification and written notice with the reason, effective date, and new room before relocation.
A resident with HTN, atrial fibrillation, cardiomyopathy, and CKD received Metoprolol ER 50 mg even though his BP was 90/60 and the order required the medication to be held if SBP was under 110, DBP was under 60, or pulse was under 60. The ADON and DON both confirmed the dose should not have been administered, and the MD noted the resident’s BP was low when he saw him that morning.
A resident with HTN, atrial fibrillation, cardiomyopathy, and CKD had metoprolol held because vital signs were outside ordered parameters, but MA A did not document the BP or pulse on the MAR. MA A said she checked vitals before medication administration but could not explain why the readings were missing, and the ADON and DON confirmed the omission during record review.
Bathroom sink water temperatures were not maintained within the expected range in occupied rooms for three residents. One resident's sink water was measured at 81 degrees F, while two other residents' bathroom sinks measured 115 degrees F. The affected residents included one cognitively intact resident, one severely cognitively impaired resident who needed extensive assistance with toileting hygiene and mobility, and one resident with moderate cognitive impairment. Staff stated the hot water should not exceed 110 degrees F, and the Administrator said out-of-range temperatures would be entered into TELS.
A nurse entered a resident’s room on contact precautions without gown and gloves, a breathing mask for another resident’s nebulizer was left unbagged when not in use, and a CNA failed to clean her hands before entering and after leaving a resident’s room on EBP. The residents involved had significant medical conditions including ESBL UTI, acute respiratory failure, pulmonary edema, dementia, COPD, and wounds, and staff acknowledged the required PPE, bagging, and hand hygiene practices.
A resident with severe cognitive impairment, vascular dementia, heart failure, lack of coordination, and dysphagia was fed lunch by a CNA who stood beside him instead of sitting at his level. The CNA said she rushed to the room and forgot to get a chair, while the ADON and DON stated staff were required to sit when assisting with meals and identified standing while feeding as a dignity issue.
Failure to follow care plans led to two accidents involving residents who needed assistance. An RN repositioned a resident who required 2-person assistance without checking the care plan, and another resident with severe cognitive impairment and dysphagia had a meal tray left within reach while unattended, leading him to spill coffee on himself. Staff and the DON acknowledged that residents needing repositioning or feeding assistance were to be managed according to the care plan and that meal trays were not to be left unattended.
IV Dressing Not Dated or Initialed: An LVN failed to ensure a resident’s peripheral IV dressing was dated and initialed. The resident had pneumonia, COPD, and severe cognitive impairment, and was receiving IV hydration. During observation, the IV site was covered with a transparent dressing with no date or initials, and the DON stated the nurse who inserted the IV should have labeled it.
Pest control program failed to keep a resident room free of cockroaches. Surveyors observed one live cockroach next to a floor mat in a room shared by two residents, and records showed cockroaches had been reported multiple times since October. The MDS and ADM said the facility used a monthly pest control vendor and staff logged sightings, but the facility did not have a pest control policy.
A resident with multiple chronic conditions and a known fall risk experienced a fall, but the responsible LVN did not document the required change of condition form in the medical record, despite following other fall protocols and being trained on documentation requirements. The DON confirmed that the documentation was missing and that staff are expected to complete all required forms for such incidents.
A resident with severe cognitive impairment was found on the floor with a Foley catheter pulled out. After the catheter was re-inserted by an LVN, the procedure was not documented in the electronic medical record as required by facility policy. Staff interviews and record review confirmed the omission, resulting in incomplete medical documentation.
A resident with severe cognitive impairment and mobility issues exited the facility undetected after a door alarm failed to activate. Despite being identified as an elopement risk and having interventions in place, staff did not hear any alarms and only discovered the resident missing during routine rounds. The resident was later found outside, across the street, wearing only socks. The alarm system had been serviced earlier that day and was reported as operational, but the cause of the failure during the incident was not determined.
A resident with multiple comorbidities was assisted to the floor by two CNAs after her knees gave out during a transfer. Although initially assessed with no pain or visible injury, the resident later reported leg pain, and an x-ray revealed a nondisplaced proximal fibular fracture. The injury was not reported to the state agency within the required 2-hour window, as the administrator waited for a second x-ray to confirm the diagnosis, resulting in a delayed report.
A nurse failed to document and report a resident's guided fall and subsequent assessment, resulting in delayed recognition and treatment of a leg fracture. The incident was not reported or recorded in the clinical record as required, and supervisory staff were not notified until days later, contrary to facility policy for timely and complete documentation.
A resident with multiple health conditions experienced significant weight loss due to the facility's failure to monitor and address nutritional needs as outlined in the care plan. Despite the care plan's instructions to notify the physician of weight loss, the facility did not implement timely interventions, leading to a 6.95% weight loss over a short period.
The facility failed to properly store, label, and date food items in the kitchen, risking food contamination. Observations revealed open and undated milk jugs, cheese, and vegetables, with the absence of a permanent Dietary Manager contributing to the issue. Sister facility managers were assisting, but some problems persisted.
A resident with severe cognitive impairment and multiple health issues was found without access to a call light, which was hanging off the bed and touching the floor. Staff interviews revealed that while procedures were in place to ensure call light accessibility, there was a lapse in execution, as the resident was unaware of the call light's location. This failure to adhere to the facility's policy on call light accessibility could prevent the resident from obtaining necessary assistance.
The facility failed to maintain effective infection control practices, as observed in the care of two residents receiving incontinent care and a resident with a urinary catheter. CNAs did not adhere to proper protocols, such as using one wipe per swipe and sanitizing hands between glove changes. Additionally, a resident's catheter bag was found touching the floor, posing a risk of infection. Despite ongoing training, these lapses indicate a failure to implement the facility's infection prevention policies.
Two residents experienced falls that were not accurately coded in their MDS assessments, leading to deficiencies in the facility's assessment processes. One resident had a fall resulting in a cut lip and chipped tooth, while another had a fall with a head injury and skin tears. The MDS Nurse and DON acknowledged the oversight, which could lead to improper care and services.
Care Plan Missing Weight-Bearing Status
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a right 3rd toe amputation, diabetes mellitus, peripheral vascular disease, atherosclerotic heart disease, lack of coordination, and impaired lower extremities. The resident was admitted with physician orders for non-weight bearing to the right lower extremity, and the MDS assessment reflected intact cognition with a BIMS score of 14 and dependence for toileting hygiene. The care plan included an ADL self-care performance deficit related to the surgical procedure and an intervention for toileting hygiene, but the weight-bearing status intervention was not initiated until the resident’s discharge date. Record review showed the physician’s orders changed over the course of the stay, including non-weight bearing to the right lower extremity and later permission to bear weight with a toe wedge shoe. During interviews, the LVN stated the resident had been non-weight bearing since admission, and the MDS Nurse stated the weight-bearing intervention should have been added to the care plan since admission or when the MDS was completed. The ADON stated that if a resident was admitted non-weight bearing, that status should have been in the care plan since admission, and that the intervention should not have been added only on the discharge date.
Failure to Provide Written Notice Before Room Changes
Penalty
Summary
The facility failed to ensure a resident received written notice, including the reason for the change, before being moved to different rooms within the facility. Resident #3 was admitted with diagnoses including diabetes, acute kidney failure, and dementia, and her quarterly MDS reflected a BIMS score of 11, indicating cognition that was moderately intact. Her census record showed she was admitted to one room on 01/21/26 and then transferred on 03/04/26 and again on 04/07/26. During interview, the resident’s family member stated the resident had been transferred multiple times without consent or written notice, and the resident stated she had not received written notification of her room changes. Staff interviews confirmed the room changes were handled by the DON and communicated by phone or in person rather than by written notice. The SW stated she remembered calling the family member about the 03/04/26 room change, but she found no documentation of either room change in the resident’s electronic record. The DON also reviewed the record and said she did not see documentation regarding the room changes, while the Administrator stated written notification was not necessary. The facility’s undated policy stated the resident and responsible party would be notified prior to transfer and, except in an emergency, written notice must be provided at least 5 days before relocation within the facility, including the reason, effective date, and new room.
Medication Given Outside Ordered Blood Pressure Parameters
Penalty
Summary
The facility failed to ensure a resident was free from a significant medication error when Metoprolol Succinate ER 50 mg was administered despite the resident’s blood pressure being outside the physician’s ordered parameters. The resident was admitted with diagnoses including hypertension, atrial fibrillation, cardiomyopathy, and chronic kidney disease, and his care plan directed staff to give antihypertensive medications as ordered and monitor for side effects. His physician order for Metoprolol Succinate ER 50 mg twice daily specified to hold the medication if systolic blood pressure was under 110, diastolic blood pressure was under 60, or pulse was under 60. Record review showed that on the morning of the medication error, the resident’s vital signs were 90/60 with a pulse of 80, yet the Metoprolol was administered by an LVN. The resident’s MDS assessment reflected a BIMS score of 13, indicating he was cognitively intact. During interview and observation, the ADON reviewed the record and acknowledged that the medication had been given even though the blood pressure was not within the required parameters, and stated she had overlooked the error during her review of the MAR. The MD stated he had seen the resident that morning and noticed the blood pressure was low when the medication was given, and he ordered a recheck of the blood pressure. The DON also reviewed the record and confirmed that the medication should not have been administered because the blood pressure reading did not meet the ordered hold parameters. The DON stated the facility’s ADONs and DON reviewed residents’ orders and MARs daily, and that nursing staff were regularly in-serviced on medication administration.
Incomplete MAR Documentation for Held BP Medication
Penalty
Summary
The facility failed to maintain an accurate medical record for one resident when MA A did not document the resident’s blood pressure on the MAR after the resident’s metoprolol was held because the vital signs were outside the ordered parameters. The resident was admitted with diagnoses including hypertension, atrial fibrillation, cardiomyopathy, and chronic kidney disease, and his MDS reflected a BIMS score of 13, indicating he was cognitively intact. His care plan included giving antihypertensive medications as ordered and monitoring for side effects and effectiveness. The physician order for metoprolol succinate ER 50 mg twice daily directed staff to hold the medication if SBP was under 110, DBP was under 60, or pulse was under 60. On the MAR, the medication was not administered at 9:00 a.m. because the vitals were outside the required parameters, but MA A did not enter the vital readings. During interview, MA A stated she was responsible for administering oral medications, knew some blood pressure medications had parameters, and said she checked and entered vitals before administration, but she was not sure why the resident’s electronic medication record did not show the vitals for that entry. The ADON and DON both reviewed the record and confirmed that the medication had been held because the vitals were not within parameters, but the vital signs were not documented. They stated that MA’s and nursing staff were required to document vital signs before administering blood pressure medication and that staff reviewed MARs daily for accuracy. The facility’s Documentation in Medical Record policy required complete, accurate, and timely documentation of assessments, observations, and services provided in the resident’s medical record.
Bathroom Sink Water Temperatures Out of Range
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for 3 of 8 residents reviewed for safe environment because bathroom sink water temperatures were not maintained within the expected range in occupied rooms. Resident #77, Resident #50, and Resident #26 were identified in the report as affected residents. The report states that the facility failed to ensure bathroom sink water temperatures were between 100 and 110 degrees Fahrenheit in occupied rooms, and that water temperatures over 110 degrees Fahrenheit placed residents at risk for burn injuries. Resident #77 was a female resident with diagnoses including orthopedic care aftercare following surgical amputation, dementia, depression, muscle wasting and atrophy, and type 2 diabetes mellitus. Her MDS assessment showed a BIMS score of 15, indicating she was cognitively intact and independent of self-care. Resident #50 was a female resident with diagnoses including metabolic encephalopathy, type 2 diabetes mellitus, anxiety, dementia, depression, and need for assistance with personal care. Her MDS assessment showed a BIMS score of 05, indicating severe cognitive impairment, and she required maximal assistance for toileting hygiene and was dependent on staff for mobility. Resident #26 was a female resident with diagnoses including type 2 diabetes mellitus without complications, essential primary hypertension, and hypothyroidism; her MDS assessment showed a BIMS score of 10 and supervision or touching assistance for personal hygiene. During observation, Resident #26's bathroom hot water faucet was not warming up after a minute of running the water, and later the bathroom sink hot water temperature was measured at 81 degrees Fahrenheit. In contrast, the bathroom sink hot water temperatures in Resident #77's and Resident #50's bathroom were measured at 115 degrees Fahrenheit. Resident #77 stated she used the restroom sink and adjusted the water temperature before using it, and Resident #26 stated she wanted the option to use warm water and had not reported the issue to staff because she thought they would not be able to fix it. The Maintenance Director stated he checked water temperatures in rooms daily, documented them on paper and later entered them into TELS, and said the hot water should not be over 110 degrees Fahrenheit. The Administrator stated the hot water should not be over 112 degrees Fahrenheit and that out-of-range temperatures would be entered into TELS and a plumber contacted.
Infection Control Lapses With PPE, Respiratory Equipment, and Hand Hygiene
Penalty
Summary
LVN H entered Resident #29’s room without donning a gown and gloves even though the resident had a physician order for Contact Isolation every shift for ESBL in the urine. The resident’s record showed diagnoses including metabolic encephalopathy, type 2 diabetes mellitus, muscle wasting and atrophy, depression, hemiplegia, and GERD, and the most recent MDS reflected a BIMS score of 12. A red contact precaution sign was posted outside the room instructing staff to wear a gown and gloves when entering and to discard gowns in the room. During the observation, LVN H was seen entering the room without PPE, and she later stated she knew the resident was on contact precautions but forgot to put PPE on before going in. Resident #117 had diagnoses including acute respiratory failure with hypoxia, acute pulmonary edema, gastrostomy, dementia, Alzheimer’s, and heart failure, and the MDS reflected a BIMS score of 0. The resident had an order for ipratropium-albuterol inhalation solution three times a day. During observation, a nebulizer machine was on the resident’s side table with a breathing mask connected to it, and the mask was not bagged when not in use. LVN M confirmed she had used the mask earlier and said she had intended to place it in a bag but forgot. The ADON and DON stated the mask was supposed to be bagged when not in use and labeled with the resident’s name, room number, and date. Resident #9 had diagnoses including type 2 diabetes mellitus without complications, COPD, and acquired absence of the left upper limb, and the admission MDS reflected a BIMS score of 15. The resident’s care plan identified the need for Enhanced Barrier Precautions due to a wound and noted the resident was at risk of infection. During observation, CNA A entered and exited the room without hand sanitizing or washing hands, despite a sign outside the room stating that everyone must clean their hands before entering and leaving. CNA A stated she knew she was supposed to sanitize before entering and after leaving but forgot to do so. Interviews with staff confirmed that hand hygiene was required for rooms with EBP and that PPE was required for contact precautions.
Dignity Issue During Meal Assistance
Penalty
Summary
The facility failed to treat a resident with respect and dignity during lunch assistance when a CNA stood while feeding him instead of sitting at his level. Resident #44 was an [AGE]-year-old male with vascular dementia, heart failure, lack of coordination, and dysphagia. His quarterly MDS reflected a BIMS score of 3, indicating severely impaired cognition, and his care plan stated he required supervision assistance by staff to eat. During an observation, CNA A was seen assisting Resident #44 with his lunch while standing on his left side the entire time. After the resident finished eating, the CNA removed his lunch plate from the bedside table. In interviews, CNA A stated the facility protocol was to sit next to the resident at their level while feeding, and she had forgotten to get a chair because she rushed to the room. ADON B and the DON both stated that staff were required to sit at the resident's level when feeding and identified standing while feeding as a dignity issue. The facility policy stated that all staff will be seated, if possible, while feeding a resident.
Failure to Follow Care Plans for Repositioning and Meal Assistance
Penalty
Summary
The facility failed to keep the resident environment as free of accident hazards as possible and failed to provide adequate supervision and assistance devices to prevent accidents for two residents. One event involved a resident with vascular dementia and an acquired absence of the left upper limb who required substantial to maximal assistance by two staff for bed mobility. His care plan directed two-person assistance, but during a wound care observation, an RN repositioned him without using two employees. The RN stated he did not know the resident was a two-person assist and had not checked the care plan, and the WCN said he also forgot to review the care plan before the procedure. A second event involved a resident with vascular dementia, heart failure, lack of coordination, and dysphagia whose cognition was severely impaired and who required substantial to maximal assistance with eating. His care plan directed supervision assistance by one staff for meals. During an observation, his breakfast tray was left directly in front of him and within reach while he was unattended. He attempted to reach for the coffee cup, dropped it, and spilled coffee on his plate, tray, and bed sheet. He told staff the coffee was cold and that he had not been burned. CNA staff later entered the room, removed the tray, and checked him for injury. Interviews showed staff understood that residents needing assistance with repositioning or feeding were to be managed according to the care plan and that leaving a meal tray unattended for a resident who required assistance was not allowed. The DON stated staff should follow the plan of care for proper repositioning and that both residents and staff could be injured if the plan was not followed. The DON also stated that meal trays for residents needing assistance were to be delivered only when a CNA was available to assist and were not to be left unattended in resident rooms.
IV Dressing Not Dated or Initialed
Penalty
Summary
Facility staff failed to ensure parenteral fluids were administered consistent with professional standards of practice for Resident #96, a female admitted with pneumonia and COPD. Her care plan stated she was on IV medications related to pneumonia, and her quarterly MDS showed a BIMS score of 7, indicating severe cognitive impairment. The order summary showed an order for 0.9% sodium chloride IV hydration, 2 liters every shift for 2 days at 60 mL/hr, starting 12/13/25. During observation on 12/15/25, Resident #96 was sitting in her wheelchair with a peripheral IV lock in her right hand covered by a transparent dressing that had no date and no initials. No signs or symptoms of infection or infiltration were noted at the IV site. The LVN stated the nurse who initiated the IV was responsible for labeling the dressing with the date and initials, and confirmed the dressing was not labeled or dated. The DON stated the insertion site dressing should have been dated and initialed and that she could not find a policy on IVs.
Pest Control Program Failed to Keep Resident Room Free of Cockroaches
Penalty
Summary
The facility failed to maintain an effective pest control program, and surveyors found that Resident #43's and Resident #54's room was not free of pests. On 12/15/25 from 9:00 AM to 9:30 AM, observation revealed one live cockroach next to the floor mat in the room shared by Residents #43 and #54. The deficiency was cited after review showed the room had live pests present during the survey observation. Record review of the facility's pest control log showed cockroaches had been reported four times since October 2025, and pest control had treated for cockroaches every month, with the last visit on 11/15/25. The Maintenance Director stated the pest control company treated the whole facility and any rooms identified by staff or residents as having live bugs, and that the company also sealed openings found during treatments. The ADM stated the facility had a monthly pest control vendor and staff completed morning rounds and documented concerns in a pest control sighting logbook, but also stated the facility did not have a pest control policy. The invoice from 11/15/2025 documented regular pest service, a flying insect program, inspection and treatment of multiple rooms for roaches, treatment of common areas, and exterior perimeter treatment with rodent bait station replacement.
Failure to Document Change of Condition After Resident Fall
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Specifically, an LVN did not document a required change of condition form in the electronic medical record after a resident experienced a fall. The LVN worked the shift during which the fall occurred and stated that he followed the fall protocol, including assessing the resident, assisting him up, initiating neuro checks, and notifying the physician, responsible party, and DON. However, upon review, there was no documentation of the change of condition form for the incident, despite the LVN acknowledging he was trained and expected to complete this documentation for every fall. The resident involved had multiple significant diagnoses, including type 2 diabetes, end stage renal disease, heart failure, peripheral vascular disease, hypertension, anxiety disorder, and chronic obstructive pulmonary disease. The resident was identified as being at risk for falls due to a history of falls, decreased mobility, and generalized weakness. Facility policy required that all assessments, observations, and services provided be documented accurately and timely in the resident's medical record. Both the LVN and DON confirmed that the documentation protocol was not followed in this instance.
Failure to Document Foley Catheter Re-Insertion in Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Specifically, after a resident was found on the floor with her Foley catheter pulled out, the nurse responsible for re-inserting the catheter did not document the procedure in the resident's electronic medical record. The facility's policy requires that any insertion or re-insertion of a Foley catheter be documented, including details such as the time, gauge size, and the resident's tolerance of the procedure. The incident involved a female resident with a history of sepsis and vascular dementia, who was severely cognitively impaired. On the day of the event, staff responded to a scream and found the resident sitting on the floor with the Foley catheter removed. A head-to-toe assessment was performed, and no injuries were noted. The resident was unable to communicate what had happened. The nurse on duty at the end of her shift reported that another nurse agreed to re-insert the Foley catheter, but there was no documentation of this procedure in the medical record. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and Director of Nursing (DON), confirmed that the re-insertion of the Foley catheter was not documented as required by facility policy. Review of the facility's documentation policy further supported that all assessments, observations, and services provided must be recorded in the resident's medical record. The lack of documentation was verified through review of the electronic medical record and staff interviews.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Alarm Malfunction
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment exited the facility undetected. The resident, a male with diagnoses including diabetes, hypertension, gait and mobility abnormalities, and lack of coordination, had a BIMS score indicating severely impaired cognition. Although his initial care plan identified him as an elopement risk and included interventions such as distraction and structured activities, a prior wandering evaluation had not classified him as a wandering risk. On the evening of the incident, the resident was moved to a different room due to plumbing issues, and staff last observed him in his room before discovering him missing during routine rounds. Staff did not hear any door alarms when the resident exited through the east exit door, and the alarm system did not activate at the time of his departure. The resident was found outside the facility, across the street, wearing only socks and conversing with two individuals. Multiple staff interviews confirmed that no alarms were heard, and the door alarm was not triggered when the resident left. The maintenance supervisor and an external technician had serviced the door and checked the alarm system earlier that day, confirming it was operational at that time, but the reason for the alarm's failure during the incident remained unclear. The facility's policy required adequate supervision and timely response to alarms for residents at risk of elopement. Despite these protocols, the resident was able to leave the premises without detection or immediate staff response, as the alarm system did not function as intended. Staff were trained on elopement prevention and response, and regular elopement drills were conducted, but these measures did not prevent the incident. The deficiency was identified as past non-compliance, with immediate jeopardy beginning and ending within a specified timeframe.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure timely reporting of an injury of unknown origin for a resident who was later diagnosed with a nondisplaced proximal fibular fracture. The incident began when the resident, who had diagnoses including vascular dementia, muscle wasting, osteoporosis, and weakness, was being assisted from the toilet to her wheelchair by two CNAs. During the transfer, the resident's knees gave out, and she requested to be seated on the floor. Both CNAs and the resident agreed to this, and a nurse was called to assess her. The nurse performed a head-to-toe assessment and found no abnormalities or pain reported by the resident at that time. The resident was transferred back to bed using a mechanical lift, and no incident report or change of condition was completed because the nurse did not consider it a fall. Several days later, the resident began to experience pain in her lower right leg, which she reported to the nurse practitioner (NP) during rounds. The NP ordered an x-ray, which revealed a nondisplaced proximal fibular fracture. The NP accepted the findings but ordered a second x-ray to confirm the injury, which also indicated a fracture. Despite receiving the first x-ray results, the administrator delayed reporting the injury to the state agency, waiting for the results of the second x-ray before submitting the report. The injury was ultimately reported more than 24 hours after the initial diagnosis, exceeding the required 2-hour reporting window for injuries of unknown origin. Interviews with staff confirmed that the incident was not reported promptly due to the initial lack of pain or visible injury and the belief that it was not a fall. The DON acknowledged that the nurse failed to complete an incident report or notify her of the event, and the administrator confirmed the delay in reporting was due to waiting for confirmation from a second x-ray. The facility's policy requires immediate reporting of such incidents, but this protocol was not followed in this case.
Incomplete Documentation Following Resident Fall
Penalty
Summary
A deficiency occurred when a nurse failed to maintain complete and accurate clinical records for a resident who experienced a change in condition. The resident, an older female with a history of vascular dementia, muscle wasting, osteoporosis, and weakness, was being assisted from the toilet to her wheelchair by two CNAs when her knees gave out. She was guided to the floor and subsequently assessed by the nurse, who performed a head-to-toe assessment and noted no immediate pain or injury. However, the nurse did not complete a change of condition report, incident report, or notify supervisory staff at the time of the event, as she did not consider the incident a fall. The resident later reported pain in her right lower leg, which was managed with pain medication. Days after the incident, the resident informed her physician about the pain, leading to an x-ray that revealed a nondisplaced proximal fibular fracture. The nurse's failure to document the incident and the assessment in a timely manner resulted in a delay in further evaluation and treatment. The Director of Nursing and Administrator only became aware of the incident after being notified by the resident's nurse practitioner several days later. Facility policy required that all assessments, observations, and services be documented completely and in a timely manner, with late entries clearly indicated. The nurse's omission of required documentation and failure to notify appropriate staff were identified as deficiencies in maintaining accurate and complete clinical records in accordance with professional standards and facility policy.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, leading to significant weight loss. The resident, a male with multiple diagnoses including Parkinsonism, type 2 diabetes, and dementia, experienced a weight loss of 6.95% over a short period. Despite the care plan indicating the need to monitor and report significant weight loss, the facility did not implement timely interventions when the resident lost 7 pounds in one week, nor did they notify the physician as required by the care plan. The resident's care plan required monitoring for signs of malnutrition and weight loss, with specific instructions to notify the physician if the resident lost more than 3 pounds in one week. However, the facility did not follow these instructions, and the resident's weight loss was not addressed until it became severe. The resident's weight was not consistently recorded, and there was a lack of communication between staff members regarding the resident's nutritional status and weight loss. Interviews with staff revealed that the resident's weight loss was not flagged in the system, and the dietitian was not notified until after the significant weight loss was identified. The facility's failure to adhere to the care plan and monitor the resident's weight effectively resulted in a delay in implementing necessary interventions to prevent further weight loss.
Deficiency in Food Storage and Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen's storage, preparation, and sanitation practices. Specifically, the facility did not ensure that food and drink items in the reach-in freezer, refrigerator, and dry storage area were properly stored, labeled, and dated, with some items being expired. During an initial tour, it was found that two out of six milk jugs in the refrigerator were open and used without an open date, and several bags of cheese and boxes of frozen vegetables were open to air and not sealed properly. The Dietary Aide mentioned that the Dietary Manager had quit about two weeks prior, and the facility Administrator was handling kitchen orders. Interviews with the Dietician and the Administrator revealed that dietary managers from sister facilities were assisting due to the absence of a permanent Dietary Manager. A follow-up observation with a Dietary Manager from a sister facility confirmed that some issues persisted, such as open biscuits in the freezer. The Dietary Manager acknowledged the need for proper labeling and sealing of open foods and mentioned that undated items should be discarded. The facility's policy for food storage requires all refrigerated and frozen foods to be labeled, dated, and stored in moisture-proof containers, which was not consistently followed.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident had access to a call light while in bed, which is a violation of the residents' right to reasonable accommodation of their needs and preferences. The resident in question, a male with severe cognitive impairment and multiple diagnoses including unspecified dementia and anxiety disorder, was observed without the call light within reach. The call light was found hanging off the side of the bed, touching the floor, and the resident was unaware of its location. This situation was confirmed by a Certified Nursing Assistant (CNA) who acknowledged that the resident was supposed to have the call light within reach to call for help when needed. Interviews with staff revealed that there was a lapse in ensuring the call light was accessible to the resident. One CNA mentioned that the call light was within reach during morning care but speculated that the resident might have moved it. Another CNA and a Licensed Vocational Nurse (LVN) stated that they routinely check to ensure residents can reach their call lights, as emphasized by the administration and nursing staff. The facility's policy mandates that staff ensure call lights are within reach and secure, but this was not adhered to in this instance, potentially placing the resident at risk of being unable to obtain assistance when needed.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple deficiencies observed during the care of residents. CNA A did not adhere to proper infection control protocols while providing incontinent care to a male resident diagnosed with benign prostatic hyperplasia. The CNA used the same wipe for multiple swipes during perineal care and failed to change gloves and sanitize hands when transitioning from cleaning the perineal area to the buttocks. This improper technique was acknowledged by CNA A, who admitted to being nervous and aware of the correct procedures. Similarly, CNA B did not follow infection control protocols while providing care to a female resident with muscle wasting and atrophy. The CNA failed to sanitize hands between glove changes and used the same wipe for multiple swipes during the cleaning process. Despite having received recent training on infection control, CNA B did not adhere to the established guidelines, which were reiterated by the lead CNA and the Director of Nursing (DON) during interviews. Additionally, the facility failed to prevent a male resident's urinary catheter bag from touching the floor, which was observed by LVN A. The resident, who had a severely impaired cognition and an indwelling catheter, was at risk of infection due to the catheter bag's contact with the floor. Interviews with LVN A, LVN B, LVN C, and RN A confirmed the potential for cross-contamination and infection due to this oversight. The facility's policy on infection prevention and control, which includes standard precautions and proper hand hygiene, was not effectively implemented in these instances.
Inaccurate MDS Coding for Resident Falls
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in the Minimum Data Set (MDS) coding for falls. Resident #2, who had a history of right-sided hemiplegia and hemiparesis following a cerebral infarction, experienced a fall on October 18, 2023, resulting in a cut on the bottom lip and a chipped tooth. Despite these injuries, the fall was not coded in the Discharge MDS, which was completed on November 20, 2023. The MDS Nurse acknowledged that the fall should have been captured on the Discharge MDS, but it was not considered a significant change due to the absence of major injury. The Director of Nursing (DON) indicated that the injuries sustained during the fall should have warranted a significant change MDS or at least been coded on the Discharge MDS. Resident #3, who had diagnoses including Type 2 Diabetes Mellitus and legal blindness, experienced a fall on April 4, 2024, resulting in a raised area on the left side of the head and skin tears. This fall was not coded in the subsequent MDS assessment. The MDS Nurse stated that the fall should have been coded in the MDS but was not, although it was care planned. The DON confirmed that the fall needed to be coded in the MDS to communicate the resident's needs to other staff. The facility's failure to accurately code these falls in the MDS assessments could lead to improper or incorrect care and services for the residents. The report highlights the facility's failure to adhere to the Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) guidelines, which require falls to be coded in the MDS. The MDS Nurse and DON both acknowledged the oversight in coding the falls, which could result in inaccurate assessments and care plans. The facility's incident logs and care plans documented the falls, but the MDS assessments did not reflect these events, indicating a lapse in the facility's assessment processes.
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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 Edinburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windsor Nursing And Rehabilitation Center Of Edinb | 1.9 mi | ★★★★★ | 4 | 0 |
| Hidalgo Nursing And Rehabilitation Center | 2.8 mi | ★★★★★ | 11 | 0 |
| Edinburg Nursing And Rehabilitation Center | 3.4 mi | ★★★★★ | 17 | 1 |
| Colonial Manor Advanced Rehab & Healthcare | 4.3 mi | ★★★★★ | 18 | 0 |
| Briarcliff Nursing And Rehabilitation Center | 6.2 mi | ★★★★★ | 16 | 0 |
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