Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Atrium during CMS and state inspections, most recent first.
A resident with dementia, anxiety, depression, HF, and AFIB had active orders for Eliquis, Prozac, and ibuprofen. The chart showed a severe ibuprofen-Prozac interaction warning for increased risk of upper GI bleeding, along with a moderate Prozac-apixaban interaction warning, but the consultant pharmacist did not identify or report the irregularity during the monthly MRR to the DON or MD. Later, nursing found blood clots in the resident’s stool with AMS, the NP and MD evaluated him for GI bleed, and he was sent to the ED and admitted to the hospital.
A resident with dementia, anxiety, depression, heart failure, and atrial fibrillation had psychotropic medication changes documented in an LVN progress note, including stopping Escitalopram and starting Depakote and Prozac, but there was no MH NP note in the chart for the medication start/stop. The DON and Administrator stated provider notes were expected in the EMR when medications were started or stopped, and the resident’s record also showed moderate cognitive impairment on MDS.
Two residents experienced incomplete and inaccurate documentation of controlled substance administration, with staff failing to sign required medication records and narcotic logs as per facility policy. These lapses included missing signatures for Lorazepam and Hydromorphone administration, as well as discrepancies between medication counts and documentation, resulting in incomplete medical records.
The facility did not develop or implement comprehensive care plans for two residents: one who repeatedly refused medication for GERD and another with severe dementia who attempted to get out of bed without assistance and experienced multiple falls. Staff were unaware that these behaviors required care planning, and the facility's policy for person-centered care plans was not followed.
A medication cart on one hall was observed left unlocked and unattended near the nurse's station. An LVN responsible for the cart admitted forgetting to lock it when stepping away, and the DON confirmed that staff are expected to keep carts locked when not in use, as per facility policy.
A resident with dementia, hemiplegia, and total ADL dependence had a loose, abnormal left arm noticed by CNAs during morning care, but they finished care without immediately notifying the nurse. The change was reported hours later, after which the LPN assessed the arm, notified the NP, and x-rays showed an acute displaced distal humerus fracture.
Pest control was not effectively managing roaches and ants in the facility. A live roach was observed in a hallway near an LPN's med cart, and a live ant was later seen near the main dining area. Staff interviews showed inconsistent awareness of pest control frequency, while the ADM stated the vendor came monthly and as needed, sightings were logged in TELS, and the facility had no pest control policy. Records also showed prior ant and roach sightings and monthly pest service invoices.
Failure to Obtain Prior Consent for Psychotropic Medication: A resident with severe cognitive impairment and diagnoses including amnesia and anxiety disorder received Lorazepam PRN for anxiety/agitation before consent was documented. The MAR showed the psychotropic was administered twice before the consent appeared in the chart, and facility leadership and nursing staff stated consent for psychotropic or antipsychotic medications had to be obtained before administration and that the resident or RP had to be informed of the risks, benefits, and alternatives.
Care Plan Not Updated for Oxygen Order: A resident with tracheostomy status and acute respiratory failure with hypoxia had an oxygen order changed, but the care plan was not updated to match the new physician order. During observation, the oxygen concentrator was set below the ordered rate, and the nurse confirmed the setting should have been higher per the order. The ADON and DON stated the care plan should have been updated when the order was received.
The facility failed to revise care plans for two residents after status changes. One resident with stroke history, CKD, moderate cognitive impairment, weight loss, and an indwelling Foley catheter had no catheter or weight-loss care plan entry, and another resident with Alzheimer's disease, DM2, CHF, metabolic encephalopathy, dysphagia, and moderate cognitive impairment had no insulin care plan entry despite a Tresiba order. Staff interviews showed the RN, MDS RN, and DON were responsible for updating care plans and acknowledged the need to revise them when changes occurred.
Failure to use footrests during transfer: A resident with a stroke history, unsteady gait, and total dependence for transfers was observed being wheeled to the shower room without footrests. The resident’s foot dragged and became caught between the wheelchair and the door frame until the surveyor intervened. CNA stated the footrests were forgotten, and the DON said staff were expected to always use footrests for residents who need them.
A resident with an indwelling Foley catheter and moderately impaired cognition was observed with the catheter bag lying on the floor beside the bed. Staff stated the bag should not touch the floor, and the DON acknowledged it should be positioned on the bed frame or side of the bed, though she also said a floor contact was not necessarily a problem because the system was closed. The resident’s care plan and orders included Foley catheter care every shift and keeping the bag and tubing below bladder level.
Failure to Follow Ordered Oxygen Therapy: Two residents did not receive oxygen as ordered. One resident with tracheostomy status and acute respiratory failure had oxygen set below the ordered LPM via trach, and another resident with CHF, dementia, and dysphagia was observed without her ordered NC oxygen in place. The assigned LPNs acknowledged the orders and the DON stated nurses were responsible for checking and following oxygen orders each shift.
A diabetic lancet was observed sitting on top of an unattended med cart in the hallway instead of being locked inside the cart. RN J, the DON, an LVN, and the ADON all stated the lancet should have been secured in the cart, and the facility policy states not to leave the med cart unlocked or unattended in the resident care area.
Food storage and sanitation practices were not followed in the kitchen. A container of Thick-It was covered with foil instead of a proper lid, and several refrigerated items were not labeled, dated, or had legible dates. During pureed meal prep, a DM assisted the cook without washing her hands or wearing gloves, handling a dirty blender, clean prep items, and trash at the food prep counter.
Missing Progress Note Documentation: A resident with amnesia, anxiety disorder, a history of falls, COPD, and severe cognitive impairment had no Progress Note documentation for an extended period. Staff interviews showed the LVN was responsible for documentation, the ADON said care and condition changes were documented in PCC, the DON said notes must be thorough and complete, and the Administrator acknowledged the missing notes and stated nurses were being in-serviced.
A facility failed to maintain infection prevention and control practices when a resident on contact isolation for MRSA had family enter the room without PPE, a peripheral IV dressing was left without a date or initials, and a CNA used contaminated gloves during catheter care before placing a clean brief on another resident. The DON and staff acknowledged the PPE, IV labeling, and glove-use expectations, and observations confirmed the lapses.
A resident with diabetes, hypertension, and severe cognitive impairment developed a skin tear that was reported by a CNA to an LVN. The LVN cleansed the wound but failed to notify the physician or the resident's representative, as required by facility policy, resulting in a two-day delay in appropriate treatment and communication.
A resident with multiple chronic conditions experienced hypotension after dialysis, leading the ADON to obtain and administer Midodrine. However, the medication order was entered into the system by a new LVN with an incorrect start date, and the MAR was not signed by the ADON who gave the medication. This resulted in incomplete and inaccurate clinical documentation, as confirmed by staff interviews and record review.
A facility failed to ensure proper wound care for a resident, as the WCN did not follow physician orders for treating a wound on the left buttock. The resident, with a history of diabetes and dementia, had a wound that required specific treatment, but records showed no care was documented for several days. The WCN mistakenly believed the wound was healed and did not apply the prescribed treatment until the error was realized. The resident's condition was complicated by self-inflicted scratches and a decline due to COVID-19, but the WCD was satisfied with the care provided.
A resident with an indwelling catheter was observed with the catheter tubing improperly positioned above the body, restricting urine flow to the collection bag. Despite facility protocols and staff training, the catheter care was not managed correctly, potentially risking complications. Interviews with CNAs and the DON confirmed the improper positioning and the associated risks.
A resident with dementia and muscle weakness, requiring two-person assistance for bathing, fell and fractured her femur when a CNA provided care alone, contrary to the care plan. The CNA admitted to knowing the requirement but proceeded alone, leading to the resident slipping off the bed. The incident was reported, and the resident was sent to the hospital for evaluation.
A resident with dementia and muscle weakness, requiring a two-person assist for bathing, was injured when a CNA provided a bed bath alone, resulting in the resident falling and fracturing her femur. The CNA admitted to not following the care plan, which required two staff members for bathing assistance, leading to the accident.
A facility failed to ensure accurate PASARR Level 1 Screening for a resident with mental illness, leading to a lack of referral for necessary services. The resident had diagnoses including Depression and Schizoaffective Disorder, but the screening incorrectly indicated no mental illness. Staff interviews revealed a lack of proper assessment and documentation, with the MDS team responsible for the oversight.
The facility did not ensure residents and their representatives had access to survey results, as required. Six individuals were unaware of their right to review these results, and observations showed no survey binder or notice in the reception area. The administrator had the binder in his office due to remodeling, but no sign was posted to indicate its location.
A facility failed to include a fall mat in a resident's care plan, despite its presence in the resident's room. The resident, who has Alzheimer's and other health issues, was severely cognitively impaired. The DON admitted the oversight, citing her recent start at the facility. This omission could lead to staff not following through with the intervention, affecting the resident's care.
A resident with moderate cognitive impairment and diabetes did not receive timely nail care, leading to long and dirty fingernails. Despite being scheduled for nail care, inconsistencies in staff responsibilities and lack of documentation resulted in inadequate grooming. The facility lacked specific protocols for nail care frequency, contributing to the deficiency.
A facility failed to develop a baseline care plan for a newly admitted resident with complex medical conditions, omitting critical information such as full code status and Hoyer lift use. Interviews revealed confusion among staff about responsibilities for entering this information, with the DON emphasizing its importance for ensuring resident rights and appropriate care.
A resident's care plan inaccurately listed them as a dialysis patient and omitted the need for a mechanical lift for transfers. Despite staff being aware of the resident's actual needs through verbal communication, the care plan was not updated to reflect these needs, potentially risking inadequate care.
Failure to Report Severe Drug Interaction During Monthly Pharmacy Review
Penalty
Summary
The facility failed to ensure the consultant pharmacist reported drug regimen irregularities to the attending physician, the medical director, and the DON for one resident reviewed for pharmacy services. The deficiency involved a failure to detect and/or report a drug-to-drug interaction between ibuprofen and Prozac, which the record identified as having a severe risk of gastrointestinal bleeding. The facility policy required the consultant pharmacist to perform a monthly medication regimen review, evaluate side effects and interactions, document resident-specific irregularities, and report clinically significant findings to the DON and prescriber as appropriate. The resident had diagnoses including dementia, anxiety, depression, heart failure, and atrial fibrillation. The record showed active orders for Eliquis, Prozac, and ibuprofen. The medication records and order alerts documented interaction warnings, including a severe interaction between ibuprofen and Prozac with increased risk of upper gastrointestinal bleeding, and a moderate interaction between Prozac and apixaban. The pharmacist stated he reviewed established residents once a month, but he did not know there was a severe drug-to-drug reaction of GI bleed with concurrent administration of ibuprofen and Prozac. On 03/19/2026, nursing documented blood clots in the resident’s stool and altered mental status. The NP was notified, Eliquis was held, and the resident was evaluated by the NP and MD, who documented lethargy, bright red blood clots from the rectum, and concern for GI bleed. The resident was sent to the ED and later admitted to the hospital with AKI, AMS, GI bleed, and elevated troponin. Interviews with the DON, pharmacist, physician, and nursing staff described that interaction alerts appeared in the electronic record and that staff were expected to notify the physician, but the pharmacist did not identify or report the severe ibuprofen-Prozac interaction during the monthly review.
Incomplete Documentation for Psychotropic Medication Changes
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 6 residents reviewed for medical records accuracy. For Resident #1, a male admitted with diagnoses including dementia, anxiety, depression, heart failure, and atrial fibrillation, the admission MDS reflected a BIMS score of 10, indicating moderate cognitive impairment. The MDS also showed routine use of antianxiety medications, antidepressants, anticoagulants, antibiotics, diuretics, and hypoglycemics, and noted no potential indicators of psychosis, no behavioral symptoms, and no psychotic disorder other than schizophrenia. Record review showed a Progress Note entered by an LVN on 03/08/2026 at 08:26 pm stating that the MH NP rounded in the facility and gave new orders to discontinue Escitalopram and start Depakote 500 mg PO BID and Prozac 40 mg PO. However, there was no MH NP documentation in the Progress Notes for the start and stop of the psychotropic medications. The physician order record showed orders from the MH NP for Prozac 40 mg daily for antidepressant and Depakote 250 mg, 2 tablets twice daily for labile mood with manic features. During interviews, the DON and Administrator stated that providers were expected to enter notes in the Progress Notes and that MH NP notes should be in the electronic medical record when medications were started or stopped.
Incomplete and Inaccurate Medication Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, specifically regarding the documentation of controlled substances and medication administration. For one resident with severe cognitive impairment and a diagnosis of megaloblastic anemia and generalized anxiety disorder, the Individual Narcotic Record for Lorazepam was not signed as given on multiple occasions by both the ADON and an LVN. Additionally, discrepancies were observed between the amount of medication remaining in the bottle and the amount documented on the narcotic record. Staff interviews confirmed that the process for administering and documenting narcotics was not consistently followed, with staff acknowledging that missing signatures could lead to confusion and miscommunication regarding medication administration. For another resident with multiple diagnoses including a right arm fracture, diabetes mellitus type 2, and cervical disc displacement, the Medication Administration Record (MAR) for Hydromorphone was not initialed as given by an LVN, even though the Individual Narcotic Record indicated the medication had been administered. Staff interviews revealed that the LVN evaluated the resident before and after medication administration and stated that documentation was completed on both the MAR and narcotic sheet, but the MAR was missing the required entry. The DON confirmed that audits and in-services on medication administration and documentation were ongoing, and that discrepancies in documentation could result in medication errors. Facility policy required that staff sign the MAR after administering medication and, for controlled substances, also sign the narcotic record. Policies also mandated that all assessments, observations, and services provided be documented in accordance with state law and facility policy, including recording the date, time, and credentials of the person making the entry. The observed failures to document medication administration and narcotic usage as required by policy resulted in incomplete and inaccurate medical records for the affected residents.
Failure to Develop and Implement Comprehensive Care Plans for Resident Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by policy and regulation. For one male resident with a history of muscle weakness, sequelae of cerebral infarction, muscle wasting, and GERD, the care plan did not address his repeated refusal of prescribed medication (protonix). Despite the resident's moderate cognitive impairment and ability to communicate, there were no documented care plan goals, interventions, or tasks related to his medication refusal. Nursing staff reported the refusals to the physician but assumed the issue was already care planned, while the MDS nurse was unaware that such behaviors needed to be included in the care plan. For a female resident with muscle weakness, unspecified dementia, and muscle wasting, the facility did not develop or implement a care plan to address her attempts to get out of bed without assistance. This resident had severe cognitive impairment and was unable to communicate her needs or use the call light. Progress notes documented that she had fallen, resulting in injury and requiring emergency care. Multiple staff interviews confirmed that the resident frequently attempted to get out of bed unassisted and had experienced multiple falls, yet her behaviors were not reflected in her care plan. The MDS nurse was unaware that these behaviors should be care planned, and the DON considered the resident's actions as part of her disease process rather than a behavioral issue requiring care planning. The facility's policy requires the development and implementation of a comprehensive care plan for each resident, including measurable objectives and timeframes to address medical, nursing, mental, and psychosocial needs identified in the assessment. In both cases, the facility did not follow its own policy, resulting in the absence of care plans for significant resident needs and behaviors.
Unattended and Unlocked Medication Cart
Penalty
Summary
A deficiency was identified when the facility failed to ensure that all drugs and biologicals were stored in locked compartments and labeled according to professional standards. During an observation, a medication cart assigned to the 300 Hall was found unlocked and unattended near the nurse's station. No staff or residents were present at the time. Shortly after, an LVN responsible for the cart noticed it was unlocked and secured it. The LVN acknowledged responsibility for the cart and stated that it should have been locked whenever unattended, admitting she forgot to do so. Further interviews with the DON confirmed that multiple staff, including herself and the ADON, were responsible for ensuring medication carts were locked. The DON reiterated that staff were expected to lock the cart when leaving it unattended and recognized the potential for medications to be accessed by unauthorized individuals if left unsecured. Review of the facility's policy indicated that medication carts are to remain locked at all times when not in use and should not be left unlocked or unattended in resident care areas.
Delayed Reporting of Abnormal Arm Finding During Care
Penalty
Summary
The facility failed to ensure that a resident received care and treatment in accordance with orders, the comprehensive care plan, and the resident’s choices when staff identified a change in the resident’s left arm during care but did not immediately report it to the nurse. The resident had dementia, hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, functional limitations in range of motion of the upper and lower extremities, and was totally dependent for all activities of daily living. Her care plan reflected total assistance for transfers, eating, dressing, bed mobility, oral care, and personal hygiene. During morning incontinent care and a bed bath, two CNAs noticed that the resident’s left arm, which was normally contracted inward across her chest, appeared loose and different. They completed the care without notifying the charge nurse at that time. One CNA later remembered that she had not reported the abnormality, and the nurse was not informed until several hours later. The nurse then assessed the arm and noted it appeared flaccid with sensitivity to touch, after which the nurse practitioner was notified and x-rays were ordered. The resident’s x-ray showed an acute oblique displaced fracture of the distal humerus. The nurse practitioner later documented that the resident was seen after the arm was reported as flaccid and that touching the arm caused facial grimacing. The facility’s investigation also reflected that the resident was admitted to the hospital with the fracture and later returned to the facility. The report states that the CNAs were trained to report any changes immediately to the charge nurse, but that did not occur during the care event.
Pest Control Program Not Effectively Managing Roaches and Ants
Penalty
Summary
The facility failed to maintain effective pest control for roaches and ants. During an observation on 08/03/2025 at 11:15 a.m., a live roach was seen on the wall in the hallway of the 100 hall, and maintenance staff captured it after the observation was pointed out to LVN Q. LVN Q was in the hallway with her medication cart at the time. During another observation on 08/03/2025 at 11:38 a.m., a large black live ant was seen on the wall by the light fixture near the main dining area. During interviews, LVN Q stated he had not seen roaches in the facility until then and did not know how often pest control came, though there was a pest control sighting logbook at the nurse's station for staff to document ants or roaches. The Maintenance Director stated pest control came monthly per contract and that he checked the logbook monthly, captured and disposed of bugs, and provided sightings to pest control. The Administrator stated the facility had a pest control vendor scheduled once a month and as needed, that sightings were entered into TELS, and that the facility did not have a pest control policy. Record review showed two pest sightings in June 2025, including ants in one room and roaches in a room and restroom, and pest control invoices from 06/21/2025 and 07/21/2025 documented treatment of the facility, common areas, hallways, bathrooms, kitchen, dining, offices, exterior perimeter, glue boards, and rodent bait stations.
Failure to Obtain Prior Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that Resident #16 was informed of the risks, benefits, and alternatives for a psychotropic medication before it was administered. Resident #16 was a [AGE]-year-old female admitted on 03/20/2023 with diagnoses including amnesia, anxiety disorder, history of falling, and chronic obstructive pulmonary disease. Her annual MDS showed a BIMS score of 01, indicating severe cognitive impairment. A physician order dated 06/17/2025 prescribed Lorazepam oral concentrate 2 mg/mL, 0.5 mL by mouth every four hours as needed for anxiety or agitation for 14 days, and the June 2025 MAR showed Lorazepam was administered on 06/17/2025 at 9:08 PM and again on 06/22/2025 at 2:27 PM. Record review showed no consent for Lorazepam in the medical record until 07/08/2025, and the care plan dated 06/20/2025 did not mention the psychotropic medication. During interviews, the Administrator, LVN, ADON, RN, and DON all stated that consent for psychotropic or antipsychotic medications needed to be obtained before the medication was given, and that the resident or responsible party had to be informed of the medication and sign consent in advance. The facility policy also stated that prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed in advance of the benefits, risks, and alternatives, and that the facility would document that this information was provided before the resident accepted or declined the medication.
Care Plan Not Updated for Oxygen Order
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with tracheostomy status and acute respiratory failure with hypoxia. The resident’s quarterly MDS indicated that he received oxygen therapy, and his care plan, initiated on 7/22/2025, identified oxygen use related to acute respiratory failure status post tracheostomy status with an intervention of oxygen via tracheostomy collar at 6 liters per minute continuous. Record review showed a physician order dated 08/3/2025 for oxygen at 2 LPM via trach tube every shift for hypoxia, but the care plan was not updated to reflect this order. During observation on 08/3/2025, the oxygen concentration machine was set at 1.5 liters per minute via tracheostomy, and the resident was in bed with the head of the bed slightly elevated with no signs of respiratory distress noted. The nurse stated the setting should have been 2 liters per minute per the physician order and that she was not sure who had moved it. The ADON and DON stated the care plan should have been updated when the order was received, and the DON stated she missed updating it.
Failure to Revise Care Plans for Catheter Use and Insulin
Penalty
Summary
The facility failed to review and revise comprehensive person-centered care plans after assessment changes for 2 of 8 residents reviewed. Resident #10 had an original admission date of 04/10/2025 and a readmission date of 06/12/2025. His diagnoses included cerebral infarction affecting the left side, seizures, hypertension, chronic kidney disease, and pain. The admission MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and noted that he was always incontinent of bladder. His weight at the time of assessment was 220 pounds, compared with 233 pounds on 04/10/2025, reflecting weight loss. A physician order dated 06/12/2025 showed a catheter was ordered, and progress notes documented an indwelling Foley catheter, but the care plan dated 06/19/2025 did not mention either the catheter or the weight loss. Resident #4 had an original admission date of 04/15/2021 and a readmission date of 07/06/2025. Her diagnoses included Alzheimer's Disease, Type 2 Diabetes Mellitus, Congestive Heart Failure, Metabolic Encephalopathy, and Dysphagia. Her comprehensive MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and identified insulin as a high-risk medication. The physician order summary showed Tresiba Insulin with a start date of 07/07/2025, but the care plan dated 07/14/2025 did not mention insulin. During interviews, the RN, MDS RN, DON, and Administrator stated that care plans were to be updated by nursing leadership and MDS staff, with revisions expected immediately or within the required timeframe. The MDS RN stated Resident #10's care plan would be updated by MDS staff after a MDS assessment, and the DON stated the care plan was to be revised immediately. For Resident #4, the MDS RN stated he was responsible for updating the care plan and acknowledged he had seven days to complete the comprehensive care plan, while the DON stated insulin should be care planned even if it was not a black box medication. The facility policy stated comprehensive care plans are to be reviewed and revised when a resident experiences a status change.
Failure to Use Footrests During Resident Transfer
Penalty
Summary
The facility failed to ensure that a resident received the assistance devices needed during transfer. Resident #110 was a [AGE]-year-old male admitted on 6/20/25 with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of the left posterior cerebral artery, unsteadiness on feet, and other abnormalities of gait and mobility. His care plan dated 6/20/25 stated that he was totally dependent on staff to wheel at least 150 feet in a corridor or similar space, and his MDS assessment dated 6/25/25 stated that he was totally dependent for assistance with transfers. On 8/05/25 at 10:35 a.m., CNA E was observed wheeling Resident #110 to the shower room without using the resident’s footrests. The resident was dragging his feet, and one foot was between the wheelchair and the door frame until the surveyor intervened to prevent injury. During interview, CNA E stated that the resident had footrests but she forgot to put them in the wheelchair, and said the resident could have been hurt because his foot was stuck between the wheelchair and the door frame. The DON later stated that staff were expected to always use footrests on residents who needed them and that transferring the resident without the footrest placed Resident #110 at high potential risk for injury.
Foley Catheter Bag Left on Floor
Penalty
Summary
The facility failed to ensure appropriate care for a resident with an indwelling Foley catheter when the catheter tubing/bag was found touching the floor. Resident #91 was a [AGE]-year-old male admitted with diagnoses including metabolic encephalopathy and obstructive and reflux uropathy. His MDS documented moderately impaired cognition with a BIMS score of 8, and his care plan and orders included an indwelling Foley catheter with catheter care every shift and as needed, along with keeping the catheter bag and tubing below bladder level and away from the entrance room door. During observation, the resident’s Foley catheter bag was noted lying on the floor on the right side of the bed. CNA B and LVN A both stated the bag should not be touching the floor, and LVN A hung the bag on the bedframe after being shown its position. The DON stated catheters should be on the side of the bed and not touching the floor, although she also stated that if the catheter bag did touch the floor it was not necessarily a problem because the system was closed. The record also noted the facility had no policy on Foley catheters.
Failure to Follow Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with physician orders for two residents who required oxygen therapy. Resident #10, a male with tracheostomy status and acute respiratory failure with hypoxia, had a care plan calling for oxygen via trach collar at 6 liters per minute continuous, but the physician order dated 08/3/2025 specified oxygen at 2 LPM via trach tube every shift for hypoxia. During observation, the oxygen concentration machine was set at 1.5 liters per minute via tracheostomy. The assigned LVN stated the setting should have been 2 liters per minute per the physician order and that she checked the setting at the beginning of her shift, but was not sure who had moved it. Resident #13, a 90-year-old female with congestive heart failure, dysphagia, dementia, hypertension, and muscle wasting and atrophy, had a physician order for oxygen at 2 LPM via nasal cannula every shift for hypoxia. During observation, she was in bed with the head of the bed slightly elevated and had no oxygen via nasal cannula in place. The assigned LVN stated the resident was not on oxygen, had checked her SpO2 that morning and it was 98, and was not aware of the active oxygen order. The DON stated nurses assigned to the hall were responsible for checking oxygen orders each shift and following the active physician orders.
Unsecured diabetic lancet left on medication cart
Penalty
Summary
The facility failed to ensure that diabetic equipment was stored in a locked compartment for 1 of 4 medication carts. During an observation on 08/06/2025 at 12:05 PM, a diabetic lancet was seen sitting on top of the 600 hall medication cart, which was unattended in the 600 hallway. During an interview at 12:07 PM, RN J stated the lancet was supposed to be secured in the medication cart and said someone could come by and grab it off the cart. During later interviews, the DON stated the lancet should be kept in the medication cart until use and said it would be a safety issue if left on top of the medication cart unattended. LVN H stated the lancet was supposed to be locked inside the medication cart and not left unattended, and the ADON stated it was not okay to leave the lancet unattended on top of the cart. The facility's Medication Administration policy dated 10/01/2019 stated not to leave the medication cart unlocked or unattended in the resident care area.
Food Storage and Hand Hygiene Lapses During Meal Preparation
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed. During observation of the kitchen counter, 1 container of Thick-It was found covered with foil instead of a proper lid. During observation of the walk-in refrigerator, 1 bag of sliced melons had a date that was not legible, 1 crate of onions had loose onions out of the bag and was not labeled or dated, and 1 bell pepper in a cardboard box was not labeled or dated. In interview, the DA stated the thickener should have had a plastic lid and that food items received and put away were responsible for being labeled and dated with dates that were easy to read. During observation of meal preparation, the DM assisted the cook with preparing pureed meals without washing her hands or putting on gloves. The DM picked up a dirty blender with bare hands, took it to be washed, returned it to the prep counter, lined a clean metal food container with a disposable bag, and handled trash around the counter, all without hand hygiene or gloves. The cook later washed his hands, put on gloves, and continued preparing the pureed meal. The cook stated he generally prepared the pureed meals on his own but that the DM helped him that day. The facility's Food Storage Policy required opened and bulk items to be stored in tightly covered containers and refrigerated foods to be dated, labeled, and tightly sealed in approved containers. The Employee Sanitation Policy required staff to wash hands before food preparation, during food preparation as needed to prevent cross contamination, and to use single-use gloves for one task and change gloves between tasks or after leaving the food prep area. In interview, the DM stated she forgot to wash her hands and put on gloves, and the cook stated he did not notice this while concentrating on his task.
Missing Progress Note Documentation
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for 1 resident reviewed for medical records accuracy. Resident #16, a [AGE]-year-old female admitted on 03/20/2023, had diagnoses including amnesia, anxiety disorder, history of falling, and chronic obstructive pulmonary disease. Her Annual MDS showed a BIMS of 01, indicating severe cognitive impairment. Record review showed no documentation in the Progress Notes from 01/31/2025 through 06/04/2025. During interviews, LVN I stated LVNs were responsible for documentation and that if the nurses had not documented, it was not done. The ADON stated that anything and everything was documented on PCC, including changes in medications and condition. The DON stated nurses' notes are to be thorough and complete, and if the notes were not written, it does not show the care or progress of the resident. The Administrator stated that when nurses wrote risk management or nursing assessments, there was a button to click that would transfer the notes to the resident's progress notes, and he believed the nurses were not doing that even though they knew they should. He also stated he was aware of the missing progress notes for Resident #16 and that nurses were being in-serviced.
Infection Control Failures With PPE, IV Dressing, and Glove Use
Penalty
Summary
The facility failed to maintain an infection prevention and control program when a resident on contact isolation for MRSA bacteremia had family members enter the room without donning PPE. The resident’s record showed he was admitted with sepsis due to MRSA and bloodstream infection related to a central venous catheter, had a BIMS score of 11, and had an IV peripheral access. His care plan documented contact isolation precautions and noted that the family refused to follow proper PPE use despite education. On observation, a sign and PPE were available outside the room, but a family member and a child entered the room without PPE while the resident remained on contact isolation. During interviews, CNA G stated the resident was on contact isolation and that visitors entering the room needed gown and gloves, but the family had refused PPE despite repeated education. The family member stated they had been educated about PPE but believed they were okay as long as they did not have contact with blood or body fluids, and said they washed their hands when entering and leaving the room. LVN H and the DON both stated that anyone entering the room had to wear PPE, but also stated the family could not be prevented from visiting the resident. The facility also failed to ensure the resident’s peripheral IV dressing was dated and initialed. On observation, the resident had a peripheral IV lock in the right hand covered with a transparent dressing that had no date or initials. LVN P stated the nurse who initiated the IV was responsible for labeling the dressing and that the IV site should be checked every shift. The DON stated the charge nurse was responsible for labeling the dressing with the date and initials of the nurse who inserted the IV, and that the dressing should be labeled to track when it was last changed. In a separate infection control failure, CNA C did not remove contaminated gloves after catheter care before placing a clean brief on another resident with an indwelling catheter and neurogenic bladder. During observation, CNA C washed hands, donned gloves, performed catheter care, discarded gloves, sanitized hands, donned new gloves, completed catheter care, and then used the same pair of gloves to place a new brief on the resident. CNA C stated the gloves should have been changed after cleaning the Foley catheter to minimize infection, and the DON stated hand hygiene should have been performed before moving to the second part of applying the new brief. The DON stated this practice could put the resident at risk for infection.
Failure to Notify Physician and Responsible Party of Skin Tear
Penalty
Summary
A resident with a history of diabetes mellitus type 2, essential hypertension, and severe cognitive impairment was identified as having limited mobility and was at risk for skin breakdown according to her care plan. During routine care, a CNA was informed by the resident's family member about a skin tear, which the CNA then reported to an LVN. The LVN assessed and cleansed the skin tear but failed to notify the physician or the resident's responsible party, as required by facility policy and professional standards of practice. The LVN stated that the omission occurred because he became occupied with another resident and forgot to make the necessary notifications. The facility's policy required prompt notification of the physician and the resident's representative in the event of a change in condition. The DON and ADON confirmed that the LVN did not follow protocol, resulting in the skin tear not being reported or treated according to physician orders for two days. The resident was at risk for infection due to the delay in appropriate treatment and communication.
Incomplete and Inaccurate Medication Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was being treated for multiple complex conditions, including chronic pulmonary edema, end stage renal disease, and type 2 diabetes. On the day in question, the resident returned from dialysis and experienced hypotension, prompting the ADON to obtain a physician's order for Midodrine to address the low blood pressure. The ADON administered the medication but did not enter the order into the system herself, instead allowing a new LVN to input the order. The LVN, unfamiliar with the process, entered the order with an incorrect start date, causing the medication administration record (MAR) to reflect the wrong date for the Midodrine order. Additionally, the MAR was not signed by the ADON, who had administered the medication, leaving the documentation incomplete. The facility's policies require that the MAR be reviewed and signed after medication administration, and that all services provided be accurately and timely documented in the resident's medical record. Interviews with the ADON, DON, and LVN confirmed that the order was entered incorrectly and that the MAR was not signed as required. This resulted in an incomplete and inaccurate clinical record for the resident, as the documentation did not accurately reflect the medication administration or the timing of the physician's order.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated appropriate competencies and skills to provide necessary wound care for a resident, leading to a deficiency in care. Specifically, the Wound Care Nurse (WCN) did not treat a resident's wound on the left buttock according to the physician's orders. The resident, who had a history of diverticulosis, Type 2 Diabetes Mellitus, and dementia, was admitted with a wound that required specific treatment with Santyl ointment. However, the Treatment Administration Record showed no documentation of wound care being provided from August 15 to August 21, 2024. Observations and interviews revealed that the WCN mistakenly believed the wound on the left buttock was healed and did not apply the prescribed treatment. This oversight was noted during a wound care session on August 19, 2024, when the WCN initially failed to clean and treat the wound on the left buttock. The WCN later corrected this by applying Santyl after realizing the mistake. Interviews with the WCN and other staff members indicated a misunderstanding of the physician's orders and a lack of proper documentation and communication regarding the resident's wound care needs. The resident's wound had shown signs of deterioration, with measurements indicating an increase in size before eventually decreasing. The deterioration was attributed to the resident's self-inflicted scratches and a decline in condition due to COVID-19. Despite the WCN's oversight, the Wound Care Doctor (WCD) expressed satisfaction with the care provided by the facility and the WCN, attributing the resident's condition to the effects of COVID-19 and the resident's comorbidities. The facility's Director of Nursing (DON) acknowledged the potential for wound deterioration and infection if wounds were not treated as ordered.
Improper Catheter Care Leading to Potential Complications
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, which could potentially lead to urinary tract infections and other complications. The resident, an elderly female with Alzheimer's Disease, muscle wasting, dehydration, and functional urinary incontinence, was observed with her catheter urine drainage port draped over the side rail, above the level of her body. This improper positioning of the catheter tubing was noted during multiple observations, indicating a restriction in the flow of urine to the collection bag. Interviews with facility staff, including CNAs and the Director of Nursing (DON), confirmed that the catheter tubing should not be positioned above the resident's body as it could cause backflow of urine and lead to complications. Despite the facility's training protocols, which instruct staff to hang the collection bag below the bladder, the catheter tubing was not properly managed for this resident. The care plan for the resident also specified the correct positioning of the catheter bag and tubing, which was not adhered to during the observations.
Neglect Due to Failure to Follow Care Plan
Penalty
Summary
The facility failed to ensure a resident's right to be free from neglect, resulting in a significant incident involving a resident who required two-person assistance for bathing. Despite being aware of this requirement, a CNA proceeded to provide care alone, leading to the resident falling and fracturing her left femur. The incident occurred when the CNA attempted to turn the resident to wash her back, and the resident slipped off the bed due to shorter bed rails and the resident being wet and slippery. The resident involved was an elderly female with a history of dementia, muscle weakness, and other health issues, including chronic obstructive pulmonary disease. Her care plan clearly indicated the need for two-person assistance for bathing due to her substantial/maximal assistance needs. The CNA admitted to knowing the care plan requirements but chose to bathe the resident alone, believing it would be manageable as she had done it before under different circumstances. The incident was immediately reported by the CNA, and the charge nurse assessed the resident, who was then sent to the hospital for evaluation due to injuries sustained from the fall. The CNA was subsequently removed from the floor and terminated following an investigation that confirmed the failure to adhere to the resident's care plan, which directly led to the resident's fall and injury.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and that residents received adequate supervision and assistance devices to prevent accidents. This deficiency was identified in the case of a resident who required a two-person assist for bathing due to her medical conditions, including dementia, muscle weakness, and lack of coordination. Despite this requirement, a CNA provided a bed bath to the resident alone, which resulted in the resident rolling out of bed and sustaining a left femoral fracture. The resident's care plan clearly indicated the need for substantial/maximal assistance for bathing, requiring two staff members to assist. However, the CNA, who had been trained on ADLs and knew the resident's care plan, chose to perform the bed bath alone. During the process, the resident slipped off the bed due to inadequate support and supervision, leading to her fall and subsequent injury. The CNA admitted to not following the care plan and acknowledged that the incident could have been prevented if the care plan had been adhered to. Interviews with facility staff, including the charge nurse and the DON, confirmed that the CNA did not follow the resident's care plan, which was a direct cause of the accident. The charge nurse responded promptly to the incident, and the resident was sent to the hospital for evaluation due to the injuries sustained. The facility's policy on quality of care emphasizes the need for adherence to care plans to maintain residents' highest possible functional status, which was not followed in this case.
Failure to Accurately Screen for Mental Illness in PASARR
Penalty
Summary
The facility failed to ensure that all residents with a serious mental disorder, intellectual disability, or related condition were properly assessed for PASARR Level II upon a significant change in status. Specifically, Resident #33, who had diagnoses including Depression, Schizoaffective Disorder Bipolar Type, and Post-Traumatic Stress Disorder, was not accurately screened for mental illness in the PASARR Level 1 Screening. The screening incorrectly indicated that there was no evidence of mental illness, despite the resident's documented diagnoses. Interviews with facility staff revealed that the MDS team was responsible for conducting assessments and reviewing medical histories. However, they failed to identify and document Resident #33's mental illness in the PASARR Level 1 Screening. This oversight was acknowledged by MDS staff and the Director of Nursing, who confirmed that the resident should have been referred to the Local Mental Health Authority for further assessment and potential services. The facility did not have a specific policy for PASARR, relying instead on state regulations.
Failure to Provide Access to Survey Results
Penalty
Summary
The facility failed to ensure that residents, family members, and legal representatives had easy access to the results of Federal or State surveys, as required by regulations. During a confidential interview, six individuals reported being unaware of the location of the survey results and their right to review them. Observations in the reception area revealed the absence of a surveyor binder and a notice indicating its location. The receptionist was unable to locate the binder, and it was later found in the administrator's office. The administrator explained that the survey binder was in his office due to recent remodeling activities, which included purchasing new furniture and painting the walls in the reception area. The maintenance director had removed the shelf that previously held the survey binder, and as a result, it was temporarily stored in the administrator's office. Despite these explanations, there was still no sign posted in the reception area indicating the location of the survey binder, which contributed to the deficiency.
Failure to Document Fall Mat in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as Resident #31, which included measurable objectives and timeframes to meet her medical and nursing needs. Specifically, the care plan did not address the use of a fall mat, an intervention that was observed in the resident's room. The resident, a female with Alzheimer's Disease, muscle weakness, muscle wasting and atrophy, unsteadiness on feet, and chronic obstructive pulmonary disease, was severely cognitively impaired as indicated by her BIMS score. Despite the presence of a fall mat in her room, this intervention was not documented in her care plan, which is a critical component for ensuring continuity and quality of care. Interviews with the Director of Nursing (DON) and MDS A revealed that the fall mat was not included in the care plan due to oversight and lack of communication. The DON, who was responsible for initiating care planning, admitted to not including the fall mat in the care plan because she had recently started working at the facility and was unaware of who initially implemented the intervention. The facility's policy on Quality of Care and Comprehensive Care Plans emphasizes the importance of documenting all necessary interventions in the care plan to maintain the highest possible functional status for residents. The failure to include the fall mat in the care plan could lead to staff not following through with the intervention, potentially affecting the resident's health promotion and continuity of care.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to provide adequate grooming and personal care for a resident who was unable to perform activities of daily living independently. The resident, who had a moderate cognitive impairment and required assistance with personal hygiene, was observed with long, pointy, and dirty fingernails. Despite being scheduled for nail care, the resident's nails were not trimmed in a timely manner, which could potentially lead to scratches, infection, and loss of self-esteem. The resident, who had a history of Type 2 diabetes mellitus and other health issues, expressed uncertainty about why her nails had not been cut as scheduled. Interviews with facility staff revealed inconsistencies in the nail care process. CNAs were responsible for cleaning and washing nails during bath times, but they did not clip nails for diabetic residents. The charge nurse indicated that any nurse could clip fingernails, but there was no clear documentation or protocol followed to ensure regular nail care. The Director of Nursing acknowledged the lack of specific written protocols for nail care frequency and relied on informal methods such as group texts to remind staff. The facility's policy required documentation of care services, but there was no record of the resident's nails being trimmed as per the schedule. This lack of documentation and adherence to protocols contributed to the deficiency in providing necessary grooming and personal care for the resident.
Failure to Implement Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, which is required to provide effective and person-centered care. The deficiency was identified for a resident who was admitted with multiple complex medical conditions, including an acquired absence of the right leg above the knee, end-stage renal disease, and liver cell carcinoma. The baseline care plan did not include critical information such as the resident's full code status and the use of a Hoyer lift, which are essential for ensuring appropriate care and communication among staff. Interviews with facility staff revealed a lack of clarity and responsibility regarding the entry of essential information into the baseline care plan. The Licensed Vocational Nurse (LVN) and Social Services staff indicated that the code status should be confirmed and entered by Social Services, while the Minimum Data Set (MDS) coordinator stated he was not responsible for baseline care plans. The Director of Nursing (DON) acknowledged the importance of including the code status and Hoyer lift information in the baseline care plan to ensure staff follow the resident's rights and provide appropriate care. The facility's policy requires the development of a baseline care plan within 48 hours of admission, including necessary healthcare information and interventions to address the resident's current needs.
Inaccurate Care Plan Documentation
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included incorrect information and omissions. The care plan inaccurately indicated that the resident was a dialysis patient, despite the resident not having received dialysis since admission. This error persisted even though the resident's doctor had determined that dialysis was no longer necessary based on lab results. Additionally, the care plan failed to document the resident's need for a mechanical lift for transfers, despite the resident's inability to bear weight on her right leg due to knee pain and swelling. Interviews with multiple staff members, including CNAs and nurses, confirmed that the resident was not a dialysis patient and required a mechanical lift for transfers. The staff were aware of the resident's needs through verbal communication from charge nurses, but these needs were not accurately reflected in the written care plan. The oversight in the care plan documentation did not result in a negative outcome for the resident, as staff were already using a mechanical lift for transfers based on their knowledge of the resident's condition. The facility's policy mandates the development of a comprehensive care plan that includes measurable objectives and timeframes to meet the resident's needs. However, the care plan for this resident did not comply with these requirements, as it contained outdated and incorrect information. The facility's failure to update the care plan in a timely manner could potentially place residents at risk of not receiving the necessary care or services tailored to their specific needs.
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 170 citations issued within 25 miles in the last 12 months — including the 5 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 Harlingen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sun Valley Rehabilitation And Healthcare Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Golden Palms Rehabilitation And Retirement | 0.7 mi | ★★★★★ | 7 | 0 |
| Treasure Hills Healthcare And Rehabilitation Cente | 0.9 mi | ★★★★★ | 10 | 0 |
| Windsor Nursing And Rehabilitation Center Of Harli | 1.2 mi | ★★★★★ | 4 | 0 |
| Harlingen Nursing And Rehabilitation Center | 1.7 mi | ★★★★★ | 11 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.