Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
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 Calallen during CMS and state inspections, most recent first.
Unsecured IT Room on 300 Hall: The door to the IT room was left unlocked and unattended, allowing access to a room containing cable wiring, floor polishing equipment, a cart, 2 vacuums, and a high voltage power loss relay box. The maintenance man said he and the floor tech had keys and that it was his responsibility to ensure the door was shut, while the Adm stated only those 2 staff had keys and the facility had no policy or procedure for door maintenance or function.
A resident with dysphagia, aphasia, hemiplegia, hemiparesis, and moderately impaired cognition had an order for oxygen at 4 L/min via NC, but the concentrator was observed set at 2 L/min. The charge nurse and ADON stated nurses were responsible for verifying and setting oxygen per MD orders, and the Administrator stated there was no Oxygen Administration Policy.
Medication Held Outside Ordered Parameters: A resident with HTN and severe cognitive impairment had metoprolol tartrate held twice even though BP readings were within the prescriber’s hold parameters. The DON stated the medication should have been administered, while the RN said she used nursing judgment to hold it without contacting the MD, despite the order requiring administration unless SBP was below 100 or DBP was below 60.
An open insulin pen for a resident with Type 2 DM and severe cognitive impairment was found in a nurse cart without an open date documented. The RN stated he had already administered the insulin using the undated pen and had not checked the expiration date before giving it. The DON confirmed the pen lacked both the open date and new expiration date, and the facility policy required opened injectable medications to be dated and monitored for expiration.
Improper food storage, sanitation, and hair restraint use were observed in the kitchen. A kitchen manager and a cook were seen with beard restraints not properly covering facial hair, while the refrigerator and freezer contained unsealed food items, including ham, boiled eggs, and cooked fried chicken exposed to air. The hot steam table wells also had a grey scaly substance at the bottom, and staff stated food items should be sealed completely and facial hair should be fully covered.
A resident with a trach and chronic respiratory failure was observed receiving trach care with multiple infection control lapses. An LVN and an RN performed inadequate hand hygiene, touched dirty items and equipment before returning to clean care, and did not maintain proper PPE or sterile technique during the procedure. The trach and neck area were not cleaned as documented, and the RN also performed inadequate hand hygiene during med pass.
Missed Keppra Lab Monitoring: A resident with epilepsy and severe cognitive impairment did not have the ordered Keppra level drawn every 3 months. The care plan called for lab monitoring of seizure meds, but the last documented Keppra level was months earlier, and both ADONs acknowledged the monitoring should have occurred sooner. An active order later discontinued routine labs after hospice admission.
Kitchen staff failed to wear required hair and beard covers while assisting with lunch tray preparation. The DM was observed in the kitchen with uncovered hair and a beard while helping another kitchen staff member set up resident trays, and later stated he knew the requirement but was walking through the kitchen to get a hairnet and beard cover from the front entrance. The Administrator stated staff knew they were supposed to wear hair and beard covers in the kitchen, even when moving between entrances.
A resident with severe cognitive impairment and total incontinence had missing bowel and bladder documentation in PCC for two days. The resident required substantial to maximal assistance with toileting hygiene, and the ADON, charge nurse, and CNA all confirmed the charting should have been completed but was not present.
A resident with metabolic encephalopathy, acute respiratory failure with hypoxia, and a BIMS of 05 had his beard completely shaved off without permission from him and/or his RP. The care plan directed staff to ask the RP for preference before beard grooming, but staff accounts conflicted about whether the resident agreed to trimming versus shaving. The family member stated the beard had been worn for many years, defined him, and was removed while he was asleep; the DON and ADON acknowledged the resident likely needed RP involvement for a decision like this.
A resident admitted with cellulitis of the right lower limb and severely impaired cognition did not have a comprehensive admission MDS assessment completed within the required 14-day timeframe. The MDS was finalized several days late, despite facility policy assigning the MDS coordinator responsibility for tracking due dates. A baseline care plan was initiated on admission, but the comprehensive care plan was not completed because the resident discharged before it was due. In interviews, the MDS nurse and DON both acknowledged the required timeframe, stated the assessment should have been completed earlier, and were unsure why it had been overlooked.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions, resulting in incomplete planning and documentation.
A narcotic medication prescribed for a resident with chronic pain was not properly received or counted by nursing staff upon admission. The responsible RN accepted the medication from a hospice nurse and relied on the count listed on the bottle, failing to physically verify the quantity as required by facility policy. The next day, a nurse discovered the count was short by 15 pills, and the discrepancy was reported to the DON, confirming that the required verification process was not followed.
Surveyors found extensive deficiencies in food storage, labeling, and sanitation, including unlabeled and expired food, missing thermometers, moldy and dirty equipment, and improper storage of personal items and waste. Staff interviews revealed a lack of adherence to facility policies and cleaning schedules, contributing to unsanitary conditions and potential food safety risks.
A facility failed to complete an accurate PASRR screening and referral for a resident with multiple mental health diagnoses, including major depressive disorder, anxiety disorder, and PTSD. The initial PASRR Level 1 screening did not reflect these diagnoses, and no Level 2 evaluation was conducted, despite documentation of significant mental illness and behavioral symptoms. The MDS nurse misread form instructions and did not submit a new positive screening, and the facility lacked a PASRR policy.
A resident with multiple chronic conditions experienced significant, unaddressed weight loss due to the facility's failure to consistently obtain and document weekly weights, lack of communication among staff, and missed notifications to the physician. Despite orders and care plans for close monitoring, staff did not follow through with required interventions, resulting in a prolonged period of unmonitored weight loss.
Surveyors found expired medications, an unlabeled saline nasal spray, and expired medical supplies on two medication carts and in a medication room. Staff interviews revealed that while ADONs and the DON were responsible for routine checks, expired items remained accessible, including narcotics and other prescription drugs for two residents. Facility policies required proper labeling and removal of expired medications, but these procedures were not followed.
Staff failed to follow infection control procedures by leaving wet linen and resident clothing in laundry bins overnight without drying or properly storing them. This practice was observed and confirmed by interviews with laundry aides and the supervisor, who acknowledged that wet items were sometimes left until the next day, contrary to facility policy requiring immediate drying.
A resident with dementia and anxiety, who frequently misplaced items and accused staff of theft, did not have these behaviors addressed in their care plan. Staff interviews confirmed awareness of the issue and acknowledged the care plan should have included interventions and measurable objectives for this behavior, in accordance with facility policy.
A CNA failed to perform hand hygiene after removing gloves and before putting on new gloves while providing incontinent care to a resident with severe cognitive impairment. Despite recent in-service training and facility policy requiring hand hygiene between glove changes, the CNA did not wash or sanitize hands, a lapse confirmed by interviews with the DON and ADON.
A resident with COPD and on continuous oxygen therapy experienced elevated room temperatures above the facility's acceptable range, leading to discomfort and difficulty breathing. Despite the resident and several staff noticing and reporting the issue, no effective action was taken, and the room temperature remained high. The facility only monitored hall temperatures, not individual rooms, and lacked a policy for addressing such concerns.
A facility failed to develop a baseline care plan for a resident within 48 hours of admission, despite the resident's complex medical needs. The resident's care plan was incomplete, with unmarked sections related to vision care, ADLs, fall risk, and medication management. Staff interviews revealed that the admitting nurse did not complete the necessary documentation, leading to gaps in care coordination.
A facility failed to ensure a resident received proper wound care according to physician orders. The Wound Care Nurse did not pat dry a non-healing surgical wound on the resident's right breast before applying a bacteriostatic foam, contrary to the prescribed treatment. This oversight was acknowledged by the nurse and confirmed by the DON, highlighting a lapse in following professional standards of practice.
A medication cart on the 600 hall was left unlocked and unattended by an LVN, allowing access to non-narcotic medications. The LVN admitted to thinking the cart was locked before entering a resident's room. The facility's policy requires carts to be locked or within the staff's line of sight.
Unsecured IT Room on 300 Hall
Penalty
Summary
The facility failed to provide a safe environment in the 300 Hall when the door to the IT room was left unlocked and unattended. During observation, the IT room was found open with no staff in the hallway to monitor access, and the room contained a large wall panel with multiple television cable wires, floor polishing equipment, a cart, 2 vacuums, and a high voltage power loss relay box. The report stated these items were hazardous and that the room should have been secured when not in use. During interview, the maintenance man stated that he and the floor tech had keys to the IT room and that it was his responsibility to make sure the door was shut. He said the floor tech may have entered and left the door open, and that he performs monthly checks on facility doors to ensure they are working and that non-residential rooms can be locked. The Administrator stated that only the maintenance man and floor tech had keys to the IT room, that the door was supposed to be locked every time the room was left, and that the facility did not have a policy or procedure on the maintenance or functions of the doors, although it did have a policy on the physical environment.
Oxygen Concentrator Set Below Ordered Flow Rate
Penalty
Summary
Resident #6, a [AGE]-year-old male admitted on 06/10/2026 with diagnoses including dysphagia, aphasia, hemiplegia, and hemiparesis, had a current quarterly MDS dated 07/17/2026 showing a BIMS score of 10, indicating moderately impaired cognition. His active physician order, started 06/10/2026, directed oxygen at 4 liters per minute via nasal cannula every shift for hypoxia. On 07/20/2026 at 10:06 AM, the resident’s oxygen concentrator was observed set at 2 liters per minute instead of the ordered 4 liters per minute. RN-A stated it was the charge nurse’s responsibility to set and adjust oxygen concentrator settings, verify the order, and confirm the concentrator matched the order, and he was not sure how the concentrator ended up on 2 liters. The ADON stated floor nurses set and adjusted oxygen based on physician orders, confirmed the resident had an order for 4 liters per minute continuous oxygen, and was not sure why it was set at 2 liters per minute. The Administrator stated the facility did not have an Oxygen Administration Policy.
Medication Held Outside Ordered Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when metoprolol tartrate was held on two occasions despite blood pressure readings that were within the physician’s ordered parameters. The resident had a diagnosis of essential primary hypertension and severe cognitive impairment, with an active order for metoprolol tartrate 25 mg by mouth twice daily, to be held only for systolic blood pressure less than 100 or diastolic blood pressure less than 60. The MAR showed the medication was held on 07/17/26 when the blood pressure was 103/64 and on 07/20/26 when the blood pressure was 101/66. During interview, the DON stated the MAR indicated the metoprolol appeared to have been held when it should have been administered on both dates. The DON stated that if blood pressure and heart rate were within physician parameters, the medication should be given. RN B stated she checked the resident’s blood pressure and pulse before administering medications, believed the blood pressure was just above the threshold on both dates, and used nursing judgment to hold the metoprolol without contacting the doctor. The facility policy stated medications are administered in accordance with written orders of the prescriber.
Undated Insulin Pen Stored in Medication Cart
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored and labeled in accordance with accepted professional principles when an open Insulin Lispro pen for Resident #97 was found in the 400-Hall Nurse Cart without the date it was opened. Resident #97 was a male admitted on 07/09/26 with Type 2 Diabetes and severe cognitive impairment, with an active order for Insulin Lispro by sliding scale before meals and at bedtime. During observation of the nurse cart on 07/21/26, the open insulin pen was identified in the top drawer with no open date documented. During interview, the RN in charge of the cart stated he had administered the insulin to Resident #97 earlier that day using the undated pen and acknowledged he had forgotten to check the expiration date before administration. He stated insulin pens expire about a month after opening and that checking expiration dates is important to ensure the resident is not given an expired medication. The DON stated insulin pens should have the open date and new expiration date written on them so the dates are readily visible, and confirmed the pen for Resident #97 did not have either date written on it. The facility policy stated multi-dose injectable vials are to be dated and initialed when opened and that expired medications will not be administered in the facility.
Improper Food Storage, Sanitation, and Hair Restraint Use
Penalty
Summary
The facility failed to ensure proper food storage and sanitation practices in the kitchen. During the initial kitchen tour, the kitchen manager was observed not wearing a beard restraint correctly, with part of his mustache and beard uncovered. On a later observation, a cook was also observed not wearing a beard restraint properly over the mustache and beard. The Dietary Manager stated that all facial hair must be covered to prevent contamination of food being prepared. The refrigerator and freezer contained food items that were not sealed correctly. The refrigerator had a container of ham that was not sealed correctly and a box of packaged boiled eggs with one package open and two eggs exposed. The freezer contained a bag of cooked fried chicken that was unsealed and exposed to air. Staff interviewed stated that food items should be sealed completely to prevent cross contamination and that the items found open should have been discarded if not properly sealed. The hot steam table wells were observed with a grey scaly substance at the bottom of each well. Record review showed the facility policy required food to be stored in tightly covered, labeled, and dated containers, with refrigerated foods sealed in clean, nonabsorbent covered containers and frozen foods stored in moisture-proof containers. The employee sanitation policy also required hairnets, hairbands, caps, beard coverings, or other effective hair restraints to be worn to keep hair from food and food-contact surfaces.
Infection Control Failures During Tracheostomy Care and Medication Pass
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for one resident with a tracheostomy and chronic respiratory failure. Resident #11 had diagnoses including cerebral palsy and chronic respiratory failure, and the record showed active orders for daily and as-needed tracheostomy inner cannula changes and Enhanced Barrier Precautions due to the tracheostomy and device-related risk. The resident’s care plan also included Enhanced Barrier Precautions interventions for high-contact care activities such as hygiene, linen changes, toileting, and device care. During observation of tracheostomy care, LVN-E performed hand hygiene and gathered supplies, but the bedside table was not sanitized again after she stated it had already been disinfected. RN-B was observed performing hand hygiene improperly, with only brief scrubbing and rinsing before assisting with the procedure. LVN-E placed her stethoscope around her neck with her hair falling over it, then assessed the resident while the resident was forcefully coughing up thick, green sputum throughout the respiratory assessment and trach care. LVN-E then performed hand hygiene with ABHS and continued trach care, but touched the trash can and later the resident’s oxygen concentrator before proceeding without stopping to perform hand hygiene again or donning clean gloves. Her gown became untied and fell loosely below her chest during the procedure, while her hair remained loose over her shoulders and gown, and her scrub top was exposed for most of the care. The trach and neck area were not cleaned in the documented circular motion from inner to outer 3 to 4 inches around the trach; instead, each side of the trach area was wiped. RN-B did not perform hand hygiene and apply new gloves when assisting with the new trach collar after care, and RN-B was also observed during medication pass to perform inadequate hand hygiene with ABHS.
Missed Keppra Lab Monitoring
Penalty
Summary
The facility failed to provide or obtain laboratory services to meet the needs of one resident who had epilepsy and severe cognitive impairment. The resident’s care plan directed staff to give seizure medications as ordered and monitor labs, including reporting subtherapeutic or toxic results to the physician. A physician order dated 11/10/2023 required a Keppra level every 3 months, but the last documented Keppra level was drawn on 12/20/2025, and no subsequent level was found in the record for the expected March and June 2026 monitoring periods. The resident’s physician orders showed ongoing Keppra use, with the most recent revision on 06/04/2026 for levetiracetam 500 mg/5 mL, 5 mL by mouth four times daily for epilepsy. Although an active order on 06/10/2026 discontinued all routine labs after hospice admission, staff interviews indicated the resident should have had the Keppra level checked every three months before that change. The ADONs stated they were not sure how often epilepsy medication labs were supposed to be drawn or what the therapeutic range was, and both acknowledged the resident’s last Keppra level had been in December 2025.
Kitchen Staff Failed to Wear Hair and Beard Covers
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 an observation of the dining room and kitchen on 06/24/2026 at 12:27 PM, the DM was seen in the kitchen talking to and assisting another kitchen staff member who was preparing and setting up lunch trays for residents. The DM had hair on his head and a beard, but was not wearing a hairnet or beard cover while in the kitchen. During an interview on 06/24/2026 at 1:34 PM, the DM stated he knew he was supposed to wear hairnets and beard covers while in the kitchen. He said he had gone out the back entrance and was returning through the kitchen to get a hairnet and beard cover from the front entrance because none were available at the back entrance where he usually kept them. He stated that if hair or a beard cover was not worn in the kitchen, hair could have fallen into residents' food and caused cross contamination. The Administrator stated in an interview on 06/24/2026 at 2:13 PM that the DM and kitchen staff knew they were supposed to wear hair and beard covers while in the kitchen, even when walking from one kitchen entrance to another.
Incomplete bowel and bladder charting in PCC
Penalty
Summary
The facility failed to ensure medical records were maintained and accurately documented for one resident whose bowel and bladder care documentation was missing in PCC for 06/20/2026 and 06/21/2026. The resident was an older male originally admitted to the facility with a readmission, and his diagnoses included Chronic Kidney Disease Stage 2. His Annual MDS dated 04/16/2026 showed a BIMS score of 00, indicating severely impaired cognition, and also showed he was always incontinent of both bladder and bowel and required substantial or maximal assistance with toileting hygiene. The resident’s comprehensive care plan for ADL self-care performance deficit related to confusion identified dependent assistance for toileting hygiene. Review of the bladder elimination documentation from 06/09/2026 through 06/22/2026 showed the entries for 06/20/2026 and 06/21/2026 were missing, and the bowel elimination documentation for the same period also lacked entries for those two dates. During interview, the ADON stated CNAs were supposed to document bowel movements and incontinent episodes in PCC and confirmed the documentation for those dates was not present, though it should have been. The charge nurse stated CNAs documented bowel and bladder notes in PCC and that it was ultimately the charge nurse’s responsibility to verify the charting, but she had not had time to check whether it was completed. A CNA stated she documented bowel movements and incontinent briefs in PCC and was unsure why the documentation was not present.
Facial Hair Shaved Without Permission
Penalty
Summary
The facility failed to ensure a resident’s right to dignified existence when CNA-A completely shaved off the resident’s facial hair without first obtaining permission from the resident and/or the responsible party. The resident was a [AGE]-year-old male admitted with diagnoses including metabolic encephalopathy and acute respiratory failure with hypoxia. His admission MDS showed a BIMS score of 05, indicating severely impaired cognition, and he required substantial or maximal assistance with showering or bathing and partial assistance with shaving. The resident’s care plan, initiated for ADL self-care performance deficit related to confusion, included an intervention to ask the RP for preference prior to beard grooming. A written statement from CNA-B indicated she asked the resident if he wanted his beard trimmed, and he did not refuse or tell her to stop. However, the resident’s family member stated the beard was shaved completely off while he was asleep, that he had worn his beard for many years, and that he never shaved it. The family member also stated the beard defined him and that he would never have given permission for it to be completely shaved off. During interviews, CNA-B stated she remembered asking about trimming and cleaning up the beard because it had oatmeal in it after breakfast, but then said she asked if the beard should be shaved off and that the resident told her to shave the beard but leave the mustache. CNA-A stated she had previously called a family member before shaving another resident because some residents cannot make that decision themselves and family members may want to be asked first. The Administrator stated that with a BIMS of 05, the resident had the cognitive capacity for some decisions but not major decisions or health care decisions, and the ADON stated that based on the BIMS score, the RP probably should have been contacted.
Late Completion of Comprehensive Admission MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a comprehensive admission MDS assessment within 14 calendar days of admission for one resident. The resident was an elderly female admitted with cellulitis of the right lower limb on 02/23/2026. Her admission MDS, with an admission date of 02/23/2026, showed a BIMS score of 06, indicating severely impaired cognition. Record review showed that the comprehensive admission MDS assessment was not completed and signed until 03/11/2026, which was beyond the required 14-day timeframe. The facility’s policy, dated 10/24/2022, stated that the MDS Coordinator was responsible for tracking due dates for all MDS assessments and that the comprehensive admission assessment would be completed within 14 days after admission. The baseline care plan for this resident was initiated on the date of admission, but the comprehensive care plan was not completed because the resident discharged before it was due. In interviews, the MDS nurse acknowledged that the admission MDS should have been completed within 14 days and stated it should have been done by 03/08/2026, but she was unsure why it was not completed on time and believed it must have been overlooked. She stated she was responsible for assessing residents, collecting data, and ensuring the accuracy and timeliness of the MDS, and that the MDS triggered different areas of the care plan. The DON confirmed that the MDS nurse completed the assessment and that she, as DON, signed it as completed and ready to be submitted, and agreed that the admission MDS should have been completed within 14 days, but was also unsure why it was late. The DON stated the MDS was used to help develop the care plan and for billing purposes.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the review of resident records and care planning documentation, where it was noted that the care plan did not comprehensively cover all identified needs of the resident, nor did it include clear, measurable goals or interventions.
Failure to Properly Receive and Count Narcotic Medication
Penalty
Summary
A deficiency occurred when a narcotic medication, Oxycodone-Acetaminophen Oral Tablet 10-325 MG, prescribed for a resident with chronic pain due to liver cirrhosis, was not properly received and counted upon admission. The resident, who had severe cognitive impairment and multiple medical diagnoses including cirrhosis, substance abuse, hypertension, hepatitis C, and a history of repeated falls, was admitted with physician orders for the narcotic to be administered as needed for pain. Upon arrival of the medication, the responsible RN accepted the pill bottle from the hospice nurse and relied on the count listed on the bottle, failing to physically count the pills as required by facility policy. The facility's policy mandated that controlled substances be verified and counted by a licensed nurse in the presence of the delivery person, with both parties signing the delivery log. However, the RN did not follow this protocol and instead locked the medication away without verification. The off-going nurse had not seen or counted the narcotics either, and only other medications brought from home were signed in. The next day, another nurse discovered that the narcotic count was short by 15 pills when performing the routine count at the start of his shift. This discrepancy was reported to the DON, who confirmed the shortage and initiated an investigation. Interviews with involved staff revealed that the medication had been left at the hospice office for over 24 hours before being delivered, and that the required two-person verification process was not followed. The failure to properly receive and count the narcotic medication resulted in an inaccurate medication count for the resident.
Widespread Food Storage and Sanitation Failures in Kitchen
Penalty
Summary
Surveyors identified multiple failures in the facility's food storage, preparation, and sanitation practices during an inspection of the kitchen. Observations revealed that numerous food items in both refrigerators and freezers were unlabeled, undated, and in some cases, expired. Containers of cheese, sliced meat, salads, and various unknown substances were found without proper labeling or sealing. Expired containers of mustard and coleslaw dressing with visible mold were present, and several trays of beverages and other food items were not identified or dated. Additionally, internal thermometers were missing from some refrigerators and freezers, preventing accurate monitoring of food storage temperatures. Further inspection found significant sanitation issues, including a chest-type milk refrigerator with mold on the gasket, ice accumulation, condensation, and a dirty interior. Rotten tomatoes were stored with fresh ones, and dry goods such as instant breakfast cereal were left unsealed and undated. The meat slicer and roasting pans were found with food debris and dust, and the steamer oven contained a thick, caked-on yellow-white substance that was flaking into the water. The dumpster side doors were observed to be open or partially open throughout the survey period, and personal items were found on a prep table in the kitchen. A spatula with missing chunks was also discovered, raising concerns about potential contamination. Interviews with the Food Service Supervisor (FSS), cook, and Registered Dietitian (RD) revealed a lack of awareness and adherence to facility policies regarding food labeling, dating, and cleaning schedules. The FSS admitted to not knowing the use-by dates for many items and was unaware of the presence of mold and expired products. Cleaning schedules were not provided upon request, and some equipment, such as the meat slicer and roasting pans, were not included in the cleaning routine. The facility's policies required proper labeling, dating, and cleaning of food and equipment, but these procedures were not consistently followed, as evidenced by the findings.
Failure to Complete Accurate PASRR Screening and Referral for Mental Illness
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) evaluation was properly completed for a newly admitted resident prior to or after admission. Specifically, the PASRR Level 1 screening for the resident did not accurately reflect the resident's diagnoses of mental illness, including major depressive disorder, anxiety disorder, and post-traumatic stress disorder (PTSD). There was no evidence that the resident was referred for a Level 2 PASRR screening and evaluation, despite documentation of multiple mental health diagnoses in the medical record and care plans. The resident in question was an older male with a history of stroke, alcohol abuse, kidney failure, major depressive disorder, anxiety disorder, PTSD, mood disorder, dementia, insomnia, altered mental status, and agitation. The resident exhibited severe cognitive impairment, behavioral symptoms, and required extensive assistance with activities of daily living. He was also prescribed antianxiety, antidepressant, and hypnotic medications, and was receiving hospice care. Despite these significant mental health and behavioral concerns, the initial PASRR Level 1 screening from the hospital was negative for mental illness, intellectual disability, and developmental disability, and no subsequent screenings were completed. Further review of the resident's care plan and psychiatric assessments confirmed ongoing diagnoses of mood and anxiety disorders, as well as PTSD. The facility's MDS nurse acknowledged that the PASRR process was not followed correctly, including misreading instructions on the required forms and failing to submit a new positive Level 1 screening when indicated. Additionally, the facility administrator confirmed that there was no policy in place for PASRR at the time of the review.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to maintain acceptable parameters of nutritional status for a resident with multiple complex medical conditions, including Type 2 Diabetes Mellitus, Congestive Heart Failure, Pressure Ulcers, Chronic Kidney Disease, and Muscle Wasting and Atrophy. The resident experienced a significant weight loss of 47 pounds (21%) over a two-month period. Despite physician orders for weekly weights and a care plan that included monitoring for signs of malnutrition and significant weight loss, the facility did not consistently obtain or document weekly weights as required. There were missed weight checks, and when the resident refused a weight, there was no documented follow-up or notification to the physician. Staff interviews revealed confusion and lack of clarity regarding responsibilities for obtaining, recording, and monitoring weights. The Restorative Aide (RA), who was primarily responsible for obtaining weights, was frequently reassigned to floor duties, resulting in missed weight checks. The process for entering weights into the electronic chart was also inconsistent, with only nurses or the DON entering the data. Alerts for missed weights were not consistently reviewed or acted upon by the DON or ADONs, and the Registered Dietitian (RD) was not reviewing orders to determine which residents required weekly weights, relying instead on weight variance reports that were not always up to date. Despite the resident's ongoing weight loss and the presence of interventions such as nutritional supplements and fortified diets, there was no timely reassessment or adjustment of the weight monitoring schedule. The lack of communication and follow-through among nursing staff, the RD, and the DON led to a failure to recognize and address the resident's significant weight loss in a timely manner. There was also no documentation that the physician was notified of the resident's weight loss or refusals, and the care plan was not updated to reflect the need for continued weekly weights.
Expired and Unlabeled Medications Found on Medication Carts and in Medication Room
Penalty
Summary
Surveyors identified multiple deficiencies related to the labeling and storage of drugs and biologicals within the facility. During observations, two medication carts and one medication room were found to contain expired medications and supplies, as well as an unlabeled, opened bottle of saline nasal spray. Specifically, the Hall #3 medication cart contained an open, unlabeled bottle of saline nasal spray and expired medications, including Morphine 30 mg tablets prescribed for a resident with chronic pain syndrome and Pravastatin 20 mg tablets prescribed for another resident with hyperlipidemia. The Hall #5 medication cart contained an open tube of Hydrocortisone Cream that was expired. Additionally, the medication room contained a large bin of single-use Tuberculin Safety Syringes that were past their expiration date. Interviews with staff revealed that the ADONs and DON were responsible for routinely checking medication carts and rooms for expired medications and supplies, typically every week or two. However, floor nurses were also expected to check their carts for expired items. Staff members acknowledged that expired medications could be ineffective or potentially harmful, and that expired narcotics were to be reported to the DON for removal. Despite these procedures, expired medications and supplies remained on the carts and in the medication room, indicating lapses in the established checking routines. A review of the facility's medication policies confirmed that all drugs and biologicals are to be labeled according to federal and state regulations, and that expired, unused, or unwanted medications should be removed from storage and secured until destroyed. The policies also specified that drugs dispensed for individual residents are not to be used beyond their expiration date. The facility failed to adhere to these policies, resulting in the presence of expired and improperly labeled medications and supplies accessible in resident care areas.
Failure to Properly Handle and Store Wet Linen and Resident Clothing
Penalty
Summary
The facility failed to properly handle, store, process, and transport linens in accordance with infection prevention and control protocols. During an observation, two laundry bins containing wet white linen and wet resident clothing were found in the dryer area after laundry aides had left for the day. The laundry supervisor confirmed that it was common practice for staff to leave wet linen and clothing overnight to be dried or rewashed the next day, and that she did not routinely check the laundry room after staff left. Both laundry aides involved admitted to leaving wet items overnight on multiple occasions, with one stating she would typically dry them the next day without rewashing, and the other initially drying them before being instructed to rewash by the supervisor. Facility policy requires that linens and personal clothing be dried immediately after washing to prevent mildew, and if immediate processing is not possible, wet items should be stored in a bin with a plastic, airtight cover. The assistant director of nursing was unaware of the issue and acknowledged that leaving wet linen and clothing overnight could result in mildew and odor, which could affect resident dignity. The facility's failure to follow established procedures for handling wet linen and clothing was directly observed and confirmed through staff interviews.
Failure to Update Care Plan for Resident's Habitual Misplacing of Items and Accusations of Theft
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan that addressed a resident's habitual misplacing or losing of items and subsequent accusations of theft against staff. The resident, who had diagnoses of dementia and anxiety and a BIMS score indicating moderately impaired cognition, had a history of losing property and accusing staff of theft, sometimes later finding the items. Despite these ongoing behaviors, the care plan did not include interventions or measurable objectives related to this issue. Multiple staff interviews confirmed that the resident's behavior of losing items and making accusations was known and should have been included in the care plan. The social worker, MDS nurse, and assistant directors of nursing all acknowledged that the care plan should have been updated to reflect these behaviors so that staff would be aware and could implement appropriate interventions. Review of the facility's policy confirmed the requirement for comprehensive, person-centered care plans that address all identified needs.
Failure to Perform Hand Hygiene Between Glove Changes During Incontinent Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to perform proper hand hygiene during incontinent care for a female resident with dementia and severe cognitive impairment. During the observed care, the CNA removed her gloves but did not wash or sanitize her hands before donning new gloves, contrary to the facility's hand hygiene policy. The CNA acknowledged during an interview that she forgot to perform hand hygiene between glove changes, despite recent in-service training on infection control and hand washing. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the CNA should have washed or sanitized her hands between glove changes to prevent cross-contamination. The facility's policy, reviewed as part of the investigation, clearly states that hand hygiene must be performed prior to donning gloves and immediately after removing them. This lapse in infection control practices was observed and verified through staff interviews and record review.
Failure to Maintain Safe and Comfortable Room Temperature for Resident on Oxygen Therapy
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for a resident with chronic obstructive pulmonary disease and shortness of breath, who was on continuous oxygen therapy. The resident's room temperature was observed to be 81.6 degrees, exceeding the facility's stated acceptable range of 71 to 81 degrees. The resident reported feeling hot and experiencing some difficulty breathing, despite having two fans running in her room. She stated that she had reported the issue to CNAs, nursing staff, and the Maintenance Director, but no action had been taken to address the temperature. Multiple staff members, including CNAs, a charge nurse, and a guardian angel, noticed the elevated temperature and stuffiness in the resident's room over the previous two days. Some staff reported the concern to others, but the issue was not escalated or addressed. The Maintenance Director stated he only checked temperatures in the halls, not individual rooms, unless a concern was reported directly to him, and he had not received any such report. The facility's temperature logs only reflected hall temperatures, which were within the acceptable range, and did not include individual room checks. Interviews revealed a lack of clear communication and follow-up regarding the resident's discomfort and the elevated room temperature. The charge nurse did not recognize the concern as significant, and the Maintenance Director had not serviced the air conditioning unit in the resident's room for 12 months. The facility did not have a policy related to monitoring or maintaining individual room temperatures, and the administrator was unaware of the issue until it was brought to his attention during the survey.
Failure to Implement Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required. The resident, who was admitted for aftercare following joint replacement surgery, had multiple diagnoses including anemia, type 2 diabetes, and hypertension. Despite these conditions, no baseline or comprehensive care plan was created during the 20 days the resident was at the facility. This oversight was identified through record reviews and interviews with facility staff. The resident's admission records indicated a need for various care interventions, such as anticoagulant medication for DVT prophylaxis and pain management with Tramadol. However, the baseline care plan form was incomplete, with several sections unmarked, including those related to vision care, ADLs, fall risk, skin integrity, and medication management. Interviews with staff revealed that the admitting nurse was responsible for completing the baseline care plan, which was then reviewed by the interdisciplinary team (IDT) the following day. Despite this process, the care plan for the resident was not completed, leaving significant gaps in the documentation of care needs. Interviews with various staff members, including the ADONs and CMNs, highlighted the importance of a thorough and accurate care plan to ensure coordinated and effective care. The lack of a completed care plan was attributed to a failure in the admission process, where the necessary boxes were not checked, preventing the automatic population of care planning areas. This deficiency could lead to a delay in care and potential harm to residents, as staff may not be aware of the specific needs and interventions required for each resident.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the Wound Care Nurse did not follow the doctor's orders during wound care for a resident with a non-healing surgical wound on the right breast. The physician's orders required the wound to be cleansed with anasept, patted dry with gauze, and then covered with a blue bacteriostatic foam and a bordered dry dressing. However, during an observation, the Wound Care Nurse applied the foam without pat drying the wound, which was against the prescribed orders. The resident involved was an elderly female with dementia, end-stage renal failure, and an unspecified open wound on the right breast. The Wound Care Nurse acknowledged the oversight, stating that the wound should have been patted dry to ensure a dry surface before applying the foam. The nurse admitted to usually following the procedure but forgot on this occasion. The Director of Nursing confirmed that the nurse should have adhered to the doctor's orders, as failing to pat dry the wound could retain moisture and increase the risk of infection.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments, as observed with one of the nine medication carts. On the 600 hall, a medication cart was left unlocked and unattended by an LVN. The cart was unlocked for two minutes while the LVN was in a resident's room administering medication. Although the narcotics were secured in a locked drawer, other non-narcotic medications were accessible, posing a risk of unauthorized access and ingestion by residents. During an interview, the LVN acknowledged that the cart was her responsibility and admitted she thought it was locked before entering the resident's room. She confirmed that it is the proper procedure to lock the carts when not in view or use. The Assistant Director of Nursing reiterated the facility's expectation that all medication carts should be locked or within the line of sight of the staff member using them. The facility's policy, dated 10/01/2019, clearly states that medication carts should not be left unlocked or unattended in resident care areas and must remain in the staff's line of sight when not locked.
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What surveyors actually found near you
We read the 162 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Corpus Christi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At River Ridge | 1.8 mi | ★★★★★ | 15 | 1 |
| Robstown Nursing And Rehabilitation Center | 4.4 mi | ★★★★★ | 7 | 0 |
| Avir At Corpus Christi | 12.6 mi | ★★★★★ | 4 | 0 |
| Windsor Nursing And Rehabilitation Center Of Morga | 14.6 mi | ★★★★★ | 5 | 0 |
| Windsor Nursing And Rehabilitation Center Of Corpu | 15 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.