Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Windsor Gardens during CMS and state inspections, most recent first.
Call lights were found out of reach for three residents, including two with significant cognitive impairment and one who said she had been looking for her call light because she needed staff assistance. An ADON moved the call lights back within reach, and staff, the Administrator, and the DON stated that call lights should be with residents at all times and accessible while in bed.
Resident medical information was left unsecured on staff carts. An LVN left a medication box with a resident's name and medication information on top of a cart while attending another resident, and an MA left a paper with multiple residents' BP and pulse readings visible in the hallway while the cart was unattended. The ADON, Administrator, and DON stated the information was confidential and should not have been visible to unauthorized individuals.
The facility failed to ensure care plans reflected the needs of three residents. One resident with pulmonary embolism had no care plan for that diagnosis, another resident with HTN had no care plan for HTN, and a third resident’s care plan did not reflect use of a BiPAP machine even though the device was observed at the bedside and the resident said he used it nightly. Staff and leadership stated the care plans should have included these issues.
Incomplete and Overdue Care Plan Reviews: The facility failed to ensure comprehensive care plans were reviewed and revised by the IDT after each MDS assessment for multiple residents. Several residents had recent MDS assessments, but their quarterly care plans were months out of date, and one resident with moderate cognitive impairment had a care plan with only two problem areas documented. Staff interviews confirmed care plans were expected to be updated quarterly and when condition changes occurred, and an MDS nurse identified the care plans as overdue.
A resident with ESRD had carbonate powder left in her room, then placed on top of an LPN's cart unattended. Another resident with dementia had antiseptic liquid and topical analgesic in plain view on a bedside table, and a third resident had TUMS left in a medicine cup on a dresser while he was away for a procedure. Staff stated medications should not be left in resident rooms or unattended on carts.
Infection Control and Medication Handling Deficiencies: Staff failed to follow EBP and hand hygiene requirements during resident care, including a transfer for a resident with a catheter, incontinent care for a resident with bowel and bladder incontinence, and IV antibiotic administration through a PICC line for a resident on EBP. Staff also placed a personal beverage on a med cart and stored oral liquid medication bottles with open syringes secured to them, creating contamination concerns noted by the DON, ADON, and other staff.
Incomplete Baseline Care Plans for Two Newly Admitted Residents: The facility failed to complete baseline care plans within 48 hours for two newly admitted residents and did not provide the resident and representative with a summary. One resident had cirrhosis of the liver, cholelithiasis with obstruction, and lymphedema, while the other had type 2 DM, HF, AFib, and a back wedge compression fracture. Their care plans contained missing goals and/or interventions for issues including DNR status, impaired cognition, pressure ulcer prevention, limited mobility, fall risk, and constipation.
A resident who was frequently incontinent of bladder and bowel and had moderate cognitive impairment did not receive proper pericare when a CNA cleaned the penis from the base of the shaft toward the tip instead of downward. The CNA acknowledged the technique was incorrect, and the ADON and DON stated staff were expected to use the proper method to help prevent UTI.
A resident with COPD and severe cognitive impairment had a nasal cannula left unbagged on a wheelchair, and another resident with COPD had oxygen tubing and a BiPAP mask left out of a bag when not in use. Staff stated the respiratory items should have been bagged for infection control, and the second resident also had no physician order for the BiPAP at the time of observation.
A resident with diabetes and other serious health conditions did not have blood sugar checks performed or documented on six occasions as ordered for insulin administration. Interviews with an LPN, the DON, and the Administrator confirmed that blank entries in the MAR meant the checks were not done, and no alternative documentation was found. Facility policy required all procedures and results to be recorded, but this was not followed.
Two residents with wounds did not have required dressings in place as ordered, resulting in open wounds being left uncovered. Staff interviews confirmed that dressings are essential for healing and infection prevention, and that all staff are responsible for monitoring and replacing dressings when missing. The facility's wound management policy requires appropriate dressing of wounds, but this was not followed for these residents.
A resident with multiple medical conditions, including diabetes and seizure disorder, did not have a comprehensive person-centered care plan developed or implemented during their stay. Despite identified care needs and standard procedures for care plan completion, staff confirmed that no care plan was created or maintained for this individual.
The facility failed to properly label medications in one medication room and two medication carts, with open vials and bottles lacking open dates. Staff interviews revealed a lack of adherence to the facility's policy on medication labeling, which requires open dates to ensure effectiveness and safety. The responsibility for labeling was acknowledged to fall on the administering MA or nurse, with oversight by unit managers and the pharmacy.
A CNA failed to perform hand hygiene after direct contact with multiple residents while serving meals, despite being trained and aware of the facility's infection control policy. This deficiency involved residents with various medical conditions, potentially risking cross-contamination and infections.
The facility's main kitchen was found to have several deficiencies related to food safety and hygiene. Observations revealed dirty ice machine filters, improperly labeled and stored food items, and poor hand hygiene practices among dietary staff. Additionally, unsanitary conditions such as unclean floors and cracked food container lids were noted, posing a risk to food safety.
The facility failed to maintain a clean and functional environment in the rehabilitation satellite kitchen, with issues such as dirty sinks, cabinets, and floors, and missing cabinet handles. Staff interviews revealed a lack of awareness and communication regarding the kitchen's condition and use, with no documentation of needed repairs in the maintenance logbook. The Administrator acknowledged the area should be cleaned daily, while the Medical Director highlighted its potential use for rehabilitation.
A resident with a complex medical history was subjected to an inappropriate comment by a CNA, compromising her dignity and quality of life. The comment, made in a joking manner, led to discomfort for the resident's family, who decided to discharge her the same night. The facility's policy on residents' rights was not upheld, and the incident was investigated.
A facility failed to document emergency medical services notification and physician orders for a resident who was lethargic and unresponsive. The resident, with multiple health conditions, was sent to the hospital at the family's request, but necessary documentation, including assessments and times of emergency service calls, was missing. Interviews with staff highlighted the lack of adherence to documentation policies.
A resident with a G-tube experienced a feeding tube error that was not promptly addressed by an LVN, who failed to check tube placement before attempting to clear a clog. This resulted in the resident not receiving her prescribed formula for nearly an hour. Interviews revealed that proper procedures were not followed, which could have prevented potential complications.
A resident with quadriplegia and total dependence for care was injured after a CNA failed to follow the care plan requiring a two-person assist for transfers and showers. The CNA attempted to shower the resident alone, resulting in a fall and head injury. The facility identified this as an Immediate Jeopardy situation due to the failure to adhere to the care plan.
A resident in a persistent vegetative state, requiring total care, was injured after being transferred and showered by a single CNA, contrary to the care plan's requirement for a two-person assist. The resident fell from a shower bed, sustaining a head injury, due to inadequate supervision and failure to ensure equipment safety. The facility lacked a system to monitor equipment functionality, contributing to the incident.
A resident with chronic kidney disease was administered hydrocodone after it was ordered to be discontinued, leading to a significant medication error. Interviews with staff revealed that the medication administration process failed to prevent this error, as the medication was given twice post-discontinuation. The facility's policy defines this as a medication error, emphasizing the need for adherence to physician's orders.
Call Lights Not Within Reach of Residents
Penalty
Summary
The facility failed to ensure that the call light system was reasonably accessible to three residents whose call lights were found on the floor or otherwise out of reach in their rooms. Resident #98, a female with muscle weakness, abnormal gait and mobility, and moderate cognitive impairment with a BIMS score of 10, was observed awake in bed with her call light on the floor. When asked about it, she did not respond and shrugged her shoulders. Resident #104, a female with muscle weakness, lack of coordination, and severe cognitive impairment with a BIMS score of 7, was also observed awake in bed with her call light on the floor between the bed and side table; when asked where it was, she said she did not have it. Resident #7, a female with muscle weakness, right ankle pain, and moderate cognitive impairment with a BIMS score of 12, was observed awake in bed with her call light on the floor under the bed. She told staff she had been looking for her call light because she needed to call for assistance. Each of the three residents had care plans identifying them as at risk for falls and directing that the call light be within reach. During the observations, the ADON entered the rooms, picked up the call lights from the floor, and placed them where the residents could reach them. He stated that call lights should be with residents at all times and that staff were responsible for ensuring they were within reach before leaving the room. Other staff interviewed stated they had not noticed the call lights were on the floor, and the Administrator and DON stated that all staff were responsible for making sure call lights were within reach. The facility policy also stated that call lights must be within reach and accessible to residents in bed and should be accessible to a resident lying on the floor.
Resident medical information left visible on carts
Penalty
Summary
The facility failed to ensure the resident's right to personal privacy and confidentiality of personal and medical records for 11 of 28 residents reviewed for resident rights. One event involved LVN B leaving Resident #5's medication box on top of her cart while she went into another resident's room, with the box still displaying the resident's name and medication information. Resident #5's face sheet reflected that the resident was an [AGE]-year-old female admitted to the facility and diagnosed with end-stage renal disease. A second event involved MA C leaving her cart unattended in the hallway while she went to another hall to get a blood pressure cuff. A piece of paper was left on top of the cart with the blood pressures and pulses written beside the names of Resident #2, #33, #40, #44, #49, #53, #91, #100, #116, and #117. The cart was facing the hallway, and several residents and non-nursing staff were passing by. The residents whose information was visible had diagnoses including pulmonary embolism, hypertension, and heart failure. During interviews, LVN B stated the medication box should have been placed inside the drawer of the cart because medical information was attached to it and should have been secured. MA C stated she should have flipped the paper before leaving the cart because the blood pressures and pulses were medical information and should have been secured. The ADON, Administrator, and DON all stated that resident medical information should not be left unattended or visible to unauthorized individuals and that the information left on the cart was confidential.
Incomplete Care Plans for Medical Needs
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, with care plans that included measurable objectives and timeframes for needs identified in their assessments. For one resident with a diagnosis of pulmonary embolism, the comprehensive care plan dated 01/09/2026 did not include a care plan for pulmonary embolism, even though the resident’s MDS assessment reflected the diagnosis and a physician order was in place for Xarelto for a history of pulmonary embolism. A physician order also directed anticoagulant side effect monitoring. For another resident with hypertension, the comprehensive care plan dated 12/03/2025 did not include a care plan for hypertension. The resident’s MDS assessment reflected hypertension, and a physician order was in place for Hyzaar related to essential hypertension with parameters to hold the medication for low blood pressure. During interview, the MDS Nurse stated that if a resident had hypertension or pulmonary embolism, there should be a care plan for it, and he reviewed the profiles and confirmed that both residents did not have those care plans before adding them. For a third resident with COPD and asthma, the comprehensive care plan dated 12/26/2025 did not reflect the use of a BiPAP machine. An observation showed the BiPAP machine and face mask on the resident’s nightstand, and the resident stated he brought the BiPAP from home and used it every night for almost 15 years. The resident’s physician orders did not reflect an order for BiPAP. The DON stated the BiPAP should have been included in the care plan, and staff later stated the care plan had been updated to reflect it.
Incomplete and Overdue Care Plan Reviews
Penalty
Summary
The facility failed to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team after each assessment for seven residents reviewed for care plan revision. Record reviews showed that Residents #33, #44, #91, #98, #104, and #116 each had a recent comprehensive MDS assessment, but their last quarterly care plans were completed months earlier and were not updated after those assessments. Resident #100’s record showed a comprehensive MDS assessment with moderate cognitive impairment and a BIMS score of 11, but the care plan dated 12/03/2025 contained only two problem list foci, code and ADLs. For Resident #33, the last MDS was done on 12/29/2025 and the last quarterly care plan was completed on 09/17/2025. For Resident #44, the last MDS was done on 11/18/2025 and the last quarterly care plan was completed on 08/19/2025. For Resident #91, the last MDS was done on 12/29/2025 and the last quarterly care plan was completed on 08/25/2025. For Resident #98, the last MDS was done on 11/12/2025 and the last quarterly care plan was completed on 08/18/2025. For Resident #104, the last MDS was done on 11/26/2025 and the last quarterly care plan was completed on 08/18/2025. For Resident #116, the last MDS was done on 11/17/2025 and the last quarterly care plan was completed on 08/21/2025. During interviews, the ADON stated care plans were done during admission and updated quarterly, and also updated with changes in condition, new wounds, or falls. The Administrator stated care plans were supposed to be updated quarterly to ensure the care being given was still appropriate, and the DON stated every resident needed a thorough care plan to ensure needed care was received and that care plans should be done quarterly to monitor new interventions and whether goals were being met. An MDS Nurse stated she was responsible for making the care plans for the identified residents, opened their profiles, and saw the care plans were overdue. The facility policy stated the comprehensive care plan would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.
Medications Left in Resident Rooms and Unsecured on Cart
Penalty
Summary
Drugs and biologicals were not consistently stored in locked compartments and were left accessible in resident areas. Resident #5, who had end stage renal disease and moderate cognitive impairment with a BIMS score of 08, was observed with a box of carbonate powder on the side table in her room. She stated she did not know who placed it there. LVN B confirmed that medications should not be inside resident rooms and removed the box, stating it was being given by the dialysis center rather than the facility. After removing Resident #5's carbonate from the room, LVN B placed the box on top of her medication cart and then left the cart unattended while she entered another resident's room. Several residents were observed passing by the cart. LVN B later stated she should have secured the medication inside the cart before leaving it unattended because a resident might take it and consume it. Resident #17, who had dementia, osteoarthritis, and severe cognitive impairment with a BIMS score of 06, was observed with an antiseptic liquid and topical analgesic inside a transparent container on the bedside table in plain view. The resident identified the items as her medications. LVN B later confirmed the medications were in the room and stated they should not have been there because the resident might consume them or put them in her eyes causing irritation. Resident #111 was also observed with a small medicine cup containing over-the-counter TUMS on the dresser in his room while he was away from the facility for a procedure. Staff stated the medication should not have been left in the room and that another resident could have taken it.
Infection Control and Medication Handling Deficiencies
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for three residents reviewed for infection control. Resident #24 had a suprapubic catheter and was on Enhanced Barrier Precautions (EBP) with a sign posted outside the room indicating a gown was required during transfer. On 01/14/2026, CNA D and the ABOM transferred the resident to a wheelchair using a mechanical lift after washing their hands and putting on gloves, but they did not wear gowns during the transfer. The ADOM stated she was not aware they were supposed to wear a gown during the transfer, and CNA D stated she would only wear a gown during direct care and guessed she should have worn one during the transfer. Resident #77 was frequently incontinent of bladder and bowel and had a care plan intervention to provide pericare after each incontinent episode. During incontinent care, CNA E put on a gown and gloves but did not wash her hands before donning PPE. She cleaned the resident, handled a brief and skin barrier sachet, and did not change her gloves after cleaning the resident’s bottom before applying the skin barrier cream and touching the new brief. CNA E stated she should have changed her gloves after cleaning the resident’s bottom and before touching the new brief, and that she applied the skin barrier using dirty gloves. The DON and ADON stated staff should perform hand hygiene before, after, and during care, and should change gloves after cleaning the resident’s bottom and before touching the new brief. Resident #128 had osteomyelitis of the lumbar vertebra, a PICC line, and was ordered EBP with gown and glove use. During observation, LVN M entered the room to administer IV vancomycin, washed her hands, and put on gloves, but did not put on a gown. LVN M stated she did not have to wear a gown to administer IV medication and would have worn one only if changing the dressing over the IV site. The DON stated LVN M should have worn a gown when administering medication via the resident’s PICC line, and ADON A stated the EBP sign indicated staff were expected to gown up for residents with IVs and other listed devices. The report also documented additional infection control and medication handling issues. MA C was observed passing medications with a cup of coffee on top of the medication cart, and the Administrator removed it. Two oral liquid medication bottles, one for levetiracetam and one for potassium chloride, were found with open oral syringes secured to the bottles with rubber bands in the medication cart. Staff stated the syringes should not have been stored that way because they were open to air and should be discarded after use. The facility’s policies on EBP, hand hygiene, and medication administration were reviewed and reflected expectations for gown and glove use during specified resident care activities, hand hygiene before and after PPE use and resident care, and medication administration in a manner to prevent contamination or infection.
Incomplete Baseline Care Plans for Two Newly Admitted Residents
Penalty
Summary
The facility failed to develop a complete baseline care plan within 48 hours of admission for two residents and failed to provide the resident and representative with a summary of the baseline care plan. Resident #127 was a [AGE]-year-old female admitted with diagnoses including cirrhosis of the liver, cholelithiasis with obstruction, and lymphedema. Her comprehensive care plan dated 01/11/2026 showed missing data in the focus, goal, and/or interventions sections, including a DNR code status focus with no interventions, impaired cognitive function/impaired thought processes with no goal listed, and pressure ulcer prevention with no goal listed. Resident #128 was a [AGE]-year-old female admitted with diagnoses including type 2 diabetes, heart failure, atrial fibrillation, and a back area wedge compression fracture. Her comprehensive care plan dated 01/11/2026 also had missing data in the focus, goal, and/or interventions sections, including limited physical mobility with no interventions listed, impaired cognitive function/impaired thought processes with no goal reflected, risk for falls with no goal listed, risk for constipation with no interventions listed, and pressure ulcer prevention with no goal or intervention stated. The MDS Nurse stated she was responsible for updating comprehensive care plans but not baseline care plans, and the DON stated the MDS department was expected to ensure each new admission had a completed baseline care plan, but Resident #127 and Resident #128's baseline care plans were started but not finished.
Improper Incontinent Care Technique
Penalty
Summary
The facility failed to ensure appropriate incontinent care for a resident who was frequently incontinent of bladder and bowel and had moderate cognitive impairment with a BIMS score of 12. The resident’s care plan directed staff to provide pericare after each incontinent episode. During an observation, a CNA was preparing to provide incontinent care and donned a gown and gloves before cleaning the resident’s perineal area. The CNA cleaned the resident’s penis starting from the base of the shaft toward the tip, and repeated the procedure twice. In interview, the CNA stated she was not aware she had cleaned upward and acknowledged the proper procedure was to clean downward. The ADON and DON both stated that cleaning the penis upward was not the correct technique and that staff were expected to follow the proper procedure to prevent urinary tract infection. The facility policy stated that residents who are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and restore continence to the extent possible.
Improper storage of respiratory equipment and missing BiPAP order
Penalty
Summary
The facility failed to ensure that respiratory equipment was stored properly when not in use for two residents receiving respiratory care. Resident #96, a female with COPD and severe cognitive impairment with a BIMS score of 00, had an order for oxygen at 2 LPM every shift. On observation, she was in bed while her nasal cannula was found coiled on the push handle of her wheelchair, not bagged, and there was no bag at the back of the wheelchair. The resident did not respond when asked who had removed the cannula. Resident #111, a male with COPD and intact cognition with a BIMS score of 13, was observed without his oxygen tubing stored in a bag. The tubing was connected to the concentrator and draped across the top of the concentrator, and the BiPAP machine and breathing mask were on the nightstand without being bagged. Staff interviews stated that the oxygen tubing and BiPAP mask should have been bagged when not in use for infection control, and that the nurse was responsible for ensuring respiratory items were stored properly. Staff also stated the resident used the BiPAP himself and that the equipment could become contaminated if left open to air. The record review also showed that Resident #111 did not have a physician's order for the BiPAP machine on the date of observation. Staff interviews indicated the resident had brought the BiPAP from home and that an order should have been obtained for its use at the facility. The facility policy stated delivery devices should be kept covered in a plastic bag when not in use, and the consulting physician/practitioner orders policy stated the attending physician shall authenticate orders for the care and treatment of assigned residents.
Failure to Document and Perform Ordered Blood Sugar Checks for Diabetic Resident
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of drugs for a resident with multiple complex diagnoses, including end stage renal disease, heart disease, heart failure, and type 2 diabetes mellitus with hyperglycemia. The resident was admitted with orders for NovoLOG insulin to be administered according to a sliding scale, with blood sugar (BS) checks required four times daily. Record review revealed that on six separate occasions within a specified period, the resident's BS was not checked as ordered, and there was no documentation indicating that the procedure was attempted or any reason for omission. Interviews with an LPN, the DON, and the Administrator confirmed that all BS checks and medication administrations should be documented in the medical record, and that blank entries on the Medication Administration Record (MAR) indicated the procedure was not performed. The facility's policy required detailed documentation for each BS check, including the result, the person performing the procedure, and any reasons for not completing it. The DON was unable to locate any alternative documentation for the missing BS checks, and all staff interviewed acknowledged the importance of following physician orders and documenting all procedures as required.
Failure to Maintain Wound Dressings for Two Residents
Penalty
Summary
The facility failed to ensure that two residents with wounds received the necessary treatment and services to promote healing and prevent infection. For one male resident with a history of intellectual disabilities, anemia, and hypertension, the care plan and physician orders required a dressing to be applied to a venous or arterial ulcer on his right lateral ankle. On the day of observation, the resident was found without a dressing on the wound, which was open and missing the top layer of skin. The resident reported discomfort without the dressing, and the treatment nurse confirmed that the dressing was missing, possibly due to it falling off during a shower. The nurse acknowledged that staff were responsible for monitoring dressings and that a new dressing should have been applied if it was found missing. A second resident, a female with pressure ulcer of the sacral region, chronic kidney disease, and dysphagia, was also found without a required dressing on her sacral wound. The care plan and physician orders specified the use of a gauze-soaked Dakin's Solution and a dry dressing. During observation, a CNA discovered the wound was uncovered and stated that the nurse should have been notified to apply a new dressing. The treatment nurse and LVN both confirmed that they were not aware the dressing was missing and would have applied a new one if notified. The wound was described as large and uncovered at the time of observation. Interviews with staff, including the treatment nurse, LVN, physician, and DON, confirmed that dressings are essential for wound protection and healing, and that staff are expected to monitor and replace dressings as needed. The facility's policy on wound management also requires wounds to be managed and dressed appropriately to maximize healing. The failure to ensure dressings were present and maintained as ordered led to the deficiency for both residents.
Failure to Develop and Implement Comprehensive Person-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one resident during their 35-day stay. Despite the resident having multiple medical diagnoses, including hypertension, diabetes, seizure disorder, bacterial infection, and anxiety, and requiring several medications and interventions, no comprehensive care plan was created or maintained during their admission. The Minimum Data Set (MDS) assessment identified several care areas that required attention, such as ADL function, urinary incontinence, nutritional status, and pressure ulcer risk, but these were not addressed in a formal care plan. Interviews with facility staff confirmed that the comprehensive care plan was not completed or entered into the system while the resident was present. The MDS nurse acknowledged responsibility for care plan entry and stated that the plan was typically completed within 14 days, but admitted that it was not done for this resident. The DON and other staff also confirmed that care plans are expected for all residents and are monitored by multiple team members, but in this case, no care plan was in place. No facility policy for care plans was provided during the survey.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure proper labeling of drugs and biologicals in one medication room and two medication carts. Specifically, the [NAME] medication room contained an open multi-dose vial of tuberculin without an open date. Additionally, the 300-hall medication cart had seven open eye drop medications without open dates, and the 500-hall cart contained one open eye drop medication and one bottle of liquid protein, both without open dates. These labeling deficiencies were identified during observations and interviews with staff, who acknowledged the importance of open dates for ensuring the medications' effectiveness and safety. Interviews with staff, including Medication Aides (MAs), Assistant Directors of Nursing (ADONs), and the Director of Nursing (DON), revealed a lack of awareness and adherence to the facility's policy on medication labeling and storage. The policy, revised in February 2023, requires that multi-dose vials be dated when opened and discarded within 28 days unless otherwise specified by the manufacturer. The staff admitted that the responsibility for labeling fell on the MA or nurse administering the medication, and that unit managers and the pharmacy were responsible for monitoring compliance. The failure to label medications properly could potentially lead to medication errors and reduced therapeutic effects, as noted by the DON.
Inadequate Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of CNA C, who did not perform hand hygiene after direct contact with residents while serving meals. This deficiency was observed during meal service on the rehabilitation hallways, where CNA C interacted with nine residents without using hand sanitizer or washing hands between contacts. The lack of hand hygiene could potentially lead to healthcare-associated cross-contamination and infections among residents. The residents involved in this deficiency included individuals with various medical conditions such as anemia, hypertension, heart failure, renal insufficiency, diabetes, and other health issues. These residents required assistance with activities of daily living and were either cognitively able to make decisions or moderately impaired. The failure to perform hand hygiene occurred despite the availability of hand sanitizer in the hallway and the facility's policy requiring hand hygiene before and after direct contact with residents. Interviews with CNA C and the Director of Nursing (DON) revealed that CNA C was aware of the hand hygiene requirements but did not comply due to nervousness and the urgency to serve lunch trays. The DON confirmed that all staff are trained to perform hand hygiene and that failure to do so can spread germs to residents and staff. The facility's policy emphasizes hand hygiene as the primary means to prevent the spread of infections, and CNA C had previously received training on this procedure.
Food Safety and Hygiene Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain food safety standards in its main kitchen, as observed during a survey. The ice machine filters and vents were found to be dirty and dusty, which could lead to contamination. Additionally, food items in the refrigerator, freezer, and dry storage room were not properly labeled or stored according to professional standards. This included items without discard dates and some past their expiration dates, which were not discarded as required. The survey also revealed poor hand hygiene practices among dietary staff. Staff members were observed not washing their hands or changing gloves after touching other surfaces or upon re-entering the kitchen. This lack of proper hand hygiene could lead to cross-contamination and increase the risk of food-borne illnesses among residents. Further observations noted unsanitary conditions in the kitchen, such as unclean floors with debris and slippery residues, as well as cracked lids on food containers that prevented airtight seals. These conditions, combined with the improper storage and labeling of food, posed a significant risk to the safety and quality of food served to residents.
Deficient Maintenance and Cleanliness in Rehabilitation Satellite Kitchen
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the satellite kitchen located on the rehabilitation halls. Observations revealed several issues, including a sink with dried dark particles and a dark slime area around the drain, cabinets with dried dark gooey stains and missing handles, and a chipped decorative wood area above the sink. Additionally, the wall next to the portable steam table had dried fluid stains, and the kitchen floor was sticky. A dirty refrigerator shelf was found on the floor, and the refrigerator contained a pitcher of orange juice with no food present. Interviews with staff members, including the Director of Rehabilitation, Maintenance Man A, Housekeeper B, LVN D, the Administrator, the Medical Director, and the Housekeeper Supervisor, revealed a lack of awareness and communication regarding the condition and use of the satellite kitchen. Maintenance and housekeeping staff were unaware of the need for repairs and cleaning, and there was no documentation in the maintenance logbook for necessary repairs. The Administrator acknowledged the area should be cleaned daily and expressed dissatisfaction with the current state, while the Medical Director emphasized the potential positive use of the space for rehabilitation purposes.
Resident's Dignity Compromised by Inappropriate CNA Comment
Penalty
Summary
The facility failed to ensure that a resident received treatment with respect and dignity, which compromised the maintenance of her quality of life. The incident involved a certified nursing assistant (CNA H) who made an inappropriate comment to the resident, stating, "oh, I sure would like to hit you on that big old booty," in what was perceived to be a joking manner. This comment was made in the presence of the resident's family, who initially laughed but later lodged a complaint, indicating that the comment was in poor taste and not reflective of good customer service. The resident, an elderly female with a complex medical history including unspecified encephalopathy, hypertension, hyperlipidemia, type II diabetes mellitus, breast cancer, and unspecified dementia, was admitted to the facility for rehabilitation. She required assistance with transfers and needed step-by-step cues for safe movement. The incident occurred shortly after her admission, and she was discharged the same night following the family's decision to take her home due to discomfort with the situation. Attempts to interview the involved CNA and the resident's family were unsuccessful, but the Executive Director and Director of Nursing provided insights into the incident. The Executive Director confirmed that the family felt uncomfortable with the CNA's comment, and despite efforts to address the family's concerns, the resident was taken home. The Director of Nursing noted that the family had been joking with the CNAs initially, but the situation was later perceived differently. The facility's policy on residents' rights emphasizes the right to be free from abuse and neglect, and the incident was investigated as per the facility's procedures.
Incomplete Documentation of Emergency Medical Services for a Resident
Penalty
Summary
The facility failed to ensure the medical record was complete and accurately documented for a resident who was reviewed for resident records. Specifically, the facility did not document the notification of emergency medical services when the resident's family requested that she be sent to the hospital due to lethargy and unresponsiveness to verbal stimuli. Additionally, there was no assessment completed for the resident, and physician orders for the hospital transfer were not recorded in the electronic health record. The resident in question was an elderly female with multiple diagnoses, including dementia, chronic kidney disease, insomnia, and other significant health conditions. On the day of the incident, the resident's family requested emergency medical services due to her lethargic state and inability to respond to verbal stimuli. Despite this request, the necessary documentation, including the time emergency services were called and the time they arrived, was missing from the resident's medical record. Interviews with facility staff, including LVNs and the ADON, revealed that there were expectations for documenting such incidents, including the use of nurses' notes or SBAR forms. However, these were not completed in this case. The facility's policy on changes in a resident's condition required detailed observations and documentation, which were not adhered to, resulting in incomplete records for the resident's emergency situation.
Failure to Monitor and Address Feeding Tube Error
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for a resident with a feeding tube. The resident, a severely cognitively impaired female with multiple diagnoses including gastrostomy status, experienced a feeding tube issue when the enteral feeding pump displayed a 'FLOW ERROR: Clog in line downstream of pump' message. LVN A did not address the error message promptly and failed to check the placement of the G-tube before attempting to clear the clog by injecting air and water into the tube. This oversight occurred over a period of nearly an hour, during which the resident did not receive her prescribed formula. Interviews with LVN A, LVN B, and the DON revealed that LVN A did not follow proper procedures, such as checking the G-tube placement, which could have prevented potential complications like aspiration or dislodgement of the tube. The DON confirmed that the issue was due to a kink in the line rather than a clog, and emphasized the importance of following facility policies to ensure resident safety. The facility's policy and the operating manual for the feeding pump both highlight the necessity of checking tube placement and using appropriate methods to restore patency, which were not adhered to in this instance.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, leading to a significant incident. The resident, who was quadriplegic and in a persistent vegetative state, required total dependence for all activities of daily living, including transfers and showers. The care plan specified that the resident needed a two-person assist for mechanical lift transfers and showers. However, CNA A did not follow this care plan and attempted to transfer and shower the resident alone, resulting in the resident falling from the shower bed and sustaining a frontal scalp hematoma and laceration on her forehead, which required stitches. The incident occurred when CNA A was giving the resident a shower and turned the resident over, causing her to slide off the shower bed. The facility's incident report and subsequent investigation revealed that CNA A did not adhere to the care plan's requirement for a two-person assist, which was a critical safety measure for the resident's condition. Interviews with facility staff, including the Executive Director and DON, confirmed that CNA A acted alone during the transfer and shower, contrary to the established care plan and facility policy. The failure to follow the care plan placed the resident at risk of injury, as evidenced by the fall and subsequent head injury. The facility's policy required that all mechanical lifts and transfers be conducted with two staff members to ensure resident safety. Despite the availability of the care guide and training provided to staff, CNA A did not seek assistance, leading to the incident. The facility identified this as an Immediate Jeopardy situation, highlighting the severity of the deficiency in adhering to the resident's care plan.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not adhere to the comprehensive care plan for a resident who required a two-person assist with a mechanical lift for transfers and showers. This oversight led to the resident being transferred and showered by a single CNA, contrary to the care plan's requirements. The resident, who was quadriplegic and in a persistent vegetative state, was entirely dependent on staff for all activities of daily living, including hygiene and transfers. During a shower, the resident fell from the shower bed, resulting in a frontal scalp hematoma and a laceration on the forehead that required stitches. The incident occurred because the CNA attempted to turn the resident over on the shower bed without the assistance of another staff member, as mandated by the care plan. Additionally, the facility lacked a system to monitor the safety and functionality of equipment, such as shower beds. The investigation revealed that the shower bed's side rail was not properly secured, which may have contributed to the fall. The facility's maintenance records did not show regular checks or documentation of equipment safety, and staff were not formally trained to report maintenance issues, leading to a breakdown in communication and safety protocols.
Medication Error Due to Failure to Discontinue Hydrocodone
Penalty
Summary
The facility failed to ensure that residents were free of significant medication errors, specifically in the case of a male resident with a history of cellulitis and chronic kidney disease. The resident was prescribed hydrocodone for pain management, which was ordered to be discontinued by the physician. However, the medication was administered twice after the discontinuation order, on two separate occasions. This oversight placed the resident at risk for adverse effects such as confusion, respiratory depression, and potential kidney damage. Interviews with facility staff, including the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs), revealed discrepancies in the medication administration process. The DON stated that discontinued medications should not appear in the system for administration, and any administration post-discontinuation is considered a medication error. The facility's policy on medication errors, revised in April 2014, defines such errors as the administration of drugs not in accordance with physician's orders, highlighting the unauthorized administration of the hydrocodone as a clear violation.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 872 citations issued within 25 miles in the last 12 months — including the 46 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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lancaster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Millbrook Healthcare And Rehabilitation Center | 0.8 mi | ★★★★★ | 5 | 0 |
| Avir At Lancaster | 2.5 mi | ★★★★★ | 15 | 1 |
| Desoto Nursing & Rehabilitation Center | 2.7 mi | ★★★★★ | 15 | 1 |
| Lancaster Nursing & Rehabilitation | 2.7 mi | ★★★★★ | 2 | 0 |
| Five Points Nursing And Rehabilitation | 3.1 mi | ★★★★★ | 6 | 0 |
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.