Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Mission Oaks during CMS and state inspections, most recent first.
The facility did not obtain food from approved or satisfactory sources and failed to ensure that food was stored, prepared, distributed, and served according to professional standards.
Two residents with incontinence did not receive proper perineal care, as one CNA failed to clean the buttocks and hips, and another used a back-to-front cleaning technique instead of the required front-to-back method. Both CNAs acknowledged their errors despite recent training, and the facility's policy specifies thorough cleaning and correct technique to prevent infection and skin breakdown.
Two CNAs did not follow proper incontinent care procedures for two residents with chronic conditions and cognitive impairment. One CNA failed to clean the buttocks and hips during care, while another used a back-to-front cleaning motion instead of the required front-to-back technique. Both CNAs had received recent training and passed competency checks, but did not adhere to facility policy during observed care.
A nurse left a vial of insulin unsecured on top of an unlocked medication cart while administering medication to a resident, leaving both the medication and cart unattended. Additionally, the medication refrigerator was found to be consistently below the recommended temperature range, with no guidance on the log for acceptable storage temperatures, and staff were unable to state the correct range. Multiple medications, including insulin, were stored in this refrigerator.
Staff failed to follow infection control protocols during care for three residents, including not performing hand hygiene before donning gloves, using items that had fallen to the floor, and not changing gloves after touching potentially contaminated surfaces. These lapses occurred during transfer assistance, catheter care, and incontinent care, despite staff having received infection control training and facility policies requiring proper hand hygiene.
The facility did not maintain an effective pest control program, as numerous flies were observed in multiple units, hallways, resident rooms, and dining areas. Staff and Resident Council members confirmed the persistent presence of flies. Records showed monthly pest control visits, but there was no facility policy on pest control, and the program was acknowledged as ineffective by the Administrator.
A resident with a legal guardian received multiple psychoactive medications without proper documentation of informed consent, as required by facility policy. Consent forms for antipsychotic and antidepressant medications were missing dated signatures from the legal guardian and facility representative, and there was no clear record of when telephone consent was obtained. The resident, who had intact cognition but was unable to answer questions about his medications, was not fully informed about his treatment as required.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
A resident with a G-tube and a history of stroke and dysphagia did not receive a prescribed water flush before enteral feeding, as an LVN administered formula prior to flushing the tube as ordered. The LVN realized the omission midway and attempted to correct it, but both the LVN and ADON confirmed that the physician's orders and facility policy were not followed, which could result in tube clogging.
The facility failed to report allegations of misappropriation of property for two residents to the State Agency within the required timeframe. Both residents reported their cellular devices missing, and although the grievances were documented, the incidents were not reported to the State Agency or local police department as required by the facility's policy and state regulations.
The facility failed to investigate allegations of misappropriation of property for two residents. Both residents reported their cellular devices missing, but the Social Worker and Administrator did not conduct thorough investigations or document necessary steps, despite the facility's policy requiring immediate reporting and investigation.
A resident with cognitive impairments and a history of wandering eloped from the facility during a smoke break by removing boards from a fence and scaling it. The facility's practice of disengaging door alarms during smoke breaks contributed to the incident. The resident was found and returned without injuries.
The facility failed to meet food service safety standards, including improper use of facial hair restraints, storing thermometers in a hand-washing sink, expired food items, unlabeled containers, wearing jewelry during food preparation, and inadequate chemical sanitizing solution in the dish machine.
An LVN pre-poured medications for three residents and stored them in the top drawer of the medication cart, leading to potential inaccuracies in medication administration records. The DON confirmed that this practice was against facility policy.
The facility failed to maintain a sanitary environment in four of five resident hallways, with observations revealing unclean and sticky hallway side rails. Despite regular cleaning assignments and daily monitoring, the issue persisted, as confirmed by the Housekeeping Director and the Administrator.
The facility failed to maintain an effective pest control program, resulting in the presence of flies throughout the building. Observations revealed flies on various surfaces, including a resident's bed, and staff confirmed the ongoing issue. Despite having a pest control contract, the facility's records showed inadequate treatment for flies.
The facility failed to ensure that four staff members, including a CNA, the Food Service Director, the Physical Therapist, and the Speech Therapist, received the required training on resident rights during 2023. Interviews and record reviews confirmed the lack of documentation for this training, and the facility did not have a policy mandating the completion of required in-service training.
The facility failed to ensure that five staff members, including a CNA, the Food Service Director, an LVN, the Occupational Therapist, and the Speech Therapist, received the required training on abuse, neglect, and exploitation during 2023. This deficiency was identified through interviews and record reviews, revealing a lack of documentation and a gap in the facility's training program.
The facility failed to ensure a resident's call light was within reach, despite the resident's care plan specifying this need. The resident, who has moderate cognitive impairment and requires assistance due to unsteadiness, was found with the call light on the floor. Staff acknowledged the issue, and the facility's policy mandates call light accessibility for all residents.
The facility failed to ensure a resident's right to personal privacy during incontinent care when CNAs did not close the window privacy curtain, exposing the resident. The DON confirmed that privacy should have been provided and that staff had received training on resident rights.
A facility failed to provide appropriate incontinent care for a resident with severe cognitive impairment, leading to potential infection risk. CNA E used an incorrect cleaning technique and neglected to clean the buttocks and anal area, despite having received training. The DON confirmed the correct procedures, which were not followed.
A facility failed to ensure that a CNA demonstrated competency in providing incontinent care for a resident with severe cognitive impairment and multiple medical conditions. The CNA did not clean between the resident's buttocks and used an incorrect technique to clean the resident's penis. Despite having received training, the CNA admitted to not following the correct procedures, which was confirmed by the DON.
The facility failed to ensure PRN orders for anti-psychotic drugs are limited to 14 days and reviewed by a physician. A resident's order for Lorazepam was written as indefinite, posing a risk of drug dependence and falls. Interviews revealed the error and lack of a policy to prevent such issues.
A CNA failed to change gloves or wash hands after providing incontinent care for a resident, leading to a deficiency in the facility's infection prevention and control program. The resident had multiple diagnoses and required extensive assistance with daily activities. The facility's policy on perineal care was not followed.
Noncompliance with Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating noncompliance with established food safety and handling requirements. No additional details regarding specific residents, staff, or events leading to the deficiency are provided in the report.
Deficient Perineal Care and Improper Technique During Incontinent Care
Penalty
Summary
Two residents with a history of incontinence and multiple comorbidities did not receive appropriate perineal care as required by facility policy. For one resident with moderate cognitive impairment and frequent bladder incontinence, a CNA failed to clean the buttocks and hips during incontinent care, as observed by surveyors. The CNA acknowledged the omission and stated she was nervous, despite having received recent training in infection control and incontinent care. The resident's care plan specifically identified the need to prevent skin breakdown due to incontinence. For another resident with mild cognitive impairment, an indwelling catheter, and bowel incontinence, a CNA used an improper back-to-front cleaning technique during perineal care, moving from the buttocks to the scrotum. The CNA admitted to using the incorrect technique and recognized that the correct method was front to back, as outlined in facility policy. Both incidents were confirmed by interviews with the ADON, who stated that staff are trained to clean the perineal area front to back to prevent cross-contamination and infection.
CNAs Failed to Demonstrate Competency in Incontinent Care Techniques
Penalty
Summary
Certified Nursing Assistants (CNAs) at the facility failed to demonstrate competency in providing proper incontinent care for two residents. In the first instance, a CNA did not thoroughly clean the buttocks and hips of a resident with multiple chronic conditions, including diabetes, COPD, hypertension, and mild to moderate cognitive impairment, during incontinent care. The resident's care plan specifically required thorough cleaning to prevent skin breakdown, but observation revealed these areas were not cleaned. The CNA acknowledged the omission and stated she was nervous during the care, despite having received recent training and passing a competency check for infection control and incontinent care. In the second case, another CNA used an incorrect cleaning technique while providing incontinent care to a resident with diabetes, hypertension, dementia, and an indwelling catheter. The CNA cleaned the resident using a back-to-front motion from the buttocks to the scrotum, contrary to facility policy and standard infection control practices, which require a front-to-back motion to prevent cross-contamination. The CNA admitted to using the wrong technique and attributed the error to nervousness, despite having received recent training and passing a competency check. Both incidents were observed directly by surveyors and confirmed through interviews with the CNAs and the Assistant Director of Nursing (ADON). Facility policy and training materials reviewed by surveyors clearly outlined the correct procedures for perineal care, which were not followed in these instances. The failures were identified through a combination of observation, record review, and staff interviews.
Medication Security and Storage Deficiencies Identified
Penalty
Summary
A nurse prepared insulin for a resident by drawing up the medication and then entered the resident's room to administer it, leaving the vial of insulin unsecured on top of the medication cart and the cart itself unlocked and unattended in the hallway. This action left the medication accessible to others and out of the nurse's line of sight, contrary to facility policy and accepted professional standards for medication security. The nurse acknowledged during an interview that the insulin and cart should not have been left unsecured and unattended. Additionally, an inspection of the medication refrigerator in the facility's medication room revealed that the temperature was consistently below freezing, with recorded temperatures as low as 29-30 degrees Fahrenheit. Review of the temperature logs for the month showed that on 17 out of 25 days, the temperature was below the recommended range for medication storage. The temperature log did not include the acceptable temperature range, and staff were initially unable to state the correct storage temperature for medications. Multiple types of medications, including insulin, were stored in this refrigerator.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during care for three residents. In one instance, a CNA assisted a resident with a transfer by touching the bedroom door with bare hands and then failed to sanitize or wash hands before donning gloves and providing care. The CNA acknowledged the door was considered dirty and that hand hygiene should have been performed prior to gloving and care. In another case, while providing catheter care to a resident with an indwelling catheter, a CNA picked up a catheter strap from the floor and used it on the resident, touched the bed and bed remote with gloved hands, and did not change gloves or sanitize hands before continuing care. Additionally, another CNA touched a gown before washing hands. Both CNAs confirmed they should have followed proper hand hygiene and not used items that had fallen to the floor. A third incident involved a CNA providing incontinent care to a resident. The CNA touched the privacy curtain with bare hands, then handled clean supplies without sanitizing hands or donning gloves, and subsequently touched the bed and bed remote with gloved hands before providing care, without changing gloves or sanitizing hands. The CNA admitted to forgetting proper procedures due to nervousness. In all cases, staff confirmed receiving infection control training within the year, and facility policy required hand hygiene before gloving and after contact with potentially contaminated surfaces.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program on three of five units, specifically units 100, 300, and 400. Numerous flies were observed in hallways, resident rooms, and dining areas during the investigation period. Staff interviews confirmed the presence of flies during meal service, and members of the Resident Council reported that flies were present throughout the facility and were bothersome, including in their rooms and dining areas. Observations were made at various times, including during meal service, further confirming the widespread issue. A review of facility records showed that there was an undated contract for pest control services, and pest control visits were documented as occurring once per month from February through June. However, both the ADON and the Administrator confirmed that the facility did not have a policy regarding pest control. The Administrator acknowledged that the pest control program had been ineffective in addressing the fly problem.
Failure to Obtain and Document Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that a resident with a legal guardian was fully informed and provided with proper consent for the use of multiple psychoactive medications, including antipsychotics and antidepressants. Record reviews showed that consent forms for medications such as Zyprexa, Haldol, Perseris, Zoloft, and Trazodone were either missing the legal guardian's dated signature or lacked documentation of when telephone consent was obtained. The facility's care plan included interventions to educate the resident, family, or caregivers about the risks, benefits, and side effects of these medications, but documentation did not confirm that this education and informed consent process was properly completed. During interviews, the ADON acknowledged that she had failed to date her signature and the legal guardian's telephone consent on the relevant forms, attributing this to oversight. The resident in question had diagnoses including schizoaffective disorder, anxiety disorder, and major depressive disorder, and was assessed as having intact cognition. Despite this, the resident was unable to answer questions about his medications during an interview. Facility policy required that residents or their representatives be informed of the risks, benefits, and alternatives to psychotropic medications prior to initiation or dose changes, and that this be documented, but this process was not followed as required.
Failure to Timely Develop and Review Comprehensive Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Follow Physician Orders for Enteral Feeding Tube Flushing
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow physician orders for the administration of enteral feeding to a resident with a history of cerebral infarction, dysphagia, and gastrostomy status. The resident, who was moderately cognitively impaired and dependent on tube feeding, had specific physician orders requiring the G-tube to be flushed with 130ml of water before and after each feeding. During an observed feeding, the LVN administered half of the prescribed formula without first flushing the tube with water as ordered. Upon realizing the error, the LVN administered the water flush midway through the feeding, followed by the remainder of the formula. The LVN acknowledged during an interview that she forgot to flush the tube with water before the feeding because she was in a hurry, and recognized that this could result in the tube not being cleared and potentially becoming clogged. The Assistant Director of Nursing confirmed that the LVN should have followed the physician's orders and that not flushing the tube first could lead to clogging. Facility policy also required flushing with water at several steps during tube medication administration, as confirmed by record review.
Failure to Report Allegations of Misappropriation of Property
Penalty
Summary
The facility failed to report allegations of misappropriation of property for two residents to the State Agency within the required timeframe. Resident #1, a [AGE] year-old female with schizoaffective disorder and multiple fractures of the pelvis, reported her cellular device missing on 03/29/2024. The Social Worker documented the grievance and informed the resident that she would look for the device. The Administrator, who is the Abuse Prevention Coordinator, signed the grievance form but did not report the incident to the State Agency or local police department. During interviews, both the Social Worker and the Administrator acknowledged the failure to report the missing phone as required by the facility's policy and state regulations. Resident #5, a [AGE] year-old female with hypertension and mild neurocognitive disorder, reported her cellular device missing on 03/27/2024. The Social Worker documented the grievance and informed the resident that she would look for the device. The Administrator signed the grievance form but did not report the incident to the State Agency or local police department. During interviews, both the Social Worker and the Administrator acknowledged the failure to report the missing phone as required by the facility's policy and state regulations. The facility's policy on Abuse, Neglect, and Exploitation requires that all alleged violations involving misappropriation of resident property be reported immediately, but not later than 2 hours, to the State Agency and other required agencies. The failure to report these incidents could place residents at risk of abuse, neglect, or misappropriation of property. The Administrator admitted that not reporting such allegations could cause psychological harm to the residents.
Failure to Investigate Allegations of Misappropriation of Resident Property
Penalty
Summary
The facility failed to thoroughly investigate allegations of misappropriation of resident property for two residents. Resident #1, a [AGE] year-old female with schizoaffective disorder and multiple fractures of the pelvis, reported her cellular device missing. Despite the resident's clear report and the Social Worker’s acknowledgment of the missing phone, no thorough investigation was conducted. The Social Worker only looked around the facility and asked some staff members but did not document any interviews or further investigative steps. The Administrator, who is the Abuse Prevention Coordinator, was unaware of the missing phone despite having signed the grievance form, indicating a lack of proper communication and follow-up on the allegation. Similarly, Resident #5, a [AGE] year-old female with hypertension and mild neurocognitive disorder, reported her cellular device missing shortly after receiving it. The Social Worker acknowledged the report and noted the missing phone on the grievance form but did not conduct a thorough investigation. The Social Worker informed the resident that nothing could be done about the missing phone. The Administrator, who signed the grievance form, also failed to investigate the allegation properly, despite being responsible for such investigations as the Abuse Prevention Coordinator. The facility's policy on Abuse, Neglect, and Exploitation requires immediate reporting and thorough investigation of all allegations of misappropriation of resident property. However, in both cases, the facility did not adhere to its policy, resulting in a failure to protect the residents' property and rights. The lack of proper investigation and documentation highlights significant deficiencies in the facility's handling of such allegations.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents. Specifically, the facility did not properly supervise a resident who eloped from the facility. The resident, a 55-year-old male with diagnoses including unspecified dementia, schizoaffective disorder, and anxiety disorder, was identified as having a significant risk of wandering behavior. Despite this, the resident managed to elope from the facility during a smoke break by removing several boards from an eight-foot-high fence and scaling it to leave the property. The incident occurred on 05/02/24, and the resident was found and returned to the facility approximately an hour later without injuries. The facility's practice of disengaging hall corridor door alarms during smoke breaks contributed to the resident's ability to elope. The facility's Director of Nursing (DON) confirmed that the door alarms were disengaged by activity staff to allow residents to enter the outside smoking area and were re-engaged after the smoke break. Upon noticing the fence breakage, the staff initiated an immediate elopement protocol, which included a resident head count, notification of local authorities, and a search for the missing resident. The resident was found several blocks away from the facility and returned without injuries. The facility's failure to maintain door alarms and supervise the resident adequately led to the elopement incident. The facility's policy on elopements and wandering residents, dated 11/21/22, was not effectively implemented to prevent this incident. The facility's inaction in maintaining a secure environment and providing adequate supervision directly contributed to the resident's elopement.
Removal Plan
- The practice of the hall corridor alarms being de-activated during the smoke breaks was immediately terminated and all hall corridor door alarms would stay activated at all times.
- Resident #21 was placed immediately on one-on-one supervision.
- A new fencing structure was put into place on the facility grounds which would restrict all resident access to any outside area which was not in direct visual observation of the staff who were outside with the residents.
- The Administrator ordered that all resident corridor doors keep their door alarms engaged at all times.
- The Administrator approved the construction of a 10-foot tall fence on the outside grounds of the facility which would restrict resident access to only being under the direct visual observation of the staff at all times.
- The Regional President for Operations authorized the financial payment for the facility's fence construction to prevent resident elopement.
- The Maintenance Director completed regular inspections of the outside fence area surrounding the facility for structural integrity.
- The Maintenance Director changed the resident hallway door alarm codes on a regular basis.
- Facility staff received in-service training on elopement, which included information on routine resident checks, awareness of the elopement binder, and monitoring residents for exit-seeking behaviors such as checking exits, pushing on doors, and verbalizing wanting to leave the facility.
- Facility staff work as a team to prevent resident elopements, which included facility perimeter checks during shifts.
Multiple Food Safety Violations in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in several instances. Cook A was observed not wearing a facial hair restraint while engaged in food preparation and service, despite having facial hair that covered his upper lip and chin. Cook A admitted to knowing the requirement but failed to put the restraint back on after using the restroom. The Food Service Supervisor (FSS) confirmed that Cook A should have been wearing a facial hair restraint. Additionally, ten bimetallic stemmed thermometers were found in the hand-washing sink, with one thermometer's indicator head inside the drain. The FSS confirmed that the thermometers should not have been in the hand-washing sink and that the sink was designated solely for handwashing. In the reach-in cooler, a 5-lb. bag of Mozzarella cheese was found past its use-by date, and containers of thickened juice and milk were not labeled with use-by dates. The FSS acknowledged that the cheese should have been discarded and that the juice and milk should have been properly labeled. Cook B was observed wearing a wristwatch while preparing food, which is against the facility's policy. Cook B admitted to forgetting to remove the watch. The FSS confirmed that dietary staff were trained not to wear jewelry on their hands during food preparation. Furthermore, the chemical sanitizing solution in the dish machine did not reach the minimum required parts per million (ppm) for effective sanitization. The FSS initially attributed this to expired test strips but even with new test strips, the chlorine concentration remained inadequate. The facility's policies and the U.S. Food Code were reviewed, confirming the deficiencies in food safety practices.
Improper Storage of Pre-Poured Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were secured properly for three residents. Specifically, an LVN pre-poured medications for three residents and stored them in the top drawer of the medication cart. This practice was observed during an interview with the LVN, who admitted to pre-pouring the medications and signing out the medication administration record in advance. The LVN acknowledged that this practice could lead to inaccurate documentation if the residents needed to be sent to the hospital. The Director of Nursing (DON) confirmed that the LVN should not have pre-poured the medications and stored them in the medication cart drawer, as it could result in incorrect medication administration records. The residents involved had various medical conditions, including dementia, hypertension, schizoaffective disorder, paranoid schizophrenia, diabetes mellitus, epilepsy, and overactive bladder. The residents had moderately impaired cognition, as indicated by their BIMS scores. The medications involved included Invega, Losartan, Lyrica, Metformin, Provera, Gabapentin, Valbenazine tosylate, and Levetiracetam. The facility's policy on monitoring medication administration, dated 10/1/19, required that medication administration, including frequency, be documented accurately. The DON stated that the Assistant Directors of Nursing (ADONs) monitored nurses at random during the week to ensure compliance with medication storage policies.
Unclean and Sticky Hallway Side Rails
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in four of five resident hallways reviewed. Observations revealed that the hallway side rails in these areas were unclean and had a noticeable sticky touch. Specifically, on 5/5/24, the side rails on both sides of the resident 500 hallway were found to be sticky, causing the surveyor's pants to stick to them. Further observations on 5/8/24 with the Housekeeping Director confirmed that the side rails outside of specific rooms and on both sides of the resident hallway 200 were also unclean and sticky to the touch. The Housekeeping Director acknowledged that housekeepers were assigned to clean these areas regularly and would address sticky portions when reported, but the issue persisted despite daily monitoring of cleaning assignments. During interviews, the Housekeeping Director and the Administrator both expressed that they believed the resident hall handrails were cleaned regularly. The Administrator emphasized the importance of maintaining clean handrails for the facility's cleanliness. However, the facility's Environmental Services Policies and Procedures Manual, which was undated, stated that the facility should provide sufficient housekeeping and maintenance personnel, equipment, and supplies to maintain a clean and orderly environment. The observations and interviews indicated a failure to adhere to these policies, resulting in an unsanitary environment in the resident hallways.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies throughout the building. Observations on multiple occasions revealed flies landing on various surfaces, including a laptop, a resident, and in the kitchen and dishwashing areas. Interviews with staff confirmed the ongoing issue with flies, noting that they likely entered through doors used by people going in and out of the facility. Despite having a contract with a pest control company, the facility's records showed that the company treated for fire ants instead of flies during a recent visit, and only treated for flies once in the past month. One resident, who had multiple diagnoses including dementia and chronic kidney disease, was observed with flies on their bed during an insulin administration. The resident referred to the flies as his friends. Staff interviews indicated that the problem with flies had been ongoing, with some improvement but still persistent. The administrator acknowledged the issue and mentioned plans to increase pest control visits and ensure treatment for flies during each visit.
Failure to Ensure Staff Training on Resident Rights
Penalty
Summary
The facility failed to ensure that four staff members, including a CNA, the Food Service Director, the Physical Therapist, and the Speech Therapist, received the required training on resident rights during the year 2023. This deficiency was identified through interviews and record reviews, which revealed that these staff members had not completed the necessary training. The Director of Human Resources confirmed the lack of documentation for the required training and acknowledged that multiple parties, including department heads, the Human Resources Director, the Administrator, and the employees themselves, were responsible for ensuring the completion of this education. The facility did not have a policy mandating the completion of required in-service training. During interviews, both the Director of Human Resources and the Administrator emphasized the importance of completing the required training to improve the overall provision of resident care. The Administrator reiterated that employees needed to complete their required training to ensure proper care for residents. The absence of this training could place residents at risk of receiving care from staff who are insufficiently trained in resident rights and facility responsibilities.
Failure to Ensure Staff Training on Abuse, Neglect, and Exploitation
Penalty
Summary
The facility failed to ensure that five staff members, including a CNA, the Food Service Director, an LVN, the Occupational Therapist, and the Speech Therapist, received the required training on abuse, neglect, and exploitation during the year 2023. This deficiency was identified through interviews and record reviews, which revealed that these staff members did not have documentation of completing the necessary training. The Human Resources Director acknowledged the lack of documentation and stated that the responsibility for ensuring the completion of required education fell on multiple parties, including department heads, the Human Resources Director, the Administrator, and the employees themselves. The facility did not have a policy mandating the completion of required in-service training, which contributed to this oversight. During interviews, both the Human Resources Director and the Administrator emphasized the importance of completing the required in-service training to improve the overall provision of resident care. The deficiency places residents at risk of receiving care from staff who are insufficiently trained in recognizing and reporting abuse, neglect, and exploitation. The lack of training documentation for these five staff members highlights a significant gap in the facility's training program and oversight mechanisms.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that Resident #94's call light was within reach, which is a reasonable accommodation of the resident's needs and preferences. Resident #94, a [AGE] year-old male with diagnoses including dementia, HIV, and encephalopathy, was observed on 5/06/24 with his call light on the floor, out of reach. The resident, who has moderate cognitive impairment and requires assistance due to unsteadiness, was unaware of how the call light ended up on the floor. This lack of access to the call light could potentially lead to the resident attempting to get up without assistance, increasing the risk of falls and injury. The care plan for Resident #94 specifically included an intervention to ensure the call light was within reach, which was not adhered to in this instance. During interviews, the assigned CNA and the DON acknowledged the issue. The CNA was unaware of how the call light ended up on the floor but promptly clipped it back to the resident's pillow. The DON confirmed that call lights should be within arm's length of all residents and recognized that the lack of accessibility could lead to falls. The facility's policy on call light accessibility, dated 10/13/22, mandates that the call light system be available to all residents, which was not followed in this case.
Failure to Ensure Resident Privacy During Incontinent Care
Penalty
Summary
The facility failed to ensure residents' right to personal privacy for one resident during incontinent care. Specifically, CNAs C and D did not close the window privacy curtain while providing care to Resident #42, exposing the resident by the window. This incident was observed on 05/07/2024 at 1:01 p.m. Resident #42 has multiple diagnoses, including schizoaffective disorder, Parkinsonism, hypertension, epilepsy, hypothyroidism, hyperlipidemia, dementia, and major depressive disorder. The resident's Annual MDS assessment indicated a BIMS score of 7, showing severe cognitive impairment, and the care plan required extensive assistance for toileting due to the resident's condition. Both CNAs confirmed during an interview that the window curtain was not completely closed and acknowledged that it should have been. The Director of Nursing (DON) confirmed that privacy must be provided during nursing care and that the window curtain should have been closed completely. The DON also confirmed that the staff had received training on resident rights within the year, provided by the Assistant Directors of Nursing (ADONs), and that staff skills are checked annually and as needed. The facility's policy on resident rights includes the right to privacy, which was not upheld in this instance.
Improper Incontinent Care Leading to Potential Infection Risk
Penalty
Summary
The facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. During an observation, CNA E did not clean between the resident's buttocks and used an incorrect technique to clean the resident's penis. Specifically, CNA E used a base-to-tip motion instead of the correct tip-to-base motion and neglected to clean the buttocks and anal area. This improper care practice was confirmed by CNA E during an interview, where she admitted to not following the correct cleaning technique and not cleaning the buttocks area, despite having received training for infection control and incontinent care within the last year. The resident involved, identified as having severe cognitive impairment with a BIMS score of 4, was frequently incontinent of bowel and bladder and required extensive assistance with activities of daily living. The resident's care plan highlighted the need for maintaining clean and intact skin due to potential skin integrity issues related to debility and incontinence. The Director of Nursing (DON) confirmed the correct cleaning procedures and acknowledged that the Assistant Directors of Nursing (ADONs) were responsible for training staff and checking their skills annually or as needed. The facility's policy on perineal care also outlined the correct cleaning procedures, which were not followed in this instance.
Incompetent Incontinent Care by CNA
Penalty
Summary
The facility failed to ensure that nurse aides demonstrated competency in providing incontinent care for a resident. Specifically, CNA E did not clean between the resident's buttocks and used an incorrect technique to clean the resident's penis. This was observed during an incontinent care session for a resident with severe cognitive impairment and multiple medical conditions, including Alzheimer's disease, hypothyroidism, hyperlipidemia, liver disease, chronic kidney disease, schizoaffective disorder, and major depressive disorder. The resident required extensive assistance with activities of daily living and was frequently incontinent of bowel and bladder. During an interview, CNA E admitted to not using the correct technique and not cleaning the buttocks area, despite having received training for infection control and incontinent care within the last year. The Director of Nursing (DON) confirmed the correct procedures for cleaning a male resident and stated that the Assistant Directors of Nursing (ADONs) were responsible for training staff and checking their skills annually. A review of the facility's policy on perineal care and CNA E's annual skills check revealed that CNA E had previously passed competency for perineal care/incontinent care.
Failure to Limit PRN Orders for Anti-Psychotic Drugs
Penalty
Summary
The facility failed to ensure PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. Specifically, the facility did not include a stop date for Resident #70's order of Lorazepam 0.5 mg every 4 hours X 2 doses. The order was written as indefinite, which is against the regulatory requirement for PRN orders of anti-psychotic drugs. The resident had not received the medication in May 2024, but the lack of a stop date posed a risk of the resident potentially receiving more doses than ordered, which could lead to drug dependence and falls. The resident, a male with diagnoses including post-traumatic disorder, benign prostatic hyperplasia, and anxiety disorder, had a BIMS score indicating mild impairment. Interviews with the LVN and DON revealed that the indefinite order was a mistake, and the facility did not have a policy to cover this scenario. The LVN acknowledged that PRN orders for anti-anxiety medication should only be written for 14 days and then reviewed by a physician. The DON admitted that the order should have had an end date after 14 days and that the ADONs were responsible for monitoring this task daily. The facility's oversight in this matter led to the deficiency, as there was no proper monitoring or policy in place to prevent such errors.
Infection Control Deficiency Due to Improper Glove Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a CNA who did not change her gloves or wash her hands after providing incontinent care for a resident. This incident was observed during a survey, where the CNA was seen touching and fastening a clean brief to the resident without changing gloves or performing hand hygiene. The CNA confirmed during an interview that she did not follow proper infection control procedures, despite having received training within the year. The Director of Nursing (DON) also confirmed that gloves must be changed after cleaning and before touching a clean brief to prevent cross-contamination. The resident involved had multiple diagnoses, including Alzheimer's disease, hypothyroidism, hyperlipidemia, liver disease, chronic kidney disease, schizoaffective disorder, and major depressive disorder. The resident's care plan indicated a need for extensive assistance with activities of daily living and highlighted the potential for skin integrity issues due to incontinence. The facility's policy on perineal care, dated 10/24/2022, clearly stated that gloves should be removed and hand hygiene performed after cleaning and before applying a clean brief, which was not adhered to in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Rio At Mission Trails | 1.4 mi | ★★★★★ | 19 | 0 |
| San Jose Nursing Center | 2 mi | ★★★★★ | 0 | 0 |
| Highland Nursing Center | 2.7 mi | ★★★★★ | 20 | 0 |
| Mccullough Hall Nursing Center Inc | 3.6 mi | — | 0 | 0 |
| Pecan Valley Rehabilitation And Healthcare | 3.6 mi | ★★★★★ | 9 | 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 July 2026) and official state health department websites.