Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Windsor Nursing And Rehabilitation Center Of Duval during CMS and state inspections, most recent first.
A resident with dementia and severe cognitive impairment received 13 doses of topical Ativan despite no active order for that medication. The resident had an active PRN order for oral Ativan, but the topical form had been discontinued and remained on the med cart, where it was still administered. The PNP and pharmacist both confirmed there was no current order for the topical medication.
Controlled medication reconciliation and documentation failures were identified on multiple med carts. An RN, an MA, and an LVN were involved in discrepancies with Lorazepam and Hydrocodone-Acetaminophen counts, including signing controlled logs before administration, failing to document doses after giving them, and overlooking mismatched blister pack and syringe contents. Residents involved included individuals with severe cognitive impairment, dementia, anxiety, pain, and agitation.
A resident with schizoaffective disorder, epilepsy, anxiety, depression, and severe cognitive impairment received repeated incorrect doses of Ativan when an RN gave 0.5 mg tablets instead of the ordered 1 mg dose from the wrong blister pack. The MAR and controlled medication record documented multiple wrong-dose administrations, and the RN stated he was unsure when the dose changed. The Psych NP and DON/ADON acknowledged the incorrect dosing and controlled medication discrepancy as a medication error.
Kitchen staff failed to properly seal, label, date, and discard food items in the reach-in refrigerator, walk-in refrigerator, walk-in freezer, dry pantry, and on trays, with surveyors finding expired milk, cream, tortillas, produce, sandwiches, and other items left in storage. Surveyors also observed staff and a delivery driver entering the kitchen without proper hair restraints, including a beard cover that did not cover a mustache and a hairnet that did not fully cover the hair. Facility leaders and the RD acknowledged the labeling, storage, and hair restraint expectations, and records showed repeated prior concerns in monthly quality monitors and in-service training.
Call Light Left Out of Reach: A resident with CVA-related left-sided paralysis, impaired balance, and substantial assistance needs was observed sitting in a wheelchair while her call light remained clipped to the bed and out of reach. The resident stated she could not reach it, and an MA confirmed the call light was supposed to be attached to the wheelchair. The DON and ADM stated call lights were expected to remain within residents' reach at all times.
Improper Email Disclosure of Resident PII: An AMD emailed a PEME request form with a resident’s full name, DOB, SS#, and income information to the RP of another resident by mistake. The recipient opened the attachment after seeing only a brief message in the email body, and the resident involved had moderately impaired cognition, dementia, anxiety, and needed staff assistance with ADLs and reminders.
A resident with HTN, seizure disorder, bipolar disorder, schizophrenia, lack of coordination, and moderately impaired cognition was observed vaping in his room and placing the vape in his dresser drawer. His care plan and smoking acknowledgement required supervised smoking and stated that all tobacco products, including vapes, were to be kept by staff and not stored in resident rooms. Staff later retrieved the vape, and interviews confirmed that smoking materials were not permitted in rooms and were supposed to be secured by nursing staff.
The facility failed to maintain infection control for two residents. A CNA changed gloves during incontinent care but did not clean her hands before continuing care, and a resident with a blistering rash suspected to be chickenpox was placed on contact precautions instead of the CDC-recommended airborne precautions with appropriate PPE. Staff interviews confirmed the hand hygiene lapse and that the isolation precautions used did not match CDC guidance.
A resident with severe cognitive impairment and multiple complex medical conditions had an identified responsible party who requested copies of the resident’s medical records for continuity of care. The responsible party completed the facility’s medical record request form for a wide range of documents and wanted the records before or on the day of discharge for follow-up with the PCP. The Medical Records staff delayed sending the request to the corporate legal department for several days, citing a perceived seven-day window and workload, and the facility’s policy required legal approval before any records could be released. The Administrator stated the request was denied because the requester was not the POA, while the responsible party reported not being initially informed of the need to complete a request form. As a result, the requested records were not provided within the required timeframe and had still not been received weeks after the resident’s discharge.
Two residents were involved in a physical altercation in which one threw cold coffee and the other responded by hitting, resulting in a facial bruise and arm scratch. Staff recognized the event as abuse and reported it internally, but the administrator did not report the incident to the state survey agency as required, citing lack of distress and minor injury. This failure to report the incident within the mandated timeframe constituted a deficiency in abuse reporting procedures.
Staff failed to knock before entering the rooms of three residents with varying cognitive and physical impairments, despite being trained on the policy and its importance for resident privacy and dignity. One resident with intact cognition reported being upset by this practice. Both the CNA and LVN involved acknowledged the requirement to knock and attributed their failure to forgetfulness, while management confirmed ongoing monitoring of this policy.
The facility did not ensure that meals served matched posted menus or that menu substitutions were properly documented and approved by the dietitian. During two observed meal services, food items served differed from those listed on the menus, and only one substitution was recorded. Staff interviews confirmed that menu changes were made without updating posted menus or consistently following the facility's substitution policy.
Multiple residents with complex medical needs received meals that were cold, unappetizing, and poorly prepared, with repeated complaints about food quality, temperature, and menu substitutions. Staff did not consistently check food temperatures, and food often sat out before being served, leading to dissatisfaction and ongoing grievances about meal service.
Surveyors found multiple deficiencies in food service sanitation, including improper food storage, unclean kitchen and equipment, malfunctioning shelving, and a dishwasher not reaching the required temperature. Staff were observed eating in the kitchen area, and interviews revealed gaps in knowledge and adherence to cleaning protocols. Facility policy requiring cleanliness and equipment maintenance was not followed.
Three residents with significant care needs did not have accessible call lights in their rooms, as required by facility policy. Observations showed call lights were out of reach or improperly placed, and interviews with staff confirmed awareness of the policy but could not explain the inaccessibility. Residents were unable to call for assistance when needed.
A resident with dementia and mobility issues was using bed rails as an assistive device, but the care plan was not updated to reflect this use. Staff interviews confirmed awareness of the bed rails, but documentation and assessment were missing from the care plan, despite facility policy and recent audits.
A resident with Parkinson's disease and dementia experienced a malfunctioning oxygen concentrator that emitted a loud beeping and displayed a red warning light for about 45 minutes. Staff did not respond to the alarm until notified by a surveyor, and the device was found wrapped in plastic, causing it to overheat and deliver less oxygen than ordered. Interviews confirmed that staff failed to notice or address the alarm despite being present in the hallway.
A nurse failed to change gloves and perform hand hygiene during wound care for a resident, and EBP signage was not posted for two residents with wounds or indwelling devices. Additionally, a nurse provided suprapubic catheter care without wearing the required gown. Staff interviews and facility policy confirmed these actions did not follow infection control protocols.
The facility failed to act on a pharmacist's reports regarding missing medication consents for two residents. One resident received Trazodone without a signed consent, while another had an incomplete consent for Lorazepam. Interviews revealed staff expectations for signed consents, but the facility did not ensure these were completed and documented.
A resident with complex medical needs was physically assaulted by a hospitality aide, resulting in a red mark on her thigh. The incident was reported by a scheduler CNA who intervened and informed the abuse coordinator. The resident's care plan noted her resistance to care, and assessments found no distress post-incident. The facility's policy required staff training on abuse prevention, but the aide's file lacked training records, leading to her suspension and termination.
The facility failed to report an abuse allegation involving two residents to the State Agency within the required timeframe. One resident reported being hit by another in the dining room, resulting in skin tears and bleeding. Despite multiple witnesses and the resident's desire to report the incident, the Administrator did not follow through with the reporting.
Unnecessary psychotropic medication administered without active order
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary drugs used in excessive dose, duplicated drug therapy, excessive duration, and without adequate monitoring or indication. Resident #14, an elderly female with dementia, chronic atrial fibrillation, and a BIMS score of 6 indicating severe cognitive impairment, had a care plan addressing anti-anxiety medication use related to adjustment issues and dementia with behavioral disturbances. Her record showed an active order for oral Ativan 0.5 mg every 8 hours as needed for anxiety, but no active order for topical Ativan 1 ml/mg. Record review of the controlled medication log showed that topical Ativan 1 ml/mg was administered 13 times to Resident #14 on multiple dates despite the absence of an active physician order for that medication. The medication had been discontinued, yet it remained available and was given from the medication cart. During observation and attempted interview, the resident was lying in bed and could not comprehensibly respond to questions about her medication or condition. The PNP stated that Resident #14 did not have an active order for topical Ativan and that the topical form had been discontinued because the resident no longer required it. The pharmacist also stated there was no current order for topical Ativan and that the order had expired without being refilled. The DON and ADM described medication administration and controlled-substance counting processes, and the facility in-service record stated discontinued medications should be marked appropriately and destroyed, but the report documented that the topical Ativan remained on the cart and was administered without an active order.
Controlled Medication Reconciliation and Documentation Failures
Penalty
Summary
The facility failed to establish an accurate system for reconciling controlled medications and maintaining drug records in order for three medication carts. During surveyor observation, interview, and record review, discrepancies were identified in the controlled medication logs and medication counts for residents receiving Lorazepam and Hydrocodone-Acetaminophen. The facility also failed to ensure that controlled medications were documented immediately after administration, and in one instance a controlled medication was signed out before it was administered. For one resident with schizoaffective disorder, epilepsy, anxiety, and depression, RN A administered Lorazepam 0.5 mg but did not document the dose on the controlled medication record. The resident’s narcotic log showed a count discrepancy, with fewer tablets in the blister pack than recorded. RN A stated he gave the medication but forgot to sign the controlled log because he was busy. The resident had severe cognitive impairment and could not provide a comprehensive response during interview. For another resident with osteoarthritis, anxiety disorder, major depressive disorder, and pain, MA E signed the controlled medication log for Hydrocodone-Acetaminophen 5-325 mg before administration. The controlled medication count for that resident was also discrepant, with one more tablet in the blister pack than on the log. MA E stated controlled medications should be documented immediately after administration and that failing to do so, or documenting without administering, could cause confusion and medication errors. A third resident’s controlled medication record showed a discrepancy when Hydrocodone-Acetaminophen 10-325 mg was signed out but not documented as administered. On another cart, LVN F found a discrepancy involving Lorazepam 1 mg tablets for a resident with dementia and agitation, with fewer tablets in the blister pack than recorded on the log. LVN F also found a discrepancy in prefilled Lorazepam 1 mg/ml gel syringes for another resident with severe cognitive impairment, where one syringe contained less medication than expected. LVN F stated she counted the syringes by the tips and did not look at the medication content, and she acknowledged that controlled medications were supposed to be documented immediately after administration and that discrepancies should be reported right away.
Medication Administration Error and Controlled Drug Discrepancy
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors and failed to report drug errors to the resident’s physician in a timely manner and record them in the resident’s record. Resident #91 had diagnoses that included schizoaffective disorder, bipolar type, epilepsy, anxiety, and depression disorder, and the annual MDS reflected severely impaired cognitive skills for daily decision making. The care plan identified the resident’s need for antianxiety medication as ordered by the physician. Record review showed orders for Ativan 1 mg by mouth three times daily and a separate PRN Ativan 1 mg order for anxiety/irritability. The controlled medication record and MAR showed that RN A administered 0.5 mg doses instead of the ordered 1 mg dose on multiple occasions, including several administrations across late April and May, totaling 10 doses documented as given at the wrong dose. During interview, RN A stated he gave 0.5 mg tablets from the PRN blister pack rather than the blister pack containing the 1 mg medication and said he was not sure when the dosage had changed. He also stated that giving the wrong dose could be considered a medication error. The resident was observed on the day of survey trying to get out of bed and could not comprehensibly respond to questions about medication administration or her condition. The Psych NP stated that if nurses gave Ativan without an active order, it would be a medication error, and that giving 0.5 mg instead of 1 mg could mean the resident was not receiving needed treatment. The DON, ADON, and ADM stated that staff were responsible for following the physician order, counting controlled medications at shift change, and using a red sticker to identify medication changes, and they acknowledged that incorrect dosing and discrepancies were medication errors.
Food Storage, Labeling, and Hair Restraint Failures in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen reviewed for food and nutrition services. During the initial kitchen tour, surveyors observed multiple food items that were not properly sealed, labeled, or dated in the reach-in refrigerator, dry pantry, walk-in refrigerator, and walk-in freezer. These included cups of liquid in the reach-in refrigerator, hamburger buns, bread, flour tortillas, cereal containers, and an unidentified frozen meat item. Several items in storage were also expired or spoiled, including corn tortillas past the best-by date, salad mix that was open and exposed to air, sandwiches that were not sealed, lettuce with black spoilage, cilantro, an unlabeled coleslaw mix, open milk past the best-by date, and unopened heavy cream past the use-by date. Surveyors also observed food service staff and individuals entering the kitchen without proper hair restraints. One staff member wore a beard cover that did not cover his mustache, and another wore a hairnet that did not fully cover her hair around the forehead and neck. The dietary administrator, registered dietitian, and director of maintenance each stated that food should be labeled, dated, sealed, and discarded when expired, and that hairnets and beard guards should cover all visible hair. The milk delivery driver was also observed entering the kitchen multiple times wearing a hoodie, with a visible beard and goatee, and no hairnet. Additional observations showed food items still in use after their dates, including fresh apples on the lunch test tray and finished lunch trays with empty apple packs bearing the same date. A later kitchen observation found meat and cheese sandwiches and peanut butter and jelly sandwiches in the reach-in refrigerator that were not labeled or dated. Review of the facility’s monthly quality monitor reports and kitchen in-service trainings showed repeated concerns with food items not being covered, labeled, dated, or expired, and the facility policies required opened and bulk items to be tightly covered, labeled, and dated, with hair restraints worn to keep hair from food and food-contact surfaces.
Call Light Left Out of Reach
Penalty
Summary
The facility failed to ensure Resident #179 had her call light within reach. Resident #179 was admitted with diagnoses including diabetes mellitus, muscle wasting, age-related physical disabilities, and cerebrovascular accident with left-sided paralysis. Her care plan identified her as high risk for falls related to stroke, impaired balance, and impaired coordination, and included interventions to keep the call light within reach and encourage her to use it for assistance. Her MDS reflected a BIMS score of 14, indicating she was cognitively intact, and she required substantial to maximal assistance with personal hygiene and dressing. During observation, Resident #179 was sitting upright in her wheelchair with her bedside table in front of her, while the call light was located on the bed behind her and out of reach. She stated she could not reach it and said she would eventually get help because she could holler if needed. A later observation showed the call light remained clipped to the bed and still out of reach. An MA stated the resident could not reach the call light when it was on the far side of the bed and that it was supposed to be attached to the resident's wheelchair. The DON and ADM stated call lights were expected to remain within residents' reach at all times and that all staff were responsible for ensuring accessibility.
Improper Email Disclosure of Resident PII
Penalty
Summary
The facility failed to keep Resident #40’s personal and medical records private and confidential when the AMD emailed a PEME request form containing the resident’s full name, date of birth, Social Security number, and personal income information to the RP of another facility resident. The report states that the email was sent on 03/27/2026 and that the body of the message only said, “LET ME KNOW IF I DID IT RIGHT,” with the resident’s information contained in the attached document. Resident #40 was a [AGE]-year-old female admitted to the facility with diagnoses including high blood pressure, non-Alzheimer’s dementia, anxiety, lack of coordination, altered mental status, and restlessness and agitation. Her MDS reflected a BIMS score of 08, indicating moderately impaired cognition, and her care plan stated that she was dependent on staff for meeting emotional, intellectual, physical, and social needs and needed assistance and reminders to activities. During the investigation, a confidential interviewee stated that the email came from the facility where their family member lived and that they opened the attachment to determine what it was about, which revealed Resident #40’s PII. The AMD stated the PEME form was used to reapply a resident for Medicaid and verified that Resident #40 was one of three residents for whom the form had recently been used. The ADM stated the facility did not have a HIPAA policy, though staff were trained in privacy and confidentiality during onboarding, and the facility’s HIPAA guidance described individually identifiable health information as including name, address, birth date, and Social Security number.
Resident Kept Vape in Room Despite Smoking Policy
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for one resident who was identified as a smoker. Resident #29 had diagnoses including hypertension, seizure disorder, bipolar disorder, schizophrenia, lack of coordination, and allergic eczema, and his BIMS score was 12, indicating moderately impaired cognition. His care plan stated that he was PASRR positive for severe mental illness, was an e-cigarette smoker, would not smoke without supervision, and required supervision while smoking. His smoking/tobacco acknowledgement also stated that all tobacco products, including vapes, lighters, and matches, were to be kept by facility staff and were not to be kept in residents’ rooms or on their person. During observation, Resident #29 was seen standing at his dresser, blowing smoke from his mouth, and quickly placing something into the top drawer of the dresser. When asked, he stated it was nothing and shook his head yes when asked if staff had informed him of the smoking policy, adding that staff said it was okay for him to vape in his room. Shortly afterward, staff brought him to his room, and he retrieved a vape from the top dresser drawer and handed it to the SW. The SW then informed him of the facility’s smoking rules and stated the vape would be placed in his smoking box. Interviews with facility staff showed that residents were not permitted to keep vapes in their rooms and that such items were supposed to be secured by staff. The AD stated Resident #29’s vape should have been in the secured smoking box, and the DON and ADM stated that smoking materials were not permitted in resident rooms and were expected to be turned in to staff for secure storage. The facility policy stated that smoking was prohibited except in designated areas, that e-cigarettes could catch fire or explode if not handled and stored safely, and that smoking materials were to be maintained by nursing staff.
Infection Control Failures With Hand Hygiene and Isolation Precautions
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 2 residents reviewed for infection control. One deficiency involved a CNA who provided incontinent care to a resident with bowel and bladder incontinence and, after cleansing the resident’s perineal area and buttocks, changed gloves but did not cleanse her hands with soap and water or alcohol-based hand sanitizer before donning a new pair of gloves and continuing care. The CNA stated she had been trained to cleanse her hands after removing gloves and acknowledged she had forgotten to do so. The second deficiency involved a resident with severe cognitive impairment, hospice services, and a new rash with fluid- or pus-filled blisters on the abdomen, chest, and under both breasts. The resident’s record reflected suspected chickenpox, and the care plan identified active chickenpox and contact isolation. The room had a contact precautions sign posted, gloves and gowns available at the door, and a stop sign directing staff to see the nurse before entering. The facility’s documentation also reflected antiviral treatment and ongoing contact precautions while the diagnosis was being evaluated. Surveyor review of CDC guidance showed that suspected or known chickenpox requires airborne precautions and use of a fit-tested N95 or higher-level respirator. The DON stated that if chickenpox was suspected, the proper precautions should have been followed, and the NP stated that the facility should have been using contact and airborne precautions with masks worn in the resident’s room. The facility’s infection prevention and hand hygiene policies stated that transmission-based precautions should follow current CDC guidelines and that hand hygiene must be performed before donning gloves and immediately after removing them.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident’s medical records to the resident’s representative within the required timeframe after a request was made. The resident was an elderly male with multiple significant diagnoses, including atherosclerosis of native arteries of extremities, severe protein-calorie malnutrition, gastrostomy status, type 2 diabetes mellitus with unspecified complication, Parkinson’s disease without dyskinesia, and dementia. His admission MDS showed a BIMS score of 4, indicating severe cognitive impairment, and his care plan documented ADL self-care deficits related to dementia and impaired cognitive function. The face sheet identified a responsible party (RP), who was the same individual requesting the records. On 03/31/2026, the RP completed a medical record request form seeking a broad set of documents, including the history and physical, MARs, chest X-ray report, discharge and transfer summaries, lab data, and PT/OT/ST records. The form itself stated that the information was required for optimal continuing care. The RP wanted the records before or on the day of the resident’s discharge so they could be used for follow-up with the primary care provider. The resident was discharged on 04/03/2026, but the records were not provided by that time. The Medical Records staff did not forward the request to the corporate legal department until 04/06/2026, six days after the request and three days after discharge, stating she believed she was still within a seven-day window and attributing the delay to being busy. Interviews showed that the facility’s process required a written request form, review by the Administrator, and then submission to the corporate legal department before any records could be released. The Administrator reported that he spoke with the RP the day after she requested records, offered to review the medication list with her on the computer, and stated that legal had to approve any release. He also stated the request was ultimately denied because the RP was not the POA. The RP, however, stated she was not initially told she needed to complete a request form and only learned this about a week later from a nurse. As of 04/15/2026, the Medical Records staff reported that the family still had not received the records because corporate had not authorized release, and as of 04/17/2026, the RP confirmed she still had not received the requested records. The facility’s written policy required all medical record requests to be cleared through the Legal Department and prohibited release of records until legal authorization was obtained, contributing to the delay and failure to provide the records within two working days of the request.
Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegation was made, as required by regulation. Specifically, an incident occurred involving two residents in which one resident threw cold coffee at another, and the second resident responded by hitting the first, resulting in a bruise beneath the eye and a scratch on the arm of the first resident. Despite staff recognizing the incident as a resident-to-resident altercation and a form of abuse, the event was not reported to the state survey agency as required. The first resident involved had a history of Parkinson's Disease, schizoaffective disorder, and bipolar disorder, but was assessed as having no cognitive impairment. The second resident had severe cognitive impairment due to dementia and a history of physical aggression. After the altercation, staff immediately separated the residents, assessed them for injuries, and initiated neuro checks for the resident who sustained a facial bruise. Both residents were interviewed and assessed for pain and psychological distress, with the first resident reporting ongoing pain in the face but no distress at the time of assessment. Multiple staff members, including RNs and LVNs, acknowledged in interviews that the incident constituted abuse and that it was their practice to report such events to the administrator. However, the administrator did not report the incident to the state survey agency, stating that he did not consider the event to be abuse or neglect because the injury did not require first aid and the resident did not appear distressed. This failure to report the incident as required by state law and facility policy constituted a deficiency in the facility's abuse reporting procedures.
Failure to Knock Before Entering Resident Rooms Compromises Resident Dignity
Penalty
Summary
Staff at the facility failed to consistently honor residents' rights to privacy and dignity by not knocking before entering residents' rooms. Specifically, a CNA was observed entering a male resident's room without knocking, and an LVN was observed entering the rooms of two female residents without knocking. These actions were directly witnessed by surveyors during their rounds in the facility. The residents involved had varying degrees of cognitive and physical impairment. One male resident had moderate cognitive impairment and multiple chronic conditions, including pneumonia, diabetes, and end-stage renal disease. One female resident had intact cognitive function and several chronic illnesses such as diabetes, heart failure, and anxiety. The other female resident had severe cognitive impairment and diagnoses including chronic pain, diabetes, and epilepsy. One of the residents interviewed expressed that staff do not knock on her door and that this upsets her, as she would prefer staff to always knock before entering. Interviews with staff, including the CNA, LVN, DON, and Administrator, confirmed that all had been trained on the policy requiring staff to knock, introduce themselves, and wait for a response before entering a resident's room, except in emergencies. Staff acknowledged the importance of this practice for resident privacy and dignity, and stated that management monitors compliance through observation. Despite this, staff admitted to forgetting to knock, even when the door was open, and were unaware at the time that they had failed to follow the policy.
Failure to Follow Posted Menus and Document Substitutions
Penalty
Summary
The facility failed to ensure that meals served to residents matched the posted menus and met the nutritional needs of residents according to established national guidelines. During two observed meal services, the food items served did not correspond with the posted menus. For lunch, residents were served two fried chicken patties instead of chicken piccata, and for dinner, plain ham and white potatoes with cheese were served instead of maple glazed ham and sweet potatoes. Only one substitution was documented, despite multiple menu changes, and the posted menus were not updated to reflect these changes. Interviews with facility staff revealed that the Food Service Supervisor (FSS) frequently made changes to the corporate menu to accommodate resident preferences but did not update the posted menus or consistently document substitutions. The FSS stated that residents did not complain about the changes and that he attended resident council meetings to gauge preferences, but did not keep formal records beyond tray tickets. The DON and ADM both confirmed that posted menus should accurately reflect what is served and that all changes should be approved by the dietitian, as per facility policy. Review of the substitution policy indicated that documentation and dietitian approval are required for all menu changes, which was not consistently followed.
Failure to Provide Palatable, Attractive, and Properly Tempered Food
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. Multiple meal test trays observed on three separate days were found to be at inappropriate temperatures, with food that was unappetizing in appearance, lacked seasoning, and was overcooked or otherwise poorly prepared. Observations included food items that were hard, bland, or had flavors that transferred between items, and pureed meals where foods ran together, making them unappealing and difficult to eat. Residents consistently reported dissatisfaction with the quality, temperature, and taste of the food, and noted that menu items often did not match what was actually served. Several residents with complex medical histories, including severe cognitive impairment, intellectual disabilities, and chronic health conditions, were affected by these deficiencies. Interviews with these residents revealed ongoing complaints about cold food, lack of preferred alternatives, and poor meal quality. Resident council notes and grievance records from the previous three months documented repeated complaints about the food, including issues with menu substitutions, dietary restrictions not being honored, and a lack of fresh fruits and vegetables. Residents also reported that meals were often served late, and that food sometimes sat in the hallways for extended periods before being delivered, contributing to the temperature and quality issues. Staff interviews confirmed that food was not routinely checked with a thermometer for appropriate temperature, but rather assessed by touch. The Food Service Supervisor acknowledged awareness of the complaints and stated that grievances were reviewed but did not result in changes to the corporate-set menu. Nursing and dietary staff described processes for offering alternatives and encouraging residents to eat, but also indicated that food quality and menu adherence were ongoing concerns. Facility policies required timely meal service and cooperation between nursing and dietary departments, but observations and interviews indicated these procedures were not consistently followed, resulting in residents receiving food that was not palatable, attractive, or at the proper temperature.
Deficiencies in Food Service Sanitation and Safety Practices
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service operations, including improper storage, preparation, distribution, and serving of food. Observations revealed unknown food items on the pantry floor, dust and dirt in the walk-in fridge, and a box labeled Butcher Box Pork with red liquid on top. The microwave was found with red splatters inside, and shelving units in the walk-in fridge were rusted and propped up with wood blocks. Food and cooking oil debris were present on the floor and behind kitchen equipment, and the dishwasher failed to reach the required hot water temperature, only reaching 112 degrees Fahrenheit. Additionally, a dietary aide was observed eating in the kitchen production area, contrary to facility policy. Interviews with staff indicated a lack of knowledge regarding proper dishwasher operation and uncertainty about when broken shelves would be replaced. The Food Service Supervisor (FSS) acknowledged that cleaning behind ovens was infrequent due to equipment constraints and that staff were expected to follow a cleaning schedule. The Director of Nursing and Administrator both stated that the FSS was responsible for ensuring compliance with food safety and sanitation regulations. Facility policy requires all kitchen areas and equipment to be kept clean and in good repair, but these standards were not met as evidenced by the observations and staff interviews.
Failure to Ensure Accessible Call Light System for Residents
Penalty
Summary
The facility failed to ensure that a working call system was available and within reach for residents in their bedside, toilet, and bathing areas, as required. Observations revealed that three residents did not have accessible call lights: one resident's call light was found on the floor at the foot of the bed, another's was on a roommate's bedside table and not within reach, and a third resident's call light was clipped to a light fixture approximately 40 feet above the bed, making it inaccessible. These findings were corroborated by interviews and direct observation. The affected residents had significant medical and functional needs. One resident had a history of stroke, vascular dementia, and required assistance with all activities of daily living, using a wheelchair for mobility. Another resident had diagnoses including muscle wasting, lack of coordination, severe intellectual disability, and was also dependent on staff for daily care. The third resident had Parkinson's disease, dementia, and was similarly dependent on staff. Care plans for all three residents specified that call lights should be within reach and that staff should encourage their use for assistance. Interviews with staff, including CNAs, an LVN, the DON, and the administrator, confirmed that they were trained on the policy requiring call lights to be within reach and acknowledged responsibility for ensuring this. Staff stated that call lights should be checked during rounds and placed on the resident's non-paralyzed side if applicable. Despite this, staff were unable to explain why the call lights were not accessible at the time of the survey, and residents reported being unable to call for help when needed.
Failure to Update Care Plan for Bed Rail Use
Penalty
Summary
The facility failed to revise and update the care plan for one resident to reflect the use of bed rails as an assistive device. The resident, an older female with diagnoses including unspecified dementia without behavioral disturbances, muscle wasting and atrophy, unsteadiness on feet, and cognitive communication deficit, was observed using bed rails to assist with mobility in bed. Her most recent care plan did not mention the use of bed rails, and there was no documented bedrail assessment in her medical records. Interviews with the resident confirmed her use of the bed rails for assistance, and she demonstrated how she used them to adjust her position and get out of bed. Staff interviews revealed that the RN was aware of the resident's use of bed rails but did not realize it was not included in the care plan. The DON stated that bed rails should be care planned and that a bedrail assessment should be completed, with proper documentation and consent. The administrator also confirmed that bed rails should be included in the care plan if used as assistive devices. Despite an audit and training on physical device assessments, the resident's use of bed rails was not identified or documented in her care plan, contrary to facility policy.
Failure to Respond to Malfunctioning Oxygen Equipment
Penalty
Summary
A deficiency occurred when a resident with Parkinson's disease and dementia, who was followed by hospice and had a PRN order for oxygen, experienced a malfunction with his oxygen concentrator. The device was observed to be beeping loudly with a red warning light for approximately 45 minutes, indicating a malfunction. The concentrator was also found wrapped in plastic, which covered the vents and caused the device to overheat. Despite the noise, staff did not respond until alerted by a surveyor. Upon investigation, the LVN confirmed the malfunction, noted the oxygen concentration was lower than ordered, and identified the overheating due to the plastic wrap. Interviews revealed that staff on the hallway, including a medication aide, did not notice or respond to the beeping, and other residents reported the noise had persisted for a significant period while staff passed by. The ADON and DON both acknowledged that staff should promptly investigate such alarms, as they indicate equipment issues. The facility was unable to provide a specific policy addressing this situation, instead providing a general Quality Assessment and Assurance Committee policy, which was not applicable.
Failure to Implement and Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for three residents reviewed for infection control. In one instance, a nurse did not change gloves or perform hand hygiene after cleansing a resident's left heel wound and before applying wound treatment and a clean dressing. The nurse acknowledged not following proper hand hygiene protocol and stated she had received training but could not recall when. The Director of Nursing (DON) and Administrator confirmed that facility policy requires hand hygiene and glove changes during wound care, and that failure to do so could result in the spread of microorganisms to residents. Additionally, the facility did not post Enhanced Barrier Protection (EBP) signage on the doors of two residents who were admitted with a wound and a suprapubic catheter, respectively. Observations confirmed the absence of EBP signage, which is required to inform staff of necessary infection control precautions. Interviews with staff, including the Assistant Director of Nursing (ADON) and Infection Control Staff (ICS), confirmed that EBP signage should be posted immediately upon admission for residents with wounds or indwelling medical devices. Furthermore, a nurse was observed providing care for a resident's suprapubic catheter without wearing the required gown, and there was no EBP signage on the resident's door. The nurse admitted to not wearing the appropriate PPE and acknowledged the importance of following EBP requirements. Facility policy and staff interviews confirmed that gowns and gloves are required for high-contact care activities involving wounds or indwelling devices, and that failure to follow these protocols could expose residents to infection.
Failure to Obtain and Document Medication Consents
Penalty
Summary
The facility failed to act upon the pharmacist's drug regimen review irregularity reports for two residents, leading to deficiencies in obtaining and documenting medication consents. For Resident #1, the facility did not respond to the pharmacist's notification that the consent for Trazodone, an antidepressant and sedative medication, was missing. Despite having an unsigned written consent from the resident's responsible party (RP), the medication was administered without the necessary signed consent being obtained and uploaded into the resident's electronic health records. Similarly, for Resident #2, the facility did not address the pharmacist's notification regarding the missing consent for Lorazepam, a medication used to treat anxiety. The consent form was incomplete, with both the resident and the RP having printed their names but not signing the document. Although the medication order was completed, the facility failed to ensure the consent was properly signed and documented. Interviews with facility staff, including the Nurse Practitioner (NP) and the Assistant Director of Nursing (ADON), revealed that there were clear expectations for obtaining signed consents for medications. The ADON emphasized the importance of having consents signed by the resident or their RP to authorize treatment. However, the facility's oversight in ensuring these consents were completed and documented led to the identified deficiencies.
Failure to Protect Resident from Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from abuse, specifically a physical assault by a hospitality aide. The incident involved a resident with a complex medical history, including schizoaffective disorder, profound intellectual disabilities, and other chronic conditions. The resident was found crying with a red mark on her thigh, which was reported by a scheduler CNA who heard the incident and intervened by removing the aide from the room and reporting the event to the abuse coordinator and charge nurse. The resident's care plan indicated she required extensive assistance with activities of daily living and was noncompliant with her medical regimen, often resisting care. On the day of the incident, the resident was reportedly agitated during incontinence care, likely due to being awakened. Despite encouragement from staff, she declined assistance. A subsequent assessment by the DON found no signs of distress, and the resident's demeanor was described as excited and usual. The facility's policy on abuse, neglect, and exploitation required ongoing staff training and oversight, but the personnel file of the involved aide lacked records of such training. The facility's in-service logs showed various training sessions on abuse and resident behavior, but the incident highlighted a lapse in preventing abuse, as the aide was suspended and later terminated following the investigation.
Failure to Report Abuse Allegation
Penalty
Summary
The facility failed to report an abuse allegation involving Resident #1 and Resident #2 to the State Agency within the required timeframe. Resident #1, who has diagnoses including unspecified dementia and bipolar disorder, reported being hit by Resident #2 in the dining room. The incident resulted in Resident #1 sustaining skin tears and bleeding on his right forearm and upper arm. Despite the severity of the incident, the facility did not report it to the State Agency as required by their policy and federal regulations. Resident #1's medical records indicated he was moderately impaired with decision-making and required assistance with eating. On the day of the incident, the Assistant Director of Nursing (ADON) documented that Resident #1 was upset and reported being assaulted by Resident #2. The ADON and Licensed Vocational Nurse (LVN) A both noted the injuries and provided immediate care, including dressing the wounds and administering pain medication. However, there was no documentation or evidence that the incident was reported to the State Agency or other appropriate authorities. Interviews with other residents and staff revealed that multiple witnesses observed the incident, and Resident #1 expressed a desire to report the incident to the police and the State Agency. Despite this, the Administrator (ADM) did not follow through with the reporting. The facility's policy clearly states that all suspected violations and substantiated incidents of abuse must be reported immediately, but this protocol was not followed in this case.
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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 Austin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Austin Wellness & Rehabilitation | 2.4 mi | ★★★★★ | 20 | 0 |
| Avir At Park Bend | 2.5 mi | ★★★★★ | 8 | 0 |
| Gracy Woods Nursing Center | 2.7 mi | — | 20 | 0 |
| Gracy Woods Ii Living Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Sage Park Austin | 3.3 mi | ★★★★★ | 0 | 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 August 2026) and official state health department websites.