Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Windsor Nursing And Rehabilitation Center Of Edinb during CMS and state inspections, most recent first.
A resident with dementia, diabetes, a history of falls, and impaired balance had an unwitnessed fall found by CNAs with no injury or pain noted, but the event was not documented in the nursing notes, incident log, assessment record, or EMR, and the MD was not notified. Staff interviews confirmed the fall occurred and that the LPN assessed the resident and returned her to bed, while the DON stated all falls had to be reported to the physician.
A resident with dementia, impaired balance, and a fall history sustained an acute L humeral head/neck fracture after a fall. Although the resident was discharged with a sling to the L arm, the care plan did not include the sling order or the resident’s noncompliance with sling use. Staff interviews showed the sling should have been care planned, but the order was not entered into the chart and the MDS RN did not review the discharge paperwork.
Unlocked Medication Cart Left Unattended: The B hall nurse's medication cart was observed left unlocked and unattended at the nurse's station with the keys attached to the lock. RN A stated he was responsible for the cart and should have locked it when he walked away, but he left it unlocked while showing a coworker something. The DON stated staff were expected to lock medication carts when not in use, and the facility policy said the cart is locked at all times when not in use.
A resident with dementia, falls, and impaired balance sustained a left humeral fracture after being found on the floor. Hospital discharge paperwork stated the resident was sent back with a sling to the left arm, but the sling order was not entered into the chart and was not reflected in the care plan. Nursing notes showed the sling was not on arrival back from the hospital, EMS said it had been removed during transport, and the nurse reapplied it. The MDS RN said he did not see the order in the EMR and had not reviewed the discharge paperwork, and the DON stated the sling should have been care planned and ordered.
Food storage and hand hygiene lapses were observed in the kitchen. Multiple items in dry storage, the refrigerator, and the freezer were not labeled or dated, and a cook was seen preparing fruit cocktail cups without gloves after leaving the prep area and not washing hands. The cook acknowledged the missed hand hygiene and glove use, and the DM stated that opened items should be labeled and dated.
Incomplete Physician Orders and Medical Record Documentation: The facility failed to keep accurate records for three residents by not documenting physician orders for IV access and IV maintenance for two residents and contact precautions for another resident. One resident had IV antibiotics without current orders for IV access, flushes, or dressing changes, another had an IV lock in place with no documented IV insertion or maintenance orders, and a third had scabies prophylaxis with contact precautions used in practice but no corresponding order in the chart. Staff and the DON acknowledged the missing orders.
A resident with dementia, severe cognitive impairment, and limited mobility was placed in a room with a door handle that locked from the outside. Surveyors found the door locked and had to get Maintenance to unlock it, while multiple CNAs, LPNs, and an RN said they did not know the handle was different and had only seen the door kept open or cracked open. The DON and Administrator said the room was kept open, and Maintenance said he did not notify staff that the handle had a lock.
Indwelling Catheter Lacked Securement Device: A resident with an indwelling catheter was observed during catheter care with the tubing not secured by a securement device. CNA stated a strap had been applied earlier by the nurse, while an LVN and the DON said nurses were responsible for ensuring catheter securement was in place for residents with Foley catheters. The resident’s record showed an indwelling catheter, related care plan interventions, and a Foley order, and the administrator stated there was no policy on Foley catheters.
IV Dressings Not Labeled Two residents receiving IV therapy had peripheral IV dressings that were not dated or initialed. One resident with cancer diagnoses and moderate cognitive impairment had an unlabeled left forearm IV site with tape coming off and dried blood under the dressing on repeated observations. Another resident with fractures, malnutrition, depression, dysphagia, and severe cognitive impairment had a transparent dressing over a left hand IV lock with no date or initials. Staff stated the nurse who inserted the IV was responsible for labeling the dressing, and the DON confirmed the dressing should have been dated and initialed.
A facility failed to ensure physician orders were documented for IV access and IV maintenance for two residents receiving IV therapy, including one resident with bladder and liver cancer and another resident with an IV lock already in place. The record also lacked a contact precautions order for a resident receiving permethrin for prophylactic scabies, even though a contact precaution sign and PPE were present at the room door. Staff confirmed the missing orders were not found in the electronic record.
Infection control failures were observed when staff entered rooms under contact precautions without the required PPE, including a maintenance worker, an RN/ADON, and a housekeeper. The affected residents had scabies-related contact precautions or suspected scabies, and PPE was available outside the rooms. The report also noted two residents with IV sites that were not dated or labeled, with one dressing showing tape lifting and dried blood under the transparent cover.
A resident with Alzheimer's and a history of removing his peg tube did not have a comprehensive care plan addressing this behavior, leading to two hospitalizations for reinsertion. Despite family-provided monitoring and the use of an abdominal binder, the facility failed to document specific interventions in the care plan.
The facility failed to ensure that expired medications were not stored with non-expired ones in the main medication storage room. Expired IV antibiotics, including Aztreonam and Azithromycin, were found alongside non-expired medications, posing a risk of administration errors. Staff interviews revealed inadequate procedures for handling expired medications, and the facility's policy on storage was incomplete.
A resident with severe cognitive and physical impairments was not provided with a padded call light as required by their care plan. Observations showed the resident unable to use the standard call light due to physical limitations. Staff interviews confirmed the resident's inability to use the call light, necessitating frequent checks. The care plan was not updated to reflect the resident's needs, contrary to the facility's policy on accommodating unique resident needs.
A resident's care plan failed to accurately reflect the need for consistent two-person assistance for ADLs, despite severe cognitive impairment and multiple health conditions. Staff relied on personal judgment without formal training, leading to potential inconsistencies in care. The facility's policy required measurable objectives, but the care plan's ambiguity highlighted a gap in adherence.
Two residents were administered antipsychotic medications without appropriate diagnoses, contrary to facility policy. One resident received Risperidone for dementia without behavioral disturbances, while another was given Lurasidone for unspecified dementia. Interviews with staff, including an LVN, ADON, and DON, confirmed the medications were used to manage behaviors rather than for a diagnosed condition. The facility's policy requires psychotropic drugs to be given only when necessary for a specific condition.
Failure to Notify Physician and Resident Representative After Fall
Penalty
Summary
The facility failed to immediately inform the resident, consult with the resident’s physician, and notify the resident’s representative when there was a significant change in the resident’s status after a fall. Resident #1 was an elderly female with diagnoses including type 2 diabetes mellitus, dementia, history of falling, and impaired balance. Her quarterly MDS showed a BIMS of 3 and severe cognitive impairment, and her care plan identified her as at risk for falls related to impaired balance, confusion, and self-transfers. Record review showed no nursing note, incident/accident log entry, assessment, or electronic medical record documentation for a fall around midnight on 06/17/26. During interviews, CNA C, CNA D, and CNA E each stated that Resident #1 had an unwitnessed fall around midnight, was found on the floor mat next to her bed, and was assessed by LVN B with no injury or pain noted before being placed back in bed. They also stated that LVN B was notified of the fall. The NP later stated she was notified only of the later fall at 5:30 a.m. that resulted in a shoulder fracture and was not aware of the earlier fall. The DON stated it was the charge nurse’s responsibility to notify the physician about a fall and that all falls had to be reported to the physician. The DON also stated she was not aware that Resident #1 had fallen twice on 06/17/26 and was not aware that LVN B had not notified the physician of the earlier fall. The facility policy titled Notification of Changes stated the facility promptly informs the resident, consults the resident’s physician, and notifies the resident’s representative when there is a change requiring notification.
Care Plan Did Not Include Sling Order or Noncompliance
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with dementia, impaired balance, and a history of falls. The resident’s care plan addressed fall risk and included interventions such as reviewing past falls, x-rays, neuro checks, wedges, and transfer to the emergency room, with a goal that the resident would resume usual activities without further incident. However, the care plan did not include the resident’s sling order or the resident’s noncompliance with use of the sling after an acute fracture to the left humeral head/neck. Record review showed the resident fell while in bed and was found on the floor next to the roommate’s bed with skin tears to the left elbow and minor swelling to the left shoulder. Imaging showed an acute fracture of the left humeral head/neck, and the resident was discharged from the hospital with a sling to the left arm. Nursing documentation later noted that the sling was not applied upon return from the hospital and that EMS stated the resident had removed the sling during transport; the nurse reapplied it. The resident’s care plan did not reflect the sling order or the resident’s refusal/noncompliance with sling use. Interviews showed staff awareness that the sling should have been included in the care plan. An LVN stated the sling had to be care planned and added as an order, and the NP stated the sling was supposed to be care planned. The MDS RN stated he was not aware of the sling order because it was not entered into the electronic chart and said he relied on nurses to input orders and did not review the discharge paperwork. The DON stated the resident did not want to use the sling and acknowledged that the sling was supposed to be care planned and that orders should have been put in place for its use.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles when the B hall medication cart was left unlocked and unattended. During an observation on 7/1/26 at 2:48 p.m., the B Wing Hall nurse's medication cart was observed left unlocked and unattended against the nurse's station, with the keys attached to the lock. RN A stated he was responsible for the cart and was expected to lock it when walking away from it, but he had left it unlocked because he had only gone to show a coworker something. During an interview on 7/3/26 at 4:27 p.m., the DON stated that numerous staff, including herself and the ADON, were responsible for ensuring medication carts were locked and that staff were expected to lock the cart when they walked away from it. The DON also stated that a resident or visitor could grab medication from the cart and it could harm them. Review of the facility's Medication Administration policy, revised 10/01/2019, stated that the mobile medication cart is used to facilitate administration of medications and that the medication cart is locked at all times when not in use.
Incomplete documentation of hospital discharge sling order
Penalty
Summary
The facility failed to maintain Resident #1’s clinical record in a complete and accurate manner when it did not add a physician’s order for a sling to the resident’s left arm after the resident returned from the hospital. Resident #1 was an elderly female with diagnoses including type 2 diabetes mellitus, dementia, history of falling, and impaired balance. Her quarterly MDS showed severely impaired cognition with a BIMS of 3, and her care plan addressed falls related to poor balance and confusion. On 06/17/26, nursing documentation stated the resident was found on the floor beside her roommate’s bed, with skin tears to the left elbow and minor swelling to the left shoulder. Imaging later showed an acute fracture of the left humeral head/neck. Hospital discharge records stated the resident was discharged with a sling to the left arm. When the resident returned from the hospital, nursing documentation noted the sling was not applied on arrival, EMS stated the resident had removed it during transport, and the nurse reapplied it. However, the sling order was not entered into the electronic medical record. During interview, the MDS RN stated all nurses were responsible for entering new orders and said he was not aware of the sling order because it was not in the chart. He also stated he was responsible for updating the care plan and had not reviewed the discharge paperwork. The DON stated nurses were responsible for updating the care plan and said the sling should have been care planned and orders should have been put in place for its use. The facility policy stated the medical record must contain an accurate representation of the resident’s actual experiences and include complete, accurate, and timely documentation.
Food Storage and Hand Hygiene Lapses in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed. On 08/26/2025, observation of the kitchen counter showed 2 jars of spices that were not labeled or dated, 1 jar of spice with the date smeared off, a metal container with individually wrapped rolls that was not labeled or dated, and a tray of covered juice cups that was not labeled or dated. Observation of the walk-in refrigerator showed 1 bag of cabbages that was not labeled or dated. Observation of the walk-in freezer showed 2 bags of hotdog buns that were not labeled or dated. During an observation and interview on 08/26/2025, the cook was seen filling plastic cups with fruit cocktail and covering them with cellophane wrap while not wearing gloves. The cook stated he had gone to his vehicle to get his name tag but forgot to wash his hands and put on gloves before preparing food. The cook stated it was important to wash hands and wear gloves while preparing meals because it could have contaminated the food and made residents sick. The DM stated all staff were responsible for ensuring items were stored, labeled, and dated, and that every opened item should have an open date in the refrigerator, freezer, and dry storage. The DM also stated that if staff had not washed their hands or worn gloves, it would have caused cross contamination and food borne illnesses and could make residents sick.
Incomplete Physician Orders and Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for three residents by not having complete physician orders documented for IV access, IV maintenance, and contact precautions. The report states that Resident #34 had an order for Aztreonam IV for bacterial infection, but the order summary did not reflect an order for IV access, IV flushes, or dressing changes. During interview, an LVN stated she had been flushing the IV with normal saline and had redressed the site based on previous orders, but she could not find current orders for IV access or maintenance in the order summary. Resident #10 was observed with a peripheral IV lock in place on the left hand, and the site had a transparent dressing with no signs of infection or infiltration. Record review showed an order for IV hydration, but the order summary lacked evidence of orders for IV insertion, IV dressing changes, and IV flushes. The nurse stated it was the nurse’s responsibility to obtain IV site care or maintenance orders when receiving physician orders, and the DON later stated there were no other orders pertaining to the IV care and that if the order was not in the system, then the order was not there. Resident #51 had an order for Permethrin cream for prophylactic scabies, and the room had a contact precaution sign and PPE outside the door. However, the order summary did not reflect contact precautions for scabies. The LVN stated the resident was on contact precautions for prophylactic scabies and that it was important to have the order in the point click center for staff awareness. The DON stated she was not able to find the order for contact precautions and said the resident was not harmed because the order was not in the point click center.
Locked Resident Room Door Not Recognized by Staff
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices to prevent accidents for one resident with severe cognitive impairment. The resident’s record showed a diagnosis of dementia, a BIMS score of 06, limited physical mobility, and a care plan indicating he was non-weight bearing and required assistance by one staff for locomotion using a wheelchair as needed. He was moved into room [ROOM NUMBER] during a period of contact precautions, and staff later reported that his door was kept open or cracked open during the day and night so they could hear and monitor him. During observation, surveyors attempted to enter the resident’s room and found the door locked from the outside. The surveyor had to ask an LVN to open it, and Maintenance A unlocked the door within about a minute and a half. The LVN stated he did not know the door handle had a lock. The resident was found lying in bed, covered, and said he was fine; the call light was within reach and he demonstrated how to use it. Maintenance A then changed the door handle after the observation. Interviews showed that multiple staff members were unaware the room’s door handle was different from the others and could lock from the outside. Maintenance A said the room was a showroom with a lock/key system and that he did not notify staff that the handle differed from the regular handles. Several nurses and CNAs stated they had seen the door open or cracked open during their shifts and did not know the handle locked from the outside. The DON and Administrator also stated the door was kept open or cracked open, and the Administrator said the facility did not have any policies for locks.
Indwelling Catheter Lacked Securement Device
Penalty
Summary
The facility failed to ensure a resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections when the resident’s catheter tubing was observed without a securement device. Resident #15 was a female admitted with diagnoses including type 2 diabetes, hypertension, and malfunction, dislodgement, and/or obstruction. Her care plan documented that she had an indwelling catheter and included an intervention to monitor that the collection bag was off the floor and hung below bladder level, and the physician’s orders included a Foley catheter order dated 8/18/25. During an observation on 8/27/25, the resident received catheter care and had an indwelling catheter present in a privacy bag, but the tubing was not secured with a securement device. CNA H stated that the resident had a strap applied earlier that morning by the nurse and that lack of a securement strap could cause harm or pain from pulling or the weight of the drainage bag. LVN K stated nurses were responsible for securement devices on residents with indwelling catheters and that residents should have a securement device to prevent dislodgement or trauma. The DON stated nurses were responsible for assessing residents with indwelling catheters to ensure a securement device was in place, that the charge nurse should assess it each shift, and that she expected every resident with an indwelling catheter to have a securement device. The administrator stated there was no policy on Foley catheters.
IV Dressings Not Dated or Initialed
Penalty
Summary
The facility failed to ensure parenteral care and services were administered consistent with professional standards of practice for 2 residents receiving IV therapy. For one resident with diagnoses including malignant neoplasm of the bladder, liver cancer, and displacement of a nephrostomy catheter, the care plan showed IV antibiotic therapy for sepsis and the resident had moderate cognitive impairment with a BIMS score of 12. On observation, the resident’s IV access in the left forearm was covered with a clear dressing that was not labeled, with tape coming off the sides and dried blood under the dressing. The same unlabeled IV site was observed again the next day with tape adhesive coming off and dried blood under the clear dressing. For the second resident, who had diagnoses including a right radius fracture, protein-calorie malnutrition, major depressive disorder, and dysphagia, the quarterly MDS showed severe cognitive impairment with a BIMS score of 2 and that the resident was receiving IV medications. The order summary showed IV dextrose hydration at 80 ml/hr for 2 days. During observation, the resident’s peripheral IV lock on the left hand was covered with a transparent dressing that had no date and no initials. The site showed no signs or symptoms of infection or infiltration at the time of observation. Interviews and record review showed staff awareness that IV dressings should be dated and initialed. An LVN stated the nurse who initiated the IV was responsible for labeling the dressing with the date and initials, and that the IV site should be checked each shift for signs of infection, the date and signature on the dressing, and the saline lock cap. The DON stated she did not know why the dressing label had not been dated and initialed, and confirmed the nurse who inserted the IV should have dated and initialed the dressing. The facility policy stated staff were responsible for following infection prevention and control policies, including safe injection and medication administration practices.
Missing Physician Orders for IV Care and Contact Precautions
Penalty
Summary
The facility failed to ensure physician orders were written, signed, and documented for required care for three residents. For one resident with bladder cancer, liver cancer, and a displaced nephrostomy catheter, the order summary showed an order for intravenous aztreonam, but it did not reflect an order for intravenous access or for intravenous maintenance such as flushes or dressing changes. Nursing staff stated they had been flushing the IV with normal saline and had redressed the site based on prior orders, but no current written orders were found in the record for IV access, flushing, or dressing change. For another resident, the August order summary showed an order for intravenous hydration, which indicated the resident already had an IV lock in place, but no orders were found showing the date, time, or location the IV lock was initially placed. No orders were found for maintenance of the IV lock, including flushes or IV lock replacements. On observation, the resident still had an IV lock in place, and the record still did not contain orders for IV access or IV maintenance for the site. For a third resident with prophylactic treatment for scabies, type 2 diabetes, and severe cognitive impairment, the MAR reflected permethrin cream for prophylactic scabies, and a contact precaution sign was observed at the room door with PPE outside the room. However, the order summary did not reflect contact precautions for scabies. Staff stated the resident was on contact precautions for prophylactic scabies and that the order needed to be in the electronic record for staff awareness, but the DON was unable to locate the order in the system.
Infection Control Failures With PPE Use and IV Site Labeling
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Surveyors observed multiple staff members entering resident rooms under contact precautions without donning PPE as ordered. Maintenance A entered a room for a resident with scabies contact precautions and worked on the door handle without putting on PPE. RN/ADON B entered another resident’s contact precaution room and delivered a meal tray without PPE. Housekeeper B was observed inside a third resident’s contact precaution room mopping while wearing gloves but no gown. The residents involved had diagnoses including dementia, Alzheimer’s disease, stroke with hemiplegia, and severe or moderate cognitive impairment, and their physician orders required contact precautions with gloves and disposable gowns available on entry. Resident #11 had physician orders for contact precautions due to scabies prophylaxis, with staff and visitors directed to follow contact precautions using gloves and disposable gowns. Resident #3 also had contact precautions ordered due to scabies, with PPE available outside the room. Resident #12 had contact precautions ordered due to suspected scabies, with gloves and disposable gowns available at the doorway. Despite these orders and posted signage, staff entered the rooms without the required PPE. During interviews, Maintenance A stated he believed PPE was not needed because he did not get near the resident. RN/ADON B stated he did not need PPE because he was not touching the resident and did not render care. Housekeeper B stated she had been told there was only one room where she had to wear a gown and was not sure why she had to wear one. The report also documented IV-related infection control issues for two residents. Resident #34 had an IV access in the left forearm with a clear dressing that was not labeled, with tape coming off and dried blood under the dressing on two observations. Resident #10 had a peripheral IV lock in the left hand covered with a transparent dressing that had no date or initials. Staff interviews confirmed the dressings were not labeled as expected, and one nurse stated the IV site should be checked each shift for signs of infection and that the dressing should be dated and signed. The DON stated the nurse who inserted the IV should have dated and initialed the dressing and acknowledged that failure to do so could allow the IV to remain beyond the recommended time and could cause infection.
Failure to Implement Comprehensive Care Plan for Resident with Peg Tube
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a history of removing his peg tube, which led to two hospitalizations for reinsertion. The resident, who has Alzheimer's Disease, chronic kidney disease, and other medical conditions, was admitted with a known behavior of removing his peg tube. Despite this, the care plan did not include specific interventions to address this behavior, even though the family had informed the facility about it upon admission. The resident's care plan only noted the need for tube feeding due to dysphagia, without addressing the behavior of peg tube removal. Interviews with facility staff revealed that the resident had removed his peg tube on two separate occasions, requiring hospital visits for reinsertion. The MDS nurse acknowledged the lack of specific interventions in the care plan and admitted responsibility for this oversight. The Director of Nursing (DON) mentioned that the family was providing monitoring through private pay sitters and family members taking turns staying with the resident, which was not documented in the care plan. Despite the use of an abdominal binder as a preventive measure, the facility did not document any interventions for the resident's behavior of removing the peg tube.
Expired Medications Found in Storage
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring that all medical supplies in the main medication storage room were within their expiration dates. During an observation, it was found that several IV antibiotic medications, specifically Aztreonam and Azithromycin, were past their expiration dates. These expired medications were stored alongside non-expired medications, which could lead to the administration of expired drugs to residents if nursing staff did not check expiration dates. Interviews with staff revealed that expired medications were temporarily stored in a red bin in the main medication storage room until they were taken to the Director of Nursing's (DON) office for disposal. However, the DON was unable to articulate the negative outcomes of storing expired and non-expired medications together. The facility's policy on labeling and storage was requested but only a Labeling of Medication policy was provided, indicating a lack of comprehensive procedures for medication storage and expiration management.
Failure to Provide Padded Call Light for Resident
Penalty
Summary
The facility failed to provide a padded call light for a resident, as indicated in the resident's care plan. The resident, a male with severe cognitive impairment and multiple physical limitations, including Parkinsonism and hemiplegia, was observed without the necessary padded call light. This oversight was noted during observations and interviews, where it was found that the resident was unable to use the standard call light due to his physical condition. The resident's care plan, which was supposed to accommodate his needs, specified the use of a padded call light. However, during multiple observations, the resident was found with a non-padded call light within reach, which he was unable to use due to his contracted left hand and shaking right hand. Interviews with staff, including a CNA and an LVN, confirmed that the resident had never used the call light and required frequent checks by staff to ensure his needs were met. Further investigation revealed that the care plan had not been updated to reflect the resident's current needs accurately. The MDS-LVN and other staff members acknowledged the discrepancy and noted that the resident's care plan indicated a need for a padded call light, which was not provided. The facility's policy on call lights emphasized the need for evaluating each resident's unique needs, which was not adhered to in this case.
Inadequate Care Plan for Resident Assistance
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as Resident #23, which did not accurately reflect the level of assistance required for activities of daily living (ADLs). The care plan, dated June 6, 2024, indicated that the resident required assistance from one to two staff members for various ADLs, despite the resident's condition necessitating consistent two-person assistance. This discrepancy was observed during interviews and record reviews, where it was noted that the resident was severely cognitively impaired and dependent on staff for all ADLs due to multiple health conditions, including Parkinsonism, vascular dementia, and hemiplegia. Interviews with staff, including CNAs and LVNs, revealed that the care plan's ambiguity allowed CNAs to determine whether one or two staff members were needed based on their judgment and the resident's condition on a given day. However, this approach lacked formal training or guidelines, relying instead on personal experience and the CNAs' comfort level. The MDS-LVN and DON confirmed that the care plan's flexibility was intended to accommodate varying conditions, but it did not provide clear, consistent instructions for staff, potentially leading to inadequate care. The facility's policy on comprehensive care planning emphasized the need for measurable objectives and timeframes to meet residents' needs, yet the care plan for Resident #23 did not align with these requirements. The policy required that care plans be based on comprehensive assessments, but the lack of specific training for CNAs on determining assistance levels and the reliance on subjective judgment highlighted a gap in the facility's adherence to its own policy. This deficiency could place residents at risk of not receiving the necessary care tailored to their specific needs.
Inappropriate Use of Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that residents who have not used psychotropic drugs are not given these drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficiency was identified for two residents. Resident #1 was prescribed Risperidone, an antipsychotic medication, without an appropriate diagnosis. The resident had a diagnosis of dementia without behavioral disturbance, psychotic disturbance, or mood disturbance, which is not an appropriate indication for Risperidone. Despite a gradual dose reduction being initiated, the medication was still being administered based on an improper diagnosis. Resident #16 was similarly affected, receiving Lurasidone, another antipsychotic medication, without a proper diagnosis. The resident's diagnosis included unspecified dementia without behavioral disturbance, psychotic disturbance, or mood disturbance, which does not justify the use of Lurasidone. The facility's Pharmacy Consultant had recommended a gradual dose reduction due to the improper diagnosis, but the medication continued to be administered. Interviews with facility staff, including an LVN, the ADON, the Pharmacist Consultant, and the DON, revealed a consensus that the antipsychotic medications were not appropriate for the residents' diagnoses. The staff acknowledged that the medications were being used to manage behaviors rather than for a diagnosed condition that warranted such treatment. The facility's policy on psychotropic medication requires that such drugs are only given when necessary to treat a specific condition, which was not adhered to in these cases.
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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 Edinburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windsor Arbor View | 1.9 mi | ★★★★★ | 12 | 0 |
| Hidalgo Nursing And Rehabilitation Center | 2.1 mi | ★★★★★ | 11 | 0 |
| Edinburg Nursing And Rehabilitation Center | 2.6 mi | ★★★★★ | 17 | 1 |
| Colonial Manor Advanced Rehab & Healthcare | 3.5 mi | ★★★★★ | 18 | 0 |
| Mcallen Nursing Center | 6.3 mi | ★★★★★ | 12 | 0 |
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