Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Nursing And Rehabilitation Center Of Morga during CMS and state inspections, most recent first.
Two male residents with dementia and severe cognitive impairment were involved in a physical altercation in a lobby area after one resident, who had a documented history of verbal aggression and prior threatening and hitting behaviors, walked across the room and began punching the other resident seated in a wheelchair. The only staff member present, a receptionist, attempted to verbally intervene and then left to call for help as the assault continued, during which both residents fell to the floor while striking each other. The resident in the wheelchair subsequently exhibited head redness, swelling, and ear pain, was found to have an ear injury, and was later diagnosed with an acute left distal clavicular fracture related to the fall. The incident occurred despite an existing care plan identifying the aggressor’s potential for physical aggression and facility policies prohibiting abuse, and the internal investigation later characterized the event as unsubstantiated, stating there was no prior history of this type of behavior for either resident.
A resident with dementia, severe cognitive impairment, and a history of verbal aggression and threatening behavior toward others was not provided with a comprehensive, person-centered care plan addressing these behaviors, despite multiple documented episodes of yelling, rude comments, profane language, and a prior gesture to strike another resident with a cane. Staff notes and assessments over several months recorded anger toward roommates and others, but no behavior care plan with measurable objectives and timeframes was developed until after the resident physically assaulted another resident and then attempted a second physical confrontation that staff were able to prevent. Interviews with facility staff confirmed that such behaviors should have been care planned in accordance with the facility’s comprehensive care plan policy.
A resident with Type 2 DM, dementia, and moderately impaired cognition, who was care planned to use a smoking apron and to be supervised while smoking, sustained a partial-thickness burn to the upper thigh when an activities assistant lit the resident’s cigarette without first applying the required smoking apron. The resident reported dropping the cigarette in her lap, and although the assistant retrieved the cigarette and later brushed an ember from the resident’s lap, the burn was not recognized until a CNA observed a fresh blistered burn during peri-care. Facility policies on abuse/neglect and resident smoking required protections and a safe smoking plan, but these were not followed when the apron was not used before lighting the cigarette.
A cognitively intact male resident with a history of TIA, who had over $1,200 in a facility-managed trust fund and was care planned as independent, requested access to his personal funds on a Friday afternoon but was denied because key staff had left for the day and the ABOM had forgotten the key to the petty cash box. The resident, who believed he should receive a $75 monthly allowance when he wanted it, did not receive any money until the following Monday. The BOM described a practice of using petty cash for withdrawals during weekday business hours, while the Administrator acknowledged there was no specific written policy governing access to resident funds and no staff available on weekends to provide funds, despite existing written procedures on trust fund transactions and petty cash handling.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition at the time.
A resident with severe cognitive impairment and multiple medical conditions was moved to a different room without receiving the required written notice or explanation. The resident's representative was not informed of the reason for the move, and facility staff could not provide documentation or a clear rationale for the room change, despite policy requiring advance notification.
A resident with end stage renal disease and a dialysis fistula did not receive required assessments for thrill and bruit each shift, as mandated by physician orders and facility policy. Nursing staff admitted to not performing these checks, and the resident confirmed the assessments were not done. Facility leadership acknowledged the deficiency in following established protocols.
Surveyors found that multiple medication and treatment carts contained expired medications, such as insulin Glargine, Promethazine, Tramadol, and Hemorrhoidal Pads, which were not properly labeled or removed as required. Additionally, a staff member's personal cup was found stored with resident medications and supplies, contrary to facility policy. Staff interviews confirmed that these practices did not align with established procedures for medication storage and labeling.
Two elevators used by residents, staff, and visitors consistently had strong foul odors, described as urine and feces, despite frequent cleaning and shampooing of the carpeted floors. Multiple staff, visitors, and residents confirmed the ongoing issue, attributing it to residents having accidents and the presence of carpet, which retained odors. The facility's housekeeping policies require maintaining a clean and odor-free environment, but the elevators remained malodorous.
Surveyors found that all resident rooms with two beds did not meet the required minimum of 80 square feet per resident, with measured room sizes ranging from 149 to 156.5 square feet. The ADM confirmed no changes had been made to the rooms and provided a waiver request for the deficiency.
A resident with severe cognitive impairment and high fall risk was left unsupervised in the therapy gym due to miscommunication among therapy staff, resulting in a fall from her wheelchair and injuries including a hematoma and laceration. The care plan required supervision and frequent rounding, but these interventions were not followed, and the facility's fall prevention policy did not address supervision for high-risk residents.
A resident with a history of behavioral issues struck his cognitively impaired roommate on the forehead with a grabber after repeated interference with personal belongings. The incident, which was not witnessed by staff, resulted in a minor injury and was confirmed through resident and staff interviews as well as facility documentation. The aggressor had a known risk for physical aggression, and the event met the facility's definition of abuse.
The facility did not ensure timely reporting of alleged abuse and injuries of unknown source for two residents with cognitive impairment. In both cases, staff delayed notifying the administrator and appropriate authorities, despite facility policy and recent training on abuse, neglect, and exploitation reporting requirements.
Two residents' care plans were not updated by the interdisciplinary team after changes in their conditions. One resident with severe cognitive impairment had a history of giving money to others that was not reflected in the care plan, while another resident with multiple falls and complex medical needs did not have fall prevention interventions documented. Staff interviews confirmed these omissions were due to oversight and inconsistent care plan updates.
The facility failed to secure medication carts and maintain proper temperature logs for medication storage, leading to potential risks of medication contamination and ineffectiveness. Unlocked carts were found on the 200 and 300 floors, and temperature logs were incomplete in the 300 and 200-floor medication storage rooms. Staff interviews revealed a lack of awareness and training on the importance of securing medications and maintaining accurate temperature records.
A resident with a stage 3 pressure ulcer did not receive proper wound care as the Wound Care nurse failed to pat dry the wound after cleansing, contrary to physician orders. The nurse admitted to missing this step due to nervousness, which could lead to complications like maceration. The resident, with a history of cerebral infarction and contractures, was unable to be interviewed. The DON confirmed the importance of following orders and noted that the nurse was usually compliant with wound care procedures.
The facility's kitchen operations were found deficient in maintaining sanitary conditions. Juice dispenser guns were unsanitary, with nozzles resting in sticky substances and not cleaned after use. Equipment and storage practices were inadequate, with scratched and stained dishes, open spice containers, and a worn frying pan still in use. Staff interviews revealed a lack of awareness and adherence to sanitation practices, with concerns about cross-contamination and resident safety.
A facility failed to maintain a safe environment when a covered needle syringe was found in a resident's room, posing a risk of injury or infection. The resident, who requires enhanced barrier precautions, was unaware of the needle's presence. Staff interviews revealed a lack of awareness and adherence to proper sharps disposal procedures, with the DON acknowledging deficiencies in staff rounding practices and uncertainty about recent in-service training.
A resident with multiple medical conditions did not receive a prescribed nasal spray due to its unavailability in the medication cart. Despite this, several nurses documented that the medication was administered. Interviews and observations confirmed the medication was not given, leading to false documentation. The facility's policy requires accurate documentation and notification if medications are unavailable, which was not followed in this case.
The facility did not meet the required 80 square feet per resident in 46 multiple resident rooms, with room sizes ranging from 120 to 132.3 square feet for two residents. This was identified through observation and record review, despite an existing room size waiver from a previous survey.
A resident with severe cognitive impairment was transferred without a written 30-day notice, proper documentation, or timely notification to the Ombudsman. The transfer was deemed necessary due to the resident's high risk of elopement and the facility's inability to provide extended one-to-one care.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. A male resident with unspecified dementia, severe cognitive impairment (BIMS score of 03), and a history of verbal behaviors toward others had documented episodes of demanding and rude comments toward another resident, yelling at his girlfriend and her neighbor, and making threatening gestures. On one occasion, he tried to hit another resident with his cane after becoming upset, and on another, he hit a resident in the face. His care plan, initiated after these behaviors, identified a potential for physical aggression toward other residents and included interventions such as de-escalation by redirection and monitoring for signs that he posed a danger to himself or others. Another male resident with Alzheimer’s disease, a cognitive communication deficit, and severe cognitive impairment (BIMS score of 07) had no documented history of physical or verbal behaviors toward others on his admission MDS. On the date of the incident, this resident was sitting in his wheelchair at the front desk near the front door, talking to the receptionist and looking around. The first resident was seated approximately 25 feet away in the lobby area. According to the receptionist, the first resident began cursing across the room at the second resident, believing he was looking at his girlfriend, and continued to curse while walking across the lobby toward him. As the first resident crossed the room, the receptionist told him to stop and then ran to call for assistance when he did not listen. The first resident then began punching the second resident in the side and back of the head while the second resident remained in his wheelchair. The second resident cursed back and wrapped his arms around the first resident, and both fell to the floor while still punching each other. Staff and another resident intervened to separate them. A nurse later documented that the second resident had redness and slight swelling to his head and complained of right ear pain, and he was sent to the ER, where an ear injury was noted. A subsequent x-ray revealed an acute left distal clavicular fracture with superior displacement of the clavicle, associated with a fall from his wheelchair during the altercation. At the time of the incident, the receptionist was the only staff member monitoring the first-floor lobby area, and there was no requirement for additional staff presence in that area. The facility’s abuse, neglect, and exploitation policy stated that it would provide protections for each resident’s health, welfare, and rights by implementing policies and procedures that prohibit and prevent abuse, defined as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish. The facility’s investigation report described that the first resident became upset and agitated when the second resident was talking to a female resident, then walked from his chair toward the second resident while using foul language and proceeded to punch him, resulting in both residents falling to the floor. The report documented that the second resident was evaluated in the ER for an ear injury and later diagnosed with a left distal clavicular fracture related to the fall during the altercation. Despite prior documentation of the first resident’s threatening and physically aggressive behavior toward other residents, the investigation summary concluded the incident was unsubstantiated, stating that both residents had no prior history of this type of behavior. The facility’s failure to prevent the assault and resulting injuries, in the context of known behavioral risks and limited supervision in the lobby area, constituted a failure to ensure residents’ right to be free from abuse and neglect.
Failure to Care Plan for Escalating Aggressive Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes to address a resident’s aggressive behaviors. The resident was an older male with unspecified dementia and a history of transient ischemic attack with cerebral infarction, admitted in mid-2024. His Quarterly MDS assessment in late February 2026 showed a BIMS score of 03, indicating severely impaired cognition, and documented that he exhibited verbal behaviors toward others and used a cane for mobility. Despite these findings, there was no care plan in place addressing his verbally or physically aggressive behavior prior to a physical aggression incident at the end of March 2026. Multiple progress notes documented a pattern of verbal aggression and threatening behavior over several months that was not incorporated into a behavior-focused care plan. An activities note from late November 2025 described the resident as very demanding and making rude comments toward another resident. Nursing notes from December 2025 and early January 2026 recorded episodes where he used profane language toward his girlfriend and yelled at another person for walking around in a brief. A social work note dated early January 2026 documented that he was educated about other patients’ rights after he made a gesture to try to hit another resident with his cane when upset. A change of condition assessment from early October 2025 also recorded that he was angry and yelling at his roommate. On March 29, 2026, an incident report and staff interviews described a resident-to-resident altercation in which the resident crossed a room while cursing at another resident and then punched him on the side and back of the head, despite the receptionist’s attempts to verbally intervene. The following day, a social work note documented that he attempted again to engage in physical contact with another resident in an elevator but was stopped by nursing staff. Only after this physical aggression was a care plan initiated on March 30, 2026, which identified potential for physical aggression and included general interventions such as de-escalation by redirection and monitoring for danger to self or others. Interviews with the SW, Administrator, and MDS nurse confirmed that prior verbal and threatening behaviors should have been care planned and that the facility’s policy required comprehensive care plans with measurable objectives and timeframes to meet identified medical, nursing, and psychosocial needs.
Failure to Apply Required Smoking Apron Resulting in Resident Burn
Penalty
Summary
The facility failed to ensure a resident’s environment remained as free of accident hazards as possible and failed to provide adequate supervision to prevent accidents when a resident sustained a cigarette burn while smoking. The resident was an older female with Type 2 diabetes and dementia with behavioral disturbances, and a BIMS score of 09 indicating moderately impaired cognition with intermittent disorganized thinking. Her care plan, initiated after the incident, documented that she had sustained a burn to her left thigh while smoking and included an intervention to educate her on safe smoking practices. Another care plan, initiated earlier and later revised, specified that she required a smoking apron and supervision while smoking. On the date of the incident, the activities assistant (AA) reported that the resident was very impatient to smoke. The AA gave and lit the resident’s cigarette without first applying the required smoking apron, despite the resident’s care plan indicating she needed it. The AA stated she did not initially see the resident drop the cigarette, but the resident said she had dropped it, and the AA picked the cigarette up from the resident’s lap and handed it back to her. While the AA was then putting on the smoking apron, the resident reported that the area was still burning, and the AA observed and knocked an ember off the resident’s lap but did not notice a hole in the clothing. Later, a CNA discovered a fresh partial-thickness burn with a fluid-filled blister and surrounding redness on the resident’s upper left thigh during peri-care and reported it to the charge nurse. The facility’s policies on abuse, neglect, and resident smoking required protections against neglect and the development of a safe smoking plan, but the resident was not protected from neglect when the apron was not applied before lighting the cigarette.
Failure to Provide Timely Access to Resident Personal Funds
Penalty
Summary
The facility failed to honor a resident’s right to manage his personal funds by not providing timely access to money held in the resident trust fund. The resident was an adult male with a history of transient cerebral ischemic attack and an intact cognition status, evidenced by a BIMS score of 14 on a recent MDS, and was care planned as independent in meeting emotional, intellectual, physical, and social needs. His resident statement showed a trust fund balance of $1,250.37. The resident reported that on a Friday he requested some of his money but the facility would not give it to him, and that although he was supposed to receive $75.00 per month, sometimes he did not receive it when he wanted it. The Business Office Manager (BOM) explained that residents’ checks were applied to room and board, with remaining funds deposited into trust accounts, and that Medicaid allowed $75.00 for resident spending. She stated that when residents requested withdrawals, a form was completed and money was taken from a petty cash box, which was replenished as needed, and that residents typically waited no more than about two hours. However, the Assistant Business Office Manager (ABOM) stated that on a Friday afternoon the resident came to the business office requesting his money and was told the BOM had left for the day and would not return until Monday. Although the ABOM had access to petty cash, she had forgotten her key at home, so the resident did not receive any funds that day and did not get his money until the following Monday. The Administrator confirmed there was no specific written policy for providing access to resident funds, that access was limited to business hours on weekdays, and that no one was available on weekends to provide funds, despite the facility’s written procedures addressing resident trust fund transactions and petty cash reconciliation.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or inactions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Provide Required Written Notice Prior to Resident Room Change
Penalty
Summary
The facility failed to provide a resident with written notice, including the reason for a room change, prior to relocating the resident to a different room. The resident, who had severe cognitive impairment and multiple complex medical diagnoses including Multiple Sclerosis, quadriplegia, Alzheimer's disease, and major depressive disorder, was dependent on staff for all activities of daily living and preferred to spend time in his room. Despite facility policy requiring a 30-day written notice to the resident or their representative before any room change, there was no documentation or notification provided to the resident's representative regarding the reason for the move. Interviews with the resident's family member and facility staff confirmed that no written or verbal explanation was given prior to the room change, and the family member only learned of the move after it occurred. The family member reported that the resident was comfortable with his previous roommate and struggled with the new room environment, which was too cold for him. Facility staff, including the Social Worker and DON, were unable to provide documentation or a clear reason for the room change, and acknowledged that the required notification process was not followed in this instance.
Failure to Perform Required Dialysis Fistula Assessments
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care in accordance with professional standards of practice. Specifically, nursing staff did not consistently assess the resident's dialysis fistula for thrill and bruit every shift, as required by physician orders and facility policy. Observation revealed that a nurse placed a stethoscope over the fistula to listen for bruit but did not properly assess for thrill. Interviews with nursing staff confirmed that the required assessments were often not performed, with one nurse stating that she either forgot or was too busy, and believed that the checks were unnecessary since the resident's fistula was assessed at the dialysis center. The resident involved was an adult male with diagnoses including alcoholic cirrhosis of the liver with ascites, congestive heart failure, and end stage renal disease requiring dialysis. The resident had intact cognition and confirmed that his fistula was not being checked by facility nurses. Facility leadership acknowledged that the assessments should have been performed each shift and that the failure to do so was not in line with established orders and policy. The facility's policy required checking for thrill and bruit each shift and monitoring for bleeding upon return from dialysis.
Failure to Properly Label, Store, and Dispose of Medications and Personal Items in Medication Carts
Penalty
Summary
Surveyors observed that the facility failed to ensure all drugs and biologicals were properly labeled and stored according to professional standards on multiple medication and treatment carts. Specifically, a vial of insulin Glargine on the 2nd Floor Nurse-Med-Cart-A was found to be expired, discontinued, and not labeled with an open or expiration date. Additionally, a container of Hemorrhoidal Pads on the 2nd Floor Treatment Cart and cards of Promethazine and Tramadol on the 3rd Floor Nurse-Med-Cart-B were found to be expired but not removed from the carts. These expired medications and supplies were accessible and had not been disposed of as required by facility policy. Further, the 3rd Floor Treatment Cart was found to contain a large personal aluminum cup with a straw, which belonged to a staff member, in the bottom drawer alongside resident medications and supplies. Staff interviews confirmed awareness that personal items should not be stored with medications due to the risk of cross-contamination. Facility policy required medication carts to be kept clean, organized, and free of expired medications, but these procedures were not consistently followed, as evidenced by the presence of expired medications and personal items in the carts.
Persistent Foul Odors in Elevators Due to Inadequate Environmental Maintenance
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in two of three elevators, as both Elevator 1 and Elevator 2 were found to have persistent foul odors, described as smelling of urine and feces. Multiple observations by the surveyor over two consecutive days confirmed the presence of strong, offensive odors in both elevators. Interviews with staff, visitors, and residents corroborated these findings, with several individuals reporting ongoing complaints about the smell. The MDS Coordinator, WCN, HS, RD, ADM, MS, and SW all acknowledged the issue, attributing the odors primarily to the carpet installed in the elevators and to residents having accidents in them. Despite frequent cleaning, including daily and as-needed shampooing and vacuuming, the odors persisted. The facility's General Housekeeping Policies require maintaining the environment free from offensive odors through proper housekeeping practices, not by masking odors with deodorizers. However, the report indicates that the elevators continued to have foul odors despite adherence to cleaning routines. Housekeeping staff did not keep a log of cleaning activities but indicated an intention to start one. The issue was further compounded by the presence of carpet in the elevators, which was identified as a contributing factor to the persistent odor problem.
Resident Room Size Requirements Not Met
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple occupancy rooms and 100 square feet for single occupancy rooms, as mandated by regulations. During a recertification survey, all 89 resident rooms were measured using a laser measuring device, and it was found that rooms with two beds measured between 149 and 156.5 square feet, which does not meet the minimum requirement of 80 square feet per resident. The deficiency was observed in all 89 rooms listed in the report, each containing two beds. Record review of the Health and Human Services Form 3740 Bed Classifications confirmed the room configurations, and the administrator provided a letter requesting a room size waiver for the affected rooms. The administrator also stated that there had been no changes to the rooms. The report notes that this failure could restrict the amount of resident care equipment and personal effects that could be accommodated in these rooms and limit residents' ability to move about, but does not provide specific details about individual residents' medical histories or conditions at the time of the deficiency.
Failure to Provide Adequate Supervision Resulting in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, high fall risk, and a history of multiple falls was left unsupervised in the therapy gym, resulting in a fall from her wheelchair. The resident, who required substantial assistance for activities of daily living and had a BIMS score of 0, was dependent on staff for mobility and safety. On the day of the incident, the resident was brought to the therapy room by a CNA and left in the care of a therapist. The therapist subsequently left the area, believing another staff member would supervise the resident, but there was a miscommunication and no one was directly supervising her. The resident was found on the floor with a hematoma and laceration above her left eyebrow. Documentation and staff interviews confirmed that the resident was left unattended due to a lack of clear hand-off communication between therapy staff. The care plan for the resident included interventions such as frequent rounding, supervision in the therapy room, and staff anticipation of needs, but these were not followed at the time of the incident. The facility's fall prevention policy did not specifically address supervision of high fall risk residents. Multiple staff statements indicated that the failure to ensure direct supervision and a proper hand-off process led to the resident being left alone, which allowed the fall to occur. The event was unwitnessed, and the resident required hospital evaluation for her injuries. The deficiency was attributed to inadequate supervision and a breakdown in staff communication regarding responsibility for the resident's safety.
Resident-to-Resident Physical Abuse Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident was not protected from abuse by another resident. One resident, who had a history of potential physical aggression and required supervision for all activities of daily living, struck his roommate on the forehead with a grabber after the roommate repeatedly touched his personal belongings. The incident resulted in a small, reddened area on the victim's forehead, which resolved within minutes. The aggressor admitted to hitting his roommate because he would not stop touching his grabber, and the event was confirmed by staff and documented in the facility's records. The resident who was struck had moderate cognitive impairment, required substantial assistance with daily activities, and was dependent on a wheelchair. At the time of the incident, he did not display behavioral issues and was taking multiple psychotropic medications. The altercation was not witnessed by staff, but was reported by another resident who heard arguing and shouting. Upon investigation, staff found the aggressor cursing at the victim, who was able to indicate where he had been hit but could not verbally describe the event. Facility records indicated that the aggressor had a known history of behavioral issues, including grumpiness and resistance to care, and had previously experienced roommate conflicts. Despite these known risks, the altercation occurred, resulting in physical contact and a minor injury. The facility's policy defines abuse as the willful infliction of injury, and the incident met this definition based on the deliberate action taken by the aggressor.
Failure to Timely Report Alleged Abuse and Injuries of Unknown Source
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported within the required timeframes to the administrator and appropriate authorities. Specifically, two residents were involved in incidents where reporting did not occur as mandated by facility policy and federal regulations. In one case, an allegation of abuse concerning a male resident with severe cognitive impairment and multiple comorbidities was not reported to the administrator until four days after the incident, despite policy requiring immediate notification. In another instance, a certified nursing assistant (CNA) observed bruising on a male resident with moderate cognitive impairment and a history of falls but did not report the injury of unknown source to the administrator until two days later. The CNA assumed the injury had already been reported and did not act immediately, even though the bruising was significant and the resident was unable to communicate discomfort. The wound care nurse and DON both confirmed that the bruising should have been reported immediately, and the wound care nurse was not informed until two days after the initial observation. Interviews with staff indicated that they were aware of the types of abuse, neglect, and exploitation, and had received recent training on reporting requirements. However, despite this training, the required immediate reporting did not occur in these two cases. Facility policy clearly outlined the need for prompt reporting of such incidents, but the actions taken did not align with these procedures, resulting in a deficiency.
Failure to Revise Care Plans After Resident Status Changes
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for two residents. For one resident with Alzheimer's disease and severe cognitive impairment, the care plan was not updated to reflect a history of attempting to give money to other residents and staff. Interviews with the DON, ADON, and MDS Coordinator confirmed that this behavior should have been care planned to inform staff and provide individualized care, but it was overlooked. Another resident with multiple diagnoses, including stroke, dementia, and severe cognitive impairment, had a history of multiple falls. Although the resident required significant assistance with daily activities and had interventions such as a helmet, fall mat, and frequent rounding discussed by staff, these interventions were not documented in the care plan. The DON acknowledged that these fall prevention measures were not entered into the care plan, and the care plan lacked updates regarding the resident's high fall risk and other relevant diagnoses, such as PTSD. Facility policy required that the MDS Coordinator and interdisciplinary team discuss resident condition changes and update care plans accordingly. However, interviews revealed that care plan updates were inconsistently performed, with responsibilities shared among the MDS Coordinator, ADONs, nurses, and the DON. The lack of timely and accurate care plan revisions for both residents was attributed to oversight and failure to follow established procedures.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and under proper temperature controls. On the 200-floor, a treatment/medication cart was observed unlocked by the nurse's station, with its drawers facing outward, making medications easily accessible. LVN A, who was on duty, stated that she was not aware the cart was unlocked and had not been in-serviced on the importance of keeping it locked. Similarly, on the 300-floor, another medication cart was found unlocked and unattended, with LVN D acknowledging that it had been left unsecured while assisting a resident. In addition to the unsecured medication carts, the facility also failed to maintain proper temperature logs for medication storage refrigerators. On the 400-floor, the temperature log for the medication refrigerator was incomplete, with missing entries for specific dates, and a brown sticky substance was found on the bottom shelf, indicating a lack of cleanliness. LVN E and other staff members acknowledged the potential for contamination and the importance of maintaining accurate temperature logs to ensure medication efficacy. The 300 and 200-floor medication storage rooms also had incomplete temperature logs, with missing entries for certain dates. Interviews with the DON and ADON highlighted the responsibility of nurses on both shifts to check and log temperatures, as well as to maintain cleanliness in the medication storage areas. The failure to record temperatures and clean spills could lead to medications becoming ineffective or contaminated, posing a risk to resident health.
Failure to Follow Wound Care Protocol for Pressure Ulcer
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, identified as Resident #46, who had a stage 3 pressure injury on the left posterior ischium. The physician's orders required the wound to be cleansed with a wound cleanser, patted dry, and then have a barrier cream applied daily. During an observation of wound care, the Wound Care nurse cleansed the wound and applied the barrier cream without patting the area dry, as was ordered. The nurse admitted to missing this step due to nervousness and acknowledged the importance of following the physician's orders to prevent potential complications such as maceration, which could delay healing. Resident #46, a male with a history of cerebral infarction, contractures, and muscle atrophy, was unable to be interviewed. The Director of Nursing (DON) confirmed the importance of adhering to physician orders and noted that an in-service training on following doctor's orders and infection control was conducted following the incident. The DON also mentioned that the Wound Care nurse was usually observed to perform wound care correctly and that the wound care doctor had not previously noted any issues with the nurse's performance.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. The juice dispenser guns were found unsanitary, with one gun's nozzle resting in a sticky red substance on a cardboard box and the other touching a cabinet. Both guns had a buildup of red and black substances, indicating they were not cleaned after each use as required. Additionally, there were personal items, such as open soda bottles, in the prep area and refrigerator, which is against facility policy. The kitchen equipment and storage practices were also found lacking. Many coffee cups, juice glasses, and plastic bowls were scratched and stained, yet they were on the clean rack and ready for use. The sugar bin and several spice containers were left open, exposing contents to air, which could lead to contamination. A worn non-stick frying pan was still in use, despite the risk of the surface flaking into food. The facility's cleaning schedule appeared complete, but the actual cleanliness of the kitchen did not reflect this. Interviews with staff revealed a lack of awareness and adherence to proper sanitation practices. The Food Service Manager (FSM) acknowledged the issues but was unaware of some conditions, such as the underside of the holding table shelf being dirty. Staff expressed concerns about the potential for cross-contamination and the risk of making residents sick, but there was a fear of repercussions for speaking up. The facility's policies on cleaning and personal items were not provided upon request, indicating a possible gap in training and enforcement.
Failure to Maintain Safe Environment Due to Improper Sharps Disposal
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for Resident #273, as well as other residents, staff, and the public. During an observation, a surveyor found an empty covered needle syringe on the dresser in Resident #273's room. The resident, who has intact cognition and requires enhanced barrier precautions due to an open wound and wound vacuum, was unaware of the needle's presence and denied receiving any injections. The presence of the needle posed a risk of injury or infection to anyone who might come into contact with it. Interviews with staff revealed a lack of awareness and adherence to proper disposal procedures for sharps. LVN B, who was on duty at the time, was unaware of the needle's presence and admitted to not being recently in-serviced on sharps disposal. The DON speculated that the needle might have been left by the previous night nurse, LVN C, during wound care activities. The DON acknowledged that the presence of the needle was a safety risk and highlighted deficiencies in staff rounding practices, as well as uncertainty about when the last in-service training on rounding was conducted.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that sufficient staff with the appropriate competencies and skill sets were available to provide nursing and related services, specifically in the administration of medication to a resident. This deficiency was identified during a review of medication administration for a resident who had multiple medical conditions, including orthopedic aftercare following surgical amputation, congestive heart failure, type 2 diabetes, and chronic kidney disease. The resident had an order for Alkalol Saline Nasal Solution to be administered daily, but the medication was not available in the medication cart or storage room, and it was not administered as ordered. The medication administration records (MAR) indicated that the nasal spray was documented as administered on several occasions by different nurses, but observations and interviews revealed that the medication was not actually given. The WCN, who was the charge nurse on the day of observation, confirmed that the nasal spray was not in the medication cart and was advised by the nurse practitioner to obtain it from the pharmacy. However, the pharmacy indicated that the nasal spray was an over-the-counter medication and should be obtained by central supply. Interviews with the resident's family member and the resident himself confirmed that the nasal spray had not been administered since the resident's admission to the facility. The facility's Medication Administration Policy and Procedure outlined the proper steps for medication administration and documentation, including the requirement for nurses to document medications as they are given and to notify appropriate personnel if a medication is not available. Despite these guidelines, the nurses involved documented the administration of the nasal spray without actually administering it, leading to false documentation. The Director of Nursing (DON) acknowledged the issue and indicated that the nurses involved would be disciplined and retrained on medication administration and documentation.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to provide the required 80 square feet per resident in 46 multiple resident rooms out of a total of 90 resident rooms. The rooms in question measured between 120 and 132.3 square feet, which is insufficient for accommodating two residents per room as required. This deficiency was identified through observation and record review, specifically referencing the facility's Bed Classification Form 3740 dated 06/18/24. An existing room size waiver from a recertification survey exit dated 01/14/22 was noted during offsite facility reviews, but the current room sizes still did not meet the necessary standards for resident space.
Failure to Provide Proper Notice and Documentation for Resident Transfer
Penalty
Summary
The facility failed to ensure the notice of transfer or discharge was made at least 30 days before the resident was transferred or discharged. Specifically, Resident #1, who had severe cognitive impairment and was at risk for elopement, was transferred without a written 30-day notice. The facility did not document the discharge appropriately and failed to contact the Ombudsman in a timely manner. The resident's progress notes indicated that the transfer occurred on 3/18/2024, but the Ombudsman was only informed on 3/19/2024. Additionally, the reasons for the transfer were not recorded in the resident's medical record as required by the facility's policy. Interviews with the Social Worker and Nurse Practitioner revealed that the transfer was deemed necessary due to the resident's high risk of elopement and the facility's inability to provide 30 days of one-to-one care. The Social Worker informed the resident's family member about the transfer, who initially disagreed but later accepted after being told they had five days to find an alternative placement. The Administrator justified the immediate transfer by citing the resident's urgent medical needs and the risk posed to other residents. However, the facility's Transfer and Discharge policy requires documentation of the necessity for the transfer and notification to the resident, their representative, and the Ombudsman as soon as practicable, which was not adequately 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 Corpus Christi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alameda Oaks Nursing Center | 0.7 mi | ★★★★★ | 8 | 0 |
| Windsor Nursing And Rehabilitation Center Of Corpu | 1 mi | ★★★★★ | 10 | 0 |
| Brookdale Trinity Towers | 1.4 mi | ★★★★★ | 11 | 0 |
| San Rafael Nursing And Rehabiliation | 2.9 mi | ★★★★★ | 12 | 2 |
| Avir At Corpus Christi | 2.9 mi | ★★★★★ | 6 | 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.