Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Rehabilitation And Healthcare during CMS and state inspections, most recent first.
Care plans failed to reflect significant weight loss for several residents, and ordered supplements were not consistently provided. A resident with Alzheimer’s disease, a resident with stroke-related impairment, and a resident with dementia/dysphagia all had nutritional care plans that did not address documented weight loss, despite orders for health shakes and other supplements. In addition, two residents did not receive health shakes that were listed on their tray cards, and staff confirmed the shakes were unavailable or not sent.
A resident with severe cognitive impairment had a wander guard that did not function when tested, while two other residents with fall histories did not have required fall mats properly in place at the bedside. Staff interviews and record review showed the wander guard placement was checked, but its function was not being verified by nursing staff, and the fall mats were missing or positioned away from the bed despite care plan and order requirements.
A facility failed to provide ordered health shakes and correct meal portions for multiple residents with significant weight loss and nutritional risk. Residents with diagnoses including dementia, dysphagia, malnutrition, stroke, and metabolic encephalopathy had orders for supplements with meals, but tray observations showed missing health shakes, and staff said the kitchen had run out on multiple occasions and did not report it. The report also states the facility did not serve the ordered glazed ham portions or use the correct scoop sizes for mechanical soft and pureed servings.
Improper meal portion sizes were served when an LPN and dietary staff prepared glazed ham for a resident on a regular diet and for residents on mechanical soft and pureed diets using incorrect amounts. The ham on the tray weighed 2 oz instead of the ordered 4 oz, and staff used the wrong scoop sizes despite the menu specifying exact portions. The resident had Alzheimer's disease, severely impaired cognition, and required assistance with meals.
A resident council voiced that food was cold, and a food temperature log showed multiple lunch items served at temperatures that were not consistently appetizing. Surveyors observed the tray cart move from the kitchen to the halls, with trays taking an extended time to be passed before the test tray reached the work room. During a test tray interview, the RD and surveyors described items as warm, cold, bland, soggy, and not hot, and staff stated residents had complained about cold food and that delayed hall tray passing was causing the food to cool.
Incorrect Diet and Missing Supplement Service: A resident with dysphagia was served cornbread despite an order for no bread, and two residents ordered health shakes with meals but did not receive them. Staff confirmed the tray error and stated the kitchen was out of health shakes, while the residents had diagnoses including dementia, dysphagia, and malnutrition with orders for supplements to support intake.
Kitchen Food Safety and PPE Failures: Staff were observed failing to follow food safety procedures in the kitchen, including no log for the sanitation bucket, an out-of-range 3-compartment sink sanitizer level, incomplete high-heat dishwasher documentation, and staff working without required hair restraints or beard guards. Dietary staff stated they were responsible for the bucket, sink, and dishwasher checks, but could not demonstrate proper documentation when observed.
The facility failed to maintain infection control practices for residents receiving wound care and incontinent care. A resident with an open facial lesion was not placed on EBP and staff provided wound care without PPE; another resident’s peri-anal area was not fully cleaned before a clean brief was placed; a CNA did not change gloves or perform hand hygiene when moving from dirty to clean during incontinent care; and a CNA wore a gown into the hallway and back into a resident’s room after caring for a resident on EBP.
Poor Lighting Along Smoking Area Pathway: The facility failed to ensure adequate lighting along the exterior path to the designated smoking area for three residents who used wheelchairs. A resident said the path had been dark for months, and staff including a CNA, maintenance staff, and the ADON acknowledged the lighting was poor and that the solar lights along the route were old or not working well. The gazebo area had adequate light, but the pathway itself remained dark during evening smoke times.
Surveyors found that a crash cart at the central nurse's station contained numerous expired alcohol wipes, despite documented shift checks and audit processes. Night shift nurses were assigned to check the cart each shift, with an ADON periodically verifying their work, and the administrator reported that ADONs and a pharmacy technician also audited the cart while nurses were expected to complete a daily checklist. The facility’s written policy required immediate removal and proper disposal of outdated medications and supplies, but the expired alcohol wipes remained available for use, indicating the required monitoring and removal processes were not effectively carried out.
Failure to Obtain Consent Before Administering Paxil: A resident with major depressive disorder and severe cognitive impairment received Paxil for depression even though the resident’s representative did not consent to the medication. The consent form showed no approval for Paroxetine, yet the MAR documented daily administration. Staff interviews confirmed the medication should not have been given without consent and that the provider was not notified to discontinue the order.
MDS assessments for two residents receiving hospice services were not coded accurately for prognosis. One resident with dementia, hypertension, and syncope and collapse had a quarterly MDS that marked no for a life expectancy of less than 6 months despite a care plan and MD order showing hospice. Another resident with Alzheimer’s disease had an MDS that also marked no for a life expectancy of less than 6 months even though the care plan and order summary documented hospice services. The MDS Coordinator stated both should have been coded yes.
Failure to provide communication assistance for a resident with severe cognitive impairment and Spanish as her preferred language. The resident’s care plan called for a translator and a communication clipboard with pictures, but staff repeatedly did not observe a communication board in the room and used only English, gestures, or brief conversations to communicate. Interviews with the family and staff showed inconsistent awareness of the resident’s communication needs, and the ADON and Administrator were unaware the board was in place until surveyor intervention.
Failure to Maintain Fingernail Hygiene: A resident with dementia and dependence for personal hygiene was observed with jagged fingernails and a thick black substance under both hands on repeated observations. Staff stated CNAs were responsible for cleaning the nails and nurses for trimming them, but the resident’s nails remained untrimmed and uncleaned, and the resident said it made her feel dirty. The facility policy called for cleanliness, safety, and a neat appearance.
Failure to Perform Ordered Wound Treatments: An LPN did not complete ordered wound care for a resident with non-pressure wounds to the buttock and thigh, yet documented the treatments as done. The resident had diabetes, HTN, and dementia, and the wounds were being monitored with ordered daily NS cleansing, collagen, and dressings. Interviews and record review showed the dressing remained dated from an earlier change, and the nurse acknowledged missing one treatment and charting another as completed without performing it.
Incontinent care was not performed correctly for two residents. One resident with severe cognitive impairment and bowel/bladder incontinence was not fully cleaned before a clean brief was placed, and stool remained on the wipes used during care. Another resident with moderate cognitive impairment and a recent UTI was provided peri-care with the same dirty gloves while moving from dirty to clean tasks, with no hand hygiene or glove change before applying a clean brief and touching the resident’s belongings. The ADON and Administrator stated the peri-anal area should be fully cleaned and hand hygiene and glove changes should occur during incontinent care.
Incorrect Enteral Feeding Rate: A resident with a gastrostomy tube and swallowing problems was ordered Jevity 1.5 at 74 ml/hr, but the feeding pump was observed running at 67 ml/hr. An LVN stated the order had been changed in PCC but the pump settings were not updated, and staff said charge nurses were responsible for verifying the order and pump rate each shift and each time the feeding was administered.
A resident with COPD had an order for continuous O2 at 2 L via NC, but was observed in bed without oxygen connected to either the concentrator or portable tank. The nurse acknowledged knowing the resident was off oxygen while he was occupied with other residents’ breathing treatments. In a separate finding, the suction machine on the crash cart at the central nurse’s station did not work when tested, despite staff responsibility to check that crash cart equipment was current and working.
Unlocked Medication Carts: Two nurse medication carts were observed unlocked near the nurse's station with no nurse present. An LVN stated she left one cart unlocked while rushing to assist a resident, and an RN stated he thought he had locked the other cart before walking away to check on a resident. The ADON and administrator stated the carts should be locked when not in use, and the facility policy stated medication rooms, carts, and supplies are locked or attended by authorized persons.
A resident receiving hospice services had an outdated hospice binder in the facility, with no updated POC since the last IDT meeting and an old med list that still included Plavix. The RN case manager, LVN, ADON, and Administrator all acknowledged the binder should be updated and used to coordinate care, but the facility had no system to monitor hospice binders or ensure hospice documentation was kept in the chart.
Antibiotic Stewardship and Wound Culture Documentation: A resident with dementia and COPD was treated with Doxycycline for a right buttock abscess, but the wound evaluation did not include a wound culture order before the antibiotic was started. The wound exam documented intact skin, no exudate, no pain, and no signs of infection, while the wound doctor and ADON stated there was no documented reason for the antibiotic order and no culture was obtained.
A resident was prescribed Lantus without a documented diabetes diagnosis, leading to a deficiency in medication management. Despite elevated blood sugars noted by MD A, the resident's medical records lacked a diabetes diagnosis, and the resident refused insulin treatment. Facility staff acknowledged the oversight, citing delays in receiving physician notes and issues with record-keeping during a transition to digital records.
The facility's kitchen failed to meet food safety standards, with expired food items, unsealed packages, and dirty kitchenware observed. A menu item was not at the correct temperature, and the dry storage room was cluttered. The Dietary Manager acknowledged these issues, which were against the facility's policy.
Two residents were not provided full privacy during medical procedures by an LVN, who failed to close doors or pull privacy curtains during blood glucose checks and insulin administration. This lack of privacy was acknowledged by the DON and Administrator, who emphasized the importance of maintaining resident dignity and privacy as per facility policy.
A facility failed to implement a baseline care plan for a newly admitted resident within 48 hours, as required. The resident, with multiple medical conditions and mild cognitive impairment, did not receive a timely care plan, potentially affecting individualized care. Interviews with staff revealed that the responsibility for initiating care plans lies with an RN, and the DON was surprised by the oversight despite daily reviews.
A facility failed to update a resident's care plan to include her blood pressure medications, Midodrine and Amlodipine, within seven days of the comprehensive assessment. The resident, with multiple health conditions including hypertension and hypotension, had specific physician orders for these medications, which were not documented in her care plan. This oversight was confirmed by the MDS Coordinator during an interview.
A resident with hypertension was administered Midodrine HCL outside prescribed blood pressure parameters on multiple occasions. The ADON consulted the physician verbally but failed to document the interaction, contrary to facility policy. This posed a risk of unclear assessments and potential health issues for the resident.
Two residents in an LTC facility experienced medication administration errors, resulting in a 10% error rate. One resident received the wrong dosage of Candesartan and was not given Claritin-D as prescribed, while another did not receive their Autologous Serum Eyedrops. The errors were not caught during pharmacy audits, and the facility's procedures for handling medication orders were not followed.
Two residents in a LTC facility were administered blood pressure medications outside of prescribed parameters, leading to significant medication errors. A resident with hypertension was given Carvedilol despite low blood pressure readings, while another resident received Midodrine when her blood pressure was too high. Staff interviews revealed a failure to adhere to medication administration policies, highlighting documentation and procedural lapses.
A facility failed to maintain accurate clinical records for a resident's medication administration. The MAR for Levothyroxine had blanks, indicating a lack of documentation on whether the medication was given. Interviews with staff confirmed that MARs should have no blanks, and the facility's policy emphasized accurate documentation.
A resident with complex medical conditions received wound care during which RN A failed to perform proper hand hygiene after changing gloves, contrary to the facility's infection control policy. This lapse in protocol was observed and confirmed by staff interviews, placing multiple residents at risk for infection.
Care plans failed to address significant weight loss and ordered supplements were not provided
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for residents with significant weight loss, and failed to follow an ordered supplement intervention for one resident. Record review showed that Resident #12, a female with Alzheimer’s disease and severely impaired cognition, had a comprehensive care plan revised on 02/13/26 that identified potential nutritional problems related to protein calorie malnutrition, with interventions for a divided plate, adaptive equipment, and supplements as ordered. However, the care plan did not address her 10.42% weight loss over 3 months. Her orders included a regular diet, puree texture, thin liquids, divided plate, assistance with all meals, health shake all meals, and magic cup at lunch and dinner. Her weight record showed a decline from 138.2 pounds on 12/9/25 to 123.89 pounds on 02/25/26. Resident #64, a male with cerebral infarction and severely impaired cognition, had a comprehensive care plan revised on 02/13/26 that identified a potential nutritional problem related to weakness and included providing and serving supplements as ordered. The care plan did not address his 13.01% weight loss over 6 months. His orders included a NAS diet, regular texture, thin liquids, and health shake at lunch and dinner. His weight record showed a decline from 166 pounds on 9/2/25 to 144.4 pounds on 02/25/26. During interview, the ADON stated she was aware of the weight loss and said the care plan should have reflected the significant weight loss, and the Administrator stated he expected the care plan to address weight loss because it was a communication tool reflecting the resident’s issues and/or problems. Resident #7, a female with dementia, dysphagia, and depression, had a significant change MDS assessment showing severe cognitive impairment and dependence for multiple ADLs. Her care plan revised on 02/13/26 identified nutritional problems related to aspiration risk, malnutrition, depression, acid reflux, and oropharyngeal dysphagia, with an intervention to provide and serve diet and supplements as ordered, but it did not address her 14.5% weight loss over 6 months. Her physician orders included a No Added Salt puree diet, health shakes with all meals, and magic cup for nutrition. During observation, she was eating lunch and her tray card indicated a health shake with meals, but no health shake was on her tray. An LVN stated the kitchen staff said they were out of health shakes, and dietary staff confirmed they had run out during breakfast. Resident #38, a male with dementia, hypertension, and syncope and collapse, had a care plan revised on 02/24/26 that identified potential nutritional problems related to dysphagia and included providing and serving supplements as ordered. His physician order required a regular diet with health shake every meal, magic cup with lunch, and super. During observation, his tray card indicated a strawberry health shake with all meals, but no health shake was on his breakfast tray. A CNA verified the shake was missing, and the dietary aide stated strawberry health shakes were not sent because they were unavailable. The LVN stated the shakes were needed because they were ordered by the dietitian and could potentially lead to weight loss if not given. The Administrator stated he expected staff to follow the care plan for Resident #38.
Wander Guard and Fall Mat Deficiencies
Penalty
Summary
The facility failed to ensure that the resident environment remained as free of accident hazards as possible for three residents reviewed for accidents. The deficiencies involved a malfunctioning wander guard for one resident and missing or improperly placed fall mats for two residents. The report states these failures could place residents at risk of elopement, injury, or harm. One resident was a female with diagnoses including dementia, stroke, depression, and high blood pressure. Her quarterly MDS showed a BIMS score of 05, indicating severe cognitive impairment, and she required assistance with ADLs. Her care plan identified a history of elopement and directed staff to check the wander guard placement every shift and its function every Sunday night. During observation, she had a wander guard bracelet on her right ankle, but when the Maintenance Supervisor tested it, the bracelet did not work. Staff interviews showed the day and night nurses checked placement but were not aware of any device for checking function, and the facility had no extra wander guards or testers available at that time. A second resident was a male with diagnoses including dementia, hypertension, and syncope and collapse. His MDS showed a BIMS score of 08, indicating moderate cognitive impairment, and he had a history of falls. His care plan had included fall mats beside the bed since 12/27/25. After he fell out of bed, the incident report noted the intervention was to place fall mats. The nurse who was present at the fall stated he did not have fall mats beside the bed and that she was not aware he should have had them, even though the care plan already identified fall mats as an intervention. A third resident was a female with diagnoses including high blood pressure, Parkinson’s disease, and scoliosis. Her MDS showed a BIMS score of 01, indicating severe cognitive impairment, and she required total assistance with ADLs. Her care plan and physician order required two fall mats at the bedside, with checks every shift. During observations on two consecutive days, one fall mat was beside the bed while the other was against the wall, and staff confirmed the resident was supposed to have two fall mats. The nurse later stated she was unaware the resident did not have both mats in place, and the ADON and Administrator confirmed nursing staff were responsible for ensuring the fall mats were beside the bed.
Missed Supplements and Incorrect Meal Portions
Penalty
Summary
The facility failed to ensure residents received ordered nutrition supplements and correct meal portions for residents with nutritional risk and weight loss. Resident #7 had diagnoses including dementia, dysphagia, and depression, required assistance with eating, and had a 14.5 percent weight loss over 6 months. Her care plan identified nutritional problems related to aspiration risk, malnutrition, depression, acid reflux, and oropharyngeal dysphagia, and her physician ordered a puree diet with health shakes at all meals and magic cup. During lunch observation, her tray card indicated a health shake, but none was on the tray, and the LVN stated the kitchen said they were out. Resident #56 had diagnoses including malnutrition, depression, hypertension, and UTI, required assistance with ADLs, and had an 11.60 percent weight loss over 6 months and 7.83 percent over 3 months. Her physician ordered a mechanical soft diet with health shakes at all meals and peanut butter and jelly with lunch and dinner. During lunch observation, her tray card indicated health shakes, but none were on her tray. Resident #12 had severe cognitive impairment with a BIMS score of 0, a care plan for potential nutritional problems related to protein calorie malnutrition, and an order for a regular diet with puree texture, thin liquids, divided plate, assistance with all meals, health shake at all meals, and magic cup at lunch and dinner. Her weight summary showed a 10.42 percent weight loss in 3 months, with further loss documented on 02/25/26. Resident #64 had a diagnosis of cerebral infarction, severe cognitive impairment, and a 13.01 percent weight loss over 6 months. His order was for a NAS regular diet with health shake at lunch and dinner, and his care plan identified a potential nutritional problem related to weakness. Resident #72 had metabolic encephalopathy, severe cognitive impairment, and a 19.78 percent weight loss over 3 months. Her order was for a NAS mechanical soft diet with thin liquids and shake BID. Staff interviews confirmed that health shakes were not provided on multiple days because the kitchen had run out, that this had happened before, and that staff did not report the shortage. The report also states the facility did not ensure 4 oz of glazed ham was given to residents on a regular diet, did not ensure the #12 scoop was used for mechanical soft glazed ham, and did not ensure 2 #8 scoops were used for pureed glazed ham.
Improper Meal Portion Sizes Served
Penalty
Summary
The facility failed to ensure that lunch portions met the nutritional needs of a resident who required a therapeutic diet, supervision/touching assistance with eating, and had a history of Alzheimer's disease with severely impaired cognition. Resident #40's care plan directed staff to provide and serve the diet as ordered, and the physician order summary reflected a NAS regular diet with thin liquids, assistance with meals, and a divided plate. The extended week three menu specified 4 oz of glazed ham for the regular diet, #12 scoops for the mechanical soft diet, and two #8 scoops for the pureed diet. During observation of the lunch meal, the surveyor saw one slice of glazed ham on the resident's tray and asked that it be taken back to the kitchen to verify the serving size. The ham was weighed and found to be 2 oz. In the kitchen, staff were preparing the mechanical soft glazed ham using a #16 scoop and the pureed glazed ham using one #8 scoop. After reviewing the extended menu, staff stated that the mechanical soft portion should have been a #12 scoop and the pureed portion should have been two #8 scoops. Staff also stated that hall trays and half of the dining room had already been served with the improper scoop size. The dietary manager stated the staff should have weighed the ham to ensure it equaled 4 oz before serving residents. The dietary manager, dietician, ADON, and administrator each stated that menus and portion sizes were expected to be followed, and the administrator stated he expected dietary staff to follow the recipe and meal ticket. The facility policy on standardized portions stated that standard portions would be used to ensure adequate nutrients were provided and to avoid waste, and that portion sizes were written on the menu to ensure equal portions were served to provide adequate nutrition.
Cold and Unappetizing Meal Service
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Record review showed a Resident Council Meeting Form dated 2/19/2026 documented that the council voiced concerns that their food was cold, but the form did not address how the grievances would be managed. A food temperature log dated 2/24/2024 showed the regular meat at 137 degrees Fahrenheit, cooked vegetables at 176 degrees Fahrenheit, savory rice at 155 degrees Fahrenheit, and an egg roll at 153 degrees Fahrenheit at the time of serving. During a confidential group interview, 8 of 8 residents said the food trays served on the halls were cold. On 2/04/2026 at 12:09 p.m., surveyors observed the tray cart leave the kitchen preparation area, pass through the dining room, and go directly to the hall; trays began being passed at 12:11 p.m. and the test tray did not arrive in the work room until 12:27 p.m. During the test tray interview on 2/24/2026, the Registered Dietitian and State Surveyors described the lunch items as warm, cold, bland, soggy, and not hot, with the rice and vegetables noted as cold by the surveyors. Staff interviews stated residents had complained about cold food, hall trays were taking an extended time to be passed, and the residents were at risk of weight loss if they did not eat.
Incorrect Diet and Missing Supplement Service
Penalty
Summary
The facility failed to ensure Resident #85 received food prepared in the form ordered by the physician. Resident #85 had COPD, anxiety, dysphagia, and high blood pressure, and her orders included a No Added Salt diet, mechanical soft texture, divided plate, and no bread per speech therapy, including no sandwiches, rolls, cornbread, or tortillas. During lunch observation, her tray ticket indicated no cornbread, but cornbread was on her plate and she had already eaten about two bites. The LVN verified the cornbread was present and stated it was an oversight, noting the ticket read no bread and that the resident was at risk for choking. The facility also failed to ensure Resident #7 received a health shake with the meal as ordered. Resident #7 had dementia, dysphagia, and depression, was severely cognitively impaired, and required assistance with eating. Her physician orders included a puree diet, Health shakes with all meals, and magic cup for nutrition. During lunch observation, her tray card indicated health shake with meals, but no health shake was on the tray. The LVN later stated she realized the resident did not have the health shake and was told by kitchen staff that they were out. The facility further failed to provide Resident #56 with the ordered health shake. Resident #56 had malnutrition, depression, hypertension, and UTI, and her care plan identified unplanned weight loss related to poor food intake with an intervention to give supplements as ordered. Her physician orders included a regular diet, mechanical soft texture, Health shakes with all meals, and peanut butter and jelly with lunch and dinner. During lunch observation, her tray card read health shakes, but no health shake was on the tray. The resident stated she sometimes had health shakes but could not remember when she last did not receive one. Staff interviews indicated the kitchen had run out of health shakes and that this had happened at times before.
Kitchen Food Safety and Personal Protective Equipment Failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in its only kitchen reviewed for food safety requirements. During the initial tour on 2/23/2026, the sanitation bucket was not checked for chlorine level and had no log, and the three-compartment sink sanitization level was found at 0 ppm before being remade and rechecked at 100 ppm. The log for the high heat dishwasher for February 2026 was not tracked with temperature and chemical, and the sanitation bucket level was also observed at 0 ppm without a log being created. Kitchen staff were observed working without required hair restraints. [NAME] AA was seen walking in the kitchen and entering through the dining room entrance without a hair restraint, with short blonde hair approximately five inches long. Dietary Aid EE was observed in the kitchen without a beard guard while washing dishes, despite having a beard approximately one inch thick with dark black hair along the chin, jaw line, and upper lip. During observation, Dietary Aid EE checked the three-compartment sink, was asked to check the sanitation bucket, and ran the high heat dishwasher but could not show how to properly document the dishwasher temperature and chlorine level. Record review showed prior Quality Assurance Monitor kitchen observations dated 8/1/2025 and 10/7/2025 that identified problems with the sanitation bucket log, including that the log was not complete and that it had been completed days in advance. During interview, Dietary Aid EE stated he had forgotten to put on a beard guard and said staff were responsible for the sanitation bucket, three-compartment sink, and dishwasher logs. He also stated he was unaware what to do when the three-compartment sink was out of range and did not document the out-of-range finding. The Dietary Manager, RNC, [NAME] AA, and the Administrator all stated that the sanitation bucket, three-compartment sink, dishwasher, hairnets, and beard guards were required and that kitchen sanitation was important to prevent foodborne illness and hair in food.
Infection Control Lapses During Wound Care, Incontinent Care, and PPE Use
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for four residents reviewed for infection control. For one resident with Alzheimer’s disease, severe cognitive impairment, and an open lesion on the left upper face, the record showed an active order for vitamin A&D ointment but did not address enhanced barrier precautions. During observation, there was no EBP signage outside the resident’s room. A nurse stated she had provided wound care without PPE after being told she did not have to wear it, and the ADON stated she believed the resident did not need EBP because the wound did not require dressing, then acknowledged the resident should have been on EBP because the wound was open. For another resident with severe cognitive impairment, dependence with toileting, and bowel and bladder incontinence, two CNAs provided incontinent care. After wiping the buttocks, one CNA was about to place a clean brief under the resident before the surveyor intervened. The CNA then wiped again and stool was still observed on the wipes. The CNA stated she should have continued wiping until the resident was cleaned. The ADON and Administrator both stated the resident should have been completely cleaned before a clean brief was placed under her. For a third resident with moderate cognitive impairment and bowel and bladder incontinence, a CNA provided incontinent care but did not perform hand hygiene or change gloves when moving from dirty to clean tasks. The CNA wiped the genital area, then turned the resident while still wearing the same dirty gloves, wiped the buttocks incompletely, grabbed a clean brief without hand hygiene or new gloves, applied the brief, adjusted clothing and covers, and touched the resident’s phone with the same gloves. The CNA later stated she was supposed to do hand hygiene before applying new gloves and between dirty and clean tasks. For a fourth resident on EBP for wounds, a CNA exited the room wearing a gown and gloves, removed only the gloves in the hallway, performed hand hygiene, and then re-entered the room still wearing the gown to answer the resident’s call light. As she exited again, she stated she had forgotten to remove her PPE. She acknowledged she was supposed to remove the gown and gloves before leaving the room and before entering the room again. The ADON and Administrator stated staff should not be in the hallway with gowns or gloves on and should remove PPE before exiting the room.
Poor Lighting Along Smoking Area Pathway
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for residents, staff, and the public by not ensuring adequate lighting along the exterior pathway leading to the designated smoking area for Residents #17, #52, and #61. During an observation and interview, the three residents self-propelled in wheelchairs approximately 45 yards from the building to the smoking area with a staff member present. Resident #61 stated the pathway had been dark since January 2026, and maintenance man E stated the pathway outside was dark at night. He also stated he brought residents outside at night when designated staff were not available and that the pathway needed to be well lit for resident safety. He reported the gazebo area had a good light, but the pathway itself was dark, and the solar lamps were old and did not work well. Additional interviews showed CNA D, who worked on Hall 200 and was assigned to take residents out for the 7:00 PM smoke time, stated the pathway was dark and there was a definite need for more lighting. CNA D said she told the ADON at the end of December 2025. The Head of Maintenance stated he was never told the path was too dark, pointed out three solar lights along the sidewalk, and said they were about a year old and did not work as well as they did and had been damaged by the lawn equipment. The ADON stated residents complained about poor lighting in mid-January 2026 and that maintenance and administration were told, after which solar lights were placed along the pathway. The Administrator stated he was not aware of any issues with poor lighting and expected maintenance to promptly remedy any issues. The facility policy stated it would provide and maintain adequate and comfortable lighting levels in all areas.
Expired Supplies and Inadequate Monitoring of Crash Cart Medications
Penalty
Summary
Surveyors identified a deficiency in the storage and monitoring of drugs and biologicals on the crash cart located at the central nurse's station. During an observation, the crash cart contained 86 individual alcohol wipes with an expiration date of 10/3/2024 in the third drawer, indicating expired medical supplies were available for resident use. The facility’s Medication Access and Storage policy, dated 5/2007, required that outdated, contaminated, or deteriorated medications be immediately removed from stock and disposed of according to procedures for medication destruction. Interviews with staff revealed that night shift nurses were responsible for checking the crash cart each shift to ensure all medications and supplies were current and accounted for, and that an ADON occasionally checked the cart after night nurses to ensure it was done properly. The administrator stated that ADONs and a pharmacy technician completed cart audits, and that nurses were expected to maintain the cart and complete a daily checklist, with nursing leadership monitoring the process. An attempted interview with the night nurse who had signed off on checking the crash cart on the day of the observation was unsuccessful, leaving unresolved how the expired alcohol wipes remained on the cart despite documented checks.
Failure to Obtain Consent Before Administering Paxil
Penalty
Summary
The facility failed to ensure Resident #40 was informed of and consented to the use of Paroxetine (Paxil) before the medication was administered. Resident #40 was an elderly female admitted with a diagnosis of major depressive disorder. Her annual assessment reflected that she made herself understood and understood others, but her BIMS score was 2, indicating severe cognitive impairment. The care plan identified that she was receiving an antidepressant for depression, and the physician order summary showed an active order for Paroxetine 10 mg by mouth daily for depression with a start date of 04/16/24. The psychoactive medication therapy informed consent form showed that the resident’s representative did not give consent for Paroxetine, yet the CMA administration record showed the medication was administered daily during the February medication cycle. During interviews, Clinical Resource GG stated the resident should not have received the medication based on the consent, and LVN A stated she was unaware the prior representative had not consented because the medication had been given since 2024. ADON O stated she and LVN HH obtained the consent from the prior representative, but could not recall who discussed the medication with the representative and acknowledged that the physician should have been notified and the order discontinued when consent was not given. The Administrator stated the medication should never have been given against the representative’s wishes and that the order should have been discontinued.
MDS Assessments Did Not Accurately Code Hospice Status
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected resident status for two residents who were receiving hospice services. Resident #38’s record showed diagnoses including dementia, hypertension, and syncope and collapse. His quarterly MDS dated 12/12/25 indicated he usually understood and was usually understood by others, had a BIMS score of 08, required maximum assistance with ADLs, and was independent with eating, but Section J1400 was coded as no for a prognosis of less than 6 months. However, his care plan dated 10/31/25 identified him as having a terminal prognosis and being on hospice, and a physician order dated 10/31/25 documented hospice services. Resident #9’s record showed a diagnosis of Alzheimer’s disease. His quarterly MDS dated 12/02/25 indicated he usually made himself understood and usually understood others, noted long-term and short-term memory problems, and stated he did not have a life expectancy of less than 6 months while also indicating he received hospice services. His care plan identified a terminal prognosis and hospice services for Alzheimer’s disease, and the order summary showed an order to admit to hospice dated 08/07/25. During interview, the MDS Coordinator stated both residents should have been coded yes for a life expectancy of less than 6 months and that the omission was an oversight.
Failure to Provide Communication Assistance for a Spanish-Speaking Resident
Penalty
Summary
The facility failed to provide the necessary care and services to ensure that Resident #100’s abilities in activities of daily living did not diminish based on the comprehensive assessment and the resident’s needs and choices. Resident #100 was a female admitted with a diagnosis of non-traumatic intracranial hemorrhage. Her quarterly MDS reflected that her preferred language was Spanish, that she needed and wanted an interpreter to communicate with health care staff, and that her cognition was severely impaired with a BIMS score of 6. Her care plan identified her as at risk for communication problems related to hearing deficit and speaking Spanish, and included interventions to anticipate and meet needs, provide a translator as necessary, and use adaptive communication equipment such as a communication clipboard with pictures. During observations, Resident #100 was seen lying in bed on multiple occasions, and no communication board was observed in her room. The surveyor attempted to speak with her in English, and she responded with a smile, but there was no communication board present. During incontinent care, a CNA asked her in English if she was okay, and she did not respond. The resident’s family member stated that Spanish was her preferred language and that she should have a communication board in her room, adding that communication with staff and physicians had been an issue in the past. Staff interviews showed inconsistent awareness of the resident’s communication needs and the planned communication supports. One CNA stated she used hand gestures and was unaware the resident was supposed to have a communication board. Another CNA stated the resident understood very little English and that a communication board would be more effective. An LVN stated she was not aware of the communication board and said it would help English-speaking staff meet the resident’s needs. The ADON and Administrator both stated they were unaware the communication board was in place until surveyor intervention, and the ADON stated the resident should have a communication clipboard. The facility policy stated that resident rights and responsibilities must be explained in a language clear and understandable to the resident, and in the language familiar to the resident if English was inadequate.
Failure to Maintain Fingernail Hygiene
Penalty
Summary
The facility failed to ensure Resident #43, a female with dementia and moderately impaired cognition, received necessary assistance with personal hygiene when her fingernails were not kept trimmed and free of a black-colored substance. Her quarterly MDS reflected she was dependent with personal hygiene, and her care plan identified an ADL self-care performance deficit related to muscle weakness and an unsteady gait. During observation, the surveyor noted both hands had jagged fingernails approximately 0.25 to 0.50 cm long with a thick line of black substance under them, and the resident stated it made her feel dirty. The same condition was observed again the following day, with the fingernails still jagged and still containing the black substance. Staff interviews showed CNA B stated she was responsible for cleaning the resident’s nails and that nail care should occur at least three times a week and as needed, while LVN A stated CNAs cleaned the nails and nurses clipped them because the resident was diabetic. The ADON and Administrator stated nails should be cleaned and trimmed on shower days and as needed, with nurses and CNAs responsible for completing and monitoring the task. The facility policy titled Nail Care reflected the facility’s policy to promote cleanliness, safety, and neat appearance.
Failure to Perform Ordered Wound Treatments
Penalty
Summary
The facility failed to ensure treatment and care were provided according to physician orders and the resident’s care plan for Resident #3, a cognitively intact female with diagnoses including a pressure ulcer to the sacral area, diabetes, hypertension, and dementia. Her care plan identified non-pressure wounds of the left inferior lower lateral buttock and left proximal posterior thigh related to incontinence and immobility, with staff directed to administer treatments as ordered and monitor effectiveness. Physician orders dated 02/20/26 directed staff to clean both wounds with normal saline, pat dry, apply anasept collagen sheets, and cover with gauze island border dressings daily and as needed. Record review showed the treatment administration record documented LVN T as having completed both wound treatments on 02/23/26 and 02/24/26. However, during interviews, LVN T stated she did not perform the dressing change on 02/23/26 because the resident returned from dialysis late and she was passing supper trays, and she said she marked the treatment as completed in error. She also stated that on 02/24/26 she was told in report that another nurse had already done the treatment around 6:00 a.m., so she did not perform it again, yet she still documented it as completed. Observation and interviews on 02/24/26 and 02/25/26 showed the resident’s dressing was still in place and dated 02/22/26 by RN V, who confirmed he had changed it on 02/22/26 and was off on the following two days. The resident stated the nurses usually did her treatment, but she knew it had not been done that day. The wound care notes showed both wounds were present and being measured during the same period. The facility’s wound care policy required specific orders and immediate documentation after treatment, and the ADON and Administrator stated nurses were responsible for wound treatments and that following wound care orders was important for wound healing and prevention of infection.
Incontinent Care and Hand Hygiene Not Performed Correctly
Penalty
Summary
Appropriate care for residents who were incontinent of bowel and bladder was not provided for 2 residents. Resident #100 was a female with diagnoses including non-traumatic intracranial hemorrhage and need for assistance with personal care. Her quarterly MDS reflected a BIMS score of 6 and severe cognitive impairment, and she was dependent with toileting. Her care plan identified actual bowel/bladder incontinence related to dementia, confusion, history of UTI, and impaired mobility, with interventions to check for incontinence and wash, rinse, and dry the perineum. During an observation, CNA B and CNA M provided incontinent care to Resident #100. After transferring her to bed, CNA B wiped the buttocks with peri-wash and a washcloth, but was about to place a clean brief under the resident before the state surveyor intervened. CNA B then wiped the buttocks again, and stool was observed on both wipes. CNA B later stated she should have continued wiping until the resident was cleaned and that it was important to ensure the resident was cleaned before placing a clean brief under her to prevent UTI or skin breakdown. The ADON and Administrator both stated the peri-anal area should have been completely cleaned with no evidence of stool. Resident #56 was a female with diagnoses including malnutrition, depression, hypertension, and UTI. Her MDS reflected a BIMS score of 10, moderate cognitive impairment, assistance needed with ADLs including toileting, and bowel and bladder incontinence. Her care plan directed staff to check for incontinence, wash, rinse, and dry the perineum, and monitor for signs and symptoms of UTI. During an observation, CNA M wiped the genital area, then turned the resident while still wearing the same dirty gloves, wiped only the center of the buttocks where there was a smear of bowel, and then grabbed a clean brief without hand hygiene or changing gloves. She applied the brief, adjusted clothing and covers, and touched the resident’s phone with the same dirty gloves before removing them and performing hand hygiene in the hallway. CNA M stated she did not wipe or perform hand hygiene correctly and that this could lead to cross contamination.
Incorrect Enteral Feeding Rate
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition was provided the tube feeding at the physician-ordered rate and that appropriate treatment and services were provided for a resident with a feeding tube. Resident #6, a male admitted with a gastrostomy tube and swallowing problems, was documented on the quarterly MDS as rarely or never making himself understood and rarely or never understanding others, with long-term and short-term memory problems. His care plan reflected tube feeding with Jevity 1.5 at 75 ml/hr, and the physician order summary reflected Jevity 1.5 at 74 ml/hr for 20 hours starting 02/24/26. During observation, the feeding pump was running at 67 ml/hr instead of the ordered 74 ml/hr. The LVN who was interviewed stated she needed to review the chart to confirm the rate and then acknowledged the rate should have been 74 ml/hr. Another LVN stated she received the new order, changed it in PCC, but forgot to change the pump settings. Staff stated charge nurses were responsible for verifying each order every shift and each time the feeding was administered, and the Administrator stated nurses were expected to ensure the correct rate was set per physician order. The facility policy titled Enteral Nutrition stated enteral nutrition is provided to residents who cannot or will not take necessary nutrients by mouth due to physical disorders of disease and have a functioning gastrointestinal tract.
Oxygen Not Applied as Ordered and Crash Cart Suction Equipment Not Working
Penalty
Summary
Resident #85, a [AGE] year-old female with COPD, anxiety, dysphagia, and high blood pressure, had a physician order for oxygen at 2 liters per minute via nasal cannula continuously. Her admission MDS indicated she usually understood and was rarely understood by others, had severe impairment in daily decision making, required extensive assistance with ADLs, and was receiving oxygen during the look-back period. Her care plan stated she required oxygen for COPD and that staff were to apply oxygen as ordered. During an observation on 02/24/26 at 9:27 p.m., Resident #85 was found in bed with no oxygen connected to her oxygen concentrator or portable tank, and no distress was noted. When asked if she wore oxygen, she did not respond. At 9:31 p.m., CNA Q entered the room to answer the resident’s call light, and CNA B stated the resident wore oxygen but could not say why it was not on. At 10:12 p.m., the resident was observed in bed with oxygen applied at 2 liters and no distress or signs of hypoxia were noted. During interview, RN G stated he was the resident’s nurse and was responsible for ensuring her oxygen was on as ordered. He acknowledged he knew the resident did not have her oxygen on, but said he was giving two other residents breathing treatments and would connect her oxygen when finished. He stated that failure to apply oxygen even for 20 to 30 minutes could lead to hypoxia. In a separate observation on 02/27/26, the suction machine on the crash cart at the central nurse’s station did not work when plugged in and turned on. ADON O stated night shift was responsible for checking the crash cart each shift and ensuring all medications, supplies, and equipment were current, accounted for, and working, and the administrator stated the equipment on the crash cart should work.
Unlocked Medication Carts
Penalty
Summary
The facility failed to ensure medications were secured in locked medication carts in 2 of 7 carts reviewed for medication storage, specifically the 300 Hall nurse medication cart and the 400 Hall nurse medication cart. During an observation on 2/24/26 at 9:31 p.m., the 300 Hall nurse medication cart was observed unlocked near the nurse's station with no nurse present. During an observation on 2/24/26 at 9:44 p.m., the 400 Hall nurse medication cart was also observed unlocked near the nurse's station with no nurse present. During interviews, LVN H stated she left in a rush to assist a resident and left the 300 Hall medication cart unlocked, and RN G stated he thought he had locked the 400 Hall medication cart before walking away to check on a resident. ADON O stated whoever was using the cart was responsible for keeping it locked and that it should be locked if they were away from it. The facility administrator stated he expected the cart to always be locked when not in use and when the nurse stepped away. Record review of the facility's Medication Access and Storage policy, dated 5/2007, stated medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.
Hospice Records and Care Coordination Not Maintained
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate LTC staff participation in the hospice care planning process for a resident receiving hospice services, and failed to ensure the resident’s hospice records were part of the facility record. Resident #9 was an older male admitted with Alzheimer’s disease, and the quarterly MDS reflected long- and short-term memory problems. The record also showed an order to admit to hospice and a care plan noting a terminal prognosis and election of hospice services for Alzheimer’s disease, with interventions to support the resident’s emotional, spiritual, intellectual, physical, and social needs in cooperation with the hospice team. Review of the hospice binder showed no updated plan of care since the last IDT meeting and included a medication list that still listed clopidogrel bisulfate (Plavix). The RN case manager stated the resident had been admitted to hospice for Alzheimer’s disease, that she was responsible for bringing IDT meeting notes, and that she should reconcile medications every visit. Staff interviews showed the LVN, ADON, and Administrator were aware the hospice binder should contain updated information, including the plan of care and medication list, but the binder was not updated and there was no system in place to monitor hospice binders. The facility policy on End of Life Care: Hospice stated collaboration with hospice includes documentation and record keeping requirements.
Antibiotic Stewardship and Wound Culture Documentation
Penalty
Summary
The facility failed to establish an infection prevention and control program that included antibiotic stewardship and a system to monitor antibiotic use for Resident #50. Resident #50 was an 88-year-old female admitted with diagnoses including unspecified dementia and COPD. Her annual MDS reflected that she was understood and able to express ideas and wants, had the ability to understand others, had a BIMS score of 7, and addressed current antibiotic use and a pressure ulcer/injury. Her care plan identified antibiotic therapy related to an abscess to the right buttocks, with interventions to administer medications as ordered, observe for side effects every shift, and use enhanced barrier precautions. Record review showed a wound evaluation by the wound care physician that recommended Doxycycline 100 mg by mouth twice daily for 10 days for a right medial buttock abscess, but the wound evaluation form did not contain an order for a wound culture before the antibiotic was started. The focused wound exam described the wound as unstageable with intact skin, 17 cm x 11 cm x not measurable depth, no exudate, purple/maroon discoloration, no pain, and no signs of infection. A progress note documented the wound doctor saw the resident and noted no drainage or warmth, only a fluid-filled area, and ordered Doxycycline. The MAR showed the resident received Doxycycline for the ordered course. During interview, the wound doctor stated she would expect a documented reason for the order, such as signs or symptoms or drainage, and the ADON stated she did not contact the doctor about obtaining cultures with the new antibiotic order and did not reach out unless there was a decline. The administrator stated the facility used the McGeer Criteria for infection surveillance and that nurses should discuss antibiotic stewardship and the McGeer tool with physicians.
Resident Prescribed Lantus Without Diabetes Diagnosis
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically Lantus, which was prescribed without a medical diagnosis of diabetes. The resident, a male with a history of dementia, hypertension, and other conditions, was prescribed Lantus by MD A after noting elevated blood sugars. However, there was no documented diagnosis of diabetes in the resident's medical records, and the resident himself denied having diabetes and refused the insulin treatment multiple times. The deficiency was identified through a review of the resident's medical records, which showed no diagnosis of diabetes despite the prescription of Lantus. Interviews with facility staff, including the MDS nurse, DON, and other nursing staff, revealed that the facility did not receive physician notes in a timely manner, which contributed to the oversight. The staff acknowledged that medications should not be administered without a corresponding diagnosis, yet the Lantus was prescribed and administered without proper documentation. The resident's lab history showed an A1C level within normal limits, further questioning the necessity of the insulin prescription. Despite the resident's refusal of insulin and lack of a diabetes diagnosis, the facility did not have a system in place to verify the appropriateness of the medication order. The interviews highlighted a gap in communication and record-keeping, as the facility had transitioned to digital records but failed to ensure all necessary information was accurately documented and accessible.
Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. During an inspection, it was found that food items in the kitchen's cooler were expired and beyond their use-by date. Additionally, food items in the walk-in cooler and freezer were not properly sealed, and cleaned baking sheets, pans, utensils, and divided plates had food particles on them. A menu item on the steam table was not maintained at the correct holding temperature, and the floor of the dry storage room was cluttered with paper and other debris. These deficiencies were identified through observations, interviews, and record reviews. The Dietary Manager acknowledged these issues during interviews, noting that leftover food should be used within three days and that staff are expected to check and ensure cleanliness of kitchenware before storage. The manager also recognized the risk of foodborne illness from off-temperature foods and expressed the need to find a solution to maintain correct holding temperatures. The facility's policy, based on the Texas Food Establishment Regulations and the U.S. Public Health Service Food Code, was not followed, as evidenced by the improper storage and handling of food and kitchen equipment.
Failure to Ensure Resident Privacy During Medical Procedures
Penalty
Summary
The facility failed to ensure the privacy and dignity of two residents during medical procedures, as observed by surveyors. Licensed Vocational Nurse (LVN) B did not provide full privacy for Resident #49 and Resident #18 while performing blood glucose checks and insulin administration. Specifically, LVN B did not close the entrance door or pull the privacy curtain in Resident #49's room, leaving the resident exposed to their roommate and passers-by. Similarly, for Resident #18, LVN B did not pull the privacy curtain before checking the blood glucose and administering insulin, compromising the resident's privacy. Resident #49, who has a BIMS score indicating no impaired cognition, expressed embarrassment over the lack of privacy, stating that staff usually did not pull the privacy curtains. The Director of Nursing (DON) and the Administrator both acknowledged that maintaining resident privacy and dignity is the responsibility of all staff members, and failure to do so could lead to resident embarrassment. The facility's policy on resident rights emphasizes the importance of treating residents with dignity and respect, including ensuring privacy during examinations and treatments.
Failure to Implement Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by professional standards of quality care. This deficiency was identified during a review of records and interviews with staff. The resident in question, a female with multiple medical diagnoses including paroxysmal atrial fibrillation, colon cancer, hypertension, and mild cognitive impairment, was admitted to the facility but did not have a baseline care plan completed within the specified timeframe. The absence of this care plan could lead to the resident not receiving individualized services and care upon admission. Interviews with facility staff, including the MDS Nurse and the DON, revealed that the responsibility for initiating baseline care plans lies with an RN, with MDS Nurses approving the plans. The DON expressed surprise that the baseline care plan was not completed on time, despite daily reviews of resident plans by nursing management. The facility's policy on resident assessments emphasizes the importance of documenting residents' preferences, goals of care, and health status, but this was not adhered to in the case of the resident in question.
Failure to Update Care Plan for Blood Pressure Medications
Penalty
Summary
The facility failed to develop a comprehensive care plan within seven days after the completion of the comprehensive assessment for a resident, specifically regarding her blood pressure medications. The resident, a 67-year-old female with multiple diagnoses including Alzheimer's disease, COPD, hypertension, and diabetes, was not care planned for her prescribed medications Midodrine and Amlodipine. The care plan, last updated in October 2024, did not include documentation for these medications, which are critical for managing her hypotension and hypertension. The deficiency was identified through record reviews and interviews. The resident's physician orders from November 2024 included specific instructions for administering Midodrine and Amlodipine based on her blood pressure readings. However, these were not reflected in her care plan. An interview with the MDS Coordinator confirmed that the care plan was not updated to address the resident's blood pressure medications, despite the facility's policy requiring care plans to be updated with changes in a resident's condition or medications.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medications for a resident with essential hypertension. The resident was prescribed Midodrine HCL to be held if systolic blood pressure (SBP) exceeded 130 or diastolic blood pressure (DBP) exceeded 70. However, the medication was administered on multiple occasions when the resident's blood pressure was outside the prescribed parameters, including instances where the SBP was 140 and 139. The resident reported experiencing high blood pressure and attributed it to the medication administered outside the parameters. The Assistant Director of Nursing (ADON A) admitted to administering the medication outside the parameters and verbally consulting the physician without documenting the interaction. The Director of Nursing (DON) confirmed that the expectation was to report any deviations to the nurse on duty, who would then contact the physician. The facility's policies required that medications be administered only upon a licensed prescriber's order and documented accordingly. The lack of documentation and adherence to the physician's orders posed a risk of unclear assessments and potential health deterioration for the resident.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to provide accurate pharmaceutical services, resulting in a medication error rate of 10%. Two residents were affected by these errors. Resident #75 was administered the incorrect dosage of Candesartan and was not given Claritin-D as prescribed. The medication administration was observed to be incorrect, and the medication aide admitted to not checking the dosage properly. The facility had the correct medications available, but they were not administered as per the physician's orders. Resident #2 did not receive the prescribed Autologous Serum Eyedrops as ordered by the physician. The medication aide claimed to have administered the drops, but the medication was found in the refrigerator, and the resident confirmed not receiving the second dose. The pharmacist noted that the eyedrops should be used within 90 days to avoid infection, indicating a lapse in proper medication administration. Interviews with the Director of Nursing (DON) revealed a lack of awareness regarding the errors and a failure in the system to catch these issues during pharmacy audits. The DON expressed surprise at the errors, especially given the facility's procedures for handling discontinued or changed doses. The facility's policy requires accurate implementation of physician orders, but this was not adhered to, leading to the deficiencies observed.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for two residents who were administered blood pressure medications outside of the prescribed parameters. Resident #44, a male with multiple diagnoses including hypertension and schizophrenia, was given Carvedilol despite his blood pressure readings being below the threshold set by the physician's orders. The medication was not held on several occasions, as indicated by the November Medication Administration Records (MARs), which showed blood pressure readings below the prescribed parameters. Similarly, Resident #52, a female with conditions such as Alzheimer's disease and hypertension, was administered Midodrine when her blood pressure exceeded the parameters set by her physician's orders. The MARs for November indicated that the medication was not held on at least two occasions when her systolic blood pressure was above the prescribed limit. Interviews with staff revealed a lack of adherence to the facility's policy on medication administration, which requires holding medications when vital signs fall outside of specified parameters. Interviews with the facility's staff, including medication aides and registered nurses, highlighted a failure to document and follow physician orders accurately. Staff members acknowledged the potential risks of administering medications outside of prescribed parameters, such as causing dizziness or a drop in blood pressure. The facility's policies on physician orders and medication administration emphasize the importance of adhering to prescribed parameters and documenting any deviations, which were not followed in these instances.
Incomplete Medication Administration Record
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for one resident, specifically in the area of medication administration. The deficiency was identified during a review of the Medication Administration Record (MAR) for a resident who was prescribed Levothyroxine for thyroid dysfunction. The MAR for October and November 2024 contained blanks on specific dates, indicating a lack of documentation on whether the medication was administered or not. This lack of documentation could lead to uncertainty about whether the resident received their medication as prescribed. Interviews with facility staff, including a Registered Nurse (RN) and the Director of Nursing (DON), confirmed that there should be no blanks on the MARs. The RN stated that medications should be documented as administered or, if refused, the reason should be noted. The DON expressed that her expectation was for nurses and medication aides to document all medication administrations accurately. The facility's policy on medication administration emphasized the importance of accurate preparation, administration, and documentation of oral medications, yet the policy was not adhered to in this instance.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper hand hygiene practices of RN A during wound care for Resident #10. Resident #10, a male with multiple complex medical conditions including multiple sclerosis and Felty's syndrome, was observed receiving wound care for wounds on his right medial buttocks and left medial sacrum. During the procedure, RN A did not wash or sanitize his hands after changing gloves, which is a critical step in preventing cross-contamination and infection spread. The observation of RN A's actions was corroborated by interviews with ADON A and RN A himself, who acknowledged the lapse in hand hygiene. The facility's infection control policy, which mandates hand hygiene after glove removal, was not adhered to, placing 18 residents who received wound care at risk for cross-contamination. Despite recent in-service training on infection control, the expectation for proper hand hygiene was not met, as confirmed by the DON and ADON A.
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What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Terrell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Terrell Healthcare Center | 2.4 mi | — | 43 | 0 |
| Countryview Nursing & Rehabilitation | 3.1 mi | ★★★★★ | 23 | 1 |
| Ridgecrest Healthcare And Rehabilitation Center | 7.4 mi | ★★★★★ | 4 | 0 |
| Sunflower Park Health Care | 11.2 mi | ★★★★★ | 19 | 0 |
| Avir At Kaufman | 12 mi | ★★★★★ | 19 | 0 |
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