Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Grove Health And Rehabilitation during CMS and state inspections, most recent first.
The facility did not provide enough nursing staff to meet resident needs, resulting in residents with complex behavioral and medical conditions not receiving required one-to-one supervision. Staff assignment records and interviews confirmed that only two CNAs were often scheduled for shifts where five residents needed individual supervision, and documentation of supervision was lacking. Residents reported delays in care, and staff described being unable to safely cover all required duties due to ongoing staffing shortages and the absence of a formal staffing policy.
Certified Nurse Aides did not receive annual performance evaluations or regular in-service education based on those reviews, as confirmed by personnel file reviews and staff interviews. The Administrator attributed this lapse to frequent changes in nurse management, resulting in missed competency assessments and training opportunities.
Staff failed to prevent significant medication errors for two residents, including missed and delayed antipsychotic injections for a resident with schizophrenia and improper administration of Midodrine without following blood pressure parameters for another resident. Nursing staff did not consistently document actions taken when medications were unavailable or ensure required assessments were completed before administration.
A resident with morbid obesity and multiple complex medical conditions was not provided with a bed of appropriate size, resulting in discomfort, difficulty moving, and fear of falling. Despite the resident's repeated concerns and visible struggle to adjust in the bed, staff did not address the issue until after it was observed by surveyors. Interviews with staff confirmed that bed size should be matched to resident needs, but this was not done in a timely manner.
A resident with severe cognitive impairment developed multiple pressure injuries, but the responsible party was not promptly notified of these changes in condition as required by facility policy. Although treatment was initiated and the wound care physician was involved, the responsible party only learned of the wounds days later through a physician follow-up call.
A resident with severe cognitive impairment and total dependence on staff was found with facial bruising of unknown origin. The facility delayed reporting the incident to the Department of Health beyond the required two-hour window and failed to complete the necessary investigation documentation, including witness statements and investigation notes, as outlined in facility policy.
A resident with severe cognitive impairment and total dependence on staff was found with facial bruising of unknown origin. The facility did not complete or document a thorough investigation as required by policy, including missing witness statements and investigation notes, despite reporting the incident to the state and Adult Protective Services.
A resident with a recently replaced hip and a history of falls was not provided with a care plan intervention for fall mats, despite requests from the resident's spouse and discussions among the IDT. Observations confirmed the absence of fall mats, and staff interviews indicated the omission of this intervention in the care plan, failing to address the risk of injury from falls.
Facility staff did not update a care plan to reflect a resident's self-catheter care and failed to ensure that the interdisciplinary team attended care conferences for two residents. One resident independently managed Foley catheter care without this being reflected in the care plan, and staff were unclear about their roles in assisting. For two other residents, care conferences were attended only by social services staff and either the resident or a family member, with no participation from nursing, dietary, or therapy departments, and concerns raised by the residents and family were not addressed.
A resident with severe cognitive impairment and a pacemaker returned from an ER visit with physician orders for urgent cardiology follow-up to address a low pacemaker battery. Facility staff failed to schedule the required cardiology appointment, missing the physician's order, as confirmed by both administrative and nursing staff during interviews and documentation review.
A resident with severe cognitive impairment and dementia did not receive required toenail care, resulting in long, thick, discolored toenails. Despite a care plan and a podiatry referral order, staff were unaware of the resident's condition, and confusion existed regarding responsibility for toenail care. The facility's policy lacked clarity on departmental responsibility, leading to the deficiency.
Three residents did not have valid DNR documentation on file, including missing physician signatures and incorrect or unsigned forms, despite facility policy requiring proper advance directive records. As a result, staff and EMS would not be able to honor the residents' DNR wishes in an emergency.
A resident with multiple chronic conditions did not receive prescribed morning medications, missed evening doses of metoprolol ER and potassium chloride on two occasions, and had several shifts without documented vital sign monitoring as ordered. The DON confirmed that these physician orders were not followed.
Two residents with visual impairments did not receive necessary vision services, including eye exams and corrective lenses, despite documented needs and physician orders. Staff failed to schedule appointments or include the residents on service lists, and communication lapses between nursing, activities, and administrative staff contributed to the deficiency.
Two residents with significant medical needs were observed to have long, thick, and discolored toenails, with one experiencing pain due to toenails catching on bedcovers. Neither resident had recent documentation of podiatry or foot care, and staff confirmed that foot care had not been provided as needed.
Multiple deficiencies were identified, including failure to provide consistent one-to-one supervision for a resident with aggressive behaviors, leaving a syringe with an unknown substance unattended in a resident's room, and inadequate supervision of a resident with dementia and balance issues who sustained a hip fracture after an unwitnessed fall. Staff interviews and record reviews confirmed lapses in supervision and safety protocols.
A resident with severe cognitive impairment and multiple medical conditions experienced a weight loss of over 17% in five months due to the facility's failure to ensure adequate nutrition. Dietary interventions were inconsistently implemented, and supplements were delayed, resulting in continued weight decline despite ongoing documentation of significant weight loss by the dietician.
Surveyors found that medications and biologicals were not properly stored or labeled in several medication carts and a medication room. Loose, unidentified tablets and capsules were present, discontinued medications were not separated for return or destruction, and topical medications were stored with oral medications. Staff interviews confirmed these practices did not align with facility policy, and regular inspections failed to prevent these deficiencies.
A visually impaired resident with a history of neuromuscular bladder dysfunction and diabetes was allowed to perform his own urinary catheter care without proper staff assistance or training in infection prevention measures. Observation showed improper technique, including the use of a single basin and reusing washcloths, contrary to facility policy. Staff interviews revealed a lack of clear instruction and oversight regarding catheter care responsibilities.
A resident with multiple medical conditions and full ADL assistance was found to have a significant ant infestation in their room, specifically around a bag and chair. The resident was unaware of the infestation, and the issue was identified by a CNA during a facility tour. The room was subsequently added to the pest control log and treated, but the initial failure to prevent or promptly address the pest issue constituted a deficiency.
Failure to Provide Sufficient Staffing and Supervision
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all 106 residents, including not ensuring a licensed nurse was present on each unit during every shift. On multiple occasions, staffing records and interviews confirmed that only two CNAs were scheduled for shifts where five residents required one-to-one supervision as part of their care plans. These residents had complex medical and behavioral needs, such as dementia with agitation, physical aggression, wandering, and inappropriate behaviors, yet did not consistently receive the required supervision. Staff assignment sheets and behavior monitoring documentation showed that one-to-one supervision was not provided as required, particularly during night shifts, and staff reported it was impossible to meet these needs with the available personnel. Observations during the survey revealed that staff were sometimes assigned to supervise more than one resident at a time, and at other times, residents who required one-to-one supervision were left without any assigned staff. Interviews with CNAs and the staffing coordinator confirmed ongoing staffing shortages, with staff unable to complete required monitoring and documentation. The Director of Nursing acknowledged the absence of a formal staffing policy or a policy for one-to-one supervision, and that nursing judgment was used to determine supervision needs without physician orders or defined timeframes. Additional findings included reports from residents about delays in receiving assistance, with some stating they had to wait for help or were told they could not return to bed due to insufficient staff. The Social Services Director indicated that staffing shortages prevented all required interdisciplinary team members from attending care conferences. Staff also reported being asked to cover multiple units, which they felt was unsafe and put their professional licenses at risk. The administrator confirmed multiple open CNA, LPN, and RN positions and the lack of a staffing policy.
Failure to Provide Timely CNA Performance Reviews and In-Service Education
Penalty
Summary
Certified Nurse Aides (CNAs) at the facility did not receive required performance evaluations at least once every 12 months, nor did they receive regular in-service education based on the outcomes of such reviews. Personnel files for four CNAs showed no documented evidence of performance evaluations or related in-service education, despite their employment ranging from several months to over a year. Interviews with additional CNAs revealed that some had not received performance reviews or competency training since starting at the facility, with one CNA stating she had only received one performance review in three years and never received competency training. The Administrator confirmed that due to multiple changes in nurse management, the facility had not completed competencies and performance evaluations for CNAs. This lack of regular performance assessment and training was identified through interviews and record reviews, and it was noted that this had the potential to negatively impact resident care.
Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
Facility staff failed to ensure that two residents were free from significant medication errors. For one resident with diagnoses including dementia and schizophrenia, staff did not administer Risperdal Consta injections every two weeks as ordered by the physician. The medication was missed on multiple occasions, with gaps between doses and no oral antipsychotic coverage provided despite manufacturer recommendations for missed doses. Documentation showed that the medication was sometimes not available, and there was a lack of follow-up to ensure timely administration. Interviews with nursing staff revealed uncertainty about who was responsible for managing the resident's psychiatric medications and inconsistent notification of the appropriate parties when the medication was unavailable. For another resident with a history of alcohol abuse, anemia, hypertension, and cognitive deficits, staff failed to administer Midodrine according to the physician's parameters. The order specified that the medication should be held if the systolic blood pressure was above 110, but there were multiple instances where blood pressure was not assessed before administration, or the medication was given despite readings above the specified threshold. Review of the medication administration records for several months showed repeated failures to follow the prescribed parameters, including both missed assessments and inappropriate administration. Interviews with the unit manager confirmed that staff did not consistently follow the required procedures for medication administration, including checking blood pressure before giving Midodrine and holding the medication when parameters were not met. The deficiencies were brought to the attention of the facility administrator, but no additional information was provided at the time of the survey.
Failure to Provide Appropriate Bed Size for Resident with Morbid Obesity
Penalty
Summary
Facility staff failed to provide reasonable accommodation for a resident with morbid obesity, whose BMI was 47.8 and weight was 334 pounds. The resident, admitted with multiple complex diagnoses including acute and chronic respiratory failure, hypertensive heart and chronic kidney disease, diabetes, chronic pulmonary edema, sleep apnea, and a mood disorder, reported that the bed provided was too small. The resident expressed difficulty moving in the bed, a fear of falling, and a need for bed rails for support. Observations confirmed that there was less than three inches of space on either side of the mattress, and the resident was seen struggling to adjust his position. Despite staff being present in the room on multiple occasions, no action was taken to address the resident's concerns about the bed size until after the survey observations. Interviews with staff, including an LPN and the DON, acknowledged that bed size should be tailored to the resident's needs and that safety assessments for bed rails are required. However, the clinical record and staff actions showed that the resident's size and comfort needs were not initially accommodated, resulting in the resident remaining in an inappropriately sized bed until the issue was later addressed.
Failure to Promptly Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to promptly notify the responsible party of a significant change in condition for one resident with severe cognitive impairment and total dependence on staff for activities of daily living. According to facility policy, the resident, attending physician, and resident representative must be promptly notified of any change in status or condition, including the development of new wounds. The resident was admitted with dementia and was at risk for pressure injuries. On a weekly skin integrity review, the resident was found to have an unstageable deep tissue injury to the right hip, a stage two pressure ulcer to the left hip, and moisture-associated dermatitis to the sacrum. Treatment was initiated, and the wound care physician was involved as documented. However, the responsible party was not notified of the wounds until several days after their discovery. The initial wound evaluation and management summary confirmed the presence of the wounds, but the responsible party only became aware after the physician called for a follow-up, at which point she realized she had not been previously informed. The Director of Nursing and Assistant Director of Nursing confirmed that the wounds were discovered and treatment started, but notification to the responsible party did not occur until several days later, contrary to facility policy.
Failure to Timely Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report an injury of unknown origin for a resident with severe cognitive impairment and total dependence on staff for activities of daily living. The resident, who had a primary diagnosis of dementia, was found with bruising to the right forehead, right eye, bridge of nose, and slight bruising under the left eye. The injury was discovered in the morning, and the resident was evaluated by a nurse practitioner and sent to the emergency department for further assessment. The responsible party was notified, and the resident returned to the facility later that day with no abnormal findings from the CT scan. Despite the facility's policy requiring immediate reporting of injuries of unknown origin to the Department of Health within two hours, the initial report was filed more than three hours after the injury was noted. Additionally, the facility did not have a completed investigation, witness statements, or investigation notes on file as required by their policy. The current administrator confirmed these documentation gaps and stated that the expected procedures were not followed at the time of the incident.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident with severe cognitive impairment and total dependence on staff for activities of daily living. The resident was found with bruising to the face, including the forehead, right eye, bridge of the nose, and under the left eye, and was sent to the emergency department for evaluation. The facility's policy required a detailed investigation, including obtaining statements from the victim, suspects, and witnesses, as well as securing physical evidence and filing an incident report. However, there was no completed investigation on file, no witness statements, and no investigation notes available for review. Interviews revealed that staff present at the time of the incident could not recall any disputes or events leading to the injury, and some staff involved were no longer employed at the facility. The administrator confirmed the absence of required documentation related to the investigation. The facility did file an initial report with the state health department and notified Adult Protective Services, but the lack of a thorough and documented investigation was identified as a deficiency.
Failure to Address Fall Risk and Hip Protection in Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, person-centered care plan for one resident who had a history of hypertensive heart disease with heart failure, a recently replaced artificial hip joint following a cerebrovascular event, and depression. The resident was admitted for therapy following a hip fracture and required assistance with activities of daily living. Despite being cognitively intact, the resident experienced two falls since admission, as reported by his wife, who expressed concerns about the risk of re-injury to the recently replaced hip and requested the use of fall mats, which she had observed being used for other residents. Observations on multiple occasions confirmed that no fall mats were present at the resident's bedside. Interviews with facility staff, including an LPN and the Physical Therapy Director, revealed that while interventions to maintain resident safety were discussed in interdisciplinary meetings, the care plan did not include the use of fall mats as an intervention to reduce the risk of injury from falls. The deficiency was identified when the care plan review showed the omission of this intervention, despite the resident's history and the family's expressed concerns.
Failure to Revise Care Plan and Ensure Interdisciplinary Team Participation
Penalty
Summary
Facility staff failed to review and revise the care plan for a resident who was performing self-catheter care. The resident, who had a history of neuromuscular bladder dysfunction and multiple urinary tract infections, was observed performing his own Foley catheter care. The care plan did not reflect that the resident was independently managing this aspect of his care, and staff interviews revealed a lack of awareness and guidance regarding the resident's self-care practices. The CNA involved was not informed to assist with catheter care beyond emptying the Foley, and the LPN stated that CNAs were responsible for catheter care as part of ADLs. The Assistant Director of Nursing acknowledged that CNAs should help with Foley care and indicated a need for resident education on proper care techniques. Additionally, the facility failed to ensure that the interdisciplinary team (IDT) was present at care plan meetings for two residents. For one resident with Wernicke's encephalopathy and intact cognitive status, care conference records showed that only social services staff and the resident or responsible party attended, with no participation from other required departments such as nursing, dietary, or therapy. The resident did not recall attending any care conferences and had ongoing concerns about social security, community transition, and personal belongings that were not addressed in these meetings. For another resident with severe cognitive impairment due to dementia, care conference records similarly indicated that only social services staff and a family member attended, with no other departments present. The family member reported inconsistent communication about care changes and concerns regarding pressure ulcers, activity participation, and hydration. Staff interviews confirmed that nursing and other departments were not consistently invited or present at care conferences, and there was no system in place to ensure attendance or documentation of participation. The Social Services Director cited staffing shortages as a reason for the lack of interdisciplinary involvement and did not escalate the issue to administration.
Failure to Schedule Cardiology Follow-Up for Pacemaker Battery Replacement
Penalty
Summary
Facility staff failed to ensure that services were provided in accordance with professional standards of quality for one resident with multiple complex medical conditions, including hypertension, high cholesterol, dementia, depression, muscle weakness, cognitive and communication deficits, insomnia, and a pacemaker. The resident, who was severely cognitively impaired and unable to follow simple instructions or feed herself, returned from a recent emergency room visit with discharge instructions that included urgent follow-up with a cardiologist for pacemaker battery replacement and an outpatient ultrasound for thyroid nodules. Upon review, it was found that while the facility staff followed up on the thyroid nodule recommendation, they failed to schedule the required cardiology appointment for pacemaker battery replacement as ordered by the physician. Both the administrative staff responsible for transportation and the LPN unit manager confirmed that no cardiology appointment had been scheduled for the resident, and the need for follow-up was missed upon the resident's return from the ER. This omission was only identified during the survey, and the lack of scheduled follow-up was confirmed through interviews and documentation review.
Failure to Provide Toenail Care for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide appropriate activities of daily living (ADL) care related to toenail care for one resident with severe cognitive impairment and a primary diagnosis of dementia. The resident's care plan required staff to check, trim, and clean nails on bath day and as necessary, and to report any changes to the nurse. The resident had an order for a podiatry referral to clip toenails, but there was no documentation that the resident had been seen by a podiatrist since admission. Observations revealed the resident had long, thick, discolored toenails, and the resident reported waiting several years to see a podiatrist. Interviews with facility staff indicated confusion regarding responsibility for toenail care. CNAs believed they were to notify the nurse if toenail care was needed, and the nurse would then notify social services to schedule a podiatry visit. The LPN and DON confirmed this process, but neither was aware of the resident's current toenail condition. The facility's foot care policy did not specify which department was responsible for toenail care, contributing to the lack of action. As a result, the resident did not receive necessary toenail care, and the issue was not identified or addressed by staff.
Failure to Maintain Valid Advance Directive Documentation for DNR Orders
Penalty
Summary
The facility failed to ensure that three residents had valid advance directive documents on file, specifically regarding Do Not Resuscitate (DNR) orders. For one resident with hypertensive heart disease and heart failure, the care plan and facility records indicated DNR status, but the Durable Do Not Resuscitate Order from the Virginia Department of Health lacked a physician's signature, rendering it invalid. Despite the resident being cognitively intact and on hospice, the absence of a valid physician signature meant the DNR order could not be honored. Another resident with dementia and severe cognitive impairment was listed as DNR in the order summary, but the only advance directive document on file was for the resident's deceased spouse, not the resident herself. The responsible party confirmed the resident's DNR status, but no valid documentation existed in the medical record. Facility staff acknowledged the error and confirmed that the necessary documents were missing or incorrect. A third resident with multiple diagnoses, including severe cognitive impairment, had a DNR form in the clinical record that was unsigned by the authorized person, making it invalid. Staff interviews confirmed that without a signature, the DNR order was not legal, and the resident would receive CPR in an emergency. Facility policy required that valid advance directives be obtained, documented, and placed in the resident's record, but this process was not followed for these residents, resulting in incomplete or invalid documentation for their code status.
Failure to Follow Physician's Orders for Medication Administration and Vital Sign Monitoring
Penalty
Summary
The facility failed to ensure that physician's orders were followed for one resident, as evidenced by a review of records, interviews, and facility policy. The facility's policy requires medications to be administered in a safe and timely manner, specifically within one hour of the prescribed time unless otherwise specified. For the resident in question, who had diagnoses including hypertension, chronic kidney disease, major depressive disorder, atrial fibrillation, and vitamin B-12 deficiency, the physician had ordered multiple medications and regular vital sign monitoring. Record review revealed that there was no documented evidence that the resident received their morning medications as ordered over a specified period. Additionally, there was no documentation that the evening doses of metoprolol tartrate ER and potassium chloride were administered on two separate days. The records also showed missing documentation of vital signs on several day and night shifts as ordered. The Director of Nursing confirmed in an interview that the medications should have been administered as ordered, but they were not.
Failure to Provide Vision Services to Residents with Visual Impairment
Penalty
Summary
Facility staff failed to ensure that two residents received necessary vision services. One resident, with a history of primary open-angle glaucoma and diabetes, was coded as having moderate visual impairment and required corrective lenses. Despite care plan interventions to arrange consultations with an eye care practitioner and physician orders for an eye exam and eyeglasses, there was no documentation that these services were provided. Staff interviews revealed that the resident had requested assistance obtaining glasses, but no appointment was made, and the resident was not included on the list for the vision van visit. The resident reported being blind and only able to see people as gray shadows, and staff acknowledged awareness of the need but did not follow through with scheduling the required services. Another resident, with diagnoses including dementia, schizophrenia, and severe cognitive impairment, also did not receive routine vision screening since admission. The resident expressed difficulty seeing and an inability to recall the last eye examination. Review of the clinical record confirmed that the resident had not been seen by an optometrist since admission. Administration staff confirmed that routine vision screenings should occur annually and that the resident had not been scheduled for such services. Interviews with staff and review of facility documentation indicated a lack of communication and follow-through in identifying and scheduling residents in need of vision services. The process relied on unit managers to notify the person responsible for arranging appointments, but this did not occur for the affected residents. As a result, both residents with documented visual impairments did not receive timely or appropriate vision care as required.
Failure to Provide Timely Foot Care for Residents
Penalty
Summary
Facility staff failed to provide appropriate foot care for two residents who required assistance with activities of daily living. Both residents had long, thick, and discolored toenails, with one resident reporting that her toenails were getting caught in bedcovers and causing pain. Observations revealed that neither resident had received recent podiatry care, and there was no documentation in their clinical records indicating that foot or podiatry care had been provided. One resident did not recall seeing a podiatrist, while the other stated it had been a long time since her last visit. During interviews, staff acknowledged the lack of recent podiatry care and indicated that the residents would be added to the schedule for the next podiatry visit. The facility did not have an independent foot care policy, and the only documentation available was a health care agreement for podiatry services. The deficiency was identified through direct observation, record review, and staff interviews, which confirmed that necessary foot care had not been provided to the affected residents.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards for multiple residents, resulting in several deficiencies. One resident with a history of cerebral infarction, severe vascular dementia with agitation, and memory deficit was involved in multiple incidents of verbal and physical aggression toward other residents. Despite documented care plans and psychiatric recommendations for one-to-one supervision, there were periods when the resident was left unsupervised, including overnight, and there was no physician order for the required supervision. Staff interviews confirmed inconsistent implementation of one-to-one supervision, and the facility lacked a formal policy or physician order protocol for such supervision. Another deficiency was observed when a syringe containing an unknown clear liquid was found unattended on a resident's dresser. The resident had diagnoses including bipolar disorder and PTSD. The presence of the syringe was confirmed by an LPN, who acknowledged it should not have been left in the room. The DON stated that staff are expected to ensure syringes are not left in resident rooms, indicating a lapse in following established safety protocols regarding hazardous items. A third incident involved a resident with vascular dementia and significant balance and gait issues who sustained a right hip fracture after an unwitnessed fall in the bathroom. The resident's care plan identified a high risk for falls and included interventions such as ensuring appropriate footwear and anticipating needs. However, the fall occurred when the resident was alone, and staff interviews indicated the resident was often in his room and did not like to leave for therapy. The fall was unwitnessed, and the resident was found on the floor by staff, resulting in hospitalization and surgery for a hip fracture.
Failure to Prevent Significant Weight Loss Due to Inadequate Nutrition Management
Penalty
Summary
Facility staff failed to ensure adequate nutrition for a resident with multiple medical conditions, including dementia, depression, muscle weakness, and cognitive and communication deficits. The resident was severely cognitively impaired, unable to follow instructions, feed herself, or engage in meaningful conversation. Despite being admitted with a weight of 184.4 pounds, the resident experienced a significant weight loss of over 17% within five months, dropping to 151 pounds. The clinical record showed that while dietary interventions such as large protein portions and liquid protein supplements were ordered, these were not consistently reflected in the resident's meal tickets or diet orders, and some supplements were not added until months after significant weight loss had occurred. Dietician notes indicated ongoing concerns about the resident's weight, with repeated documentation of significant weight loss triggers and adjustments to dietary interventions. However, there was a lack of timely and coordinated implementation of these interventions, and communication with the dietician was unsuccessful during the survey. The resident's weight continued to decline despite these measures, and the facility did not provide further information when the deficiency was brought to the administrator's attention.
Improper Storage and Labeling of Medications
Penalty
Summary
Surveyors observed that medications and biologicals were not properly stored or labeled in multiple medication carts and a medication room. In several instances, loose tablets, capsules, and partial pills were found in drawers, with staff unable to identify the medications or their intended recipients. Discontinued medications, such as cipro and permethrin cream, were found in medication carts and storage rooms instead of being separated for return or destruction as per facility policy. Additionally, a narcotic blister pack was found taped closed, and topical medications were stored alongside oral medications, contrary to policy requirements. Staff interviews confirmed that these practices were not in line with facility expectations, and that loose or unidentified medications were typically discarded in sharps containers. The facility's policy required medications to be stored in an orderly manner, with external and internal use medications separated, and discontinued or expired medications removed from active storage. However, observations revealed that these procedures were not consistently followed. Staff were unable to provide documentation for medication start and stop dates in the electronic medical record, and regular inspections of medication storage areas did not prevent the accumulation of loose, unidentified, or improperly stored medications. These findings were confirmed by both administrative and nursing staff during the survey.
Failure to Provide Infection Prevention Support for Visually Impaired Resident Performing Catheter Self-Care
Penalty
Summary
Facility staff failed to ensure that a visually impaired resident received appropriate training and assistance with infection prevention measures during self-care of a urinary catheter. The resident, who had a history of neuromuscular bladder dysfunction, diabetes, and visual impairment, was assessed as cognitively intact but required varying levels of assistance with activities of daily living, including being dependent for toileting hygiene and requiring partial to maximal assistance with personal hygiene. Despite these needs, the resident reported performing his own catheter care, and staff interviews confirmed that CNAs were not instructed to assist the resident with this task beyond emptying the catheter. Observation of the resident's catheter care revealed improper technique, including the use of a single basin for both washing and rinsing, and reusing washcloths, which does not align with the facility's policy for urinary catheter care. The CNA assisting the resident acknowledged the error, stating that two basins should have been used—one for soapy water and one for rinsing. The CNA also indicated she had not been informed to assist the resident with catheter care aside from emptying the Foley catheter. Further interviews with nursing staff and facility leadership confirmed a lack of clear guidance and training for staff regarding their role in assisting the resident with catheter care. The facility's policy required specific steps for catheter care, including the use of separate washcloths and basins, but these procedures were not followed during the observed care. The resident's medical record indicated a history of urinary tract infections, underscoring the importance of proper infection prevention practices.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
Facility staff failed to maintain an effective pest control program for one resident, as evidenced by the presence of a large number of ants in and around a bag, chair, and wall in the resident's room. The resident, who had diagnoses including hemiplegia, hemiparesis, dysphagia, chronic congestive heart failure, and dementia, required assistance with all activities of daily living but had no cognitive impairment. During an initial tour, the resident was unaware of the ants or the contents of the bag. The issue was identified by staff, who then added the room to the pest control log for treatment. A review of the pest control log confirmed that the room was treated the following day. The deficiency was communicated to the Administrator and Director of Nursing during an end-of-day meeting. No additional documentation was provided regarding the incident.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 96 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Windsor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lake Prince Woods, Inc | 7.4 mi | ★★★★★ | 3 | 0 |
| Autumn Care Of Suffolk | 9 mi | ★★★★★ | 0 | 0 |
| Nans Pointe Rehabilitation And Nursing | 10.7 mi | ★★★★★ | 9 | 0 |
| Riverside Lifelong Health & Rehab Smithfield | 13.6 mi | ★★★★★ | 0 | 0 |
| Southampton Memorial Hosp | 13.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.