WINDSOR, VA - A May 2025 federal inspection at Consulate Health Care of Windsor revealed systematic failures in medication management, staff supervision, and infection control practices that put residents at risk of adverse health outcomes.
Critical Medication Administration Failures
Federal inspectors documented serious medication errors affecting residents with complex medical needs, including failures to administer prescribed psychiatric medications and improper handling of blood pressure medications with specific clinical parameters.
Inspection records revealed a resident with schizophrenia experienced irregular administration of Risperdal Consta, an injectable antipsychotic medication prescribed every 14 days. The resident had been switched to the injectable form due to refusal of oral medications and worsening behavioral symptoms. Between January and April 2025, the resident missed multiple scheduled doses, receiving injections on only sporadic dates rather than the prescribed bi-weekly schedule.
Documentation showed the medication was often unavailable when doses were due, with pharmacy notifications made but no consistent follow-up. On March 3, 2025, nursing notes indicated the medication "will be delivered tonight," but no evidence confirmed the resident received that dose. Similar patterns occurred in April, with notes stating the medication was "not available" and "pharmacy made aware" on April 2 and April 16.
The psychiatric implications of inconsistent antipsychotic administration are significant. When long-acting injectable antipsychotics like Risperdal Consta are administered irregularly, patients fail to achieve steady-state therapeutic blood levels, which typically require four consecutive injections. This can result in breakthrough psychotic symptoms, increased agitation, and higher risk of hospitalization. According to the manufacturer's clinical guidelines, when doses are missed before steady-state is achieved, the medication must be restarted with three weeks of oral coverage to prevent symptom recurrence.
Despite documented missed doses and the absence of steady therapeutic levels, facility records showed no oral antipsychotic coverage was provided during gaps in the injectable medication. The resident's psychiatric provider noted in an April 10 visit that the current medications should be continued, apparently unaware of the administration gaps.
A unit manager interviewed during the inspection confirmed that when medications are unavailable, staff should document their actions, notify the physician, pharmacy, resident or representative, and nursing leadership. However, these protocols were not consistently followed. On April 30, inspectors found an unopened dose of Risperdal Consta in the medication refrigerator dated April 16 - two weeks after it should have been administered.
Blood Pressure Medication Administered Without Required Assessments
Inspectors identified a second pattern of medication errors involving a resident prescribed Midodrine, a medication used to raise low blood pressure. The physician's order specified the medication should be given three times daily but held if systolic blood pressure exceeded 110 mmHg.
This parameter exists for critical safety reasons. Midodrine works by constricting blood vessels to increase blood pressure in patients with orthostatic hypotension (low blood pressure when standing). Administering it when blood pressure is already elevated can cause dangerously high readings, potentially triggering strokes, heart attacks, or hypertensive crises.
Medication administration records for April 2025 documented numerous instances where proper protocols were not followed. On multiple dates, blood pressure was not assessed before administration, yet the medication was either given without the required vital sign check or incorrectly withheld without knowing the blood pressure reading. On several occasions, staff documented blood pressure readings above the 110 mmHg threshold but administered the medication anyway, directly contradicting the physician's safety parameters.
The pattern extended across three months of records reviewed. When interviewed, the unit manager demonstrated clear understanding of the clinical rationale, stating that Midodrine keeps blood pressure up and that parameters prevent it from going too high. She correctly stated that nurses should never administer the medication without first checking blood pressure and should hold it if readings exceed parameters. However, she acknowledged these protocols were not being followed for this resident.
Widespread Staffing Shortages and Missing Performance Reviews
The facility reported significant nursing staff vacancies that likely contributed to lapses in clinical oversight. The administrator disclosed six open certified nursing assistant positions, seven open licensed practical nurse positions, and seven open registered nurse positions. The facility acknowledged it had no staffing policy in place.
Beyond raw numbers, inspectors found the facility failed to conduct required annual performance evaluations and competency training for nursing assistants. Personnel file reviews revealed four of five CNAs examined had no documented performance evaluations or competency-based in-service education, despite some having worked at the facility for over two years.
Regular performance evaluations and competency assessments serve essential quality assurance functions in nursing homes. They identify skill gaps, reinforce best practices, ensure staff maintain current knowledge of care techniques, and provide opportunities to correct problematic patterns before they affect residents. The absence of this oversight creates conditions where medication errors, infection control lapses, and other care deficiencies can persist undetected.
Staff interviews confirmed the documentation gaps reflected actual practice rather than mere paperwork oversights. One CNA who had worked at the facility for one year stated she had never received a performance review or competency training since starting. Another CNA with three years of tenure reported receiving only one performance review during that entire period and no competency training. A third CNA noted she had not received a performance evaluation "in many years" but would appreciate feedback and recognition for her work.
The administrator attributed these failures to "multiple changes in nurse management" but provided no corrective action plan during the inspection.
Infection Control Breakdown in Catheter Care
Inspectors documented infection control failures affecting a resident with an indwelling urinary catheter and severe visual impairment. The resident, who had experienced multiple urinary tract infections, performed his own catheter care despite documented moderate vision impairment and lack of proper training in infection prevention techniques.
During an observed catheter care episode, a CNA set up only one basin of soapy water rather than the two-basin system required by facility policy and infection control standards. The resident used the same washcloth and water to clean his back, groin, perineal area, and catheter - a practice that spreads bacteria rather than removing it. Proper catheter care requires using separate clean cloths and rinse water to prevent introducing fecal bacteria into the urinary tract, which is the primary cause of catheter-associated urinary tract infections.
The CNA acknowledged she should have provided two basins but stated she was never informed she should assist the resident with catheter care beyond emptying the drainage bag. The facility's written policy clearly specified the correct procedure: washing the perineal area front to back with soap and water, rinsing, drying, and then cleaning the catheter tubing separately.
This resident's cognitive abilities were intact, but his severe visual impairment in one eye and moderate impairment in the other made it impossible to safely perform the detailed cleaning required to prevent infection. Despite a care plan goal stating the resident would "show no signs or symptoms of urinary infection," staff failed to provide the hands-on assistance necessary to achieve that outcome. The licensed practical nurse on the unit stated CNAs should perform catheter care as part of activities of daily living, indicating a gap between policy and actual practice.
Medication Storage and Labeling Deficiencies
Inspections of four medication carts and two medication rooms revealed widespread failures to maintain proper medication storage. Surveyors found numerous loose, unidentified tablets and capsules in cart drawers - some whole, some broken - that staff could not identify or attribute to specific residents. On one cart, inspectors counted 44 solid tablets, one capsule, and 13 partial tablets loose in a single drawer.
Loose medications create multiple safety hazards. Staff cannot verify medication identity or intended recipient, tablets may have degraded through exposure to light and moisture, and there is risk of accidentally administering the wrong medication to the wrong resident. Broken or partial tablets indicate possible contamination or previous administration attempts.
Additional storage violations included discontinued medications left in active medication areas rather than segregated for pharmacy return, topical creams stored alongside oral medications, and narcotic blister packs taped closed rather than properly disposed of following facility protocols. Staff interviewed consistently stated the correct procedure was to immediately discard unidentifiable loose medications in sharps containers, indicating awareness of proper protocols that were not being followed.
Additional Issues Identified
Federal inspectors cited the facility for failure to maintain an effective pest control program after discovering ants infesting a resident's room, crawling on a chair, bag, and wall near the bed. The resident was unaware of the infestation. The room was added to the pest control treatment schedule only after inspectors identified the problem.
The facility also received citations for failing to ensure nurse aides received required supervision, though specific details of those deficiencies were limited in available documentation beyond the staffing and performance review gaps already noted.
All cited deficiencies were classified as causing "minimal harm or potential for actual harm" to residents, the lowest severity level in federal inspection ratings. However, the cumulative effect of medication errors, staffing gaps, infection control failures, and inadequate oversight created an environment where more serious incidents could readily occur.
The inspection occurred on May 1, 2025, with findings presented to facility administration, the director of nursing, and corporate consultants during an exit conference. Facility representatives were offered opportunities to provide additional documentation or clarification but presented no additional information to contest the findings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Consulate Health Care of Windsor from 2025-05-01 including all violations, facility responses, and corrective action plans.
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