Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Windcrest Health And Rehab Inc during CMS and state inspections, most recent first.
The facility failed to provide a clean and safe environment, with issues such as soiled bedsheets for a resident, water-damaged ceilings, and poorly maintained air conditioning units. Observations revealed inadequate housekeeping practices and structural issues, including peeling rubber stripping and exposed, eroding walls. The Maintenance Director and Administrator acknowledged these problems, highlighting the need for improved cleaning and maintenance efforts.
A facility failed to ensure medications were not pre-popped before administration for seven residents. An LPN was observed placing pre-popped medication cups in a cart drawer, contrary to facility policy. The LPN admitted to the practice, acknowledging it was a bad habit. The DON was unaware of this practice and expressed dissatisfaction upon discovery.
A facility failed to maintain appropriate food temperatures, affecting meal palatability and nutritional intake. A resident reported cold food, and an observation revealed that an unheated food cart was used improperly, leading to inadequate food temperatures. The CNA acknowledged leaving the cart open, contributing to the issue.
The facility failed to maintain a sanitary kitchen environment, with issues such as rusty air vents, dirty floors, and expired food items. Additionally, staff did not follow proper hygiene practices, handling food and utensils without washing hands, contrary to facility policy.
A resident with Parkinsonism and dementia was observed with unshaven facial hair, food-stained clothing, and unclean hands and face after meals, despite needing extensive assistance with personal hygiene. Staff interviews confirmed the resident's preference for cleanliness and the need for assistance, highlighting a failure to maintain the resident's dignity.
The facility failed to ensure accurate MDS assessments for two residents, leading to discrepancies between care plans and actual care provided. One resident, with Parkinsonism and dementia, was observed with inadequate personal hygiene and dressing assistance, while another, with cerebral infarction and dementia, showed inconsistencies in required assistance levels. Staff confirmed the care plans did not match the residents' needs, and despite awareness of these issues, no documented corrective actions were taken.
The facility failed to update care plans accurately for three residents, leading to discrepancies between documented care needs and actual assistance provided. One resident with Parkinsonism and dementia was observed with inadequate personal hygiene and dressing assistance, while another with cerebral infarction had inconsistencies in care plan documentation. A third resident's care plan included outdated interventions for diuretic therapy. Staff interviews confirmed the misalignment between care plans and residents' current needs.
The facility failed to update care plans for two residents, resulting in discrepancies between documented needs and actual care requirements. One resident, with conditions like Parkinsonism and dementia, had hygiene issues and varying assistance needs not reflected in their care plan. Another resident, with cerebral infarction and dementia, had a care plan indicating total dependence, yet was observed eating independently. Staff confirmed the inaccuracies, and despite identifying the issue, no documented corrective actions were taken.
A resident with Parkinsonism, dementia, chronic pain, and muscle weakness required extensive assistance with personal hygiene and dressing. Observations showed the resident was not shaved, had food stains on clothing, and was not cleaned after meals. The resident preferred to be clean, and staff confirmed the need for assistance. The DON acknowledged the resident's face and hands should have been cleaned, and a soiled shirt should have been changed.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for its residents, as evidenced by several observations of unaddressed maintenance issues and inadequate housekeeping practices. Resident #11 was found with soiled bedsheets that were not changed promptly, indicating a lack of proper care and attention to hygiene. Additionally, the facility had visible signs of water damage, such as brown stains on ceiling tiles and light fixtures, and structural issues like peeling rubber stripping and exposed, eroding walls in the dining room. Further observations revealed that the facility's air conditioning units and vents were in poor condition, with visible accumulations of dirt and substances that could potentially affect air quality. The air conditioning units were described as having a yellowish tinge and blackish-brown substances, while the vents contained fuzzy, dark brown substances. These conditions were confirmed by the Maintenance Director, who acknowledged the difficulty in cleaning the units and the ongoing process of replacing them. The facility's housekeeping practices were also found lacking, as there was no established housekeeping policy, and the deep cleaning schedule was not effectively implemented. The Director of Nursing and the Administrator both acknowledged the issues with air filtration and the need for improved cleaning practices. The absence of a structured housekeeping policy and the failure to address maintenance issues contributed to the overall deficiency in providing a safe and homelike environment for the residents.
Medication Pre-Popping Deficiency
Penalty
Summary
The facility failed to ensure medications were not pre-popped prior to administration for seven residents. This deficiency was identified through observations, interviews, and reviews of records and facility policies. The facility's policy on administering medications, revised in April 2019, mandates that medications be administered safely, timely, and as prescribed, with verification of the resident's identity and medication details before administration. However, during an observation, an LPN was seen placing empty medication cups on the cart and later observed placing pre-popped medication cups in the cart's drawer. The LPN admitted to pre-popping medications, acknowledging it was against policy and a bad habit. The LPN confirmed that pre-popped medications had been destroyed and described the correct procedure for medication administration, which includes verifying the right resident and medication details before popping the medication. The LPN admitted to pre-popping medications the previous day as well. The Director of Nursing (DON) was unaware of this practice and expressed dissatisfaction upon discovery. The DON confirmed that there were no competencies on medication administration for the LPN involved, and a list of affected residents and actions taken to prevent recurrence was provided.
Removal Plan
- Replace medications that had to be wasted at the facility's expense.
- In-service LPN #3 on proper medication administration.
- Assistant Director of Nursing (ADON) to observe medication administration with LPN #3.
- Provide education to the rest of the nursing staff on duty.
- Conduct in-service training titled 'Preventing Medication Errors'.
Inadequate Food Temperature Control
Penalty
Summary
The facility failed to ensure that food and drink were served at appropriate temperatures to maintain palatability and encourage adequate nutritional intake. During an observation, it was noted that a resident complained about the food being cold when served in the dining room and even colder when served in their room. This issue was further evidenced during a meal service where an unheated food cart was used to transport and serve meals. The cart was left open while being loaded and during the distribution of meal trays, which contributed to the food items being served at inadequate temperatures. Temperature readings taken immediately after the last resident was served revealed that both hot and cold food items were not at safe or appetizing temperatures. For instance, milk was served at 54.8 degrees Fahrenheit, and various hot food items, such as mashed potatoes and pepper steak, were served at temperatures ranging from 93 to 113 degrees Fahrenheit. The CNA involved acknowledged leaving the food cart open during the meal service, which likely contributed to the temperature deficiencies observed.
Sanitation and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen and food preparation areas, as observed during a survey. The dishwashing machine air vent was found to be rusty, and the kitchen floors, baseboards, and walls were not free of dirt. Chipped floor tiles were not replaced, exposing concrete and cement in several areas. Additionally, expired spices and leftover fruit items were not promptly removed from stock, with a container of leftover diced peaches and a container of red pepper found past their expiration dates. Furthermore, the facility did not adhere to proper hygiene practices. A scoop holder by the ice machine had a gray, wet residue, which was in contact with the scoop used for serving beverages to residents. Dietary staff were observed handling food and utensils without washing their hands, including picking up glasses by the rims and serving beverages. These actions were contrary to the facility's policy on preventing foodborne illness, which requires employees to wash their hands after activities that contaminate them.
Failure to Maintain Resident Dignity and Personal Hygiene
Penalty
Summary
The facility failed to maintain the dignity of a resident by not providing adequate personal hygiene and clothing changes. The resident, who was admitted with diagnoses including Parkinsonism, dementia, chronic pain, and muscle weakness, was observed on multiple occasions with unshaven facial hair, food stains on clothing, and unclean hands and face after meals. Despite the resident's cognitive intactness and expressed preference for cleanliness, staff did not ensure the resident's personal hygiene needs were met, as evidenced by observations of the resident with long facial hair and wearing the same stained shirt throughout the day. Interviews with staff, including a CNA and the Director of Nursing, confirmed that the resident required extensive assistance with personal hygiene and dressing. The CNA acknowledged that the resident liked to be shaved and that the resident's face and hands should have been cleaned after meals, with a change of clothing offered. The Director of Nursing also confirmed that the resident should have been cleaned and offered a change of clothing after meals, indicating a lapse in the facility's adherence to its policy on resident dignity and personal care.
Inaccurate MDS Assessments and Care Plan Discrepancies
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents, leading to discrepancies between the MDS, care plans, and actual care provided. Resident #2, who was admitted with diagnoses including Parkinsonism and dementia, was assessed as needing varying levels of assistance with activities of daily living (ADLs). However, observations revealed inconsistencies in the care provided, such as the resident being left unshaven and in soiled clothing, indicating a lack of proper assistance with personal hygiene and dressing. Interviews with staff confirmed that the care plan did not accurately reflect the resident's needs, as the resident required extensive assistance with transfers and personal care. Resident #14, admitted with conditions such as cerebral infarction and dementia, was also subject to inaccurate MDS assessments. The resident was documented as needing substantial assistance with ADLs, including total dependence for transfers using a mechanical lift. However, observations showed the resident eating independently without assistance, and staff interviews confirmed discrepancies between the care plan and the actual assistance required. The MDS coordinator acknowledged that the care plans were not updated to reflect the residents' current needs, leading to inconsistencies in the care provided. The Director of Nursing (DON) and the MDS coordinator were aware of the inaccuracies in the MDS assessments and care plans, as these issues were identified and discussed in Quality Assurance meetings. Despite this, there was no documented follow-up or corrective action taken to address the discrepancies. The facility's failure to ensure accurate assessments and care plans resulted in inadequate care for the residents, as evidenced by the observations and staff interviews.
Removal Plan
- Interdisciplinary team members were in-serviced to make sure information was entered correctly on the MDS
- MDS coordinator and DON/Assistant Director of Nursing (ADON) in-serviced to ensure accuracy prior to signing and/or submitting the MDS
- The MDS coordinator will ensure the care plan was updated when completing the MDS
- MDS sections will be audited to ensure all sections were being completed accurately by the DON or designee
- Hire new MDS coordinator
- Sign MDS coordinator up for training
Inaccurate and Outdated Care Plans for Residents
Penalty
Summary
The facility failed to ensure care plans were updated with accurate information and failed to resolve care plans that were no longer needed for three residents. Resident #2, who was admitted with diagnoses including Parkinsonism and dementia, had a care plan that did not accurately reflect the level of assistance needed for activities of daily living. Observations showed that Resident #2 was not receiving adequate assistance with personal hygiene and dressing, as evidenced by the resident's unshaven appearance and stained clothing. Interviews with staff confirmed that the care plan used did not match the resident's current needs. Resident #14, admitted with diagnoses such as cerebral infarction and dementia, also had discrepancies between the care plan and the actual assistance required. The care plan indicated total dependence on staff for bathing and transferring, yet observations and staff interviews revealed inconsistencies in the level of assistance provided. The care plan did not accurately reflect the resident's current needs, leading to potential gaps in care. Resident #23's care plan included interventions for diuretic therapy, despite the resident no longer being on such medication. The care plan had not been updated since the discontinuation of the diuretic, leading to outdated and inaccurate information. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the care plans and MDS assessments were not aligned, and there was a lack of documented follow-up on identified inaccuracies.
Removal Plan
- Interdisciplinary team members were in-serviced to make sure information was entered correctly on the MDS
- MDS coordinator and DON/Assistant Director of Nursing (ADON) in-serviced to ensure accuracy prior to signing and/or submitting the MDS
- MDS coordinator will ensure care plan is updated when completing the MDS
- MDS sections will be audited to ensure all sections are being completed accurately by the DON or designee
- Hire new MDS coordinator
- Sign MDS coordinator up for training
Inaccurate and Outdated Care Plans for Residents
Penalty
Summary
The facility failed to ensure that care plans were updated within the appropriate time frame with accurate information for two residents. Resident #2, who was admitted with diagnoses including Parkinsonism, dementia, chronic pain, and muscle weakness, had a care plan that was not reflective of their current needs. Observations revealed that Resident #2 required varying levels of assistance with activities of daily living, such as bed mobility and toileting, which were not accurately documented in the care plan. Additionally, Resident #2 was observed to have personal hygiene issues, such as unshaven facial hair and stained clothing, indicating a lack of proper care. Resident #14, admitted with conditions including cerebral infarction and dementia, also had discrepancies between their care plan and actual needs. The care plan indicated total dependence on staff for certain activities, but observations showed that Resident #14 was able to eat without assistance. Interviews with staff confirmed that the care plan did not match the resident's current abilities and needs, as Resident #14 required a mechanical lift for transfers and was unable to dress or position themselves in bed. The facility's failure to update care plans was acknowledged by the MDS Coordinator and the Director of Nursing (DON), who confirmed that the care plans and MDS assessments did not align. Despite identifying the issue in a Quality Assessment and Assurance Committee meeting, there was no documented follow-up or corrective action taken to address the inaccuracies. This lack of action resulted in care plans that did not accurately reflect the residents' needs, potentially impacting the quality of care provided.
Removal Plan
- Interdisciplinary team members were in-serviced to make sure information was entered correctly on the MDS
- MDS coordinator and DON/Assistant Director of Nursing (ADON) in-serviced to ensure accuracy prior to signing and/or submitting the MDS
- MDS coordinator will ensure the care plan is updated when completing the MDS
- MDS sections will be audited to ensure all sections are being completed accurately by the DON or designee
- Hire new MDS coordinator
- Sign MDS coordinator up for training
Failure to Assist Resident with Personal Hygiene and Dressing
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living for a resident who was unable to independently perform these tasks. The resident, who was admitted with diagnoses including Parkinsonism, dementia, chronic pain, and muscle weakness, required extensive assistance with personal hygiene and dressing. Despite this, observations revealed that the resident was not shaved for several days, had food stains on their clothing, and had not been cleaned after meals. The resident expressed a preference to be clean, indicating that the lack of care was not due to refusal. Interviews with staff confirmed that the resident typically allowed staff to assist with shaving and that their face and hands should have been cleaned after meals. The CNA acknowledged that the resident needed extensive assistance with dressing and that the soiled shirt should have been changed if the resident agreed. The Director of Nursing also confirmed that the resident's face and hands should have been cleaned before leaving the dining room and that staff should have offered to change the soiled shirt.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 65 citations issued within 25 miles in the last 12 months — 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 Springdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shiloh Nursing And Rehab, Llc | 1.4 mi | ★★★★★ | 0 | 0 |
| Springdale Health And Rehabilitation Center | 2.1 mi | ★★★★★ | 13 | 0 |
| Westwood Health And Rehab, Inc | 2.1 mi | ★★★★★ | 1 | 0 |
| Edgewood Health And Rehab | 3.9 mi | ★★★★★ | 0 | 0 |
| The Maples At Har-ber Meadows | 4.4 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.