Average — CMS composite of the measures below.
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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 & Rehabilitation during CMS and state inspections, most recent first.
Resident Council Meeting Not Kept Private: A resident council meeting was interrupted when an LVN entered while the meeting was in progress and remained after being told staff could not be present. The LVN said she needed to take a resident's BP and give medication before leaving. The AD stated the meeting should have been private and staff should only enter when invited, while the SW said the activity director facilitated the meetings and staff had not been told they were entering uninvited.
Failure to Care Plan Secure-Unit Placement Needs: The facility did not develop person-centered care plans that addressed secure-unit placement for multiple residents, including residents with dementia and other cognitive disorders. Some residents had physician orders for specialized dementia care on a secure unit, while others were observed living or spending time on secure units without corresponding care plan focus, goals, or interventions. The DON, Regional Clinical Nurse, and Administrator all acknowledged that secure-unit needs should have been reflected in the care plans.
A facility failed to ensure physician orders were in place for residents admitted to the Alzheimer's secure care unit, and one resident also lacked a qualifying dementia diagnosis for that placement. Records showed several residents in the secure unit without the required order, while staff interviews confirmed the admission nurses, nurse managers, ADON, and DON were responsible for obtaining and monitoring those orders. The DON stated the orders had not been properly entered into the system, and the MD said residents admitted to secure units should have physician orders and a medical diagnosis of dementia before placement.
Nurse aide certification oversight failed when a full-time NA continued providing direct resident care without completing the required training and competency evaluation within the required timeframe. The DON, LVN, and ADMN stated the aide had been allowed to work after failing the skills test, while the facility’s policy and job description required competency and certification within four months of employment.
Kitchen staff were observed handling and serving food, stacking dishes, rolling silverware, and scooping ice while wearing thin hair nets that left hair exposed at the temples, neck, forehead, and behind the ears. The Dietary Manager, Lead, and other staff acknowledged they knew hair nets were required to fully cover hair during food handling, and one staff member said the facility-issued hair net would ride up and expose her hair.
An LVN entered a resident council meeting carrying meds and a BP cup, was told the meeting was in progress, and still took a resident’s BP and gave medication in front of other residents. The resident was cognitively intact per BIMS, and the AD and SW stated resident council meetings and medication administration should be private.
Inaccurate MDS reflected walker use. A resident with dementia and osteoarthritis had an MDS that indicated walker use, but PT notes and staff interviews showed she was not currently using a walker for mobility. Observations also showed her standing without a walker, and the DON and ADMN stated the MDS was expected to be accurate and based on observation and communication with staff.
The facility failed to label natural tears eye drops with an open date for several residents, as observed on two medication carts. Interviews with staff confirmed that multi-use vials should be dated when opened, as per facility policy, to prevent the use of expired medications. This oversight could lead to residents receiving expired medications.
The facility failed to maintain an effective infection control program when an LVN did not clean a glucometer between uses for two residents, risking cross-contamination. Despite being trained, the LVN admitted to not following protocol due to nervousness. The DON and Administrator confirmed the requirement for cleaning glucometers before and after each use to prevent infection.
Resident Council Meeting Not Kept Private
Penalty
Summary
The facility failed to provide a resident council meeting with private space and allowed staff to enter without being invited by the group. During an observation and interview on 05/12/2026 at 2:05 PM, LVN E entered the resident council meeting after being told that a resident council meeting was in session and that facility staff could not be present. LVN E did not leave when requested and stated she needed to take Resident #18's blood pressure and give her medication before she left, saying she would do it really quick. During an interview on 05/14/2026 at 10:00 a.m., the AD stated resident council should have been private and that staff should have only entered when invited. She stated she attended the meetings because the residents wanted her to facilitate them, and that nursing staff should have known a meeting was in progress by the activity calendar. During an interview on 05/14/2026 at 10:12 a.m., SW J stated the activities director facilitated resident council meetings and that staff had never been told they came to those meetings uninvited. Review of the facility policy titled Resident Council Meetings dated 04/20/2020 stated meeting minutes may include names of staff members, speakers, and other guests present in the meeting as invited by the group to attend.
Failure to Care Plan Secure-Unit Placement Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for 8 of 21 residents reviewed, specifically failing to include the need for residents to reside on a secure unit. The report states that the care plans for Residents #4, #5, #7, #9, #21, #24, #44, and #81 did not contain a focus, goal, or interventions addressing secure-unit placement, even when some residents had physician orders for secure-unit admission for specialized dementia care. Resident #4 was admitted with sepsis, type II diabetes, unspecified dementia, and hypertension. His quarterly MDS showed a BIMS score of 15 and no wandering, yet his physician ordered admission to a secure unit for specialized dementia care. Resident #81 was admitted with COPD, psychotic disorder with delusions, and unspecified dementia; his quarterly MDS showed a BIMS score of 6 and no wandering, and he also had a physician order for secure-unit admission for specialized dementia care. Resident #5 had dementia, major depressive disorder, and hypertension with a BIMS score of 6; Resident #7 had Parkinsonism, dementia, bipolar disorder, Alzheimer’s disease with late onset, major depressive disorder, and anxiety with a BIMS score of 15; Resident #9 had major depressive disorder, dementia, and anxiety with a BIMS score of 5; Resident #21 had Alzheimer’s disease with late onset, dementia, and cognitive communication deficit with a BIMS score of 3; Resident #44 had dementia with a BIMS score of 12; and Resident #24 had type II diabetes and major depressive disorder, with no diagnosis of dementia and a BIMS score of 15. Observations showed residents present on the secure units, including Resident #24 in a room on the 400 hall Alzheimer’s secure care unit, Resident #7 sitting in the lobby of the 100 hall Alzheimer’s secure care unit, Resident #9 standing at the nurse’s station of the 100 hall Alzheimer’s secure care unit, Resident #4 in his room on the 200 hall Alzheimer’s secure unit, and Resident #21 coming out of her room on the 200 hall Alzheimer’s secure unit. During interviews, the DON stated the MDS assessments should be accurate and that care plans should be updated with current care needs such as residing in the secure unit, but acknowledged the secure-unit need had been overlooked. The Regional Clinical Nurse stated care plans should be updated with secure-unit care needs for residents who resided on the secure unit, and the Administrator stated she expected residents on secure units to have care plan updates for that need. The facility policy stated it was the facility’s policy to develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights and identified needs.
Missing physician orders and qualifying diagnosis for secure unit placement
Penalty
Summary
The facility failed to ensure physician orders were in place for residents admitted to the Alzheimer's certified secure care unit and failed to ensure one resident had a qualifying diagnosis for placement in that unit. Resident #7 had diagnoses including Parkinsonism, dementia, bipolar disorder, Alzheimer's disease with late onset, major depressive disorder, and anxiety, but the physician orders reviewed did not include an order to admit her to the secure care unit. Resident #9 had diagnoses including major depressive disorder, dementia, and anxiety, but likewise had no physician order to admit her to the secure care unit. Resident #44 had dementia and no physician order to admit her to the secure care unit was found in the record. Resident #24 was observed in the 400 hall Alzheimer's secure care unit even though her diagnoses did not include Alzheimer's disease or another related dementia. Her admission MDS showed moderate cognitive impairment, but Section I of the MDS did not indicate Alzheimer's disease or non-Alzheimer's dementia. Her physician orders also did not include an order to admit her to the secure care unit, and her care plan did not address secure unit placement. The report states the DON later obtained a diagnosis for Resident #24 on the day of the interview, but that diagnosis and order had not been obtained before she was placed in the secure unit. Observations showed Resident #7 and Resident #9 in the 100 hall Alzheimer's secure care unit and Resident #24 and Resident #44 in the 400 hall Alzheimer's secure care unit. Interviews with the LVN, ADON, DON, RCN, ADMN, and MD confirmed that residents on the secure units should have physician orders and qualifying diagnoses, and that the admission nurses, nurse managers, ADON, and DON were responsible for obtaining and monitoring those orders. The DON stated the orders for Resident #7, Resident #9, Resident #24, and Resident #44 had not been properly entered into the system, and that Resident #24's qualifying diagnosis and order should have been obtained before admission to the secure unit.
Nurse Aide Not Certified Within Required Timeframe
Penalty
Summary
The facility failed to ensure that a full-time nurse aide was certified within four months of hire. Record review showed NA C was hired on 10/29/2025 as a full-time nurse aide and began working on the floor providing resident care on 11/3/2025. During interviews, NA C stated she had completed an online course before hire, passed the written test at the end of March 2026, failed the skills test on 4/21/2026, and was scheduled to retake it on 5/26/2026. The DON stated NA C had been working as a full-time nurse aide and was taken off the schedule on the day of the survey. Interviews with LVN D, the DON, and the ADMN showed the facility allowed NA C to continue providing direct resident care after failing the clinical skills test. LVN D stated the facility performed its own skills checkoff and allowed nurse aides to provide showers, incontinent care, feeding assistance, and other direct care independently, though they could not use the mechanical lift. The DON stated LVN D was responsible for making sure nurse aides were certified, and the ADMN stated her expectation was that nurse aides complete training and the CNA test within 180 days of working full-time; if the clinical test was failed, they should be moved to hospitality aid until they passed. The facility policy required nurse aides to demonstrate competency in skills and techniques necessary to care for residents' needs, and the job description stated nurse aides must be certified or complete state-required training and competency evaluation within four months of employment.
Kitchen Staff Failed to Fully Cover Hair While Handling and Serving Food
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. During observations on 05/12/2026 and 05/13/2026, multiple kitchen staff members were seen handling food, utensils, and kitchen equipment while wearing thin hair nets that did not fully contain their hair. The Dietary Manager had a hair net covered by a gray headband with about 1 inch of hair exposed above the neck. The Lead had hair exposed at both temples and above the forehead. Other staff were observed with exposed hair at the back of the neck, temples, and behind the ears while placing dinner rolls on a baking sheet, stacking cups, rolling silverware into napkins, stacking bowls, and scooping ice into cups. During interviews, the Lead, Dietary Manager, and kitchen staff acknowledged they had been trained in food handling and knew hair nets were required to cover all hair while working in the kitchen and serving food. They stated that uncovered hair could fall into food and cause cross-contamination or illness. One staff member stated the facility-provided hair net would not stay on properly and would ride up, exposing her hair. Another staff member who did not speak English was interviewed through interpretation and stated she knew her hair had to be covered to prevent hair from falling into food.
Resident Council Privacy Breach During Medication Administration
Penalty
Summary
The facility failed to treat a resident with respect and dignity when an LVN entered a resident council meeting carrying a medication cup and blood pressure cup, was told the meeting was in progress, and still proceeded to take the resident’s blood pressure and administer medication in front of the other residents attending the meeting. The resident involved was a 93-year-old female admitted to the facility with diagnoses including dementia, dysphagia, lack of coordination, and cognitive communication disorder. Her quarterly MDS documented a BIMS of 15, indicating she was cognitively intact. During the observation, the LVN stated she needed to do it really quick and completed the blood pressure check and medication administration in the meeting area in front of 10 residents. The resident stated the LVN was just trying to do her job and that receiving medication in a public setting did not happen very often. The AD stated resident council should have been private and staff should have left when informed a meeting was in progress. The SW stated resident council meetings were a resident right and that residents had the right to have vitals and medications administered in private.
Inaccurate MDS reflected walker use
Penalty
Summary
The facility failed to ensure Resident #9’s MDS assessment accurately reflected her use of a walker. Resident #9 was a [AGE]-year-old female admitted with diagnoses including dementia and osteoarthritis. Her quarterly MDS reflected a BIMS score of 05, indicating severe cognitive impairment, and also indicated that she used a walker as a mobility device. However, the comprehensive care plan stated she was independent with ambulation using a walker, while PT documentation showed she was able to perform standing activity and gait training using no ambulatory aid (walker). PT certification period documentation further stated that due to her cognitive status and poor safety education memory, the two-wheel walker had recently become a safety hazard because she was leaving it in unsafe areas and not using it for mobility purposes. During observation, Resident #9 was seen standing by the nurses’ station and later standing in a doorway without a walker and without holding onto anything for support. Staff interviews reflected that she did not currently use a walker for mobility, with one LVN stating she did not utilize a walker at this time and a CNA stating she had used one in the past but not for the last month or two. The DON stated the MDS nurse was responsible for ensuring assessments were accurate and that if the resident did not need a walker, it should not have been checked on the MDS. The ADMN stated the MDS assessment was expected to be filled in accurately by the MDS nurse, and the facility policy required the assessment process to include direct observation and communication with the resident and direct care staff.
Failure to Label and Store Medications Properly
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled and stored according to professional standards, specifically concerning the labeling of natural tears eye drops. During observations, it was noted that the medication carts for Unit #1 and Unit #2 contained bottles of natural tears eye drops without an open date for four residents. This oversight was confirmed during interviews with the LVN and the DON, who both acknowledged that multi-use vials, including eye drops, should be dated when opened to prevent the administration of expired medications. The facility's policy on over-the-counter medications requires that multi-use eye drops be dated when opened and are valid for 28 days. However, the lack of open dates on the eye drops for the residents indicates a failure to adhere to this policy. The Administrator also confirmed that it was the nurse's responsibility to label medications upon opening, and the absence of such labeling could lead to the administration of expired medications, posing a risk to residents' safety.
Infection Control Deficiency Due to Improper Glucometer Use
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper handling of a glucometer by LVN A. During an observation, LVN A did not clean the glucometer after using it for one resident and before using it for another, which could lead to cross-contamination and infection. LVN A admitted to not following the proper procedure due to nervousness while being observed, despite being trained on the correct protocol. The Director of Nursing (DON) and the Administrator confirmed that the facility's policy requires glucometers to be cleaned before and after each use to prevent infection. Both acknowledged that the failure to adhere to these procedures could result in cross-contamination. The facility's policy and LVN A's personnel file indicated that she was up to date with all training, including infection control and glucometer use, yet the deficiency occurred.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Abilene
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wesley Court Health Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Mesa Springs Healthcare Center | 2.3 mi | ★★★★★ | 15 | 0 |
| Wisteria Place | 2.7 mi | ★★★★★ | 5 | 1 |
| Brightpointe At Lytle Lake | 5 mi | ★★★★★ | 10 | 2 |
| Willowcreek Rehab And Nursing | 5.2 mi | ★★★★★ | 9 | 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.