Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Windcrest Nursing And Rehabilitation during CMS and state inspections, most recent first.
Food Storage and Date Marking Deficiencies: Surveyors observed unlabeled ice cream in the prep freezer, butter and cheese in the prep refrigerator without proper discard dating, and boxes stored too close to the ceiling in the walk-in refrigerator. A package of tortillas also lacked a discard date. The CDM and RD stated staff sometimes did not label food names or discard dates, and the facility policy and FDA Food Code required dated and labeled refrigerated foods.
A resident dependent on staff for showers did not receive consistent bathing because a CNA said she was told by the Administrator not to provide care for him due to personality conflicts. In addition, two residents with care plans for eating assistance were observed at lunch without staff in the room helping them, despite one resident being dependent for eating and the other needing limited to extensive assistance.
The facility failed to ensure RN coverage for at least 8 consecutive hours per day, 7 days a week. Payroll review showed no RN services on multiple days, and the Incidents & Accidents review did not identify negative resident outcomes related to the lack of RN coverage. The Administrator stated she was not aware of the missed coverage, noted the former DON was available on-call, and said the DON was responsible for ensuring RN coverage and notifying her of any non-coverage.
Improper Storage and Labeling of Latanoprost in Medication Carts: The facility failed to ensure Latanoprost eye drops in two med carts were properly labeled and discarded within the allowed room-temperature timeframe after removal from refrigeration. One vial in the B hall cart had an opened date showing it was kept past 6 weeks, and in the C hall cart one vial had no open date while another was also kept past 6 weeks. The MA, RN, and DON each acknowledged the labeling and storage problems.
The facility failed to maintain infection control practices for 3 CNAs observed. Two CNAs were seen leaving resident rooms with unbagged soiled linen, including one who wore gloves in the hallway, and both stated the linen should have been bagged before transport. A CNA caring for a resident with a foley catheter donned PPE in the wrong order and did not change gloves or perform hand hygiene during catheter care, including before touching the catheter tube and before continuing care.
Broken Drawer Left in Resident Room: A broken drawer with the front hanging off and bent joints was observed placed on top of a dresser in a resident room. Staff interviewed stated they were not aware the drawer was broken, and different staff described notifying maintenance through a supervisor, maintenance book, or electronic work order system. The maintenance staff member stated he had not been notified of the broken drawer, and the facility policy stated resident equipment should be clean and properly maintained.
MDS Did Not Reflect Depression Diagnosis: A resident with Parkinson’s disease and adult failure to thrive had a quarterly MDS that did not list any psychiatric or mood disorder in Section I, despite active orders for sertraline for depression and a psych NP note documenting major depressive disorder, recurrent, moderate. The MDS NS and DON stated the MDS diagnoses should match provider documentation and orders, and that inaccurate or missing diagnoses could affect psychotropic medication monitoring.
Failure to monitor oxygen saturation per physician order. A resident with COPD, atrioventricular block, and peripheral autonomic neuropathy had an order for O2 at 2 L/min via NC to maintain sats above 92% as needed for SOB, but records showed no oxygen saturation monitoring on the MAR/TAR. Staff interviews confirmed the RN did not routinely check oxygen levels, the LVN did not monitor them, and the ADON stated she would expect oxygen saturations to be monitored at least once per shift for residents with PRN oxygen orders.
A resident with dysphagia, dementia, and a pureed diet order was served a lunch tray that included 2 baked cookies that were not pureed. Staff stated the tray ticket had been reviewed before the tray was passed out, but the ADON said she may have missed the non-pureed item. Dietary and nursing staff confirmed tray tickets were supposed to match the tray contents and that pureed diets should contain pureed foods.
Incomplete and Inaccurate Medical Record Documentation: A resident’s chart did not consistently document depression, even though Remeron was ordered for depression, and the MDS also omitted that diagnosis. The care plan also inaccurately described a behavior history involving reports of being beat up, while progress notes did not document any abuse allegation occurring at the facility; staff interviews confirmed they were unaware of such incidents.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, compromising resident safety.
A male resident with a history of sexually inappropriate behavior was not consistently monitored or supervised, leading to two incidents of non-consensual sexual contact with a severely cognitively impaired female resident. Staff interviews revealed gaps in communication and training regarding required one-to-one supervision, and documentation errors contributed to the failure to implement effective preventative measures.
A resident with significant cardiac history experienced an unwitnessed fall and did not receive all required neurological assessments at scheduled intervals. The LPN on duty missed several neuro checks and did not inform the incoming nurse, who also failed to perform or document a neurological assessment or vital signs. The resident was later found deceased, and staff interviews confirmed that the facility's neuro check protocol was not followed or communicated as required.
A CNA assisted a resident with severe cognitive and physical impairments in dressing and standing, during which both lost balance and ended up on the floor. The CNA did not report the incident, believing it was not a fall, and the resident was not assessed for injuries until the next day when pain and a fractured arm were discovered. The facility failed to follow its policy requiring immediate reporting of suspected neglect and injury.
A resident with dementia and major depressive disorder, who exhibited sexually inappropriate behaviors, did not receive the 1:1 supervision intervention as outlined in their care plan. Staff interviews and record reviews showed inconsistencies in implementing and documenting this intervention, despite it being added to the care plan to address the resident's behaviors.
A resident with dementia, osteoporosis, and on hospice care did not receive prescribed Methadone on three occasions because the medication was not available at the time of administration. Nursing staff confirmed the missed doses and the need to request urgent refills, while documentation showed the facility was responsible for ensuring medication availability and administration as ordered.
The facility failed to implement policies to prevent abuse, neglect, and exploitation by not conducting required EMR/NAR checks for three newly hired agency CNAs. The facility relied on the agency's OIG checks, which did not include EMR/NAR, potentially placing residents at risk.
The facility failed to report several allegations of abuse, neglect, and injuries of unknown origin involving multiple residents to the appropriate authorities within the required timeframes. Incidents included unwitnessed injuries, neglect due to lack of clean mechanical lift slings, and complaints of verbal abuse and medication errors by staff. These failures violated the facility's prevention program and could place residents at risk for harm.
A resident with Alzheimer's and severe cognitive impairment was left in bed for long periods without necessary assistance for ADLs, including hydration, eating, and personal hygiene. Despite requiring extensive support, the resident was observed eating alone, spilling food, and lacking hydration, with no fall mats in place despite being a fall risk. Staff interviews and observations highlighted a lack of reporting and adherence to the care plan.
A resident with a history of a broken hip and stroke was not provided with necessary assistance to maintain continence, as his custom wheelchair did not fit into the bathroom. Despite being continent upon admission, the resident was forced to rely on adult briefs, which he found undignified. Staff were instructed not to assist him to the toilet due to safety concerns, leading to a deficiency in care.
The facility failed to ensure snacks were offered to all residents at bedtime, resulting in more than 14 hours between dinner and breakfast for some residents. Interviews revealed that only certain residents received labeled snacks, and staff were unaware of the requirement to offer snacks to all residents. This oversight placed residents at risk for unplanned weight loss and other health issues.
A resident's hard-shell helmet was found dirty with hair and stains, indicating a failure to maintain a clean and homelike environment. Interviews with staff revealed inconsistencies in cleaning procedures, with a CNA unsure of documentation and the DON unable to confirm the last cleaning. The facility's policy requires decontamination of equipment between residents.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their specific needs. One resident's care plan did not include interventions for her anxiety disorder, while another resident's plan lacked provisions for non-verbal pain assessment and communication tools. These oversights resulted in inadequate management of their conditions and unmet care needs.
A resident with hemiplegia, hemiparesis, and aphasia experienced unmanaged mouth pain due to the facility's failure to use communication boards and pain scales. Despite requiring extensive assistance with daily activities, the care plan lacked necessary tools for effective communication and pain management, leading to unmet personal care needs and inadequate pain relief.
A resident with severe cognitive impairment and at risk for pressure ulcers did not have a pressure-relieving cushion on her wheelchair, despite an active order. Observations and staff interviews revealed confusion about responsibility for ensuring the cushion was in place, with no specific guidance in the facility's policy.
A resident with dementia and a high risk for falls was left unsupervised in the dining room, despite her care plan requiring constant supervision. Observations showed no staff present, and interviews revealed staff were unaware of the supervision requirement. The facility's policy on person-centered care plans was not followed, putting the resident at risk of injury.
A resident with heart failure and diabetes was administered Midodrine despite having a systolic blood pressure above the prescribed threshold. The medication was given twice in July 2024, contrary to the physician's orders to hold it if SBP exceeded 130. The DON was unaware of the errors, and no staff reported the incidents, despite the facility's policy requiring adherence to prescribed medication administration practices.
A resident with dementia and other conditions experienced a significant decline, but the LTC facility failed to notify the family, believing hospice would do so. The DON and Administrator confirmed the facility's policy required direct notification to the family.
A resident in a LTC facility was allegedly abused by a healthcare aide, who was witnessed slapping the resident. The facility failed to immediately remove the aide from duty and did not report the incident within the required timeframe. Additionally, not all staff received proper training on abuse and neglect following the incident. The resident, who had dementia and was under hospice care, exhibited new behaviors of rejecting care, but did not receive psychiatric services.
A resident with a history of heart failure, hypertension, and high cholesterol exhibited stroke symptoms, including left-sided weakness and slurred speech, which were reported by therapy staff. However, the RN on duty dismissed the concerns, attributing symptoms to shoulder pain and administering Tylenol. The resident was not sent to the hospital until six hours after the initial symptoms were reported, due to a lack of communication and documentation among staff.
A staff member at an LTC facility misappropriated over $5,000 from a deceased resident's bank account by stealing their debit card. The theft was discovered through surveillance footage, and the staff member was charged with debit/credit card abuse. The facility failed to prevent this incident, despite having a policy in place to protect residents from such exploitation.
A facility failed to update a resident's care plan to reflect a doctor's order for honey consistency liquids, leading CNAs to administer nectar thick liquids instead. The resident, with conditions including dementia and dysphagia, was at risk of aspiration due to this oversight. Despite the kitchen providing the correct liquids during meals, the care plan's outdated information caused a discrepancy in care.
Food Storage and Date Marking Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During the initial kitchen tour, surveyors observed containers of ice cream in the food preparation freezer that were dated but not labeled with the name of the food product. In the food preparation refrigerator, a clear container held butter and cheese; the cheese was labeled with the product name and an open date, while the butter had an older date label and no discard date. The CDM stated that sometimes food product names were labeled and sometimes they were not, and that the butter label was probably old. He also stated the cheese date was the open date and it was supposed to be placed back in the freezer, and that there were no discard dates on either item. In the walk-in refrigerator, surveyors observed boxes stored on the top shelf less than 12 inches from the ceiling, and a package of tortillas labeled with a date but no discard date. The CDM stated the boxes should be moved to lower shelves and that kitchen staff did not write discard dates because they knew when to throw food away. The RD stated food products only had to be labeled by name if they could not be identified and that discard dates were not required, while also stating foods needed an open date and staff knew when to throw them out. The facility policy required refrigerated foods to be dated, labeled, and tightly sealed, and to use leftovers within 72 hours, while the FDA Food Code required date marking for ready-to-eat refrigerated foods held more than 24 hours.
Inconsistent showers and missed feeding assistance
Penalty
Summary
The facility failed to ensure a resident dependent on staff for showers received consistent bathing during July and August 2025. Resident #76 was a male with Parkinson’s disease and adult failure to thrive, and his care plan directed staff to provide shower assistance. His shower schedule was documented for Tuesdays, Thursdays, and Saturdays each week, but the shower record showed missed showers on 7/31/25 and 8/9/25. A CNA stated she was assigned to the resident’s hall on those dates but did not assist with showers because the Administrator had directed her not to provide care for him due to personality conflicts, and she was unsure whether another CNA was asked to help. The facility also failed to provide appropriate feeding assistance to two residents during the 08/14/25 lunch meal. Resident #28 had diagnoses including weakness, protein-calorie malnutrition, and Alzheimer’s disease, and his MDS reflected setup or clean-up assistance for eating, while his care plan stated he required supervision to limited assistance by one staff member for eating. Resident #69 had diagnoses including dysphagia, dementia, and cognitive communication deficit, his MDS reflected he was dependent for eating, and his care plan directed extensive assistance by one staff member because he sometimes attempted to eat without assistance. During observation on 08/14/25, Resident #69 was eating lunch and Resident #28 appeared to be having trouble eating, but no staff were in the room assisting either resident. The Reg NS later entered the room and asked if they needed help eating. In interview, the Reg NS stated Resident #69 appeared more alert and did not need much help that day, while Resident #28 may need help with eating; she also stated there was no one in the room helping them at lunch. CNA H stated Resident #69 needed extensive assistance with eating when she worked with him and that Resident #28 was starting to need extra assistance when eating, and she would sometimes help both residents when working with them.
No RN Coverage on Multiple Days
Penalty
Summary
The facility failed to ensure the services of an RN for at least 8 consecutive hours a day, 7 days a week. Record review of RN staff payroll hours for 1/1/2025 through 8/14/2025 showed no RN services on 04/13/25, 04/19/25, 04/27/25, 05/04/25, 05/10/25, and 05/11/25. Review of the facility's Incidents & Accidents for April 2025 and May 2025 did not show any negative resident outcomes related to the lack of RN services. During an interview on 8/14/25, the Administrator stated she was not aware there was no RN coverage on those dates, said the former DON was available on-call as needed, and stated the DON was responsible for ensuring RN coverage and notifying her of any non-coverage. The Administrator also stated the facility follows TAC guidelines to use an RN for at least 8 consecutive hours per day, 7 days per week.
Improper Storage and Labeling of Latanoprost in Medication Carts
Penalty
Summary
The facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and stored under proper temperature control for 2 of 3 medication aide carts reviewed, specifically the B hall and C hall carts. During observation and interview, a vial of Latanoprost was found in the B hall cart with an opened date of 6/28/2025, which was 56 days old, and the medication aide stated she was unsure when it should be discarded after removal from refrigeration. In the C hall cart, one vial of Latanoprost was observed without any date showing when it had been opened, and a second vial was dated 7/7/2025, which was 47 days old. The RN stated the undated vial should have had a date and would be discarded because she was not sure when it was opened, and she stated the dated vial should also have been discarded. The DON stated Latanoprost could be stored at room temperature for six weeks and was unaware that multiple vials were being stored in medication carts past 6 weeks. The facility policy reviewed stated medications requiring refrigeration should be stored appropriately.
Infection Control Failures With Soiled Linen Handling and Foley Catheter Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for 3 of 4 CNAs observed for infection control. CNA N was observed leaving a resident’s room with unbagged linen in the hallway while wearing gloves, and stated she had been assisting with incontinent care and a linen change but did not bag the soiled linen before leaving because she was in a hurry. CNA M was later observed carrying unbagged linen out of a resident’s room in the acute rehabilitation hall after assisting with a linen change and stated he did not have a trash bag in the room, so he chose to carry it out. The DON stated the facility expectation was that all soiled linen be bagged before exiting a resident’s room. Record review of the facility’s Infection Control policy did not include guidance related to transporting soiled linen. CNA O was observed preparing to provide care for a resident with a foley catheter and EBP precautions. She donned gloves first and then a disposable gown, stating the picture on the EBP sign indicated the order for PPE application. While assisting the resident with removing clothing, repositioning, and catheter care, CNA O did not change gloves or perform hand hygiene before touching the catheter tube or before continuing care. CNA O stated she should have changed gloves and performed hand hygiene after removing the resident’s clothing, and the DON stated the facility expectation during foley catheter care was glove changes and hand hygiene before and after performing catheter care and during the procedure. Record review of the CNA catheter care policy directed staff to wash hands and put on gloves, then remove gloves and wash hands and don new gloves during catheter care.
Broken Drawer Left in Resident Room
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 4 rooms reviewed for physical environment when a broken drawer was found placed on top of a dresser in room [ROOM NUMBER]. The drawer front was hanging off and the joints were bent. During the observation, the broken drawer was present in the room, and staff interviewed at the time stated they were not aware the drawer was broken. During interviews, HSKPR A stated she would notify her supervisor if equipment was broken, CNA A stated maintenance should be notified right away if something was broken so a resident could not get hurt, RN B stated she would notify maintenance staff right away if she saw something broken, and LVN A stated she would submit a work order in the electronic reporting system to notify maintenance. Maint A stated he had not been notified that a drawer was broken and would remove it from the room and repair it right away. Record review of the facility policy titled Environmental Services dated 05/2022 stated resident equipment and equipment used by residents should be clean and properly maintained.
MDS Did Not Reflect Resident’s Depression Diagnosis
Penalty
Summary
The facility failed to ensure Resident #76’s assessment accurately reflected the resident’s status by omitting a diagnosis of depression from the quarterly MDS submitted 7/4/2025. Resident #76 was a [AGE]-year-old male admitted on [DATE] with diagnoses including Parkinson’s Disease and adult failure to thrive. The MDS reflected a BIMS score of 10, indicating moderately impaired cognition, and Section I did not list any psychiatric or mood disorders. Record review showed active orders for Buspirone HCl 5 mg three times daily for anxiety and Sertraline HCl 25 mg daily for depression. A psychiatric nurse practitioner evaluation dated 8/06/2025 documented major depressive disorder, recurrent, moderate, and included depression in the assessment/plan with sertraline and buspirone. In interviews, the MDS NS stated diagnoses related to psychotropic medications were drawn from provider documentation and that the MDS should accurately reflect provider diagnoses. The DON stated the MDS diagnoses should match the resident’s orders and provider diagnoses and that inaccurate or missing diagnoses could result in improper monitoring of psychotropic medications.
Failure to Monitor Oxygen Saturation per Physician Order
Penalty
Summary
The facility failed to ensure that Resident #10 received oxygen monitoring in accordance with the physician’s order to maintain oxygen saturations above 92% as needed for shortness of breath. Resident #10 was a [AGE]-year-old female admitted on [DATE] with diagnoses including COPD, atrioventricular block, and peripheral autonomic neuropathy. Her MDS dated [DATE] showed a BIMS score of 8, indicating moderate cognitive impairment, and noted that oxygen was not in use and no special treatments were received. The active physician order dated 8/14/2025 directed oxygen at 2 L/min via nasal cannula to maintain O2 sats greater than 92% as needed for SOB.
Pureed Diet Not Followed on Meal Tray
Penalty
Summary
The facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 8 residents reviewed for dietary services. Resident #69 had diagnoses including dysphagia, dementia, and cognitive communication deficit, and his care plan reflected that he was at risk for aspiration, weight loss, and complications related to dysphagia. His quarterly MDS indicated he had a mechanically altered diet, and his order summary showed a pureed texture diet with regular consistency. During lunch meal service, Resident #69 was observed with 2 baked cookies on his meal tray even though his ordered diet was pureed. A nursing student confirmed the cookies were not pureed and stated a nurse had reviewed the tray ticket before the tray was given to the resident. The ADON stated she checked the tray ticket and may have missed the cookie that was not pureed on the plate. The CDM, RD, and dietary staff stated tray tickets were checked before meals were passed out and that it was important for the tray contents to match the resident's diet order, especially for pureed diets.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for Resident #6. The resident’s electronic health record did not reflect a diagnosis of depression on the admission record, even though the medication list showed Remeron Oral Tablet 15 MG ordered at bedtime for depression. The quarterly MDS assessment also did not reflect a diagnosis of depression, while the care plan included a focus that the resident used antidepressant medication related to poor appetite and an intervention to administer antidepressant medications as ordered by the physician. The resident’s care plan also did not accurately document a behavior history related to the resident reporting that someone had beat her up when no one was around her. The care plan listed a behavior problem and stated that the resident reports she has been beat up when nobody is around her, but progress notes did not document any allegation of abuse occurring at the facility. During interviews, staff stated they were not aware of any incidents or allegations of abuse at the facility, and the MDS nurse noted the record did not show a diagnosis of depression and that the care plan language should have reflected a history of reporting being beat up rather than an event occurring at the facility.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a severely cognitively impaired female resident from sexual abuse by another male resident with a history of sexually inappropriate behaviors. The male resident, who had diagnoses including dementia and major depressive disorder but was assessed as cognitively intact, had documented incidents of inappropriate sexual behavior, including masturbating in public and making sexual advances toward staff and other residents. Despite these documented behaviors, the facility did not consistently implement or communicate effective preventative measures, such as one-to-one supervision, to all staff members responsible for his care. On two separate occasions, the male resident engaged in non-consensual sexual contact with the female resident, who was unable to consent due to her cognitive impairment. The first incident involved kissing, and the second involved fondling in a common area. Staff interviews revealed a lack of awareness and training regarding the need for one-to-one supervision for the male resident, with several CNAs and new hires stating they were not informed about any such requirements or the resident's behavioral risks. Documentation errors were also noted, including backdating of care plan interventions and inconsistent communication of behavioral interventions across shifts and departments. The facility's records showed that previous incidents of sexually inappropriate behavior by the male resident were discussed in meetings but did not always result in clear, actionable interventions or consistent staff oversight. There was no established process to ensure that information about behavioral risks and required interventions was reliably passed on between shifts or to all relevant staff. As a result, the male resident was observed unsupervised in his room and in common areas, and staff failed to prevent further incidents of abuse against the cognitively impaired female resident.
Removal Plan
- The Administrator/designee will place the male resident involved on 1:1 supervision immediately to ensure no sexually inappropriate behavior occurs. This 1:1 supervision will be provided until alternate placement for resident #1 is secured or he is cleared by the medical director or psychiatrist.
- Resident #2 was evaluated by the psychiatric nurse practitioner. The psychiatric nurse practitioner did not note a deviation of the resident's baseline behavior or mood. Resident #2 has an order for behavior monitoring that occurs every shift and is ongoing to monitor for mood changes.
- The Administrator/Designee will interview all team members to determine if team members have knowledge of any inappropriate sexual behavior of male residents that may have occurred and has not been reported. If any are identified, an immediate assessment and a self-report will be completed.
- The Administrator and Director of Nursing will be educated by the Regional Director of Clinical Services on reportable sexually inappropriate behavior, including: residents must have the capacity to make decisions to give consent for sexual activity; sexual activity without consent or cognitive ability to give consent is a reportable event; definitions of abuse and sexual abuse; monitoring for sexually aggressive behavior; and placing any resident displaying sexually inappropriate behaviors involving non-cognitive residents on 1:1 supervision until evaluated and deemed safe.
- DON/Designee will provide training for all team members on reportable sexual inappropriate behavior, including: education on male residents' 1:1 status and sexually inappropriate behavior; sexual activity without consent or cognitive ability to give consent is a reportable event; definitions of abuse and sexual abuse; monitoring for sexually aggressive behavior; reporting all sexually inappropriate behavior to the Admin/DON immediately and intervening to prevent any injury; training to be provided upon hire, annually, and as needed; all staff to be educated before their next scheduled shift.
- Education was provided to all staff regarding residents who do not have the cognitive ability to give consent.
- The Administrator/Designee conducted safe surveys with all cognitively intact residents residing on the A and B wings, asking about inappropriate touching or unwelcome advances and feelings of safety.
- DON/Designee completed full skin assessments for non-cognitively intact residents residing on A and B wings to check for evidence of sexually inappropriate behavior or signs of sexual abuse.
- DON/Designee will monitor process compliance and understanding daily during the morning clinical process and room rounding observations.
- An Ad Hoc QAPI committee meeting was held with the Medical Director regarding the current IJ and plan of correction.
- Results of in-servicing and interviews will be reviewed during the monthly QA meeting.
Failure to Complete and Communicate Required Neurological Assessments After Resident Fall
Penalty
Summary
A deficiency occurred when nursing staff failed to provide neurological assessments in accordance with professional standards of practice for a resident following an unwitnessed fall. The resident, who had a history of atrial fibrillation, atherosclerotic heart disease, hypertension, and a recently implanted pacemaker, was found on the floor in her bedroom early in the morning. Initial neurological checks were performed every 15 minutes as required, but subsequent scheduled assessments at 6:45 AM and 7:15 AM were not completed or documented by the nurse on duty. The nurse also failed to communicate the missed assessments to the oncoming nurse during the shift change. The oncoming nurse, who arrived late for her shift, did not perform a neurological assessment when she first checked on the resident, nor did she document the resident's vital signs. Shortly after, the resident was found unresponsive and was pronounced deceased. Documentation and interviews confirmed that the required neuro checks were not performed or recorded as per the facility's protocol, and there was a lack of clear communication between nursing staff regarding the resident's ongoing assessment needs. Interviews with staff revealed that all were aware of the facility's neuro check protocol, which required immediate initiation of neurological assessments after any unwitnessed fall or head injury, with specific intervals for monitoring and documentation. Despite this, the protocol was not followed in this instance, resulting in a lapse in the standard of care provided to the resident.
Failure to Timely Report and Investigate Resident Fall Resulting in Injury
Penalty
Summary
The facility failed to ensure that an alleged violation involving neglect was reported immediately, but not later than 24 hours, to the administrator and appropriate authorities as required by policy and regulation. A certified nursing assistant (CNA) assisted a resident with dementia, muscle weakness, and ataxic gait in dressing and attempted to help her stand from the bedside. During this process, both the CNA and the resident lost their balance and ended up on the floor. The CNA did not report this incident to the nurse, the Director of Nursing (DON), or the Administrator. The resident, who was dependent on staff for dressing and transfers due to severe cognitive and physical impairments, was not assessed for injuries following the incident because the CNA did not believe the event constituted a fall and therefore did not report it. The nurse on duty during the shift was unaware of the incident and did not perform an assessment. The following day, another CNA noticed the resident had shoulder pain during ADL care, and a nurse subsequently assessed the resident, discovering limited range of motion and pain in the left arm. A mobile x-ray revealed a fractured arm, and the resident was sent to the hospital for further evaluation and treatment. The facility's policy requires immediate reporting of suspected abuse, neglect, or injury of unknown source to the administrator and appropriate authorities. The incident was not reported until the injury was discovered and investigated by the administrator the following day. The delay in reporting and assessment resulted from the CNA's misunderstanding of what constitutes a fall and the failure to follow established reporting procedures.
Failure to Implement Person-Centered Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident with a history of dementia and major depressive disorder, who exhibited sexually inappropriate behaviors. The resident's care plan identified issues such as entering other residents' rooms, masturbating in inappropriate settings, making sexually inappropriate comments, and attempting to touch female staff and residents. The care plan included an intervention for 1:1 supervision when the resident was out of bed and room, with the goal of reducing these behaviors. However, interviews and record reviews revealed that this intervention was not consistently implemented as intended. Staff interviews indicated that while the inappropriate behaviors were discussed in morning meetings and interventions were added to the care plan, there were inconsistencies in the documentation and implementation of the 1:1 supervision intervention. The intervention was backdated in the care plan, and staff acknowledged the importance of following interventions as part of the resident's care plan. The facility's policy required the care plan to describe services to maintain the resident's highest practicable well-being, but the failure to implement the 1:1 supervision intervention as planned resulted in the deficiency.
Missed Methadone Doses Due to Medication Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring the accurate acquiring, receiving, dispensing, and administering of Methadone as ordered. Specifically, a resident with multiple diagnoses including dementia, osteoporosis, osteoarthritis, and who was on hospice care, did not receive her prescribed Methadone oral tablet on three occasions: once in July 2024 and twice in February 2025. Medication Administration Records (MAR) showed blank entries for the missed doses, and progress notes confirmed that at least one dose was not administered because the medication was not available. The nurse requested a STAT refill from hospice, and the resident was assessed for pain, which was documented as 0/10 at the time of the missed dose. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the facility was responsible for ensuring medication availability and administration as ordered. The process for obtaining urgent medication refills involved notifying hospice or the charge nurse, but in this instance, the medication was not on hand when needed. The facility's policy outlined procedures for refill and urgent orders, but the failure to have Methadone available resulted in missed doses for the resident.
Failure to Conduct Proper Background Checks for Agency CNAs
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. This deficiency was identified in the files of three newly hired CNAs (A, B, and C) who were agency staff. The facility did not conduct the required EMR/NAR checks for these CNAs before they began working on the floor. Although the agency completed OIG background checks, the facility did not verify these checks included EMR/NAR, which is a requirement according to their policy. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention, dated April 2021, mandates conducting employee background checks and not employing individuals with findings in the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of their property. However, the facility's administrator admitted that they did not check the CNAs' background for EMR/NAR, relying instead on the agency's OIG checks. This oversight could place residents at risk of abuse, neglect, and exploitation.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and injuries of unknown origin to the appropriate authorities within the required timeframes. Specifically, the Administrator, Director of Nursing (DON), and various Licensed Vocational Nurses (LVNs) did not report several incidents involving Resident #15, including unwitnessed injuries and allegations of neglect. On multiple occasions, Resident #15 was found with injuries such as abrasions and bruises, and there were complaints from the resident's representative about neglect due to a lack of clean mechanical lift slings. Despite these incidents, the facility did not report them to the state agency as required. Additionally, the facility failed to report allegations of abuse and neglect involving Residents #140 and #141. Resident #140 complained about a rude overnight nurse, lack of an arm sling, and issues with pain medication, while Resident #141 reported verbal abuse and negligence in pain medication administration by the overnight nurse. These grievances were documented but not reported to the state agency, as the DON and Administrator did not consider them reportable incidents. The facility's failure to report these incidents is a violation of their Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, which mandates the identification, investigation, and reporting of all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property within the required timeframes. The lack of timely reporting could place residents at risk for harm by abuse or neglect, as the facility did not adhere to established procedures for protecting residents from such incidents.
Failure to Provide Necessary ADL Support for Resident
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to perform activities of daily living (ADLs) independently. The resident, who had Alzheimer's disease, anxiety disorder, and weakness, was observed left in bed for extended periods without assistance. On multiple occasions, the resident was found without hydration at his bedside and with remnants of meals on his gown and bed linens, indicating a lack of assistance with eating and personal hygiene. The resident's care plan required extensive assistance with dressing, personal hygiene, toileting, and transferring, as well as limited assistance with eating. Despite these requirements, the resident was observed eating alone and spilling food, and there was no evidence of staff providing the necessary support. Additionally, the resident was identified as a fall risk, yet no fall mats were placed beside the bed, and the resident's refusal to get out of bed was not reported by the CNA responsible for his care. Interviews with staff and observations revealed that the resident often refused to get out of bed and was left without water, relying on a roommate's representative for hydration. The facility's policy stated that residents should receive care to maintain or improve their ADLs, but the resident's needs were not adequately met, as evidenced by the lack of hydration, assistance with meals, and personal hygiene support.
Failure to Support Resident's Continence and Bathroom Use
Penalty
Summary
The facility failed to ensure that a resident who was continent of bladder and bowel upon admission received the necessary services and assistance to maintain continence. This deficiency was identified for one resident who was reviewed for their right to use the bathroom. The resident, who had a history of a broken right hip and right-side body weakness following a stroke, was assessed with moderate cognitive impairment but had adequate hearing and speech. Despite being able to make himself understood and understand others, the resident was not provided with a toileting program and was instead assessed as frequently incontinent. The resident expressed grievances about being unable to use the bathroom due to the size of his custom wheelchair, which did not fit into the bathroom. The resident felt that he was being forced to soil himself and rely on adult briefs, which he found undignified. Despite his requests for assistance to use the toilet, staff were instructed not to take him to the bathroom, citing safety concerns. The resident's care plan indicated that he required extensive assistance for toileting and transfers, but no effective solution was implemented to address his needs. Interviews with staff, including the Director of Rehabilitation and the Physical Therapist, confirmed that the resident's larger wheelchair was necessary after his hip fracture, but it could not fit into the bathroom. The facility's maintenance director confirmed that all resident bathrooms were of the same size, which was inadequate for the resident's needs. Despite the resident's grievances and the facility's policy on supporting activities of daily living, the resident's right to use the bathroom was not upheld, leading to a deficiency in care.
Failure to Provide Bedtime Snacks
Penalty
Summary
The facility failed to ensure that there were no more than 14 hours between the evening meal and breakfast the following day, unless a nourishing snack was provided at bedtime. This deficiency was identified for 4 out of 7 residents reviewed for meal frequency. The facility did not offer snacks at bedtime as required, which could affect all residents receiving meals from the facility's kitchen. The lack of snacks placed residents at risk for unplanned weight loss, side effects from medication taken without food, and diminished quality of life. Interviews and record reviews revealed that the facility's snack distribution process was inadequate. The facility's snack list only included residents with specific orders, and there was no general list for all residents. Staff interviews indicated that snacks were labeled and distributed to certain residents, but not all residents were informed or offered snacks. The Director of Nursing and the Administrator were unaware that snacks had to be offered to all residents, and the facility's policy on snacks was incorrect. The facility's failure to provide snacks as required was a significant oversight in their care practices.
Failure to Maintain Cleanliness of Resident Equipment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, specifically in the maintenance of the resident's hard-shell helmet. The helmet, which was observed on the nurse's station desk, was found to have hair, brown and black particulate, and brown stains on the inside where it sat atop the resident's head. This observation was made during a survey, and the resident was unable to respond during an attempted interview. Interviews with facility staff revealed a lack of clarity and consistency in the cleaning procedures for resident equipment. A CNA mentioned that they clean equipment when it appears dirty and believed that overnight staff were responsible for regular cleaning, but was unsure where such cleanings would be documented. The DON stated that resident helmets should ideally be cleaned daily, but could not confirm when the helmet was last cleaned. The facility's policy on cleaning and disinfection of resident-care items was reviewed, indicating that reusable equipment should be decontaminated between residents according to manufacturers' instructions.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which led to deficiencies in their care. Resident #60, a female with severe cognitive impairment and diagnoses including generalized anxiety disorder, did not have her anxiety disorder adequately addressed in her care plan. The care plan only mentioned the use of antidepressant medication related to depression and poor appetite, without any specific interventions for managing her anxiety disorder. This oversight could potentially impact the effectiveness of her treatment and overall well-being. Resident #1, who has a history of hemiplegia, cerebrovascular disease, and aphasia, did not have a care plan that addressed the use of a non-verbal pain scale or communication board. Despite her communication challenges, staff did not consistently use non-verbal pain assessment tools, leading to inadequate pain management. Observations revealed that Resident #1 experienced mouth pain, which was not promptly addressed due to communication barriers. Interviews with staff indicated a lack of awareness and documentation regarding her pain and personal care needs, such as bathing and oral hygiene. The report highlights that staff were not fully utilizing available communication tools to understand and meet Resident #1's needs. Additionally, there was a lack of documentation and follow-up on her dental issues, which contributed to her ongoing discomfort. The facility's failure to incorporate these critical aspects into the residents' care plans resulted in deficiencies that could compromise their physical, mental, and psychosocial well-being.
Failure to Use Communication Aids and Pain Assessment Tools
Penalty
Summary
The facility failed to provide necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish unless unavoidable due to clinical conditions. Specifically, the facility did not use a communication board or a facial pain scale for a resident with hemiplegia, hemiparesis, and aphasia, which are conditions that affect communication and mobility. This oversight led to the resident experiencing unmanaged mouth pain and a lack of proper communication regarding her needs. The resident, who was admitted with multiple diagnoses including cerebrovascular disease, dementia, and aphasia, required extensive assistance with activities of daily living such as bathing, dressing, and personal hygiene. Despite these needs, the care plan did not include the use of non-verbal pain scales or communication boards, which are crucial for residents with communication difficulties. Observations revealed that the resident was in pain and had difficulty communicating this to the staff, who did not consistently use available tools to assess her pain levels. Interviews with staff indicated a lack of awareness and use of communication aids, leading to inadequate pain management and unmet personal care needs. The resident expressed dissatisfaction with the staff's understanding of her pain and needs, and there were inconsistencies in the documentation of her care, such as bathing and oral hygiene. The facility's failure to implement appropriate communication strategies and pain assessment tools resulted in a deficiency in maintaining the resident's dignity and quality of life.
Failure to Provide Pressure-Relieving Cushion for Resident
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services to promote healing and prevent new ulcers from developing. Specifically, the facility did not equip Resident #53's wheelchair with a pressure-relieving cushion, as ordered. The resident, an elderly woman with severe cognitive impairment and at risk for pressure ulcers, was observed without the cushion on multiple occasions. Despite having an active order for the cushion since March, it was not present during observations in late June. Interviews with staff revealed a lack of clarity regarding responsibility for ensuring the cushion was in place. The Housekeeping Manager believed it was the responsibility of physical therapy, while the LVN was unsure of the cushion's whereabouts. The ADON and DON both expressed that it was the responsibility of all staff to ensure residents had their necessary equipment, but this expectation was not met. The facility's policy on pressure ulcer care did not provide specific guidance on ensuring pressure-reducing devices were in place, contributing to the oversight.
Failure to Supervise High-Risk Resident in Dining Room
Penalty
Summary
The facility failed to provide adequate supervision for a resident, identified as Resident #39, who was at high risk for falls due to multiple health conditions including dementia, dysphagia following a stroke, and diabetes. The resident's care plan specifically required constant supervision while in the dining room due to her high fall risk and other behavioral issues. However, observations on two separate occasions revealed that the resident was left unsupervised in the dining room, with no staff within ear or eyeshot, contrary to the care plan's directives. Interviews with staff, including an LVN and the DON, highlighted a lack of awareness and adherence to the supervision requirements outlined in the resident's care plan. The LVN was unaware of the need for constant supervision, while the DON acknowledged that staff should supervise the resident at all times in the dining room to prevent potential injuries from falls. The facility's policy on comprehensive, person-centered care plans was not effectively implemented, as evidenced by the lack of supervision for Resident #39, placing her at risk of injury.
Medication Administration Error for Midodrine
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Midodrine. The resident, a male with a history of heart failure and diabetes, was prescribed Midodrine to be administered via PEG-Tube twice daily for hypotension, with instructions to hold the medication if the systolic blood pressure (SBP) exceeded 130. However, the medication was administered on two occasions in July 2024 when the resident's SBP was 132, which was above the threshold specified in the physician's orders. Interviews and record reviews revealed that the Director of Nursing (DON) was unaware of these medication errors, and no staff had reported the incidents. The facility's policy on medication administration, dated December 2021, emphasized that medications should be administered as prescribed and in accordance with good nursing practices. Despite this policy, the errors occurred, and the DON confirmed that there was no notification of issues with the parameters set for the medication administration.
Failure to Notify Resident's Family of Condition Change
Penalty
Summary
The facility failed to immediately notify a resident's representative when there was a significant change in the resident's condition. Specifically, a resident with diagnoses including unspecified dementia, schizoaffective disorder, and high blood pressure, who was receiving hospice services, experienced a significant decline in condition. On the day of the incident, the resident was found to be very lethargic with critically low oxygen saturation levels. Although the facility contacted the hospice service, they did not notify the resident's family member, who was the responsible party. Interviews revealed that the Licensed Vocational Nurse (LVN) involved believed it was the hospice's responsibility to inform the family, which led to the oversight. The Director of Nursing (DON) and the Administrator both acknowledged that the facility's policy required the nursing staff to notify the resident's family directly, regardless of hospice involvement. The failure to notify the family was recognized as a deficiency, as it could cause emotional distress to the family if they were unaware of the resident's condition change.
Failure to Protect Resident from Abuse and Timely Report Incident
Penalty
Summary
The facility failed to protect a resident from abuse, neglect, and exploitation, as evidenced by an incident involving a resident who was allegedly abused by a healthcare aide. The incident was witnessed by a CNA who reported seeing the aide slap the resident on the shoulder twice. The resident, who was described as small, fragile, and nonverbal, exhibited signs of shock and flinching during the incident. The facility did not ensure that the alleged perpetrator was removed from duty immediately, allowing the aide to continue working and have access to residents. The facility also failed to report the abuse incident within the required two-hour timeframe, as mandated by federal regulations. The administrator was informed of the incident the following morning but did not report it promptly. Additionally, the facility did not ensure that all staff members were properly educated on abuse, neglect, and exploitation following the incident, with missing signatures on in-service training records. The resident involved in the incident had a history of dementia and major depressive disorder and was under hospice care. Despite the resident's nonverbal status, the facility did not provide psychiatric services after the incident, even though the resident exhibited new behaviors of rejecting care. The medical doctor was not informed of these new behaviors, which could have warranted further assessment and intervention.
Delayed Response to Stroke Symptoms in Resident
Penalty
Summary
The facility failed to provide timely treatment and care for a resident who exhibited signs and symptoms of a stroke. The resident, who had a history of heart failure, hypertension, and high cholesterol, was not sent to the hospital for evaluation until approximately six hours after a change in condition was reported. Initially, a Certified Occupational Therapy Assistant (COTA) observed the resident's inability to use his left side and reported it to a Registered Nurse (RN), who dismissed the concerns. The Physical Therapy Assistant (PTA) also noted the resident's slurred speech and left-sided weakness and reported these findings to the Director of Rehabilitation (DOR). Despite multiple reports from therapy staff, the RN on duty did not document any findings or escalate the issue appropriately. The RN believed the resident was fine and attributed the symptoms to shoulder pain, administering Tylenol instead of recognizing potential stroke symptoms. The DOR later assessed the resident and reported the changes to the oncoming nurse, who then contacted the Nurse Practitioner (NP) and received orders to send the resident to the emergency room. However, the resident was not transported until three hours after this assessment, and six hours after the initial symptoms were reported. The delay in recognizing and responding to the resident's stroke symptoms was attributed to a lack of communication and documentation among staff, as well as a failure to follow established protocols for emergency situations. The RN on duty at the time of the incident was unfamiliar with the residents and did not receive adequate information during the shift change. The facility's Director of Nursing (DON) later stated that assessments should be documented immediately, and changes in condition should be reported promptly to the primary care provider.
Misappropriation of Resident's Property by Staff Member
Penalty
Summary
The facility failed to protect a resident from misappropriation and exploitation of their property. A staff member, identified as MA G, stole a debit card belonging to a resident who had passed away, and subsequently withdrew over $5,000 from the resident's bank account. The theft was discovered when a police officer arrived at the facility to confirm the identity of the staff member from surveillance footage. The administrator confirmed the individual in the footage was MA G, who was then charged with debit/credit card abuse to an elderly person. Further investigation revealed that the Assistant Director of Nursing (ADON) was aware that the resident kept an address book containing sensitive financial information, which went missing after MA G provided post-mortem care to the resident. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention was not effectively implemented, as the incident was not prevented. Attempts to contact the resident's family were unsuccessful, and the facility's failure to prevent this misappropriation placed residents at risk of similar incidents.
Failure to Update Care Plan for Liquid Consistency
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team to reflect the current condition, specifically regarding the resident's need for honey consistency liquids instead of nectar thick liquids. The resident, who was admitted with diagnoses including dementia, dysphagia, and cognitive communication deficit, had a doctor's order for honey consistency liquids since August 2022. However, the care plan still indicated nectar thick liquids, leading to the CNAs administering the incorrect liquid consistency. Interviews and record reviews revealed that the CNAs were following outdated directives from the care plan, which had not been revised to reflect the doctor's updated order. The Speech Therapist highlighted the risk of aspiration and potential severe health consequences if the resident received the incorrect liquid consistency. Despite the kitchen providing the correct honey thickened liquids during meals, the care plan's outdated information led to a discrepancy in care, as CNAs were tasked with providing nectar thick liquids based on the care plan's instructions.
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 999 citations issued within 25 miles in the last 12 months — including the 21 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Windcrest
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Heritage | 1.8 mi | ★★★★★ | 3 | 0 |
| Northeast Rehabilitation And Healthcare Center | 2.7 mi | ★★★★★ | 10 | 1 |
| Crestway Nursing & Rehabilitation | 2.8 mi | ★★★★★ | 2 | 0 |
| The Army Residence Community Health Care Center | 3 mi | ★★★★★ | 0 | 0 |
| Avir At Converse | 3.5 mi | ★★★★★ | 13 | 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.