Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Windflower Health Center during CMS and state inspections, most recent first.
Food service staff failed to follow required hygiene and sanitation practices in 2 kitchens. Surveyors observed multiple food items uncovered, unlabeled, undated, or not sealed, including fruit, tortillas, ice cream, desserts, and packaged items; staff were also observed without required hairnets, beard covers, or gloves while handling food. In addition, the dishwasher in one kitchen did not reach the required temp, with readings far below the stated 155-degree F standard.
A facility failed to keep call lights within reach for two residents with severely impaired cognition and fall risk. One resident with dementia, anxiety, and weakness was observed in bed and later in a recliner with the call light out of reach, while another resident with brain degeneration, depression, and a history of falls was observed in bed with the call light across the room. Staff, including the ADM, RN, CNAs, and LVN, stated call lights should always be accessible and that the residents could use them to request assistance.
A resident with Alzheimer’s disease, psychotic disorder with hallucinations, Parkinson’s disease, and major depression was receiving mirtazapine via PEG tube, but the facility did not complete a GDR review for the psychotropic medication. The DON stated the resident was not on psych services and could not find a GDR, while the RDHS and DON reported pharmacy had reviewed the medication with no changes recommended but no physician review had been completed. The facility policy required GDRs and behavioral interventions unless clinically contraindicated, including attempts in two separate quarters within the first year after admission or medication initiation.
Baseline Care Plan Not Completed Within 48 Hours: A resident admitted with dementia, hypothyroidism, hyperlipidemia, and hospice status required extensive ADL assistance and had a history of falls. Staff observed the resident with the bed in the lowest position and a fall mat in place, but the baseline care plan did not address the fall mat, and RN/MDS staff stated the resident was not care planned for it within the required timeframe.
Failure to care plan mechanical lift use: A resident with intact cognition, pneumonia, atrial fibrillation, and HTN was dependent for multiple transfers and ADLs and was being assisted with a sit-to-stand mechanical lift, but the lift use was not documented in the care plan. Staff interviews confirmed the device was in use and acknowledged it should have been included so caregivers would know how to transfer and assist the resident.
Care plans were not reviewed and revised within the required 7-day timeframe after MDS completion for two residents. One resident had dementia, cognitive communication deficits, and a BIMS of 11, and the other had stroke-related deficits, DM2, hemiplegia, and a BIMS of 14. Staff stated care plans were due within 7 days of the comprehensive assessment, but the documented care plan dates did not align with the MDS completion dates.
Failure to Assess and Obtain Consent for Bed Rail Use: Two residents had one-quarter bed rails in place with physician orders for positioning and mobility, but the clinical record lacked documented bed rail safety assessments and signed informed consent. One resident had moderately impaired cognition and the other had severely impaired cognition; both were observed with the rails up and locked in place. The ADM and DON acknowledged the assessments and consents were missed, and staff stated the required documentation should have been completed before bed rail use.
Missed and Incorrect Anticoagulant Administration: A resident with AFib, CHF, diabetes, and PVD did not receive anticoagulants as ordered. Staff failed to enter clarified Coumadin instructions into the system, and the resident also missed multiple Pradaxa doses because the medication was reported unavailable or not documented, with some doses not reported to management or the physician.
A resident with PVD, DM, CHF, and a-fib had significant anticoagulant medication errors. The MAR showed multiple missed Pradaxa doses, including doses not given because the medication was reported unavailable even though capsules had been delivered to the facility, and Coumadin was not administered as ordered after discharge instructions were confused and the clarified order was not entered. Staff interviews confirmed the missed doses were not consistently reported or escalated, and an INR drawn after the Coumadin error was out of range.
A resident with a PICC line, diabetes, obesity, atrial fibrillation, and CHF had no documented PICC-related care plan interventions, and the PICC dressing was found stained, loosening, and dated well beyond the weekly change schedule. Although the MAR showed the dressing change as completed, staff interviews confirmed it was overdue and should have been changed sooner, with the DON acknowledging it was late and that loose or soiled dressings require more frequent attention.
The facility did not ensure that comprehensive care plans were developed within seven days after completion of the required MDS assessments for four residents with complex medical conditions. Record reviews showed care plan revision dates did not meet regulatory timelines, and staff interviews confirmed responsibility for timely updates was not met, as required by facility policy.
The facility failed to maintain accurate records and proper handling of controlled medications, resulting in missing narcotics and improper documentation for three residents. An LPN was found to have left medications in drawers, discarded narcotics in the trash, and failed to follow required administration and waste procedures. Residents denied receiving medications that were documented as given, and staff interviews confirmed discrepancies in medication management.
An LVN failed to properly store, administer, and destroy narcotic medications, including discarding controlled substances in a trash can instead of following destruction protocols, and leaving narcotics unattended in residents' nightstand drawers or on meal trays. These actions resulted in discrepancies in medication counts and improper documentation, with residents sometimes not receiving their prescribed medications as intended.
An LVN failed to properly administer and dispose of narcotic medications, including discarding them in the trash and leaving them in residents' nightstand drawers or on meal trays, rather than directly administering and observing ingestion. These actions led to discrepancies in medication counts and unaccounted narcotics for three residents, as confirmed by interviews and a medication audit. The LVN admitted to not following professional standards or facility policy regarding medication management.
A resident with dementia and Alzheimer's fell and was hospitalized, but the family was not notified immediately due to miscommunication among staff. The facility lacked a formal policy for notifying families after such incidents, leading to a delay in informing the family.
Food Storage, Labeling, and Dishwashing Temperature Failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 2 kitchens reviewed. During observations, surveyors found multiple food items that were not properly labeled, dated, covered, or sealed. In Kitchen 1, a silver bowl with a white powdery substance was covered with plastic wrap that was not labeled, a bottle of sweet and sour sauce had been opened and was supposed to be refrigerated after opening, and a bottle of cayenne pepper was past its best-by date. Later observations in Kitchen 1 found fruit bowls, tortillas, an open silver container with a ladle, ice cream containers, individual bowls of ice cream, salads with breaded meat, gelatin cups, and desserts that were uncovered, unlabeled, undated, or not sealed. In Kitchen 2, surveyors observed CK M walking between stations without a hairnet, and later found multiple food items in the refrigerator and freezer that were undated, including Boston creme pie, boxes of ice cream, apple juice, and packaged snack items. On the following morning, EC was observed handling food items without a beard cover or gloves, and additional individual servings of ice cream and sherbet were uncovered, unlabeled, and undated. Staff interviews confirmed that hairnets, beard coverings, gloves, covering food, and labeling and dating food were required, and staff acknowledged that the observed practices were not being followed. The dishwasher in Kitchen 1 was also observed not reaching the appropriate temperature. It measured 103 degrees F on the first observation and 108 degrees F on a second round, while staff stated the correct temperature was 155 degrees F. The facility policy reviewed stated that employees must follow hygiene and sanitary procedures, that food must be labeled and dated, and that dishwashing equipment must operate within required temperature ranges.
Call Lights Not Kept Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had their call lights within reach. Resident #10 had diagnoses including unspecified dementia with behavioral disturbance, anxiety disorder, and weakness. Her MDS showed severely impaired cognition with a BIMS score of 04, and her care plan identified her as a high fall risk with interventions to keep her call light within reach and to encourage her to request assistance. Resident #89 had diagnoses including senile degeneration of brain, major depressive disorder, and history of falling. Her MDS showed severely impaired cognition with a BIMS score of 03, and her care plan also directed staff to keep her call light within reach and encourage her to use it for assistance. During observations, Resident #10 was found lying in bed asleep with her call light on the floor, partially underneath the bed and out of reach. Later, she was observed sitting in a recliner in her room with the call light hanging on the wall across the room and not within reach. Resident #89 was observed lying in bed asleep with her call light hanging on the wall across the room and not accessible. On another observation, Resident #89 was again lying in bed asleep with the call light out of reach. Staff interviews confirmed that call lights were required to remain within residents' reach at all times and that all staff were responsible for ensuring this. The ADM, RN, CNAs, LVN, and the resident's family member all stated the residents were capable of using their call lights and that the call lights should be accessible. The facility policy stated the resident's call system would be positioned conveniently for use and within reach.
Failure to Complete GDR for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that Resident #4, a female with diagnoses including Alzheimer's disease, psychotic disorder with hallucinations, Parkinson's disease, and major depression, received gradual dose reductions for a psychotropic medication when indicated. Record review showed she was receiving mirtazapine 15 mg via PEG tube, with therapy start documented as 2/07/25, and the facility's Gradual Dose Reduction Tracking Report listed a next GDR evaluation date of 2/07/26. Her quarterly MDS assessment showed she could not be evaluated for BIMS because she was rarely or never understood and that she was dependent on staff for activities of daily living. During interviews, the DON stated she completed GDR reviews quarterly with the physician for residents on psych services, but said Resident #4 was not on psych services and she could not find a GDR at that time. The RDHS and DON also reported that pharmacy had completed a review on 11/28/25 with no recommended changes and a next review date of 2/07/26, but no physician review had been completed. The facility policy stated residents who use psychotropic drugs should receive gradual dose reduction and behavioral interventions unless clinically contraindicated, and within the first year after admission on a psychotropic medication or after initiation, the facility would attempt a GDR in two separate quarters unless clinically contraindicated.
Baseline Care Plan Not Completed Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #104. The resident was admitted on [DATE] with diagnoses including unspecified dementia without behavioral disturbance, hypothyroidism, hyperlipidemia, and hospice status. Record review showed the resident required substantial to maximal assistance with eating, oral hygiene, toileting hygiene, bathing, dressing, footwear, personal hygiene, rolling, sitting to lying, and chair/bed transfers, and was dependent for toilet and tub/shower transfers. The resident’s baseline care plan, completed on 06/18/2026, documented hospice status and safety risks, including a history of falls, but did not address the use of a fall mat. Observations on 06/16/2026, 06/17/2026, and 06/18/2026 showed the resident in bed with the bed in the lowest position and a fall mat in place. During interviews, RN H stated fall mats should be care planned and that Resident #104 was not care planned for a fall mat. MDS staff stated floor nurses complete baseline care plans and that the baseline care plan had not yet been uploaded to the electronic medical record at the time of interview. The DON stated care plans are patient centered and can include anything regarding the resident’s care, and that fall mats would be carefully planned as part of another incident.
Failure to Care Plan Mechanical Lift Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #64 that included measurable objectives and timeframes to meet his medical, nursing, and psychosocial needs. Resident #64 was an [AGE]-year-old male with diagnoses including pneumonia, paroxysmal atrial fibrillation, and essential hypertension, and his MDS showed a BIMS score of 15 with intact cognition. Section GG indicated he was dependent for sit to lying, lying to sitting, sit to stand, bed-to-chair transfer, and toilet transfers, and required substantial to maximal assistance for toileting, bathing, dressing, and footwear. His care plan, dated 06/16/2026, included only an intervention that he required 2 people for maximum assistance for ADL completion, but it did not document his use of a sit-to-stand mechanical lift for transfers and ADLs. Interviews confirmed that staff were using a sit-to-stand mechanical lift for Resident #64. The family caregiver stated he was assisted with showers and used a lift for transfers. RN F, LVN E, MDS S, the DON, CNA T, and RN H all stated that Resident #64 used a mechanical lift or sit-to-stand device, and several staff members acknowledged that it was not documented in the care plan. Staff also stated that the lift should have been included so caregivers would know how to properly care for and transfer the resident, and the DON stated the lift should have been initiated in the care plan by the nurse who first determined the need for it. The RAI Manual excerpt reviewed stated the care plan must be reviewed after each assessment and revised based on changing goals, preferences, needs, and current interventions.
Care Plans Not Updated Within Required Timeframe
Penalty
Summary
The facility failed to review and revise the comprehensive person-centered care plans within 7 days after completion of the comprehensive and quarterly MDS assessments for Resident #5 and Resident #14. Resident #5 was a female resident with diagnoses including unspecified dementia without behavioral disturbance, unspecified atrial fibrillation, and cognitive communication deficit; her MDS showed a BIMS score of 11, indicating moderate cognitive impairment. Her quarterly MDS assessments were completed on 03/05/2026 and 06/13/2026, while the last two completed care plans were dated 04/27/2026 and 06/11/2026. Resident #14 was a female resident with diagnoses including cerebral infarction due to embolism of an unspecified cerebral artery, type 2 diabetes, hemiplegia, and hemiparesis; her MDS showed a BIMS score of 14, indicating intact cognitive function. Her quarterly MDS assessments were completed on 03/09/2026 and 06/13/2026, while the last two completed care plans were dated 03/06/2026 and 06/11/2026. During interviews, the ADM stated the facility followed the RAI policy for care planning, and MDS staff stated care plans were due within 7 days of the comprehensive assessment. Staff also stated the care plan for Resident #14 was completed before the MDS completion date, while the MDS was signed on 06/13/2026, and the RAI Manual requires the care plan to be completed no later than 7 calendar days after the CAA/RAI completion date.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to assess two residents for the risk of entrapment from bed rails before the rails were installed and failed to document informed consent for their use. Resident #38 had diagnoses including unspecified dementia, unspecified fall, subsequent encounter, and major depressive disorder. Her quarterly MDS showed a BIMS score of 11, indicating moderately impaired cognition, and Section GG showed she was independent with sit-to-lying and sit-to-stand. Her care plan identified a one-quarter bed rail for mobility, and physician orders dated 06/09/2026 authorized the rail for positioning and mobility, but the clinical record contained no signed bed rail consent and no current bed rail safety assessment prior to installation. During observation, she was seen in her room with the one-quarter bed rail up and locked in place. Resident #89 had diagnoses including senile degeneration of the brain, major depressive disorder, and history of falling. Her quarterly MDS showed a BIMS score of 03, indicating severely impaired cognition, and Section GG showed she required supervision or touching assistance with sit-to-stand and chair-to-bed transfer. Her care plan identified a one-quarter bed rail for mobility and positioning, and physician orders dated 06/01/2026 authorized the rail for positioning and mobility, but the clinical record contained no signed bed rail consent and no current bed rail safety assessment prior to installation. During observations, she was seen lying in bed asleep with the one-quarter bed rail up and locked in place. During interviews, the ADM stated she and the DON had recently audited bed rail assessments and consents, but Residents #38 and #89 had been missed. The DON stated the missed assessments were her responsibility and that bed rail assessments and consents were required before implementation and reviewed quarterly. Facility staff also stated that completion of bed rail assessments and consents was the responsibility of the charge nurse, and the facility policy required review of alternatives, assessment of entrapment risk, and informed consent before bed rail use.
Missed and Incorrect Anticoagulant Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not administering prescribed anticoagulant therapy as ordered. Resident #43 was admitted with diagnoses including peripheral vascular disease, diabetes, congestive heart failure, and atrial fibrillation, and the record showed she was cognitively intact with a BIMS of 15 and was receiving anticoagulant therapy. Her hospital discharge instructions included warfarin (Coumadin) 2 mg to start as directed, and the facility also had a delivered supply of dabigatran etexilate (Pradaxa) 75 mg capsules documented on the prescription delivery form. The MAR showed warfarin 4 mg daily ordered for 3 days starting 06/05/26, and it was administered on 06/05/26 and 06/06/26. The MAR also showed Pradaxa 75 mg twice daily starting 06/02/26, but multiple doses were not administered. Documentation stated the medication was not available on some shifts, while other missed doses had no documented reason. One dose was documented as refused, and one dose was missed because the resident was in the hospital. During interviews, the unit manager stated there was confusion about the Coumadin instructions and that the clarified order was not entered into the system. She reported that when the error was discovered, a stat lab was obtained and the Coumadin was restarted. Staff interviews also showed that nurses looked for Pradaxa in the medication area and surplus area but could not find it, and some did not report the missed doses. The DON stated that when a significant medication such as an anticoagulant cannot be administered, staff were expected to check emergency stock, contact the pharmacy, notify the physician, and inform management. The pharmacy representative confirmed the Pradaxa had been filled, but staff may not have recognized it because it was delivered in a bottle rather than a blister pack.
Missed anticoagulant doses and failure to follow Coumadin orders
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors involving anticoagulant therapy. Resident #43 was admitted with diagnoses including peripheral vascular disease, diabetes, congestive heart failure, and atrial fibrillation, and the MDS indicated she was cognitively intact and receiving anticoagulant therapy. Her record showed orders for Dabigatran Etexilate Mesylate (Pradaxa) 75 mg twice daily starting 6/02/26 and a later order for Warfarin Sodium (Coumadin) 4 mg daily for 3 days starting 6/05/26. The MAR showed multiple missed doses of Pradaxa. On 6/02/26 the morning dose was not administered because the medication was not available, the evening dose was given, on 6/03/26 the morning dose was given and the evening dose was not administered because the medication was not available, on 6/04/26 the morning dose was not administered with no documented reason, on 6/05/26 the morning dose was not administered with no documented reason, on 6/06/26 the morning dose was not administered because the medication was not available, and on 6/07/26 the morning dose was refused. The record also showed that 60 capsules of Pradaxa had been delivered to the facility on 6/02/26. The record further showed that Coumadin was not given as ordered after discharge instructions were received from the hospital. The unit manager reported there was confusion with the Coumadin instructions, clarification was obtained from the NP, but the clarified order was not entered into the system. When the missed Coumadin doses were discovered on 6/05/26, a stat lab was obtained and the INR was 1.20. Interviews with nursing staff and leadership confirmed that the medication issues were not reported or escalated when the doses were missed, and the DON stated staff were expected to notify the physician, pharmacy, and management when a significant medication could not be administered.
PICC Dressing Not Changed as Ordered
Penalty
Summary
The facility failed to ensure parenteral fluids and central venous catheter care were provided in accordance with professional standards of practice and physician orders for one resident with a PICC line. The resident was admitted with diagnoses including cellulitis of the left lower limb, type 2 diabetes mellitus, morbid obesity, unspecified atrial fibrillation, and acute-on-chronic systolic heart failure, and had a BIMS score of 15 indicating intact cognition. The baseline care plan contained no documented interventions, monitoring, or care planning related to the PICC line or IV antibiotic therapy. The order summary included an order to monitor the PICC site every shift for signs and symptoms of infection and an order to change the PICC dressing weekly and every Monday. Although the MAR documented the PICC dressing change as completed on 05/18/26, an observation and interview on 05/19/26 found the PICC dressing visibly stained, loosening around the edges, and dated 05/08/26. The resident stated the dressing had not been changed since admission. Staff interviews confirmed the dressing should have been changed the prior day, that a loose or rough dressing could be changed more frequently under PRN orders, and that the RN charge nurse was going to change it that day. The DON stated PICC lines are to be changed every 7 days and acknowledged the dressing should have been changed the day before.
Failure to Timely Develop Comprehensive Care Plans After Assessment
Penalty
Summary
The facility failed to develop comprehensive care plans within seven days after the completion of the comprehensive assessment for four out of ten residents reviewed. Specifically, the care plans for residents with diagnoses including Alzheimer's disease, type 2 diabetes mellitus, parkinsonism, chronic kidney disease, psychotic disorder, atypical atrial flutter, atherosclerotic heart disease, generalized anxiety disorder, chronic pain syndrome, multiple sclerosis, congestive heart failure, atrial fibrillation, hypertension, cognitive communication deficit, restless legs syndrome, hemiplegia, and muscle wasting were not updated in accordance with regulatory requirements. Record reviews showed that the care plan revision dates did not meet the required timeline following the completion of the Minimum Data Set (MDS) assessments. Interviews with the MDS LVN and the DON confirmed that it was the responsibility of the MDS nurse and floor nurses to keep care plans updated, and acknowledged that failure to update care plans after MDS assessments could result in missing important changes in resident status or medication needs. The facility's own policy, revised in March 2022, requires that comprehensive, person-centered care plans be developed within seven days of the required MDS assessment, and that interventions are based on thorough analysis of assessment data. The observed deficiencies were based on direct record review and staff interviews.
Failure to Account for and Properly Administer Controlled Medications
Penalty
Summary
The facility failed to establish and maintain an adequate system for the receipt, disposition, and reconciliation of controlled drugs for three residents. Specifically, the facility did not ensure that all controlled medications were properly accounted for, as evidenced by missing narcotics and incomplete documentation on narcotic count sheets. For example, one nurse, LVN B, was found to have dispensed narcotics without proper documentation, misplaced medications, and failed to follow required procedures for medication administration and waste. For one resident with spastic diplegic cerebral palsy, acute kidney failure, and colon cancer, records showed that narcotic medications were marked as 'dropped' or 'wasted' without proper documentation or adherence to facility policy. Another resident with multiple sclerosis and diabetes had a narcotic medication dispensed and noted as 'placed in drawer/missing' without a corresponding time or signature, and the medication was later found to be missing from the medication card. A third resident with Alzheimer's disease and hypertension had a narcotic dose missing from the count sheet, and there was no documentation of administration for a scheduled dose. Interviews with staff and residents confirmed that medications were sometimes left in drawers or on meal trays, and that narcotics were improperly discarded in the trash rather than following the facility's destruction protocol. Residents denied receiving medications that were documented as administered, and the DON confirmed discrepancies in narcotic counts and improper medication handling by LVN B. Facility policies required medications to be administered according to orders and staff to demonstrate competency in medication management, but these were not followed in the cited incidents.
Improper Storage, Administration, and Destruction of Narcotic Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals, particularly controlled substances, were stored and administered in accordance with state and federal laws, as well as facility policy. Specifically, an LVN was observed discarding narcotic medications intended for a resident into the trash can on the medication cart, rather than following the required destruction protocol using a drug buster. This occurred on at least two occasions and was witnessed by a CNA, who reported the incidents to administration. The medication administration records and narcotic count sheets showed discrepancies, including narcotics being marked as 'dropped' or 'wasted' without proper documentation or destruction. Additionally, the LVN failed to remain with residents until they had taken their prescribed narcotic medications. Instead, the LVN placed narcotics in residents' nightstand drawers or on meal trays, leaving the medications unattended. Interviews with residents revealed that they did not always receive their medications as intended, and in some cases, were unaware that medications had been left for them. The narcotic count sheets further indicated missing doses and improper documentation of medication administration. Facility policy required that unused controlled substances be securely locked until disposal and that staff remain with residents until all medications are taken. The LVN admitted to leaving medications in drawers or on trays due to feeling overwhelmed and acknowledged that this practice was not in line with professional standards. The DON confirmed discrepancies in narcotic counts and improper handling of medications for multiple residents, as well as the failure to follow established protocols for medication administration and destruction.
Improper Narcotic Handling and Administration by LVN
Penalty
Summary
The facility failed to ensure that nursing staff, specifically an LVN, demonstrated appropriate competencies and skills in the management and administration of narcotic medications. On two occasions, a CNA observed the LVN discarding narcotic medications into the trash can on the medication cart, rather than using the designated drug destruction method. The CNA reported these incidents to the administrator after witnessing the improper disposal a second time, both involving the same resident. Further investigation by the DON revealed additional discrepancies involving narcotic medications for three residents. The LVN admitted to placing narcotics in residents' nightstand drawers or on meal trays, rather than administering them directly and observing ingestion as required. In one instance, the LVN signed out medication for a resident but placed it in the resident's nightstand drawer, and the medication was later unaccounted for. Interviews with the residents involved indicated that they had not received or seen the medications left for them in this manner. The facility's policy requires that all nursing staff meet competency requirements and demonstrate skills in medication management and pain management. The LVN acknowledged during interviews that her actions were not in accordance with professional standards or facility policy, attributing her behavior to being overwhelmed during her shift. The DON confirmed that such practices could result in residents not receiving their medications as intended and highlighted the importance of following proper medication administration protocols.
Failure to Notify Family After Resident's Fall
Penalty
Summary
The facility failed to immediately inform a resident's family member and physician following an accident that resulted in the resident being transported to the hospital. The incident involved a resident with a history of dementia, Alzheimer's disease, and peripheral vascular disease, who suffered a fall while attempting to get up from a wheelchair. This fall resulted in injuries that required hospital evaluation. Despite the facility's protocol to notify family and physicians immediately after such incidents, the family was not informed until several hours later. Interviews with staff revealed a breakdown in communication, as multiple nurses assumed others had contacted the family. The family member expressed dissatisfaction upon learning of the incident hours later, despite receiving apologies and follow-up calls from the staff. The nursing staff, including LVNs and RNs, acknowledged the importance of notifying families promptly and recognized the potential negative outcomes of failing to do so. The Director of Nursing (DON) confirmed the facility's protocol required immediate notification of the family and physician following a fall. However, the DON was unable to locate documentation confirming when the family was notified. Additionally, the facility lacked a formal policy regarding the notification protocol for falls, contributing to the communication lapse in this incident.
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 82 citations issued within 25 miles in the last 12 months — including the 3 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 Amarillo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Convalescent Center | 0.1 mi | ★★★★★ | 8 | 0 |
| Amarillo Medical Lodge | 0.1 mi | ★★★★★ | 4 | 0 |
| Landmark Of Amarillo Rehabilitation And Nursing Ce | 0.7 mi | ★★★★★ | 16 | 1 |
| Amarillo Center For Skilled Care | 0.8 mi | ★★★★★ | 8 | 0 |
| Kirkland Court Health And Rehabilitation Center | 1 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Windflower Health Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.