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 Windsor Healthcare Residence during CMS and state inspections, most recent first.
Failure to Prevent Resident-to-Resident Abuse Involving an Aggressive Resident: A resident with schizophrenia, dementia, anxiety, and psychotic features was involved in repeated resident-to-resident altercations after entering other residents’ rooms, pushing two residents to the floor and causing head strikes that required ER evaluation. The record showed the resident had a history of behavioral issues, moderate cognitive impairment, and missing antipsychotic orders after a BH hospitalization, while the DON stated 1:1 monitoring began but the monitoring log was incomplete because the facility did not have the correct forms when monitoring started.
Expired and moldy food was found in kitchen storage, including moldy tomatoes and cucumbers, parmesan cheese past its use-by date, blueberry muffin mix past its use-by date, and marshmallows with a use-by date. During food temp checks, an CK dropped a thermometer into brown gravy and did not discard the gravy. The DA, CK, and DM stated that expired, moldy, or contaminated food should be discarded, and the facility policy required food to be stored to prevent contamination and perishable foods to be used before the use-by date.
A resident with schizophrenia, major depressive disorder with psychotic features, and anxiety did not receive ordered Risperdal after return from a behavioral health hospital because the admitting LVN failed to transcribe the discharge medication orders. The Risperdal 2 mg BID and 0.5 mg BID were absent from the active orders and MAR, and the DON stated the facility did not have a medication reconciliation policy. The resident had documented paranoia, delusions, and medication noncompliance in the care plan.
The facility failed to ensure safe storage of food items in residents' personal refrigerators, as temperature logs were not maintained. Observations showed that refrigerators were not monitored for safe temperatures, and interviews confirmed staff neglect in checking them. The DON and ADM acknowledged the oversight, attributing it to turnover in housekeeping supervision, which led to the deficiency.
A resident's call light was found out of reach, despite their care plan requiring it to be accessible due to their fall risk and need for assistance. The resident, who was cognitively intact but had multiple health issues, reported the call light had been out of reach and non-functional for days. Staff interviews confirmed the expectation that call lights should always be within reach, as per facility policy.
A resident's urinal was not emptied for several hours, despite staff being responsible for ensuring it was done promptly. The resident, who was cognitively intact and required assistance with personal hygiene, reported the issue, which was confirmed by observations. Interviews with staff indicated a lack of adherence to the facility's policy on urinal maintenance, leading to unsanitary conditions.
A resident's call light was found to be non-functional, preventing them from calling for assistance. Despite the facility's policy requiring functional call systems, the issue was not addressed promptly, as maintenance staff did not complete the repair. Interviews with the DON and ADM revealed they were unaware of the problem, highlighting a lapse in ensuring resident safety and adherence to facility policies.
A resident with Alzheimer's and a stage 3 pressure ulcer did not receive privacy during wound care as an LVN left the door open, allowing others to see inside. The LVN admitted to typically closing doors for privacy but was nervous due to a state inspector's presence. The facility's policy emphasizes resident privacy, which was not maintained in this case.
A facility failed to accurately assess a resident's status, incorrectly documenting the presence of a urinary catheter in the MDS assessment. The resident, with severe cognitive impairment and multiple health issues, was observed without a catheter, contradicting the assessment. Interviews revealed the error was due to incorrect coding by the MDS nurse, despite training. The facility's policy requires accurate assessments reflecting the resident's condition and care plan.
Failure to Prevent Resident-to-Resident Abuse Involving an Aggressive Resident
Penalty
Summary
The facility failed to ensure residents were free from abuse when Resident #62 was involved in multiple resident-to-resident altercations that resulted in residents being pushed to the floor and sent to the ER for evaluation. On 7/28/25, Resident #10 was pushed by Resident #62 after attempting to enter Resident #62's room without permission. On 8/07/25, Resident #52 and Resident #62 were engaged in a pushing match, and Resident #62 pushed Resident #52 to the floor; Resident #52 hit her head and was sent to the ER, where no injuries were found. On 08/25/25, Resident #32 was pushed by Resident #62 after entering Resident #62's room without permission, fell to the floor, hit her head, and was sent to the ER, where no injuries were found. Resident #62 had diagnoses including catatonic schizophrenia, major depressive disorder with psychotic features, generalized anxiety disorder, drug-induced subacute dyskinesia, insomnia, and UTI. Her MDS reflected a BIMS score of 10, indicating moderate cognitive impairment, and her care plan identified a potential for physical behaviors related to poor impulse control and paranoia/delusions. The care plan included interventions such as assessing contributing factors, separating residents immediately during altercations, providing 1:1 continuous monitoring, encouraging medication compliance, and referring her for behavioral health services. The record also showed that her discharge instructions from the behavioral health hospital included Risperdal, but the facility's PCC orders from 8/20/25 through 8/26/25 did not reflect a current antipsychotic order. The facility's incident investigations documented the three altercations involving Resident #62 and the resulting injuries or evaluations for Residents #10, #52, and #32. During interview, the DON stated Resident #62 was placed on immediate 1:1 monitoring beginning 8/25/25 at 6:00 PM and that the 1:1 monitoring checklist was blank from 8/25/25 at 6:00 PM through 8/26/25 at 6:00 AM because the facility did not have the correct forms when monitoring began. The DON also stated Resident #62 had gone to a behavioral health hospital on 8/8/25 after refusing her injectable antipsychotic medication and that the facility was seeking re-admission to the behavioral health hospital. The report states that the facility remained out of compliance at a scope and severity of pattern due to not providing interventions for Resident #62.
Expired and Moldy Food Found in Kitchen Storage and Contaminated Gravy Served
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. During observation on 8/26/2025, surveyors found moldy tomatoes in a box with no date and moldy cucumbers in a box with no date in the cooler. Surveyors also observed parmesan cheese dated 3-23-2025 with a use-by date of 5-29-2025. In the pantry, blueberry muffin mix was dated 6-18-25 with a use-by date of 7-08-2025, and marshmallows had a use-by date of 8-18-2025. During a separate observation, CK was taking temperatures of food before serving and dropped the food thermometer into the brown gravy, but did not discard the gravy. In interviews, the DA, CK, and DM each stated that staff are responsible for checking for expired or moldy food, rotating older food before newer food, and discarding food that is expired, moldy, or contaminated. The facility's undated Food Safety and Sanitation policy stated that stored food is handled to prevent contamination and growth of pathogenic organisms and that perishable foods with expiration dates should be used prior to the use-by date on the package.
Omitted Antipsychotic Medication After Hospital Discharge
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of one resident by not accurately acquiring, receiving, dispensing, and administering prescribed medications. Resident #62, a female with diagnoses including schizophrenia, major depressive disorder with psychotic features, generalized anxiety disorder, drug-induced subacute dyskinesia, insomnia, and UTI, had a BIMS score of 10 indicating moderate cognitive impairment. Her care plan identified medication noncompliance related to paranoia and delusions, and also addressed potential physical behaviors related to poor impulse control and paranoia/delusions. Record review showed discharge orders from a behavioral health hospital listed Risperdal 2 mg by mouth twice daily and Risperdal 0.5 mg by mouth twice daily to be continued after discharge. However, those medications were not included in the active physician orders or on the August MAR. The facility’s medication reconciliation policy was requested, and the DON stated the facility did not have one. An admissions checklist indicated the admitting nurse was required to complete Drug Regimen Review ASAP/Medication Reconciliation. During interview, the admitting LVN stated she reviewed the discharge orders and contacted the on-call NP to obtain the ordered medications, but later recognized she had failed to transcribe an order for Risperdal, and the resident therefore had not received her antipsychotic medication. The psychiatric NP later stated it was unlikely the omission caused untoward effects because Risperdal remains in the system for approximately 6 days after the last dose. The DON stated the outcome of omitting a medication would depend on the type of medication and could cause an exacerbation of symptoms.
Failure to Monitor Personal Refrigerator Temperatures
Penalty
Summary
The facility failed to have a policy ensuring the safe and sanitary storage of food items brought by family and visitors for residents, specifically for three residents. Observations revealed that the personal refrigerators in the rooms of these residents were not monitored for safe temperatures. The temperature logs for these refrigerators had not been updated since July, and in one case, there was no temperature log present at all. Interviews with the residents confirmed that staff had not been checking the refrigerator temperatures, and the residents typically stored items like sodas, fruits, and meats in their refrigerators. The Director of Nursing (DON) and the Administrator (ADM) acknowledged the lack of monitoring and stated that it was previously the responsibility of the housekeeping supervisor to ensure that the temperature logs were completed daily. However, due to turnover in the housekeeping supervisor position, this task was not consistently performed. The DON and ADM both recognized that the failure to monitor refrigerator temperatures could lead to food spoilage and potential malfunction of the refrigerators. The facility's existing policy on storage refrigerators, dated 2012, required that all storage refrigerators be maintained at a proper temperature and have their temperatures frequently monitored and recorded. Despite this policy, the personal refrigerators in residents' rooms were not being monitored as required, leading to the deficiency noted in the report.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for residents who require assistance with activities of daily living. On the morning of December 4th, the call light for a resident was observed to be placed on a nightstand out of reach. This resident, who was cognitively intact with a BIMS score of 14, had multiple diagnoses including muscle wasting, cognitive communication deficit, and lack of coordination, and was care planned for falls due to being unaware of safety needs. The care plan specifically included an intervention to ensure the call light was within reach and to encourage its use. Interviews with the resident and staff revealed that the call light had been out of reach for several days, and the resident reported that it was not functioning properly. The CNA stated that CNAs should make rounds every two hours to ensure call lights are within reach and residents are comfortable. Both the DON and the ADM emphasized that it is the responsibility of anyone entering the resident's room to ensure the call light is accessible. The facility's policy on answering call lights, revised in September 2022, outlines the importance of ensuring call lights are accessible and functioning at all times.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, as evidenced by the improper handling of the resident's urinal. The resident, who was cognitively intact and required assistance with personal hygiene, reported that his urinal had not been emptied since the morning, despite staff being responsible for ensuring it was emptied promptly. Observations confirmed that the urinal contained a yellowish liquid, presumed to be urine, for several hours. Interviews with staff, including a CNA and the DON, revealed that it was the responsibility of anyone entering the resident's room to ensure the urinal was emptied, with CNAs being primarily accountable due to their frequent rounds. The facility's policy required urinals to be checked frequently and emptied as necessary, but this was not adhered to, leading to unsanitary conditions and potential infection control issues.
Non-Functioning Call Light in Resident's Room
Penalty
Summary
The facility failed to ensure that a working call system was available for a resident, which is essential for calling staff assistance. Specifically, the call light in the resident's room was not functioning, as observed on 12/04/24 when the resident attempted to use it, and the light above the door did not illuminate. The resident confirmed that the call light was not working and mentioned that maintenance staff had been working on it but did not return to complete the repair. Interviews with the Director of Nursing (DON), Administrator (ADM), and Maintenance Staff (MS) revealed a lack of awareness about the non-functioning call light. The DON and ADM both acknowledged the importance of functioning call lights for resident safety and assistance. The facility's policy requires that call systems be functional at all times and routinely maintained, but this was not adhered to in this instance, leading to the deficiency.
Failure to Ensure Resident Privacy During Wound Care
Penalty
Summary
The facility failed to ensure the privacy of a resident during a wound care procedure. Specifically, an LVN did not close the door while performing wound care on a resident's right heel, which allowed other staff and residents in the hallway to see inside the room. This incident occurred despite the LVN's acknowledgment that she typically closed doors during care to maintain privacy and had been trained to do so. The LVN attributed her oversight to feeling nervous due to the presence of a state inspector. The resident involved was an elderly female with Alzheimer's Disease, COPD, and a stage 3 pressure ulcer on her right heel, requiring substantial assistance with daily activities. Interviews with the resident, the Director of Nursing (DON), and the Administrator (ADM) confirmed that staff were trained to provide privacy during care, and the failure to do so could have compromised the resident's dignity and confidentiality. The facility's policy on resident rights emphasizes the importance of privacy and confidentiality, which was not upheld in this instance.
Inaccurate MDS Assessment for Resident's Urinary Catheter Status
Penalty
Summary
The facility failed to ensure that the assessments accurately reflected the status of a resident, specifically regarding the presence of a urinary catheter. Resident #25, an elderly female with severe cognitive impairment and multiple diagnoses including muscle wasting, anxiety, atrial fibrillation, and senile brain degeneration, was inaccurately documented as having an indwelling catheter in her most recent quarterly MDS assessment. However, observations and interviews confirmed that the resident did not have a catheter, indicating a discrepancy between the resident's actual condition and the recorded assessment. Interviews with the MDS nurse, DON, and ADM revealed that the MDS assessment was coded incorrectly due to an error, despite the MDS nurse having received training on completing assessments accurately. The facility's policy mandates that assessments should be completed by qualified staff and should consistently reflect the resident's care plan and condition. The inaccurate coding of the MDS assessment could lead to inadequate care due to the provision of false information about the resident's needs.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Groesbeck
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Groesbeck Ltc Nursing And Rehabilitation | 1.1 mi | ★★★★★ | 0 | 0 |
| The Manor Healthcare Residence | 11.5 mi | ★★★★★ | 6 | 0 |
| Mexia Ltc Nursing And Rehab | 11.7 mi | ★★★★★ | 5 | 0 |
| Skilled Care Of Mexia | 11.7 mi | ★★★★★ | 3 | 1 |
| Teague Nursing And Rehabilitation | 16.6 mi | ★★★★★ | 7 | 0 |
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