Average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Nursing And Rehabilitation Center Of Bastr during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and documented severe allergies to sulfonamide antibiotics was admitted with hospital paperwork clearly listing these allergies, but the DON and nursing staff failed to fully enter the allergy list into the EMR. Due to this incomplete documentation and unclear responsibility for admission reconciliation, an NP, relying on the EMR and nurse communication, ordered Bactrim DS for cellulitis, and nurses administered it multiple times without recognizing the sulfa allergy. Over several days, the resident developed a worsening rash and hives over much of the body, prompting further assessment, at which point the NP reviewed hospital records, discovered the sulfa allergy, and discontinued the antibiotic. Staff and the administrator acknowledged that the allergy information had been missed during admission and not accurately transcribed, resulting in a significant medication error and allergic reaction.
Surveyors found that food items in the kitchen, including frozen and cooked foods, were not properly labeled, dated, or sealed, and that dry storage shelves were not clean. These deficiencies were confirmed by dietary staff and the administrator, who acknowledged that facility policy requires all food items to be labeled and dated when opened, and that kitchen areas must be kept sanitary.
The facility failed to provide palatable and attractive meals, as observed during a lunch service where a test tray contained a mushy, salty, and visually unidentifiable main dish, with vegetables mixed together and missing dessert and beverage. A resident reported the food was unappealing and relied on family for snacks, while staff interviews confirmed awareness of the issue and deviations from standard recipes.
A resident with a g-tube and multiple complex diagnoses was observed receiving medication via the g-tube without the administering LVN wearing a gown, as required by facility policy and CDC guidelines for enhanced barrier precautions. Interviews with staff, including the Infection Preventionist and DON, confirmed that gown and glove use was expected during such care activities, but this protocol was not followed during the observed medication administration.
A resident with multiple medical and mental health diagnoses experienced a fall, but the care plan was not updated to reflect this incident or include measurable objectives and timeframes. Only a single intervention was added, and the lack of a comprehensive update was confirmed by both the ADM and MDS Coordinator, contrary to facility policy.
The facility failed to maintain proper kitchen sanitation and food safety standards, with unclean surfaces, improperly stored food, and inadequate thawing practices. Staff interviews revealed a lack of knowledge and adherence to protocols, and the Dietary Manager noted understaffing and the absence of a system for ensuring cleanliness and food labeling.
The facility failed to provide a clean and homelike environment, as observed in a resident's room and the dining room. A resident's room had trash and debris on the floor, while the dining room had dead and wiggling insects visible during meal service. Staff interviews confirmed expectations for cleanliness, which were not met.
A facility failed to limit PRN orders for psychotropic drugs to 14 days for a resident prescribed Ativan for anxiety. The resident, with a history of Alzheimer's and anxiety disorder, had a physician's order for Ativan without an end date, which was administered on two consecutive days. Interviews with the DON and ADON confirmed the facility's policy required PRN orders to be limited to 14 days unless a documented rationale for extension was provided.
A facility failed to maintain proper infection control when an LVN did not consistently perform hand hygiene during wound care for a resident with multiple health issues. The LVN changed gloves approximately 20 times but only washed hands six times, contrary to the facility's policy. This lapse increased the risk of cross-contamination and infection spread.
The facility failed to post daily nurse staffing information in a prominent place accessible to residents and visitors on two consecutive days. An observation revealed outdated staffing information, and the DON acknowledged the oversight, stating it did not meet expectations. The facility's policy requires daily posting of staffing information, which was not followed, resulting in the deficiency.
The facility did not meet the required 80 square feet per resident in double occupancy rooms, as confirmed by the acting ADM. Despite the deficiency, a waiver was previously requested and accepted, and the facility met the criteria for a waiver, including ensuring residents' health and safety were not adversely affected.
Allergy Documentation Failure Leads to Significant Medication Error and Allergic Reaction
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to incomplete documentation and verification of medication allergies at admission. The resident was an elderly female with severe cognitive impairment (BIMS score of 6) and multiple diagnoses including a displaced comminuted fracture of the left tibia, coronary artery disease, hyperlipidemia, and unspecified dementia. Hospital discharge records and a facility resident evaluation uploaded to the electronic file on the day prior to admission clearly listed severe allergies to penicillins, sulfonamide (sulfa) antibiotics, azithromycin, and clindamycin, with reactions of swelling and rash. However, when the former DON entered allergy information into the electronic medical record, only penicillin, clindamycin, and azithromycin were added on the day of admission; sulfa antibiotics and Bactrim were not entered until several days later, after the adverse reaction occurred. The admission process and responsibility for entering and verifying orders and allergies were fragmented among multiple nurses. The former DON stated she began entering the allergy information but stopped when state surveyors arrived for an investigation and then passed the task to another nurse, while a different LVN was the admitting nurse. One LVN reported only completing the second page of the admission checklist and stated the DON completed the first page, which included admitting medication orders and allergy information. Another LVN denied participating in the admission at all. Staff interviews showed confusion about who was responsible for completing the admission process, entering allergies into the EMR, and communicating clinical information and allergies to the NP. The NP stated that allergies are normally placed in the computer files and communicated by the nurse, and that she did not review the full chart within the first 24 hours of admission. Due to the incomplete allergy profile, the NP ordered Bactrim DS (sulfamethoxazole-trimethoprim) for cellulitis of the resident’s left lower extremity, and the medication was administered a total of 12 times over several days. During this period, the resident developed a rash that was first noted as red spots on the back of the neck and back, later described as erythema and inflamed patches/hives with pruritus on the arms, thighs, back, and stomach, which worsened over time. The resident’s representative observed hives and a rash covering the resident’s body and questioned staff about possible causes. Nursing staff initially considered petechiae and possible reaction to soap or food, and were unaware of a Bactrim or sulfa allergy because it was not listed in the EMR at that time. After the NP was informed that the rash appeared more consistent with an adverse reaction, she reviewed the hospital records, identified the documented sulfa allergy, and discontinued the antibiotic. The NP reported that when she informed the DON, the DON acknowledged not having entered all of the allergies. The facility’s own medication administration policy required checking for drug allergies as part of the “10 Rights” of medication administration, but this was not effectively carried out, resulting in the resident receiving a medication to which she had a known allergy and developing a significant rash over her body. The administrator confirmed that the admitting nurse was responsible for entering new resident information, including discharge orders and diagnoses, into the EMR and for communicating all clinical information to the physician and NP. He acknowledged that the allergy information for this resident was missed and not accurately transcribed, and that the former DON failed to complete the allergy portion of the ADT process. Multiple staff, including LVNs and the NP, recognized that the resident’s allergies were present on the hospital discharge paperwork but were not properly entered into the EMR or communicated, and that this failure led to the administration of Bactrim despite a known sulfa allergy. The facility’s failure to have clear processes and accountability for accurate verification and reconciliation of physician orders and allergies upon admission directly contributed to the significant medication error and the resident’s allergic reaction.
Failure to Properly Store, Label, and Sanitize Food Items in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage, preparation, and sanitation. Specifically, several items in the freezer, including bags of French toast sticks and waffles, were found not labeled, dated, or properly sealed. Additionally, cooked biscuits were observed stored in a plastic bag on top of canned goods, and food debris was present on the dry storage shelf. These observations were confirmed during interviews with dietary staff and the administrator, who acknowledged that all food items should be labeled and dated when opened, as per facility policy. Record reviews showed that the facility's policies require all food to be stored, labeled, and dated according to state, federal, and US Food Codes, and that kitchen areas must be kept clean and sanitary to minimize the risk of infection and foodborne illness. Despite these policies, the observed practices did not align with professional standards for food service safety, as required by regulation. The lack of proper labeling, dating, and sanitation in food storage areas was directly identified during the survey process.
Unpalatable and Unattractive Food Service
Penalty
Summary
The facility failed to serve foods that were palatable and attractive, and did not prepare food by methods that conserve nutritive value, flavor, and appearance for the kitchen observed. During a lunch meal observation, the regular diet test tray included Arroz Con [NAME] that was described as mushy in texture, overly salty, and visually unidentifiable, as it was formed into a round ball shape. The broccoli and corn were mixed together on the divided plate, and the tray was missing both a dessert and a beverage. A resident interviewed stated the food was not good, too salty, and unrecognizable, and reported only eating the vegetables and dessert, relying on family to bring snacks if hungry. The resident also noted the alternative meal was always the same option. Interviews with the dietitian consultant and dietary manager confirmed awareness of the unappealing lunch and acknowledged that the food did not look as it should, with the dietitian noting the importance of following recipes. The cook reported using shredded chicken instead of cubes as instructed, which may have affected the dish's outcome. The administrator expressed dissatisfaction with the meal's presentation and emphasized the expectation for meals to be appealing and palatable. Review of the facility's test tray policy indicated a requirement for routine quality assurance monitoring to ensure food is appealing, palatable, and served at correct temperatures.
Failure to Follow Enhanced Barrier Precautions During G-Tube Medication Administration
Penalty
Summary
The facility failed to maintain an infection prevention and control program in accordance with accepted national standards for a resident who required enhanced barrier precautions due to the presence of a gastrostomy tube (g-tube). During a medication administration observation, a licensed vocational nurse (LVN) did not wear a gown while administering medications via the g-tube, despite facility policy and CDC guidelines requiring gown and glove use for high-contact care activities involving residents with indwelling medical devices. The resident involved was a female with multiple diagnoses, including Huntington's Disease, dysphagia, aphasia, and Alzheimer's disease, and was dependent on staff for all care and received nutrition exclusively through a feeding tube. Interviews with the LVN, the Infection Preventionist, the Director of Nursing (DON), and the Administrator confirmed that staff were expected to wear gowns and gloves during g-tube medication administration for residents on enhanced barrier precautions. The facility's infection control policy and CDC guidelines both specified the need for such precautions for residents with indwelling medical devices. The failure to follow these protocols was observed and acknowledged by staff, with the potential for infection risk noted in their statements.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident following a significant change in condition. Specifically, after the resident experienced a fall on 03/25/2025, the care plan was not revised to reflect this most recent incident. The only update made was the addition of an intervention (nonskid tape), but the care plan did not include the new fall event or provide measurable objectives and timeframes to address the resident's current needs as identified in the comprehensive assessment. The resident involved was an older female with a history of essential primary hypertension, major depressive disorder, delirium, and anxiety. She was assessed as moderately cognitively intact. Despite facility policy requiring care plan revisions upon a status change, the MDS Coordinator did not update the care plan to include the most recent fall, which was confirmed during interviews with both the Administrator and the MDS Coordinator. This omission resulted in the resident's needs not being fully addressed in her care plan.
Deficiency in Kitchen Sanitation and Food Safety
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in its kitchen, as observed during a survey. The kitchen floors, food preparation surfaces, pantry shelves, and refrigerator shelves were found to be unclean, with spilled liquids, food debris, and moldy food items present. Additionally, a mop head was improperly stored on top of canned goods, and a 10-pound roll of hamburger meat was left out on the countertop, partially thawed and at an unsafe temperature. Interviews with staff revealed a lack of knowledge and adherence to food safety protocols. A staff member admitted to not knowing the correct temperature for thawing meat and acknowledged that the hamburger meat should not have been left on the counter. The Dietary Manager, who had been with the facility for four months, noted that the kitchen was understaffed and lacked a system for ensuring cleanliness and proper food labeling. He admitted that spoiled food should have been discarded and that there was no checklist or accountability system in place to ensure these tasks were completed. The facility's policies and procedures, dated 2018, outlined the importance of maintaining clean and sanitary kitchen facilities to prevent foodborne illnesses. However, these guidelines were not followed, as evidenced by the presence of moldy food, improperly stored cleaning materials, and inadequate thawing practices. The FDA Food Code 2022 was also referenced, highlighting the requirements for proper thawing and cleaning of nonfood-contact surfaces, which were not adhered to in this instance.
Facility Fails to Maintain Clean Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by observations in a resident's room and the dining room. In the case of Resident #38, the room was found to have loose trash and debris on the floor beside the bed, and the floor appeared dingy and unclean. This observation was made while the resident, a male with a diagnosis of Chronic Systolic Heart Failure and moderate cognitive impairment, was sleeping and unavailable for an interview. Additionally, during a meal service in the dining room, surveyors observed a dead roach, a wiggling roach, and two dead crickets on the floor, visible to residents receiving their lunches. Interviews with facility staff, including an LVN, the DON, and the ADM in training, revealed expectations for cleanliness and pest-free conditions, which were not met. The facility's policy on housekeeping emphasized maintaining a clean and orderly environment, which was not adhered to in these instances.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner documented a rationale for extending the order in the resident's medical record. This deficiency was identified for one resident who was prescribed Ativan, a medication used to treat anxiety. The resident, an elderly female with a history of Alzheimer's Disease, anxiety disorder, and depression, had a physician's order for Ativan without an end date, which was administered on two consecutive days in June 2024. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that the facility's policy required PRN psychotropic medication orders to be limited to 14 days to ensure continued necessity. The DON acknowledged that it did not meet her expectations that there was a PRN Ativan order without an end date and stated she was responsible for monitoring psychotropic medications. The facility's policy on psychotropic medication, dated August 2022, also reflected the requirement for PRN orders to be limited to 14 days unless a documented rationale for extension was provided.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A during wound care for a resident. LVN A did not perform hand hygiene consistently after removing gloves and before donning new ones while attending to the resident's wounds. This lapse in protocol was observed during a wound care session where LVN A changed gloves approximately 20 times but only washed her hands six times. The resident involved had multiple health issues, including cerebral infarction, hypertension, peripheral arterial disease, hemiplegia, dysphagia, schizophrenia, legal blindness, and muscle wasting, and was receiving care for skin integrity impairments on the buttocks and heel. Interviews with LVN A, the ADON, and the acting ADM confirmed that hand hygiene was not performed as required by the facility's policy, which mandates hand hygiene before donning gloves, at every glove change, and after removing gloves. The facility's policy, implemented in October 2022, clearly states that the use of gloves does not replace the need for hand hygiene. The failure to adhere to these guidelines increased the potential for cross-contamination and the spread of infection among residents.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required nurse staffing information in a prominent place readily accessible to residents and visitors on two consecutive days, 06/08/24 and 06/09/24. An observation on 06/09/24 at 10:29 AM revealed that the posted staffing information was outdated, showing the date 06/07/24. During an interview on 06/11/24, the Director of Nursing (DON) acknowledged that the staffing information should be posted daily and that it was her responsibility to ensure this was done. She also stated that the weekend charge nurse was responsible for updating the posting. The DON admitted that the failure to update the posting did not meet her expectations, although she believed there was no risk to residents, only a risk of being cited by surveyors. The facility's policy, dated 10/24/22, requires that nurse staffing information be made readily available in a readable format to residents and visitors at any given time, with the Nurse Staffing Sheet to be posted at the beginning of each shift. This policy was not adhered to, leading to the deficiency noted by the surveyors.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that resident rooms met the required 80 square feet per resident for double occupancy rooms. During an interview, the acting Administrator (ADM) confirmed that all double occupancy rooms measured less than the required 80 square feet per resident. The ADM stated that there were no plans to make changes due to the impossibility of doing so and mentioned that a waiver had been requested and accepted in the previous year's plan of correction. The facility's map and Bed Classification form confirmed that 47 rooms did not meet the required square footage. The Room Size Waiver for Facilities form indicated that the facility met the criteria for a waiver, including having a minimum of 72 square feet per resident, ensuring residents' health and safety were not adversely affected, and that there was no impediment to residents attaining the highest practicable well-being.
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What surveyors actually found near you
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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 Bastrop
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bastrop Lost Pines Nursing And Rehabilitation Cent | 0.1 mi | ★★★★★ | 10 | 1 |
| Silver Pines Nursing And Rehabilitation Center | 0.3 mi | ★★★★★ | 0 | 0 |
| Towers Nursing Home | 13.7 mi | ★★★★★ | 3 | 0 |
| Elgin Nursing And Rehabilitation Center | 17.6 mi | ★★★★★ | 2 | 0 |
| Oakcrest Nursing And Rehabilitation Center | 23.1 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.