Average — CMS composite of the measures below.
The next survey window likely opens around April 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 Windsor Quail Valley Post-acute Healthcare during CMS and state inspections, most recent first.
A resident who was totally dependent for ADLs did not receive consistent bathing, hygiene, and skin care as ordered. The bathing record showed a refusal, but a CNA later said the resident accepted a bed bath and that the G-tube area was usually cleaned by nursing on nights. When the resident was sent to the hospital, ED staff documented dried feces, possible yeast in the groin, wounds without dressings, and a G-tube dressing with dried brown substance and a new dressing placed over a dirty dressing.
A resident with depression, schizophrenia, mood disorder, severe cognitive impairment, and behavioral issues had PASARR Level I screenings that reflected MI only, even after an inpatient psych stay that should have triggered a new review. The PASARR evaluator later stated she missed the resident's psychiatric hospitalization when completing the latest Level I, resulting in a negative finding and no eligibility for additional MI services, while the MDS Nurse said she relied on the evaluator's determination and the DON said the MDS Nurse was responsible for ensuring PASARR evaluations were scheduled and received.
A resident with dysphagia, GERD, muscle wasting, and a stroke history received Miralax mixed with an unmeasured amount of water even though the order did not specify the fluid amount. The CMA stated she should have held the medication and contacted the provider for clarification, and the DON, ADON, and MD stated the order should have included 4 to 8 oz of fluid and that unclear medication orders require clarification.
WCN failed to follow PPE and hand hygiene procedures after wound care for a resident on EBP. While still wearing a yellow gown and holding a trash bag with soiled supplies, she left the room, used the treatment cart and computer, and then placed the regular trash bag into a red isolation trash bag. The ICPN and DON stated she should have removed PPE, performed hand hygiene, and disposed of trash properly before doing any other activity, and facility policy required PPE to be removed before leaving EBP rooms.
Improper Dumpster Trash Disposal: Multiple trash bags were observed on the ground in front of two outdoor dumpster bins, and one dumpster door was left open. The RD of dietary services, Housekeeping Supervisor, DON, and ADM all stated trash should not be left outside the bins and that dumpster doors/lids should remain closed. The record also showed an in-service and policy requiring all trash to be placed in the dumpster with no waste left on the ground.
A resident with multiple medical conditions received an anticoagulant medication from a CNA after an RN, who had prepared the medication, instructed the CNA to administer it when the resident refused the RN entry. The CNA was not authorized or trained to give medications, and both the RN and CNA acknowledged this was outside the CNA's scope of practice. Facility policy required only licensed or legally authorized staff to administer medications.
A resident with moderate cognitive impairment and multiple health issues expressed a preference not to receive care from a specific CNA, which was initially honored by the former DON. However, after the DON's departure, the CNA was reassigned to the resident, causing discomfort and a sense of powerlessness. Despite the CNA informing the ADON of the resident's preference, the issue persisted until the new DON became aware. This failure to respect the resident's choice compromised their dignity and self-determination.
A resident with complex medical conditions developed severe pressure ulcers due to inadequate care and prevention measures at an LTC facility. Despite being at risk, the facility failed to identify or treat the resident's pressure sores, leading to hospitalization. Staff inconsistencies in skin assessments and reporting contributed to the oversight.
A resident with severe cognitive impairment and multiple medical conditions was physically abused by a CNA, resulting in noticeable bruising on her face. The facility failed to document the injuries or implement protective measures, and staff provided conflicting accounts of the incident. The abuse was reported to HHSC, and the resident was transferred to the hospital for evaluation.
The facility failed to implement abuse and neglect policies, resulting in a resident being physically abused by a CNA. The resident, with multiple medical conditions, was found with facial bruising, and staff did not follow proper procedures to investigate or report the abuse. Inconsistencies in staff observations and actions led to the identification of Immediate Jeopardy.
A facility failed to investigate and report alleged abuse of a resident with severe cognitive impairment, leading to the resident being found with suspicious injuries. The facility did not take immediate action to protect the resident or complete a thorough investigation, placing the resident at risk of further harm.
A facility failed to maintain accurate clinical records for a resident with severe cognitive impairment and multiple medical conditions, leading to incomplete documentation of an unexplained eye injury. Despite the injury being observed by multiple staff members, no documentation was completed, and the resident's care plan was not updated. The resident's family member reported the injury, but received inconsistent responses from the staff, who failed to document the injury or the investigation process.
Failure to Provide Bathing, Hygiene, and G-Tube Site Care
Penalty
Summary
The facility failed to ensure that a totally dependent resident received bathing, hygiene, and skin care in accordance with orders, preferences, and goals. The resident had a history of non-Alzheimer's dementia and epilepsy, and the MDS indicated she was totally dependent on staff for all ADLs, including bathing, dressing, toileting, grooming, and eating. Her care plan also identified the need for tube feeding and local care to the G-tube site with monitoring for signs of infection. On the day in question, the bathing task record showed that the resident refused a shower or bed bath and did not receive a bath. However, a CNA later stated she had given the resident a bed bath that evening and washed around the G-tube area, while also stating that the resident had not refused and that the task may have been marked as refused earlier when the resident declined and then later accepted care. The CNA also stated that nurses usually cleaned the G-tube area during night shift. When the resident was transferred to the hospital, the emergency department record noted dried feces, possible yeast in the groin, wounds with no dressings, and a G-tube dressing covered with dried brown substance with a new dressing placed on top of a dirty dressing. The hospital admission diagnosis included aphasia, facial droop, and stroke-like symptoms. A wound care nurse stated that the brown substance around the tube could have reflected improper tube insertion or infection, that the physician should have been notified immediately if that was occurring, and that the area should have been cleaned nightly. The wound care nurse also stated there should never have been a new dressing placed on top of a dirty one.
PASARR screening not coordinated for resident with MI
Penalty
Summary
The facility failed to coordinate assessments with the PASARR program to the maximum extent practicable for one resident with mental illness. Resident #2 was a male admitted and readmitted to the facility with diagnoses that included depression, mood disorder due to a physiological condition, memory deficit following cerebral infarction, paranoid schizophrenia, other impulse disorders, and drug induced secondary parkinsonism. His quarterly MDS reflected severe cognitive impairment with a BIMS score of 04, and his care plan documented physical aggression, screaming outbursts, swinging at staff, impaired cognitive function, antidepressant use for depression and insomnia, psychotropic use for behavior management, and mood problems. Record review showed PASARR Level I screenings dated 02/26/2025 and 08/26/2025 both reflected a diagnosis of MI only. The resident later had an inpatient psychiatric stay from 01/27/2026 to 02/20/2026, and a change of condition communication dated 02/24/2026 documented behaviors including throwing personal foods and items throughout the room, creating a safety hazard for the roommate and self. A progress note dated 02/26/2026 documented that the MD attempted to discuss the resident's behavior of throwing personal items, but the resident declined. During interviews, the MDS Nurse stated the psychiatric inpatient stay should have qualified the resident for PASARR services and that she was unaware what disqualified him from services. The PASARR Evaluator stated the inpatient stay initiated the need for a new PASARR Level I evaluation, but when she completed the latest evaluation on 03/25/2026 she missed that the resident had not had an inpatient psychiatric stay, which resulted in a negative PASARR Level I and no eligibility for additional MI services. The MDS Nurse stated she received the results and relied on the evaluator's determination, while the DON stated the MDS Nurse was responsible for ensuring PASARR evaluations were scheduled, received, and that specialized services were offered to PASARR positive residents.
Incomplete Miralax Order Administered Without Clarification
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident #21 when CMA Q administered polyethylene glycol 3350 (Miralax) without clarifying an incomplete order. Resident #21 was a cognitively intact female with diagnoses including dysphagia, GERD, muscle wasting, and cerebral infarction, and her care plan addressed constipation related to decreased mobility. Her physician order directed 17 gm of polyethylene glycol by mouth daily for constipation, but it did not specify how much fluid to use for mixing the powder. During medication administration, CMA Q poured and mixed the powder with an unmeasured amount of water and gave it to the resident. In interview, CMA Q stated she should have held the medication and contacted the provider for clarification because the order was incomplete and could result in the medication being ineffective. The DON, ADON, and MD stated the order should have included 4 to 8 oz of fluid and that staff should contact the provider when medication orders are missing instructions for administration.
WCN Failed to Follow PPE and Hand Hygiene Procedures After Wound Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program when the WCN did not follow proper infection control procedures after completing wound care for a resident on Enhanced Barrier Precautions (EBP). During observation, the WCN finished wound care while still wearing a yellow gown and holding a trash bag containing soiled supplies and dressings. She left the resident’s room, went to the treatment cart, logged into the computer on top of the cart, opened the cart with a key, removed a red trash bag used for isolation-room trash, and placed the regular trash bag inside it. The yellow gown and the regular trash bag both rubbed against the treatment cart. The resident’s room had EBP signage posted outside. During interview, the WCN stated she should have had the red trash bag ready before starting wound care and should have disposed of the trash while still wearing gloves, then removed her gloves and yellow gown and performed hand hygiene before doing anything else. The ICPN and DON stated they expected the WCN to complete wound care without engaging in other activities until PPE was removed, hand hygiene was performed, and trash was disposed of properly. Record review showed the facility’s EBP policy required gown and gloves for wound care and stated PPE should be removed before leaving the room, and the in-service on hand washing and PPE instructed staff to doff all PPE before leaving isolation/EBP rooms.
Improper Dumpster Trash Disposal
Penalty
Summary
The facility failed to dispose of garbage and refuse properly for trash bins A and B. On 05/12/2026 at 07:46 a.m., multiple trash bags were observed on the ground in front of the two dumpster trash bins located outside the facility, and one of the dumpster doors was left open. The report stated that trash bags were not in the dumpster and that the dumpster doors were not secured. During interviews, the Regional Director of dietary services stated the trash was normally not left in that condition and suggested it may have been left by a new staff member. The Housekeeping Supervisor stated housekeeping staff moved trash from residents’ rooms, the nurse’s station, and the main bathrooms each shift, while nursing staff were responsible for disposing of briefs, chuck pads, PPE, and wipes. The DON stated she observed the trash on the ground while driving into the facility and immediately texted maintenance to have it removed, and the ADM stated his expectation was for the dumpster area to remain free from trash and debris. The record review included an in-service titled "Dumpster: Keep Lid Closed and no Trash on the Ground" and a facility policy stating outdoor refuse storage must have tight-fitting lids or doors kept closed with no waste outside the receptacle.
Unlicensed Staff Administered Medication at RN's Direction
Penalty
Summary
A deficiency occurred when a registered nurse (RN) instructed a certified nursing assistant (CNA) to administer the medication Eliquis to a resident, despite facility policy and state regulations prohibiting CNAs from administering medications. The RN had already prepared the medication for the resident's evening dose but, after the resident refused to allow the RN into the room, handed the medication to the CNA who was delivering the resident's dinner tray. The RN remained at the doorway and observed as the CNA administered the medication. The resident involved was an adult male with multiple complex medical conditions, including chronic kidney failure, colostomy, sepsis, type 2 diabetes mellitus, abnormalities of gait and mobility, and rhabdomyolysis. The resident was cognitively intact and was care planned for anticoagulant therapy with Eliquis, which was ordered to be administered twice daily. The resident confirmed that on one occasion, a CNA had given him his Eliquis medication at the instruction of an RN. Interviews with the RN, CNA, and Director of Nursing (DON) confirmed that the CNA was not authorized or trained to administer medications and that this action was outside the CNA's scope of practice. The facility's policy clearly stated that only licensed nurses or other legally authorized staff could administer medications. The DON was not informed of the incident at the time it occurred. Both the RN and CNA acknowledged that the CNA should not have administered the medication.
Failure to Respect Resident's Choice of Caregiver
Penalty
Summary
The facility failed to honor a resident's right to choose their caregiver, which compromised the resident's dignity and self-determination. The resident, a male with a history of bipolar disorder, spinal issues, and moderate cognitive impairment, expressed a preference not to receive care from a specific CNA. Despite this, the CNA continued to offer care, making the resident feel uncomfortable and powerless. The resident had previously communicated this preference to the former Director of Nursing (DON), and an alternative CNA was assigned. However, after the former DON left, the original CNA was reassigned to the resident. Interviews revealed that the CNA was aware of the resident's preference and had informed the Assistant Director of Nursing (ADON), who suggested a room swap with another CNA. Despite this, the CNA continued to offer care when the resident's call light was on, leading to further discomfort for the resident. The ADON confirmed that the CNA was instructed not to provide care to the resident due to a previous incident involving a missing charger. However, the new DON was unaware of the resident's request until the day of the survey. The facility's document on resident rights emphasizes the right to be treated with dignity and respect, which was not upheld in this case. The failure to respect the resident's choice of caregiver could potentially lead to emotional harm, as acknowledged by the DON. The situation highlights a breakdown in communication and adherence to resident preferences, which are critical to maintaining a dignified and respectful care environment.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, leading to the development of severe pressure ulcers. The resident, who had a history of dementia, Alzheimer's disease, and other complex medical conditions, was dependent on staff for mobility and was at risk for pressure ulcers. Despite being identified as at risk, the facility did not identify or treat pressure sores on the resident's right buttock and hip, resulting in an unstageable wound and a stage III wound, respectively. The facility's records indicated that skin assessments were conducted weekly, and no abnormalities were noted by the responsible nurse. However, the resident's family intervened after noticing a wound and called emergency services, leading to the resident's hospitalization. The hospital confirmed the presence of severe pressure injuries that were not documented by the facility's staff. Interviews with the facility's staff revealed inconsistencies in the assessment and reporting of the resident's skin condition, with one nurse applying a protective dressing without a physician's order and another nurse failing to identify any open wounds during assessments. The facility's policy required full body skin assessments upon admission, weekly, and as needed, with immediate notification to the physician and responsible party if new issues were identified. However, these procedures were not followed, resulting in the resident's pressure ulcers going untreated until hospitalization. The facility's interim DON and other staff members were unable to explain how the oversight occurred, highlighting a breakdown in communication and adherence to established protocols.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure that residents were free from abuse, resulting in a deficiency for one resident who was physically abused by a CNA. The incident occurred when the CNA allegedly assaulted the resident, leading to noticeable bruising on the resident's face. The abuse was discovered by another CNA at the start of her morning shift, who observed the bruising and reported it to the charge nurse. Despite the severity of the injuries, the facility did not have any documentation or care plan updates addressing the resident's facial injuries or any measures to ensure her safety going forward. The resident involved had a history of severe cognitive impairment, as indicated by a BIMS score of 4, and multiple medical conditions including anoxic brain damage, type 2 diabetes, hypertension, dysphagia, major depression disorder, chronic kidney disease, cognitive communication deficit, anxiety disorder, and dementia. The resident's progress notes and care plan did not reflect any incidents of abuse or injuries prior to the discovery of the bruising. Interviews with staff and other residents revealed that the resident had been in a vulnerable state and had expressed distress during the time of the alleged abuse. The facility's response to the incident was inadequate, as evidenced by the lack of timely reporting and investigation. The DON and other staff members provided conflicting accounts of the resident's condition and the events leading up to the discovery of the bruising. The facility's failure to promptly address and document the abuse, as well as to implement protective measures for the resident, contributed to the deficiency. The incident was reported to HHSC, and the resident was eventually transferred to the hospital for further evaluation and treatment.
Failure to Implement Abuse and Neglect Policies
Penalty
Summary
The facility failed to implement abuse and neglect policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents. Specifically, the facility did not conduct an immediate investigation when there was a suspicion of abuse involving a resident (CR#1). This failure resulted in the resident being physically abused by a CNA, which was observed by another CNA at the start of her morning shift. The facility did not identify the staff responsible for the investigation or take immediate action to protect the resident from further harm. The resident involved, CR#1, is an elderly female with multiple medical conditions, including anoxic brain damage, type 2 diabetes, hypertension, dysphagia, major depression disorder, chronic kidney disease, cognitive communication deficit, anxiety disorder, and dementia. The resident was found with bruising on her face, which was not present during a previous visit by her family member. The family member reported the bruising to the facility staff, but the staff's response was dismissive and did not follow the facility's abuse policy. Interviews with various staff members revealed inconsistencies in their observations and actions regarding the resident's injuries. Some staff members noticed the bruising but did not document it or report it appropriately. The facility's Director of Nursing (DON) and Administrator were not immediately aware of the situation and did not take prompt action to investigate or report the abuse. The lack of proper documentation, communication, and adherence to the abuse policy led to the identification of Immediate Jeopardy, which was later removed after corrective actions were initiated.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate all alleged violations of abuse, prevent further potential abuse or mistreatment while the investigation was in progress, and report the results of all investigations to the State Survey Agency within the required timeframe. This deficiency was identified in the case of a resident who was found with suspicious injuries of unknown origin. The facility did not complete the investigation of the allegation of abuse, report the results of the investigation to the appropriate authorities within five days, or take adequate measures to prevent further potential abuse while the investigation was ongoing. This failure placed the resident at risk of continued abuse, mistreatment, further injury, pain, and physical and emotional distress, contributing to further serious injuries. The resident involved had a history of severe cognitive impairment, anoxic brain damage, type 2 diabetes, hypertension, dysphagia, major depression disorder, chronic kidney disease, cognitive communication deficit, anxiety disorder, and dementia. The resident was found with facial injuries, including bruising and swelling, which were not present during a previous visit by the family member. The facility staff, including CNAs and LPNs, provided inconsistent accounts of the resident's condition and the events leading up to the discovery of the injuries. The facility's documentation and communication regarding the resident's injuries were inadequate, and there was a lack of immediate action to protect the resident and investigate the incident thoroughly. Interviews with staff and other residents revealed that the resident had expressed pain and distress during care, and there were reports of a scuffle and the resident's cries for help. Despite these reports, the facility did not take immediate action to suspend the suspected staff member or ensure the resident's safety. The facility's investigation was incomplete, lacking interviews with key nursing staff and immediate in-service training for abuse and neglect. The facility's failure to respond appropriately to the alleged abuse and protect the resident from further harm was a significant deficiency that required immediate attention and corrective action.
Failure to Maintain Accurate Clinical Records
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for one resident, leading to incomplete and inaccurate documentation. The resident, who had severe cognitive impairment and multiple medical conditions, was found with an unexplained eye injury. Despite the injury being observed by multiple staff members, including LVNs and ADONs, no documentation was completed regarding the injury, the assessments conducted, or the actions taken to address it. The resident's care plan was also not updated to reflect the injury or any measures to ensure her safety going forward. The resident's family member (FM) noticed the injury and reported it to the facility staff, but received unsatisfactory and inconsistent responses. The FM was not notified of the injury by the facility and had to inquire about it herself. The staff, including the ADONs and the Administrator, provided conflicting explanations and failed to document the injury or the investigation process. The Administrator eventually initiated an investigation but did not document the findings or actions taken. Interviews with various staff members revealed a lack of communication and documentation regarding the resident's injury. The LVNs and ADONs acknowledged observing the injury but did not complete any documentation. The DON was also unaware of the injury until informed by the FM and did not document any findings or actions. This lack of documentation and communication could potentially place residents at risk for errors in care and treatment.
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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 Missouri City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chelsea Gardens | 0.6 mi | ★★★★★ | 10 | 2 |
| Park Manor Of Quail Valley | 1.2 mi | ★★★★★ | 0 | 0 |
| Paradigm At First Colony | 2.5 mi | ★★★★★ | 8 | 0 |
| Ignite Medical Resort Sugar Land, Llc | 5.1 mi | ★★★★★ | 7 | 0 |
| Sugar Land Health Care Center | 5.6 mi | ★★★★★ | 2 | 0 |
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