Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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.
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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 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 | — | 9 | 0 |
| Amarillo Medical Lodge | 0.1 mi | — | 4 | 0 |
| Landmark Of Amarillo Rehabilitation And Nursing Ce | 0.7 mi | — | 14 | 0 |
| Amarillo Center For Skilled Care | 0.8 mi | — | 8 | 0 |
| Kirkland Court Health And Rehabilitation Center | 1 mi | — | 8 | 3 |
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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 August 2026) and official state health department websites.