Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 2027
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 Windsor Nursing And Rehabilitation Center Of Alice during CMS and state inspections, most recent first.
Improper Food Storage and Date Marking: A kitchen tour found food stored past the 72-hour limit in refrigerators, a bag of onions placed next to a pail of cleaning solution and rag, and open freezer items including hashbrowns and raw bread loaves that were not sealed. The DA, cook, and DM stated staff were responsible for checking dates, sealing food, and keeping chemicals away from food, but the expired and improperly stored items remained in place.
Care Plan Not Updated to Match Current Code Status: A resident with acute respiratory failure with hypercapnia, COPD, MDD, insomnia, and vascular dementia had a care plan listing DNR status, while the physician order summary showed Full Code. The MDS coordinator, SW, Regional Nurse, and DON described their roles in updating code status and revising the care plan, but the record showed the care plan was not reviewed and revised after assessments as required.
A resident with obstructive and reflux uropathy, moderately impaired cognition, and a suprapubic Foley catheter had the catheter bag observed on the floor beside the bed. An LVN confirmed the bag should not have been on the floor, a CNA stated staff were responsible for keeping Foley bags off the floor and below bladder level, and the DON stated the same.
A facility failed to provide respiratory care as ordered for two residents. One resident with respiratory failure and COPD was observed on oxygen at 2 LPM instead of the ordered 3 LPM, and the LPN verified the setting was incorrect. Another resident with a tracheostomy, acute respiratory failure with hypoxia, and COPD did not have an emergency trach kit easily accessible at bedside; the LVN could not find the Ambu bag, extra trach tube, or obturator in the room, and the DON stated the supplies should have been kept at bedside.
Surveyors found the C Hall discontinued medication cabinet unlocked in the medication storage room. LVN D said he knew the cabinet was supposed to be locked but did not know it was unlocked, and the DON and ADON both confirmed it should have been secured, with staff placing discontinued meds through a small opening and the pharmacist removing them when needed. The facility policy stated medications awaiting disposal or return must be stored in a locked secure area.
Infection control practices were not followed for multiple residents. A resident with an indwelling device had a care plan for EBP but no physician order, a wound care nurse failed to use proper hand hygiene, clean barriers, and clean applicators while treating a resident with LLE venous ulcers, and a medication aide touched the bed remote and light cord with the same gloves used to give eye drops to another resident. The DON and staff acknowledged the improper practices.
A resident with anxiety, major depressive disorder, dementia with behavioral disturbance, and a history of schizoaffective disorder received risperidone with the order and care plan documenting the indication as dementia with behavioral disturbance rather than the intended psychiatric diagnosis. The MDS showed moderately impaired cognition and antipsychotic use but did not document behaviors. Interviews with an LVN, ADON, pharmacist, NP, and DON revealed that the antipsychotic was prescribed for schizoaffective disorder, but the indication was incorrectly entered as dementia when the phone order was taken, and the resident’s schizoaffective diagnosis had been removed at readmission. This conflicted with facility policy requiring psychotropic medications to have an adequate, documented clinical rationale tied to a specific diagnosed condition.
A nurse failed to wear gloves and perform proper hand hygiene while handling a paper towel containing a resident's phlegm, instead disposing of it in the hallway and only washing hands afterward. The nurse cited concerns about resident dignity and did not initially recognize the infection control issue, despite facility policy requiring standard precautions for all residents.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The report notes the presence of hazards and insufficient supervision, but does not specify further details or individuals involved.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft. Surveyors found gaps in staff training and a lack of clear protocols, which left residents vulnerable to mistreatment and delayed detection of incidents.
The facility failed to maintain kitchen equipment, specifically the doors of a 3-door and a 2-door refrigerator, which did not close properly. The issue persisted since December 2024, leading to a temperature rise and food disposal. The Dietary Manager reported the problem, but the Maintenance Director was unaware of its continuation. The acting Administrator was informed later and was unaware of the ongoing issue. The FDA food code requires equipment to be maintained in good repair, which was not adhered to.
The facility failed to ensure accurate MDS assessments for two residents receiving oxygen therapy. One resident with chronic pulmonary disease was on continuous oxygen, but her MDS did not reflect this. Similarly, another resident's MDS failed to indicate oxygen use despite physician orders. The MDS LVN acknowledged the oversight, and interviews with the DON and ADON revealed a focus on financial implications rather than clinical accuracy.
The facility failed to implement comprehensive care plans for two residents, leading to deficiencies in addressing their specific needs. One resident, with respiratory conditions, was fed high-sodium cheese despite a no added salt diet, and her family's non-compliance was not documented. Another resident, with severe cognitive impairment, refused to wear a palm protector, but her refusal was not reflected in her care plan. The facility's policy requires documentation of services not provided due to refusal, which was not followed in these cases.
The facility failed to provide proper respiratory care for two residents. A resident with COPD received oxygen at an incorrect setting due to a nurse's oversight, while another resident's room lacked an oxygen use sign, posing safety risks. These deficiencies highlight lapses in adhering to safety protocols.
A resident with chronic pain was prescribed Tramadol, which was administered but not signed off on the MAR, leading to a failure in maintaining accurate records for controlled drugs. Despite the oversight, the narcotic sheet and blister pack count matched, confirming the medication was given. The facility's policy mandates signing off medications on the MAR post-administration, which was not followed.
A CNA failed to perform proper hand hygiene between glove changes while providing catheter and perineal care to a resident with a Foley catheter, risking infection spread. The resident had multiple health conditions, including diabetes and cognitive deficits, increasing her infection risk. Facility policy and CDC guidelines emphasize hand hygiene, which was not followed in this instance.
The facility did not post daily nurse staffing information for three consecutive days, displaying outdated details instead. The ADON was responsible for posting this information by 8:30 a.m., but it was not done, leaving residents uninformed about staffing levels. The facility's policy requires this information to be readily available, which was not followed.
A resident with vascular dementia and a history of wandering exited a facility unnoticed due to a malfunctioning alarm on a side exit door. The resident was found outside in her wheelchair after being unaccounted for 29 minutes. Staff failed to report the alarm issue earlier in the day, contributing to the incident.
Improper Food Storage and Date Marking
Penalty
Summary
The facility failed to store food in accordance with professional standards in the kitchen, including 2 of 3 refrigerators and 1 of 2 freezers reviewed for storage, preparation, and sanitation. During the kitchen tour, a bag of onions was observed sitting next to a pail of cleaning solution and a rag on the bottom shelf of a kitchen counter. In the refrigerators, containers of tuna, corn, chocolate pudding, vanilla pudding, chilled fruit, and jello were observed dated past the 72-hour used-by date and were still present in storage. In the freezer, a box of raw bread loaves and 2 boxes of hashbrowns were observed with the plastic bag unsealed and the box open, leaving the items exposed to air and possible contaminants. The DA stated that kitchen staff were responsible for cleaning the refrigerator, ensuring food was labeled, sealed, and not expired, and that expired food was thrown out daily, but could not explain why the dated items remained in the refrigerator. The DA also stated that the cleaning solution should not have been stored near food and that the open freezer items should have been sealed. The cook stated she could not recall when the hashbrowns and raw bread loaves were left open in the freezer and said she did not make sure all food items were closed and sealed correctly. The DM stated that staff clean out the refrigerator daily and that the expired items must have been overlooked, and she also stated the pail with the rag had been used that morning and staff in a rush did not ensure proper placement away from food. The facility food storage policy required chemicals to be stored away from food, leftovers to be discarded after 72 hours, and frozen foods to be stored in moisture-proof wrap or containers that are labeled and dated.
Care Plan Not Updated to Match Current Code Status
Penalty
Summary
The facility failed to review and revise the comprehensive care plan after each assessment, including both the comprehensive and quarterly review assessments, for Resident #5. Record review showed the resident had diagnoses including acute respiratory failure with hypercapnia, COPD, major depressive disorder, insomnia, and vascular dementia, and the Annual MDS documented a BIMS score of 06, indicating severely impaired cognition. The resident’s care plan dated [DATE] listed a DNR code status and included interventions such as ensuring a signed DNR was in the medical record and not calling 911 or initiating CPR if the resident had a cardiac arrest. Record review of the Physician Order Summary Report dated [DATE] showed the resident had a Full Code Status order dated [DATE], which did not match the DNR status listed on the care plan. During interviews, the MDS coordinator stated she updated code status in the care plan and on the MDS, the SW stated he followed up with the doctor for the DNR signature and notified the MDS coordinator when signatures were obtained, and the Regional Nurse and DON stated they oversaw the process and care plan revisions. The DON stated it was ultimately her responsibility to ensure the code status was updated on the care plan, and the facility policy stated the comprehensive care plan would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.
Foley Catheter Bag Left on Floor
Penalty
Summary
The facility failed to ensure that Resident #33, a male with obstructive and reflux uropathy, moderately impaired cognition with a BIMS score of 9, and an indwelling suprapubic Foley catheter, received appropriate catheter care to prevent urinary tract infections and support continence to the extent possible. The resident’s care plan directed staff to keep the collection bag off the floor and below bladder level, check the suprapubic Foley catheter every shift, secure it with a statlock, and monitor tubing and privacy bag placement. The order summary also showed a Foley catheter change order every 6 weeks for patency. During observation, Resident #33’s indwelling catheter bag was found laying on the floor on the right side of the bed. An LVN confirmed the bag was on the floor and stated it should not be there, explaining that staff were responsible for keeping it properly placed and off the floor. A CNA stated she had hung the bag on the bed frame after laying the resident down, and that staff were responsible for ensuring Foley bags did not touch the floor and remained below the bladder. The DON also stated Foley catheter bags should not be on the floor and that staff were responsible for making sure they were properly placed.
Respiratory Care Not Provided as Ordered for Oxygen and Tracheostomy Needs
Penalty
Summary
The facility failed to ensure Resident #56 received oxygen at the physician-ordered setting of 3 liters per minute via nasal cannula. Resident #56 was a female with diagnoses including respiratory failure and COPD, had a BIMS score of 15, and had an active order for oxygen at 3 LPM every shift for hypoxia. During observation, the portable oxygen cylinder regulator was set at 2 LPM while the resident was sitting in her wheelchair. The resident stated she did not move the setting and could not reach the regulator behind her wheelchair, and she said she only knew she was supposed to be on 2 liters. The LVN verified the order was for 3 LPM and adjusted the oxygen to the correct setting. The facility also failed to ensure Resident #8 had an emergency tracheostomy kit at the bedside. Resident #8 was a male with diagnoses including tracheostomy, acute respiratory failure with hypoxia, and COPD, and his MDS showed a BIMS score of 0. His care plan directed staff to keep an extra trach tube and obturator at bedside, same size and one smaller. During observation, there was no emergency trach kit easily accessible at the bedside, and the LVN searched drawers in the room but could not find the emergency supplies, including the Ambu bag. The LVN stated there was no emergency trach kit containing an Ambu bag at the bedside and that the next lower size trach was not easily accessible. She stated the Ambu bag should be easily accessible in the room, along with the extra trach tube, and that it was the nurse’s responsibility to ensure the kit was at bedside. The DON stated the extra trach tubes and Ambu bag should be kept at bedside and that she was not aware the Ambu bag was not in the room. The report also noted the facility had no policy for oxygen administration and no policy for respiratory care services tracheostomy care.
Unlocked Discontinued Medication Cabinet
Penalty
Summary
The facility failed to ensure the C Hall discontinued medication cabinet was locked and secured in accordance with its medication storage and disposal policy. During an observation in the C Hall medication storage room, surveyors found the cabinet containing discontinued medications was not locked. LVN D stated he knew the cabinet was supposed to be locked, but he was not aware it was unlocked and did not have a key for it, although he thought the DON might have one. In interviews, the DON stated the cabinet should have been locked and that nurses should have a key, with staff placing medications through a small opening at the top of the cabinet door. The DON said the pharmacist would be the only person to unlock the cabinet to remove discontinued medications and relock it afterward. The ADON also confirmed the cabinet was supposed to be locked and stated the DON had the key. The facility policy stated medications awaiting disposal or return are to be stored in a locked secure area until disposed of or returned to the pharmacy.
Infection Control Lapses During Wound Care, Eye Drop Administration, and EBP Ordering
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 3 residents reviewed for infection control practices. One resident had no physician order for enhanced barrier precautions despite a care plan that identified the need for EBP due to an indwelling medical device. The resident’s record showed a severely impaired BIMS score and a history of sepsis due to Enterococcus. The care plan directed staff to place the resident on EBP and to place a sign on the door, with gown and gloves used for high-contact resident care activities. A second resident had physician orders for EBP for high-contact care activities and for wound care to venous ulcers of the left lower extremity. During wound care observation, the wound care nurse performed hand hygiene, set up a clean barrier for supplies, and donned PPE, but did not place a clean barrier or pad between the resident’s wounds and the bed. After removing soiled gloves, the nurse re-gloved without sanitizing hands, performed hand hygiene for only about 5 seconds at one point and about 3 seconds at another, and used the same soiled cotton-tipped applicator each time she re-entered the medication cup containing gel. The nurse also cleansed the wound with one pass of wound cleanser and one dry gauze, applied the gel to only about half of the wound bed, sprinkled powder on only half of the wound, and did not cleanse the wound adequately. The wound care nurse stated she should have placed a clean barrier between the wound and the bed, should have cleansed the wound from cleanest to dirtiest, should have sanitized hands until dry, and should have used a clean cotton-tipped applicator each time she re-entered the medication cup. A third resident received eye drops from a medication aide who donned gloves, touched the bed remote and light cord, and then touched the resident’s face and administered the eye drops with the same gloves. The medication aide stated she should have removed the gloves, sanitized, and put on new gloves after touching the remote and light cord. The DON stated staff should change gloves when they touch something dirty or any other surface not part of the procedure, and that the medication aide should have changed gloves before administering the eye drops. The facility’s infection prevention and control program policy stated staff are responsible for following infection control policies and procedures, and staff education includes demonstrating competence in infection control practices.
Inaccurate Indication for Antipsychotic Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary drugs by not having an adequate, accurate indication for the use of the antipsychotic medication risperidone prior to administration. The resident was an older female with anxiety disorder, major depressive disorder, and dementia with behavioral disturbance, admitted with an initial admission date in 2022 and a later admit date in 2026. Her quarterly MDS showed a BIMS score of 12, indicating moderately impaired cognition, and documented use of antipsychotic and antidepressant medications, but did not indicate behaviors. The resident’s quarterly care plan identified a problem of antipsychotic use, listing risperidone 0.5 mg at bedtime related to dementia, and a separate problem of calling/yelling out for help related to unspecified dementia with behavioral disturbances, with interventions including monitoring, redirection, documentation of behaviors, and medication administration as ordered. Record review showed an active order for risperidone 0.5 mg at bedtime with the indication of unspecified dementia with other behavioral disturbance, with an order and start date in late February 2026. Interviews with staff revealed inconsistent understanding and documentation of the indication for this antipsychotic. An LVN stated that if a psychiatrist ordered an antipsychotic with an indication of dementia, she would ensure the order also indicated it was for behaviors, and she would consult the DON if she had questions, but she could not state the negative outcome of having an antipsychotic order with an indication of dementia. The ADON stated it was her responsibility to ensure all antipsychotic orders had the correct indication and believed the risperidone order with an indication of dementia was correct because that was how the physician had written it, while also acknowledging that a gradual dose reduction had been initiated because the resident did not have a diagnosis that fit that medication. Further interviews clarified that the documented indication on the order did not match the prescriber’s intent or the resident’s psychiatric diagnosis. The pharmacist stated the order did not have the correct indication and reported initiating a gradual dose reduction, explaining that the resident had behavioral issues due to schizoaffective disorder. The psychiatric NP reported he had ordered risperidone with an indication of schizoaffective disorder and stated he would never prescribe an antipsychotic with an indication of dementia, attributing the incorrect indication to an error when the phone order was entered. The DON confirmed that the risperidone order did not have the correct indication and explained that the resident had a diagnosis of schizoaffective disorder prior to readmission, which must have been struck out at readmission. The facility’s own policy on psychotropic medications required an adequate, documented clinical rationale and use only for a specific, diagnosed, and documented condition, which was not met in this case due to the incorrect and inadequate indication documented for risperidone.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for one resident who was observed coughing up copious amounts of thick phlegm. During the incident, a nurse (LVN-A) handled a paper towel containing the resident's phlegm without wearing gloves and disposed of it by walking out to the medication cart in the hallway. The nurse then returned to the resident's room, provided a cup for the resident to spit into, and only washed her hands after these actions. The nurse stated she did not wear gloves because she believed it was a dignity issue for the resident and did not consider it an infection control issue at the time. The resident involved had a history of cerebral infarction, expressive language disorder, and seizures, and was noted to be lethargic with slurred speech and coughing up phlegm on the day of the incident. The facility's infection prevention and control policy requires staff to use standard precautions, including the use of gloves and proper hand hygiene when handling potentially infectious materials. Both the ADON (infection control nurse) and DON confirmed that gloves should have been worn and hand hygiene performed according to policy, and that the nurse's actions did not follow established infection control procedures.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment contained hazards that could lead to accidents, and supervision was not sufficient to prevent such incidents. Specific details regarding the nature of the hazards, the supervision provided, or the individuals affected are not included in the report.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. Surveyors identified that the facility did not have comprehensive or consistently enforced protocols in place to safeguard residents from these forms of mistreatment. This deficiency was observed through a review of facility documentation and staff interviews, which revealed gaps in staff training and a lack of clear guidance on reporting and preventing such incidents. The absence of robust preventive measures contributed to an environment where abuse, neglect, or theft could occur without timely detection or intervention.
Refrigerator Door Malfunction in Kitchen
Penalty
Summary
The facility failed to maintain kitchen equipment in good condition, specifically the doors of a 3-door and a 2-door refrigerator, which did not close properly. This issue was observed during a kitchen tour, where it was noted that closing one door would cause the other doors to open. The Dietary Manager (DM) reported that the problem had persisted since December 2024 and had been reported to the Maintenance Director multiple times. The DM also mentioned an incident where the night crew failed to check the refrigerator doors, resulting in a temperature rise to 60 degrees Fahrenheit, necessitating the disposal of all food in the refrigerator. The Maintenance Director acknowledged ordering and installing a new gasket for the 3-door refrigerator in December 2024 but was unaware that the problem persisted. He admitted to not checking the doors after the installation and was unsure of the frequency required for such checks. The acting Administrator, informed of the issue on February 25, 2025, was unaware of the ongoing problem with both refrigerators. The facility's records showed only one instance of a temperature rise to 60 degrees Fahrenheit, and the FDA food code requires equipment to be maintained in good repair, which was not adhered to in this case.
Inaccurate MDS Assessments for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the use of oxygen therapy for two residents. Resident #36, a female with chronic pulmonary disease and other significant health issues, was on continuous oxygen therapy as per her physician's order and care plan. However, her admission MDS did not indicate the use of oxygen therapy. The MDS Licensed Vocational Nurse (LVN) responsible for completing the assessment acknowledged the oversight and mentioned that the error could lead to less payment for the facility. Similarly, Resident #27, who had chronic obstructive pulmonary disease and was on continuous oxygen therapy, also had an MDS assessment that failed to reflect the use of oxygen. The MDS nurse admitted to forgetting to mark the oxygen therapy on the MDS and emphasized the importance of accuracy for reimbursement purposes. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed a lack of oversight and understanding of the MDS process, with both focusing on the financial implications rather than the potential impact on resident care. The report highlights that the inaccuracies in the MDS assessments could place residents at risk for receiving inadequate care and services due to the failure to accurately document their treatment needs. The facility's staff, including the MDS LVN, DON, and ADON, appeared to prioritize the financial aspects of the MDS over the clinical accuracy and potential impact on resident care, as evidenced by their statements during interviews.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which led to deficiencies in addressing their specific needs. Resident #9, a female with chronic obstructive pulmonary disease and other respiratory conditions, was observed being fed high-sodium cheese by a CNA, despite being on a no added salt diet. The resident's family frequently brought outside food, and although the staff was aware of this non-compliance, it was not reflected in the care plan. Interviews with staff revealed that the issue was discussed in meetings, but no formal documentation or care plan adjustments were made to address the resident's dietary non-compliance. Resident #31, a female with severe cognitive impairment due to Alzheimer's disease and dementia, had an order to wear a palm protector on her left hand continuously. However, observations showed that she was not wearing the palm protector, and interviews with staff indicated that she resisted wearing it. Despite this, her refusal was not documented in her care plan. Staff members assumed that the behavior would be care planned, but the MDS LVN was not informed of the resident's refusal, leading to a lack of appropriate care planning. The facility's policy on comprehensive care plans requires that any services not provided due to a resident's refusal be documented in the care plan. However, in both cases, the residents' non-compliance and refusals were not adequately documented or addressed in their care plans, resulting in a failure to meet their medical, nursing, and psychosocial needs as identified in their comprehensive assessments.
Deficiencies in Respiratory Care and Safety Signage
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in their care. Resident #9, a female with chronic obstructive pulmonary disease (COPD), emphysema, and acute respiratory failure with hypoxia, was observed receiving oxygen at 3 liters per minute (lpm) instead of the physician-ordered 2 lpm via nasal cannula. This discrepancy occurred when the resident was transferred to the dining room, and the charge nurse responsible for ensuring the correct oxygen setting was distracted and did not verify the setting. Despite the incorrect oxygen setting, Resident #9 did not exhibit any signs of distress during the observation. For Resident #49, a male with heart failure and essential hypertension, the facility failed to post an oxygen sign outside his room, indicating that oxygen was in use. This oversight was noted during an observation when the resident was using oxygen in his room. The absence of the sign posed a potential safety risk, as it could lead to unawareness of oxygen use by staff, visitors, and other residents, increasing the risk of accidents or exposure to flammable materials. Interviews with staff revealed that it was the responsibility of the admitting nurse to place the sign, and the lack of signage was acknowledged as a safety concern. The facility's policy on oxygen safety emphasizes the importance of training staff on the operation and safety precautions of oxygen equipment, as well as the necessity of posting 'No Smoking' signs to indicate oxygen use. However, the failure to adhere to these protocols for both residents highlights lapses in the facility's implementation of its own safety policies, potentially compromising resident safety.
Failure to Document Controlled Drug Administration
Penalty
Summary
The facility failed to maintain an accurate system of records for controlled drugs, specifically for a resident who was prescribed Tramadol for breakthrough pain. The resident, a cognitively intact male with chronic obstructive pulmonary disease, cognitive communication deficit, and hypertension, was admitted with a PRN order for Tramadol to manage chronic pain related to gout and hypertension. On one occasion, the medication was administered but not signed off on the Medication Administration Record (MAR), which could lead to discrepancies in medication administration and potential drug diversion. The incident involved a lapse in documentation by a licensed vocational nurse (LVN), who administered the medication but failed to record it on the MAR. Despite the oversight, the narcotic sheet and blister pack count matched, indicating that the medication was indeed given. The Director of Nursing (DON) confirmed the oversight but could not determine any negative outcome from the failure to sign off the medication. The facility's policy requires that medications be signed off on the MAR after administration, which was not adhered to in this instance.
Inadequate Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA B during the care of a resident with a Foley catheter. CNA B did not wash her hands or use hand sanitizer between glove changes while providing catheter and perineal care to the resident. This lapse in protocol was observed during a specific incident where CNA B removed soiled gloves and donned new ones without performing hand hygiene, which is a critical step in preventing the spread of infection. The resident involved was an elderly female with multiple health conditions, including diabetes, hypertension, and cognitive communication deficit. She was at risk for impaired skin integrity and infection due to her physical and cognitive limitations and the presence of a stage IV pressure ulcer. The facility's policy on infection prevention and control, as well as guidelines from the CDC, emphasize the importance of hand hygiene, particularly before and after glove removal and when transitioning from a dirty to a clean area. Interviews with the ADON and DON confirmed the expectation for staff to adhere to these protocols to prevent the spread of microorganisms.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information on a daily basis, as required, for three consecutive days. During observations, it was noted that the staffing information displayed was outdated, showing details from 02/21/25 instead of the current dates of 02/22/25, 02/23/25, and 02/24/25. The information was supposed to include the facility name, current date, total number, and actual hours worked by licensed and unlicensed nursing staff responsible for resident care per shift. This information was not posted in a prominent place, which could potentially leave residents uninformed about the staffing levels available to provide care. Interviews with the Assistant Director of Nursing (ADON) and the Administrator revealed that the ADON was responsible for ensuring the daily posting of staffing information by 8:30 a.m. The ADON acknowledged the importance of this task, especially in emergencies, to know the number of staff present. However, the Administrator stated there were no negative outcomes from not having the staff information posted. The facility's policy, dated 10/24/22, mandates that nurse staffing information be readily available in a readable format to residents and visitors at any given time, which was not adhered to during the days in question.
Resident Elopement Due to Alarm Malfunction and Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, who was unaccounted for approximately 29 minutes. During this time, the resident, who had a history of vascular dementia with psychotic disturbance and was identified as an elopement risk, managed to exit the facility without staff knowledge. The resident was later found outside the facility in her wheelchair, stuck in the grass, by a third party who notified a CNA. The resident was not in distress and had no signs of dehydration or injury upon assessment. The deficiency was partly due to a malfunctioning alarm on a side exit door, which was noted by a CNA earlier in the day but not reported to management. The alarm system was supposed to alert staff to unauthorized exits, but it failed to function properly, allowing the resident to leave the building unnoticed. The facility's Director of Nursing (DON) stated that the resident was not considered an elopement risk at the time of the incident, despite her history of wandering and exit-seeking behavior. Interviews with staff revealed that the facility had procedures in place for responding to elopement alarms, including conducting headcounts and checking the immediate vicinity. However, these procedures were not effectively implemented due to the alarm malfunction and lack of communication about the issue. The facility's maintenance staff acknowledged that the alarm system had a history of disengaging at random times, which contributed to the failure to prevent the resident's elopement.
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 47 citations issued within 25 miles in the last 12 months — including the 5 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 Alice
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Premier Snf Of Alice | 0 mi | — | 9 | 0 |
| Meridian Care Of Alice | 2.4 mi | — | 9 | 4 |
| Windsor Nursing And Rehabilitation Center Of San D | 11.9 mi | — | 0 | 0 |
| Lone Star Ranch Rehabilitaion And Healthcare Cente | 21.6 mi | — | 3 | 0 |
| Kingsville Nursing And Rehabilitation Center | 22.3 mi | — | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Windsor Nursing And Rehabilitation Center Of Alice.
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.