Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 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 Rehabilitation And Healthcare during CMS and state inspections, most recent first.
Surveyors found that a crash cart at the central nurse's station contained numerous expired alcohol wipes, despite documented shift checks and audit processes. Night shift nurses were assigned to check the cart each shift, with an ADON periodically verifying their work, and the administrator reported that ADONs and a pharmacy technician also audited the cart while nurses were expected to complete a daily checklist. The facility’s written policy required immediate removal and proper disposal of outdated medications and supplies, but the expired alcohol wipes remained available for use, indicating the required monitoring and removal processes were not effectively carried out.
A resident was prescribed Lantus without a documented diabetes diagnosis, leading to a deficiency in medication management. Despite elevated blood sugars noted by MD A, the resident's medical records lacked a diabetes diagnosis, and the resident refused insulin treatment. Facility staff acknowledged the oversight, citing delays in receiving physician notes and issues with record-keeping during a transition to digital records.
The facility's kitchen failed to meet food safety standards, with expired food items, unsealed packages, and dirty kitchenware observed. A menu item was not at the correct temperature, and the dry storage room was cluttered. The Dietary Manager acknowledged these issues, which were against the facility's policy.
Two residents were not provided full privacy during medical procedures by an LVN, who failed to close doors or pull privacy curtains during blood glucose checks and insulin administration. This lack of privacy was acknowledged by the DON and Administrator, who emphasized the importance of maintaining resident dignity and privacy as per facility policy.
A facility failed to implement a baseline care plan for a newly admitted resident within 48 hours, as required. The resident, with multiple medical conditions and mild cognitive impairment, did not receive a timely care plan, potentially affecting individualized care. Interviews with staff revealed that the responsibility for initiating care plans lies with an RN, and the DON was surprised by the oversight despite daily reviews.
A facility failed to update a resident's care plan to include her blood pressure medications, Midodrine and Amlodipine, within seven days of the comprehensive assessment. The resident, with multiple health conditions including hypertension and hypotension, had specific physician orders for these medications, which were not documented in her care plan. This oversight was confirmed by the MDS Coordinator during an interview.
A resident with hypertension was administered Midodrine HCL outside prescribed blood pressure parameters on multiple occasions. The ADON consulted the physician verbally but failed to document the interaction, contrary to facility policy. This posed a risk of unclear assessments and potential health issues for the resident.
Two residents in an LTC facility experienced medication administration errors, resulting in a 10% error rate. One resident received the wrong dosage of Candesartan and was not given Claritin-D as prescribed, while another did not receive their Autologous Serum Eyedrops. The errors were not caught during pharmacy audits, and the facility's procedures for handling medication orders were not followed.
Two residents in a LTC facility were administered blood pressure medications outside of prescribed parameters, leading to significant medication errors. A resident with hypertension was given Carvedilol despite low blood pressure readings, while another resident received Midodrine when her blood pressure was too high. Staff interviews revealed a failure to adhere to medication administration policies, highlighting documentation and procedural lapses.
A facility failed to maintain accurate clinical records for a resident's medication administration. The MAR for Levothyroxine had blanks, indicating a lack of documentation on whether the medication was given. Interviews with staff confirmed that MARs should have no blanks, and the facility's policy emphasized accurate documentation.
A resident with complex medical conditions received wound care during which RN A failed to perform proper hand hygiene after changing gloves, contrary to the facility's infection control policy. This lapse in protocol was observed and confirmed by staff interviews, placing multiple residents at risk for infection.
Expired Supplies and Inadequate Monitoring of Crash Cart Medications
Penalty
Summary
Surveyors identified a deficiency in the storage and monitoring of drugs and biologicals on the crash cart located at the central nurse's station. During an observation, the crash cart contained 86 individual alcohol wipes with an expiration date of 10/3/2024 in the third drawer, indicating expired medical supplies were available for resident use. The facility’s Medication Access and Storage policy, dated 5/2007, required that outdated, contaminated, or deteriorated medications be immediately removed from stock and disposed of according to procedures for medication destruction. Interviews with staff revealed that night shift nurses were responsible for checking the crash cart each shift to ensure all medications and supplies were current and accounted for, and that an ADON occasionally checked the cart after night nurses to ensure it was done properly. The administrator stated that ADONs and a pharmacy technician completed cart audits, and that nurses were expected to maintain the cart and complete a daily checklist, with nursing leadership monitoring the process. An attempted interview with the night nurse who had signed off on checking the crash cart on the day of the observation was unsuccessful, leaving unresolved how the expired alcohol wipes remained on the cart despite documented checks.
Resident Prescribed Lantus Without Diabetes Diagnosis
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically Lantus, which was prescribed without a medical diagnosis of diabetes. The resident, a male with a history of dementia, hypertension, and other conditions, was prescribed Lantus by MD A after noting elevated blood sugars. However, there was no documented diagnosis of diabetes in the resident's medical records, and the resident himself denied having diabetes and refused the insulin treatment multiple times. The deficiency was identified through a review of the resident's medical records, which showed no diagnosis of diabetes despite the prescription of Lantus. Interviews with facility staff, including the MDS nurse, DON, and other nursing staff, revealed that the facility did not receive physician notes in a timely manner, which contributed to the oversight. The staff acknowledged that medications should not be administered without a corresponding diagnosis, yet the Lantus was prescribed and administered without proper documentation. The resident's lab history showed an A1C level within normal limits, further questioning the necessity of the insulin prescription. Despite the resident's refusal of insulin and lack of a diabetes diagnosis, the facility did not have a system in place to verify the appropriateness of the medication order. The interviews highlighted a gap in communication and record-keeping, as the facility had transitioned to digital records but failed to ensure all necessary information was accurately documented and accessible.
Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. During an inspection, it was found that food items in the kitchen's cooler were expired and beyond their use-by date. Additionally, food items in the walk-in cooler and freezer were not properly sealed, and cleaned baking sheets, pans, utensils, and divided plates had food particles on them. A menu item on the steam table was not maintained at the correct holding temperature, and the floor of the dry storage room was cluttered with paper and other debris. These deficiencies were identified through observations, interviews, and record reviews. The Dietary Manager acknowledged these issues during interviews, noting that leftover food should be used within three days and that staff are expected to check and ensure cleanliness of kitchenware before storage. The manager also recognized the risk of foodborne illness from off-temperature foods and expressed the need to find a solution to maintain correct holding temperatures. The facility's policy, based on the Texas Food Establishment Regulations and the U.S. Public Health Service Food Code, was not followed, as evidenced by the improper storage and handling of food and kitchen equipment.
Failure to Ensure Resident Privacy During Medical Procedures
Penalty
Summary
The facility failed to ensure the privacy and dignity of two residents during medical procedures, as observed by surveyors. Licensed Vocational Nurse (LVN) B did not provide full privacy for Resident #49 and Resident #18 while performing blood glucose checks and insulin administration. Specifically, LVN B did not close the entrance door or pull the privacy curtain in Resident #49's room, leaving the resident exposed to their roommate and passers-by. Similarly, for Resident #18, LVN B did not pull the privacy curtain before checking the blood glucose and administering insulin, compromising the resident's privacy. Resident #49, who has a BIMS score indicating no impaired cognition, expressed embarrassment over the lack of privacy, stating that staff usually did not pull the privacy curtains. The Director of Nursing (DON) and the Administrator both acknowledged that maintaining resident privacy and dignity is the responsibility of all staff members, and failure to do so could lead to resident embarrassment. The facility's policy on resident rights emphasizes the importance of treating residents with dignity and respect, including ensuring privacy during examinations and treatments.
Failure to Implement Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by professional standards of quality care. This deficiency was identified during a review of records and interviews with staff. The resident in question, a female with multiple medical diagnoses including paroxysmal atrial fibrillation, colon cancer, hypertension, and mild cognitive impairment, was admitted to the facility but did not have a baseline care plan completed within the specified timeframe. The absence of this care plan could lead to the resident not receiving individualized services and care upon admission. Interviews with facility staff, including the MDS Nurse and the DON, revealed that the responsibility for initiating baseline care plans lies with an RN, with MDS Nurses approving the plans. The DON expressed surprise that the baseline care plan was not completed on time, despite daily reviews of resident plans by nursing management. The facility's policy on resident assessments emphasizes the importance of documenting residents' preferences, goals of care, and health status, but this was not adhered to in the case of the resident in question.
Failure to Update Care Plan for Blood Pressure Medications
Penalty
Summary
The facility failed to develop a comprehensive care plan within seven days after the completion of the comprehensive assessment for a resident, specifically regarding her blood pressure medications. The resident, a 67-year-old female with multiple diagnoses including Alzheimer's disease, COPD, hypertension, and diabetes, was not care planned for her prescribed medications Midodrine and Amlodipine. The care plan, last updated in October 2024, did not include documentation for these medications, which are critical for managing her hypotension and hypertension. The deficiency was identified through record reviews and interviews. The resident's physician orders from November 2024 included specific instructions for administering Midodrine and Amlodipine based on her blood pressure readings. However, these were not reflected in her care plan. An interview with the MDS Coordinator confirmed that the care plan was not updated to address the resident's blood pressure medications, despite the facility's policy requiring care plans to be updated with changes in a resident's condition or medications.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medications for a resident with essential hypertension. The resident was prescribed Midodrine HCL to be held if systolic blood pressure (SBP) exceeded 130 or diastolic blood pressure (DBP) exceeded 70. However, the medication was administered on multiple occasions when the resident's blood pressure was outside the prescribed parameters, including instances where the SBP was 140 and 139. The resident reported experiencing high blood pressure and attributed it to the medication administered outside the parameters. The Assistant Director of Nursing (ADON A) admitted to administering the medication outside the parameters and verbally consulting the physician without documenting the interaction. The Director of Nursing (DON) confirmed that the expectation was to report any deviations to the nurse on duty, who would then contact the physician. The facility's policies required that medications be administered only upon a licensed prescriber's order and documented accordingly. The lack of documentation and adherence to the physician's orders posed a risk of unclear assessments and potential health deterioration for the resident.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to provide accurate pharmaceutical services, resulting in a medication error rate of 10%. Two residents were affected by these errors. Resident #75 was administered the incorrect dosage of Candesartan and was not given Claritin-D as prescribed. The medication administration was observed to be incorrect, and the medication aide admitted to not checking the dosage properly. The facility had the correct medications available, but they were not administered as per the physician's orders. Resident #2 did not receive the prescribed Autologous Serum Eyedrops as ordered by the physician. The medication aide claimed to have administered the drops, but the medication was found in the refrigerator, and the resident confirmed not receiving the second dose. The pharmacist noted that the eyedrops should be used within 90 days to avoid infection, indicating a lapse in proper medication administration. Interviews with the Director of Nursing (DON) revealed a lack of awareness regarding the errors and a failure in the system to catch these issues during pharmacy audits. The DON expressed surprise at the errors, especially given the facility's procedures for handling discontinued or changed doses. The facility's policy requires accurate implementation of physician orders, but this was not adhered to, leading to the deficiencies observed.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for two residents who were administered blood pressure medications outside of the prescribed parameters. Resident #44, a male with multiple diagnoses including hypertension and schizophrenia, was given Carvedilol despite his blood pressure readings being below the threshold set by the physician's orders. The medication was not held on several occasions, as indicated by the November Medication Administration Records (MARs), which showed blood pressure readings below the prescribed parameters. Similarly, Resident #52, a female with conditions such as Alzheimer's disease and hypertension, was administered Midodrine when her blood pressure exceeded the parameters set by her physician's orders. The MARs for November indicated that the medication was not held on at least two occasions when her systolic blood pressure was above the prescribed limit. Interviews with staff revealed a lack of adherence to the facility's policy on medication administration, which requires holding medications when vital signs fall outside of specified parameters. Interviews with the facility's staff, including medication aides and registered nurses, highlighted a failure to document and follow physician orders accurately. Staff members acknowledged the potential risks of administering medications outside of prescribed parameters, such as causing dizziness or a drop in blood pressure. The facility's policies on physician orders and medication administration emphasize the importance of adhering to prescribed parameters and documenting any deviations, which were not followed in these instances.
Incomplete Medication Administration Record
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for one resident, specifically in the area of medication administration. The deficiency was identified during a review of the Medication Administration Record (MAR) for a resident who was prescribed Levothyroxine for thyroid dysfunction. The MAR for October and November 2024 contained blanks on specific dates, indicating a lack of documentation on whether the medication was administered or not. This lack of documentation could lead to uncertainty about whether the resident received their medication as prescribed. Interviews with facility staff, including a Registered Nurse (RN) and the Director of Nursing (DON), confirmed that there should be no blanks on the MARs. The RN stated that medications should be documented as administered or, if refused, the reason should be noted. The DON expressed that her expectation was for nurses and medication aides to document all medication administrations accurately. The facility's policy on medication administration emphasized the importance of accurate preparation, administration, and documentation of oral medications, yet the policy was not adhered to in this instance.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper hand hygiene practices of RN A during wound care for Resident #10. Resident #10, a male with multiple complex medical conditions including multiple sclerosis and Felty's syndrome, was observed receiving wound care for wounds on his right medial buttocks and left medial sacrum. During the procedure, RN A did not wash or sanitize his hands after changing gloves, which is a critical step in preventing cross-contamination and infection spread. The observation of RN A's actions was corroborated by interviews with ADON A and RN A himself, who acknowledged the lapse in hand hygiene. The facility's infection control policy, which mandates hand hygiene after glove removal, was not adhered to, placing 18 residents who received wound care at risk for cross-contamination. Despite recent in-service training on infection control, the expectation for proper hand hygiene was not met, as confirmed by the DON and ADON A.
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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 Terrell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Terrell Healthcare Center | 2.4 mi | — | 43 | 0 |
| Countryview Nursing & Rehabilitation | 3.1 mi | — | 0 | 0 |
| Ridgecrest Healthcare And Rehabilitation Center | 7.4 mi | — | 1 | 0 |
| Sunflower Park Health Care | 11.2 mi | — | 19 | 0 |
| Avir At Kaufman | 12 mi | — | 19 | 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 August 2026) and official state health department websites.