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 Winnie L Nursing & Rehabilitation during CMS and state inspections, most recent first.
A LVN failed to follow established fall assessment protocol by instructing a CNA to move a resident with a head injury from the floor to the bed before completing a head-to-toe assessment and obtaining vital signs. Despite prior in-service training on fall procedures, the LVN did not adhere to facility policy, as confirmed by interviews with staff and review of the resident's care plan and medical history.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment and oversight did not meet required standards to minimize accident risks.
Three residents with dementia and communication deficits were found without their call lights within reach, despite care plans requiring this safety measure. Staff interviews revealed a lack of specific training and policy on call light placement, and observations confirmed that residents were unable to access assistance as needed.
Surveyors found that expired insulin pens remained on a medication cart and expired tube feeding formula was stored in the medication room. Nursing staff and the DON confirmed that these items should have been removed according to facility policy and manufacturer guidelines, but had not been, with responsibility for removal shared among nurses, medication aides, the DON, and the pharmacy consultant.
A resident with severe cognitive impairment and physical limitations was not properly assisted with personal hygiene before a meal, resulting in visible BM on her face and under her fingernails while eating. Staff did not notice or address the soiling until it was pointed out by surveyors, despite the resident's care plan requiring assistance with ADLs and incontinence care.
A resident with severe cognitive impairment, multiple falls, and a care plan requiring a low bed and fall mat was found without these interventions in place. Staff interviews and observations confirmed the absence of a fall mat and improper bed positioning, despite the resident's documented fall risk and facility policy requiring such measures.
A resident with moderate dementia continued to receive PRN doses of Olanzapine after a physician had ordered the medication to be discontinued following a pharmacy review. The discontinuation order was not implemented in the electronic health record, and the medication was administered despite the order. Staff interviews revealed confusion and lack of follow-through regarding responsibility for executing pharmacy and physician orders, leading to the administration of unnecessary medication.
A resident with a history of psychiatric and medical conditions developed MASD that progressed to an open wound, but the RP and physician were not notified of this change in condition until weeks after the initial finding. Documentation and staff interviews confirmed that the required notifications were not made promptly, despite facility expectations for immediate communication.
A resident with psychiatric and medical conditions did not consistently receive or have documented wound care treatments as ordered by the physician. Staff interviews revealed frequent refusals of care by the resident, but these refusals and missed treatments were not properly documented in the TAR or progress notes, contrary to facility policy and physician orders. Leadership confirmed the expectation for complete documentation, but record review showed multiple gaps, resulting in a deficiency.
A resident with MASD and at risk for skin breakdown did not receive all ordered wound care treatments, with multiple missed or undocumented treatments over two months. Staff and physician interviews confirmed frequent refusals of care by the resident, but these refusals were not consistently documented as required by facility policy. The resident's wound worsened, progressing to a Stage 3 pressure ulcer.
A resident with a history of embolism and thrombosis was admitted to a facility without receiving the prescribed anticoagulant Xarelto due to an oversight. The error was discovered after the resident's family noticed leg swelling, indicative of a blood clot. The facility's DON missed the medication order during admission, and a delay in performing a doppler ultrasound further complicated the resident's condition. The error was acknowledged by the facility, revealing a lack of communication and verification during the admission process.
A resident with severe cognitive impairment and a history of falls was found on the floor by a CMA, who failed to follow the facility's fall protocol. The CMA moved the resident without notifying a nurse or the DON, and the LVN on duty was unaware of the incident. The resident was later sent to the ER with a hip fracture, highlighting a significant lapse in communication and protocol adherence.
A resident with Alzheimer's and high fall risk was not assessed by qualified staff after an unwitnessed fall. A CMA improperly conducted a range of motion assessment and moved the resident without notifying administrative staff. The resident was later hospitalized with a hip fracture. Staff interviews revealed a failure to adhere to fall protocols, as only nurses are authorized to perform such assessments.
A resident with Alzheimer's and high fall risk was found on the floor by a CMA, who improperly assessed and moved the resident without notifying a nurse. The incident was not documented or reported to the DON or Administrator, leading to an Immediate Jeopardy situation due to failure to follow fall protocol and ensure proper assessment.
Failure to Follow Fall Assessment Protocol by LVN
Penalty
Summary
The facility failed to ensure that a licensed vocational nurse (LVN) demonstrated the required competencies and skill sets necessary to care for a resident following a fall. Specifically, after being informed by a certified nurse aide (CNA) that a resident was found on the floor, the LVN entered the room and observed the resident with a head injury. The LVN instructed the CNA to transfer the resident from the floor to the bed before conducting a head-to-toe assessment or obtaining vital signs, which was contrary to the facility's fall protocol and training. The resident involved had a history of Alzheimer's disease, poor memory, disorganized thinking, and was at risk for falls due to lack of safety awareness and coordination. The care plan identified the resident as requiring moderate assistance with transfers and at risk for falls. The facility's fall protocol, which the LVN had been in-serviced on, required that residents not be moved after a fall until a thorough assessment and vital signs were completed to check for injuries such as fractures or other complications. Interviews with the LVN, CNA, and Director of Nursing confirmed that the LVN did not follow the established protocol, as the assessment and vital signs were only completed after the resident was moved. The LVN acknowledged forgetting the protocol and stated she was aware of the correct procedure from previous training. The Director of Nursing reiterated that the expectation was for assessments and vital signs to be completed prior to moving any resident after a fall, and that the LVN did not adhere to this requirement.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Ensure Call Lights Within Reach for Residents with Cognitive Impairments
Penalty
Summary
The facility failed to ensure that the call lights were within reach for three residents with significant cognitive and communication impairments. Observations revealed that one resident was in bed without her call light within reach, and she was not able to be interviewed due to her condition. Another resident, also with Alzheimer's disease and a history of falls, was observed sitting in a reclining wheelchair in her room without a call light in reach and was similarly non-interviewable. A third resident, diagnosed with unspecified dementia and a cognitive communication deficit, was found sitting in her wheelchair with her call light placed on her bed, out of reach. This resident verbally indicated a need for help and confirmed she could use the call light if it were accessible. Record reviews for all three residents showed care plans that specifically required call lights to be kept within reach as part of ensuring a safe environment and meeting their needs. Staff interviews confirmed that there was an expectation for call lights to be accessible to all residents, regardless of their location in bed or in a wheelchair. However, one CNA stated she had not received any in-service training regarding call light placement, and the facility administrator acknowledged there was no specific policy addressing call light placement. The deficiency was identified through direct observation, interviews with staff, and review of resident records and care plans. The lack of accessible call lights for these residents, all of whom had cognitive impairments and were unable to independently communicate or seek help, constituted a failure to reasonably accommodate their needs and preferences as outlined in their care plans.
Expired Medications and Supplies Not Removed from Medication Cart and Storage Room
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate removal of expired or discontinued medications and supplies from both a medication cart and the medication storage room. During an observation of the secure unit's medication cart, two insulin pens for a resident were found to be beyond their 28-day use period after opening. The pens, a Lantus Solostar and an Insulin Lispro, had open dates and corresponding expiration dates that had already passed, but remained on the cart until they were identified and discarded during the survey. The nurse present acknowledged that it was her responsibility to check expiration dates prior to administration and confirmed that the pens should have been removed. In a separate observation of the medication storage room, eight bottles of Jevity 1.2K tube feeding formula were found to be expired and had not been removed from stock. The DON confirmed that these expired products should have been discarded and stated that the pharmacy consultant had not recently reviewed the storage areas. Facility policy and manufacturer instructions for medication storage and use were reviewed, confirming that the insulin pens should have been discarded after 28 days from opening. Interviews with staff indicated that the responsibility for removing expired products was shared among nursing staff, the DON, and the pharmacy consultant.
Failure to Provide Adequate ADL Assistance and Hygiene Prior to Meal
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, Alzheimer's disease, and an above-elbow amputation was not provided adequate assistance with activities of daily living (ADLs), specifically personal hygiene and grooming. The resident required extensive assistance for bed mobility, transfers, and toileting, and had a care plan in place for incontinence care and ADL deficits. Despite these documented needs, the resident was observed with a brown substance, later identified as BM, smeared on her right cheek and under her fingernails prior to and during a meal. The resident was also noted to have a noticeable odor of BM. Staff interviews revealed that the CNA responsible for the resident's care before the meal stated she had cleaned the resident's hands with a wipe but did not notice the residue on the face or under the nails until it was pointed out by the surveyor. The CNA later confirmed the substance was BM and cleaned the resident after the issue was identified. Other staff members acknowledged the importance of assisting residents with hand hygiene, especially before meals, and recognized the risk of infection if this care was not provided. The facility did not have a specific policy for ADL care, relying instead on a general infection control policy. The observations and interviews demonstrated that the resident did not receive the necessary assistance to ensure proper hygiene before eating, as required by her care plan and her documented needs. The failure to provide this assistance resulted in the resident eating with soiled hands and face, with staff only addressing the issue after it was brought to their attention by surveyors.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the environment for a resident with significant fall risk remained as free from accident hazards as possible and that adequate supervision and assistance devices were provided. The resident, an elderly man with dementia, bipolar disorder, aphasia, and deafness, was assessed as having severe cognitive impairment and required extensive assistance with bed mobility and transfers. His care plan included interventions such as keeping the bed in the lowest position and using a fall mat, based on his history of falls and risk factors including gait and balance problems, unawareness of safety needs, and hearing impairment. Despite these documented interventions, observations on multiple occasions revealed that the resident's bed was not in the low position and no fall mat was present in his room while he was in bed. Staff interviews confirmed that the resident did not have a fall mat in place and that some staff were unaware of the specific fall interventions required for him. The resident had experienced previous falls, including unwitnessed incidents where he was found on the floor next to his bed, and documentation indicated that a fall mat was to be used as an intervention following these events. The facility's own fall prevention policy required individualized care plans and environmental modifications such as keeping beds in the low position and using fall mats or similar devices for residents at risk. However, these interventions were not consistently implemented for this resident, as evidenced by the lack of a fall mat and improper bed positioning during the survey period. This failure to follow the care plan and facility policy resulted in a deficiency related to accident hazards and supervision.
Failure to Discontinue Unnecessary Antipsychotic Medication After Physician Order
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's drug regimen was free from unnecessary drugs. Specifically, an order to discontinue an as-needed (PRN) antipsychotic medication, Olanzapine 2.5 mg, was signed by the Medical Director following a pharmacy medication regimen review. Despite this, the PRN order for Olanzapine remained active in the resident's record, and doses were administered after the discontinuation order was given. The resident involved was an older adult male with diagnoses including moderate dementia with behavioral disturbance, hypertension, and vitamin D deficiency. His care plan included the use of antipsychotic medication for behaviors and agitation, with monitoring for side effects and effectiveness. The medication administration record showed that the resident received PRN doses of Olanzapine after the discontinuation was ordered, and there was no documentation that the order to discontinue was implemented in a timely manner. Interviews with facility staff revealed a lack of clarity and follow-through regarding responsibility for executing pharmacy recommendations and physician orders. The Regional Compliance Nurse, Administrator, DON, and Pharmacy Consultant each described gaps in communication and execution of the discontinuation order. Facility policy required that physician orders be reviewed and entered into the electronic health record, but this process was not completed as required, resulting in the resident receiving unnecessary medication.
Failure to Notify Responsible Party and Physician of Change in Skin Condition
Penalty
Summary
The facility failed to immediately notify a resident's responsible party (RP) and physician of a significant change in the resident's physical condition. Specifically, a female resident with a history of major depression, schizophrenia, and other medical conditions developed Moisture Associated Skin Damage (MASD) on her buttocks, which later progressed to a non-pressure open wound with drainage. Documentation showed that the MASD was first identified during a weekly skin assessment, but there was no evidence that the RP or physician were notified at that time. The care plan was updated to reflect the skin impairment, but subsequent assessments continued to indicate that no new areas had been communicated to the physician or family. Interviews with facility staff confirmed that the RP was not notified of the resident's MASD until several weeks after the initial finding, when the DON contacted the RP regarding multiple skin issues. The LVN responsible for the initial assessment stated she believed the family had already been informed and admitted she did not recall notifying them. The DON and administrator both stated their expectation was for immediate notification of any change in condition, but acknowledged this did not occur in this case. The RP also confirmed she was not informed of the MASD until the later notification by the DON.
Failure to Document and Provide Ordered Wound Care Treatments
Penalty
Summary
The facility failed to ensure that a resident received wound care treatments as ordered by the physician and in accordance with the resident's care plan and preferences. Documentation was lacking for multiple wound care treatments, with several instances where treatments were not recorded on the Treatment Administration Record (TAR) and no progress notes indicating whether the resident refused care. The care plan required staff to monitor, document, and report on the resident's skin integrity and wound care, but these interventions were not consistently documented or followed. The resident involved had a history of psychiatric diagnoses, including major depression and schizophrenia, and was noted to have intact cognitive status. She frequently refused care, including wound care, bathing, and other activities of daily living. Multiple staff interviews confirmed that the resident often declined assistance and that staff made repeated attempts to provide care, sometimes involving family members to encourage cooperation. Despite these refusals, staff did not consistently document the refusals or the care provided, as required by facility policy and physician orders. Facility leadership, including the DON, administrator, and VP of Clinical Operations, confirmed that all ordered treatments should be completed and documented, and that refusals should be recorded in both the TAR and progress notes. The facility's documentation policy required timely and complete entries in the electronic health record, but review of records showed gaps in documentation for wound care treatments. This lack of documentation and failure to follow professional standards of practice led to the deficiency cited in the report.
Failure to Provide and Document Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident with Moisture Associated Skin Damage (MASD) who was at risk for worsening skin breakdown. The resident, an older adult female with a history of psychiatric and medical conditions including schizophrenia, depression, and incontinence, was admitted and later readmitted to the facility. Her care plan identified actual and potential skin integrity impairment related to MASD and outlined interventions such as keeping the skin clean and dry, monitoring and documenting the wound, and following physician-ordered treatments. Despite these interventions, the resident did not receive all of her ordered wound care treatments. Documentation revealed that eight ordered treatments in one month and two in the following month were either missed or not documented. The Treatment Administration Record (TAR) showed multiple instances where wound care was not completed or not recorded as done. Staff interviews confirmed that the resident frequently refused care, including wound care, repositioning, and hygiene, and that these refusals were not always properly documented in the TAR or in progress notes as required by facility policy. Medical records and wound assessments indicated that the resident's wound worsened over time, with the development of a partial thickness non-pressure wound and later a Stage 3 pressure ulcer. The physician and staff noted repeated refusals of care by the resident, and the family was informed of the situation. Staff acknowledged that missed or undocumented treatments could lead to further complications. The facility's policy required complete and accurate documentation of care, but this was not consistently followed in this case.
Significant Medication Error with Anticoagulant in Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the anticoagulant Xarelto. The resident, who had a history of chronic embolism and thrombosis, was admitted to the facility with orders to receive Xarelto daily. However, due to an oversight during the admission process, the medication was not included in the resident's medication administration record (MAR), resulting in the resident missing 24 doses over a period of several weeks. The error was discovered when the resident's family inquired about the medication after noticing swelling in the resident's leg, a symptom indicative of a blood clot. Upon investigation, it was found that the Director of Nursing (DON) had missed the Xarelto order during the admission process. The resident's condition was further complicated by a delay in performing a doppler ultrasound to rule out deep vein thrombosis (DVT), which was ordered by the hospice agency but not completed in a timely manner due to issues with the sonogram provider. Interviews with facility staff and hospice personnel revealed a lack of communication and coordination during the resident's admission, as well as a failure to verify medication orders properly. The DON admitted to the oversight, and the facility acknowledged the error, which was compounded by the absence of a hospice nurse during the resident's admission. The resident's condition was eventually assessed, and a blood clot was confirmed, leading to an adjustment in the resident's medication regimen.
Failure to Notify Physician After Resident Fall
Penalty
Summary
The facility failed to immediately notify a resident's physician following an unwitnessed fall, which was a violation of resident rights. The incident involved a female resident with severe cognitive impairment and a history of falls, who was found on the floor by a Certified Medication Aide (CMA). Despite the resident's high risk for falls and the presence of a fall protocol, the necessary assessments and notifications were not conducted promptly. The resident's medical records lacked documentation of the fall, pain assessment, or incident report on the day of the incident. Interviews with staff revealed a breakdown in communication and adherence to protocol. The CMA who found the resident on the floor did not follow the facility's fall protocol, which required a nurse to assess the resident before any movement. Instead, the CMA performed an unauthorized range of motion assessment and moved the resident without notifying a nurse or the Director of Nursing (DON). The Licensed Vocational Nurse (LVN) on duty was preoccupied with a new admission and did not recall being informed of the fall, leading to further delays in appropriate medical evaluation and notification. The facility's Director of Nursing and other supervisory staff were unaware of the incident until much later, indicating a significant lapse in communication and protocol adherence. The resident was eventually sent to the emergency room the following day after showing signs of decline, where a hip fracture was diagnosed. The failure to follow established procedures for fall incidents placed the resident at risk of further harm and delayed necessary medical intervention.
Failure to Ensure Qualified Staff Assessment After Resident Fall
Penalty
Summary
The facility failed to ensure that services provided or arranged by the facility, as outlined by the comprehensive care plan, were delivered by qualified persons in accordance with each resident's written plan of care. Specifically, the facility did not ensure that a qualified staff member assessed a resident after an unwitnessed fall. On the day of the incident, a Certified Medication Aide (CMA) conducted a range of motion assessment and transferred the resident from the floor to a wheelchair without informing administrative staff or ensuring a qualified nurse performed the necessary assessments. The resident involved was an elderly female with a history of Alzheimer's disease, impaired cognitive function, and a high risk for falls due to unsteady balance and poor safety awareness. On the day of the incident, there were no nursing note entries, pain assessments, or incident reports documented for the resident. The following day, the resident's condition declined, leading to her being sent to the emergency room, where she was diagnosed with a minimally displaced left subcapital femoral neck fracture. Interviews with staff revealed a lack of adherence to the facility's fall protocol. The CMA admitted to performing actions outside her scope of practice and failing to report the incident to the appropriate personnel. Other staff members, including CNAs and LVNs, confirmed that only nurses were authorized to perform assessments and that the incident was not properly communicated to the Director of Nursing (DON) or the Administrator. The failure to follow protocol and ensure proper assessment by qualified staff placed residents at risk for not receiving appropriate care and treatment.
Failure to Follow Fall Protocol and Ensure Proper Assessment
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. This deficiency was identified when a resident, who had a history of Alzheimer's disease, impaired cognitive function, and was at high risk for falls, was found on the floor by a CMA. The resident was not properly assessed or monitored after the incident, and there was no documentation of a pain assessment or incident report on the day of the fall. The incident occurred when the CMA found the resident on the floor and attempted to perform range of motion exercises and transfer the resident back to her wheelchair without notifying a nurse or following the facility's fall protocol. The CMA did not report the incident to the DON or Administrator, and the resident was not assessed by a licensed nurse until the following day when she was transferred to the hospital. Interviews with staff revealed a lack of communication and adherence to protocol, as the incident was not properly reported or documented. The facility's failure to follow proper procedures and ensure that only qualified staff performed assessments and interventions led to an Immediate Jeopardy situation. The lack of documentation and communication among staff members contributed to the deficiency, as the resident's condition was not adequately monitored or addressed following the fall.
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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 Cameron
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legacy Nursing And Rehabilitation | 0.5 mi | — | 8 | 0 |
| Heritage House Nursing And Rehabilitation | 14.2 mi | — | 4 | 0 |
| Rockdale Estates & Rehabilitation | 16.1 mi | — | 0 | 0 |
| Crossroads Nursing & Rehabilitation | 23 mi | — | 9 | 0 |
| Avir At Caldwell | 25.1 mi | — | 12 | 0 |
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