Inspection Reports for Winters Park Nursing and Rehabilitation Center
TX, 75040
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
94% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Dec 9, 2025
Visit Reason
The inspection was conducted due to complaints regarding misappropriation of medication, failure to coordinate PASRR services, and concerns about food quality and temperature during meal service.
Findings
The facility failed to protect residents from misappropriation of medication, specifically 11 missing Soma pills for Resident #2, failed to submit timely and accurate PASRR NFSS forms for Resident #1, and failed to ensure food was served at a safe and appetizing temperature during lunch, affecting resident satisfaction and potentially their health.
Complaint Details
The complaint investigation focused on the misappropriation of 11 Soma pills for Resident #2, with police and pharmacy consultants involved. The facility could not confirm staff involvement. Additionally, the investigation included failure to submit PASRR NFSS forms timely for Resident #1 and complaints about cold food served during lunch.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to protect each resident from the wrongful use of the resident's belongings or money, specifically missing 11 Soma pills for Resident #2. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to coordinate assessments with the pre-admission screening and resident review program and failed to submit a complete and accurate NFSS request within 20 days after the IDT meeting for Resident #1. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food and drink were palatable, attractive, and served at a safe and appetizing temperature during lunch on 12/09/2025. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Missing medication count: 11
Medication delivery: 60
Medication dosage frequency: 3
Medication count temperature: 208
Medication count temperature: 188
Medication count temperature: 40
Meal tray delay: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide B | Noted medication count discrepancies and reported missing medication to DON | |
| RN D | Noted medication count discrepancies and reported missing medication to DON | |
| LVN F | Agency Nurse | Involved in medication count; could not be contacted after investigation |
| LVN E | Agency Nurse | Worked night shift during medication count discrepancies; could not be contacted |
| DON | Director of Nursing | Received reports of missing medication, coordinated investigation and staff in-service |
| Administrator | Administrator | Reported missing medication to police and agency; involved in investigation and corrective actions |
| Medical Director | Medical Director | Notified of missing medication and investigation; assured no missed doses |
| DOR | Director of Rehabilitation | Provided information on PASRR services and habilitation therapy for Resident #1 |
| MDS Nurse | Attended PASRR meeting and managed NFSS form submissions | |
| CNA A | Certified Nursing Assistant | Reported resident complaints about cold food |
| CNA G | Certified Nursing Assistant | Reported resident complaints about cold food and reheated trays |
| DM | Dietary Manager | Conducted food temperature checks and reported food service issues |
| ADM | Assistant Director of Nursing | Set expectations for food service temperature and tray delivery accountability |
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 30, 2025
Visit Reason
The inspection was conducted to evaluate compliance with food service safety standards in the facility's kitchen, focusing on food storage, labeling, dating, and kitchen sanitation.
Findings
The facility failed to ensure staff wore appropriate hair and beard coverings in the kitchen, which could risk food contamination and foodborne illness. Observations and interviews confirmed that the Dietary Manager and Environmental Director were not wearing beard coverings during food preparation and delivery.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff wore appropriate hair and beard coverings in the kitchen. | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Observed not wearing beard covering while checking food temperatures and during interview regarding hair covering policy. |
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 30, 2025
Visit Reason
The inspection was conducted to assess compliance with food service safety standards in the facility's kitchen, focusing on food storage, labeling, dating, and kitchen sanitation.
Findings
The facility failed to ensure staff wore appropriate hair and beard coverings in the kitchen, which could risk food contamination and foodborne illness. Observations and interviews confirmed that the Dietary Manager and Environmental Director were not wearing beard coverings during food preparation and delivery.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff wore appropriate hair and beard coverings in the kitchen. | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Named in finding for not wearing beard covering during food temperature checks and food preparation. | |
| Environmental Director | Observed delivering food without wearing a beard covering. |
Inspection Report
Deficiencies: 1
Mar 26, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care plan requirements, specifically to assess whether the interdisciplinary team reviewed and revised comprehensive care plans for residents, including after hospital readmissions.
Findings
The facility failed to ensure that all members of the interdisciplinary team were present to review and revise the comprehensive care plan for Resident #1 after hospital readmission. Only the Social Worker and Director of Nursing attended the care plan meeting, which placed residents at risk for unmet care needs and decreased quality of life.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a comprehensive care plan was reviewed and revised by an interdisciplinary team including attending physician, registered nurse, nurse aide, and food and nutrition services staff for Resident #1. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents Affected: 3
Residents Affected: Few
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding scheduling and attendance of interdisciplinary team at care plan meetings |
| Social Worker | Social Worker | Interviewed regarding scheduling care plan meetings and notifying interdisciplinary team |
Inspection Report
Complaint Investigation
Deficiencies: 4
Dec 7, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding physical abuse of Resident #16 by a CNA during incontinence care on 11/29/23, and review of care planning and food safety concerns.
Findings
The facility failed to protect Resident #16 from physical abuse when CNA J pushed the resident off the bed onto the floor. The abuse was confirmed by video review, and CNA J was terminated immediately. The facility also failed to develop and implement comprehensive person-centered care plans for Residents #6 and #235, specifically regarding oxygen therapy noncompliance and significant weight loss. Additionally, the facility failed to properly date and discard food items in the kitchen, risking foodborne illness.
Complaint Details
The complaint investigation was substantiated. Resident #16 was physically abused by CNA J who pushed him off the bed onto the floor on 11/29/23. The abuse was confirmed by video evidence and CNA J was terminated immediately. The facility implemented corrective actions including in-service training and increased nursing staff on the secure unit.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 1
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to protect Resident #16 from physical abuse by CNA J who pushed the resident off the bed onto the floor. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to develop and implement a comprehensive person-centered care plan for Resident #6 regarding noncompliance with oxygen therapy orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement a comprehensive person-centered care plan for Resident #235 addressing significant weight loss of 8.64% in 1 month. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store, prepare, distribute, and serve food in accordance with professional standards by not dating food in freezer and refrigerator, and not discarding expired food. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for abuse: 3
Residents affected by abuse: 1
Weight loss percentage: 8.64
Oxygen flow rate: 2
Tube feeding rate: 80
Tube feeding rate: 75
Weight of Resident #235: 103.6
Weight of Resident #235: 111.6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA J | Named in physical abuse finding; terminated immediately for gross misconduct and resident abuse | |
| RN M | Nurse who assessed Resident #16 after fall and observed no signs of pain | |
| ADM | Administrator | Reviewed video of abuse incident, terminated CNA J, called police, and initiated corrective actions |
| DON | Director of Nursing | Identified abuse on video, confirmed no immediate injuries to Resident #16, responsible for nursing administration |
| CNA K | Witnessed incident night shift, received in-service training after abuse incident | |
| CNA L | Interviewed about Resident #16's behavior and care | |
| SW | Social Worker | Interviewed Resident #16 after incident |
| FSD | Food Service Director | Responsible for kitchen food safety, acknowledged undated food items and expired food |
| AM Cook/Aide | Responsible for food storage in kitchen, acknowledged importance of dating food | |
| Dietitian | Provided nutritional interventions for Resident #235 and educated kitchen staff on food safety | |
| ADON | Assistant Director of Nursing | Responsible for care planning and monitoring weights, unaware of Resident #6 oxygen noncompliance |
| LVN F | Licensed Vocational Nurse | Aware of Resident #235 weight loss and care planning responsibilities |
| Charge RN O | Aware of Resident #235 weight loss and care planning importance | |
| Staffing Coordinator/CNA C | Conducts weights and notified ADON of Resident #235 weight loss |
Inspection Report
Complaint Investigation
Deficiencies: 4
Dec 7, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding physical abuse of Resident #16 by a CNA during incontinence care on 11/29/2023.
Findings
The facility failed to protect Resident #16 from physical abuse when CNA J pushed the resident off his bed onto the floor. The abuse was confirmed by video review and CNA J was terminated immediately. The facility corrected the noncompliance before the survey began. Additionally, the facility failed to develop and implement comprehensive person-centered care plans for Residents #6 and #235, and failed to maintain proper food safety practices in the kitchen.
Complaint Details
The complaint investigation was substantiated. Resident #16 was physically abused by CNA J who pushed him off the bed. The abuse was confirmed by video evidence and CNA J was terminated immediately. The facility implemented corrective actions including in-service training and increased nursing staff on the secure unit.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 1
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to protect Resident #16 from physical abuse by CNA J who pushed the resident off the bed onto the floor. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to develop and implement a comprehensive person-centered care plan for Resident #6 regarding noncompliance with oxygen therapy orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement a comprehensive person-centered care plan for Resident #235 addressing significant weight loss of 8.64% in 1 month. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store, prepare, distribute, and serve food in accordance with professional standards, including undated food in freezer and expired food in refrigerator. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for abuse: 3
Residents affected by abuse deficiency: 1
Weight loss percentage: 8.64
Oxygen order: 2
Tube feeding rate: 80
Tube feeding rate: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA J | Named in physical abuse finding for pushing Resident #16 off the bed; terminated immediately | |
| RN M | Registered Nurse | Observed and assessed Resident #16 after fall; interviewed regarding incident |
| ADM | Administrator | Reviewed video evidence of abuse incident and took immediate action including termination of CNA J |
| CNA K | Witnessed incident night shift; interviewed about Resident #16 behavior and abuse incident | |
| CNA L | Interviewed about Resident #16 behavior and care | |
| SW | Social Worker | Interviewed Resident #16 after incident |
| FSD | Food Service Director | Interviewed regarding undated and expired food in kitchen |
| AM Cook/Aide | Responsible for food storage; interviewed about food safety practices | |
| Dietitian | Interviewed regarding Resident #235 weight loss and feeding interventions | |
| LVN F | Licensed Vocational Nurse | Interviewed regarding Resident #235 care planning and weight loss |
| Charge RN O | Charge Nurse | Interviewed regarding Resident #235 feeding and weight loss care planning |
| Staffing Coordinator/CNA C | Responsible for weights in facility; interviewed about Resident #235 weight monitoring | |
| MDS RN | MDS Nurse | Interviewed regarding care planning responsibilities and weight loss interventions |
| ADON | Assistant Director of Nursing | Interviewed regarding care planning responsibilities and monitoring of resident conditions |
| DON | Director of Nursing | Interviewed regarding care planning and abuse incident |
| Administrator | Interviewed regarding care planning and facility expectations |
Inspection Report
Annual Inspection
Deficiencies: 3
Sep 19, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with providing care and assistance for activities of daily living (ADLs) to residents unable to perform them independently, focusing on grooming, nutrition, and personal hygiene.
Findings
The facility failed to ensure that three residents (Resident #1, Resident #2, Resident #3) received proper ADL care related to facial hair removal and nail trimming/cleaning. These deficiencies could place residents at risk of infections, skin tears, discomfort, and decreased psychosocial well-being.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure Resident #1's facial hair was removed and nails were trimmed and cleaned. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure Resident #2's facial hair was removed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure Resident #3's nails were trimmed and cleaned. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for ADL care: 5
Residents affected: 3
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 12, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding inadequate supervision and assistance provided to Resident #1, which resulted in a fall and injury, and a failure to maintain an effective pest control program in resident bathrooms.
Findings
The facility failed to ensure adequate supervision and assistance for Resident #1 during incontinence care, leading to the resident falling out of bed and sustaining a black eye. Additionally, the facility failed to maintain an effective pest control program, as live roaches were found in one resident bathroom.
Complaint Details
The complaint investigation was substantiated as the facility failed to provide adequate supervision and assistance to Resident #1, resulting in a fall and injury. The investigation also found failure in pest control measures with live roaches observed in resident bathrooms.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure adequate supervision and assistance to prevent Resident #1 from falling out of bed during care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain an effective pest control program resulting in live roaches in resident bathrooms. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for accidents: 4
Bathrooms reviewed for pest control: 6
Residents affected by deficiencies: 1
Residents affected by pest control deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Nurse on duty | Assessed Resident #1 after fall and provided care |
| CNA A | Certified Nursing Assistant | Failed to provide adequate supervision and assistance to Resident #1 during incontinence care |
| CNA B | Certified Nursing Assistant | Interviewed regarding proper care procedures for Resident #1 |
| CNA C | Certified Nursing Assistant | Interviewed regarding proper care procedures for Resident #1 |
| DON | Director of Nursing | Provided information on staff education and facility policies |
| Administrator | Facility Administrator | Discussed expectations and disciplinary actions related to Resident #1 incident |
| Regional Director of Operations | Regional Director of Operations | Discussed investigation and staff reeducation following Resident #1 incident |
| Maintenance Director | Maintenance Director | Provided information on pest control procedures and schedules |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jul 22, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify a resident's physician of critical lab results and elevated blood sugar readings, and failure to provide appropriate treatment and care according to professional standards.
Findings
The facility failed to notify Resident #1's physician of critical lab results including a glucose reading of 480 and a blood sugar reading of 453, and failed to administer insulin or assess the resident's condition accordingly. This resulted in an Immediate Jeopardy (IJ) which was removed after corrective actions. The resident subsequently passed away in the hospital. The facility also failed to maintain medical records accurately for Resident #2, missing urine analysis and culture results.
Complaint Details
The complaint investigation revealed failure to notify the physician of critical lab results and elevated blood sugar for Resident #1, resulting in an Immediate Jeopardy. The IJ was removed after the facility implemented a Plan of Removal including staff in-services, audits, and competency testing. Resident #1 later died in hospital. The facility also failed to maintain medical records for Resident #2.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 1
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to notify Resident #1's physician of critical CMP lab with glucose reading of 480 and elevated blood sugar of 453, and failure to provide appropriate treatment and care. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to maintain medical records accurately for Resident #2, missing urine analysis and culture and sensitivity test results. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Blood glucose reading: 480
Blood sugar reading: 453
Date of Immediate Jeopardy identification: Jul 21, 2023
Date of Immediate Jeopardy removal: Jul 22, 2023
Audit period start: Jun 21, 2023
Audit period end: Jul 21, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN J | Registered Nurse | Named in failure to notify physician of critical lab results and failure to document notifications |
| LVN D | Licensed Vocational Nurse | Agency nurse involved in failure to notify physician of elevated blood sugar and failure to document insulin administration |
| NP E | Nurse Practitioner | Resident #1's nurse practitioner who was not notified of critical lab results |
| PHY B | Physician | Resident #1's physician who was not notified of critical lab results |
| DON | Director of Nursing | Interviewed regarding failures and corrective actions |
| ADON H | Assistant Director of Nursing | Responsible for in-services and monitoring critical lab notifications |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 22, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to respect residents' rights to personal privacy, specifically related to the opening of residents' mail without consent.
Findings
The facility failed to ensure that Residents #1 and #2 received their mail unopened, with evidence that the Business Office Manager regularly opened mail addressed to residents when expecting payments or facility-related information. This practice was confirmed by interviews and observation of opened mail labeled as such.
Complaint Details
The complaint was substantiated as the facility admitted to and was observed opening mail addressed to Residents #1 and #2, violating their privacy rights.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to respect residents' right to personal privacy by opening mail addressed to residents without consent. | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Named as the individual who regularly opened residents' mail and provided opened mail as evidence. | |
| Administrator | Confirmed the practice of opening mail intended for the facility by the Business Office Manager. | |
| Admissions Director | Interviewed regarding Resident Rights policy provided at admission. |
Inspection Report
Deficiencies: 5
Oct 6, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, activities of daily living care, pharmaceutical services, quality assurance, and environmental conditions including pest control.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity by not providing privacy bags for catheter drainage, inadequate assistance with activities of daily living such as nail care, failure to properly manage pharmaceutical services including medication blister pack integrity, lack of quarterly Quality Assessment and Assurance meetings, and ineffective pest control program evidenced by presence of live and dead insects in shower rooms.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure residents were treated with respect and dignity by not providing privacy bags for foley catheter drainage bags. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide necessary services for residents unable to perform activities of daily living, specifically failure to trim and clean fingernails of a diabetic resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide pharmaceutical services ensuring accurate acquiring, receiving, dispensing, administering and securing of medications, including failure to report damaged blister packs of controlled medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain a Quality Assessment and Assurance committee that meets at least quarterly. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide an effective pest control program, with live and dead insects observed in shower rooms and lack of pest sighting log or pesticide policy. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for dignity issues: 8
Residents reviewed for ADL care: 8
Medication carts reviewed: 3
Residents reviewed for pharmacy services: 5
Broken blister pack seals: 8
QA&A meetings missed: 2
Live insects observed: 4
Dead insects observed: 6
Missing tiles: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Licensed Vocational Nurse | Charge nurse for Resident #67 and involved in medication blister pack observation |
| ADON | Assistant Director of Nursing | Interviewed regarding privacy bag use, nail care, medication blister packs, QA&A meetings, and pest control |
| CNA A | Certified Nursing Assistant | Observed pushing Resident #67 and interviewed about nail care |
| LVN D | Licensed Vocational Nurse | Interviewed about nail care responsibilities |
| Administrator | Facility Administrator | Interviewed about QA&A meetings |
| CNA E | Certified Nursing Assistant | Interviewed about pest sightings |
| PT F | Physical Therapist | Interviewed about pest sightings |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed about shower stall conditions and pest sighting log |
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