Windsor Healthcare: Missed Skin Assessments - TX
Resident #1's skin assessment was due on August 13, 2025. The assessment never happened.
During a complaint inspection on August 21, federal investigators discovered the missed assessment and interviewed facility leadership about the lapse. Both the director of nursing and administrator admitted they were unaware the assessment had been skipped.
LVN A was responsible for completing the weekly skin check. When investigators asked about the consequences of missing such assessments, LVN A stated that "a resident could have a skin issue that go untreated."
The director of nursing echoed this concern during her interview at 2:20 PM on August 21. She told investigators that weekly skin assessments were meant "to identity and address any skin concerns" and that all residents were supposed to receive them. She confirmed LVN A was responsible for Resident #1's assessment.
"If a resident did not receive weekly skin assessment, then the resident could have a skin condition go untreated," the director of nursing told investigators. She said she expected weekly assessments to be conducted as scheduled.
The administrator expressed similar concerns when investigators interviewed him at 2:50 PM the same day. He described the purpose of skin assessments as ensuring "residents did not have any adverse skin issues from the previous week."
Like the director of nursing, the administrator was unaware that LVN A had failed to complete the August 13 assessment. He told investigators that missing weekly skin checks could result in "skin integrity issues that go untreated."
The administrator confirmed that all residents were supposed to receive weekly skin assessments and that he expected them to be conducted on schedule.
When investigators asked about facility policies governing weekly skin assessments, the administrator revealed the facility had no specific policy for these routine checks. Instead, he provided the facility's "Pressure Ulcers/Skin Breakdown - Clinical Protocol policy," which was last revised in April 2018.
That policy focused primarily on pressure ulcer prevention rather than routine weekly monitoring. It required nursing staff and practitioners to "assess and document an individual's significant risk factors for developing pressure ulcers," including immobility, recent weight loss, and history of previous pressure ulcers.
The policy also mandated that staff examine newly admitted residents' skin "for evidence of existing pressure ulcers and other skin conditions." For wound monitoring, it assigned physicians the responsibility to "evaluate and document the progress of wound healing especially for those with complicated, extensive, or poorly healing wounds" during resident visits.
However, the policy did not establish the weekly skin assessment schedule that facility leadership described as standard practice for all residents.
The inspection occurred in response to a complaint, though the specific nature of the complaint was not detailed in the federal report. Investigators classified the violation as causing "minimal harm or potential for actual harm" and affecting "few" residents.
The missed assessment represented a breakdown in what facility leadership described as routine care. Both the director of nursing and administrator emphasized to investigators that weekly skin checks were essential for early detection and treatment of skin problems.
Skin assessments are particularly crucial in nursing home settings, where residents often have limited mobility and may be at higher risk for developing pressure sores, skin breakdown, and other conditions that can worsen without prompt attention.
The eight-day gap between the missed August 13 assessment and the August 21 inspection meant that any skin issues Resident #1 might have developed during that period could have gone unnoticed and untreated.
Federal regulations require nursing homes to provide necessary care and services to help residents achieve their highest practicable physical, mental, and psychosocial well-being. Regular skin monitoring is considered a fundamental component of this care, especially for residents with mobility limitations or other risk factors.
The facility's acknowledgment that it lacked a specific policy for weekly skin assessments, despite treating them as standard practice, highlighted a gap between actual care procedures and written protocols.
Windsor Healthcare Residence will need to address both the immediate issue of missed assessments and the broader policy framework governing routine skin monitoring to prevent similar lapses in resident care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Windsor Healthcare Residence from 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Windsor Healthcare Residence in Groesbeck, TX was cited for violations during a health inspection on August 21, 2025.
Resident #1's skin assessment was due on August 13, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.