Windmill Village Rehabilitation & Care Center
WINDMILL VILLAGE REHABILITATION & CARE CENTER in LUBBOCK, TX — inspection on August 29, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
receive a PASRR specialized service.
She stated the facility was given an additional specific timeframe to submit the NFSS request, but the facility did not meet that timeframe in addition to the previous 20 business days that were allowed. In an interview on 08/29/25 at 2:57 PM, Resident #1 stated he occasionally attended his own care plan meetings, but his family member usually took care of his business. He stated he was aware of the fact that he could have a new wheelchair, and he was waiting to get it. He stated his current wheelchair was functioning fine but was missing a brake on one side. Resident #1 stated he was not interested in doing therapy. In an interview on 08/29/25 at 3:04 PM, the DOR stated he was not in his current position when the IDT meeting for Resident #1 took place. He stated the OT evaluation was completed and the CMWC had been measured and ordered and was awaiting PASRR approval. In an interview on 08/29/25 at 4:07 PM, the Regional LIDDA Director stated Resident #1 was recommended for a CMWC and habilitative OT and PT.
She stated the facility submitted partial information on 05/20/25 which was processed by HHSC on 05/23/25.
She stated all the required documentation was not submitted under the supplier acknowledgment tab and was lacking documentation for PT and OT services, which caused the process to be delayed beyond the 20-day timeline.
She stated it was the responsibility of the facility to follow-up on the portal process and assure timely submission and acceptance of documentation. In an interview on 08/29/25 at 4:43 PM, the ADM stated the process when a PASRR positive resident is identified was to hold an IDT meeting with PASRR workers to establish what services were needed.
She stated it was the responsibility of the MDS Nurse to assure the NFSS was entered into the LTC portal timely and follow up on the process.
She stated the monitoring system to assure timely entry of PASRR information was for the MDS Nurse to report any issues to the ADM.
The ADM stated a potential negative outcome for failure to process PASRR information timely was that residents may miss services that they were qualified for.
Record review of the facility's document titled Preadmission and Screening Resident Review (PASRR) Rules, revised 03/15/23 revealed: GuidelineIt is the intent of [named company] to meet and abide by all state and federal regulations that pertain to resident Preadmission and Screening Resident Review (PASRR) rules.RulesThe intent of this guideline is to identify residents with Mental Illness (MI), Intellectual Disability (ID) or Developmental Disability (DD)/Related Conditions (RC) and to ensure they are properly placed, whether in community or in a Nursing Facility (NF) and to ensure they receive the services they require for their MI, or ID/DD.
ProcedurePost IDT Meeting ResponsibilitiesOnce the IDT/PCSP makes its determinations about specialized care, the facility will;.2.
The facility will initiate the request for specialized services within 20 business days of the IDT/PCSP meeting, implement Specialized Services therapy within 3 business days after receiving approval from HHSC in the online portal and order CMWC and/or DME within 5 business days of receiving approval from HHSC in the online portal-.
Facility ID: