Windsor Rehabilitation And Healthcare
WINDSOR REHABILITATION AND HEALTHCARE in TERRELL, TX — inspection on February 27, 2026.
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
The facility failed to ensure expired medical supplies were not available for resident use on the crash cart.
This failure could place residents at risk of reduced germ-killing efficacy, skin irritation, contamination risks, and non-sterile cleaning.
Findings include: During an observation on 2/27/26 at 8:05 a.m., the crash cart located at the central nurse's station, revealed there were 86 individual alcohol wipes labeled with an expiration date of 10/3/2024 located in the third from the top drawer of the crash cart. An attempted telephone interview on 2/27/26 at 8:35 a.m. with the night nurse, LVN Q, who signed off checking the crash cart on 2/27/26 was unsuccessful. In an interview on 2/27/26 at 8:05 a.m., ADON O stated night shift was responsible for checking the crash cart each shift and ensuring all medications and supplies were current and accounted for. ADON O stated she occasionally checked the cart behind the night nurses to ensure it was done properly.
The ADON O stated it was important to ensure all supplies, medications, and equipment on the crash cart worked so in the event of an emergency, there were no delays with care and optimal care was provided.
During an interview with the facility administrator on 2/27/26 at 5:35 p.m., the administrator stated the ADONs and pharmacy technician completed cart audits.
The administrator stated the nurses should maintain the cart and go over the check list daily.
The administrator said he expected nursing leadership to monitor that process.
The administrator stated expired medications or supplies that were not good were not effective.
Record review of Medication Access and Storage policy, dated 5/2007 indicated: Procedures: Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.