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🔎 Windsor Nursing And Rehabilitation Center Of Bastr

Inspection Results


Inspection Overview

Windsor Nursing And Rehabilitation Center Of Bastr has been cited for a total of 47 deficiencies since we began saving each survey.

In Texas, the average facility has **34.42 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2025-03-30
Correction Date: 2025-04-07
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2024-06-11
Correction Date: 2024-06-18
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: C

Post nurse staffing information every day.

Survey Date: 2024-06-11
Correction Date: 2024-06-18
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2024-06-11
Correction Date: 2024-06-18
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2024-06-11
Correction Date: 2024-06-18
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2024-06-11
Correction Date: 2024-06-18
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: C

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Survey Date: 2024-06-11
Correction Date: 2024-06-18
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Survey Date: 2023-04-27
Correction Date: 2023-04-28
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: C

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Survey Date: 2023-04-27
Correction Date: 2023-04-28
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: F

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Survey Date: 2022-05-04
Correction Date: 2022-06-10
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2022-05-04
Correction Date: 2022-06-10
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2022-03-08
Correction Date: 2022-04-05
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2022-03-08
Correction Date: 2022-04-05
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2022-03-08
Correction Date: 2022-04-05
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2022-03-08
Correction Date: 2022-04-05
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2022-03-08
Correction Date: 2022-04-05
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: K

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2022-03-08
Correction Date: 2022-03-09
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2022-03-08
Correction Date: 2022-04-05
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2022-03-08
Correction Date: 2022-04-05
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2022-03-08
Correction Date: 2022-04-05
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Survey Date: 2022-03-08
Correction Date: 2022-04-05
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Survey Date: 2022-03-08
Correction Date: 2022-03-09
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: K

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2022-03-08
Correction Date: 2022-03-31
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2021-11-19
Correction Date: 2021-12-31
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Survey Date: 2021-08-18
Correction Date: 2021-09-10
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2021-04-21
Correction Date:
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure the activities program is directed by a qualified professional.

Survey Date: 2021-02-04
Correction Date: 2021-03-12
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2021-02-04
Correction Date: 2021-03-12
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Survey Date: 2021-02-04
Correction Date: 2021-03-12
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Protect each resident from the wrongful use of the resident's belongings or money.

Survey Date: 2020-07-30
Correction Date: 2020-08-17
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2020-07-30
Correction Date: 2020-08-17
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2020-06-30
Correction Date: 2020-06-30
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2020-06-30
Correction Date: 2020-07-01
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2019-11-14
Correction Date: 2019-12-13
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

Survey Date: 2019-11-14
Correction Date: 2019-12-13
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2019-11-14
Correction Date: 2019-12-13
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Survey Date: 2019-11-14
Correction Date: 2019-12-13
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Survey Date: 2019-11-14
Correction Date: 2019-12-13
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide activities to meet all resident's needs.

Survey Date: 2019-11-14
Correction Date: 2019-12-13
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2019-11-14
Correction Date: 2019-12-13
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Survey Date: 2019-11-14
Correction Date: 2019-12-13
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2019-11-14
Correction Date: 2019-12-13
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2019-11-14
Correction Date: 2019-12-13
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2019-11-14
Correction Date: 2019-12-13
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2019-11-14
Correction Date: 2019-12-13
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Survey Date: 2019-11-14
Correction Date: 2019-12-13
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Survey Date: 2019-11-14
Correction Date: 2019-12-13
Category: Environmental Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**