Windsor Calallen

Penalties

• Jan 25, 2024 — Fine ($4,823)

Inspection findings

1. Jun 24, 2026 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0770 Administration Deficiencies

     Provide timely, quality laboratory services/tests to meet the needs of residents.

     Corrected Jun 25, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Jun 25, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

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

     Corrected Jun 25, 2026 · CMS health inspection

2. May 13, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0550 Resident Rights Deficiencies

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

     Corrected May 14, 2026 · CMS health inspection

3. Apr 8, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0636 Resident Assessment and Care Planning Deficiencies

     Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

     Corrected Apr 10, 2026 · CMS health inspection

4. Aug 21, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

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

     Corrected Aug 22, 2025 · CMS health inspection

5. Aug 8, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

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

     Corrected Aug 9, 2025 · CMS health inspection

6. May 7, 2025 Health · 12 findings
   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected May 8, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected May 8, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected May 8, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected May 8, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 8, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected May 28, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected May 28, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected May 28, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected May 28, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected May 28, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0753 Miscellaneous Deficiencies

     Have restrictions on the use of highly flammable decorations.

     Corrected May 28, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0761 Miscellaneous Deficiencies

     To conduct inspection, testing and maintenance of fire doors by qualified individuals.

     Corrected May 28, 2025 · CMS fire safety

7. Apr 9, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

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

     Corrected Apr 10, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 11, 2025 · CMS health inspection

8. Apr 4, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0584 Resident Rights Deficiencies

     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.

     Corrected Apr 5, 2025 · CMS health inspection

9. Feb 20, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0655 Resident Assessment and Care Planning Deficiencies

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

     Corrected Mar 14, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Mar 14, 2025 · CMS health inspection

10. Jul 1, 2024 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0761 Pharmacy Service Deficiencies

      Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

      Corrected Jul 3, 2024 · CMS health inspection

11. Mar 6, 2024 Health · 11 findings
    • Not serious Scope/severity D

      F0583 Resident Rights Deficiencies

      Keep residents' personal and medical records private and confidential.

      Corrected Mar 30, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0584 Resident Rights Deficiencies

      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.

      Corrected Mar 30, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Develop and implement policies and procedures to prevent abuse, neglect, and theft.

      Corrected Mar 30, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0684 Quality of Life and Care Deficiencies

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

      Corrected Mar 30, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0755 Pharmacy Service Deficiencies

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

      Corrected Mar 30, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0756 Pharmacy Service Deficiencies

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

      Corrected Mar 30, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0758 Pharmacy Service Deficiencies

      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.

      Corrected Mar 30, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0761 Pharmacy Service Deficiencies

      Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

      Corrected Mar 30, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0812 Nutrition and Dietary Deficiencies

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

      Corrected Mar 30, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Mar 30, 2024 · CMS health inspection

    • Not serious Scope/severity E

      K0345 Smoke Deficiencies

      Have approved installation, maintenance and testing program for fire alarm systems.

      Corrected Mar 30, 2024 · CMS fire safety

12. Jan 25, 2024 Health · 2 findings
    • Not serious Scope/severity D Complaint

      F0623 Resident Rights Deficiencies

      Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

      Corrected Jan 26, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0661 Resident Assessment and Care Planning Deficiencies

      Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

      Corrected Jan 26, 2024 · CMS health inspection

13. Nov 19, 2023 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0761 Pharmacy Service Deficiencies

      Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

      Corrected Nov 22, 2023 · CMS health inspection

14. Jan 20, 2023 Health · 2 findings
    • Not serious Scope/severity D

      F0760 Pharmacy Service Deficiencies

      Ensure that residents are free from significant medication errors.

      Corrected Jan 24, 2023 · CMS health inspection

    • Not serious Scope/severity D

      K0741 Miscellaneous Deficiencies

      Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

      Corrected Feb 7, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• ALEXANDER, ALMA — managing control - governing body, NOT APPLICABLE, since 05/27/2020
• ALEXANDER, ALMA — corporate officer, NOT APPLICABLE, since 05/27/2020
• BAIRD, DANIEL — managing control - governing body, NOT APPLICABLE, since 04/13/2021
• CARVAJAL, ANTONIO — managing control - governing body, NOT APPLICABLE, since 05/16/2024
• CLAPP, BARBARA — managing control - governing body, NOT APPLICABLE, since 06/01/2021
• CORTESE, DAREN — managing control - governing body, NOT APPLICABLE, since 08/10/2021
• DEKOWSKI, DONOVAN — operational/managerial control, NOT APPLICABLE, since 02/01/2016
• DEKOWSKI, DONOVAN — adp of the snf, NOT APPLICABLE, since 02/01/2016
• DOMINGUEZ, FRANCISCO — adp of the snf, NOT APPLICABLE, since 12/30/2024
• DOMINGUEZ, FRANCISCO — operational/managerial control, NOT APPLICABLE, since 12/30/2024
• FALCONE, LYNN — managing control - governing body, NOT APPLICABLE, since 05/23/2016
• FRELS, JOHN — managing control - governing body, NOT APPLICABLE, since 11/04/2014
• GARCIA, VERONICA — adp of the snf, NOT APPLICABLE, since 01/01/2025
• GIBSON, PATRICIA — managing control - governing body, NOT APPLICABLE, since 08/01/2021
• GONZALES, VERONICA — managing control - governing body, NOT APPLICABLE, since 05/16/2024
• KAUFMAN, NICOLE — managing control - governing body, NOT APPLICABLE, since 08/10/2021
• MANDELBAUM, ELLIOT — managing control - governing body, NOT APPLICABLE, since 01/01/2025
• PAPACEK, CHARLES — managing control - governing body, NOT APPLICABLE, since 10/01/1997
• ROBERTS, SHANNON — adp of the snf, NOT APPLICABLE, since 01/01/2025
• SHEPPARD, ANNA — managing control - governing body, NOT APPLICABLE, since 05/01/2019
• SHEPPARD, CYNTHIA — managing control - governing body, NOT APPLICABLE, since 06/25/2013
• TOMPKINS, KENT — adp of the snf, NOT APPLICABLE, since 01/01/2025
• 4162 WILDCAT DRIVE LLC — adp of the snf, NOT APPLICABLE, since 02/01/2016
• CSV RHEA MANAGEMENT HOLDCO, LLC — indirect ownership interest, NOT APPLICABLE, since 02/01/2016
• DEWITT MEDICAL DISTRICT — operational/managerial control, NOT APPLICABLE, since 02/01/2016
• DEWITT MEDICAL DISTRICT — adp of the snf, NOT APPLICABLE, since 04/03/2025
• DWD TX HOLDINGS LLC — indirect ownership interest, NOT APPLICABLE, since 02/01/2016
• JACK AND NANCY DWYER WORKFORCE DEVELOPMENT CENTER INC — indirect ownership interest, NOT APPLICABLE, since 02/01/2016
• REG HG OPCO 1, LLC — indirect ownership interest, NOT APPLICABLE, since 02/01/2016
• REG HG OPCO LLC — indirect ownership interest, NOT APPLICABLE, since 02/01/2016
• REG OPERATOR HOLDCO LLC — indirect ownership interest, NOT APPLICABLE, since 02/01/2016
• REGENCY IHS CLINICAL CONSULTING, LLC — adp of the snf, NOT APPLICABLE, since 02/01/2016
• REGENCY IHS MASTER TENANT LLC — adp of the snf, NOT APPLICABLE, since 02/01/2016
• REGENCY IHS OF WINDSOR CALALLEN, LLC — direct ownership interest, NOT APPLICABLE, since 02/01/2016
• REGENCY IHS OF WINDSOR CALALLEN, LLC — operational/managerial control, NOT APPLICABLE, since 02/01/2016
• REGENCY IHS OF WINDSOR CALALLEN, LLC — adp of the snf, NOT APPLICABLE, since 04/03/2025
• REGENCY IHS REHAB LLC — adp of the snf, NOT APPLICABLE, since 02/01/2016
• REGENCY INTEGRATED HEALTH SERVICES LLC — operational/managerial control, NOT APPLICABLE, since 02/01/2016
• REGENCY INTEGRATED HEALTH SERVICES LLC — indirect ownership interest, NOT APPLICABLE, since 02/01/2016
• REGENCY INTEGRATED HEALTH SERVICES LLC — adp of the snf, NOT APPLICABLE, since 04/03/2025
• REGENCY TEXAS HOLDINGS LLC — indirect ownership interest, NOT APPLICABLE, since 02/01/2016