Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
WINDSOR REHABILITATION & HEALTH CARE CENTER
WINDSOR, MO · 60 certified beds · Last Life Safety survey June 25, 2025
CMS Certification Number 265683 · first certified September 1997
Ownership
Operated by JAMES & JUDY LINCOLN · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within MO
10 citations — more than 23% of the 487 certified nursing homes in MO. Compared within MO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 2 citations; the earlier surveys in the window averaged 4. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: August 2026 to March 2027. This facility’s last Life Safety survey was June 2025. Facilities in MO are typically surveyed 14–21 months after the last one (median 17), measured over 567 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 10 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in MO, and nationally. Surveyors differ markedly between states, so the MO figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 10 |
| Median facility in MO | 18 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 21, 2021 | 3 |
| December 14, 2023 | 5 |
| June 25, 2025 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0222 | 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. | 2 | 2025-06-25 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2023-12-14 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2023-12-14 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2021-05-21 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2021-05-21 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2023-12-14 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2025-06-25 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 1 | 2023-12-14 |
What the citations cover
- Smoke Deficiencies 3
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Egress Deficiencies 2
- Services Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Egress Deficiencies | 2 |
| Services Deficiencies | 1 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 25, 2025 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (August 5, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 5, 2025) |
December 14, 2023 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (January 26, 2024) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (January 26, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (January 26, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (January 26, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (January 26, 2024) |
May 21, 2021 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (July 2, 2021) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 2, 2021) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (July 2, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.