Cycle 1
Health 2025-12-03 · Fire 2025-12-03
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Austin, TX
The Arbour At Westminster Manor
5-star overall rating with 4-star inspections with $29,085 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
4200 Jackson Ave, Austin, TX
(512) 454-4711
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
80
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2006-04-26
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.58
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
3.46
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.97
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.48
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
5.23
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
981
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.40
Composite VBP score used to determine payment impact.
Payment multiplier
1.0165
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.91
Baseline 19.65% · Performance 19.62% · Measure score 3.91 · Achievement 3.91 · Improvement 0
Healthcare-associated infections
4.90
Baseline 5.42% · Performance 6.37% · Measure score 4.90 · Achievement 4.90 · Improvement 0
Total nurse turnover
8.78
Baseline 32.10% · Performance 27.78% · Measure score 8.78 · Achievement 8.78 · Improvement 5.46
Adjusted total nurse staffing
6.97
Baseline 4.77 hours · Performance 5.06 hours · Measure score 6.97 · Achievement 6.97 · Improvement 2.35
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.92% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 158 · Observed rate 11.39% · Lower 95% interval 8.48% |
| Discharge to community | 46.96% |
50.57%
3.6 pts worse
|
No Different than the National Rate · Eligible stays 148 · Observed rate 41.89% · Lower 95% interval 40.81% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 130 · Denominator 130 |
| Falls with major injury | 0.77% |
0.77%
About the same
|
Numerator 1 · Denominator 130 |
| Discharge self-care score | 79.21% |
53.69%
25.5 pts better
|
Numerator 80 · Denominator 101 |
| Discharge mobility score | 62.38% |
50.94%
11.4 pts better
|
Numerator 63 · Denominator 101 |
| Pressure ulcers or injuries, new or worsened | 0.77% |
2.29%
1.5 pts better
|
Numerator 1 · Denominator 130 · Adjusted rate 0.81% |
| Healthcare-associated infections requiring hospitalization | 6.37% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 134 · Observed rate 4.48% · Lower 95% interval 4.03% |
| Staff COVID-19 vaccination coverage | 9.87% |
8.2%
1.7 pts better
|
Numerator 15 · Denominator 152 |
| Staff flu vaccination coverage | 27.85% |
42%
14.1 pts worse
|
Numerator 44 · Denominator 158 |
| Discharge function score | 70.3% |
56.45%
13.8 pts better
|
Numerator 71 · Denominator 101 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 32 · Denominator 32 |
| Transfer of health information to patient | 98.75% |
96.28%
2.5 pts better
|
Numerator 79 · Denominator 80 |
| Resident COVID-19 vaccinations up to date | 22.86% |
25.2%
2.3 pts worse
|
Numerator 16 · Denominator 70 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.0 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
2.1
1.8 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.2 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.7% |
97.9%
1.2 pts worse
|
95.5%
1.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.4% |
3.3%
1.1 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 5.3% · Q3 5.5% · Q4 5.3% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.9% |
3.3%
1.4 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.7% · Q3 2.3% · Q4 0.0% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.8% |
18.9%
8.1 pts better
|
19.6%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 10.0% · Q3 4.7% · Q4 11.9% · 4Q avg 10.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.4% |
10.8%
0.6 pts worse
|
16.7%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 12.5% · Q3 10.8% · Q4 10.5% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.9% |
15.4%
5.5 pts better
|
16.3%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.9% |
16.1%
4.2 pts better
|
14.9%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 12.8% · Q3 14.6% · Q4 7.7% · 4Q avg 11.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
0.8%
1.5 pts worse
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 5.5% · Q4 1.8% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.2% |
15.0%
9.8 pts better
|
19.8%
14.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 8.9% · Q3 5.1% · Q4 1.7% · 4Q avg 5.2% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
4.2%
1 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 3.0% · Q3 4.5% · Q4 3.9% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.9% |
89.7%
4.8 pts worse
|
81.7%
3.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.1% · Q2 86.0% · Q3 81.1% · Q4 84.5% · 4Q avg 84.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.8% |
12.0%
3.2 pts better
|
12.0%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 7.9% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.2% |
88.0%
7.8 pts worse
|
79.7%
0.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.3% |
25.9%
2.6 pts better
|
23.9%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.3% · Observed 18.0% · Expected 18.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-25 · Fire 2024-09-25
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-07-21 · Fire 2023-07-21
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-01-15
F · Potential for more than minimal harm
2025-12-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-01-15
F · Potential for more than minimal harm
2023-07-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-02
E · Potential for more than minimal harm
2023-07-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-02
D · Potential for more than minimal harm
2023-07-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-02
D · Potential for more than minimal harm
2023-07-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-02
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-03
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-01-15
J · Immediate jeopardy
2024-09-25
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-09-25
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-09-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-10-23
E · Potential for more than minimal harm
2023-07-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-07-21
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-07-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-09-15
Penalties and ownership
What sits behind the stars
$29,085
2024-09-25
Fine
Fine · fine $29,085
Fine
Ownership
Westminster Manor
5% Or Greater Direct Ownership Interest · Organization
Albright, Alexandra
Corporate Director · Individual
Ashley, Olin
Corporate Director · Individual
Borst, Charles
Operational/Managerial Control · Individual
Day, Michael
Corporate Director · Individual
Dinitto, Diana
Corporate Director · Individual
Haley, Cassie
Operational/Managerial Control · Individual
Hilgers, Paul
Corporate Director · Individual
Krol, Michael
Operational/Managerial Control · Individual
Life Care Services LLC
Operational/Managerial Control · Organization
Loyd, Sarah
Operational/Managerial Control · Individual
Luevano, Richard
Corporate Director · Individual
Mcghee, John
Corporate Director · Individual
Miller, Anna
Corporate Director · Individual
Redding, David
Corporate Director · Individual
Redding, David
Corporate Officer · Individual
Scurlock, Stephen
Corporate Director · Individual
Williams, Diane
Corporate Director · Individual
Williams, Diane
Corporate Officer · Individual
Woodrick, James
Corporate Director · Individual
Woodworth, James
Corporate Director · Individual
Nearby options
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#2
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#3
Juniper Village At Spicewood Summit
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2-star overall rating with 3-star inspections with $99,713 in total fines with 5 recent health deficiencies
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