Windcrest, TX

Windcrest Nursing And Rehabilitation

1-star overall rating with 1-star inspections with abuse icon flag with $211,423 in total fines with 16 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

8800 Fourwinds Dr, Windcrest, TX

(210) 637-2700

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

180

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Caraday Healthcare

Operator or chain grouping

Approved since

1985-07-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

9 facilities

Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.28

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.88

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

1.75

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

2.91

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.16

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.70

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.13

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

0.30

CMS adjusted RN staffing hours

Adjusted total hours

3.06

CMS adjusted total nurse staffing hours

Case-mix index

1.30

Higher values indicate more complex resident acuity

RN turnover

57%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

62%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,027

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

18.28

Composite VBP score used to determine payment impact.

Payment multiplier

0.9819

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.91

Baseline 21.53% · Performance 20.54% · Measure score 1.91 · Achievement 1.91 · Improvement 1.69

Healthcare-associated infections

5.4

Baseline 6.30% · Performance 6.22% · Measure score 5.4 · Achievement 5.4 · Improvement 0.11

Total nurse turnover

Baseline 50.72% · Performance 67.05% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

Baseline 3.11 hours · Performance 2.91 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.3%	10.72% 0.6 pts worse	No Different than the National Rate · Eligible stays 103 · Observed rate 11.65% · Lower 95% interval 7.94%
Discharge to community	50.01%	50.57% 0.6 pts worse	No Different than the National Rate · Eligible stays 78 · Observed rate 44.87% · Lower 95% interval 39.5%
Medicare spending per beneficiary	1.01	1.02 About the same
Drug regimen review with follow-up	79.17%	95.27% 16.1 pts worse	Numerator 38 · Denominator 48
Falls with major injury	2.08%	0.77% 1.3 pts worse	Numerator 1 · Denominator 48
Discharge self-care score	32%	53.69% 21.7 pts worse	Numerator 8 · Denominator 25
Discharge mobility score	44%	50.94% 6.9 pts worse	Numerator 11 · Denominator 25
Pressure ulcers or injuries, new or worsened	4.17%	2.29% 1.9 pts worse	Numerator 2 · Denominator 48 · Adjusted rate 3.26%
Healthcare-associated infections requiring hospitalization	6.22%	7.12% 0.9 pts better	No Different than the National Rate · Eligible stays 63 · Observed rate 3.17% · Lower 95% interval 2.91%
Staff COVID-19 vaccination coverage	3.7%	8.2% 4.5 pts worse	Numerator 3 · Denominator 81
Staff flu vaccination coverage	53.38%	42% 11.4 pts better	Numerator 71 · Denominator 133
Discharge function score	36%	56.45% 20.5 pts worse	Numerator 9 · Denominator 25
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Transfer of health information to patient	84%	96.28% 12.3 pts worse	Numerator 21 · Denominator 25
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.1	2.1 1 pts better	1.9 0.8 pts better	Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.1	2.1 1 pts better	1.8 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.4 · 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	100.0%	97.9% 2.1 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	5.7%	3.3% 2.4 pts worse	3.3% 2.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 6.8% · Q3 4.3% · Q4 4.8% · 4Q avg 5.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	5.2%	2.7% 2.5 pts worse	11.4% 6.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 6.2% · Q3 4.3% · Q4 6.5% · 4Q avg 5.2%
Percentage of long-stay residents who lose too much weight	6.5%	3.3% 3.2 pts worse	5.4% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 5.7% · Q3 10.4% · Q4 2.3% · 4Q avg 6.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	14.2%	18.9% 4.7 pts better	19.6% 5.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 11.3% · Q3 16.7% · Q4 23.9% · 4Q avg 14.2%
Percentage of long-stay residents who received an antipsychotic medication	9.7%	10.8% 1.1 pts better	16.7% 7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 6.5% · Q3 7.3% · Q4 17.9% · 4Q avg 9.7% · 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	17.7%	15.4% 2.3 pts worse	16.3% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.2% · Q2 13.1% · Q3 15.6% · Q4 12.3% · 4Q avg 17.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	18.6%	16.1% 2.5 pts worse	14.9% 3.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 34.0% · Q2 14.0% · Q3 2.3% · Q4 22.0% · 4Q avg 18.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.5%	0.5% About the same	1.0% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.4%	0.8% 0.4 pts better	1.7% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	15.8%	15.0% 0.8 pts worse	19.8% 4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 19.8% · Q3 11.8% · Q4 15.6% · 4Q avg 15.8%
Percentage of long-stay residents with pressure ulcers	5.1%	4.2% 0.9 pts worse	5.1% About the same	Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 3.4% · Q3 6.2% · Q4 5.0% · 4Q avg 5.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	93.1%	89.7% 3.4 pts better	81.7% 11.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 90.3% · Q3 90.1% · Q4 94.8% · 4Q avg 93.1%
Percentage of short-stay residents who had an outpatient emergency department visit	15.8%	12.0% 3.8 pts worse	12.0% 3.8 pts worse	Short Stay · 20240701-20250630 · Adjusted 15.8% · Observed 16.2% · Expected 11.5% · 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	92.2%	88.0% 4.2 pts better	79.7% 12.5 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 92.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	21.5%	25.9% 4.4 pts better	23.9% 2.4 pts better	Short Stay · 20240701-20250630 · Adjusted 21.5% · Observed 18.9% · Expected 20.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-14 · Fire 2025-08-14

16 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-06-28 · Fire 2024-06-28

16 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 3 Health 2023-04-14 · Fire 2023-04-14

9 health deficiencies

Top issue: Administration (2 deficiencies)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-08-14

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2025-08-29

E · Potential for more than minimal harm 2025-08-14

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-09-20

E · Potential for more than minimal harm 2024-06-28

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-07-03

F · Potential for more than minimal harm 2023-04-14

K741 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2023-05-28

E · Potential for more than minimal harm 2023-04-14

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2023-05-28

D · Potential for more than minimal harm 2023-04-14

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-05-28

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-08-14

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 2025-08-29

E · Potential for more than minimal harm 2025-08-14

F677 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-08-29

E · Potential for more than minimal harm 2025-08-14

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2025-08-29

E · Potential for more than minimal harm 2025-08-14

F761 · Pharmacy Service Deficiencies

Health

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 2025-08-29

E · Potential for more than minimal harm 2025-08-14

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-08-29

D · Potential for more than minimal harm 2025-08-14

F584 · Resident Rights Deficiencies

Health

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 2025-08-29

D · Potential for more than minimal harm 2025-08-14

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-08-29

D · Potential for more than minimal harm 2025-08-14

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-08-29

D · Potential for more than minimal harm 2025-08-14

F805 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected 2025-08-29

D · Potential for more than minimal harm 2025-08-14

F842 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2025-08-29

J · Immediate jeopardy 2025-07-31

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-06-04

J · Immediate jeopardy 2025-03-03

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 2025-03-04

J · Immediate jeopardy 2025-03-03

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-10-16

D · Potential for more than minimal harm 2025-03-03

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-03-04

D · Potential for more than minimal harm 2025-03-03

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 2025-03-04

D · Potential for more than minimal harm 2025-03-03

F755 · Pharmacy Service Deficiencies

Health

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

Corrected 2025-03-04

E · Potential for more than minimal harm 2024-06-28

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2024-08-02

E · Potential for more than minimal harm 2024-06-28

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-08-02

E · Potential for more than minimal harm 2024-06-28

F677 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-08-02

E · Potential for more than minimal harm 2024-06-28

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-08-02

E · Potential for more than minimal harm 2024-06-28

F809 · Nutrition and Dietary Deficiencies

Health

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Corrected 2024-08-02