Cycle 1
Health 2025-05-20 · Fire 2025-05-20
12 health deficiencies
Top issue: Resident Rights (5 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Lubbock, TX
Windmill Village Rehabilitation & Care Center
2-star overall rating with 2-star inspections with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
507 Martin Luther King Blvd, Lubbock, TX
(806) 744-1113
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
105
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Priority Management
Operator or chain grouping
Approved since
2012-09-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
38 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 quality stars
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
0.39
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.97
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.12
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
2.80
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
3.43
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
70%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
0
Baseline 6.98% · Performance 8.52% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 58.23% · Performance 70.53% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.07 hours · Performance 3.17 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.55% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 60 · Observed rate 6.67% · Lower 95% interval 5.97% |
| Discharge to community | 43.69% |
50.57%
6.9 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 33.33% · Lower 95% interval 32.51% |
| Medicare spending per beneficiary | 1.34 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 97.83% |
95.27%
2.6 pts better
|
Numerator 45 · Denominator 46 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 46 |
| Discharge self-care score | 59.38% |
53.69%
5.7 pts better
|
Numerator 19 · Denominator 32 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 16 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 4.35% |
2.29%
2.1 pts worse
|
Numerator 2 · Denominator 46 · Adjusted rate 3.56% |
| Healthcare-associated infections requiring hospitalization | 8.52% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 16.13% · Lower 95% interval 4.17% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 131 |
| Staff flu vaccination coverage | 59.38% |
42%
17.4 pts better
|
Numerator 76 · Denominator 128 |
| Discharge function score | 59.38% |
56.45%
2.9 pts better
|
Numerator 19 · Denominator 32 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 22 · Denominator 22 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 37.04% |
25.2%
11.8 pts better
|
Numerator 10 · Denominator 27 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.0 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.1
1.2 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
97.1%
1.5 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.4% · Q2 98.9% · Q3 100.0% · Q4 100.0% · 4Q avg 98.6% |
| 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 | 3.3% |
3.3%
About the same
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.3% · Q3 3.3% · Q4 3.1% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.7% |
2.7%
1 pts worse
|
11.4%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 2.3% · Q3 3.3% · Q4 4.3% · 4Q avg 3.7% |
| Percentage of long-stay residents who lose too much weight | 1.1% |
3.3%
2.2 pts better
|
5.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 1.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.1% |
18.9%
1.2 pts worse
|
19.6%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 18.6% · Q3 17.6% · Q4 21.5% · 4Q avg 20.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.1% |
10.8%
5.7 pts better
|
16.7%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.3% · Q3 6.3% · Q4 3.3% · 4Q avg 5.1% · 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 | 16.3% |
15.4%
0.9 pts worse
|
16.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 42.4% · Q2 11.6% · Q3 0.0% · Q4 16.6% · 4Q avg 16.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.7% |
16.1%
1.4 pts better
|
14.9%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 13.4% · Q3 8.2% · Q4 15.6% · 4Q avg 14.7% · 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 | 0.3% |
0.8%
0.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.1% |
15.0%
4.9 pts better
|
19.8%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 12.0% · Q3 3.0% · Q4 5.6% · 4Q avg 10.1% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
4.2%
1.2 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.8% · Q3 4.3% · Q4 1.9% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
89.7%
5.4 pts better
|
81.7%
13.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.1% · Q2 92.0% · Q3 100.0% · Q4 100.0% · 4Q avg 95.1% |
| 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 8.6% · Expected 10.9% · 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 | 90.0% |
88.0%
2 pts better
|
79.7%
10.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 9.6% |
25.9%
16.3 pts better
|
23.9%
14.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.6% · Observed 8.6% · Expected 21.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-12 · Fire 2024-04-12
12 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-03-08 · Fire 2023-03-08
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-20
K222 · Egress Deficiencies
Fire Safety
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 2025-06-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-25
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2025-11-26
D · Potential for more than minimal harm
2025-08-29
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-09-29
E · Potential for more than minimal harm
2025-05-20
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-05-20
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-05-20
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-05-20
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-05-20
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 2025-06-20
E · Potential for more than minimal harm
2025-05-20
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 2025-06-30
E · Potential for more than minimal harm
2025-05-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-20
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-20
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-02-27
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 2025-03-27
E · Potential for more than minimal harm
2024-08-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-16
F · Potential for more than minimal harm
2024-04-12
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 2024-05-17
E · Potential for more than minimal harm
2024-04-12
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-04-12
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-04-12
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-04-12
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-04-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-12
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-12
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 2024-05-17
D · Potential for more than minimal harm
2024-04-12
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 2024-05-17
D · Potential for more than minimal harm
2024-03-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-01-11
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 2024-02-02
K · Immediate jeopardy
2023-03-24
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-03-25
K · Immediate jeopardy
2023-03-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-25
E · Potential for more than minimal harm
2023-03-08
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-03-10
E · Potential for more than minimal harm
2023-03-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-10
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Heritage Oaks Nursing and Rehabilitation Center
Lubbock, TX
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
The Mildred & Shirley L. Garrison Geriatric Educat
Lubbock, TX
2-star overall rating with 1-star inspections with abuse icon flag with $18,629 in total fines with 14 recent health deficiencies
#3
Southern Specialty Rehab & Nursing
Lubbock, TX
1-star overall rating with 1-star inspections with $67,291 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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