Cycle 1
Health 2025-08-28 · Fire 2025-08-28
4 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.
Groesbeck, TX
Windsor Healthcare Residence
2-star overall rating with 2-star inspections with abuse icon flag with $45,116 in total fines with 4 recent health deficiencies
1025 W Yeagua, Groesbeck, TX
(254) 729-3366
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
56
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Coryell County Memorial Hospital Authority
Operator or chain grouping
Approved since
1993-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
0.22
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.19
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.26
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.07
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.96
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.26
CMS adjusted RN staffing hours
Adjusted total hours
3.87
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
58%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,875
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
9.91
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 57.78% · Performance 65.85% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.98
Baseline 4.31 hours · Performance 3.64 hours · Measure score 1.98 · Achievement 1.98 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 11 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 5.71% |
8.2%
2.5 pts worse
|
Numerator 4 · Denominator 70 |
| Staff flu vaccination coverage | 52.94% |
42%
10.9 pts better
|
Numerator 54 · Denominator 102 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · 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 | 2.1 |
2.1
About the same
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.5 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.1 |
2.1
1 pts worse
|
1.8
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.8 · Expected 1.5 · 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 | 97.9% |
97.9%
About the same
|
95.5%
2.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| 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 7.3% · Q2 2.2% · Q3 4.3% · Q4 4.0% · 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 | 3.6% |
3.3%
0.3 pts worse
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 5.0% · Q3 0.0% · Q4 2.2% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.0% |
18.9%
1.1 pts worse
|
19.6%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 21.4% · Q3 18.2% · Q4 21.7% · 4Q avg 20.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.7% |
10.8%
1.9 pts worse
|
16.7%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 4.5% · Q3 7.4% · Q4 13.8% · 4Q avg 12.7% · 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 | 19.2% |
15.4%
3.8 pts worse
|
16.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 14.7% · Q4 12.9% · 4Q avg 19.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.3% |
16.1%
9.2 pts worse
|
14.9%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 27.5% · Q3 25.0% · Q4 38.6% · 4Q avg 25.3% · 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 | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 24.9% |
15.0%
9.9 pts worse
|
19.8%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 16.2% · Q3 6.5% · Q4 47.4% · 4Q avg 24.9% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
4.2%
1.7 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.7% · Q3 0.0% · Q4 4.5% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.5% |
89.7%
4.8 pts better
|
81.7%
12.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 100.0% · 4Q avg 94.5% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-25 · Fire 2024-07-25
6 health deficiencies
Top issue: Resident Rights (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-06-08 · Fire 2023-06-08
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-27
E · Potential for more than minimal harm
2024-07-25
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 2025-02-27
E · Potential for more than minimal harm
2024-07-25
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-02-26
D · Potential for more than minimal harm
2023-06-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-03-12
D · Potential for more than minimal harm
2023-06-08
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-03-12
Inspection history
Recent health citations
K · Immediate jeopardy
2025-08-28
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 2025-08-29
E · Potential for more than minimal harm
2025-08-28
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
D · Potential for more than minimal harm
2025-08-28
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 2025-08-29
D · Potential for more than minimal harm
2025-08-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-22
E · Potential for more than minimal harm
2024-12-05
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-12-26
D · Potential for more than minimal harm
2024-12-05
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-26
D · Potential for more than minimal harm
2024-12-05
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 2024-12-26
D · Potential for more than minimal harm
2024-12-05
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-12-26
D · Potential for more than minimal harm
2024-07-25
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-16
G · Actual harm
2023-11-20
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 2023-11-21
J · Immediate jeopardy
2023-09-15
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-09-16
D · Potential for more than minimal harm
2023-07-20
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-07-21
Penalties and ownership
What sits behind the stars
$31,100
2025-08-28
Fine
Fine · fine $31,100
Fine
$365
2023-11-20
Fine
Fine · fine $365
Fine
$13,651
2023-09-15
Fine
Fine · fine $13,651
Fine
Ownership
Byrom, David
Corporate Director · Individual
Coryell County Memorial Hospital Authority
Operational/Managerial Control · Organization
Tgr Healthcare, LLC
Operational/Managerial Control · Organization
Thomas, Brian
Operational/Managerial Control · Individual
Nearby options
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#2
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#3
Mexia Ltc Nursing And Rehab
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