Cycle 1
Health 2025-04-02 · Fire 2025-04-02
9 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Austin, TX
Windsor Nursing And Rehabilitation Center Of Duval
2-star overall rating with 2-star inspections with $23,341 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
5301 W Duval Rd, Austin, TX
(512) 345-1805
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
206
Certified beds
Average residents
205
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Wellsential Health
Operator or chain grouping
Approved since
2003-02-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
67 facilities
Chain averages 3 overall / 3 health / 2 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
0.37
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.50
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.96
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.84
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
0.88
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.59
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
2.99
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,400
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.03
Composite VBP score used to determine payment impact.
Payment multiplier
0.9874
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.61
Baseline 19.21% · Performance 19.76% · Measure score 3.61 · Achievement 3.61 · Improvement 0
Healthcare-associated infections
5.33
Baseline 7.07% · Performance 6.24% · Measure score 5.33 · Achievement 5.33 · Improvement 3.50
Total nurse turnover
4.27
Baseline 45.00% · Performance 46.23% · Measure score 4.27 · Achievement 4.27 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.02 hours · Performance 2.69 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.06% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 12.28% · Lower 95% interval 7.55% |
| Discharge to community | 32.49% |
50.57%
18.1 pts worse
|
Worse than the National Rate · Eligible stays 50 · Observed rate 20% · Lower 95% interval 21.23% |
| Medicare spending per beneficiary | 1.49 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 90% |
95.27%
5.3 pts worse
|
Numerator 18 · Denominator 20 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 20 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 20 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.24% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 40 · Observed rate 2.5% · Lower 95% interval 3.15% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 188 |
| Staff flu vaccination coverage | 53.64% |
42%
11.6 pts better
|
Numerator 140 · Denominator 261 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| 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 | Not Available |
25.2%
|
Numerator Not Available · Denominator 7 · 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 | 2.0 |
2.1
0.1 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.0 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
97.1%
1.6 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 97.5% · Q3 99.0% · Q4 99.5% · 4Q avg 98.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
97.9%
0.8 pts worse
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.3%
1.4 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.0% · Q3 2.0% · Q4 2.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
2.7%
1.1 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 3.0% · Q3 0.0% · Q4 0.5% · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 3.8% |
3.3%
0.5 pts worse
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 7.2% · Q4 7.7% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.2% |
18.9%
3.7 pts better
|
19.6%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 14.2% · Q3 15.4% · Q4 14.4% · 4Q avg 15.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.9% |
10.8%
5.1 pts worse
|
16.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 15.6% · Q3 13.7% · Q4 14.8% · 4Q avg 15.9% · 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 | 15.2% |
15.4%
0.2 pts better
|
16.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 18.1% · Q3 9.9% · Q4 9.0% · 4Q avg 15.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.5% |
16.1%
4.4 pts worse
|
14.9%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 19.9% · Q3 26.9% · Q4 22.9% · 4Q avg 20.5% · 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 | 28.7% |
15.0%
13.7 pts worse
|
19.8%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 32.6% · Q3 25.8% · Q4 30.8% · 4Q avg 28.7% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
4.2%
0.5 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.6% · Q3 4.2% · Q4 3.1% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.4% |
89.7%
4.7 pts better
|
81.7%
12.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.3% · Q2 92.9% · Q3 95.1% · Q4 94.0% · 4Q avg 94.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.4% |
12.0%
8.6 pts better
|
12.0%
8.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.4% · Observed 4.8% · Expected 15.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.5% |
1.5%
3 pts worse
|
1.6%
2.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q4 5.0% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.1% |
88.0%
5.1 pts better
|
79.7%
13.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.8% |
25.9%
11.1 pts better
|
23.9%
9.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.8% · Observed 19.0% · Expected 30.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-27 · Fire 2024-01-27
13 health deficiencies
Top issue: Environmental (3 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-11-17 · Fire 2022-11-17
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-18
F · Potential for more than minimal harm
2024-01-27
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-01-31
F · Potential for more than minimal harm
2024-01-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-22
E · Potential for more than minimal harm
2024-01-27
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 2024-01-31
E · Potential for more than minimal harm
2024-01-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-01-31
D · Potential for more than minimal harm
2024-01-27
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 2024-01-31
E · Potential for more than minimal harm
2022-11-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-05-22
E · Potential for more than minimal harm
2022-11-17
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 2023-05-22
E · Potential for more than minimal harm
2022-11-17
K900 · Miscellaneous Deficiencies
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2023-05-22
E · Potential for more than minimal harm
2022-11-17
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-05-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-27
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 2025-06-28
E · Potential for more than minimal harm
2025-04-02
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 2025-04-03
E · Potential for more than minimal harm
2025-04-02
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-04-03
E · Potential for more than minimal harm
2025-04-02
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-04-03
E · Potential for more than minimal harm
2025-04-02
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 2025-04-03
E · Potential for more than minimal harm
2025-04-02
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-04-02
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-04-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-04-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-03
D · Potential for more than minimal harm
2024-09-19
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-09-20
G · Actual harm
2024-09-09
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 2024-08-06
D · Potential for more than minimal harm
2024-05-18
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 2024-05-19
L · Immediate jeopardy
2024-01-27
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-01-28
E · Potential for more than minimal harm
2024-01-27
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 2024-01-28
E · Potential for more than minimal harm
2024-01-27
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-01-28
E · Potential for more than minimal harm
2024-01-27
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-01-28
D · Potential for more than minimal harm
2024-01-27
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-01-28
D · Potential for more than minimal harm
2024-01-27
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-01-28
D · Potential for more than minimal harm
2024-01-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-28
D · Potential for more than minimal harm
2024-01-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-01-28
D · Potential for more than minimal harm
2024-01-27
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-01-28
D · Potential for more than minimal harm
2024-01-27
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2024-01-28
E · Potential for more than minimal harm
2023-12-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-07
E · Potential for more than minimal harm
2023-10-04
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 2023-10-05
D · Potential for more than minimal harm
2023-05-31
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 2023-06-02
E · Potential for more than minimal harm
2023-03-01
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-03-02
E · Potential for more than minimal harm
2022-11-17
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 2022-11-18
E · Potential for more than minimal harm
2022-11-17
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 2022-11-18
D · Potential for more than minimal harm
2022-11-17
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 2022-11-18
D · Potential for more than minimal harm
2022-11-17
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 2022-11-18
Penalties and ownership
What sits behind the stars
$5,736
2024-09-09
Fine
Fine · fine $5,736
Fine
$17,605
2024-01-27
Fine
Fine · fine $17,605
Fine
Ownership
Val Verde County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Dekowski, Donovan
Operational/Managerial Control · Individual
Helmcamp, Terrell
Operational/Managerial Control · Individual
Jurado, Jorge
Corporate Officer · Individual
Regency Ihs Of Windsor Duval LLC
Operational/Managerial Control · Organization
Regency Integrated Health Services LLC
Operational/Managerial Control · Organization
Val Verde County Hospital District
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Austin Wellness & Rehabilitation
Austin, TX
1-star overall rating with 1-star inspections with $166,205 in total fines with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Avir at Park Bend
Austin, TX
3-star overall rating with 3-star inspections with $38,155 in total fines with 7 recent health deficiencies
#3
Gracy Woods Nursing Center
Austin, TX
0-star overall rating with 0-star inspections with Special Focus status with $171,373 in total fines with 9 recent health deficiencies
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