Seguin, TX

Windsor Nursing And Rehabilitation Center Of Segui

2-star overall rating with 3-star inspections with $34,249 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

1219 Eastwood Dr, Seguin, TX

(830) 379-7777

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

122

Certified beds

Average residents

101

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

Wellsential Health

Operator or chain grouping

Approved since

1994-08-10

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

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

0.20

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.76

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

1.82

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

2.79

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

0.96

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.41

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.16

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.00

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.20

CMS adjusted RN staffing hours

Adjusted total hours

2.75

CMS adjusted total nurse staffing hours

Case-mix index

1.39

Higher values indicate more complex resident acuity

RN turnover

Annual RN turnover

Total nurse turnover

32%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

3,560

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

Performance score

43.76

Composite VBP score used to determine payment impact.

Payment multiplier

0.9968

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

8.59

Baseline 27.27% · Performance 28.57% · Measure score 8.59 · Achievement 8.59 · Improvement 0

Adjusted total nurse staffing

0.16

Baseline 2.55 hours · Performance 2.76 hours · Measure score 0.16 · Achievement 0 · Improvement 0.16

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.98%	10.72% 0.7 pts better	No Different than the National Rate · Eligible stays 27 · Observed rate 3.7% · Lower 95% interval 6.48%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	1.02	1.02 About the same
Drug regimen review with follow-up	98.08%	95.27% 2.8 pts better	Numerator 51 · Denominator 52
Falls with major injury	5.77%	0.77% 5 pts worse	Numerator 3 · Denominator 52
Discharge self-care score	50%	53.69% 3.7 pts worse	Numerator 18 · Denominator 36
Discharge mobility score	33.33%	50.94% 17.6 pts worse	Numerator 12 · Denominator 36
Pressure ulcers or injuries, new or worsened	7.69%	2.29% 5.4 pts worse	Numerator 4 · Denominator 52 · Adjusted rate 5.55%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	10.59%	8.2% 2.4 pts better	Numerator 9 · Denominator 85
Staff flu vaccination coverage	87.5%	42% 45.5 pts better	Numerator 119 · Denominator 136
Discharge function score	47.22%	56.45% 9.2 pts worse	Numerator 17 · Denominator 36
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	Not Available	96.28%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	0%	25.2% 25.2 pts worse	Numerator 0 · Denominator 22

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.8	2.1 0.7 pts worse	1.9 0.9 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.6 · Expected 1.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.0	2.1 1.1 pts better	1.8 0.8 pts better	Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.7 · 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	4.3%	3.3% 1 pts worse	3.3% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 6.1% · Q3 2.9% · Q4 2.1% · 4Q avg 4.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.5%	2.7% 0.2 pts better	11.4% 8.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 3.3% · Q3 2.3% · Q4 2.4% · 4Q avg 2.5%
Percentage of long-stay residents who lose too much weight	1.2%	3.3% 2.1 pts better	5.4% 4.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 3.4% · Q4 0.0% · 4Q avg 1.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	34.3%	18.9% 15.4 pts worse	19.6% 14.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 34.2% · Q2 27.8% · Q3 37.8% · Q4 36.8% · 4Q avg 34.3%
Percentage of long-stay residents who received an antipsychotic medication	18.5%	10.8% 7.7 pts worse	16.7% 1.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 18.8% · Q3 18.8% · Q4 14.5% · 4Q avg 18.5% · 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	9.7%	15.4% 5.7 pts better	16.3% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 15.1% · Q3 6.9% · Q4 11.5% · 4Q avg 9.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	22.3%	16.1% 6.2 pts worse	14.9% 7.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 27.4% · Q3 13.8% · Q4 32.4% · 4Q avg 22.3% · 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	0.3%	0.8% 0.5 pts better	1.7% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	14.4%	15.0% 0.6 pts better	19.8% 5.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 16.0% · Q3 13.0% · Q4 10.9% · 4Q avg 14.4%
Percentage of long-stay residents with pressure ulcers	3.3%	4.2% 0.9 pts better	5.1% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.2% · Q3 2.5% · Q4 3.7% · 4Q avg 3.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	89.7% 10.3 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of short-stay residents who had an outpatient emergency department visit	3.8%	12.0% 8.2 pts better	12.0% 8.2 pts better	Short Stay · 20240701-20250630 · Adjusted 3.8% · Observed 4.3% · Expected 12.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.0%	1.5% 0.5 pts worse	1.6% 0.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 4.5% · 4Q avg 2.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	96.1%	88.0% 8.1 pts better	79.7% 16.4 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 96.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	28.4%	25.9% 2.5 pts worse	23.9% 4.5 pts worse	Short Stay · 20240701-20250630 · Adjusted 28.4% · Observed 26.1% · Expected 21.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-31 · Fire 2025-07-31

7 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-05-24 · Fire 2024-05-24

13 health deficiencies

Top issue: Resident Assessment and Care Planning (4 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2023-03-22 · Fire 2023-03-22

13 health deficiencies

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

2 fire-safety deficiencies

Top issue: Services (2 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-07-31

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-08-01

E · Potential for more than minimal harm 2025-07-31

K355 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-08-01

E · Potential for more than minimal harm 2025-07-31

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-08-01

C · Minimal harm 2025-07-31

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

E · Potential for more than minimal harm 2024-05-24

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-05-25

D · Potential for more than minimal harm 2024-05-24

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-05-25

C · Minimal harm 2024-05-24

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-05-25

E · Potential for more than minimal harm 2023-03-22

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-04-14

C · Minimal harm 2023-03-22

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2023-04-14

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-07-31

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-08-01

D · Potential for more than minimal harm 2025-07-31

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2025-08-01

D · Potential for more than minimal harm 2025-07-31

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 2025-08-01

D · Potential for more than minimal harm 2025-07-31

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 2025-08-01

D · Potential for more than minimal harm 2025-07-31

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 2025-08-01

D · Potential for more than minimal harm 2025-07-31

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 2025-08-01

D · Potential for more than minimal harm 2025-07-31

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-08-01

G · Actual harm 2024-05-24

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 2024-05-25

E · Potential for more than minimal harm 2024-05-24

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-05-25

E · Potential for more than minimal harm 2024-05-24

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 2024-05-25

E · Potential for more than minimal harm 2024-05-24

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 2024-05-25

E · Potential for more than minimal harm 2024-05-24

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-05-25

D · Potential for more than minimal harm 2024-05-24

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-05-25

D · Potential for more than minimal harm 2024-05-24

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 2024-05-25

D · Potential for more than minimal harm 2024-05-24

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 2024-05-25

D · Potential for more than minimal harm 2024-05-24

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-05-25

C · Minimal harm 2024-05-24

F577 · Resident Rights Deficiencies

Health

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Corrected 2024-05-25

K · Immediate jeopardy 2024-04-21

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 2024-04-22

E · Potential for more than minimal harm 2024-04-21

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 2024-04-22

D · Potential for more than minimal harm 2024-04-21

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 2024-04-22

E · Potential for more than minimal harm 2023-03-22

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 2023-04-14

E · Potential for more than minimal harm 2023-03-22

F940 · Administration Deficiencies

Health

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Corrected 2023-04-14