Cycle 1
Health 2025-03-06 · Fire 2025-03-06
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Missouri City, TX
Windsor Quail Valley Post-Acute Healthcare
2-star overall rating with 3-star inspections with $52,036 in total fines with 3 recent health deficiencies
3640 Hampton Dr, Missouri City, TX
(281) 778-5144
Overall
2 / 5
CMS overall stars
Health inspections
3 / 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
120
Certified beds
Average residents
101
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Wellsential Health
Operator or chain grouping
Approved since
2014-09-23
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
0.38
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.67
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.85
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.90
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.05
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
0.27
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
3.00
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,459
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.69
Composite VBP score used to determine payment impact.
Payment multiplier
0.9856
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.01
Performance 19.11% · Measure score 5.01 · Achievement 5.01 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.72
Baseline 6.49% · Performance 6.72% · Measure score 3.72 · Achievement 3.72 · Improvement 0
Total nurse turnover
2.08
Baseline 65.52% · Performance 55.17% · Measure score 2.08 · Achievement 2.08 · Improvement 2.04
Adjusted total nurse staffing
1.07
Baseline 2.78 hours · Performance 3.25 hours · Measure score 1.07 · Achievement 0.59 · Improvement 1.07
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.73% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 83 · Observed rate 19.28% · Lower 95% interval 9.68% |
| Discharge to community | 55.01% |
50.57%
4.4 pts better
|
No Different than the National Rate · Eligible stays 68 · Observed rate 44.12% · Lower 95% interval 42.25% |
| Medicare spending per beneficiary | 1.26 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 61.11% |
95.27%
34.2 pts worse
|
Numerator 44 · Denominator 72 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 72 |
| Discharge self-care score | 66.04% |
53.69%
12.4 pts better
|
Numerator 35 · Denominator 53 |
| Discharge mobility score | 60.38% |
50.94%
9.4 pts better
|
Numerator 32 · Denominator 53 |
| Pressure ulcers or injuries, new or worsened | 1.39% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 72 · Adjusted rate 1% |
| Healthcare-associated infections requiring hospitalization | 6.72% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 67 · Observed rate 7.46% · Lower 95% interval 3.7% |
| Staff COVID-19 vaccination coverage | 0.88% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 113 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 120 · Denominator 120 |
| Discharge function score | 64.15% |
56.45%
7.7 pts better
|
Numerator 34 · Denominator 53 |
| Transfer of health information to provider | 92% |
95.95%
4 pts worse
|
Numerator 23 · Denominator 25 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 13.33% |
25.2%
11.9 pts worse
|
Numerator 4 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
97.1%
2.6 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.9% · Q4 100.0% · 4Q avg 99.7% |
| 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 | 1.4% |
3.3%
1.9 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.1% · Q3 1.1% · Q4 2.3% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
2.7%
2.4 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.3%
3.3 pts better
|
5.4%
5.4 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 received an antianxiety or hypnotic medication | 12.3% |
18.9%
6.6 pts better
|
19.6%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 11.4% · Q3 10.7% · Q4 14.0% · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.1% |
10.8%
1.7 pts better
|
16.7%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 7.7% · Q3 7.1% · Q4 11.1% · 4Q avg 9.1% · 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 | 10.5% |
15.4%
4.9 pts better
|
16.3%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 15.0% · Q3 12.4% · Q4 4.9% · 4Q avg 10.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.9% |
16.1%
7.2 pts better
|
14.9%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 12.5% · Q3 8.0% · Q4 7.9% · 4Q avg 8.9% · 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 | 5.9% |
15.0%
9.1 pts better
|
19.8%
13.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 8.3% · Q3 6.8% · Q4 5.7% · 4Q avg 5.9% |
| Percentage of long-stay residents with pressure ulcers | 9.7% |
4.2%
5.5 pts worse
|
5.1%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 14.4% · Q3 10.6% · Q4 5.3% · 4Q avg 9.7% · 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 | 17.6% |
12.0%
5.6 pts worse
|
12.0%
5.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.6% · Observed 21.6% · Expected 13.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.7% |
25.9%
3.8 pts worse
|
23.9%
5.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.7% · Observed 40.5% · Expected 32.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-25 · Fire 2024-01-25
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-10-18 · Fire 2022-10-18
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-01-25
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2024-02-20
E · Potential for more than minimal harm
2022-10-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-11-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-03
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 2026-01-02
D · Potential for more than minimal harm
2025-03-06
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 2025-03-11
D · Potential for more than minimal harm
2025-03-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-11
D · Potential for more than minimal harm
2024-08-22
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 2024-08-29
J · Immediate jeopardy
2024-07-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-04-29
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 2024-05-17
J · Immediate jeopardy
2024-02-29
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 2024-03-01
J · Immediate jeopardy
2024-02-29
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-03-01
J · Immediate jeopardy
2024-02-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-29
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 2024-03-01
D · Potential for more than minimal harm
2024-01-12
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-01-25
E · Potential for more than minimal harm
2022-10-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-11-11
E · Potential for more than minimal harm
2022-10-18
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 2022-11-11
E · Potential for more than minimal harm
2022-10-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-10-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-11
Penalties and ownership
What sits behind the stars
$15,642
2024-07-19
Fine
Fine · fine $15,642
Fine
$36,394
2024-02-29
Fine
Fine · fine $36,394
Fine
Ownership
Oakbend Medical Center
5% Or Greater Direct Ownership Interest · Organization
Dekowski, Donovan
Operational/Managerial Control · Individual
Freudenberger, Joseph
Corporate Officer · Individual
Johnson, Demon
Operational/Managerial Control · Individual
Oakbend Medical Center
Operational/Managerial Control · Organization
Regency Ihs Of Windsor Quail Valley, LLC
Operational/Managerial Control · Organization
Regency Integrated Health Services LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Chelsea Gardens
Missouri City, TX
4-star overall rating with 4-star inspections with $56,103 in total fines with 3 fire-safety deficiencies in the latest cycle
#2
Park Manor of Quail Valley
Missouri City, TX
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Paradigm At First Colony
Missouri City, TX
1-star overall rating with 1-star inspections with $211,113 in total fines with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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