Cycle 1
Health 2024-06-06 · Fire 2024-06-06
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Hudson, FL
Windsor Woods Rehab And Healthcare Center
3-star overall rating with 3-star inspections with 9 recent health deficiencies
13719 Dallas Dr, Hudson, FL
(727) 862-6795
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
103
Certified beds
Average residents
99
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Florida Institute For Long-Term Care
Operator or chain grouping
Approved since
1987-05-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
18 facilities
Chain averages 2 overall / 2 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
0.53
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.09
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.36
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.15
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
3.54
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,531
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.03
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.71% · Performance 23.59% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.02% · Performance 9.75% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.68
Baseline 42.00% · Performance 36.36% · Measure score 6.68 · Achievement 6.68 · Improvement 2.79
Adjusted total nurse staffing
1.33
Baseline 3.65 hours · Performance 3.46 hours · Measure score 1.33 · Achievement 1.33 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.91% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 137 · Observed rate 15.33% · Lower 95% interval 8.8% |
| Discharge to community | 35.72% |
50.57%
14.9 pts worse
|
Worse than the National Rate · Eligible stays 130 · Observed rate 26.15% · Lower 95% interval 27.72% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 96.91% |
95.27%
1.6 pts better
|
Numerator 94 · Denominator 97 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 97 |
| Discharge self-care score | 33.33% |
53.69%
20.4 pts worse
|
Numerator 23 · Denominator 69 |
| Discharge mobility score | 30.43% |
50.94%
20.5 pts worse
|
Numerator 21 · Denominator 69 |
| Pressure ulcers or injuries, new or worsened | 5.15% |
2.29%
2.9 pts worse
|
Numerator 5 · Denominator 97 · Adjusted rate 5.44% |
| Healthcare-associated infections requiring hospitalization | 9.76% |
7.12%
2.6 pts worse
|
No Different than the National Rate · Eligible stays 87 · Observed rate 14.94% · Lower 95% interval 6.33% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 102 |
| Staff flu vaccination coverage | 24.43% |
42%
17.6 pts worse
|
Numerator 32 · Denominator 131 |
| Discharge function score | 39.13% |
56.45%
17.3 pts worse
|
Numerator 27 · Denominator 69 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 37 · Denominator 37 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 34 · Denominator 34 |
| Resident COVID-19 vaccinations up to date | 33.33% |
25.2%
8.1 pts better
|
Numerator 17 · Denominator 51 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
2.1
0.8 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.6 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.2
0.4 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.8%
2.2 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% |
99.2%
0.8 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 | 2.4% |
2.6%
0.2 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 2.5% · Q3 1.2% · Q4 1.1% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.7%
3.7 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 | 5.0% |
5.9%
0.9 pts better
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 10.3% · Q3 2.7% · Q4 2.6% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.7% |
15.7%
12 pts worse
|
19.6%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 21.7% · Q3 28.9% · Q4 30.9% · 4Q avg 27.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.3% |
9.8%
7.5 pts worse
|
16.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 17.8% · Q3 18.2% · Q4 16.2% · 4Q avg 17.3% · 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 | 9.1% |
11.7%
2.6 pts better
|
16.3%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 8.8% · Q3 13.8% · Q4 6.1% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.5% |
9.8%
0.3 pts better
|
14.9%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 6.6% · Q3 8.8% · Q4 10.5% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 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 1.2% · 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 | 3.3% |
12.5%
9.2 pts better
|
19.8%
16.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 1.4% · Q3 3.9% · Q4 3.7% · 4Q avg 3.3% |
| Percentage of long-stay residents with pressure ulcers | 11.3% |
5.1%
6.2 pts worse
|
5.1%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 13.7% · Q3 12.2% · Q4 10.0% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
94.3%
3.5 pts better
|
81.7%
16.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 96.1% · Q3 100.0% · Q4 99.0% · 4Q avg 97.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.5% |
9.3%
1.8 pts better
|
12.0%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 7.8% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.5%
0.6 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.7% · Q3 4.0% · Q4 1.7% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.9% |
94.7%
2.2 pts better
|
79.7%
17.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.3% |
26.2%
2.9 pts better
|
23.9%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.3% · Observed 25.0% · Expected 25.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-04 · Fire 2022-08-04
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2021-03-26 · Fire 2021-03-26
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-08-04
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-08-27
D · Potential for more than minimal harm
2022-08-04
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-08-27
D · Potential for more than minimal harm
2022-08-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-08-27
D · Potential for more than minimal harm
2021-03-26
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-04-26
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-24
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 2025-05-24
D · Potential for more than minimal harm
2025-04-24
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 2025-05-24
D · Potential for more than minimal harm
2025-04-24
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-05-24
E · Potential for more than minimal harm
2024-06-06
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 2024-07-06
D · Potential for more than minimal harm
2024-06-06
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-07-06
D · Potential for more than minimal harm
2024-06-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-06
D · Potential for more than minimal harm
2024-06-06
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-07-06
D · Potential for more than minimal harm
2024-06-06
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 2024-07-06
D · Potential for more than minimal harm
2024-06-06
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-07-06
G · Actual harm
2022-08-04
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-08-28
E · Potential for more than minimal harm
2022-08-04
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 2022-08-27
E · Potential for more than minimal harm
2022-08-04
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2022-08-27
D · Potential for more than minimal harm
2022-08-04
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-09-04
D · Potential for more than minimal harm
2022-08-04
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 2022-09-04
D · Potential for more than minimal harm
2022-08-04
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-08-27
D · Potential for more than minimal harm
2022-08-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-27
Penalties and ownership
What sits behind the stars
Ownership
Fi-Windsor Woods, LLC
5% Or Greater Direct Ownership Interest · Organization
Florida Institute For Long Term Care LLC
5% Or Greater Indirect Ownership Interest · Organization
Consulting Support Services, LLC
Operational/Managerial Control · Organization
Croucher, Stephanie
Operational/Managerial Control · Individual
Eleus Health Management LLC
Operational/Managerial Control · Organization
Facility Support Company, LLC
Operational/Managerial Control · Organization
Jaffe, Howard
Corporate Officer · Individual
Kane Financial Services, LLC
Operational/Managerial Control · Organization
Katz-Hall, Kathy
Corporate Officer · Individual
Mullarkey, James
Corporate Officer · Individual
Omega Healthcare Investors, Inc
5% Or Greater Security Interest · Organization
Richmond, Penny
Corporate Officer · Individual
Vanbelkum, Donna
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Bayonet Point Health Center By Harborview
Hudson, FL
4-star overall rating with 3-star inspections with 4 recent health deficiencies
#2
Solaris Healthcare Bayonet Point
Hudson, FL
3-star overall rating with 2-star inspections with $90,650 in total fines with 12 recent health deficiencies
#3
Bear Creek Nursing Center
Hudson, FL
2-star overall rating with 2-star inspections with $37,198 in total fines with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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