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
Staffing
Hours and turnover
RN hours / resident day
0.53
Registered nurse staffing
LPN hours / resident day
0.74
Licensed practical nurse staffing
Aide hours / resident day
2.09
Nurse aide staffing
Weekend hours
3.15
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
33%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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