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Windsor Nursing and Rehabilitation Center of Duval

5301 W Duval Rd, Austin, TX 78727 · Travis County · (512) 345-1805

206 certified beds, about 200 residents a day · Government - Hospital district · Medicare and Medicaid since 2003

Certified for Medicaid Certified for Medicare
Overall
3 of 5
Health inspections
2 of 5
Staffing
2 of 5
Quality measures
5 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 675956 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on May 22, 2026, inspectors cited 8 health deficiencies (the Texas average is 9.4, the national average 9.2).

Of 33 health citations since October 2023, 2 were rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).

CMS lists 2 fines totaling $23,341 in the last three years; the largest was $17,605, and the latest is dated September 9, 2024.

Nurses and nurse aides worked 2.93 hours per resident per day, against 3.39 across Texas and 3.86 nationally. Registered nurses accounted for 0.46 of those hours.

40.2% of nursing staff left within the year CMS measured (Texas average 55.3%).

CMS links it to Wellsential Health, an affiliated group of 67 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 33 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
1L
Actual harm
1G
0H
0I
Potential for more than minimal harm
17D
14E
0F
Potential for minimal harm
0A
0B
0C
May 22, 2026Standard inspection · 8 citations
  1. E
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    F605 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 23, 2026
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity, including the right to be free from unnecessary drugs used in excessive dose including duplicated drug therapy, excessive duration, without adequate monitoring, and without adequate indications for it for 1 of 5 residents (Resident #14) reviewed for pharmacy services and unnecessary drugs. The facility did not prevent Resident #14 from receiving 13 doses of unnecessary psychotropic drug, Ativan 1ml/mg, discontinued on [DATE]. This failure could place residents at risk for overdosing, delayed healing, and other adverse consequences.
  2. E
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 23, 2026
    Inspectors wroteBased on observation, interview, and record review, the facility failed to establish a system of accurate reconciliation and determine that drug records were in order, and that an account of all controlled drugs were maintained and periodically reconciled for 3 of 11 medication carts (Medication Cart #1, Medication Cart #2, and Medication Cart #3) in the facility effecting 5 of 11 residents (Resident #91, Resident #201, Resident #122, Resident #14, and Resident #73) reviewed for pharmacy services. The facility failed to ensure:1. RN A accurately reconciled Resident #91's narcotic medication log on medication cart #1 when he administered Resident #91's Lorazepam 0.5 mg (controlled medication used for anxiety). 2. MA E accurately reconciled Resident #122's narcotic medication log on Medication Cart #2 when she administered one tablet of Hydrocodone-Acetaminophen 10-325 mg.3. [...]
  3. E
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 23, 2026
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors and failed to report drug errors to the resident's physician in a timely manner and record them in the resident's record for 1 of 5 residents (Resident #91) reviewed for drug administration. The facility failed to ensure that RN A administered a correct dose of Lorazepam 0.5 mg (controlled medication used for anxiety) to Resident #91 for a week without obtaining a correct dose of medication according to the physician order. This failure could place residents at risk for overdosing, delayed healing, and other adverse consequences.
  4. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 23, 2026
    Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for food and nutrition services.1)The facility failed to effectively reseal all food items in the walk-in refrigerator and dry pantry to prevent contamination or spoilage on 05/19/2026.2)The facility failed to label and date all food items located in the reach-in refrigerator, walk-in refrigerator, walk-in freezer, and kitchen shelves on 05/19/2026 and 05/20/2026.3)The facility failed to dispose of expired foods items located in the walk-in refrigerator and dry pantry.4)The facility failed to ensure proper hair restraints were worn by kitchen staff and individuals entering the kitchen. [...]
  5. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 23, 2026
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs for 1 of 6 residents (Resident #179) reviewed for accommodation of needs. The facility failed to ensure Resident #179's call light had been placed within reach. This failure had the potential to place dependent residents at risk for injuries and unmet needs.
  6. D
    Keep residents' personal and medical records private and confidential.
    F583 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 23, 2026
    Inspectors wroteBased on observation, interview, and record review, the facility failed to secure confidential and personal medical records for 1 (Resident #40) of 9 residents reviewed for privacy and confidentiality of records. The facility failed to protect Resident #40's PII on 03/27/2026 when the AMD emailed a PEME request form to an RP of another facility resident. This failure placed residents' PII at risk of exposure to unauthorized parties through electronic communication.
  7. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 23, 2026
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #29) of 9 residents reviewed for accidents and hazards. The facility failed to ensure Resident #29 did not keep smoking materials in his room. This failure could place residents at risk of a fire, burning themselves, or ingesting unknown substances.
  8. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 23, 2026
    Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 14 residents (Resident #162 and Resident #179) reviewed for infection control.1. CNA C failed to wash or sanitize her hands when going from a dirty surface to a clean surface while performing incontinent care for Resident #179.2. The facility failed on 05/19/2026 to use the CDC recommendations regarding contact isolation for chicken pox for Resident #162. These deficient practices had the potential to place residents at risk for cross contamination and the spread of infection.
April 15, 2026Complaint inspection · 1 citation
  1. D
    Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
    F573 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 16, 2026
    Inspectors wroteBased on interview and record review, the facility failed to allow one of one (Resident #1) resident reviewed, or the resident representative to obtain a copy of the resident's medical records upon verbal or written request to the facility. The facility failed to provide medical records for Resident #1 to his RP / family representative within two working days of a request on 03/31/2026. This failure placed residents in the facility at risk by causing a negative health impact due to not having continuity of care. and the right to review their health care.
June 27, 2025Complaint inspection · 1 citation
  1. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 28, 2025
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures for two of eight residents (Resident #1 and Resident #2) reviewed for abuse and neglect . [...]
April 2, 2025Standard inspection · 8 citations
  1. E
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 3, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 10 residents (Resident #61, Resident #84, and Resident #131) reviewed for rights. The facility failed to ensure CNA A and LVN B knocked on Resident #61's, Resident #84's, and Resident #131's door when going into the residents' rooms. The deficient practice could place residents at risk of feeling like their privacy was being invaded or the facility was not their home.
  2. E
    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.
    F803 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 3, 2025
    Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the meals served reflected the nutritional needs of residents in accordance with established national guidelines for all residents when the facility failed to ensure menus were followed for all residents for 2 of 2 meals observed. The facility failed to follow the posted menus for two meal services served at the facility on Monday, 03/31/25 and Tuesday 04/01/25. These failures could place residents that eat food from the kitchen at risk of poor intake, chemical imbalance, and/or weight loss.
  3. E
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    F804 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 3, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared by methods that conserve nutritive value, flavor, and appearance. The meal test tray's on 03/31/2025, 04/01/2025, and 04/02/2025 were not at appropriate homelike meal temperature, had an unappetizing off-putting appearance (no seasoning observed, and food colliding together), not cooked well (overcooked), and lacked palatable seasoning including flavor. The facility failed to provide palatable food that was attractive or appetizing to residents' who complained the food did not look or taste good. This failure could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life.
  4. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 3, 2025
    Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to ensure DA I ate food outside of the kitchen production area. 2. The facility failed to ensure the dishwasher's hot water was at the appropriate temperature. 3. The facility failed to ensure areas behind the oven and stove were clean. 4. The facility failed to ensure shelves were functional and did not require additional supports for the shelves to stay upright. 5. The facility failed to ensure the items in the walk-in fridge were free from liquid from other food products. 6. The facility failed to ensure the floors in the kitchen, walk-in fridge, and storage room were swept clean and free of trash. 7. [...]
  5. E
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    F919 · Environmental · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 3, 2025
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident's bedside, toilet and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for 3 of 10 residents (Resident #13, Resident #34, and Resident #124 ) reviewed for resident call system . The facility failed to provide a working communication system, which was easily at reach, which would allow Resident #13, Resident #34, and Resident #124 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living.
  6. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 3, 2025
    Inspectors wroteBased on observation, interview, and record review the facility failed to revise the care plan for 1 of 10 (Resident #92) residents reviewed for care plans. The facility failed to update the care plan to reflect the use of bed rails as an assistive aid for Resident #92. This failure placed the resident at risk of losing mobility, becoming entrapped, and receiving improper care.
  7. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 3, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #461) of three residents reviewed for quality of care. The facility failed to respond to and assess Resident #461's malfunctioning beeping oxygen concentrator with a red-light indicating malfunction for approximately 45 minutes. This failure could place residents at risk of an oxygen delivery problem, not receiving necessary medical care, harm, and hospitalization.
  8. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 3, 2025
    Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 7 residents (Resident #114, Resident #460, and Resident #461) reviewed for infection control. 1. The facility failed to ensure the TN H sanitized her hands and changed gloves prior to applying wound treatment and clean dressing to Resident #114's left heel wound. 2. The facility failed to post Enhanced Barrier Protection signage on Resident #460 and Resident #461's doors when they admitted to the facility with a wound and a suprapubic catheter. 3. The facility failed to ensure Enhanced Barrier Protection was worn when providing resident care for Resident #461's suprapubic catheter. [...]
September 19, 2024Complaint inspection · 1 citation
  1. D
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    F756 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 20, 2024
    Inspectors wroteBased on interviews and record review the facility failed to act upon the pharmacist's drug regimen review irregularity reports for two of (Residents #1 and #2) of seven residents reviewed for medication consents. 1. The facility failed to respond to the pharmacist's notification that Resident #1's Trazodone (an antidepressant and sedative medication used to treat depression and may also be used for other conditions) consent was missing and needed to be obtained and uploaded. The facility had an unsigned written consent from Resident #1's RP before administering Trazodone. 2. The facility failed to respond to the pharmacist's notification that Resident #2's Lorazepam (a medication used to treat anxiety) consent was missing and needed to be obtained and uploaded. The facility had an unsigned written consent from Resident #2's RP before administering Lorazepam. [...]
September 9, 2024Complaint inspection · 1 citation
  1. G
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · Actual harm, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on interview and record review, the facility failed to keep residents free from abuse for 1 (Resident # 1) of 9 residents reviewed for abuse. The facility failed to ensure Resident # 1 was not physically assaulted by Hospitality Aide A. The noncompliance was identified as PNC. The IJ began on 08/02/2024 and ended on 08/06/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of physical harm, mental anguish, or emotional distress.
May 18, 2024Complaint inspection · 1 citation
  1. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 19, 2024
    Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials for 1 (Resident #1) of 6 residents reviewed for abuse, in that: The facility failed to report Resident #1's abuse allegation to the State Agency. On 04/15/24, Resident #1 informed staff that he was hit by Resident #2 in the dining room during meal service. This deficient practice could place residents at risk of abuse and revictimization.
January 27, 2024Standard inspection, Complaint inspection · 10 citations
  1. L
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    F921 · Environmental · Immediate jeopardy to resident health or safety, widespread · found on a complaint visit · Corrected (the home has a date of correction) January 28, 2024
    Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible for 1 of 1 facility reviewed for physical environment, in that: The facility failed to ensure no open flames are near oxygen cylinders, store cylinders in the upright position, and secure the cylinders from residents and the public. An Immediate Jeopardy (IJ) was identified on 01/26/24 at 10:25 AM While the IJ was removed on 01/27/24 at 10:27 AM, the facility remained out of compliance at a scope of widespread and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to monitor their corrective actions. These failures could place residents at risk of injury or death due to improper or unsafe smoking.
  2. E
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) January 28, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, for 3 of 40 residents (Residents #19, #102, #153) reviewed for resident rights, in that: 1. Resident #19 was not served her meal timely with respect to Resident #153 sitting at the same table and was served at least 16 minutes later than him. 2. Resident #102 was not fed his meal timely with respect to his roommate. This failure could place residents needing assistance at risk for diminished quality of life, loss of dignity, and self-worth.
  3. E
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    F756 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) January 28, 2024
    Inspectors wroteBased on interview and record review, the facility failed to ensure the drug regimen of 2 out of 40 residents (Resident #37 and Resident #102) were reviewed at least once a month by a licensed pharmacist, in that: 1. Resident #37 was missing monthly medication reviews documented for the months of October 2023 and July 2023. 2. Resident #102 was missing monthly medication reviews documented for the months from August 2023 to December 2023. These deficient practices could place residents at risk from harm related to unnecessary medications or dosages, could place them at risk for adverse consequences related to medication therapy, and impact residents' ability to achieve or maintain their highest practicable level of physical, mental, and psychosocial well-being.
  4. E
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    F925 · Environmental · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) January 28, 2024
    Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program within 1 of 1 facility reviewed for pest control revealed: Live and dead pests were observed in the facility. This deficient practice could lead to contamination and/or infection due to an unsanitary environment.
  5. D
    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.
    F578 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 28, 2024
    Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's right to request, refuse, and/or discontinue treatment, and to formulate an advance directive for 1 (Resident #68) of 35 residents reviewed for clinical records, in that: Resident #68's clinical record contained two OOH-DNR forms, both of which were invalid. This deficient practice could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes.
  6. D
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    F655 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 28, 2024
    Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 2 of 21 residents (Residents #396 and #190) reviewed for baseline care plan, in that: 1. The facility failed to ensure Resident #396's baseline care plan included information related to his foley catheter ( tube that helps drain urine from bladder). 2. The facility failed to initiate a baseline care plan within 48hours of admission date 1/8/2024 for resident #190 to include physical therapy for strengthening. These failures could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met.
  7. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 28, 2024
    Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that a resident who needs respiratory care for 2 of 26 residents (Residents #2 and #53) reviewed for care consistent with professional standards, in that: 1. The facility failed to post signage for the room of Resident #53 while oxygen was in use. 2. The facility failed to clean the oxygen concentrator filter for Resident #2 while the oxygen was in use. These failures could place residents at risk for improper respiratory care.
  8. D
    Ensure medication error rates are not 5 percent or greater.
    F759 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 28, 2024
    Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a medication error rate was not 5% or greater. The facility had a medication error rate of 12%, based on 3 errors out of 25 opportunities, which involved (Residents #61 and #165) and 1 of 2 staff (MA J ) reviewed for medication administration, in that: The facility failed to ensure MA J administered medications according to the physician's orders and per professional standards for Residents #61 and #165, which resulted in a 12% medication administration error rate. This deficient practice could place residents at risk of not receiving the therapeutic effects of their medications and possible adverse reactions.
  9. D
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    F806 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 28, 2024
    Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to accommodate residents' food preferences for 1 of 8 (Resident #11) residents reviewed for food preferences, in that: 1. The facility failed to ensure that Resident #79's lunch meal on 01/23/24 did not include pepper per her dislike and allergy to pepper. 2. The facility failed to ensure that Resident #37's lunch meal on 01/24/24 included soup as was reflected on her lunch meal tray ticket. These failures could affect residents with food preferences and could result in a decrease in resident choices and diminished interest in meals.
  10. D
    Have policies on smoking.
    F926 · Environmental · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 28, 2024
    Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety that also take into account non-smoking residents for 3 of 40 residents (Residents #19 and #102) reviewed so smoking, in that: The facility failed to follow the Smoking/Tobacco Policy to ensure Residents #19 and #102 remained safe while smoking. These failures could place residents at risk of injury or death due to improper or unsafe smoking.
December 1, 2023Complaint inspection · 1 citation
  1. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) December 7, 2023
    Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection and prevention control program, designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 4 (Residents #1, #2, #3 and #4) of 6 residents reviewed for infection control, as indicated by: MA A and MA B observed not cleaning and disinfecting the wrist blood pressure monitor while using it on Resident #1, #2, #3, and #4. This failure could place the residents at the facility at risk of transmission of disease and infection.
October 4, 2023Complaint inspection · 1 citation
  1. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) October 5, 2023
    Inspectors wroteBased on observation interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: The food items in the walk-in refrigerator in the kitchen were labeled and dated. The food items in the freezer were not stored on the floor. These failures could place residents at risk for food-borne illness, and food contamination.

Fire safety inspections

7 fire safety citations on file: 1 on May 22, 2026, 1 on April 2, 2025, 5 on January 27, 2024.

Every fire safety citation7 citations
  1. D
    Meet other general requirements.
    K 100 · May 22, 2026 · Corrected (the home has a date of correction)
  2. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · April 2, 2025 · Corrected (the home has a date of correction)
  3. F
    Develop and maintain an Emergency Preparedness Program (EP).
    E 4 · January 27, 2024 · Corrected (the home has a date of correction)
  4. F
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · January 27, 2024 · Corrected (the home has a date of correction)
  5. E
    Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
    K 741 · January 27, 2024 · Corrected (the home has a date of correction)
  6. E
    Have proper medical gas storage and administration areas.
    K 923 · January 27, 2024 · Corrected (the home has a date of correction)
  7. D
    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
    K 321 · January 27, 2024 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
September 9, 2024Fine $5,736
January 27, 2024Fine $17,605

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeTexasUnited States
All nursing staff (RN, LPN and aides)2.933.393.86
Registered nurses0.460.430.69
All nursing staff on weekends2.662.983.42
Nurse aides2.00
Licensed practical nurses0.47
Nursing staff turnover (share who left in a year)40.2%55.3%45.8%
Registered nurse turnover25.0%54.6%42.9%
Administrators who left1

CMS expects 4.00 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.04 on weekdays and 2.66 on weekends, 12% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 2.69 in April to June 2025 to 2.93 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20262.930.463.042.66 0.0%0 of 90200
Oct to Dec 20252.820.352.922.59 0.0%0 of 92203
Jul to Sep 20252.840.372.942.59 0.0%0 of 92205
Apr to Jun 20252.690.402.802.42 0.0%0 of 91205
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Texas, Jan to Mar 20263.330.403.502.932.2%0.7% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.

Official wage estimates for Texas

JobMedianMiddle halfEmployed
Texas, all employers
CNAs (nursing assistants)$18.03$16.97 to $20.7188,680
LPNs and LVNs$29.92$27.46 to $32.8957,560
Registered nurses$46.14$38.06 to $50.53271,380
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

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For Windsor Nursing and Rehabilitation Center of Duval. No name, email or phone, and nothing you could type about a resident: every answer is a number or a choice.

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How did staffing feel on your usual shift?

Every report is reviewed before it counts; what it says about the home never decides whether it counts. How pay reports are handled.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeTexasUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
20.115.813.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.10.30.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
0.00.81.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
2.33.33.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
3.11.51.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
10.114.014.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
2.43.84.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
13.19.615.4
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.52.21.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.22.11.8

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Windsor Nursing and Rehabilitation Center of Duval's Medicare short-stay residents. On returning residents home or to the community, CMS rates it worse than the national rate (32.5% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

32.5% this home

Worse than the national rate

US median of homes 51.5% · Texas: 116 better, 50 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 50 eligible stays.

Potentially preventable readmissions

11.1% this home

No different from the national rate

US median of homes 10.7% · Texas: 0 better, 9 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 57 eligible stays.

Infections that led to a hospital stay

6.2% this home

No different from the national rate

US median of homes 7.1% · Texas: 4 better, 11 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 40 eligible stays.

Self-care and mobility at discharge

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Texas57.3% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 12 residents counted.

Falls with major injury

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Texas0.0% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 18 residents counted.

New or worsened pressure ulcers

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Texas1.3% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 18 residents counted.

Medication list given at discharge

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Texas98.5% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 4 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: VAL VERDE COUNTY HOSPITAL DISTRICT. CMS links this home to Wellsential Health, a group of 67 nursing homes averaging 2.7 stars overall.

NameRoleTypeShareSince
Val Verde County Hospital District5% or greater direct ownership interestOrganization100%04/01/2022
Regency IHS of Windsor Duval LLCDirect ownership interestOrganization04/01/2022
Dwd Tx Holdings LLCIndirect ownership interestOrganization04/01/2022
Jack and Nancy Dwyer Workforce Development Center IncIndirect ownership interestOrganization04/01/2022
Reg Hg Opco I, LLCIndirect ownership interestOrganization04/01/2022
Reg Hg Opco LLCIndirect ownership interestOrganization04/01/2022
Reg Operator Holdco LLCIndirect ownership interestOrganization04/01/2022
Regency Integrated Health Services LLCIndirect ownership interestOrganization04/01/2022
Regency Texas Holdings LLCIndirect ownership interestOrganization04/01/2022
Baird, DanielManaging control - governing bodyIndividual04/13/2021
Carvajal, AntonioManaging control - governing bodyIndividual05/16/2024
Clapp, BarbaraManaging control - governing bodyIndividual06/01/2021
Cortese, DarenManaging control - governing bodyIndividual08/10/2021
Diaz, CrisManaging control - governing bodyIndividual05/25/2022
Gibson, PatriciaManaging control - governing bodyIndividual08/01/2021
Gonzales, VeronicaManaging control - governing bodyIndividual05/16/2024
Jurado, JorgeManaging control - governing bodyIndividual10/13/2023
Kaufman, NicoleManaging control - governing bodyIndividual08/10/2021
Mandelbaum, ElliotManaging control - governing bodyIndividual01/01/2025
Otazo, JulioManaging control - governing bodyIndividual05/25/2022
Palmer, RobinManaging control - governing bodyIndividual11/18/2020
Jurado, JorgeCorporate officerIndividual10/13/2023
Regency IHS of Windsor Duval LLCOperational/managerial controlOrganization04/01/2022
Regency Integrated Health Services LLCOperational/managerial controlOrganization04/01/2022
Val Verde County Hospital DistrictOperational/managerial controlOrganization04/01/2022
Dekowski, DonovanOperational/managerial controlIndividual04/01/2022
Helmcamp, TerrellOperational/managerial controlIndividual02/06/2012
5301 West Duval Road LLCAdp of the SNFOrganization04/01/2022
Regency IHS Clinical Consulting, LLCAdp of the SNFOrganization04/01/2022
Regency IHS Master Tenant LLCAdp of the SNFOrganization04/01/2022
Regency IHS of Windsor Duval LLCAdp of the SNFOrganization11/05/2024
Regency IHS Rehab LLCAdp of the SNFOrganization04/01/2022
Regency Integrated Health Services LLCAdp of the SNFOrganization04/01/2022
Val Verde County Hospital DistrictAdp of the SNFOrganization04/28/2025
Dekowski, DonovanAdp of the SNFIndividual04/01/2022
Faxigue, BlaiseAdp of the SNFIndividual01/01/2025
Grochowalski, KristinAdp of the SNFIndividual01/01/2025
Helmcamp, TerrellAdp of the SNFIndividual02/06/2012
Momin, ZahirAdp of the SNFIndividual08/01/2021

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 6 problems in this area, most recently on May 22, 2026: "Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards."
  2. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 6 problems in this area, most recently on May 22, 2026: "Reasonably accommodate the needs and preferences of each resident."
  3. How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 5 problems in this area, most recently on May 22, 2026: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist."
  4. How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 4 problems in this area, most recently on May 22, 2026: "Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 2.66 hours per resident per day, below the Texas average of 2.98.
  6. How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.

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Common questions

What is Windsor Nursing and Rehabilitation Center of Duval's Medicare star rating?
CMS rates Windsor Nursing and Rehabilitation Center of Duval 3 out of 5 stars overall, with 2 for health inspections, 2 for staffing and 5 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Windsor Nursing and Rehabilitation Center of Duval get at its last inspection?
8 health deficiencies at the standard inspection on May 22, 2026. The Texas average is 9.4.
Has Windsor Nursing and Rehabilitation Center of Duval been fined?
Yes. CMS lists 2 fines totaling $23,341 in the last three years.
Does Windsor Nursing and Rehabilitation Center of Duval accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Windsor Nursing and Rehabilitation Center of Duval?
CMS lists 39 owners and managers, and links the home to Wellsential Health. Legal business name: VAL VERDE COUNTY HOSPITAL DISTRICT.

Sources

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