Windsor Woods Rehab and Healthcare Center
13719 Dallas Dr, Hudson, FL 34667 · Pasco County · (727) 862-6795
103 certified beds, about 99 residents a day · Non profit - Other · Medicare and Medicaid since 1987
Last standard inspection more than 2 years ago Certified for Medicaid Certified for Medicare
Overall
3 of 5
Health inspections
3 of 5
Staffing
3 of 5
Quality measures
4 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 105568 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on June 6, 2024, inspectors cited 6 health deficiencies (the Florida average is 7.1, the national average 9.2).
Of 16 health citations since March 2021, 1 was rated as actual harm or immediate jeopardy to residents.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.24 hours per resident per day, against 3.82 across Florida and 3.86 nationally. Registered nurses accounted for 0.42 of those hours.
26.8% of nursing staff left within the year CMS measured (Florida average 41.4%).
CMS links it to Florida Institute for Long-Term Care, an affiliated group of 17 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.
003/21
708/22
606/24
304/25
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 16 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
11D
4E
0F
Potential for minimal harm
0A
0B
0C
April 24, 2025Complaint inspection · 3 citations
- E Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review the facility failed to ensure accurate and complete documentation related to Activities of Daily Living (ADLs) for toileting hygiene for four (#2, #4, #5, #6) out of four sampled residents.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interviews and record reviews, the facility failed to follow the comprehensive person-centered care plan related to providing toileting care with a two-person assist for one (#2) of eight sampled residents.
- D 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.
Inspectors wroteBased on interviews and record review, the facility failed to ensure a hospice plan of care was developed and coordinated to include communication between the facility and hospice provider related to activities of daily living (ADLs) for one (#3) of three residents reviewed for hospice care.
June 6, 2024Standard inspection · 6 citations
- E Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on record review, interview, and record review, the facility failed to provide incontinent supplies to meet resident needs for five (Residents #73, #35, #22, #49, #61) of 47 residents sampled. Findings Included: 1. An interview was conducted on 06/03/24 at 11:45 a.m. with Resident # 61. She stated staff ran out of incontinent briefs yesterday evening and she was not able to be changed. She stated staff only had a size small, and she wears an extra-large and/or extra extra-large and a small would not fit. She stated staff had to run to [local store] to pick up briefs for residents. Review of the electronic medical record (EMR) showed Resident #61 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, bipolar disorder, unspecified convulsions, primary insomnia, and anxiety disorder. Review of Minimum Data Set (MDS) dated [DATE] showed: [...]
- D PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review, interview, and record review, the facility failed to ensure the Level I readmission Screening and Resident Review (PASRR) was accurate for four residents (#15, #18, #68, #98) of 21 residents sampled for PASRR review. Findings Included: 1. Review of the electronic medical record (EMR) revealed Resident #68 was admitted to the facility on [DATE] with diagnoses that included depression, and unspecified dementia. Review of the Level I PASRR dated 10/25/23 showed qualifying diagnoses were not checked or indicated, and that no Level II PASRR was required. An interview was conducted on 06/06/24 at 12:55 p.m. with Director of Nursing (DON). [...]
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview, observation, and record review, the facility did not ensure compression stockings were ordered for one (Resident #46) of one resident sampled for chronic right lower leg swelling.
- D Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on record review and interviews, the facility failed to identify triggers related to Post Traumatic Stress Disorder (PTSD) which may retraumatize a resident and failed to develop and implement an individualized care plan with interventions that could minimize or eliminate the effect of the triggers for two (Resident #15 and #12) out of two sampled residents.
- D Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interviews, the facility failed to ensure antibiotics were administered timely for one (Resident #87) out of six residents reviewed for unnecessary medications.
- D Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations and record review, the facility failed to ensure the medication error rate was less than 5.00%. Forty-two medication administration opportunities were observed, and three errors were identified for two residents (#38 and #7) of five residents observed. These errors constituted a 7.14% medication error rate.
August 4, 2022Standard inspection · 7 citations
- G Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on record review, observations, and interviews the facility failed to ensure proper nutritional enhancements were provided as ordered for one resident (#56) of three residents sampled for nutrition resulting in a 6.1% wieght loss in 48 days.
- E 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.
Inspectors wroteBased on observations, interviews and record review, the facility failed to store medications in a safe and secure manner 1) in four medication carts (two A Wing and two C Wing) of four medication carts observed, and 2) for three residents (#16, #63, and #82) of forty one residents sampled.
- E Keep all essential equipment working safely.
Inspectors wroteBased on observations, staff interview and facility record review, the facility failed to ensure one of one walk in freezers were operating appropriately during two of four days observed (08/01/2022 and 8/4/2022). It was determined the freezer door would not latch closed in order to keep warm air from getting in, and as a result, there was ice build up inside the freezer compartment.
- D Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observations, interviews, and policy reviews the facility failed to ensure privacy of personal health information for three residents (#344, #351 and #352) out of forty-one sampled residents.
- D 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.
Inspectors wroteBased on observations, interviews and record review, the facility did not ensure air conditioning (A/C) units were maintained in a sanitary manner in 7 rooms (room [ROOM NUMBER], 128,130,219, 217, 216 and 218) out of 19 rooms in the front hall of the facility during four of four days of the survey
- D Provide activities to meet all resident's needs.
Inspectors wroteBased on observations, interviews and record review, the facility did not ensure a dependent resident (#16) was assisted to activities during three of four days of survey out of 41 residents sampled.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and policy reviews the facility did not ensure 1) proper infection control practices were followed for three Covid-19 positive residents (#344, #351, and #352) regarding personal protective equipment and 2) proper infection control practices were followed for one contact isolation resident (#67) regarding personal protective equipment out of forty one sampled residents. 1) An observation was made on 8/1/22 at 1:01 PM of Staff D, Licensed Practical Nurse (LPN), entering Resident #344's room with no goggles in place, only regular eyeglasses. Signage on the door indicated droplet precautions, stating everyone must clean hands when entering/exiting room, wear N95 mask, wear eye protection, and gown and glove at the door. [...]
March 26, 2021Standard inspection · 0 citations
Fire safety inspections
4 fire safety citations on file: 3 on August 4, 2022, 1 on March 26, 2021.
Every fire safety citation4 citations
- D Meet other general requirements.
- D Keep aisles, corridors, and exits free of obstruction in case of emergency.
- D Provide properly protected cooking facilities.
- D Have proper medical gas storage and administration areas.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Florida | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.24 | 3.82 | 3.86 |
| Registered nurses | 0.42 | 0.73 | 0.69 |
| All nursing staff on weekends | 3.10 | 3.49 | 3.42 |
| Nurse aides | 2.02 | ||
| Licensed practical nurses | 0.80 | ||
| Nursing staff turnover (share who left in a year) | 26.8% | 41.4% | 45.8% |
| Registered nurse turnover | 50.0% | 46.0% | 42.9% |
| Administrators who left | 1 |
CMS expects 3.61 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 3.30 on weekdays and 3.10 on weekends, 6% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.1% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.39 in April to June 2025 to 3.24 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.24 | 0.42 | 3.30 | 3.10 | 0.1% | 1 of 90 | 99 |
| Oct to Dec 2025 | 3.23 | 0.41 | 3.29 | 3.07 | 0.1% | 0 of 92 | 100 |
| Jul to Sep 2025 | 3.36 | 0.53 | 3.44 | 3.15 | 0.1% | 0 of 92 | 99 |
| Apr to Jun 2025 | 3.39 | 0.46 | 3.48 | 3.18 | 0.0% | 0 of 91 | 99 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Florida, Jan to Mar 2026 | 3.76 | 0.70 | 3.90 | 3.44 | 1.1% | 0.2% 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.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Florida | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 11.5 | 8.7 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.3 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.3 | 0.7 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 1.1 | 2.5 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.5 | 1.5 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 9.8 | 9.5 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 9.4 | 4.5 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 15.6 | 8.6 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 14.6 | 26.1 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 7.0 | 9.1 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.6 | 2.1 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.4 | 1.1 | 1.8 |
Owners and operators
Legal business name: FI-WINDSOR WOODS, LLC. CMS links this home to Florida Institute for Long-Term Care, a group of 17 nursing homes averaging 2.2 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Fi-Windsor Woods, LLC | 5% or greater direct ownership interest | Organization | 100% | 05/13/2003 |
| Florida Institute for Long Term Care LLC | 5% or greater indirect ownership interest | Organization | 100% | 12/23/2002 |
| Omega Healthcare Investors, Inc | 5% or greater security interest | Organization | 07/01/2003 | |
| Jaffe, Howard | Corporate officer | Individual | 07/01/2014 | |
| Katz-Hall, Kathy | Corporate officer | Individual | 07/01/2014 | |
| Mullarkey, James | Corporate officer | Individual | 07/01/2014 | |
| Richmond, Penny | Corporate officer | Individual | 07/01/2014 | |
| Consulting Support Services, LLC | Operational/managerial control | Organization | 06/28/2011 | |
| Eleus Health Management LLC | Operational/managerial control | Organization | 09/01/2009 | |
| Facility Support Company, LLC | Operational/managerial control | Organization | 12/13/2010 | |
| Kane Financial Services, LLC | Operational/managerial control | Organization | 06/06/2012 | |
| Croucher, Stephanie | Operational/managerial control | Individual | 11/15/2020 | |
| Vanbelkum, Donna | Operational/managerial control | Individual | 08/16/2019 | |
| Consulting Support Services, LLC | Adp of the SNF | Organization | 04/18/2025 | |
| Eleus Health Management LLC | Adp of the SNF | Organization | 04/18/2025 | |
| Facility Support Company, LLC | Adp of the SNF | Organization | 03/24/2025 | |
| Florida Institute for Long Term Care LLC | Adp of the SNF | Organization | 04/18/2025 | |
| Kane Financial Services, LLC | Adp of the SNF | Organization | 03/24/2025 | |
| Omega Healthcare Investors, Inc | Adp of the SNF | Organization | 07/01/2003 | |
| Select Rehabilitation, LLC | Adp of the SNF | Organization | 08/19/2016 | |
| Croucher, Stephanie | Adp of the SNF | Individual | 11/15/2020 | |
| Vanbelkum, Donna | Adp of the SNF | Individual | 08/16/2019 |
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.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 4 problems in this area, most recently on June 6, 2024: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
- When is the care plan meeting, and can family attend it?Inspectors cited 3 problems in this area, most recently on April 24, 2025: "Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 3 problems in this area, most recently on June 6, 2024: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 3 problems in this area, most recently on June 6, 2024: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.10 hours per resident per day, below the Florida average of 3.49.
- How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.
Other nursing homes nearby
- Bayonet Point Health Center by Harborview Hudson, 0.6 mi · 3 of 5 stars · 9 citations
- Solaris Healthcare Bayonet Point Hudson, 1.3 mi · 3 of 5 stars · 20 citations
- Bear Creek Nursing Center Hudson, 1.9 mi · 2 of 5 stars · 21 citations
- Heather Hill Healthcare Center New Port Richey, 6.9 mi · 2 of 5 stars · 25 citations
- Madison Pointe Care Center New Port Richey, 7.3 mi · 3 of 5 stars · 18 citations
- Nursing & Rehabilitation Center of New Port Richey New Port Richey, 7.5 mi · 1 of 5 stars · 20 citations
- Southern Pines Nursing Center New Port Richey, 7.5 mi · 2 of 5 stars · 29 citations
- Aspire at Ridge Haven New Port Richey, 8.7 mi · 3 of 5 stars · 23 citations
Florida contacts for a concern about a nursing home
These are the official offices in Florida. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Florida Agency for Health Care Administration, Long Term Care Services Unit, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Florida Long-Term Care Ombudsman Program, 1-888-831-0404. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: FloridaHealthFinder, where Florida publishes its own records on licensed homes.
Common questions
- What is Windsor Woods Rehab and Healthcare Center's Medicare star rating?
- CMS rates Windsor Woods Rehab and Healthcare Center 3 out of 5 stars overall, with 3 for health inspections, 3 for staffing and 4 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Windsor Woods Rehab and Healthcare Center get at its last inspection?
- 6 health deficiencies at the standard inspection on June 6, 2024. The Florida average is 7.1.
- Has Windsor Woods Rehab and Healthcare Center been fined?
- CMS lists no fines in the last three years.
- Does Windsor Woods Rehab and Healthcare Center 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 Woods Rehab and Healthcare Center?
- CMS lists 22 owners and managers, and links the home to Florida Institute for Long-Term Care. Legal business name: FI-WINDSOR WOODS, LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.