WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL
Open-data reference.
WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL is a government - hospital district facility in AUSTIN, TX with 206 certified beds and a 2-star overall CMS rating. The facility has 30 deficiency records on file. Total penalties: $23K.
5301 W DUVAL RD, AUSTIN, TX 78727
Phone: 5123451805
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 675956
- Ownership
- Government - Hospital district
- Provider Type
- Medicare and Medicaid
- Beds
- 206
- Residents
- 205
- In Hospital
- No
- County
- Travis
- Last Inspection
- Apr 2, 2025
Staffing Data
- RN Hours
- 0.37 (nat'l avg: 0.68)
- LPN Hours
- 0.50
- CNA Hours
- 1.96
- Total Nursing Hours
- 2.84 (nat'l avg: 3.89)
- PT Hours
- 0.03
- Nursing Turnover
- 40.2%
- RN Turnover
- 28.6%
What the CMS Record Reveals About WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL
WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL operates 206 certified beds in AUSTIN, TX with approximately 205 residents currently in care, and carries a CMS overall rating of 2 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (2★), staffing levels (2★), and quality measures (4★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 30 deficiency records from recent surveys, of which 2 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 2 penalties totaling $23K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 2.84 total nursing hours per resident day (national average 3.89), with RN coverage at 0.37 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Government - Hospital district" ownership and operating as a "Medicare and Medicaid" provider, WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 40.2%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (30 most recent)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 28, 2025
Make sure that a working call system is available in each resident's bathroom and bathing area.
Category: Environmental Deficiencies
Corrected: Apr 3, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Apr 3, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 3, 2025
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 3, 2025
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.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 3, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 3, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 3, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Apr 3, 2025
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Sep 20, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 6, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: May 19, 2024
Have policies on smoking.
Category: Environmental Deficiencies
Corrected: Jan 28, 2024
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Category: Environmental Deficiencies
Corrected: Jan 28, 2024
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category: Environmental Deficiencies
Corrected: Jan 28, 2024
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Category: Nutrition and Dietary Deficiencies
Corrected: Jan 28, 2024
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Jan 28, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Jan 28, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 28, 2024
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jan 28, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Jan 28, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Jan 28, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Dec 7, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Oct 5, 2023
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 2, 2023
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 2, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 18, 2022
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 18, 2022
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 18, 2022
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Nov 18, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 20.5% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 3.8% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 1.6% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 1.9% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 98.7% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 94.4% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 4.5% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 15.2% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 15.2% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 97.1% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 93.1% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 3.7% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 28.7% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 15.9% | Yes |
Penalty History 2 penalties totaling $23K
| Date | Type | Amount |
|---|---|---|
| Sep 9, 2024 | Fine | $6K |
| Jan 27, 2024 | Fine | $18K |
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County Health Data
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Frequently Asked Questions
What is the overall CMS rating for WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL?
What are the staffing levels at WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL?
How many beds does WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL have?
Does WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL have any deficiencies on record?
Has WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL received any fines or penalties?
Who owns WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL?
When was WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL last inspected?
What quality measures are tracked for WINDSOR NURSING AND REHABILITATION CENTER OF DUVAL?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.