Windsor Nursing and Rehabilitation Center of Duval
5301 W Duval Rd, Austin, TX 78727 · Travis County · 206 certified beds · avg 200 residents/day · certified since Feb 21, 2003
Part of chain: WELLSENTIAL HEALTH (67 facilities, chain avg rating 2.7★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, facility-wide · Jan 27, 2024 · F-0921 · triggered by a complaint
The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Why it matters: An unsafe or unclean environment raises the risk of falls, infections, and daily discomfort for residents.
Severity (L): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.
Corrected: Jan 28, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 9, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 6, 2024 (Past Non-Compliance)
All citations in the current public record (33)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 22, 2026 | E · Potential for harm, repeated | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| May 22, 2026 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| May 22, 2026 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| May 22, 2026 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 22, 2026 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| May 22, 2026 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| May 22, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| May 22, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 15, 2026 | D · Potential for harm, one-off | The facility did not let a resident or their legal representative see or buy copies of the resident's own records. · from a complaint |
| Jun 27, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Apr 2, 2025 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Apr 2, 2025 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Apr 2, 2025 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Apr 2, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 2, 2025 | E · Potential for harm, repeated | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
| Apr 2, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Apr 2, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Apr 2, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 19, 2024 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. · from a complaint |
| Sep 9, 2024 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| May 18, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jan 27, 2024 | ▲ L · Immediate jeopardy, facility-wide | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint |
| Jan 27, 2024 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Jan 27, 2024 | E · Potential for harm, repeated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. · from a complaint |
| Jan 27, 2024 | E · Potential for harm, repeated | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint |
| Jan 27, 2024 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. · from a complaint |
| Jan 27, 2024 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| Jan 27, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Jan 27, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint |
| Jan 27, 2024 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint |
| Jan 27, 2024 | D · Potential for harm, one-off | The facility did not have policies on smoking. · from a complaint |
| Dec 1, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Oct 4, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (8 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 2 | 0 | E |
| 2024 | 13 | 2 | L ▲ |
| 2025 | 9 | 0 | E |
| 2026 | 9 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $23,341.
| Date | Type | Amount / length |
|---|---|---|
| Sep 9, 2024 | Fine | $5,736 |
| Jan 27, 2024 | Fine | $17,605 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.81 | 3.46 | 3.95 | bottom 12% in Texas; bottom 8% in the U.S. |
| Registered Nurse hours | 0.44 | 0.44 | 0.69 | top 37% in Texas; bottom 28% in the U.S. |
| Weekend total nurse staffing | 2.55 | 3.04 | 3.50 | bottom 19% in Texas; bottom 11% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.39 | 0.34 | 0.48 | top 27% in Texas; top 50% in the U.S. |
| Total nursing staff turnover (%) | 40.2 | 55.3 | 45.8 | top 21% in Texas; top 37% in the U.S. |
| RN turnover (%) | 25.0 | 54.6 | 42.9 | top 11% in Texas; top 20% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.93, RN 0.46, weekend 2.66. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5
Who owns this facility
Government - Hospital district
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| DWD TX Holdings LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| Jack and Nancy Dwyer Workforce Development Center INC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| Reg HG Opco I, LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| Reg HG Opco LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| Reg Operator Holdco LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| Regency Ihs of Windsor Duval LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| Regency Integrated Health Services LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| Regency Texas Holdings LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| Val Verde County Hospital District | Organization | 5% or Greater Direct Ownership Interest | 100% | 04/01/2022 |
| 5301 West Duval Road LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/01/2022 |
| Baird, Daniel | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/13/2021 |
| Carvajal, Antonio | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/16/2024 |
| Clapp, Barbara | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/01/2021 |
| Cortese, Daren | Individual | Managing Control - Governing Body | NOT APPLICABLE | 08/10/2021 |
| Dekowski, Donovan | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2022 |
| Dekowski, Donovan | Individual | ADP of the SNF | NOT APPLICABLE | 04/01/2022 |
| Diaz, Cris | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/25/2022 |
| Faxigue, Blaise | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| Gibson, Patricia | Individual | Managing Control - Governing Body | NOT APPLICABLE | 08/01/2021 |
| Gonzales, Veronica | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/16/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "How do you protect residents' privacy, both in their medical records and in day-to-day care?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Austin Wellness & Rehabilitation | 2.4 mi | Austin, TX | ★☆☆☆☆ | 1/5 | |
| Avir at Park Bend | 2.5 mi | Austin, TX | ★★★☆☆ | 3/5 | |
| Gracy Woods Nursing Center | 2.7 mi | Austin, TX | —/5 | SFF | |
| Gracy Woods II Living Center | 2.8 mi | Austin, TX | ★★★★☆ | 4/5 | |
| Sage Park Austin | 3.3 mi | Austin, TX | ★★★☆☆ | 3/5 | |
| Coral Rehabilitation and Nursing of Austin | 5.0 mi | Austin, TX | ★☆☆☆☆ | 1/5 | abuseSFF |
| Ignite Medical Resort Round Rock, LLC | 5.1 mi | Austin, TX | ★★☆☆☆ | 1/5 | |
| Legend Oaks Healthcare and Rehabilitation - North | 5.6 mi | Austin, TX | ★☆☆☆☆ | 1/5 | abuse |
| The Center at Parmer | 5.9 mi | Austin, TX | ★★★★★ | 4/5 | |
| Sedona Trace Health and Wellness Center | 6.5 mi | Austin, TX | ★★★☆☆ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 675956.