Your report for Windsor Nursing and Rehabilitation Center of Bastr
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- TexasAbove 69% of peers1,167 rated homes · average 2.8★
- Bastrop CountyTop 1%5 rated homes · average 2.8★
- United StatesAbove 61% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point5★+2.2 vs TX avg
- StaffingCan add or remove a star1★−1.1 vs TX avg
- Quality measuresCan add or remove a star4★+0.2 vs TX avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles5★Top 10%TX avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover1★Lowest tier among peersTX avg2.1★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments4★Above only 37% of peersTX avg3.8★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff2.76hrsAbove only 7% of peersTX avg3.40Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.46hrsAbove 67% of peersTX avg0.44Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better53%Above only 44% of peersTX avg51%RN turnover—
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$0Above 71% of peersTX avg$55,368Fines · denials0 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthApr 2023 – Jul 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Jul 17, 2025Cycle 1worst E · no actual harm
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Aug 5, 2025
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryD · isolatedCorrected Aug 5, 2025
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Aug 5, 2025
Mar 30, 2025Cycle 1worst D · no actual harm
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Apr 7, 2025
Jun 11, 2024Cycle 2worst F · no actual harm
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Jun 18, 2024
- F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.EnvironmentalC · widespreadCorrected Jun 18, 2024
- F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Pharmacy ServiceD · isolatedCorrected Jun 18, 2024
- F584Honor 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.Resident RightsE · patternCorrected Jun 18, 2024
- F732Post nurse staffing information every day.Nursing and Physician ServicesC · widespreadCorrected Jun 18, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Jun 18, 2024
Apr 27, 2023Cycle 3worst E · no actual harm
- F803Ensure 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.Nutrition and DietaryE · patternCorrected Apr 28, 2023
- F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.EnvironmentalC · widespreadCorrected Apr 28, 2023
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined2.76hrs
- Registered nursesRN hours only0.46hrs
- Licensed practical nursesLPN hours0.95hrs
- Nurse aidesCNA hours1.35hrs
- Weekend nursingAll staff on Saturdays and Sundays2.39hrs
- Texas average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better53%Above only 44% of peersTX avg 51%
- RN turnoverRegistered nurses only—Not ranked by CMS
- Administrators who leftIn the past year—
- Occupancy96 certified beds · ~50 residents a day52%Above only 20% of peersTX avg 67%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $0In fines
- 0Fines
- 0Payment denials
- $55,368TX avg in fines
Actions on record
Ownership
As filed with CMSStructure
- Ownership type
- Government - Hospital district
- Chain
- Wellsential Health67 facilities in the chain2.8★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Oakbend Medical Center
- Oakbend Medical Center
- Regency Ihs of Bastrop LLC
- Regency Integrated Health Services LLC
- Donovan Dekowski
- Bertha Garza
- Joseph Freudenberger
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 675356 · 400 OLD AUSTIN HWY, BASTROP, TX, 78602.
- Percentiles compare this facility with every rated nursing home in Texas and Bastrop County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.
