01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-07-17 | 8 | 2025-07-17 | 3 |
| Cycle 2 | 2024-06-11 | 7 | 2024-06-11 | 0 |
| Cycle 3 | 2023-04-27 | 2 | 2023-04-27 | 3 |
CMS CCN 6753562026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Windsor Nursing And Rehabilitation Center Of Bastr
400 Old Austin Hwy · Bastrop, TX 78602 · Bastrop County
Certified beds96CMS provider file
Recent citation rows23current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
23 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 6 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-06-30 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2026-07-23 · complaint2026-06-30 · HEALTHF0679Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Correction field: Deficient, Provider has date of correction · 2026-07-23 · complaint2026-06-30 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2026-07-23 · complaint2026-06-30 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-07-23 · complaint2026-02-05 · HEALTHF0760Severity H · pattern of actual harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Past Non-Compliance · complaint2025-07-17 · HEALTHF0804Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Correction field: Deficient, Provider has date of correction · 2025-08-052025-07-17 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-08-052025-07-17 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-08-052025-07-17 · FIREK0211Severity C · widespread; potential for minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Past Non-Compliance · 2025-07-242025-07-17 · FIREK0511Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2025-08-112025-07-17 · FIREK0521Severity C · widespread; potential for minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Past Non-Compliance · 2025-07-242025-03-30 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2025-04-07 · complaint2024-06-11 · HEALTHF0584Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-06-182024-06-11 · HEALTHF0732Severity C · widespread; potential for minimal harm
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Correction field: Deficient, Provider has date of correction · 2024-06-182024-06-11 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Implement 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.
Correction field: Deficient, Provider has date of correction · 2024-06-182024-06-11 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2024-06-182024-06-11 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-06-182024-06-11 · HEALTHF0912Severity C · widespread; potential for minimal harm
Environmental Deficiencies
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Correction field: Deficient, Provider has date of correction · 2024-06-182023-04-27 · HEALTHF0803Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-04-282023-04-27 · HEALTHF0912Severity C · widespread; potential for minimal harm
Environmental Deficiencies
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Correction field: Deficient, Provider has date of correction · 2023-04-282023-04-27 · FIREK0211Severity C · widespread; potential for minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has date of correction · 2023-07-212023-04-27 · FIREK0355Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2023-07-212023-04-27 · FIREK0521Severity C · widespread; potential for minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2023-07-2103 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2026-02-05 | Fine | $15,920 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- OAKBEND MEDICAL CENTEROrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 03/31/2017
- REGENCY IHS OF BASTROP LLCOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 10/01/2022
- CSV RHEA MANAGEMENT HOLDCO, LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 10/01/2022
- DWD TX HOLDINGS LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 10/01/2022
- JACK AND NANCY DWYER WORKFORCE DEVELOPMENT CENTER INCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 10/01/2022
- REG LEASED OPCO LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 10/01/2022
- REG OPERATOR HOLDCO LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 10/01/2022
- REGENCY INTEGRATED HEALTH SERVICES LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 10/01/2022
- REGENCY TEXAS HOLDINGS LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 10/01/2022
- CLAPP, BARBARAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 10/01/2022
- CRAYTON, TOMIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/15/2013
- FREUDENBERGER, JOSEPHIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 06/19/2007
- HALEY, JEFFIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 07/15/2016
- POPATIA, AMIRALIIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 03/17/2020
- UTHMAN, EDWARDIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/15/2008
- FREUDENBERGER, JOSEPHIndividual · CORPORATE OFFICERNOT APPLICABLE · since 06/19/2007
- OAKBEND MEDICAL CENTEROrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/31/2017
- REGENCY IHS OF BASTROP LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2022
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours2.88per resident day
RN hours0.44per resident day
Weekend nurse hours2.61per resident day
Staff turnover45.0%CMS reported field