Windsor Nursing And Rehabilitation Center Of Bastrop

Penalties

• Feb 5, 2026 — Fine ($15,920)

Inspection findings

1. Jun 30, 2026 Health · 4 findings
   • Not serious Scope/severity D Complaint

     F0656 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.

     Corrected Jul 23, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0679 Quality of Life and Care Deficiencies

     Provide activities to meet all resident's needs.

     Corrected Jul 23, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Jul 23, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0761 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.

     Corrected Jul 23, 2026 · CMS health inspection

2. Feb 5, 2026 Health · 1 finding
   • Serious Scope/severity H Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     CMS health inspection

3. Jul 17, 2025 Health · 6 findings
   • Not serious Scope/severity D

     F0804 Nutrition and Dietary Deficiencies

     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

     Corrected Aug 5, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Aug 5, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Aug 5, 2025 · CMS health inspection

   • Not serious Scope/severity C

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Jul 24, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Aug 11, 2025 · CMS fire safety

   • Not serious Scope/severity C

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Jul 24, 2025 · CMS fire safety

4. Mar 30, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0656 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.

     Corrected Apr 7, 2025 · CMS health inspection

5. Jun 11, 2024 Health · 6 findings
   • Not serious Scope/severity E

     F0584 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.

     Corrected Jun 18, 2024 · CMS health inspection

   • Not serious Scope/severity C

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected Jun 18, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0758 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.

     Corrected Jun 18, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jun 18, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jun 18, 2024 · CMS health inspection

   • Not serious Scope/severity C

     F0912 Environmental Deficiencies

     Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

     Corrected Jun 18, 2024 · CMS health inspection

6. Apr 27, 2023 Health · 5 findings
   • Not serious Scope/severity E

     F0803 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.

     Corrected Apr 28, 2023 · CMS health inspection

   • Not serious Scope/severity C

     F0912 Environmental Deficiencies

     Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

     Corrected Apr 28, 2023 · CMS health inspection

   • Not serious Scope/severity C

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Jul 21, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Jul 21, 2023 · CMS fire safety

   • Not serious Scope/severity C

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Jul 21, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• CLAPP, BARBARA — managing control - governing body, NOT APPLICABLE, since 10/01/2022
• CRAYTON, TOM — managing control - governing body, NOT APPLICABLE, since 01/15/2013
• DEKOWSKI, DONOVAN — adp of the snf, NOT APPLICABLE, since 10/01/2022
• DEKOWSKI, DONOVAN — operational/managerial control, NOT APPLICABLE, since 10/01/2022
• FREUDENBERGER, JOSEPH — corporate officer, NOT APPLICABLE, since 06/19/2007
• FREUDENBERGER, JOSEPH — managing control - governing body, NOT APPLICABLE, since 06/19/2007
• GARZA, BERTHA — adp of the snf, NOT APPLICABLE, since 10/01/2022
• GARZA, BERTHA — operational/managerial control, NOT APPLICABLE, since 10/01/2022
• GOWDA, SUMA — adp of the snf, NOT APPLICABLE, since 10/01/2022
• HALEY, JEFF — managing control - governing body, NOT APPLICABLE, since 07/15/2016
• POPATIA, AMIRALI — managing control - governing body, NOT APPLICABLE, since 03/17/2020
• UTHMAN, EDWARD — managing control - governing body, NOT APPLICABLE, since 01/15/2008
• CSV RHEA MANAGEMENT HOLDCO, LLC — indirect ownership interest, NOT APPLICABLE, since 10/01/2022
• DWD TX HOLDINGS LLC — indirect ownership interest, NOT APPLICABLE, since 10/01/2022
• JACK AND NANCY DWYER WORKFORCE DEVELOPMENT CENTER INC — indirect ownership interest, NOT APPLICABLE, since 10/01/2022
• OAKBEND MEDICAL CENTER — adp of the snf, NOT APPLICABLE, since 04/29/2025
• OAKBEND MEDICAL CENTER — operational/managerial control, NOT APPLICABLE, since 03/31/2017
• OAKBEND MEDICAL CENTER — 5% or greater direct ownership interest, 100%, since 03/31/2017
• REG LEASED OPCO LLC — indirect ownership interest, NOT APPLICABLE, since 10/01/2022
• REG OPERATOR HOLDCO LLC — indirect ownership interest, NOT APPLICABLE, since 10/01/2022
• REGENCY IHS CLINICAL CONSULTING, LLC — adp of the snf, NOT APPLICABLE, since 10/01/2022
• REGENCY IHS OF BASTROP LLC — direct ownership interest, NOT APPLICABLE, since 10/01/2022
• REGENCY IHS OF BASTROP LLC — adp of the snf, NOT APPLICABLE, since 04/29/2025
• REGENCY IHS OF BASTROP LLC — operational/managerial control, NOT APPLICABLE, since 10/01/2022
• REGENCY IHS REHAB LLC — adp of the snf, NOT APPLICABLE, since 10/01/2022
• REGENCY INTEGRATED HEALTH SERVICES LLC — indirect ownership interest, NOT APPLICABLE, since 10/01/2022
• REGENCY INTEGRATED HEALTH SERVICES LLC — adp of the snf, NOT APPLICABLE, since 04/29/2025
• REGENCY INTEGRATED HEALTH SERVICES LLC — operational/managerial control, NOT APPLICABLE, since 10/01/2022
• REGENCY TEXAS HOLDINGS LLC — indirect ownership interest, NOT APPLICABLE, since 10/01/2022