WINDSOR REHABILITATION AND HEALTHCARE
Open-data reference.
WINDSOR REHABILITATION AND HEALTHCARE is a government - hospital district facility in TERRELL, TX with 108 certified beds and a 5-star overall CMS rating. The facility has 31 deficiency records on file.
250 W BRITISH FLYING SCHOOL BLVD, TERRELL, TX 75160
Phone: 9725510122
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 675808
- Ownership
- Government - Hospital district
- Provider Type
- Medicare and Medicaid
- Beds
- 108
- Residents
- 86
- In Hospital
- Yes
- County
- Kaufman
- Last Inspection
- Nov 21, 2024
Staffing Data
- RN Hours
- 0.24 (nat'l avg: 0.68)
- LPN Hours
- 1.10
- CNA Hours
- 2.04
- Total Nursing Hours
- 3.38 (nat'l avg: 3.89)
- PT Hours
- 0.19
- Nursing Turnover
- 52.9%
- RN Turnover
- 60.0%
What the CMS Record Reveals About WINDSOR REHABILITATION AND HEALTHCARE
WINDSOR REHABILITATION AND HEALTHCARE operates 108 certified beds in TERRELL, TX with approximately 86 residents currently in care, and carries a CMS overall rating of 5 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 (4★), staffing levels (2★), and quality measures (5★). 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 31 deficiency records from recent surveys, all falling in the no-harm or minimal-harm bands of the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 3.38 total nursing hours per resident day (national average 3.89), with RN coverage at 0.24 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 embedded within a hospital campus, WINDSOR REHABILITATION AND HEALTHCARE 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 52.9%, above the level where continuity of care typically begins to suffer. 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 (31 most recent)
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Dec 30, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 30, 2024
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Dec 30, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Dec 30, 2024
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: Dec 30, 2024
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: Dec 30, 2024
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Dec 30, 2024
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: Dec 30, 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: Dec 30, 2024
Keep residents' personal and medical records private and confidential.
Category: Resident Rights Deficiencies
Corrected: Dec 30, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Oct 31, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Oct 31, 2023
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Category: Administration Deficiencies
Corrected: Oct 31, 2023
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Category: Nursing and Physician Services Deficiencies
Corrected: Oct 31, 2023
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 31, 2023
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: Oct 31, 2023
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Oct 31, 2023
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Category: Resident Rights Deficiencies
Corrected: Oct 30, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Sep 19, 2022
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 19, 2022
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: Sep 19, 2022
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Category: Nutrition and Dietary Deficiencies
Corrected: Sep 19, 2022
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category: Nutrition and Dietary Deficiencies
Corrected: Sep 19, 2022
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.
Category: Pharmacy Service Deficiencies
Corrected: Sep 19, 2022
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 20, 2022
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: Sep 19, 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: Sep 19, 2022
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 20, 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: Sep 19, 2022
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.
Category: Resident Rights Deficiencies
Corrected: Sep 19, 2022
Ensure residents have reasonable access to and privacy in their use of communication methods.
Category: Resident Rights Deficiencies
Corrected: Sep 19, 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 | 22.4% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 1.4% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.4% | 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 | 1.8% | 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 | 2.3% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 99.5% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.8% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 39.2% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 14.3% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 98.5% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 84.0% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 2.0% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 18.1% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 4.6% | Yes |
Penalty History
No penalties on record.
Nearby Nursing Homes in TX
Accel at College Station
College Station, TX
ACCEL AT WILLOW BEND
PLANO, TX
Advanced Health & Rehab Center of Garland
Garland, TX
Advanced Rehabilitation & Healthcare of Burleson
Burleson, TX
ADVANCED REHABILITATION & HEALTHCARE OF LIVE OAK
LIVE OAK, TX
ADVANCED REHABILITATION AND HEALTHCARE OF ATHENS
ATHENS, TX
Understanding Nursing Home Data
Related Data from Other Sources
Doctors Nearby
Find physicians and specialists in TERRELL, TX on PlainDoctor
Hospitals Nearby
Hospital quality ratings and safety data for TERRELL, TX on PlainHospital
Medicare Plans
Compare Medicare plans and coverage options near TERRELL, TX on PlainMedicare
County Health Data
Health outcomes, access, and quality metrics for Kaufman on PlainHealth
Frequently Asked Questions
What is the overall CMS rating for WINDSOR REHABILITATION AND HEALTHCARE?
What are the staffing levels at WINDSOR REHABILITATION AND HEALTHCARE?
How many beds does WINDSOR REHABILITATION AND HEALTHCARE have?
Does WINDSOR REHABILITATION AND HEALTHCARE have any deficiencies on record?
Has WINDSOR REHABILITATION AND HEALTHCARE received any fines or penalties?
Who owns WINDSOR REHABILITATION AND HEALTHCARE?
When was WINDSOR REHABILITATION AND HEALTHCARE last inspected?
What quality measures are tracked for WINDSOR REHABILITATION AND HEALTHCARE?
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.