WINDSOR REHABILITATION AND HEALTHCARE
Certified for Medicare and Medicaid since 1999-09-01, WINDSOR REHABILITATION AND HEALTHCARE is a 108-bed nursing home in TERRELL, Texas, averaging 80.3 residents a day.
Has WINDSOR REHABILITATION AND HEALTHCARE been cited for violations?
CMS lists 39 health-inspection deficiencies for WINDSOR REHABILITATION AND HEALTHCARE, all of them in the three years to 2026-08-01: the highest scope-and-severity letter on record is E; the most recent health inspection was 2026-02-27.
| Survey date | Tag | Deficiency | Severity |
|---|---|---|---|
| 2026-02-27 | F0656, F0689, F0692, F0803, F0804, F0805, F0812, F0880, F0921 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide enough food/fluids to maintain a resident's health. / 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. / Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. / Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Provide and implement an infection prevention and control program. / Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | E |
| 2026-02-27 | F0552, F0641, F0676, F0677, F0684, F0690, F0693, F0695, F0755, F0761, F0849, F0881 | Ensure that residents are fully informed and understand their health status, care and treatments. / Ensure each resident receives an accurate assessment. / Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. / Provide care and assistance to perform activities of daily living for any resident who is unable. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. / Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. / Provide safe and appropriate respiratory care for a resident when needed. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / 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. / 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. / Implement a program that monitors antibiotic use. | D |
| 2024-11-21 | F0757, F0812 | Ensure each resident’s drug regimen must be free from unnecessary drugs. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E |
| 2024-11-21 | F0583, F0655, F0657, F0755, F0759, F0760, F0842, F0880 | Keep residents' personal and medical records private and confidential. / Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / Ensure medication error rates are not 5 percent or greater. / Ensure that residents are free from significant medication errors. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. / Provide and implement an infection prevention and control program. | D |
| 2023-09-27 | F0755, F0849 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / 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. | E |
| 2023-09-27 | F0622, F0641, F0656, F0694, F0726, F0880 | 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. / Ensure each resident receives an accurate assessment. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Provide for the safe, appropriate administration of IV fluids for a resident when needed. / 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. / Provide and implement an infection prevention and control program. | D |
How is WINDSOR REHABILITATION AND HEALTHCARE staffed?
| Measure | This facility | TX average |
|---|---|---|
| Total nurse staffing hours per resident per day | 3.55486 | 3.38539 |
| Total nursing staff turnover (%) | 42.9 | 55.3 |
| Average number of residents per day | 80.3 | 75.8 |
Who owns WINDSOR REHABILITATION AND HEALTHCARE, and what chain is it in?
WINDSOR REHABILITATION AND HEALTHCARE is registered with CMS as For profit - Limited Liability company, operates under the legal business name EASTLAND MEMORIAL HOSPITAL DISTRICT and belongs to the THE ENSIGN GROUP chain.
| Role | Owner | Association date |
|---|---|---|
| 5% OR GREATER DIRECT OWNERSHIP INTEREST | EASTLAND MEMORIAL HOSPITAL DISTRICT | since 03/01/2024 |
| MANAGING CONTROL - GOVERNING BODY | ARZE, STEVEN, GROVER, KENNETH | since 01/05/2021 |
| CORPORATE OFFICER | BURNAM, SOON, KEETCH, CHAD, WRIGHT, LABAN | since 03/01/2024 |
| OPERATIONAL/MANAGERIAL CONTROL | BUFFALO CREEK HEALTHCARE LLC, GROVER, KENNETH | since 03/01/2024 |
| ADP OF THE SNF | ENSIGN SERVICES INC, STANDARD BEARER HEALTHCARE OP, LP, THE ENSIGN GROUP INC, WESTERN EDGE HEALTH HOLDINGS LLC, ARZE, STEVEN, GROVER, KENNETH | since 03/01/2024 |
Were you or a family member harmed at WINDSOR REHABILITATION AND HEALTHCARE?