WINDSOR REHABILITATION AND HEALTHCARE
250 W BRITISH FLYING SCHOOL BLVD, TERRELL, TX 75160
Falls short of federal staffing minimum — elevated deficiency count.
Quality Breakdown
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RN Staffing
Registered nurse time each resident receives daily. Federal minimum: 0.55 hrs.
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0.24 ✗ Below federal minimum (0.55) |
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Health Deficiencies
Violations found during federal inspections over the last 3 years.
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10 |
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CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
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Quality: ★★★★★ (5/5)
Staffing: ★★☆☆☆ (2/5)
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NursingHomeGrade Score
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49/100 |
Data last updated: April 12, 2026
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
Most recent inspection (November 21, 2024)
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has plan of correction, corrected April 1, 2026
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2024
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2024
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2024
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 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.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2024
Keep residents' personal and medical records private and confidential.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2024
Inspection cycle 2 (September 27, 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.
Administration Deficiencies — Deficient, Provider has date of correction, corrected October 31, 2023
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected October 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.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected October 31, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 31, 2023
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 31, 2023
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 31, 2023
Develop 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 Planning Deficiencies — Deficient, Provider has date of correction, corrected October 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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 30, 2023
Inspection cycle 3 (July 27, 2022)
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected September 19, 2022
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected September 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.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected September 19, 2022
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected September 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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected September 19, 2022
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 20, 2022
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 19, 2022
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 19, 2022
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 20, 2022
Develop 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 Planning Deficiencies — Deficient, Provider has date of correction, corrected September 19, 2022
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected September 19, 2022
Ensure residents have reasonable access to and privacy in their use of communication methods.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 19, 2022
Quality Assurance & Integrity
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