| Windsor Rehabilitation and Healthcare | |
| 250 W. British Flying School Blvd, Terrell, Texas 75160 | |
| (972) 551-0122 | |
| Name | Windsor Rehabilitation and Healthcare |
|---|---|
| Location | 250 W. British Flying School Blvd, Terrell, Texas |
| Certified By | Medicare and Medicaid |
| No. of Certified Beds | 108 |
| Occupancy Rate | 74.35% |
| Medicare ID (CCN) | 675808 |
| Legal Business Name | Eastland Memorial Hospital District |
| Ownership Type | For Profit - Limited Liability Company |
| Chain | The Ensign Group (342 nursing homes) |
| Chain Average Overall Rating | 3.2 out of 5 |
| NPI Number | 1174109938 |
| Match | Confirmed listed in Medicare enrollment records |
| Organization Name | Eastland Memorial Hospital District |
| Doing Business As | Windsor Rehabilitation and Healthcare |
| Address | 250 W British Flying School Blvd, Terrell, TX 75160 |
| Phone Number | 972-551-0122 |
| NPI Number | 1952301657 |
| Match | Possible same name, address or phone number |
| Organization Name | Balmoral, Ltd |
| Doing Business As | Windsor Rehabilitation & Health Care Center |
| Address | 250 W British Flying School Blvd, Terrell, TX 75160 |
| Phone Number | 972-551-0122 |
| Ratings from Surveys (Inspections): | |
| Ratings from Quality Measures: | |
| Ratings from Staffing Data: | |
| Overall Rating: |
|---|
| Staffing Measure | Provider | National Avg. |
|---|---|---|
| Total nurse staff hours per resident per day | 3.55 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.32 | 0.69 |
| Licensed practical nurse (LPN) hours per resident per day | 1.11 | 0.86 |
| Nurse aide hours per resident per day | 2.13 | 2.32 |
| Total nurse staff hours per resident per day on the weekend | 3.08 | 3.42 |
| RN hours per resident per day on the weekend | 0.2 | 0.48 |
| Physical therapist hours per resident per day | 0.23 | 0.07 |
| Total nursing staff turnover | 42.9% | 45.8% |
| Registered nurse turnover | 50% | 42.9% |
| Number of administrators who have left the nursing home | 1 | 0.5 |
| Cited for abuse, neglect or exploitation of residents (Care Compare abuse icon) | No |
| Number of Fines | 0 |
| Total Amount of Fines in Dollars | $0 |
| Number of Payment Denials | 0 |
| Total Number of Penalties | 0 |
| Date | Deficiency | Harm Level | Status |
|---|---|---|---|
| Feb 27, 2026 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656, Resident Assessment and Care Planning, Standard inspection | Potential for harm, pattern | Corrected by Apr 1, 2026 |
| Feb 27, 2026 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Standard inspection | Potential for harm, pattern | Corrected by Apr 1, 2026 |
| Feb 27, 2026 | Provide enough food/fluids to maintain a resident's health. F0692, Quality of Life and Care, Standard inspection | Potential for harm, pattern | Corrected by Apr 1, 2026 |
| Feb 27, 2026 | 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. F0803, Nutrition and Dietary, Standard inspection | Potential for harm, pattern | Corrected by Apr 1, 2026 |
| Feb 27, 2026 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. F0804, Nutrition and Dietary, Standard inspection | Potential for harm, pattern | Corrected by Apr 1, 2026 |
| Feb 27, 2026 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. F0805, Nutrition and Dietary, Standard inspection | Potential for harm, pattern | Corrected by Apr 1, 2026 |
| Feb 27, 2026 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812, Nutrition and Dietary, Standard inspection | Potential for harm, pattern | Corrected by Apr 1, 2026 |
| Feb 27, 2026 | Provide and implement an infection prevention and control program. F0880, Infection Control, Standard inspection | Potential for harm, pattern | Corrected by Apr 1, 2026 |
| Feb 27, 2026 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. F0921, Environmental, Standard inspection | Potential for harm, pattern | Corrected by Apr 1, 2026 |
| Feb 27, 2026 | Ensure that residents are fully informed and understand their health status, care and treatments. F0552, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Apr 1, 2026 |
| Feb 27, 2026 | Ensure each resident receives an accurate assessment. F0641, Resident Assessment and Care Planning, Standard inspection | Potential for harm, isolated | Corrected by Apr 1, 2026 |
| Feb 27, 2026 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. F0676, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Apr 1, 2026 |
| Feb 27, 2026 | Provide care and assistance to perform activities of daily living for any resident who is unable. F0677, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Apr 1, 2026 |
| Feb 27, 2026 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Apr 1, 2026 |
| Feb 27, 2026 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. F0690, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Apr 1, 2026 |
| Feb 27, 2026 | 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. F0693, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Apr 1, 2026 |
| Feb 27, 2026 | Provide safe and appropriate respiratory care for a resident when needed. F0695, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Apr 1, 2026 |
| Feb 27, 2026 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. F0755, Pharmacy Service, Standard inspection, Complaint inspection | Potential for harm, isolated | Corrected by Apr 1, 2026 |
| Feb 27, 2026 | 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. F0761, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Apr 1, 2026 |
| Feb 27, 2026 | 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. F0849, Administration, Standard inspection | Potential for harm, isolated | Corrected by Apr 1, 2026 |
| Feb 27, 2026 | Implement a program that monitors antibiotic use. F0881, Infection Control, Standard inspection | Potential for harm, isolated | Corrected by Apr 1, 2026 |
| Nov 21, 2024 | Ensure each resident’s drug regimen must be free from unnecessary drugs. F0757, Pharmacy Service, Standard inspection | Potential for harm, pattern | Corrected by Dec 30, 2024 |
| Nov 21, 2024 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812, Nutrition and Dietary, Standard inspection | Potential for harm, pattern | Corrected by Dec 30, 2024 |
| Nov 21, 2024 | Keep residents' personal and medical records private and confidential. F0583, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Dec 30, 2024 |
| Nov 21, 2024 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted F0655, Resident Assessment and Care Planning, Standard inspection | Potential for harm, isolated | Corrected by Dec 30, 2024 |
| Nov 21, 2024 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. F0657, Resident Assessment and Care Planning, Standard inspection, Complaint inspection | Potential for harm, isolated | Corrected by Dec 30, 2024 |
| Nov 21, 2024 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. F0755, Pharmacy Service, Standard inspection, Complaint inspection | Potential for harm, isolated | Corrected by Dec 30, 2024 |
| Nov 21, 2024 | Ensure medication error rates are not 5 percent or greater. F0759, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Dec 30, 2024 |
| Nov 21, 2024 | Ensure that residents are free from significant medication errors. F0760, Pharmacy Service, Standard inspection, Complaint inspection | Potential for harm, isolated | Corrected by Dec 30, 2024 |
| Nov 21, 2024 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. F0842, Resident Assessment and Care Planning, Standard inspection, Complaint inspection | Potential for harm, isolated | Corrected by Dec 30, 2024 |
| Quality Measure | Provider | National Avg. |
|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | 33.78 | 13.87 |
| Percentage of long-stay residents who lose too much weight | 1.72 | 5.19 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.38 | 0.82 |
| Percentage of long-stay residents with a urinary tract infection | 0 | 1.59 |
| Percentage of long-stay residents who have depressive symptoms | 1.83 | 12.8 |
| Percentage of long-stay residents who were physically restrained | 0 | 0.13 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.28 | 3.23 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100 | 93.55 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.77 | 82.04 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.66 | 1.56 |
| Percentage of long-stay residents whose ability to walk independently worsened | 42.14 | 14.07 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.65 | 19.52 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.53 | 95.46 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.04 | 79.75 |
| Percentage of long-stay residents with pressure ulcers | 2.76 | 4.62 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.72 | 19.01 |
| Percentage of long-stay residents who received an antipsychotic medication | 3.4 | 15.38 |
Countryview Nursing & Rehabilitation Location: 1900 N Frances St, Terrell, Texas 75160 Phone: (972) 524-2503 |