Federal inspection record · CMS data as of October 1, 2026
Windsor Rehabilitation And Healthcare
250 W. British Flying School Blvd, Terrell, TX · (972) 551-0122
- Certified beds
- 108
- Residents per day
- 81
- Ownership
- For-Profit
- Chain
- The Ensign Group
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- September 1, 1999
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
-
Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Texas.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Texas homes
Windsor Rehabilitation And Healthcare carries 102 inspection points. That is fewer than 35% of Texas's 1,166 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Texas: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–26 pts
- 4★ 26–51 pts
- 3★ 51–85 pts
- 2★ 85–145.75 pts
- 1★ over 145.75 pts
Bars show every rated home in Texas by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
39 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
No citation on record at the harm or immediate-jeopardy level.
Everything else, by area of care
Quality of Life and Care9E
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- E
Provide enough food/fluids to maintain a resident's health.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
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.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Resident Assessment and Care Planning7E
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Ensure each resident receives an accurate assessment.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Ensure each resident receives an accurate assessment.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Pharmacy Service7E
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
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.
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure medication error rates are not 5 percent or greater.
- D
Ensure that residents are free from significant medication errors.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Nutrition and Dietary5E
- E
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.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Infection Control4E
- E
Provide and implement an infection prevention and control program.
- D
Implement a program that monitors antibiotic use.
- D
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
Resident Rights3D
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
- D
Keep residents' personal and medical records private and confidential.
- D
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.
Administration2E
- D
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
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.
Environmental1E
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Nursing and Physician Services1D
- D
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.
Inspection history
2026-02-27
21 health deficiencies · 0 fire-safety deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
2024-11-21
10 health deficiencies · 2 fire-safety deficiencies
Top issue: Pharmacy Service (4 deficiencies)
2023-09-27
8 health deficiencies · 0 fire-safety deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 19 min of nursing staff time a day, 18 min of it from a registered nurse.
This home
3 h 19 min
Texas average
3 h 25 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 40% of nursing staff and 60% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.6 pts worse | 2.6 | 2.0 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.3 pts better | 1.7 | 2.0 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine3.6 pts better | 100.0% | 96.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine1.1 pts worse | 95.9% | 97.0% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.1 pts worse | 3.3% | 3.2% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms0.3 pts better | 2.0% | 2.3% | 13.5% |
| Percentage of long-stay residents who lose too much weight0.3 pts better | 2.6% | 2.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication7.4 pts better | 10.4% | 17.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication6.9 pts better | 2.9% | 9.8% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened23.3 pts worse | 36.2% | 12.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased16.8 pts worse | 32.6% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.3 pts better | 0.0% | 0.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.8 pts better | 0.0% | 0.8% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence1.5 pts worse | 14.0% | 12.5% | 18.3% |
| Percentage of long-stay residents with pressure ulcers0.5 pts better | 3.2% | 3.7% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine11.1 pts better | 99.8% | 88.7% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit7.6 pts better | 4.6% | 12.2% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.8 pts better | 0.6% | 1.4% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine6.5 pts worse | 78.9% | 85.4% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission1.9 pts worse | 27.4% | 25.5% | 23.4% |
·
Who owns and runs it
14 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Eastland Memorial Hospital District | 5% Or Greater Direct Ownership Interest · Organization | 100% | 34 facilities |
| Arze, Steven | Managing Control - Governing Body · Individual | 0% | 4 facilities |
| Arze, Steven | Adp Of The SNF · Individual | 0% | 4 facilities |
| Buffalo Creek Healthcare LLC | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Burnam, Soon | Corporate Officer · Individual | 0% | 353 facilities |
| Ensign Services Inc | Adp Of The SNF · Organization | 0% | 299 facilities |
| Grover, Kenneth | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Grover, Kenneth | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Grover, Kenneth | Adp Of The SNF · Individual | 0% | 1 facilities |
| Keetch, Chad | Corporate Officer · Individual | 0% | 301 facilities |
| Standard Bearer Healthcare Op, LP | Adp Of The SNF · Organization | 0% | 78 facilities |
| The Ensign Group Inc | Adp Of The SNF · Organization | 0% | 135 facilities |
| Western Edge Health Holdings LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Wright, Laban | Corporate Officer · Individual | 0% | 12 facilities |
·
Fire safety
2 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke2E
- E
Install an approved automatic sprinkler system.
- E
Inspect, test, and maintain automatic sprinkler systems.
·
Other homes nearby
-
Terrell Healthcare Center
Terrell, TX · Nexion Health · Special Focus
Not rated- Worst citation, 3 yrs
- K
- Nursing / resident / day
- 3 h 21 min
- Fines
- $339,046
-
Countryview Nursing & Rehabilitation
Terrell, TX · Creative Solutions In Healthcare · Abuse icon
★★★★★- Worst citation, 3 yrs
- K
- Nursing / resident / day
- 3 h 20 min
- Fines
- $63,570
-
Ridgecrest Healthcare And Rehabilitation Center
Forney, TX · Nexion Health
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 4 h 12 min
- Fines
- $0