B85

WINDSOR REHABILITATION AND HEALTHCARE

Grade B 85/100 composite score

Government - Hospital district

CMS Star Ratings

Overall
5/5
Health Insp.
4/5
Quality
5/5
Staffing
2/5
RN Staffing
Not rated

Certified Beds

108

Ownership

Government - Hospital district

Total Fines

None

Last Survey

N/A

250 W BRITISH FLYING SCHOOL BLVD, TERRELL, TX 75160
9725510122

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.26h
LPN
1.20h
CNA
2.23h
Total
3.70h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

EASTLAND MEMORIAL HOSPITAL DISTRICT

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Mar 2024

100%

BUFFALO CREEK HEALTHCARE LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Mar 2024

BURNAM, SOON

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Mar 2024

GROVER, KENNETH

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Mar 2024

BURNAM, SOON

IndividualCORPORATE OFFICERSince Mar 2024

WRIGHT, LABAN

IndividualCORPORATE OFFICERSince Mar 2024

GROVER, KENNETH

IndividualCONTRACTED MANAGING EMPLOYEESince Mar 2024

Penalties & Fines

No penalties or fines on record.

Health Inspection Deficiencies (31)

November 21, 2024Health10 deficiencies
0583DMinimal harm, Isolated

Keep residents' personal and medical records private and confidential.

Resident Rights Deficiencies

Corrected Dec 30, 2024
0655DMinimal harm, Isolated

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

Corrected Dec 30, 2024
0757EMinimal harm, Pattern

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies

Corrected Dec 30, 2024
0759DMinimal harm, Isolated

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Dec 30, 2024
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Dec 30, 2024
0657DMinimal harm, Isolated

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

Corrected Dec 30, 2024
0755DMinimal harm, Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Dec 30, 2024
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Dec 30, 2024
0842DMinimal harm, Isolated

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

Corrected Dec 30, 2024
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Dec 30, 2024
September 27, 2023Health8 deficiencies
0622DMinimal harm, Isolated

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

Corrected Oct 30, 2023
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 31, 2023
0656DMinimal harm, Isolated

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

Corrected Oct 31, 2023
0694DMinimal harm, Isolated

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Oct 31, 2023
0726DMinimal harm, Isolated

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

Corrected Oct 31, 2023
0849EMinimal harm, Pattern

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

Corrected Oct 31, 2023
0755EMinimal harm, Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Oct 31, 2023
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Oct 31, 2023
July 27, 2022Health13 deficiencies
0576EMinimal harm, Pattern

Ensure residents have reasonable access to and privacy in their use of communication methods.

Resident Rights Deficiencies

Corrected Sep 19, 2022
0584DMinimal harm, Isolated

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

Corrected Sep 19, 2022
0656EMinimal harm, Pattern

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

Corrected Sep 19, 2022
0676DMinimal harm, Isolated

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

Corrected Sep 20, 2022
0677EMinimal harm, Pattern

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Sep 19, 2022
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Sep 19, 2022
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Sep 20, 2022
0761DMinimal harm, Isolated

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

Corrected Sep 19, 2022
0804EMinimal harm, Pattern

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Corrected Sep 19, 2022
0808DMinimal harm, Isolated

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

Corrected Sep 19, 2022
0812FMinimal harm, Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Sep 19, 2022
0842DMinimal harm, Isolated

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

Corrected Sep 19, 2022
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Sep 19, 2022

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Frequently Asked Questions

What is the CareGrader rating for WINDSOR REHABILITATION AND HEALTHCARE?

WINDSOR REHABILITATION AND HEALTHCARE in TERRELL, Texas has a CareGrader grade of B (Good), with a composite score of 84.8 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for WINDSOR REHABILITATION AND HEALTHCARE?

WINDSOR REHABILITATION AND HEALTHCARE has an overall CMS star rating of 5 out of 5, a health inspection rating of 4/5, and a staffing rating of 2/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does WINDSOR REHABILITATION AND HEALTHCARE have?

WINDSOR REHABILITATION AND HEALTHCARE has 31 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

How many beds does WINDSOR REHABILITATION AND HEALTHCARE have?

WINDSOR REHABILITATION AND HEALTHCARE has 108 certified beds with approximately 85 current residents (79% occupancy). The facility is located at 250 W BRITISH FLYING SCHOOL BLVD, TERRELL, Texas 75160. It is a government - hospital district facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.