Windsor Rehabilitation and Healthcare

Nursing Home · Terrell, TX

CMS overall rating 2/5 For profit - Limited Liability company

CMS certification number675808

Contact & location

250 W. British Flying School Blvd
Terrell, TX 75160
Kaufman County
Phone
(972) 551-0122
ZIP code
75160 – all care providers

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Facility details

Certified beds
108
Residents per day
80.3 (74% occupied)
Ownership
For profit - Limited Liability company
Legal name
Eastland Memorial Hospital District
Chain
The Ensign Group (342 facilities, avg 3.2★)
Medicare certified since
September 1, 1999
Participates in
Medicare and Medicaid
Council
Resident council

CMS star ratings

Overall★★★★★ 2/5
State avg 2.6
Health inspections★★★★★ 2/5
State avg 2.8
Staffing★★★★★ 2/5
State avg 1.9
Quality measures★★★★★ 4/5
State avg 3.7
Long-stay quality★★★★★ 3/5
Short-stay quality★★★★★ 5/5

Staffing

Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.

Total nurse staffing
3.55 (state 3.39 · U.S. 3.86)
Registered nurses (RN)
0.32 (state 0.43 · U.S. 0.69)
Licensed practical nurses
1.11 (state 0.95 · U.S. 0.86)
Nurse aides
2.13 (state 2.00 · U.S. 2.32)
Weekend total
3.08 (state 2.98 · U.S. 3.42)
Nursing staff turnover
42.9 (state 55.3 · U.S. 45.8)%
RN turnover
50.0 (state 54.6 · U.S. 42.9)%
Administrators who left
1 in the last year

Inspections

Last standard inspection
February 27, 2026
Health deficiencies (last cycle)
21.0 (state 9.3 · U.S. 9.3)
From complaints
1
Citations on record (3 years)
39 health · 2 fire safety
DateCitationSeverityStatus
2026-02-27 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 Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-04-01
2026-02-27 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-04-01
2026-02-27 Provide enough food/fluids to maintain a resident's health.
F0692 · Quality of Life and Care Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-04-01
2026-02-27 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 Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-04-01
2026-02-27 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F0804 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-04-01
2026-02-27 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F0805 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-04-01
2026-02-27 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-04-01
2026-02-27 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-04-01
2026-02-27 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
F0921 · Environmental Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-04-01
2026-02-27 Ensure that residents are fully informed and understand their health status, care and treatments.
F0552 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-04-01
2026-02-27 Ensure each resident receives an accurate assessment.
F0641 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-04-01
2026-02-27 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 Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-04-01
2026-02-27 Provide care and assistance to perform activities of daily living for any resident who is unable.
F0677 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-04-01
2026-02-27 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-04-01
2026-02-27 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 Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-04-01
2026-02-27 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 Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-04-01
2026-02-27 Provide safe and appropriate respiratory care for a resident when needed.
F0695 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-04-01
2026-02-27 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-04-01
2026-02-27 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 Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-04-01
2026-02-27 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 Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-04-01
2026-02-27 Implement a program that monitors antibiotic use.
F0881 · Infection Control Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-04-01
2024-11-21 Ensure each resident’s drug regimen must be free from unnecessary drugs.
F0757 · Pharmacy Service Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-12-30
2024-11-21 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-12-30
2024-11-21 Keep residents' personal and medical records private and confidential.
F0583 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-12-30
2024-11-21 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 Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-12-30
2024-11-21 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 Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-12-30
2024-11-21 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-12-30
2024-11-21 Ensure medication error rates are not 5 percent or greater.
F0759 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-12-30
2024-11-21 Ensure that residents are free from significant medication errors.
F0760 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-12-30
2024-11-21 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 Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-12-30
2024-11-21 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-12-30
2023-09-27 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2023-10-31
2023-09-27 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 Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2023-10-31
2023-09-27 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.
F0622 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-10-30
2023-09-27 Ensure each resident receives an accurate assessment.
F0641 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-10-31
2023-09-27 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 Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-10-31
2023-09-27 Provide for the safe, appropriate administration of IV fluids for a resident when needed.
F0694 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-10-31
2023-09-27 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.
F0726 · Nursing and Physician Services Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-10-31
2023-09-27 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-10-31

Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results

Fines & penalties

No federal fines or payment denials in the last three years.

Ownership & management

NameRoleSince
Eastland Memorial Hospital District (organization)5%+ Direct Ownership Interest · 100%
Arze, Steven (individual)Administrator · NOT APPLICABLE
Ensign Services INC (organization)Administrator · NOT APPLICABLE
Grover, Kenneth (individual)Administrator · NOT APPLICABLE
Standard Bearer Healthcare Op, LP (organization)Administrator · NOT APPLICABLE
The Ensign Group INC (organization)Administrator · NOT APPLICABLE
Western Edge Health Holdings LLC (organization)Administrator · NOT APPLICABLE
Burnam, Soon (individual)Corporate Officer · NOT APPLICABLE
Keetch, Chad (individual)Corporate Officer · NOT APPLICABLE
Wright, Laban (individual)Corporate Officer · NOT APPLICABLE
Arze, Steven (individual)Managing Control - Governing Body · NOT APPLICABLE
Grover, Kenneth (individual)Managing Control - Governing Body · NOT APPLICABLE
Buffalo Creek Healthcare LLC (organization)Operational/managerial Control · NOT APPLICABLE
Grover, Kenneth (individual)Operational/managerial Control · NOT APPLICABLE

Frequently asked questions

What is the rating of Windsor Rehabilitation and Healthcare?

Windsor Rehabilitation and Healthcare has a 2-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 2.6-star average in Texas.

How many beds does Windsor Rehabilitation and Healthcare have?

It has 108 certified beds and cares for about 80 residents per day.

Has Windsor Rehabilitation and Healthcare been fined?

CMS lists no federal fines or payment denials in the last three years.

Who owns Windsor Rehabilitation and Healthcare?

It is part of The Ensign Group and is classified as for profit - limited liability company. See the ownership table above for all owners and managers reported to CMS.

What is the phone number of Windsor Rehabilitation and Healthcare?

(972) 551-0122. The facility is located at 250 W. British Flying School Blvd, Terrell, TX 75160.

Other nursing homes in Terrell

Compare all nursing homes in Terrell, TX →

Source: CMS Care Compare, August 2026. Information is provided as published by CMS; verify details directly with the facility.