Public Record
Windsor Rehabilitation and Healthcare
Operated by The Ensign Group
From CMS
Facility profile
- CMS overall rating
- 2 / 5
- Certified beds
- 108
- Avg. residents per day
- 85.7
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Health citations
- 52
- Fire safety findings
- 3
- Inspections on file
- 6
- Last inspection
- 2026-02-27
*CMS
*CMS
*CMS
*CMS
Citations
52 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0849Generalpotential for harm
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.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0805Generalpotential for harm
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
- 0804Generalpotential for harm
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- 0803Generalpotential for harm
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.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0676Generalpotential for harm
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0552Generalpotential for harm
Ensure that residents are fully informed and understand their health status, care and treatments.
- 0761Generalpotential for harm
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.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0693Generalpotential for harm
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.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0921Generalpotential for harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- 0881Generalpotential for harm
Implement a program that monitors antibiotic use.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0583Generalpotential for harm
Keep residents' personal and medical records private and confidential.
- 0655Generalpotential for harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0757Generalpotential for harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0760Generalpotential for harm
Ensure that residents are free from significant medication errors.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0726Generalpotential for harm
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.
- 0694Generalpotential for harm
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
- 0849Generalpotential for harm
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.
- 0622Generalpotential for harm
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.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0804Generalpotential for harm
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- 0761Generalpotential for harm
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.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0676Generalpotential for harm
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0808Generalpotential for harm
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.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0584Generalpotential for harm
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.
- 0576Generalpotential for harm
Ensure residents have reasonable access to and privacy in their use of communication methods.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- View inspection reportInspection21 deficiencies
- View inspection reportInspectionFire Safety2 deficiencies
- Inspection10 deficiencies
F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure each…
Read full statement of deficiencies - Inspection8 deficiencies
F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN…
Read full statement of deficiencies - Inspection13 deficiencies
F 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure residents received their mail promptly for 6 of 14…
Read full statement of deficiencies - View inspection reportInspectionFire Safety1 deficiency
Ownership
The Ensign Group
338nursing homes nationwide, in CMS records
FAQ
Questions and answers
- What is Windsor Rehabilitation and Healthcare?
- Windsor Rehabilitation and Healthcare is a Medicare- and Medicaid-certified nursing home in Terrell, TX, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 675808.
- What is the CMS rating for Windsor Rehabilitation and Healthcare?
- Windsor Rehabilitation and Healthcare has a CMS overall rating of 2 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Windsor Rehabilitation and Healthcare have?
- Windsor Rehabilitation and Healthcare is certified for 108 beds. It serves an average of 85.7 residents per day.
- How many citations does Windsor Rehabilitation and Healthcare have?
- Windsor Rehabilitation and Healthcare has 52 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Windsor Rehabilitation and Healthcare last inspected?
- Windsor Rehabilitation and Healthcare was last inspected on February 27, 2026. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
/nursing-home/675808-windsor-rehabilitation-and-healthcare