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Nursing HomeMedicaid Investigative

Windsor Rehabilitation and Healthcare

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

250 W. British Flying School Blvd, Terrell, TX 75160108 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
4.4/5

based on 111 Google reviews

5
4
3
2
1

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4/ 10
moderate Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low staffing rating (2/5 stars)
  • Above-median deficiencies (10 vs median 8.0)
  • High staff turnover (53%)
  • High RN turnover (60%)

Top 10% in Texas · Critically understaffed (RN) · Best in THE ENSIGN GROUP chain · No penalties on record

Source: Medicare data

What this means for your family

This facility offers an excellent rehabilitation program and a very clean, pleasant environment that many families find comforting. However, you must be extremely vigilant regarding wound care and night-shift staffing, as multiple families have reported life-threatening neglect and pressure ulcers. If you choose this facility, establish a frequent visiting schedule to personally monitor skin integrity and medication administration.

Google Reviews

Google Reviews

111 reviews analyzed
Windsor Rehabilitation and Healthcare is highly regarded by many families for its exceptional therapy team and a warm, home-like atmosphere. However, there are extremely serious allegations regarding medical neglect, including reports of severe pressure ulcers and inadequate staffing during night shifts. Families should weigh the frequent praise for rehabilitation success against the critical reports of life-threatening lapses in care.

Quality Themes

Tap a score for details
Food7.0Staff8.0Clean9.0Activities9.0Meds3.0MemoryN/AComms5.0ValueN/A

Strengths

  • Exceptional physical therapy and rehab services
  • Clean and well-maintained facility
  • Compassionate and friendly nursing staff
  • Welcoming, home-like environment

Concerns

  • Severe medical neglect and pressure ulcers (mentioned by 2 reviewers)
  • Inadequate staffing levels, particularly at night (mentioned by 2 reviewers)
  • Poor communication regarding medical updates or results (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

234'16(3)'18(4)'20(4)'23(4)'25(14)'26(36)

Distribution

5
66
4
1
3
2
2
0
1
16
19 reviews posted between Apr 13, 2026Apr 18, 2026 · 16 were 5-star

How They Respond to Reviews

100%response rate
Good

Responds to almost all reviews with personalized messages that mirror the specific praise found in the review. Addresses negative feedback with empathy and a commitment to resolution or corrective action.

Questions for Your Tour

  • 1We've heard wonderful things about the physical therapy and rehab services here; could you tell us more about how the therapy team works with residents to reach their goals?
  • 2It's great to see how much you value feedback from the community; how does the management team typically use resident and family input to make improvements?
  • 3How do you ensure that medication is administered accurately and that there is a clear system in place for tracking any changes in a resident's prescriptions?
  • 4What is the protocol for communicating important medical updates or test results to family members, especially during the overnight hours?
  • 5How does the nursing team monitor skin integrity and prevent issues like pressure ulcers during routine care?
  • 6What kind of daily activities or social events are organized to help residents enjoy that home-like environment you've created?

Personalized based on this facility's data


Key Review Excerpts

Windsor is a great facility with a fantastic therapy team who really care and are committed to helping patients achieve their goals.

Rehab patient's family · 2026★★★★★

This place is responsible for my mother’s death. She was eating and rehabilitating in December and in January she was gone. Stage 4 bed ulcer and sepsis due to inadequate turning and failure to recognize signs of a severe infection.

Long-term resident's family · 2026☆☆☆☆

The staff here is happy… and that translates into better care for the patients. Kudos to the administration for taking good care of their employee

Physician visitor · 2023★★★★★
Source: 111 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.23hrs
30%
Registered nurses for medical care
Total Nursing
3.45hrs
84%
All nurses + aides combined
Staff Turnover
51%
Lower is better (< 30% = good)
RN Turnover
50%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 34 measures

Medicare Rating
4/ 5
Better Than Avg

22

measures

Worse Than Avg

4

measures

Mixed Results

8

measures

Long-Stay Residents
🚶

Residents whose walking got worse

↓ Lower is better
This Facility42.2%
Worse than Avg
Here
42.2%
US
15.3%
TX
14.9%
Kaufman
14.2%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility42.2%
Worse than Avg
Here
42.2%
US
15.3%
TX
14.9%
Kaufman
14.2%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility28.1%
Worse than Avg
Here
28.1%
US
14.4%
TX
16.1%
Kaufman
14.2%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility28.1%
Worse than Avg
Here
28.1%
US
14.4%
TX
16.1%
Kaufman
14.2%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility4.1%
Better than Avg
Here
4.1%
US
15.4%
TX
9.4%
Kaufman
6.9%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility4.1%
Better than Avg
Here
4.1%
US
15.4%
TX
9.4%
Kaufman
6.9%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility99.5%
Better than Avg
Here
99.5%
US
81.8%
TX
89.2%
Kaufman
84.1%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility99.5%
Better than Avg
Here
99.5%
US
81.8%
TX
89.2%
Kaufman
84.1%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility84.0%
Mixed vs Avgs
Here
84.0%
US
79.7%
TX
88.0%
Kaufman
78.9%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility84.0%
Mixed vs Avgs
Here
84.0%
US
79.7%
TX
88.0%
Kaufman
78.9%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.7%
Better than Avg
Here
0.7%
US
1.6%
TX
1.5%
Kaufman
0.7%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.7%
Better than Avg
Here
0.7%
US
1.6%
TX
1.5%
Kaufman
0.7%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

21deficiencies
Well above state avg (9.1)
15 complaint-triggered

This facility has concerning patterns with families filing complaints that triggered inspections, resulting in 7 complaint-related deficiencies. The most recurring problem areas are medication management, care planning and assessments, and infection control, which appear repeatedly across all three surveys from 2022 to 2024. While all deficiencies show correction dates, the persistence of issues in medication safety and care planning across multiple years suggests ongoing operational challenges families should carefully consider.

Feb 27, 2026Routine
20
0656ModerateCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0689ModerateCorrected

Quality of Life and Care Deficiencies

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

0692ModerateCorrected

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

0803ModerateCorrected

Nutrition and Dietary Deficiencies

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.

0804ModerateCorrected

Nutrition and Dietary Deficiencies

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

0805ModerateCorrected

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

0812ModerateCorrected

Nutrition and Dietary Deficiencies

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

0880ModerateCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0921ModerateCorrected

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

0552MinorCorrected

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

0641MinorCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0676MinorCorrected

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

0677MinorCorrected

Quality of Life and Care Deficiencies

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

0684MinorCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0690MinorCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

0693MinorCorrected

Quality of Life and Care Deficiencies

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.

0695MinorCorrected

Quality of Life and Care Deficiencies

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

0761MinorCorrected

Pharmacy Service Deficiencies

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.

0849MinorCorrected

Administration Deficiencies

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.

0881MinorCorrected

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Feb 27, 2026Complaint
1
0755MinorCorrected

Pharmacy Service Deficiencies

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

Nov 21, 2024Routine
14
0757ModerateCorrected

Pharmacy Service Deficiencies

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

0812ModerateCorrected

Nutrition and Dietary Deficiencies

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

0351ModerateCorrected

Smoke Deficiencies

Install an approved automatic sprinkler system.

0353ModerateCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0757ModerateCorrected

Pharmacy Service Deficiencies

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

0812ModerateCorrected

Nutrition and Dietary Deficiencies

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

0351ModerateCorrected

Smoke Deficiencies

Install an approved automatic sprinkler system.

0353ModerateCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0583MinorCorrected

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

0655MinorCorrected

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

0759MinorCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0583MinorCorrected

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

0655MinorCorrected

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

0759MinorCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Nov 21, 2024Complaint
10
0657MinorCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0755MinorCorrected

Pharmacy Service Deficiencies

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

0760MinorCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0842MinorCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

0880MinorCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0657MinorCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0755MinorCorrected

Pharmacy Service Deficiencies

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

0760MinorCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0842MinorCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

0880MinorCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Sep 27, 2023Routine
12
0849ModerateCorrected

Administration Deficiencies

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.

0849ModerateCorrected

Administration Deficiencies

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.

0622MinorCorrected

Resident Rights Deficiencies

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.

0641MinorCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0656MinorCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0694MinorCorrected

Quality of Life and Care Deficiencies

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

0726MinorCorrected

Nursing and Physician Services Deficiencies

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.

0622MinorCorrected

Resident Rights Deficiencies

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.

0641MinorCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0656MinorCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0694MinorCorrected

Quality of Life and Care Deficiencies

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

0726MinorCorrected

Nursing and Physician Services Deficiencies

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.

Sep 27, 2023Complaint
4
0755ModerateCorrected

Pharmacy Service Deficiencies

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

0755ModerateCorrected

Pharmacy Service Deficiencies

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

0880MinorCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0880MinorCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Ownership & Operations

Who Operates This Facility

Owner / Operator

Eastland Memorial Hospital District

Organization Type

for profit

Management Company

NA

Administrator

JAMES MIXON

Chain Affiliation

Chain Name

The Ensign Group

Chain Size

338 facilities nationwide

Chain avg rating: 2.9/5 · Rank 4 of 84 (Best)

Ownership & Management

Owners

Eastland Memorial Hospital District

Owner · Organization

100%

Key personnel

Arze, StevenManaging Control - Governing BodyGrover, KennethManaging Control - Governing BodyBurnam, SoonOfficer / DirectorKeetch, ChadOfficer / DirectorWright, LabanOfficer / Director
Source: Medicare provider data

Contact

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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