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Windsor Place

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About Windsor Place

General Information

Legal Business NameJ. Jireh, LLC
Ownership TypeFor Profit - Partnership
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareJuly 7, 1998 (18 years)
Capacity106
Residents56
Percent Occupied53%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsResident
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Windsor Place

Windsor Place
was reviewed by Medicare to have a rating of 1 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Texas Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

July 29, 2015 - 17 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionWalls that prevent smoke from passing through and would resist fire for at least one hour.
FManyPotential for HarmFire Safety InspectionPosted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
ESomePotential for HarmFire Safety InspectionExits that are accessible at all times.
CManyPotential for Minimal HarmFire Safety InspectionProper medical gas storage and administration areas.
CManyPotential for Minimal HarmFire Safety InspectionCorridor and hallway doors that block smoke.
CManyPotential for Minimal HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.

July 22, 2015 - 17 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionAllow residents to easily view the results of the nursing home's most recent inspection.
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
FManyPotential for HarmComplaint+InspectionKeep residents' personal and medical records private and confidential.
FManyPotential for HarmComplaint+InspectionHave a program that investigates, controls and keeps infection from spreading.
FManyPotential for HarmComplaint+InspectionHave a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents.
ESomePotential for HarmHealth InspectionMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
ESomePotential for HarmHealth InspectionProvide food in a way that meets a resident's needs.
ESomePotential for HarmHealth InspectionPrepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
ESomePotential for HarmHealth InspectionMake sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed.
CManyPotential for Minimal HarmHealth InspectionPost nurse staffing information/data on a daily basis.

February 21, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
GFewActual HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

September 19, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
ESomePotential for HarmComplaint1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

May 22, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
FManyPotential for HarmHealth InspectionMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
FManyPotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
FManyPotential for HarmFire Safety InspectionWeekly inspections and monthly testing of generators.
FManyPotential for HarmFire Safety InspectionProperly working alarms on sprinkler valves.
FManyPotential for HarmFire Safety InspectionOther fire safety features required by fire safety codes.
FManyPotential for HarmFire Safety InspectionWalls that prevent smoke from passing through and would resist fire for at least one hour.
ESomePotential for HarmHealth InspectionQuickly tell the resident's doctor the results of laboratory tests.
ESomePotential for HarmHealth InspectionGive or get quality laboratory services/tests in a timely manner to meet the needs of residents.
ESomePotential for HarmHealth InspectionMake sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.
ESomePotential for HarmHealth InspectionProvide resident groups or resident family groups with private space to meet.
ESomePotential for HarmHealth InspectionEnsure that residents are fully informed and understand their health status, care and treatments.
ESomePotential for HarmHealth InspectionProvide residents with private access to a telephone.
ESomePotential for HarmHealth InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
ESomePotential for HarmHealth InspectionEnsure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
ESomePotential for HarmHealth InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.

October 29, 2013 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$1,170 fine

June 5, 2013 - 4 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$1,800 fine
---Fine$2,009 fine

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Windsor Place require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

3hr 25min
2hr 25min
ReportedExpected
CNA
55min
35min
ReportedExpected
LPN
25min
55min
ReportedExpected
RN
4hr 45min
3hr 60min
ReportedExpected
Total Nursing

This facility also provides approximately 15min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

98.2%
96.9%
96.9%
90.7%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Seasonal Influenza Vaccine
58.9%
54.4%
55.2%
87.9%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Pneumococcal Vaccine
-
-
-
46.9%
Q1 2015Q2 2015Q3 2015TX
* The data for this facility for some quarters is unavailable.
Low Risk Residents Who Lose Control of Their Bowel or Bladder
41.3%
43.5%
36.2%
22.3%
Q1 2015Q2 2015Q3 2015TX
Received an Antipsychotic Medication
13.6%
28.3%
25.6%
19.6%
Q1 2015Q2 2015Q3 2015TX
Need for Help with ADLs has Increased
-
-
0.0%
8.8%
Q1 2015Q2 2015Q3 2015TX
* The data for this facility for some quarters is unavailable.
Self Report Moderate to Severe Pain
0.0%
0.0%
0.0%
6.3%
Q1 2015Q2 2015Q3 2015TX
Lose Too Much Weight
4.9%
7.3%
4.9%
6.6%
Q1 2015Q2 2015Q3 2015TX
High Risk Residents With Pressure Ulcers
17.6%
15.7%
5.7%
6.1%
Q1 2015Q2 2015Q3 2015TX
Have Depressive Symptoms
14.3%
10.7%
5.3%
5.1%
Q1 2015Q2 2015Q3 2015TX
With a Urinary Tract Infection
0.0%
0.0%
0.0%
3.5%
Q1 2015Q2 2015Q3 2015TX
Experiencing One or More Falls with Major Injury
2.8%
6.8%
3.8%
3.3%
Q1 2015Q2 2015Q3 2015TX
With a Catheter Inserted and Left in Their Bladder
0.0%
0.0%
0.0%
0.6%
Q1 2015Q2 2015Q3 2015TX
Were Physically Restrained

Quality Measures for Short Stay Residents

-
5.0%
-
71.4%
Q1 2015Q2 2015Q3 2015TX
* The data for this facility for some quarters is unavailable.
Assessed and Appropriately Given the Pneumococcal Vaccine
-
-
-
71.1%
Q1 2015Q2 2015Q3 2015TX
* The data for this facility for some quarters is unavailable.
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
-
-
-
16.5%
Q1 2015Q2 2015Q3 2015TX
* The data for this facility for some quarters is unavailable.
Self Report Moderate to Severe Pain
-
-
-
3.2%
Q1 2015Q2 2015Q3 2015TX
* The data for this facility for some quarters is unavailable.
Newly Received an Antipsychotic Medication
-
4.3%
-
1.0%
Q1 2015Q2 2015Q3 2015TX
* The data for this facility for some quarters is unavailable.
With Pressure Ulcers That Are New or Worsened