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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 (19 years)
Capacity106
Residents58
Percent Occupied55%
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 7, 2016 - 9 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
FManyPotential for HarmHealth InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.
FManyPotential for HarmHealth InspectionPrepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
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 InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
ESomePotential for HarmHealth InspectionMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
ESomePotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
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 InspectionKeep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
ESomePotential for HarmHealth InspectionProvide food in a way that meets a resident's needs.

July 22, 2015 - 2 years 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
---Fine$1,800 fine
GFewActual HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

September 19, 2014 - 3 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 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 HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
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 InspectionGive or get quality laboratory services/tests in a timely manner to meet the needs of residents.
ESomePotential for HarmHealth InspectionQuickly tell the resident's doctor the results of laboratory tests.
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 InspectionEnsure that residents are fully informed and understand their health status, care and treatments.
ESomePotential for HarmHealth InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
ESomePotential for HarmHealth InspectionProvide resident groups or resident family groups with private space to meet.

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 5min
2hr 30min
ReportedExpected
CNA
1hr 25min
40min
ReportedExpected
LPN
25min
1hr 10min
ReportedExpected
RN
4hr 55min
4hr 20min
ReportedExpected
Total Nursing

This facility also provides approximately 20min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

96.9%
96.4%
96.4%
96.4%
91.6%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine
50.9%
52.7%
64.9%
88.7%
89.8%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine
45.8%
40.0%
29.2%
40.0%
48.3%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of low risk long-stay residents who lose control of their bowels or bladder
64.0%
61.5%
66.0%
69.6%
27.1%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who received an antianxiety or hypnotic medication
22.0%
35.6%
37.4%
10.8%
20.7%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents whose ability to move independently worsened
32.6%
33.3%
32.6%
27.9%
19.1%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who received an antipsychotic medication
17.8%
21.7%
19.1%
15.6%
19.1%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents whose need for help with daily activities has increased
0.0%
10.0%
20.0%
20.8%
7.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who self-report moderate to severe pain
1.8%
9.3%
9.1%
9.4%
6.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who lose too much weight
5.1%
4.9%
5.6%
5.6%
6.3%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of high risk long-stay residents with pressure ulcers
7.4%
11.3%
11.5%
6.0%
4.9%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who have depressive symptoms
7.3%
7.4%
3.6%
3.8%
4.4%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents with a urinary tract infection
1.8%
1.8%
3.5%
3.8%
3.6%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents experiencing one or more falls with major injury
6.3%
7.2%
5.3%
3.1%
2.7%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents with a catheter inserted and left in their bladder
0.0%
0.0%
0.0%
0.0%
0.4%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who were physically restrained

Quality Measures for Short Stay Residents

10.0%
-
47.6%
71.4%
74.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine
-
-
-
-
71.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine
-
-
-
-
55.7%
Q4 2015Q1 2016Q2 2016Q3 2016TX
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who made improvements in function
-
-
-
18.2%
14.2%
Q4 2015Q1 2016Q2 2016Q3 2016TX
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who self-report moderate to severe pain
-
-
-
-
3.1%
Q4 2015Q1 2016Q2 2016Q3 2016TX
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who newly received an antipsychotic medication
0.0%
-
0.0%
0.0%
1.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents with pressure ulcers that are new or worsened