Nursing home in Lancaster, Texas
Windsor Gardens
Medicare and Medicaid
2535 W PLEASANT RUN, Lancaster, TX 75146
(972) 228-8029
CMS star ratings
CMS gives this nursing home an overall star rating of 2 out of 5. Each rating is compared with the mean of rated nursing homes in Texas (1,165 for the overall rating) and in the U.S. (14,565). How to read an inspection report.
Overall rating
- This nursing home2
- Texas average2.7 (1,165 rated)
- U.S. average3.0 (14,565 rated)
Health inspections
- This nursing home2
- Texas average2.8 (1,165 rated)
- U.S. average2.8 (14,565 rated)
Staffing
- This nursing home1
- Texas average1.9 (1,163 rated)
- U.S. average2.9 (14,494 rated)
Quality measures
- This nursing home5
- Texas average3.7 (1,162 rated)
- U.S. average3.6 (14,495 rated)
Health inspections
Most recent standard health inspection (rating cycle 1): Jan 15, 2026. CMS counts 11 health deficiencies in rating cycle 1.
- This nursing home11
- Texas average9.4 (1,171 with data)
- U.S. average9.2 (14,652 with data)
Rating cycle 1 health deficiencies. Averages include every nursing home with a count in the CMS file; fewer is better.
Deficiencies since Sep 30, 2023
Inspectors cited 27 health deficiencies on 11 inspection dates since Sep 30, 2023. By level of harm: 2 immediate jeopardy, 25 potential for harm.
- 2 Immediate jeopardy to resident health or safety
- 0 Actual harm
- 25 No actual harm, potential for more than minimal harm
- 0 No actual harm, potential for minimal harm
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| Jul 20, 2026 | F0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident Rights Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Jul 21, 2026 |
| Jan 15, 2026 | F0558 | Reasonably accommodate the needs and preferences of each resident.Resident Rights Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Jan 21, 2026 |
| Jan 15, 2026 | F0583 | Keep residents' personal and medical records private and confidential.Resident Rights Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Jan 21, 2026 |
| Jan 15, 2026 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care Planning Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Jan 21, 2026 |
| Jan 15, 2026 | F0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care Planning Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Jan 21, 2026 |
| Jan 15, 2026 | F0761 | 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.Pharmacy Service Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Jan 21, 2026 |
| Jan 15, 2026 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Jan 21, 2026 |
| Jan 15, 2026 | F0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jan 21, 2026 |
| Jan 15, 2026 | F0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jan 21, 2026 |
| Jan 15, 2026 | F0695 | Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jan 21, 2026 |
Show the other 17 deficiencies
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| Dec 8, 2025 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Dec 12, 2025 |
| Aug 23, 2025 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Sep 30, 2025 |
| Aug 23, 2025 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Sep 30, 2025 |
| Aug 23, 2025 | F0694 | Provide for the safe, appropriate administration of IV fluids for a resident when needed.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Sep 30, 2025 |
| May 21, 2025 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and Care Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Jun 23, 2025 |
| May 21, 2025 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Jun 23, 2025 |
| Nov 7, 2024 | F0761 | 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.Pharmacy Service Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Nov 15, 2024 |
| Nov 7, 2024 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Nov 15, 2024 |
| Nov 7, 2024 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Nov 15, 2024 |
| Nov 7, 2024 | F0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident Rights Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Nov 15, 2024 |
| Nov 7, 2024 | F0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Environmental Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Nov 15, 2024 |
| Aug 28, 2024 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Sep 23, 2024 |
| Aug 26, 2024 | F0693 | 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.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Sep 23, 2024 |
| Jun 22, 2024 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care Planning Deficiencies | J Immediate jeopardy, isolated | Complaint | Deficient, Provider has date of correction Jul 19, 2024 |
| Jun 22, 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | J Immediate jeopardy, isolated | Complaint | Deficient, Provider has date of correction Jul 19, 2024 |
| Jun 11, 2024 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Jul 10, 2024 |
| Oct 5, 2023 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Oct 20, 2023 |
Staffing
Total nurse staffing
Reported hours per resident per day.
- This nursing home3.43 hours
- Texas average3.39 hours (1,148 with data)
- U.S. average3.86 hours (14,351 with data)
Registered nurse staffing
Reported hours per resident per day.
- This nursing home0.37 hours
- Texas average0.43 hours (1,148 with data)
- U.S. average0.69 hours (14,351 with data)
Nursing staff turnover
Share of nursing staff who left during the year, as reported to CMS.
- This nursing home55.5%
- Texas average55.3% (1,051 with data)
- U.S. average45.8% (13,538 with data)
Penalties
CMS lists 1 penalty for this nursing home: 1 fine totaling $13,877, and 0 payment denials. CMS counts penalties from the last 3 years.
Facility details
| Certified beds | 150 |
|---|---|
| Average residents per day | 104.3 |
| Ownership | For profit - Corporation |
| Provider type | Medicare and Medicaid |
| Inside a hospital | No |
| Continuing care retirement community | No |
| Resident and family council | Both |
| Automatic sprinklers in all required areas | Yes |
| Chain | Cantex Continuing Care (37 facilities) |
| Legal business name | DALLAS COUNTY HOSPITAL DISTRICT |
| First approved for Medicare and Medicaid | Aug 2, 1989 |
| County | Dallas |
| CMS certification number | 455832 |
Also in Lancaster
| Nursing home | CMS overall rating | Health inspection rating | Certified beds | Ownership |
|---|---|---|---|---|
| Avir at Lancaster | 110 | Government - Federal | ||
| Lancaster Nursing & Rehabilitation | 120 | For profit - Limited Liability company | ||
| Millbrook Healthcare and Rehabilitation Center | 124 | For profit - Limited Liability company |
| Hospital | CMS overall rating | Type | Emergency services |
|---|---|---|---|
| Crescent Medical Center Lancaster | Acute Care Hospitals | Yes |