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Windsor Gardens
2535 W Pleasant Run, Lancaster, TX 75146 · CMS Certification Number (CCN) 455832
At a glance
- CMS overall rating
- ★★☆☆☆ 2 of 5
- Health inspection citations
- 27 in the last 3 inspection cycles (2 immediate jeopardy, 0 actual harm, 15 from complaints)
- Fire safety citations
- 7
- Fines (last 3 years)
- 1 fine, total $13,877
- Payment denials
- 0
- Most recent standard inspection
- January 15, 2026
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★★☆☆☆ 2 of 5 | 2.7 | 3 |
| Health inspections | ★★☆☆☆ 2 of 5 | 2.8 | 2.8 |
| Staffing | ★☆☆☆☆ 1 of 5 | 1.9 | 2.9 |
| Quality measures | ★★★★★ 5 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★★★ 5 of 5 | Not published | Not published |
| Short-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | January 15, 2026 | 11 | 9 | 2 |
| Cycle 2 | November 7, 2024 | 16 | 5 | 13 |
CMS weighted health inspection score: 103.25 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
27 health citations across 11 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
July 20, 2026: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 07/21/2026 |
January 15, 2026: 9 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/21/2026 |
| E | F-0761 | 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 | Standard | Deficient, Provider has date of correction Corrected 01/21/2026 |
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/21/2026 |
| D | F-0690 | 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 | Standard | Deficient, Provider has date of correction Corrected 01/21/2026 |
| E | F-0657 | 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 | Standard | Deficient, Provider has date of correction Corrected 01/21/2026 |
| E | F-0656 | 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 | Standard | Deficient, Provider has date of correction Corrected 01/21/2026 |
| D | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/21/2026 |
| E | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/21/2026 |
| E | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/21/2026 |
December 8, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 12/12/2025 |
August 23, 2025: 3 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0694 | Provide for the safe, appropriate administration of IV fluids for a resident when needed. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 09/30/2025 |
| D | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 09/30/2025 |
| D | F-0656 | 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 | Complaint | Deficient, Provider has date of correction Corrected 09/30/2025 |
May 21, 2025: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 06/23/2025 |
| D | F-0656 | 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 | Complaint | Deficient, Provider has date of correction Corrected 06/23/2025 |
November 7, 2024: 5 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies | Standard | Deficient, Provider has date of correction Corrected 11/15/2024 |
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 11/15/2024 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 11/15/2024 |
| E | F-0761 | 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 | Standard | Deficient, Provider has date of correction Corrected 11/15/2024 |
| D | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 11/15/2024 |
August 28, 2024: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0842 | 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 | Complaint | Deficient, Provider has date of correction Corrected 09/23/2024 |
August 26, 2024: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0693 | 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 | Complaint | Deficient, Provider has date of correction Corrected 09/23/2024 |
June 22, 2024: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| J | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 07/19/2024 |
| J | F-0656 | 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 | Complaint | Deficient, Provider has date of correction Corrected 07/19/2024 |
June 11, 2024: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 07/10/2024 |
October 5, 2023: 1 citation (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 10/20/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
7 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 01/15/2026 | E | K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 02/22/2026 |
| 11/07/2024 | F | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 11/13/2024 |
| 10/05/2023 | F | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies | Deficient, Provider has date of correction Corrected 10/06/2023 |
| 10/05/2023 | F | K-0352 | Properly install and monitor supervisory attachments on automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 10/06/2023 |
| 10/05/2023 | E | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 10/24/2023 |
| 10/05/2023 | F | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 10/06/2023 |
| 10/05/2023 | E | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies | Deficient, Provider has date of correction Corrected 11/01/2023 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| June 11, 2024 | Fine | $13,877 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.43 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.37 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 1.16 | Not published | Not published |
| Nurse aide hours per resident per day | 1.91 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 2.86 | Not published | Not published |
| RN hours per resident per day, weekends | 0.27 | Not published | Not published |
| Total nursing staff turnover (%) | 55.5 | 55.3 | 45.8 |
| Registered nurse turnover (%) | 57.1 | Not published | Not published |
| Administrators who have left | 0 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Dallas County Hospital District
- Ownership type
- For profit - Corporation
- Chain
- Cantex Continuing Care (37 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 150
- Average residents per day
- 104.3
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Both
- First approved for Medicare/Medicaid
- August 2, 1989
- County/parish
- Dallas
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
8 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| DALLAS COUNTY HOSPITAL DISTRICT | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 100% | undefined undefined, NaN |
| CASTANEDA, EDMUNDO | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CERISE, FREDERICK | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WINDSOR PLACE HEALTH CARE CENTER LTD CO | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| JOHNSON, NIKITA | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WINDSOR PLACE HEALTH CARE CENTER LTD CO | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| JOHNSON, NIKITA | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCFALLS, LASHONDA | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Windsor Gardens. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.