WINDSOR GARDENS
2535 W PLEASANT RUN, LANCASTER, TX 75146 · CCN 455832
Ratings
- Overall
- ★★★☆☆ 3
- Health inspection
- ★★★☆☆ 3
- Quality measures
- ★★★★★ 5
- Staffing
- ★☆☆☆☆ 1
Facility
- Ownership type
- For profit - Corporation
- Certified beds
- 150
- Avg residents/day
- 99.1
- Phone
- 9722288029
Inspection history vs Texas & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Texas avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2024-11-07 | 11 | 9.1 | 9.5 | +1.9 worse |
| 2 | 2023-10-05 | 6 | 9.4 | 9.8 | -3.4 better |
| 3 | 2022-08-17 | 2 | 8.1 | 9.3 | -6.1 better |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Quality of life and care | 3 |
| Resident assessment and care planning | 2 |
| Resident rights | 1 |
| Nutrition and dietary | 1 |
| Pharmacy service | 2 |
| Environmental | 1 |
| Infection control | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 3.41 | 53.5% |
| RN staffing (reported) | 0.35 | 53.3% |
| Total nurse staffing (adjusted) | 3.36 | — |
Fines & penalties
- Total fines
- $13,877
- Number of fines
- 1
- Number of penalties
- 1
- Payment denials
- 0
Chain
- Chain
- CANTEX CONTINUING CARE
- Facilities in chain
- 38
- Chain avg overall
- 3.10 / 5
Inspection citations (19)2 immediate jeopardy
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2025-12-08 · Health · corrected 2025-12-12
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-08-23 · Health · corrected 2025-09-30
Potential for more than minimal harm
- DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-08-23 · Health · corrected 2025-09-30
Potential for more than minimal harm
- DF0694Provide for the safe, appropriate administration of IV fluids for a resident when needed.2025-08-23 · Health · corrected 2025-09-30
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-05-21 · Health · corrected 2025-06-23
Potential for more than minimal harm
- EF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2025-05-21 · Health · corrected 2025-06-23
Potential for more than minimal harm
- DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2024-11-07 · Health · corrected 2024-11-15
Potential for more than minimal harm
- EF0761Ensure 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.2024-11-07 · Health · corrected 2024-11-15
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2024-11-07 · Health · corrected 2024-11-15
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2024-11-07 · Health · corrected 2024-11-15
Potential for more than minimal harm
- DF0921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.2024-11-07 · Health · corrected 2024-11-15
Potential for more than minimal harm
- DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2024-08-28 · Health · corrected 2024-09-23
Potential for more than minimal harm
- DF0693Ensure 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.2024-08-26 · Health · corrected 2024-09-23
Potential for more than minimal harm
- JF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-06-22 · Health · corrected 2024-07-19
Immediate jeopardy
- JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-06-22 · Health · corrected 2024-07-19
Immediate jeopardy
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2024-06-11 · Health · corrected 2024-07-10
Potential for more than minimal harm
- DF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2023-10-05 · Health · corrected 2023-10-20
Potential for more than minimal harm
- DF0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted2023-07-14 · Health · corrected 2023-08-29
Potential for more than minimal harm
- DF0694Provide for the safe, appropriate administration of IV fluids for a resident when needed.2022-08-17 · Health · corrected 2022-08-20
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| DALLAS COUNTY HOSPITAL DISTRICT | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2015-02-15 |
| WINDSOR PLACE HEALTH CARE CENTER LTD CO | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2015-02-15 |
| JOHNSON, NIKITA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2023-01-10 |
| CASTANEDA, EDMUNDO | Individual | CORPORATE OFFICER | — | 2022-01-10 |
| CERISE, FREDERICK | Individual | CORPORATE OFFICER | — | 2014-03-24 |
Other facilities in LANCASTER
| Name | Overall | Beds |
|---|
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.