Nursing homeActive
Windsor Gardens
2535 W Pleasant Run, Lancaster, TX 751469722288029150 certified beds · 104 residentsFor profit - CorporationMedicare and Medicaid
Surveys on file
10
since 2023
Deficiencies
26
● 0● 24● 2
Penalties · 3 yrs
$13,877
1 fine
Last survey
2026-01-15
Standard
CMS overall
2 / 5
stars as published by CMS
CMS overall 2/5
Health 2
Staffing 1
Quality 5
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Texas Health and Human Services Commission · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-01-15 | Standard | 090 | CMS-2567 (Care Compare) | — |
| 2025-12-08 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-08-23 | Complaint | 030 | CMS-2567 (Care Compare) | — |
| 2025-05-21 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2024-11-07 | Standard | 050 | CMS-2567 (Care Compare) | — |
| 2024-08-28 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-08-26 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-06-22 | Complaint | 002 | CMS-2567 (Care Compare) | — |
| 2024-06-11 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2023-10-05 | Standard | 010 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Texas Health and Human Services Commission publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-01-21Record 455832-20260115-F558
F583Keep residents' personal and medical records private and confidential.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-01-21Record 455832-20260115-F583
F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-21Record 455832-20260115-F655
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-01-21Record 455832-20260115-F656
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-01-21Record 455832-20260115-F657
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-21Record 455832-20260115-F690
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-21Record 455832-20260115-F695
F761Ensure 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.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-01-21Record 455832-20260115-F761
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-01-21Record 455832-20260115-F880
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-12Record 455832-20251208-F755
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-09-30Record 455832-20250823-F656
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-09-30Record 455832-20250823-F684
F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-09-30Record 455832-20250823-F694
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-23Record 455832-20250521-F656
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-06-23Record 455832-20250521-F686
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-15Record 455832-20241107-F550
F761Ensure 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.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-15Record 455832-20241107-F761
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-15Record 455832-20241107-F812
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-15Record 455832-20241107-F880
F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-15Record 455832-20241107-F921
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-23Record 455832-20240828-F842
F693Ensure 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.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-23Record 455832-20240826-F693
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity JHarm
Care planningRecords
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-07-19Record 455832-20240622-F656
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity JHarm
Care planningFalls
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-07-19Record 455832-20240622-F689
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-10Record 455832-20240611-F755
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-20Record 455832-20231005-F812
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2024-06-11 | Civil money penalty | $13,877 | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.37
Facility
Texas
National
Texas 0.43 · National 0.69
Total nurse hours per resident day3.43
Facility
Texas
National
Texas 3.39 · National 3.86
Weekend total nurse hours2.86
Facility
Texas
National
Texas 2.98 · National 3.42
Total nursing staff turnover56%
Facility
Texas
National
Texas 55% · National 46%
Registered nurse turnover57%
Facility
Texas
National
Texas 55% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Texas | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 1.0% | 3.8% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 0.0% | 3.3% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 2.7% | 9.6% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 0.0% | 0.8% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 17.7% | 15.8% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 0.0% | 3.0% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 4.1% | 18.0% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Dallas County Hospital District Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | — | — |
| Johnson, Nikita Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Windsor Place Health Care Center Ltd Co Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Castaneda, Edmundo Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Cerise, Frederick Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Johnson, Nikita Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Mcfalls, Lashonda Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Windsor Place Health Care Center Ltd Co Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
Part of a chain
Cantex Continuing Care — 37 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Texas.
No county cost figures on file for Dallas.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Millbrook Healthcare and Rehabilitation Center Lancaster | 0.8 mi | 2026-04-23 | 0261 |
| Avir at Lancaster Lancaster | 2.5 mi | 2026-06-30 | 0254 |
| Desoto Nursing & Rehabilitation Center Desoto | 2.7 mi | 2026-05-20 | 0171 |
| Lancaster Nursing & Rehabilitation Lancaster | 2.7 mi | 2026-03-06 | 2273 |
| Five Points Nursing and Rehabilitation Desoto | 3.1 mi | 2026-03-13 | 0210 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |