For profit - Corporation · 150 certified beds · CMS number 455832
Windsor Gardens, Lancaster, TX
CMS records 27 health deficiencies at Windsor Gardens in Lancaster, Texas in its last 3 inspection cycles; the Texas median is 25. Its most recent standard inspection was on Jan 15, 2026. The highest severity cited is J (immediate jeopardy to resident health or safety). 2 citations were at the immediate jeopardy level. CMS lists 1 fine totaling $13,877 in the last three years.
- 27deficiencies, 3 cycles (TX median 25)
- 11in the latest cycle (TX median 8)
- Jhighest severity · Immediate jeopardy
- $13,877fines, last 3 years
- 2CMS overall rating (of 5)
Inspections and deficiencies
CMS findings for Windsor Gardens as of Sep 1, 2026, grouped by inspection cycle (3 cycles); each is a requirement inspectors found not met, and Windsor Gardens may since have corrected or disputed it. Severity letters · Inspection cycles · Care Compare
Most recent cycle (11 deficiencies)
Standard inspection Jan 15, 2026. CMS counts 11 health deficiencies and 1 fire safety deficiency in this cycle.
Jul 20, 2026 · Complaint inspection
1 deficiency, highest E
F550 · Dignity and the right to exercise rights
Requirement cited (CMS): Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jul 21, 2026
Jan 15, 2026 · Standard inspection
9 deficiencies, highest E
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jan 21, 2026
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jan 21, 2026
F695 · Respiratory and oxygen care
Requirement cited (CMS): Provide safe and appropriate respiratory care for a resident when needed.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 21, 2026
F690 · Bladder, bowel, and catheter care
Requirement cited (CMS): Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 21, 2026
F657 · Care plan timing and team review
Requirement cited (CMS): Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jan 21, 2026
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jan 21, 2026
F655 · Baseline care plan within 48 hours
Requirement cited (CMS): Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 21, 2026
F583 · Personal privacy and confidential records
Requirement cited (CMS): Keep residents' personal and medical records private and confidential.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jan 21, 2026
F558 · Accommodating individual needs and preferences
Requirement cited (CMS): Reasonably accommodate the needs and preferences of each resident.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jan 21, 2026
Dec 8, 2025 · Complaint inspection
1 deficiency, highest D
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 12, 2025
Previous cycle: 10 deficiencies (standard inspection Nov 7, 2024)
Standard inspection Nov 7, 2024. CMS counts 10 health deficiencies and 1 fire safety deficiency in this cycle.
Aug 23, 2025 · Complaint inspection
3 deficiencies, highest D
F694 · IV fluid administration
Requirement cited (CMS): Provide for the safe, appropriate administration of IV fluids for a resident when needed.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 30, 2025
F684 · Quality of care
Requirement cited (CMS): Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 30, 2025
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 30, 2025
May 21, 2025 · Complaint inspection
2 deficiencies, highest E
F686 · Pressure ulcer prevention and care
Requirement cited (CMS): Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jun 23, 2025
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jun 23, 2025
Nov 7, 2024 · Standard + complaint inspection
5 deficiencies, highest E
F921 · Safe, functional, sanitary building
Requirement cited (CMS): Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Nov 15, 2024
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Nov 15, 2024
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Nov 15, 2024
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Nov 15, 2024
F550 · Dignity and the right to exercise rights
Requirement cited (CMS): Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Nov 15, 2024
Earlier cycle: 6 deficiencies (standard inspection Oct 5, 2023)
Standard inspection Oct 5, 2023. CMS counts 6 health deficiencies and 5 fire safety deficiencies in this cycle.
Aug 28, 2024 · Complaint inspection
1 deficiency, highest D
F842 · Complete, confidential medical records
Requirement cited (CMS): Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 23, 2024
Aug 26, 2024 · Complaint inspection
1 deficiency, highest D
F693 · Feeding tube use and care
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 23, 2024
Jun 22, 2024 · Complaint inspection
2 deficiencies, highest J
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Correction date Jul 19, 2024
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Correction date Jul 19, 2024
Jun 11, 2024 · Complaint inspection
1 deficiency, highest D
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jul 10, 2024
Oct 5, 2023 · Standard + complaint inspection
1 deficiency, highest D
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 20, 2023
Tags cited in more than one inspection
6 tags cited on more than one inspection date at Windsor Gardens; each date counts once and does not mean the same incident. PNC = past non-compliance.
| Tag | Inspections | Dates |
|---|---|---|
| F656 Comprehensive person-centered care plan | 4 | Jan 15, 2026; Aug 23, 2025; May 21, 2025; Jun 22, 2024 |
| F550 Dignity and the right to exercise rights | 2 | Jul 20, 2026; Nov 7, 2024 |
| F755 Pharmacy services and a consultant pharmacist | 2 | Dec 8, 2025; Jun 11, 2024 |
| F761 Drug labeling and secure storage | 2 | Jan 15, 2026; Nov 7, 2024 |
| F812 Food safety and sanitation | 2 | Nov 7, 2024; Oct 5, 2023 |
| F880 Infection prevention and control program | 2 | Jan 15, 2026; Nov 7, 2024 |
Fines and payment denials
| Date | Type | Amount / length |
|---|---|---|
| Jun 11, 2024 | Fine | $13,877 |
Staffing and CMS ratings
- Total nurse staff hours per resident per day
- 3.43 h (above the Texas median of 3.27 h)
- RN hours per resident per day
- 0.37 h (about the same as the Texas median of 0.38 h)
- Weekend nurse staff hours per resident per day
- 2.86 h
- Nursing staff turnover
- 55.5% (Texas median 52.1%)
- Administrators who left
- 0
- CMS overall rating
- 2 of 5
- Health inspection rating
- 2 of 5
- Staffing rating
- 1 of 5
- Quality measure rating
- 5 of 5
CMS figures for Windsor Gardens, copied as published; Texas medians are ours.
Facility details
- Address
- 2535 W Pleasant Run, Lancaster, TX 75146
- Phone
- (972) 228-8029
- County
- Dallas
- Accepts
- Medicare and Medicaid
- Ownership
- For profit - Corporation
- Chain (CMS)
- Cantex Continuing Care
- Certified beds
- 150
- Average residents per day
- 104.3
- In Medicare/Medicaid since
- Aug 2, 1989
- Inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Both
- Sprinklers in all required areas
- Yes
Questions to ask on a visit
Based on the tags cited most often here.
- How are a resident's goals and preferences written into the care plan? (F656, cited 4 times)
- How do staff learn about and respect each resident's personal routines and choices? (F550, cited 2 times)
- How are new medication orders filled, and how quickly can urgent medications arrive? (F755, cited 2 times)
- How are medications stored and secured on each unit? (F761, cited 2 times)
Other nursing homes in Lancaster and the same chain
- Lancaster Nursing & Rehabilitation
Lancaster · 32 deficiencies - Avir at Lancaster
Lancaster · 31 deficiencies - Millbrook Healthcare and Rehabilitation Center
Lancaster · 27 deficiencies - Sorrento
San Antonio · 50 deficiencies - The Crescent
Sugar Land · 43 deficiencies - Park Valley Inn Health Center
Round Rock · 42 deficiencies - The Colonnades at Reflection Bay
Pearland · 42 deficiencies
Source
CMS Provider Data Catalog: Provider Information, Health Deficiencies, Penalties, Survey Summary. Processed by CMS Sep 1, 2026; next update Oct 28, 2026.