nursing home in Lancaster, TX
Windsor Gardens
2535 W Pleasant Run, Lancaster, TX 75146 · (972) 228-8029
★★★★★2
Below average
CMS overall star rating
CMS overall star rating
- Health inspections★★★★★2
- Staffing★★★★★1
- Quality measures★★★★★5
Source: Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. We refresh our information from this source. About our data
Windsor Gardens at a glance
Windsor Gardens is a 150-bed for-profit nursing home in Lancaster, Texas (Dallas County).
CMS gives it 2 out of 5 stars on its overall star rating, worse than the Texas average of 2.7.
Residents receive about 3.4 hours of nursing care per day (0.4 of them from registered nurses), close to the state average of 3.4 hours.
Its most recent standard health inspection (January 15, 2026) found 11 health citations. The Texas average is 9.4.
Federal regulators fined it 1 time in the past three years, totaling $13,877.
Nursing staff turnover is 55.5% per year (state average 55.3%).
Facility details
- Type
- Nursing home
- Ownership
- For Profit - Corporation
- Beds
- 150
- Certified for
- Medicare and Medicaid
- Chain / affiliated entity
- Cantex Continuing Care
- Medicare-certified since
- August 2, 1989
- Resident/family council
- Both
- County
- Dallas County
- CMS Certification Number
- 455832
Ratings
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Overall star rating ⓘ (higher is better) | 2 / 5 | 2.7 / 5 | 3 / 5 | Worse |
| Health inspection rating ⓘ (higher is better) | 2 / 5 | 2.8 / 5 | 2.8 / 5 | Worse |
| Staffing rating ⓘ (higher is better) | 1 / 5 | 1.9 / 5 | 2.9 / 5 | Worse |
| Quality measures rating ⓘ (higher is better) | 5 / 5 | 3.7 / 5 | 3.6 / 5 | Better |
| Long-stay quality rating (higher is better) | 5 / 5 | 4 / 5 | 3.8 / 5 | Better |
| Short-stay (rehab) quality rating (higher is better) | 4 / 5 | 3.2 / 5 | 3.3 / 5 | Better |
Staffing
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Total nurse staff hours per resident per day ⓘ (higher is better) | 3.43 hrs | 3.39 hrs | 3.86 hrs | Worse |
| Registered nurse hours per resident per day (higher is better) | 0.37 hrs | 0.43 hrs | 0.69 hrs | Worse |
| Nurse aide hours per resident per day (higher is better) | 1.91 hrs | 2.01 hrs | 2.32 hrs | Worse |
| Weekend nurse staff hours per resident per day (higher is better) | 2.86 hrs | 2.98 hrs | 3.42 hrs | Worse |
| Nursing staff turnover (yearly) (lower is better) | 55.5% | 55.3% | 45.8% | Worse |
| Registered nurse turnover (yearly) (lower is better) | 57.1% | 54.6% | 42.9% | Worse |
| Administrators who left in the past year (lower is better) | 0 | 1 | 1 | Better |
Inspections
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Health citations in the most recent inspection (lower is better) | 11 | 9 | 9 | Worse |
| Citations from complaint investigations (latest cycle) (lower is better) | 2 | 4 | 3 | Better |
| Weighted health inspection score ⓘ (lower is better) | 103.3 | 102 | 80.6 | Worse |
Penalties
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Fines in the past 3 years (lower is better) | 1 | 1 | 1 | Worse |
| Total fines in the past 3 years (lower is better) | $13,877 | $44,141 | $30,972 | Better |
| All federal penalties in the past 3 years (lower is better) | 1 | 2 | 1 | Average |
Size
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Certified beds | 150 | 113 | 107 | |
| Average residents per day | 104 | 76 | 86 | |
| Occupancy | 69.5% | 67.6% | 80.9% |
Long-stay residents
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Long-stay residents with a fall causing major injury (lower is better) | 0% | 3.3% | 3.2% | Better |
| Long-stay residents with pressure ulcers (lower is better) | 1% | 3.8% | 4.6% | Better |
| Long-stay residents given antipsychotic medication (lower is better) | 2.7% | 9.6% | 15.4% | Better |
| Long-stay residents with a urinary tract infection (lower is better) | 0% | 0.8% | 1.6% | Better |
| Long-stay residents with a catheter left in the bladder (lower is better) | 0.2% | 0.3% | 0.8% | Better |
| Long-stay residents needing more help with daily activities (lower is better) | 17.7% | 15.8% | 13.9% | Worse |
| Long-stay residents whose walking worsened (lower is better) | 13.5% | 14% | 14.1% | Average |
| Long-stay residents who lose too much weight (lower is better) | 0% | 3% | 5.2% | Better |
| Long-stay residents with depressive symptoms (lower is better) | 0% | 2.4% | 12.8% | Better |
| Long-stay residents who were physically restrained (lower is better) | 0% | 0% | 0.1% | Better |
| Long-stay residents given anti-anxiety or sleep medication (lower is better) | 4.1% | 18% | 19.5% | Better |
| Long-stay residents with new or worse incontinence (lower is better) | 5.3% | 13.4% | 19% | Better |
| Long-stay residents given a flu vaccine (higher is better) | 100% | 98% | 95.5% | Average |
| Long-stay residents given a pneumonia vaccine (higher is better) | 100% | 96.6% | 93.6% | Better |
Short-stay residents
| Measure | This facility | Texas avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Short-stay residents newly given antipsychotic medication (lower is better) | 0% | 1.5% | 1.6% | Better |
| Short-stay residents given a flu vaccine (higher is better) | 98.4% | 88% | 79.8% | Better |
| Short-stay residents given a pneumonia vaccine (higher is better) | 98.5% | 88.9% | 82% | Better |
Inspection citations
State inspectors cited this home for 27 health deficiencies and 7 fire safety deficiencies in the inspection records CMS currently publishes. 2 citations involved actual harm, including 2 rated "immediate jeopardy".
| Date | Citation | Severity | Status |
|---|---|---|---|
| July 20, 2026 Complaint | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Tag F0550 | E Potential harm, pattern | Corrected July 21, 2026 |
| January 15, 2026 Fire safety | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0929 | E Potential harm, pattern | Corrected February 22, 2026 |
| January 15, 2026 Standard | 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 · Tag F0761 | E Potential harm, pattern | Corrected January 21, 2026 |
| January 15, 2026 Standard | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Tag F0583 | E Potential harm, pattern | Corrected January 21, 2026 |
| January 15, 2026 Standard | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | E Potential harm, pattern | Corrected January 21, 2026 |
| January 15, 2026 Standard | 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 · Tag F0657 | E Potential harm, pattern | Corrected January 21, 2026 |
| January 15, 2026 Standard | 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 · Tag F0656 | E Potential harm, pattern | Corrected January 21, 2026 |
| January 15, 2026 Standard | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Tag F0558 | E Potential harm, pattern | Corrected January 21, 2026 |
| January 15, 2026 Standard | 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 · Tag F0655 | D Potential harm, isolated | Corrected January 21, 2026 |
| January 15, 2026 Standard | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Tag F0695 | D Potential harm, isolated | Corrected January 21, 2026 |
| January 15, 2026 Standard | 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 · Tag F0690 | D Potential harm, isolated | Corrected January 21, 2026 |
| December 8, 2025 Complaint | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Tag F0755 | D Potential harm, isolated | Corrected December 12, 2025 |
| August 23, 2025 Complaint | 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 · Tag F0656 | D Potential harm, isolated | Corrected September 30, 2025 |
| August 23, 2025 Complaint | Provide for the safe, appropriate administration of IV fluids for a resident when needed. Quality of Life and Care Deficiencies · Tag F0694 | D Potential harm, isolated | Corrected September 30, 2025 |
| August 23, 2025 Complaint | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Tag F0684 | D Potential harm, isolated | Corrected September 30, 2025 |
| May 21, 2025 Complaint | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Tag F0686 | E Potential harm, pattern | Corrected June 23, 2025 |
| May 21, 2025 Complaint | 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 · Tag F0656 | D Potential harm, isolated | Corrected June 23, 2025 |
| November 7, 2024 Fire safety | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Tag K0345 | F Potential harm, widespread | Corrected November 13, 2024 |
| November 7, 2024 Complaint | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | E Potential harm, pattern | Corrected November 15, 2024 |
| November 7, 2024 Standard | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | E Potential harm, pattern | Corrected November 15, 2024 |
| November 7, 2024 Standard | 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 · Tag F0761 | E Potential harm, pattern | Corrected November 15, 2024 |
| November 7, 2024 Standard | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Tag F0921 | D Potential harm, isolated | Corrected November 15, 2024 |
| November 7, 2024 Complaint | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Tag F0550 | D Potential harm, isolated | Corrected November 15, 2024 |
| August 28, 2024 Complaint | 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 · Tag F0842 | D Potential harm, isolated | Corrected September 23, 2024 |
| August 26, 2024 Complaint | 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 · Tag F0693 | D Potential harm, isolated | Corrected September 23, 2024 |
| June 22, 2024 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | J Immediate jeopardy, isolated | Corrected July 19, 2024 |
| June 22, 2024 Complaint | 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 · Tag F0656 | J Immediate jeopardy, isolated | Corrected July 19, 2024 |
| June 11, 2024 Complaint | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Tag F0755 | D Potential harm, isolated | Corrected July 10, 2024 |
| October 5, 2023 Fire safety | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Tag K0345 | F Potential harm, widespread | Corrected October 6, 2023 |
| October 5, 2023 Fire safety | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Tag K0511 | F Potential harm, widespread | Corrected October 6, 2023 |
| October 5, 2023 Fire safety | Properly install and monitor supervisory attachments on automatic sprinkler systems. Smoke Deficiencies · Tag K0352 | F Potential harm, widespread | Corrected October 6, 2023 |
| October 5, 2023 Fire safety | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Tag K0291 | E Potential harm, pattern | Corrected November 1, 2023 |
| October 5, 2023 Fire safety | Install an approved automatic sprinkler system. Smoke Deficiencies · Tag K0351 | E Potential harm, pattern | Corrected October 24, 2023 |
| October 5, 2023 Complaint | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | D Potential harm, isolated | Corrected October 20, 2023 |
Severity letters follow the CMS scope-and-severity grid: A–C no actual harm with potential for minimal harm; D–F potential for more than minimal harm; G–I actual harm; J–L immediate jeopardy to resident health or safety. How to read inspection citations.
Fines and payment denials
CMS reports 1 federal penalty in the past three years, including $13,877 in fines.
| Date | Penalty | Amount / length |
|---|---|---|
| June 11, 2024 | Fine | $13,877 |
Owners and managers
Individuals and organizations reported to CMS as owning or operating this nursing home.
| Name | Role | Share | Since |
|---|---|---|---|
| DALLAS COUNTY HOSPITAL DISTRICT Organization | 5% or greater direct ownership interest | 100% | 02/15/2015 |
| JOHNSON, NIKITA Individual | adp of the snf | NOT APPLICABLE | 01/10/2023 |
| MCFALLS, LASHONDA Individual | adp of the snf | NOT APPLICABLE | 04/11/2011 |
| WINDSOR PLACE HEALTH CARE CENTER LTD CO Organization | adp of the snf | NOT APPLICABLE | 02/15/2015 |
| CASTANEDA, EDMUNDO Individual | corporate officer | NOT APPLICABLE | 01/10/2022 |
| CERISE, FREDERICK Individual | corporate officer | NOT APPLICABLE | 03/24/2014 |
| JOHNSON, NIKITA Individual | operational/managerial control | NOT APPLICABLE | 01/10/2023 |
| WINDSOR PLACE HEALTH CARE CENTER LTD CO Organization | operational/managerial control | NOT APPLICABLE | 02/15/2015 |
Other nursing homes near Windsor Gardens
Millbrook Healthcare and Rehabilitation Center
1850 W Pleasant Run Rd, Lancaster, TX 75146 · under 1 mi
For-profit · 124 beds · Part of The Ensign Group
★★★★★1Much below averageAvir at Lancaster
1241 Westridge Ave, Lancaster, TX 75146 · 2.5 mi
Government · 110 beds · Part of Avir Health Group
★★★★★1Much below averageDesoto Nursing & Rehabilitation Center
1101 North Hampton Road, Desoto, TX 75115 · 2.7 mi
For-profit · 110 beds · Part of Creative Solutions in Healthcare
★★★★★3AverageLancaster Nursing & Rehabilitation
1515 N Elm St, Lancaster, TX 75134 · 2.7 mi
For-profit · 120 beds · Part of Creative Solutions in Healthcare
★★★★★1Much below averageFive Points Nursing and Rehabilitation
1901 North Hampton Road, Desoto, TX 75115 · 3.1 mi
For-profit · 120 beds · Part of Creative Solutions in Healthcare
★★★★★2Below averagePark Village Healthcare and Rehabilitation
207 E Parkerville Rd, Desoto, TX 75115 · 3.3 mi
For-profit · 150 beds · Part of The Ensign Group
- Abuse citation
★★★★★2Below average
Frequently asked questions
What is Windsor Gardens's rating?
Windsor Gardens has 2 out of 5 stars on the CMS overall star rating. The average for Texas nursing homes is 2.7 stars.
How many inspection citations did Windsor Gardens receive?
Its most recent standard health inspection found 11 citations, compared with a Texas average of 9.4. Every citation is listed on this page with its severity.
Does Windsor Gardens accept Medicare and Medicaid?
CMS lists it as certified for: Medicare and Medicaid. Call the facility to confirm bed availability and whether it accepts your specific plan.
Who owns Windsor Gardens?
It is for profit - corporation and part of Cantex Continuing Care. The ownership section on this page lists the owners and managers reported to CMS.
Where is Windsor Gardens and how do I contact it?
Windsor Gardens is at 2535 W Pleasant Run, Lancaster, TX 75146. Phone: (972) 228-8029.
About this data
Ratings and measures come from the Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. They're based on state inspections, patient surveys and facility reports, and they describe the past. Facilities change, so visit in person and confirm details directly. About our data · Spotted an error? Let us know.