Windsor Gardens
2535 W Pleasant Run, Lancaster, TX 75146
Windsor Gardens, a 150-bed for profit - corporation nursing facility in Lancaster, TX, holds a 2-star CMS overall rating - below the 3.0-star national average, ranking #682 of 1,165 rated homes in TX on CMS overall stars (with health+staffing+quality tie-breaks), with nurse staffing below the national norm. 2 inspection findings reached the actual-harm or immediate-jeopardy level.
CMS combines health inspections, nurse-staffing levels, and clinical quality measures into the overall star rating, read the components below; they often tell a sharper story than the headline.
Phone: 9722288029
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- 2 / 5
- Below average · CMS overall · nat'l 3.0
- #682 of 1,165
- In-state rank among rated TX homes
- 3.43
- Below average · nurse hrs/day · nat'l 3.86
- 26
- Inspection findings · 2 serious
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The verdict
Windsor Gardens, a 150-bed for profit - corporation nursing facility in Lancaster, TX, holds a 2-star CMS overall rating - below the 3.0-star national average, ranking #682 of 1,165 rated homes in TX on CMS overall stars (with health+staffing+quality tie-breaks), with nurse staffing below the national norm. 2 inspection findings reached the actual-harm or immediate-jeopardy level.
- 2 / 5
- CMS overall · national 3.0
- #682 of 1,165
- In-state rank among rated TX homes
- 3.43
- Nurse hrs/resident-day · national 3.86
- 26
- Inspection findings · 2 serious
CMS force-curves overall stars within each state; read health, staffing, and quality sub-ratings alongside the headline.
In-state ownership mix · peer inventory
How 1,177 TX nursing homes split by ownership sector
This facility is recorded as For profit - Corporation. Sector buckets collapse CMS ownership_type into For-profit, Nonprofit, and Government, orthogonal to the RN/LPN/CNA hour bar below.
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 455832
- Ownership
- For profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 150
- Residents
- 104
- In Hospital
- No
- County
- Dallas
- Last Inspection
- Jan 15, 2026
Staffing Data
How the 3.43 total nursing hours per resident-day are staffed:
- RN Hours
- 0.37 (nat'l avg: 0.69)
- LPN Hours
- 1.16
- CNA Hours
- 1.91
- Total Nursing Hours
- 3.43 (nat'l avg: 3.86)
- PT Hours
- 0.05
- Nursing Turnover
- 55.5%
- RN Turnover
- 57.1%
What the CMS Record Reveals About Windsor Gardens
According to CMS Nursing Home Compare, Windsor Gardens ranks #682 of 1,165 rated nursing homes in TX on overall stars (tie-broken by health+staffing+quality, then fewer fines). Windsor Gardens operates 150 certified beds in Lancaster, TX with approximately 104 residents currently in care, and carries a CMS overall rating of 2 out of 5 stars (health inspection 2★ · staffing 1★ · quality 5★).
The inspection file contains 26 deficiency records from recent surveys, of which 2 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. CMS enforcement records show 1 penalty totaling $14K levied against this facility. Staffing is reported at 3.43 total nursing hours per resident day (national average 3.86), with RN coverage at 0.37 per resident day.
Classified as "For profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, Windsor Gardens falls into a category where comparative context matters. Reported nursing staff turnover at this facility is 55.5% (CMS payroll-based measure).
Why sub-scores and the CMS methodology matter
The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results, staffing levels, and quality measures. Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone, a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes, ratings and fines are lagging indicators of those upstream choices. The staffing metric in particular is the one most strongly tied to resident outcomes in peer-reviewed literature.
For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report, the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify the same record on Medicare.gov Care Compare and with the facility or your state survey agency before making placement decisions.
Deficiency History (26 most recent)
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 21, 2026
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 21, 2026
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jan 21, 2026
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jan 21, 2026
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.
Category: Pharmacy Service Deficiencies
Corrected: Jan 21, 2026
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jan 21, 2026
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jan 21, 2026
Keep residents' personal and medical records private and confidential.
Category: Resident Rights Deficiencies
Corrected: Jan 21, 2026
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Jan 21, 2026
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Dec 12, 2025
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 30, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 30, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 30, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 23, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 23, 2025
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category: Environmental Deficiencies
Corrected: Nov 15, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Nov 15, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Nov 15, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Nov 15, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Nov 15, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 23, 2024
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.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 23, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 19, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 19, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Jul 10, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Oct 20, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 17.7% | Yes |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.2% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 13.5% | Yes |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 1.0% | Yes |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 2.7% | Yes |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 0.0% | No |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 0.0% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 100.0% | No |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 4.1% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 5.3% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 98.5% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 98.4% | No |
Penalty History 1 penalties totaling $14K
| Date | Type | Amount |
|---|---|---|
| Jun 11, 2024 | Fine | $14K |
Nationwide facilities with similar scale or staffing
Two data-derived peer sets for Windsor Gardens, both outside TX so the neighborhoods are not the same-state geography list below.
Similar bed count
Nearest CMS certified bed counts outside TX (150 beds here).
Similar staffing hours
Nearest CMS adjusted total nurse hours per resident day outside TX (3.37 here).
Nearby Nursing Homes in TX
1,176 other nursing homes are on record in TX; 6 are shown here.
600 Maple Ave.
Burleson, TX
Accel at College Station
College Station, TX
Accel at Willow Bend
Plano, TX
Advanced Health & Rehab Center of Garland
Garland, TX
Advanced Rehabilitation & Healthcare of Burleson
Burleson, TX
Advanced Rehabilitation & Healthcare of Live Oak
Live Oak, TX
Understanding Nursing Home Data
What the CMS records show for Windsor Gardens
The health, staffing, and quality sub-ratings above often diverge from the CMS overall headline. Use those components and the inspection findings to read the full file, not the overall star alone.
- The TX registry aggregates state averages and the highest-rated homes in this cohort. View TX registry
- Peer homes near 150 beds show how CMS stars vary at a similar scale in TX. Compare a similar-size peer
- CMS publishes separate fields for inspections, nurse staffing hours, and quality measures; the guide explains how each star is computed. How CMS ratings work
CMS refreshes Nursing Home Compare quarterly (current extract: August 2026). PlainNursing describes published records; it does not establish suitability, availability, admissions, or individual outcomes.
Frequently Asked Questions
What is the overall CMS rating for Windsor Gardens?
Where does Windsor Gardens rank among nursing homes in TX?
What are the staffing levels at Windsor Gardens?
How many beds does Windsor Gardens have?
Does Windsor Gardens have any deficiencies on record?
Has Windsor Gardens received any fines or penalties?
Who owns Windsor Gardens?
When was Windsor Gardens last inspected?
What quality measures are tracked for Windsor Gardens?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Verify the same CCN on Medicare.gov Care Compare and with the facility or your state health department.
Read our methodology - how this data is sourced, computed, and verified.
