WINDSOR GARDENS
Open-data reference.
WINDSOR GARDENS is a for profit - corporation facility in LANCASTER, TX with 150 certified beds and a 3-star overall CMS rating. The facility has 20 deficiency records on file. Total penalties: $14K.
2535 W PLEASANT RUN, LANCASTER, TX 75146
Phone: 9722288029
Overall Rating
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
- 99
- In Hospital
- No
- County
- Dallas
- Last Inspection
- Nov 7, 2024
Staffing Data
- RN Hours
- 0.35 (nat'l avg: 0.68)
- LPN Hours
- 1.15
- CNA Hours
- 1.91
- Total Nursing Hours
- 3.41 (nat'l avg: 3.89)
- PT Hours
- 0.05
- Nursing Turnover
- 53.5%
- RN Turnover
- 53.3%
What the CMS Record Reveals About WINDSOR GARDENS
WINDSOR GARDENS operates 150 certified beds in LANCASTER, TX with approximately 99 residents currently in care, and carries a CMS overall rating of 3 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (3★), staffing levels (1★), and quality measures (5★). 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.
The inspection file contains 20 deficiency records from recent surveys, of which 2 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $14K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.41 total nursing hours per resident day (national average 3.89), with RN coverage at 0.35 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, WINDSOR GARDENS falls into a category where comparative context matters. 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. Reported nursing turnover at this facility is 53.5%, above the level where continuity of care typically begins to suffer. 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 details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (20 most recent)
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
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 23, 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
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
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
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
Provide and implement an infection prevention and control program.
Category: Infection Control 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
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: Aug 29, 2023
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Mar 31, 2023
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 20, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 13.6% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 0.4% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.0% | Yes |
| 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 experiencing one or more falls with major injury | Long Stay | 0.7% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 97.6% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 6.2% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 5.0% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 98.4% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 0.3% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 0.4% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 2.4% | Yes |
Penalty History 1 penalties totaling $14K
| Date | Type | Amount |
|---|---|---|
| Jun 11, 2024 | Fine | $14K |
Nearby Nursing Homes in 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
ADVANCED REHABILITATION AND HEALTHCARE OF ATHENS
ATHENS, TX
Understanding Nursing Home Data
Related Data from Other Sources
Doctors Nearby
Find physicians and specialists in LANCASTER, TX on PlainDoctor
Hospitals Nearby
Hospital quality ratings and safety data for LANCASTER, TX on PlainHospital
Medicare Plans
Compare Medicare plans and coverage options near LANCASTER, TX on PlainMedicare
County Health Data
Health outcomes, access, and quality metrics for Dallas on PlainHealth
Frequently Asked Questions
What is the overall CMS rating for WINDSOR GARDENS?
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. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.