Windsor Gardens

Name: Windsor Gardens
Address: 2535 W PLEASANT RUN, Lancaster, TX, 75146, US
Telephone: 9722288029

2535 W Pleasant Run, Lancaster, TX 75146 · Dallas County · 150 certified beds · avg 104 residents/day · certified since Aug 2, 1989

Part of chain: CANTEX CONTINUING CARE (37 facilities, chain avg rating 3.1★)

2/5

Health inspection rating (on-site)

Serious findings on record

$13,877

Fines, last 3 years

3.37

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, one-off · Jun 22, 2024 · F-0656 · triggered by a complaint

The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.

Why it matters: Without a complete, working care plan, important needs can slip through the cracks and no one is accountable for results.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Jul 19, 2024 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Jun 22, 2024 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Corrected: Jul 19, 2024 (Deficient, Provider has date of correction)

All citations in the current public record (26)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Jan 15, 2026	E · Potential for harm, repeated	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Jan 15, 2026	E · Potential for harm, repeated	The facility did not keep residents' personal and medical information private and confidential.
Jan 15, 2026	E · Potential for harm, repeated	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Jan 15, 2026	E · Potential for harm, repeated	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Jan 15, 2026	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Jan 15, 2026	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jan 15, 2026	D · Potential for harm, one-off	The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
Jan 15, 2026	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Jan 15, 2026	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Dec 8, 2025	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Aug 23, 2025	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Aug 23, 2025	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Aug 23, 2025	D · Potential for harm, one-off	The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. · from a complaint
May 21, 2025	E · Potential for harm, repeated	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
May 21, 2025	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Nov 7, 2024	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Nov 7, 2024	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint
Nov 7, 2024	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Nov 7, 2024	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Nov 7, 2024	D · Potential for harm, one-off	The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Aug 28, 2024	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Aug 26, 2024	D · Potential for harm, one-off	The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint
Jun 22, 2024	▲ J · Immediate jeopardy, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Jun 22, 2024	▲ J · Immediate jeopardy, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jun 11, 2024	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Oct 5, 2023	D · Potential for harm, one-off	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (5 → 9).

Year	Citations	Serious (G–L)	Worst severity that year
2023	1	0	D
2024	10	2	J ▲
2025	6	0	E
2026	9	0	E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $13,877.

Date	Type	Amount / length
Jun 11, 2024	Fine	$13,877

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Texas avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.37	3.46	3.95	top 46% in Texas; bottom 30% in the U.S.
Registered Nurse hours	0.37	0.44	0.69	bottom 44% in Texas; bottom 17% in the U.S.
Weekend total nurse staffing	2.81	3.04	3.50	bottom 39% in Texas; bottom 21% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.27	0.34	0.48	bottom 45% in Texas; bottom 26% in the U.S.
Total nursing staff turnover (%)	55.5	55.3	45.8	bottom 42% in Texas; bottom 24% in the U.S.
RN turnover (%)	57.1	54.6	42.9	bottom 46% in Texas; bottom 26% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.43, RN 0.37, weekend 2.86. Staffing rating: 1/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 4/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Dallas County Hospital District	Organization	5% or Greater Direct Ownership Interest	100%	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
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	Operational/Managerial Control	NOT APPLICABLE	02/15/2015
Windsor Place Health Care Center LTD Co	Organization	ADP of the SNF	NOT APPLICABLE	02/15/2015

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"Can you show me an example care plan, and how are families included when it's created and updated?"
"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
"How do you protect residents' privacy, both in their medical records and in day-to-day care?"
"Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
"Can you show me how medications are stored and secured on the units, including controlled drugs?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Millbrook Healthcare and Rehabilitation Center	0.8 mi	Lancaster, TX	★☆☆☆☆	2/5
Avir at Lancaster	2.5 mi	Lancaster, TX	★★☆☆☆	2/5
Desoto Nursing & Rehabilitation Center	2.7 mi	Desoto, TX	★★★☆☆	3/5
Lancaster Nursing & Rehabilitation	2.7 mi	Lancaster, TX	★☆☆☆☆	1/5
Five Points Nursing and Rehabilitation	3.1 mi	Desoto, TX	★★☆☆☆	3/5
Park Village Healthcare and Rehabilitation	3.3 mi	Desoto, TX	★★☆☆☆	1/5	abuse
Methodist Transitional Care Center-Desoto LLC	3.3 mi	Desoto, TX	★★★☆☆	2/5
Williamsburg Village Healthcare Campus	4.8 mi	Desoto, TX	★★☆☆☆	1/5	SFF
Red Oak Health and Rehabilitation Center	4.9 mi	Red Oak, TX	★★★☆☆	4/5
The Lennwood Nursing and Rehabilitation	5.0 mi	Dallas, TX	★☆☆☆☆	2/5

Compare this facility with the 3 closest →

All facilities in Lancaster →

Facility data as of CMS processing date 2026-08-01. CCN 455832.

The Care File

Visit checklist — Windsor Gardens

2535 W Pleasant Run, Lancaster, TX 75146 · 9722288029

Health inspection rating 2/5 · CMS overall 2/5· Fines (3y): $13,877

Most serious findings on record:

▲ Jun 22, 2024 (F-0656, Immediate jeopardy, one-off): The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
▲ Jun 22, 2024 (F-0689, Immediate jeopardy, one-off): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Questions for the administrator:

☐ "Can you show me an example care plan, and how are families included when it's created and updated?"
☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
☐ "How do you protect residents' privacy, both in their medical records and in day-to-day care?"
☐ "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
☐ "Can you show me how medications are stored and secured on the units, including controlled drugs?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 455832 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)