Cycle 1
Health 2024-11-07 · Fire 2024-11-07
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Lancaster, TX
Windsor Gardens
3-star overall rating with 3-star inspections with $13,877 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2535 W Pleasant Run, Lancaster, TX
(972) 228-8029
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
150
Certified beds
Average residents
99
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cantex Continuing Care
Operator or chain grouping
Approved since
1989-08-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
38 facilities
Chain averages 3 overall / 3 health / 2 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.35
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.15
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.91
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.41
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.00
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.34
CMS adjusted RN staffing hours
Adjusted total hours
3.36
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,683
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.13
Composite VBP score used to determine payment impact.
Payment multiplier
0.9961
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.66
Baseline 20.08% · Performance 17.88% · Measure score 7.66 · Achievement 7.66 · Improvement 6.70
Healthcare-associated infections
4.18
Baseline 6.94% · Performance 6.59% · Measure score 4.18 · Achievement 4.18 · Improvement 1.34
Total nurse turnover
4.51
Performance 45.26% · Measure score 4.51 · Achievement 4.51 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.91
Baseline 3.14 hours · Performance 3.34 hours · Measure score 0.91 · Achievement 0.91 · Improvement 0.26
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.18% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 138 · Observed rate 11.59% · Lower 95% interval 7.37% |
| Discharge to community | 56.13% |
50.57%
5.6 pts better
|
No Different than the National Rate · Eligible stays 123 · Observed rate 44.72% · Lower 95% interval 46.9% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 44.16% |
95.27%
51.1 pts worse
|
Numerator 34 · Denominator 77 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 77 |
| Discharge self-care score | 62.5% |
53.69%
8.8 pts better
|
Numerator 35 · Denominator 56 |
| Discharge mobility score | 44.64% |
50.94%
6.3 pts worse
|
Numerator 25 · Denominator 56 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 77 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.59% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 89 · Observed rate 6.74% · Lower 95% interval 3.7% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 135 |
| Staff flu vaccination coverage | 9.8% |
42%
32.2 pts worse
|
Numerator 20 · Denominator 204 |
| Discharge function score | 48.21% |
56.45%
8.2 pts worse
|
Numerator 27 · Denominator 56 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 18.75% |
96.28%
77.5 pts worse
|
Numerator 9 · Denominator 48 |
| Resident COVID-19 vaccinations up to date | 50% |
25.2%
24.8 pts better
|
Numerator 15 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
3.3%
2.6 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 0.4% |
3.3%
2.9 pts better
|
5.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.0% |
18.9%
13.9 pts better
|
19.6%
14.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 3.3% · Q3 4.4% · Q4 4.3% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.4% |
10.8%
8.4 pts better
|
16.7%
14.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 3.4% · Q4 3.4% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.2% |
15.4%
9.2 pts better
|
16.3%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.6% |
16.1%
2.5 pts better
|
14.9%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 7.4% · Q3 10.3% · Q4 12.7% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 0.4% |
15.0%
14.6 pts better
|
19.8%
19.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.4% |
| Percentage of long-stay residents with pressure ulcers | 0.3% |
4.2%
3.9 pts better
|
5.1%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
89.7%
7.9 pts better
|
81.7%
15.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.6% · Q2 96.0% · Q3 94.9% · Q4 99.5% · 4Q avg 97.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.6% |
12.0%
1.6 pts worse
|
12.0%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.6% · Observed 16.2% · Expected 13.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.4% |
88.0%
10.4 pts better
|
79.7%
18.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.6% |
25.9%
1.3 pts better
|
23.9%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.6% · Observed 31.2% · Expected 30.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-05 · Fire 2023-10-05
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-08-17 · Fire 2022-08-17
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-13
F · Potential for more than minimal harm
2023-10-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-10-05
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-10-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-06
E · Potential for more than minimal harm
2023-10-05
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-11-01
E · Potential for more than minimal harm
2023-10-05
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-10-24
F · Potential for more than minimal harm
2022-08-17
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-09-19
F · Potential for more than minimal harm
2022-08-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-09-19
F · Potential for more than minimal harm
2022-08-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-19
E · Potential for more than minimal harm
2022-08-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-09-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-08
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-08-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-30
D · Potential for more than minimal harm
2025-08-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-30
D · Potential for more than minimal harm
2025-08-23
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-09-30
E · Potential for more than minimal harm
2025-05-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-23
D · Potential for more than minimal harm
2025-05-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-23
E · Potential for more than minimal harm
2024-11-07
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-11-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-11-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-11-07
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-11-07
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-08-28
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-08-26
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-09-23
J · Immediate jeopardy
2024-06-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-19
J · Immediate jeopardy
2024-06-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-11
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-10
D · Potential for more than minimal harm
2023-10-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-07-14
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-08-29
D · Potential for more than minimal harm
2022-08-17
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2022-08-20
Penalties and ownership
What sits behind the stars
$13,877
2024-06-11
Fine
Fine · fine $13,877
Fine
Ownership
Dallas County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Castaneda, Edmundo
Corporate Officer · Individual
Cerise, Frederick
Corporate Officer · Individual
Johnson, Nikita
Operational/Managerial Control · Individual
Windsor Place Health Care Center Ltd Co
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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Millbrook Healthcare and Rehabilitation Center
Lancaster, TX
2-star overall rating with 3-star inspections with $13,565 in total fines with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Avir At Lancaster
Lancaster, TX
2-star overall rating with 2-star inspections with abuse icon flag with $39,757 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Desoto Nursing & Rehabilitation Center
Desoto, TX
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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