CareSentinel

Compiled from official CMS federal data

WINDSOR GARDENS, LANCASTER, TX — Violations & Inspection Reports

CCN 455832 · 2535 W PLEASANT RUN, LANCASTER, TX, 75146

Record as of Jun 2026 · Updated monthly from CMS

Does WINDSOR GARDENS have a federal violation or abuse history?

According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), WINDSOR GARDENS (CCN 455832), in LANCASTER, TX, has federal inspection findings.

In its current inspection cycle, CMS cited the facility for 9 deficiencies; the most severe is rated E — which CMS classifies as "potential for harm," a level below actual harm (risk, but no harm confirmed). The latest standard health inspection on file is dated 2024-11-07. Earlier-cycle citations appear in the dated timeline below as historical, not current. CMS has $13,877 in civil money penalties on file against the facility. This page restates the federal record and draws no conclusion of its own.

Abuse-, fall-, and care-related findings on the federal record

  • 1 citation for accident hazards or inadequate supervision (F689) — the deficiency family behind fall-related findings; most recent Jun 2024.
  • 1 pressure-ulcer care citation (F686) — the consumer term is "bedsores"; most recent May 2025.
  • 15 findings on file from complaint-triggered inspections.

Every figure above restates CMS’s own dated record; this page draws no conclusion of its own. Strict state filing deadlines can apply to nursing-home injury claims — a licensed attorney in your state can review this record.

FOR FAMILIES

What brings you to this record?

The Federal Record

CMS has $13,877 in civil money penalties on file against this facility.

Below is this facility's federal inspection record as on file with CMS.

Scope & Severity — current cycle

ANo Harm
BNo Harm
CNo Harm
DPotential
EPotential
FPotential
GActual Harm
HActual Harm
IActual Harm
JImm. Jeopardy
KImm. Jeopardy
LImm. Jeopardy

CMS's own A–L scope/severity grid. Plotted cells mark this facility's most recent (current-cycle) citations.

Civil money penalties on file

$13,877

Have a lawyer review this record →

About this record: Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.

Deficiency timeline

How to read these codes ↓

Citations are listed by scope/severity (most severe first), not chronologically; each entry is labeled current-cycle or historical.

2024-06-22
HISTORICAL
F689S/S J

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

2024-06-22
HISTORICAL
F656S/S J

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

2024-11-07
CURRENT CYCLE
F812S/S E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

16 more citations on file — Pressure ulcers 1 · Medication & pharmacy 3 · Resident rights 1 · Other citations 10 (expand)
2025-12-08
CURRENT CYCLE
F755S/S D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

2025-08-23
CURRENT CYCLE
F694S/S D

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

2025-08-23
CURRENT CYCLE
F656S/S D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

2025-08-23
CURRENT CYCLE
F684S/S D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

2025-05-21
HISTORICAL
F686S/S E

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

2025-05-21
HISTORICAL
F656S/S D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

2024-11-07
CURRENT CYCLE
F880S/S E

Provide and implement an infection prevention and control program.

2024-11-07
CURRENT CYCLE
F761S/S E

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.

2024-11-07
CURRENT CYCLE
F550S/S D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

2024-11-07
CURRENT CYCLE
F921S/S D

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

2024-08-28
HISTORICAL
F842S/S D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

2024-08-26
HISTORICAL
F693S/S D

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.

2024-06-11
HISTORICAL
F755S/S D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

2023-10-05
HISTORICAL
F812S/S D

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

2023-07-14
HISTORICAL
F655S/S D

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

2022-08-17
HISTORICAL
F694S/S D

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Overall CMS star rating

This facility: 4  ·  CMS state average: 2.7

Both figures as published by CMS.

You may be reading this record for the first time.

If something happened to someone you love at this facility, this federal record may be new to you today. The company that operates a nursing home, by contrast, is rarely seeing records like this for the first time — operators like these typically retain standing legal, risk, and insurance teams whose routine work includes records exactly like the one on this page. That is not a judgment of this facility; it is how the business is structured. Because strict time limits can apply, families often find it helps to have a qualified person review the record with them sooner rather than later.

Your federal record — tap to preview

Federal record

WINDSOR GARDENS — Federal Record

CMS overall 4/5 · 9 current-cycle deficiencies


Section 7 — Case Context

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SECTION 7 — CASE CONTEXT

Add what you saw at WINDSOR GARDENS to this record

No call centers, no auctions. CareSentinel is an independent service that compiles the public CMS record and does not provide legal advice. The federal record is a point-in-time inspection record and may understate what actually occurred. CareSentinel is operated by Nodal Logics LLC.

Strict time limits can apply to taking legal action — consider consulting a qualified attorney promptly.

What happened

What happened? Tap a category to see options — select all that apply. 'Other / I'm not sure' is fine.

No personal details on this step.

If you believe a resident is in immediate danger, call 911. Care concerns can also be reported at no cost to your state survey agency or the Long-Term Care Ombudsman program (ltcombudsman.org) — independent of any legal inquiry.

How to read this record

Making sense of a CMS inspection record

CMS scores every citation on a grid from A to L, combining how widespread a finding was with how serious it was. A–C is a deficiency CMS classifies as no harm; D–F as the potential for harm; G–I as actual harm that reached a resident; and J–L as immediate jeopardy, CMS’s most serious level. Later letters mark more serious findings.

Three questions to ask on a tour

  • How is the home staffed on nights, weekends, and holidays?
  • What happens when a resident’s condition changes suddenly?
  • How, and how quickly, are families told about an incident?

Compare this facility on CMS’s own Care Compare →

Download the full federal record (PDF) →