SNF
WINDSOR GARDENS
CCN: 455832 · LANCASTER, TX 75146 · Dallas County
Overview
- Address
- 2535 W PLEASANT RUN, LANCASTER, TX 75146
- Phone
- 9722288029
- Certified beds
- 150
- Avg daily residents
- 99 (66% of beds filled)
- Ownership
- For-profit corporation
- Provider type
- Medicare and Medicaid
- Medicare/Medicaid since
- 1989-08-02
- Setting
- Urban
3 /5
★★★★★
CMS Overall Rating
CMS 5-Star Ratings
CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.
Staffing & Workforce
Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.
| Role | Reported | Case-mix expected | Adjusted | Federal floor | |
|---|---|---|---|---|---|
| Total nurse All nursing staff combined: RN + LPN + Aide | 3.41 | 3.91 | 3.36 | ≥ 3.48 | Below floor |
| Registered Nurse (RN) Licensed RN hours. Strongest driver of clinical outcomes. | 0.35 | 0.68 | 0.34 | ≥ 0.55 | Below floor |
| Licensed Practical Nurse (LPN) LPN/LVN hours. Often handles medication administration. | 1.15 | 0.87 | 1.13 | — | |
| Nurse aide CNA hours. Bulk of direct resident care — bathing, feeding, mobility. | 1.91 | 2.36 | 1.88 | — | |
| Licensed (RN + LPN) Combined licensed nurse coverage. | 1.50 | — | — | — | |
| Physical therapist Rehabilitation therapist hours — important for post-acute / rehab admissions. | 0.05 | — | — | — |
Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.
Weekend staffing
Total nurse (weekend)
3.00
hrs / resident / day
RN (weekend)
0.24
hrs / resident / day
Total nurse (adjusted, weekend)
2.96
hrs / resident / day
Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.
Staff turnover
Total nursing staff turnover
53.5%
annual
RN turnover
53.3%
annual
Administrators departed
0
last 12 months
Resident acuity
Nursing Case-Mix Index
1.39
higher acuity than avg
Case-Mix Index Ratio
1.01
facility / state ratio
Health Inspections
CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.
| Cycle | Date | Total defs. | Standard | Complaint | Deficiency score | Revisits | Total score |
|---|---|---|---|---|---|---|---|
| Cycle 1 (most recent) | 2024-11-07 | 11 | 5 | 8 | 60 | 1 | 60 |
| Cycle 2/3 (prior) | 2023-10-05 | 7 | 1 | 7 | 145 | 1 | 145 |
Total weighted health score
81.3
lower is better
Infection-control citations
0
last cycle
Deficiencies (19)
Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).
17 D/E/F Actual harm — potential for minor
2 J/K/L Immediate jeopardy
| Tag | Description | Scope/Severity | Survey date | Corrected |
|---|---|---|---|---|
| 0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | 2025-12-08 | 2025-12-12 |
| 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | 2025-08-23 | 2025-09-30 |
| 0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | 2025-08-23 | 2025-09-30 |
| 0694 | Provide for the safe, appropriate administration of IV fluids for a resident when needed. | D | 2025-08-23 | 2025-09-30 |
| 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | 2025-05-21 | 2025-06-23 |
| 0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | E | 2025-05-21 | 2025-06-23 |
| 0761 | 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. | E | 2024-11-07 | 2024-11-15 |
| 0880 | Provide and implement an infection prevention and control program. | E | 2024-11-07 | 2024-11-15 |
| 0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | D | 2024-11-07 | 2024-11-15 |
| 0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | 2024-11-07 | 2024-11-15 |
| 0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | 2024-11-07 | 2024-11-15 |
| 0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | 2024-08-28 | 2024-09-23 |
| 0693 | 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. | D | 2024-08-26 | 2024-09-23 |
| 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | J | 2024-06-22 | 2024-07-19 |
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J | 2024-06-22 | 2024-07-19 |
| 0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | 2024-06-11 | 2024-07-10 |
| 0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | D | 2023-10-05 | 2023-10-20 |
| 0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D | 2023-07-14 | 2023-08-29 |
| 0694 | Provide for the safe, appropriate administration of IV fluids for a resident when needed. | D | 2022-08-17 | 2022-08-20 |
Penalties (1)
Fines issued
1
last 3 years
Total fines
$13,877
| Date | Type | Fine amount |
|---|---|---|
| 2024-06-11 | Fine | $13,877 |
Source: CMS Nursing Home Penalties.
Financial Health (FY 2023)
Payer mix (share of resident days)
Medicare 8.3% Medicaid 66.7% Other 24.9%
Operating performance
Operating Margin
-6.1%
Total Margin
6.3%
Occupancy Rate
58.7%
Cost per Resident Day
$40
Revenue & costs
Net Patient Revenue
$8.6M
Total Costs
$1.3M
Net Income
$617K
Balance sheet
Total Assets
$10.8M
Total Liabilities
-$178K
Fund Balance
$11.0M
Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.
Ownership & Corporate Structure
Chain: CANTEX CONTINUING CARE
- Chain ID
100- Facilities in chain
- 38
- Legal business name
- DALLAS COUNTY HOSPITAL DISTRICT
Chain-average star ratings (for peer context)
Overall
3.1
Health
2.7
Staffing
1.9
QM
4.5
Owner / manager organizations (2)
| Organization | Role | Association |
|---|---|---|
| DALLAS COUNTY HOSPITAL DISTRICT | 5% OR GREATER DIRECT OWNERSHIP INTEREST | since 02/15/2015 |
| WINDSOR PLACE HEALTH CARE CENTER LTD CO | OPERATIONAL/MANAGERIAL CONTROL | since 02/15/2015 |
Owner / manager individuals (3)
| Name | Role | Association |
|---|---|---|
| JOHNSON, NIKITA | OPERATIONAL/MANAGERIAL CONTROL | since 01/10/2023 |
| CASTANEDA, EDMUNDO | CORPORATE OFFICER | since 01/10/2022 |
| CERISE, FREDERICK | CORPORATE OFFICER | since 03/24/2014 |
Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.
Facility Features
- CCRC
- No
- Hospital-based
- No
- Resident / family council
- None
- Sprinkler systems
- Yes
- Abuse citation flag
- No
Methodology & sources
- Nursing Home Provider Info (
nh-provider-info), vintage 2026, downloaded 2026-04-14 , 14,703 rows. - Nursing Home Penalties (
nh-penalties), vintage 2026, downloaded 2026-04-14 , 16,915 rows. - Nursing Home Health Deficiencies (
nh-deficiencies), vintage 2026, downloaded 2026-04-14 , 418,972 rows. - Nursing Home Ownership (
nh-ownership), vintage 2026, downloaded 2026-04-14 , 160,393 rows. - Skilled Nursing Facility Cost Report (
snf-cost-report), vintage 2023, downloaded 2026-04-14 , 14,120 rows.
All Data
Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.
Show 112 rows
| Source | Metric | Value | Raw key |
|---|---|---|---|
| Cost Report | Cost per Resident Day ($) | $40 | metrics.cost_per_resident_day |
| Cost Report | fiscal_year | 2,023 | fiscal_year |
| Cost Report | Medicaid Day Share (%) | 66.7% | metrics.medicaid_day_share |
| Cost Report | Medicare Day Share (%) | 8.3% | metrics.medicare_day_share |
| Cost Report | Net Income ($) | $616,788 | metrics.net_income |
| Cost Report | Net Patient Revenue ($) | $8,623,818 | metrics.net_patient_revenue |
| Cost Report | Occupancy Rate (%) | 58.7% | metrics.occupancy_rate |
| Cost Report | Operating Margin (%) | -6.1% | metrics.operating_margin |
| Cost Report | Total Assets ($) | $10,810,372 | metrics.total_assets |
| Cost Report | Total Costs ($) | $1,282,831 | metrics.total_costs |
| Cost Report | Total Fund Balances ($) | $10,988,372 | metrics.fund_balance |
| Cost Report | Total Liabilities ($) | $-178,000 | metrics.total_liabilities |
| Cost Report | Total Margin (%) | 6.3% | metrics.total_margin |
| Provider Information | Abuse Icon | N | Abuse Icon |
| Provider Information | Adjusted LPN Staffing Hours per Resident per Day | 1.13420 | Adjusted LPN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Nurse Aide Staffing Hours per Resident per Day | 1.88360 | Adjusted Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Adjusted RN Staffing Hours per Resident per Day | 0.34274 | Adjusted RN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Total Nurse Staffing Hours per Resident per Day | 3.36055 | Adjusted Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day | 2.96151 | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Administrator turnover footnote | — | Administrator turnover footnote |
| Provider Information | Automatic Sprinkler Systems in All Required Areas | Yes | Automatic Sprinkler Systems in All Required Areas |
| Provider Information | Average Number of Residents per Day | 99.1 | Average Number of Residents per Day |
| Provider Information | Average Number of Residents per Day Footnote | — | Average Number of Residents per Day Footnote |
| Provider Information | Case-Mix LPN Staffing Hours per Resident per Day | 0.86838 | Case-Mix LPN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Nurse Aide Staffing Hours per Resident per Day | 2.36008 | Case-Mix Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Case-Mix RN Staffing Hours per Resident per Day | 0.68448 | Case-Mix RN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Total Nurse Staffing Hours per Resident per Day | 3.91294 | Case-Mix Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day | 3.44884 | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Chain Average Health Inspection Rating | 2.7 | Chain Average Health Inspection Rating |
| Provider Information | Chain Average Overall 5-star Rating | 3.1 | Chain Average Overall 5-star Rating |
| Provider Information | Chain Average QM Rating | 4.5 | Chain Average QM Rating |
| Provider Information | Chain Average Staffing Rating | 1.9 | Chain Average Staffing Rating |
| Provider Information | Chain ID | 100 | Chain ID |
| Provider Information | Chain Name | CANTEX CONTINUING CARE | Chain Name |
| Provider Information | City/Town | LANCASTER | City/Town |
| Provider Information | CMS Certification Number (CCN) | 455832 | CMS Certification Number (CCN) |
| Provider Information | Continuing Care Retirement Community | N | Continuing Care Retirement Community |
| Provider Information | County/Parish | Dallas | County/Parish |
| Provider Information | Date First Approved to Provide Medicare and Medicaid Services | 1989-08-02 | Date First Approved to Provide Medicare and Medicaid Services |
| Provider Information | Geocoding Footnote | — | Geocoding Footnote |
| Provider Information | Health Inspection Rating | 3 | Health Inspection Rating |
| Provider Information | Health Inspection Rating Footnote | — | Health Inspection Rating Footnote |
| Provider Information | Latitude | 32.6042 | Latitude |
| Provider Information | Legal Business Name | DALLAS COUNTY HOSPITAL DISTRICT | Legal Business Name |
| Provider Information | Location | 2535 W PLEASANT RUN,LANCASTER,TX,75146 | Location |
| Provider Information | Long-Stay QM Rating | 5 | Long-Stay QM Rating |
| Provider Information | Long-Stay QM Rating Footnote | — | Long-Stay QM Rating Footnote |
| Provider Information | Longitude | -96.811 | Longitude |
| Provider Information | Most Recent Health Inspection More Than 2 Years Ago | N | Most Recent Health Inspection More Than 2 Years Ago |
| Provider Information | Number of administrators who have left the nursing home | 0 | Number of administrators who have left the nursing home |
| Provider Information | Number of Certified Beds | 150 | Number of Certified Beds |
| Provider Information | Number of Citations from Infection Control Inspections | 0 | Number of Citations from Infection Control Inspections |
| Provider Information | Number of Facilities in Chain | 38 | Number of Facilities in Chain |
| Provider Information | Number of Fines | 1 | Number of Fines |
| Provider Information | Number of Payment Denials | 0 | Number of Payment Denials |
| Provider Information | Nursing Case-Mix Index | 1.38618 | Nursing Case-Mix Index |
| Provider Information | Nursing Case-Mix Index Ratio | 1.00619 | Nursing Case-Mix Index Ratio |
| Provider Information | Overall Rating | 3 | Overall Rating |
| Provider Information | Overall Rating Footnote | — | Overall Rating Footnote |
| Provider Information | Ownership Type | For profit - Corporation | Ownership Type |
| Provider Information | Physical Therapist Staffing Footnote | — | Physical Therapist Staffing Footnote |
| Provider Information | Processing Date | 2026-03-01 | Processing Date |
| Provider Information | Provider Address | 2535 W PLEASANT RUN | Provider Address |
| Provider Information | Provider Changed Ownership in Last 12 Months | N | Provider Changed Ownership in Last 12 Months |
| Provider Information | Provider Name | WINDSOR GARDENS | Provider Name |
| Provider Information | Provider Resides in Hospital | N | Provider Resides in Hospital |
| Provider Information | Provider SSA County Code | 390 | Provider SSA County Code |
| Provider Information | Provider Type | Medicare and Medicaid | Provider Type |
| Provider Information | QM Rating | 5 | QM Rating |
| Provider Information | QM Rating Footnote | — | QM Rating Footnote |
| Provider Information | Rating Cycle 1 Health Deficiency Score | 60 | Rating Cycle 1 Health Deficiency Score |
| Provider Information | Rating Cycle 1 Health Revisit Score | 0 | Rating Cycle 1 Health Revisit Score |
| Provider Information | Rating Cycle 1 Number of Complaint Health Deficiencies | 8 | Rating Cycle 1 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 1 Number of Health Revisits | 1 | Rating Cycle 1 Number of Health Revisits |
| Provider Information | Rating Cycle 1 Number of Standard Health Deficiencies | 5 | Rating Cycle 1 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 1 Standard Survey Health Date | 2024-11-07 | Rating Cycle 1 Standard Survey Health Date |
| Provider Information | Rating Cycle 1 Total Health Score | 60 | Rating Cycle 1 Total Health Score |
| Provider Information | Rating Cycle 1 Total Number of Health Deficiencies | 11 | Rating Cycle 1 Total Number of Health Deficiencies |
| Provider Information | Rating Cycle 2 Number of Standard Health Deficiencies | 1 | Rating Cycle 2 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 2 Standard Health Survey Date | 2023-10-05 | Rating Cycle 2 Standard Health Survey Date |
| Provider Information | Rating Cycle 2/3 Health Deficiency Score | 145 | Rating Cycle 2/3 Health Deficiency Score |
| Provider Information | Rating Cycle 2/3 Health Revisit Score | 0 | Rating Cycle 2/3 Health Revisit Score |
| Provider Information | Rating Cycle 2/3 Number of Complaint Health Deficiencies | 7 | Rating Cycle 2/3 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 2/3 Number of Health Revisits | 1 | Rating Cycle 2/3 Number of Health Revisits |
| Provider Information | Rating Cycle 2/3 Total Health Score | 145 | Rating Cycle 2/3 Total Health Score |
| Provider Information | Rating Cycle 2/3 Total Number of Health Deficiencies | 7 | Rating Cycle 2/3 Total Number of Health Deficiencies |
| Provider Information | Registered Nurse hours per resident per day on the weekend | 0.24435 | Registered Nurse hours per resident per day on the weekend |
| Provider Information | Registered Nurse turnover | 53.3 | Registered Nurse turnover |
| Provider Information | Registered Nurse turnover footnote | — | Registered Nurse turnover footnote |
| Provider Information | Reported Licensed Staffing Hours per Resident per Day | 1.49684 | Reported Licensed Staffing Hours per Resident per Day |
| Provider Information | Reported LPN Staffing Hours per Resident per Day | 1.14948 | Reported LPN Staffing Hours per Resident per Day |
| Provider Information | Reported Nurse Aide Staffing Hours per Resident per Day | 1.90898 | Reported Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Reported Physical Therapist Staffing Hours per Resident Per Day | 0.05335 | Reported Physical Therapist Staffing Hours per Resident Per Day |
| Provider Information | Reported RN Staffing Hours per Resident per Day | 0.34736 | Reported RN Staffing Hours per Resident per Day |
| Provider Information | Reported Staffing Footnote | — | Reported Staffing Footnote |
| Provider Information | Reported Total Nurse Staffing Hours per Resident per Day | 3.40582 | Reported Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Short-Stay QM Rating | 3 | Short-Stay QM Rating |
| Provider Information | Short-Stay QM Rating Footnote | — | Short-Stay QM Rating Footnote |
| Provider Information | Special Focus Status | — | Special Focus Status |
| Provider Information | Staffing Rating | 1 | Staffing Rating |
| Provider Information | Staffing Rating Footnote | — | Staffing Rating Footnote |
| Provider Information | State | TX | State |
| Provider Information | Telephone Number | 9722288029 | Telephone Number |
| Provider Information | Total Amount of Fines in Dollars | 13877.00 | Total Amount of Fines in Dollars |
| Provider Information | Total number of nurse staff hours per resident per day on the weekend | 3.00141 | Total number of nurse staff hours per resident per day on the weekend |
| Provider Information | Total Number of Penalties | 1 | Total Number of Penalties |
| Provider Information | Total nursing staff turnover | 53.5 | Total nursing staff turnover |
| Provider Information | Total nursing staff turnover footnote | — | Total nursing staff turnover footnote |
| Provider Information | Total Weighted Health Survey Score | 81.250 | Total Weighted Health Survey Score |
| Provider Information | Urban | Y | Urban |
| Provider Information | With a Resident and Family Council | None | With a Resident and Family Council |
| Provider Information | ZIP Code | 75146 | ZIP Code |