Windsor Gardens
Nursing Home · 2535 W Pleasant Run, Lancaster, TX 75146 · 9722288029
B
graded on 75% of our rubric
Why you can trust this grade. HearthGrades is independent and free to use. Every grade is computed from public CMS and state records on a fixed, published rubric — safety inspections, staffing, clinical outcomes, enforcement and financial stability. This provider was graded on 75% of that rubric. No facility can pay to change its grade or where it appears, and we take no money from the providers we grade. See the full methodology.
Scores by dimension
| Dimension | Score | Data confidence |
|---|---|---|
| Safety & compliance | 3.0 / 5 | high |
| Staffing | 2.0 / 5 | high |
| Clinical outcomes | 4.5 / 5 | high |
| Enforcement | 4.2 / 5 | high |
| Financial stability | 3.9 / 5 | med |
Key facts
| Care type | Nursing Home |
| Beds | 150 |
| Ownership | For Profit - Corporation |
| Operator | Dallas County Hospital District |
| Chain size | 38 facilities |
| Certified since | 1989-08-02 |
| CMS overall star | 4 / 5 |
| Accepts Medicaid | Yes |
| Price tier | $$$$$ of 5 · ~$457/day reported charge (within TX) |
Inspection & enforcement record
- Health-inspection citations: 2 immediate jeopardy · 0 actual harm · 17 potential for harm · 0 minor
- Federal fines: $13,877 · payment denials: 0 · penalty actions: 1
Recent inspection findings
The 8 most recent health-inspection deficiencies on file with CMS, newest first. Severity is the CMS scope/severity scale (A–L); G and above mean actual harm or immediate jeopardy. "Corrected" shows the date the facility certified the fix.
| Date | Finding | Severity | Status |
|---|---|---|---|
| 2025-12-08 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (Pharmacy Service Deficiencies, tag 0755) | D | corrected 2025-12-12 |
| 2025-08-23 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Resident Assessment and Care Planning Deficiencies, tag 0656) | D | corrected 2025-09-30 |
| 2025-08-23 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. (Quality of Life and Care Deficiencies, tag 0684) | D | corrected 2025-09-30 |
| 2025-08-23 | Provide for the safe, appropriate administration of IV fluids for a resident when needed. (Quality of Life and Care Deficiencies, tag 0694) | D | corrected 2025-09-30 |
| 2025-05-21 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Resident Assessment and Care Planning Deficiencies, tag 0656) | D | corrected 2025-06-23 |
| 2025-05-21 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Quality of Life and Care Deficiencies, tag 0686) | E | corrected 2025-06-23 |
| 2024-11-07 | 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. (Pharmacy Service Deficiencies, tag 0761) | E | corrected 2024-11-15 |
| 2024-11-07 | Provide and implement an infection prevention and control program. (Infection Control Deficiencies, tag 0880) | E | corrected 2024-11-15 |
Staffing
Nurse hours per resident per day (CMS Payroll-Based Journal) — the strongest objective predictor of care. "Expected" is what CMS's case-mix model says this facility's resident acuity calls for.
- Total nurse staffing: 3.32 hrs/resident/day (expected 3.83 for this facility's resident acuity — below expected) (US median 3.69 · TX 3.27)
- Registered-nurse staffing: 0.32 hrs/resident/day (expected 0.67 for this facility's resident acuity — below expected) (US median 0.58)
- Breakdown: nurse aide 1.84 · LPN 1.16 hrs/resident/day
- Weekend total staffing: 2.88 hrs/resident/day (expected 3.40 for this facility's resident acuity — below expected)
- Annual nursing-staff turnover: 55.2% · RN turnover 46.7% (US median 45.3% · lower is better)
- Resident acuity (nursing case-mix index): 1.38 (1.0 ≈ national average; higher = more care-intensive residents)
Clinical outcomes — the measures behind the score
The 8 CMS MDS quality measures (2025Q1-2025Q4) driving this facility's clinical score — the same measures behind the CMS QM star. All are adverse-event rates: lower is better. Worst first. The quarterly column shows the four most recent quarters (Q1→Q4); benchmarks are the national percentile and the TX state median.
| Measure | 4-qtr avg | Quarterly (Q1→Q4) | Benchmark |
|---|---|---|---|
| Percentage of long-stay residents with a catheter inserted and left in their bladder (long stay) | 0.3% | 0 → 0 → 0 → 1 | better than 56% of US homes · TX median 0% |
| Percentage of long-stay residents whose need for help with daily activities has increased (long stay) | 11.5% | 7.4 → 10.3 → 12.7 → 15.3 | better than 57% of US homes · TX median 14.8% |
| Percentage of long-stay residents whose ability to walk independently worsened (long stay) | 7.7% | not reported | better than 76% of US homes · TX median 13% |
| Percentage of long-stay residents experiencing one or more falls with major injury (long stay) | 0.3% | 1.4 → 0 → 0 → 0 | better than 92% of US homes · TX median 3% |
| Percentage of long-stay residents who received an antipsychotic medication (long stay) | 3.3% | 2.2 → 3.6 → 3.6 → 3.6 | better than 92% of US homes · TX median 8.1% |
| Percentage of long-stay residents with pressure ulcers (long stay) | 0.3% | 0 → 0 → 0 → 1.1 | better than 97% of US homes · TX median 3.4% |
| Percentage of long-stay residents with a urinary tract infection (long stay) | 0% | 0 → 0 → 0 → 0 | better than 100% of US homes · TX median 0.3% |
| Percentage of short-stay residents who newly received an antipsychotic medication (short stay) | 0% | 0 → 0 → 0 → 0 | better than 100% of US homes · TX median 0.7% |
What this costs
- This facility's reported avg daily charge: $457/day · $$$$$ (price tier 5 of 5 among Texas nursing homes) — from its own federal cost report, FY ending 2024-09. Gross charges across all payers and services: higher than a quoted private rate, but computed identically for every facility, which makes the tier a fair within-state comparison.
- Payer mix (resident days): 50% Medicaid · 10% Medicare · 40% other/private · 66% occupancy
- Texas median (quoted rates): $185/day semi-private · $250/day private (national: $315 · $355)
- Accepts Medicaid: yes
- This facility's quoted rate: not public. This facility's quoted private rate isn't published by any federal or state source. Medicare covers short rehab stays (up to 100 days, copays after day 20); long-term stays are private pay until savings spend down to Medicaid. How to get the real number →
Market medians: CareScout Cost of Care Survey 2025 (collected July–November 2025), state-level — individual providers vary widely around a median. Facility-level prices aren't published by any government source; how to get a real quote.
Hospitals serving Dallas County
Hospitals in the same county — those with an emergency department first, then by CMS hospital star rating. Useful for transfers and emergencies.
| Hospital | City | ER | CMS star | Type |
|---|---|---|---|---|
| Baylor Scott & White Heart & Vascular Hospital - Dallas | Dallas | Yes | 5★ | Acute care |
| Baylor Scott & White Medical Center at Irving | Irving | Yes | 5★ | Acute care |
| Baylor Scott and White Medical Center Lake Pointe | Rowlett | Yes | 4★ | Acute care |
| Baylor University Medical Center | Dallas | Yes | 4★ | Acute care |
| Medical City Las Colinas | Irving | Yes | 4★ | Acute care |
| Methodist Hospital for Surgery | Addison | Yes | 4★ | Acute care |
Compare nearby
- A C C Young Memorial Home · Dallas
- A Pure Health Transitional Care At Texas Health Pres · Dallas
- A- Ventana By Buckner · Dallas
- B+ San Remo · Richardson
- B+ Remington Transitional Care Of Richardson · Richardson
- B+ Presbyterian Village North Special Care Ctr · Dallas
Full interactive report card → Facility's own website ↗ CMS Care Compare ↗
Source: CMS Provider Information + Health Deficiencies + Penalties (as of 2026-05). Part of our Dallas County nursing homes coverage. Spot an error? Tell us.