Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and record reviews the facility failed to develop and implement a comprehensive
person-centered care plan that includes measurable objectives and time frames to meet a resident's
medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical,
mental, and psychosocial well-being for one (Resident #1) of five residents reviewed for comprehensive
person-centered care plans.
The facility failed to ensure Resident #1 had a comprehensive person-centered care plan for Resident #1
during their stay from 2/23/2025 to 3/30/2025 (35 days ).
This deficient practice could place residents at risk of not being provided with the necessary care or
services to address their specific needs.
Findings included:
Review of face sheet dated 05/21/25 reflected Resident #1 admitted to the facility on [DATE] and dischaged
from the facility on 03/30/25.
Record review of Resident #1's Comprehensive MDS assessment dated [DATE] revealed Resident #1 was
a [AGE] year-old [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hypertension
(high blood pressure), diabetes, seizure disorder, a bacterial infection and anxiety. The MDS also revealed
a BIMs score of 13 (suggested cognition was intact). Section M revealed Resident #1 was receiving insulin
(injectable medication for diabetes), anticonvulsants (seizure medication), an antibiotic (medication for
infection), and an anticoagulant (a blood thinner). Section V of the MDS assessment revealed care areas
triggered were ADL function/Rehab potential, urinary incontinence or indwelling catheter, nutritional status,
and pressure ulcer. The MDS assessment was signed by LVN A and the DON.
Review of Resident #1's care plan with effective date of 03.24.25 reflected Resident #1 did not have a
comprehensive person-centered care plan.
In an interview on 5/21/2025 at 2:01 p.m., MDS A stated there was not a comprehensive care plan for
Resident #1, but MDS A stated he had just entered one into their charting system. MDS A stated MDS A
was responsible for entering the comprehensive care plan for each resident. MDS A reported the
comprehensive care plan was usually completed within 14 days. MDS A stated Resident #1 did not have a
care plan while residing in the facility. MDS A stated all nursing staff was responsible for monitoring
residents' care plans. MDS A stated if a resident did not have a care plan, then residents care
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 5
Event ID:
455832
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455832
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/21/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Windsor Gardens
2535 W Pleasant Run
Lancaster, TX 75146
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
needs, ADL assistance, medications, diets, dialysis, and many other needs would not be brought to the
staff's attention.
In an interview on 5/21/2025 at 3:06 p.m., the DON reported care plans were completed by unit managers,
treatment nurse, the social worker, the MDS nurse, and the DON. The DON reported care plans were also
monitored by the unit managers, treatment nurse, the social worker, and the DON. The DON stated if there
was not a care plan for a resident then the risk was that there would be no paperwork. The DON stated her
expectation for resident care plans was that they were updated and that all residents had a comprehensive
care plan in place .
A policy for care plans was not received prior to the time of exit on 5/21/2025.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455832
If continuation sheet
Page 2 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455832
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/21/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Windsor Gardens
2535 W Pleasant Run
Lancaster, TX 75146
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure that residents received the necessary
treatment and services, to promote healing, prevent infection for two ( Resident #3, and Resident #4) of five
residents reviewed for pressure ulcers.
Residents Affected - Some
1.
The facility failed to ensure that Resident #3 had a dressing that covered the wound on Resident #3's
lateral right ankle on 5/20/2025.
2.
The facility failed to ensure that Resident #4 had a dressing that covered the wound on Resident #4's
sacrum on 5/20/2025.
These failures could place residents with wounds at risk for infection, a decline in health, and reduce wound
healing.
Findings included:
1.
Record review of Resident #3's Comprehensive MDS assessment dated [DATE] revealed Resident #3 was
a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of unspecified intellectual
disabilities, anemia (low levels of healthy red blood cells or hemoglobin), and hypertension (high blood
pressure). Section C of the MDS assessment revealed a BIMs score of 15 (suggested cognition was intact).
Section M of the MDS assessment revealed Resident #3 had one venous or arterial ulcer that required
application of a dressing and ointment/medication.
Record review of Resident #3's care plan updated 2/10/2025 revealed an intervention for skin concerns
was to perform treatments as ordered by the doctor.
Record review of Resident #3's printed physician orders dated 5/21/2025 revealed a physician's order for
wound care on Resident #3's lateral right ankle dated 2/19/2025 that stated to cleanse the right lateral
ankle with normal saline, pat dry, apply xeroform, and apply a dry protective dressing on Monday,
Wednesday, and Friday.
Record review of Resident #3's wound assessment dated [DATE] revealed the measurements for Resident
#3's right lateral ankle wound was 0.5cm long, 0.4cm wide, and 0.2cm deep.
Record review of Resident #3's wound assessment dated [DATE] revealed the measurements for Resident
#3's right lateral ankle wound was 0.4cm long, 0.4cm wide, and 0.2cm deep.
In an observation and interview on 5/20/2025 at 8:50 a.m., revealed Resident #3 reported he had a wound
on his right ankle and a nurse used to put a dressing on it. Resident #3 stated they stopped doing it, but
Resident #3 did not remember when. Resident #3 stated he wanted them to put a dressing on his wound
because it was uncomfortable when it did not have a dressing. Observed an approximately
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455832
If continuation sheet
Page 3 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455832
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/21/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Windsor Gardens
2535 W Pleasant Run
Lancaster, TX 75146
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
quarter sized area on the lateral right ankle that was open (missing the top layer of skin). No dressing was
present.
In an observation and interview on 5/20/2025 at 8:58 a.m., revealed Treatment Nurse C entered Resident
#3's room and confirmed Resident #3 did not have a dressing on his right lateral ankle. Treatment Nurse C
stated Resident #3 was supposed to have a dressing on his right lateral ankle, but it may have fell off when
Resident #3 was showered. Treatment Nurse C stated a nurse should have put another dressing over the
wound. Treatment Nurse C stated that dressings were important because they promoted healing, and all
staff were responsible for monitoring that dressings stayed on the residents. Treatment Nurse C stated the
risks to the residents was that they could develop an infection.
23.
Record review of Resident #4's Comprehensive MDS assessment revealed Resident #4 was a [AGE]
year-old female admitted to the facility on [DATE] with diagnoses of pressure ulcer of the sacral region
(lower back just above the buttocks), chronic kidney disease, and dysphagia (difficulty swallowing). Section
C of the MDS assessment revealed Resident #4's BIMs score was 11 (indicated moderate cognitive
impairment). Section M of the MDS assessment revealed Resident #4 had an area of moisture associated
skin damage and received pressure ulcer/injury care.
Record review of Resident #4's care plan with a print date of 5/21/2025 revealed Resident #4 was at risk for
infection and staff should use sterile technique policy for any treatments or care where there was an
actual/potential for loss of skin integrity.
Record review of Resident #4's printed physician orders dated 5/21/2025 revealed a physician's order for
wound care on Resident #4's sacrum that stated to cleanse the area with normal saline or skin cleanser,
pat dry, apply gauze-soaked Dakin's Solution (topical antiseptic), and cover with a dry dressing.
Record review of Resident #4's wound assessment dated [DATE] revealed Resident #4's sacral wound was
8.0cm long, 8.0cm wide, and 3.0cm deep.
In an observation and interview on 5/20/2025 at 8:30 a.m., revealed CNA D turned Resident #4 revealing a
large, uncovered wound to Resident #4's sacral area. CNA D stated there should have been a dressing and
if there was not a dressing on a resident's wound then the nurse should be notified. CNA D stated the nurse
would then apply a new dressing. CNA D stated she was not aware Resident #4's dressing was missing.
In an observation and interview on 5/20/2025 at 9:14 a.m., revealed Treatment Nurse C checked Resident
#4 for a dressing and confirmed the dressing was missing from the sacral region. Treatment Nurse C stated
she had not made her way to Resident #4 yet this morning and was not notified that the dressing was
missing. Treatment Nurse C stated the dressing may have fell off when the hospice aide bathed Resident
#4 earlier that morning. Treatment Nurse C stated it was not typical for Resident #4 to not have a dressing
and the nurse should have put a dressing on Resident #4 if they were aware it was missing.
In an interview on 5/20/2025 at 9:39 a.m., LVN E stated no one notified her that Resident #4 did not have a
dressing. LVN E stated if she had known Resident #4 did not have a dressing then she would have followed
the physician's orders and applied a new one. LVN E stated she would have then
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455832
If continuation sheet
Page 4 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455832
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/21/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Windsor Gardens
2535 W Pleasant Run
Lancaster, TX 75146
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
notified Treatment Nurse C that a dressing had been applied. LVN E reported the risk to the residents if
wounds did not have a dressing was that the wounds could get infected.
In an interview on 5/20/2025 at 3:00 p.m., Doctor F reported she visited the facility every Monday to assess
the residents' wounds. Doctor F reported that dressings were applied to wounds to protect the area from
urine and stool. Doctor F also stated that the dressings optimized healing, and every time a dressing was
removed that it took four hours to return to an optimal healing environment. Doctor F reported she expected
the wound care nurse to do the treatments when in the building, and the nurses to change the dressings if
they became dislodged or dirty.
In an interview on 5/21/2025 at 3:06 p.m., the DON reported dressings were applied to wounds to promote
healing, and she expected the nursing staff to follow the doctor's orders for wound care. The DON stated
CNAs should notify the nurse if they see a dressing was missing or soiled. The DON stated dressing should
have the correct date and initials on them. The DON stated the risks to the residents depended on their
comorbidities and declined to be more specific.
Record review of the facility policy titled Wound Management Policy, copyright dated 2023, revealed The
care service ensures that wounds . are managed and dressed appropriately to minimise the distress that
they cause and maximise healing.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455832
If continuation sheet
Page 5 of 5
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
FAQ · About this visit
Common questions about this visit
What happened during the May 21, 2025 survey of WINDSOR GARDENS?
This was a inspection survey of WINDSOR GARDENS on May 21, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WINDSOR GARDENS on May 21, 2025?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.