Windsor Gardens

Penalties

• Jun 11, 2024 — Fine ($13,877)

Inspection findings

1. Jan 15, 2026 Health · 10 findings
   • Not serious Scope/severity E

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Jan 21, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Jan 21, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0655 Resident Assessment and Care Planning Deficiencies

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

     Corrected Jan 21, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0656 Resident Assessment and Care Planning Deficiencies

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

     Corrected Jan 21, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Jan 21, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Jan 21, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Jan 21, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     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 Jan 21, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jan 21, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0929 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

     Corrected Feb 22, 2026 · CMS fire safety

2. Dec 8, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

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

     Corrected Dec 12, 2025 · CMS health inspection

3. Aug 23, 2025 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

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

     Corrected Sep 30, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Sep 30, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0694 Quality of Life and Care Deficiencies

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

     Corrected Sep 30, 2025 · CMS health inspection

4. May 21, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

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

     Corrected Jun 23, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0686 Quality of Life and Care Deficiencies

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

     Corrected Jun 23, 2025 · CMS health inspection

5. Nov 7, 2024 Health · 6 findings
   • Not serious Scope/severity D Complaint

     F0550 Resident Rights Deficiencies

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

     Corrected Nov 15, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     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 Nov 15, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Nov 15, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Nov 15, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0921 Environmental Deficiencies

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

     Corrected Nov 15, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Nov 13, 2024 · CMS fire safety

6. Aug 28, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

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

     Corrected Sep 23, 2024 · CMS health inspection

7. Aug 26, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0693 Quality of Life and Care Deficiencies

     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 Sep 23, 2024 · CMS health inspection

8. Jun 22, 2024 Health · 2 findings
   • Serious Scope/severity J Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

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

     Corrected Jul 19, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Jul 19, 2024 · CMS health inspection

9. Jun 11, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

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

     Corrected Jul 10, 2024 · CMS health inspection

10. Oct 5, 2023 Health · 6 findings
    • Not serious Scope/severity D Complaint

      F0812 Nutrition and Dietary Deficiencies

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

      Corrected Oct 20, 2023 · CMS health inspection

    • Not serious Scope/severity E

      K0291 Egress Deficiencies

      Install emergency lighting that can last at least 1 1/2 hours.

      Corrected Nov 1, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0345 Smoke Deficiencies

      Have approved installation, maintenance and testing program for fire alarm systems.

      Corrected Oct 6, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0351 Smoke Deficiencies

      Install an approved automatic sprinkler system.

      Corrected Oct 24, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0352 Smoke Deficiencies

      Properly install and monitor supervisory attachments on automatic sprinkler systems.

      Corrected Oct 6, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0511 Services Deficiencies

      Have properly installed electrical wiring and gas equipment.

      Corrected Oct 6, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• CASTANEDA, EDMUNDO — corporate officer, NOT APPLICABLE, since 01/10/2022
• CERISE, FREDERICK — corporate officer, NOT APPLICABLE, since 03/24/2014
• JOHNSON, NIKITA — adp of the snf, NOT APPLICABLE, since 01/10/2023
• JOHNSON, NIKITA — operational/managerial control, NOT APPLICABLE, since 01/10/2023
• MCFALLS, LASHONDA — adp of the snf, NOT APPLICABLE, since 04/11/2011
• DALLAS COUNTY HOSPITAL DISTRICT — 5% or greater direct ownership interest, 100%, since 02/15/2015
• WINDSOR PLACE HEALTH CARE CENTER LTD CO — operational/managerial control, NOT APPLICABLE, since 02/15/2015
• WINDSOR PLACE HEALTH CARE CENTER LTD CO — adp of the snf, NOT APPLICABLE, since 02/15/2015