Windsor Gardens: PICC Line Care Failure - TX
Inspectors cited the facility under F0694, finding that staff failed to follow the physician's orders for the resident's peripherally inserted central catheter. The assistant director of nursing, when asked about it, said it was her responsibility to make sure those orders were carried out. She said she did not know why they had been missed.
A PICC line is not a routine IV. It is a long catheter threaded into a large vein near the heart, used when a patient needs medication or fluids over an extended period. Because it provides a direct path into the bloodstream, the maintenance protocol exists for one reason: to prevent infection.
Windsor Gardens' own policy, last updated in January 2013, states that the purpose of PICC line care is to provide standards for the safe maintenance of the catheter in order to reduce the risk of infection or dislodging. When the catheter is not in use, the policy requires flushing with 10 milliliters of sodium chloride at least every 12 to 24 hours. Staff are also required to assess the catheter site and check for skin breakdown, drainage, leaking connections, changes in catheter position, and any broken or loose sutures.
None of that happened as ordered.
A second facility policy, covering intravenous administration of fluids and electrolytes and dated April 2016, states plainly that a physician order is required before IV fluids or electrolytes are given. The inspection record does not detail whether that policy was violated separately or whether it reinforced the same failure, but inspectors included it in the citation.
The assistant director of nursing did not offer an explanation for why the orders were missed. She acknowledged it was important for infection control purposes. She acknowledged it was her responsibility. She did not know why it happened.
Inspectors rated the harm level as minimal harm or potential for actual harm, meaning the resident had not, by the time of the inspection, developed a documented infection or other confirmed injury from the lapse. That designation reflects what inspectors could verify, not a ceiling on what could have occurred. A PICC line left without required flushing and site assessment creates the conditions for catheter-related bloodstream infection, one of the more serious complications a nursing home resident can develop.
The inspection was conducted on August 23, 2025, as a complaint survey, meaning someone raised a concern that prompted investigators to come.
Windsor Gardens' own written standards have been in place for over a decade. The PICC line policy dates to 2013. The IV policy dates to 2016. The gap was not a matter of missing guidance. The orders were there. The policies were there. The person responsible said she did not know why the work was not done.
The resident whose catheter went without the required care is identified in the inspection record only by her status as a patient with a PICC line in place. What she was being treated for, how long the catheter had been in, and how long the lapse continued are not detailed in the inspection findings. What is documented is that a physician wrote orders, a facility policy backed those orders, and neither was followed.
The assistant director of nursing knew it was her job. She said so herself.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Windsor Gardens from 2025-08-23 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 6, 2026 · Our methodology
WINDSOR GARDENS in LANCASTER, TX was cited for violations during a health inspection on August 23, 2025.
The assistant director of nursing, when asked about it, said it was her responsibility to make sure those orders were carried out.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.