Windsor Gardens
Inspection Findings
F-Tag F0656
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
care. In an interview with facility's DON on 08/22/2025 at 12:32 PM, she stated she was not aware of Resident #1's skin concerns around her genital area as it has not been documented or reported to her. She stated she expected any skin changes to be properly assessed by her staff, which would then triggered care plan interventions for her clinical leadership to review and add to the comprehensive care plan to ensure proper care for the resident. Record review of the facility policy Care Plans - Comprehensive, dated 09/2010 revealed an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. 1. Our facility's Care Planning/Interdisciplinary Team in coordination with the resident. develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning
the resident may be expected to attain. 3. Each resident's comprehensive care plan is designed to: a. incorporate identified problem areas b. Incorporate risk factors associated with identified problems c. Build
on the resident's strengths . g. Aid in preventing or reducing declines in the resident functional status an/or functional levels h. enhance optimal functioning of the resident by focusing on a rehabilitative program i.
Reflect currently recognized standards of practice for problem areas and conditions. 8. Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's conditions change.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 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
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/23/2025
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-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
failure to complete weekly skin assessments can affect the residents tremendously and could lead to sepsis and death. He stated the last in service on wounds took place approximately two weeks ago. In an
interview with the ADM on 8/23/2025 at 11:03am she stated it was the charge nurse's and wound care nurse's responsibility to complete weekly skin assessments. She stated there were several systems in place to ensure skin assessments were being completed. She stated she would assume she would assume someone missed the documentation on weekly skin assessments for Resident #2 because nothing was there. She stated failure to document completed skin assessments and follow protocol could cause staff to miss any new skin issues. She stated in-services on skin assessments are completed every quarter and as needed. In an interview with LVN D on 8/23/2025 at 12:26pm he stated it was the charge nurse's or wound care nurse's responsibility to completed skin assessments as ordered. He stated aides should also share any skin issues with the nurse when aides performed incontinent care or showered to residents. He stated skin assessments were documented in the TAR. He stated he could not recall not completing weekly skin assessments on Resident #2 or any other resident. He stated failure to complete skin assessments could cause a big issue such as skin breakdowns that could become worse. He stated staff was in serviced on skin assessments continuously and as needed. He stated he could not recall the last in service on skin assessments. Record review of the facility's Patient Care Management System 1 dated July 2022 revealed
- 1. The Treatment Nurse or Nurse Manager designee will complete a head-to-toe assessment and document
in the EMR to validate the findings of the initial skin assessment. Head to toe assessments must be completed weekly and prior to discharge/transfer of a Patient. 19. The Director of Nursing or designee will audit and verify system compliance weekly including prevention focused rounding and education as appropriate. Record review of facility policy Skin, dated 07/2022, revealed . 2. Head-to-toe assessments must be completed weekly. 7. Non-Pressure Injury Plan of Care will be completed by the Treatment Nurse or Charge Nurse upon identification. and updated with any changes to interventions and upon resolution.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 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
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/23/2025
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-Tag F0694
F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
physician orders for her PICC line and it was the ADON's responsibility to ensure it was completed. She stated she was not aware of why it was missed but it was important for infection control purposes. Record
review of facility policy, Care of Peripherally Inserted Central Catheter dated 01/2013, revealed Purpose. To provide standards for the safe maintenance of a PICC line in order to reduce the risk of infection or dislodging. catheter is to remain in place for the duration of treatment unless signs of complications occur.when catheter is not in use flush at least 12-24 hours with 10 ml sodium chloride 0.9% . Procedure.
Assess catheter site. Observe for the following: Skin breakdown, drainage site, leaking connections, catheter integrity, any change in catheter position, broken or loose suture. Record review of facility policy, Intravenous Administration of Fluids and Electrolytes, dated 04/2016 revealed 1. A physician order is necessary to give intravenous fluids and electrolytes.
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WINDSOR GARDENS in LANCASTER, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LANCASTER, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WINDSOR GARDENS or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.