Windsor Gardens faces challenges in its CMS ratings, earning a D grade with a score of 52/100. The facility ranks in the 58th percentile among Texas nursing homes, suggesting significant room for improvement.
With 3.41 total nurse hours per resident per day, Windsor Gardens falls below the national average of 3.8 hours. Families may want to ask about staffing levels during any facility visit.
Recent CMS inspections identified 19 deficiencies at Windsor Gardens, including 2 classified as serious — among the most concerning citation levels. The most notable finding involved: provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist..
Score Breakdown
🏥 Staffing Details
| Staff Type | Hours/Resident/Day | National Avg | Comparison |
|---|---|---|---|
| Total Nursing | 3.41 | 3.8 | Below Average |
| Registered Nurses (RN) | 0.35 | 0.7 | Below Average |
| Licensed Practical Nurses (LPN) | 1.15 | 0.7 | Above Average |
| Certified Nursing Assistants (CNA) | 1.91 | 2.4 | Below Average |
| Weekend Total Nursing | 3.00 | 3.8 | Below Average |
| Weekend RN Hours | 0.24 | 0.7 | Below Average |
🔍 Inspection & Deficiency History
View recent deficiencies (5 shown)
- Tag 0755 Severity DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Dec 7, 2025 · Pharmacy Service Deficiencies
- Tag 0656 Severity DDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Aug 22, 2025 · Resident Assessment and Care Planning Deficiencies
- Tag 0684 Severity DProvide appropriate treatment and care according to orders, resident’s preferences and goals.Aug 22, 2025 · Quality of Life and Care Deficiencies
- Tag 0694 Severity DProvide for the safe, appropriate administration of IV fluids for a resident when needed.Aug 22, 2025 · Quality of Life and Care Deficiencies
- Tag 0686 Severity EProvide appropriate pressure ulcer care and prevent new ulcers from developing.May 20, 2025 · Quality of Life and Care Deficiencies
📊 Resident Outcome Measures
Based on CMS quality measure data. Lower percentages are better for most metrics.
| Measure | This Facility | Nat'l Avg | |
|---|---|---|---|
| Residents with pressure ulcers | 0.3% | 4.5% | Better |
| Falls with major injury | 0.7% | 3.0% | Better |
| On antipsychotic medication | 2.4% | 14.5% | Better |
| Urinary tract infections | 0.0% | 2.5% | Better |
| ADL decline (daily activities) | 13.6% | 14.0% | Average |
| Excessive weight loss | 0.4% | 7.5% | Better |
| New/worsened incontinence | 0.4% | 45.0% | Better |
⚠️ Penalties & Fines
1 penalty recorded by CMS
Total fines: $13,877
How This Grade Was Calculated
This facility's grade of D is based on a score of 52 out of 100, calculated from official CMS Nursing Home Compare data:
- Overall CMS Rating: 3★ → 24 pts (max 40)
- Health Inspection Rating: 3★ → 15 pts (max 25)
- Staffing Rating: 1★ → 4 pts (max 20)
- Quality Measures Rating: 5★ → 15 pts (max 15)
- Penalty deductions: -5 pts
- Fine deductions: -1 pts
Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40
Facility Details
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