Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Windsor Atrium during CMS and state inspections, most recent first.
Two residents experienced incomplete and inaccurate documentation of controlled substance administration, with staff failing to sign required medication records and narcotic logs as per facility policy. These lapses included missing signatures for Lorazepam and Hydromorphone administration, as well as discrepancies between medication counts and documentation, resulting in incomplete medical records.
The facility did not develop or implement comprehensive care plans for two residents: one who repeatedly refused medication for GERD and another with severe dementia who attempted to get out of bed without assistance and experienced multiple falls. Staff were unaware that these behaviors required care planning, and the facility's policy for person-centered care plans was not followed.
A medication cart on one hall was observed left unlocked and unattended near the nurse's station. An LVN responsible for the cart admitted forgetting to lock it when stepping away, and the DON confirmed that staff are expected to keep carts locked when not in use, as per facility policy.
A resident with diabetes, hypertension, and severe cognitive impairment developed a skin tear that was reported by a CNA to an LVN. The LVN cleansed the wound but failed to notify the physician or the resident's representative, as required by facility policy, resulting in a two-day delay in appropriate treatment and communication.
A resident with multiple chronic conditions experienced hypotension after dialysis, leading the ADON to obtain and administer Midodrine. However, the medication order was entered into the system by a new LVN with an incorrect start date, and the MAR was not signed by the ADON who gave the medication. This resulted in incomplete and inaccurate clinical documentation, as confirmed by staff interviews and record review.
A facility failed to ensure proper wound care for a resident, as the WCN did not follow physician orders for treating a wound on the left buttock. The resident, with a history of diabetes and dementia, had a wound that required specific treatment, but records showed no care was documented for several days. The WCN mistakenly believed the wound was healed and did not apply the prescribed treatment until the error was realized. The resident's condition was complicated by self-inflicted scratches and a decline due to COVID-19, but the WCD was satisfied with the care provided.
A resident with an indwelling catheter was observed with the catheter tubing improperly positioned above the body, restricting urine flow to the collection bag. Despite facility protocols and staff training, the catheter care was not managed correctly, potentially risking complications. Interviews with CNAs and the DON confirmed the improper positioning and the associated risks.
A resident with dementia and muscle weakness, requiring two-person assistance for bathing, fell and fractured her femur when a CNA provided care alone, contrary to the care plan. The CNA admitted to knowing the requirement but proceeded alone, leading to the resident slipping off the bed. The incident was reported, and the resident was sent to the hospital for evaluation.
A resident with dementia and muscle weakness, requiring a two-person assist for bathing, was injured when a CNA provided a bed bath alone, resulting in the resident falling and fracturing her femur. The CNA admitted to not following the care plan, which required two staff members for bathing assistance, leading to the accident.
A facility failed to ensure accurate PASARR Level 1 Screening for a resident with mental illness, leading to a lack of referral for necessary services. The resident had diagnoses including Depression and Schizoaffective Disorder, but the screening incorrectly indicated no mental illness. Staff interviews revealed a lack of proper assessment and documentation, with the MDS team responsible for the oversight.
The facility did not ensure residents and their representatives had access to survey results, as required. Six individuals were unaware of their right to review these results, and observations showed no survey binder or notice in the reception area. The administrator had the binder in his office due to remodeling, but no sign was posted to indicate its location.
A facility failed to include a fall mat in a resident's care plan, despite its presence in the resident's room. The resident, who has Alzheimer's and other health issues, was severely cognitively impaired. The DON admitted the oversight, citing her recent start at the facility. This omission could lead to staff not following through with the intervention, affecting the resident's care.
A resident with moderate cognitive impairment and diabetes did not receive timely nail care, leading to long and dirty fingernails. Despite being scheduled for nail care, inconsistencies in staff responsibilities and lack of documentation resulted in inadequate grooming. The facility lacked specific protocols for nail care frequency, contributing to the deficiency.
A facility failed to develop a baseline care plan for a newly admitted resident with complex medical conditions, omitting critical information such as full code status and Hoyer lift use. Interviews revealed confusion among staff about responsibilities for entering this information, with the DON emphasizing its importance for ensuring resident rights and appropriate care.
A resident's care plan inaccurately listed them as a dialysis patient and omitted the need for a mechanical lift for transfers. Despite staff being aware of the resident's actual needs through verbal communication, the care plan was not updated to reflect these needs, potentially risking inadequate care.
Incomplete and Inaccurate Medication Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, specifically regarding the documentation of controlled substances and medication administration. For one resident with severe cognitive impairment and a diagnosis of megaloblastic anemia and generalized anxiety disorder, the Individual Narcotic Record for Lorazepam was not signed as given on multiple occasions by both the ADON and an LVN. Additionally, discrepancies were observed between the amount of medication remaining in the bottle and the amount documented on the narcotic record. Staff interviews confirmed that the process for administering and documenting narcotics was not consistently followed, with staff acknowledging that missing signatures could lead to confusion and miscommunication regarding medication administration. For another resident with multiple diagnoses including a right arm fracture, diabetes mellitus type 2, and cervical disc displacement, the Medication Administration Record (MAR) for Hydromorphone was not initialed as given by an LVN, even though the Individual Narcotic Record indicated the medication had been administered. Staff interviews revealed that the LVN evaluated the resident before and after medication administration and stated that documentation was completed on both the MAR and narcotic sheet, but the MAR was missing the required entry. The DON confirmed that audits and in-services on medication administration and documentation were ongoing, and that discrepancies in documentation could result in medication errors. Facility policy required that staff sign the MAR after administering medication and, for controlled substances, also sign the narcotic record. Policies also mandated that all assessments, observations, and services provided be documented in accordance with state law and facility policy, including recording the date, time, and credentials of the person making the entry. The observed failures to document medication administration and narcotic usage as required by policy resulted in incomplete and inaccurate medical records for the affected residents.
Failure to Develop and Implement Comprehensive Care Plans for Resident Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by policy and regulation. For one male resident with a history of muscle weakness, sequelae of cerebral infarction, muscle wasting, and GERD, the care plan did not address his repeated refusal of prescribed medication (protonix). Despite the resident's moderate cognitive impairment and ability to communicate, there were no documented care plan goals, interventions, or tasks related to his medication refusal. Nursing staff reported the refusals to the physician but assumed the issue was already care planned, while the MDS nurse was unaware that such behaviors needed to be included in the care plan. For a female resident with muscle weakness, unspecified dementia, and muscle wasting, the facility did not develop or implement a care plan to address her attempts to get out of bed without assistance. This resident had severe cognitive impairment and was unable to communicate her needs or use the call light. Progress notes documented that she had fallen, resulting in injury and requiring emergency care. Multiple staff interviews confirmed that the resident frequently attempted to get out of bed unassisted and had experienced multiple falls, yet her behaviors were not reflected in her care plan. The MDS nurse was unaware that these behaviors should be care planned, and the DON considered the resident's actions as part of her disease process rather than a behavioral issue requiring care planning. The facility's policy requires the development and implementation of a comprehensive care plan for each resident, including measurable objectives and timeframes to address medical, nursing, mental, and psychosocial needs identified in the assessment. In both cases, the facility did not follow its own policy, resulting in the absence of care plans for significant resident needs and behaviors.
Unattended and Unlocked Medication Cart
Penalty
Summary
A deficiency was identified when the facility failed to ensure that all drugs and biologicals were stored in locked compartments and labeled according to professional standards. During an observation, a medication cart assigned to the 300 Hall was found unlocked and unattended near the nurse's station. No staff or residents were present at the time. Shortly after, an LVN responsible for the cart noticed it was unlocked and secured it. The LVN acknowledged responsibility for the cart and stated that it should have been locked whenever unattended, admitting she forgot to do so. Further interviews with the DON confirmed that multiple staff, including herself and the ADON, were responsible for ensuring medication carts were locked. The DON reiterated that staff were expected to lock the cart when leaving it unattended and recognized the potential for medications to be accessed by unauthorized individuals if left unsecured. Review of the facility's policy indicated that medication carts are to remain locked at all times when not in use and should not be left unlocked or unattended in resident care areas.
Failure to Notify Physician and Responsible Party of Skin Tear
Penalty
Summary
A resident with a history of diabetes mellitus type 2, essential hypertension, and severe cognitive impairment was identified as having limited mobility and was at risk for skin breakdown according to her care plan. During routine care, a CNA was informed by the resident's family member about a skin tear, which the CNA then reported to an LVN. The LVN assessed and cleansed the skin tear but failed to notify the physician or the resident's responsible party, as required by facility policy and professional standards of practice. The LVN stated that the omission occurred because he became occupied with another resident and forgot to make the necessary notifications. The facility's policy required prompt notification of the physician and the resident's representative in the event of a change in condition. The DON and ADON confirmed that the LVN did not follow protocol, resulting in the skin tear not being reported or treated according to physician orders for two days. The resident was at risk for infection due to the delay in appropriate treatment and communication.
Incomplete and Inaccurate Medication Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was being treated for multiple complex conditions, including chronic pulmonary edema, end stage renal disease, and type 2 diabetes. On the day in question, the resident returned from dialysis and experienced hypotension, prompting the ADON to obtain a physician's order for Midodrine to address the low blood pressure. The ADON administered the medication but did not enter the order into the system herself, instead allowing a new LVN to input the order. The LVN, unfamiliar with the process, entered the order with an incorrect start date, causing the medication administration record (MAR) to reflect the wrong date for the Midodrine order. Additionally, the MAR was not signed by the ADON, who had administered the medication, leaving the documentation incomplete. The facility's policies require that the MAR be reviewed and signed after medication administration, and that all services provided be accurately and timely documented in the resident's medical record. Interviews with the ADON, DON, and LVN confirmed that the order was entered incorrectly and that the MAR was not signed as required. This resulted in an incomplete and inaccurate clinical record for the resident, as the documentation did not accurately reflect the medication administration or the timing of the physician's order.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated appropriate competencies and skills to provide necessary wound care for a resident, leading to a deficiency in care. Specifically, the Wound Care Nurse (WCN) did not treat a resident's wound on the left buttock according to the physician's orders. The resident, who had a history of diverticulosis, Type 2 Diabetes Mellitus, and dementia, was admitted with a wound that required specific treatment with Santyl ointment. However, the Treatment Administration Record showed no documentation of wound care being provided from August 15 to August 21, 2024. Observations and interviews revealed that the WCN mistakenly believed the wound on the left buttock was healed and did not apply the prescribed treatment. This oversight was noted during a wound care session on August 19, 2024, when the WCN initially failed to clean and treat the wound on the left buttock. The WCN later corrected this by applying Santyl after realizing the mistake. Interviews with the WCN and other staff members indicated a misunderstanding of the physician's orders and a lack of proper documentation and communication regarding the resident's wound care needs. The resident's wound had shown signs of deterioration, with measurements indicating an increase in size before eventually decreasing. The deterioration was attributed to the resident's self-inflicted scratches and a decline in condition due to COVID-19. Despite the WCN's oversight, the Wound Care Doctor (WCD) expressed satisfaction with the care provided by the facility and the WCN, attributing the resident's condition to the effects of COVID-19 and the resident's comorbidities. The facility's Director of Nursing (DON) acknowledged the potential for wound deterioration and infection if wounds were not treated as ordered.
Improper Catheter Care Leading to Potential Complications
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, which could potentially lead to urinary tract infections and other complications. The resident, an elderly female with Alzheimer's Disease, muscle wasting, dehydration, and functional urinary incontinence, was observed with her catheter urine drainage port draped over the side rail, above the level of her body. This improper positioning of the catheter tubing was noted during multiple observations, indicating a restriction in the flow of urine to the collection bag. Interviews with facility staff, including CNAs and the Director of Nursing (DON), confirmed that the catheter tubing should not be positioned above the resident's body as it could cause backflow of urine and lead to complications. Despite the facility's training protocols, which instruct staff to hang the collection bag below the bladder, the catheter tubing was not properly managed for this resident. The care plan for the resident also specified the correct positioning of the catheter bag and tubing, which was not adhered to during the observations.
Neglect Due to Failure to Follow Care Plan
Penalty
Summary
The facility failed to ensure a resident's right to be free from neglect, resulting in a significant incident involving a resident who required two-person assistance for bathing. Despite being aware of this requirement, a CNA proceeded to provide care alone, leading to the resident falling and fracturing her left femur. The incident occurred when the CNA attempted to turn the resident to wash her back, and the resident slipped off the bed due to shorter bed rails and the resident being wet and slippery. The resident involved was an elderly female with a history of dementia, muscle weakness, and other health issues, including chronic obstructive pulmonary disease. Her care plan clearly indicated the need for two-person assistance for bathing due to her substantial/maximal assistance needs. The CNA admitted to knowing the care plan requirements but chose to bathe the resident alone, believing it would be manageable as she had done it before under different circumstances. The incident was immediately reported by the CNA, and the charge nurse assessed the resident, who was then sent to the hospital for evaluation due to injuries sustained from the fall. The CNA was subsequently removed from the floor and terminated following an investigation that confirmed the failure to adhere to the resident's care plan, which directly led to the resident's fall and injury.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and that residents received adequate supervision and assistance devices to prevent accidents. This deficiency was identified in the case of a resident who required a two-person assist for bathing due to her medical conditions, including dementia, muscle weakness, and lack of coordination. Despite this requirement, a CNA provided a bed bath to the resident alone, which resulted in the resident rolling out of bed and sustaining a left femoral fracture. The resident's care plan clearly indicated the need for substantial/maximal assistance for bathing, requiring two staff members to assist. However, the CNA, who had been trained on ADLs and knew the resident's care plan, chose to perform the bed bath alone. During the process, the resident slipped off the bed due to inadequate support and supervision, leading to her fall and subsequent injury. The CNA admitted to not following the care plan and acknowledged that the incident could have been prevented if the care plan had been adhered to. Interviews with facility staff, including the charge nurse and the DON, confirmed that the CNA did not follow the resident's care plan, which was a direct cause of the accident. The charge nurse responded promptly to the incident, and the resident was sent to the hospital for evaluation due to the injuries sustained. The facility's policy on quality of care emphasizes the need for adherence to care plans to maintain residents' highest possible functional status, which was not followed in this case.
Failure to Accurately Screen for Mental Illness in PASARR
Penalty
Summary
The facility failed to ensure that all residents with a serious mental disorder, intellectual disability, or related condition were properly assessed for PASARR Level II upon a significant change in status. Specifically, Resident #33, who had diagnoses including Depression, Schizoaffective Disorder Bipolar Type, and Post-Traumatic Stress Disorder, was not accurately screened for mental illness in the PASARR Level 1 Screening. The screening incorrectly indicated that there was no evidence of mental illness, despite the resident's documented diagnoses. Interviews with facility staff revealed that the MDS team was responsible for conducting assessments and reviewing medical histories. However, they failed to identify and document Resident #33's mental illness in the PASARR Level 1 Screening. This oversight was acknowledged by MDS staff and the Director of Nursing, who confirmed that the resident should have been referred to the Local Mental Health Authority for further assessment and potential services. The facility did not have a specific policy for PASARR, relying instead on state regulations.
Failure to Provide Access to Survey Results
Penalty
Summary
The facility failed to ensure that residents, family members, and legal representatives had easy access to the results of Federal or State surveys, as required by regulations. During a confidential interview, six individuals reported being unaware of the location of the survey results and their right to review them. Observations in the reception area revealed the absence of a surveyor binder and a notice indicating its location. The receptionist was unable to locate the binder, and it was later found in the administrator's office. The administrator explained that the survey binder was in his office due to recent remodeling activities, which included purchasing new furniture and painting the walls in the reception area. The maintenance director had removed the shelf that previously held the survey binder, and as a result, it was temporarily stored in the administrator's office. Despite these explanations, there was still no sign posted in the reception area indicating the location of the survey binder, which contributed to the deficiency.
Failure to Document Fall Mat in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as Resident #31, which included measurable objectives and timeframes to meet her medical and nursing needs. Specifically, the care plan did not address the use of a fall mat, an intervention that was observed in the resident's room. The resident, a female with Alzheimer's Disease, muscle weakness, muscle wasting and atrophy, unsteadiness on feet, and chronic obstructive pulmonary disease, was severely cognitively impaired as indicated by her BIMS score. Despite the presence of a fall mat in her room, this intervention was not documented in her care plan, which is a critical component for ensuring continuity and quality of care. Interviews with the Director of Nursing (DON) and MDS A revealed that the fall mat was not included in the care plan due to oversight and lack of communication. The DON, who was responsible for initiating care planning, admitted to not including the fall mat in the care plan because she had recently started working at the facility and was unaware of who initially implemented the intervention. The facility's policy on Quality of Care and Comprehensive Care Plans emphasizes the importance of documenting all necessary interventions in the care plan to maintain the highest possible functional status for residents. The failure to include the fall mat in the care plan could lead to staff not following through with the intervention, potentially affecting the resident's health promotion and continuity of care.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to provide adequate grooming and personal care for a resident who was unable to perform activities of daily living independently. The resident, who had a moderate cognitive impairment and required assistance with personal hygiene, was observed with long, pointy, and dirty fingernails. Despite being scheduled for nail care, the resident's nails were not trimmed in a timely manner, which could potentially lead to scratches, infection, and loss of self-esteem. The resident, who had a history of Type 2 diabetes mellitus and other health issues, expressed uncertainty about why her nails had not been cut as scheduled. Interviews with facility staff revealed inconsistencies in the nail care process. CNAs were responsible for cleaning and washing nails during bath times, but they did not clip nails for diabetic residents. The charge nurse indicated that any nurse could clip fingernails, but there was no clear documentation or protocol followed to ensure regular nail care. The Director of Nursing acknowledged the lack of specific written protocols for nail care frequency and relied on informal methods such as group texts to remind staff. The facility's policy required documentation of care services, but there was no record of the resident's nails being trimmed as per the schedule. This lack of documentation and adherence to protocols contributed to the deficiency in providing necessary grooming and personal care for the resident.
Failure to Implement Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, which is required to provide effective and person-centered care. The deficiency was identified for a resident who was admitted with multiple complex medical conditions, including an acquired absence of the right leg above the knee, end-stage renal disease, and liver cell carcinoma. The baseline care plan did not include critical information such as the resident's full code status and the use of a Hoyer lift, which are essential for ensuring appropriate care and communication among staff. Interviews with facility staff revealed a lack of clarity and responsibility regarding the entry of essential information into the baseline care plan. The Licensed Vocational Nurse (LVN) and Social Services staff indicated that the code status should be confirmed and entered by Social Services, while the Minimum Data Set (MDS) coordinator stated he was not responsible for baseline care plans. The Director of Nursing (DON) acknowledged the importance of including the code status and Hoyer lift information in the baseline care plan to ensure staff follow the resident's rights and provide appropriate care. The facility's policy requires the development of a baseline care plan within 48 hours of admission, including necessary healthcare information and interventions to address the resident's current needs.
Inaccurate Care Plan Documentation
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included incorrect information and omissions. The care plan inaccurately indicated that the resident was a dialysis patient, despite the resident not having received dialysis since admission. This error persisted even though the resident's doctor had determined that dialysis was no longer necessary based on lab results. Additionally, the care plan failed to document the resident's need for a mechanical lift for transfers, despite the resident's inability to bear weight on her right leg due to knee pain and swelling. Interviews with multiple staff members, including CNAs and nurses, confirmed that the resident was not a dialysis patient and required a mechanical lift for transfers. The staff were aware of the resident's needs through verbal communication from charge nurses, but these needs were not accurately reflected in the written care plan. The oversight in the care plan documentation did not result in a negative outcome for the resident, as staff were already using a mechanical lift for transfers based on their knowledge of the resident's condition. The facility's policy mandates the development of a comprehensive care plan that includes measurable objectives and timeframes to meet the resident's needs. However, the care plan for this resident did not comply with these requirements, as it contained outdated and incorrect information. The facility's failure to update the care plan in a timely manner could potentially place residents at risk of not receiving the necessary care or services tailored to their specific needs.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Harlingen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sun Valley Rehabilitation And Healthcare Center | 0.5 mi | — | 0 | 0 |
| Golden Palms Rehabilitation And Retirement | 0.7 mi | — | 5 | 0 |
| Treasure Hills Healthcare And Rehabilitation Cente | 0.9 mi | — | 7 | 0 |
| Windsor Nursing And Rehabilitation Center Of Harli | 1.2 mi | — | 2 | 0 |
| Harlingen Nursing And Rehabilitation Center | 1.7 mi | — | 11 | 1 |
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