Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 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 Nursing And Rehabilitation Center Of Harli during CMS and state inspections, most recent first.
The facility did not ensure that PPE was immediately available near or outside the rooms of all residents on Enhanced Barrier Precautions (EBP), instead storing PPE in supply closets located on specific halls. Staff and visitors had to retrieve PPE from these distant locations before providing high-contact care, despite facility policy and CDC guidelines requiring PPE to be accessible at the point of care. This deficiency affected all residents on EBP, including those with wounds, indwelling devices, or certain infections.
A resident with a history of PTSD and heart failure reported being struck by another resident with dementia who wandered into his room. Although staff responded and assessed both residents, the incident was not reported to the administrator or DON until the next morning, and notification to the state survey agency was delayed beyond the required timeframe. The facility did not follow immediate reporting protocols for alleged abuse as required by policy and regulation.
The facility failed to ensure that two residents received oxygen at the prescribed rates, with one resident receiving less and another receiving more than prescribed. Staff interviews confirmed the discrepancies, although no adverse symptoms were reported at the time of observation.
The facility failed to ensure a resident's drug regimen was free from unnecessary drugs, specifically prescribing Rexulti without an adequate indication. The resident did not have a documented diagnosis of dementia, and the care plan did not include dementia with agitation and psychosis. The medication was administered without proper documentation and adherence to facility policy.
The facility failed to maintain accurate medical records for a resident's oxygen settings, as the physician order was not transcribed into the electronic health records system. Despite the resident receiving oxygen at 3 L/min, there was no corresponding order, which staff acknowledged as a deviation from policy.
The facility failed to maintain an infection prevention and control program for a resident with multiple diagnoses, including ESBL to a wound. The resident's room lacked a clinical waste covered cart for proper disposal of contaminated PPE, leading to improper disposal practices. Staff interviews confirmed the absence of the necessary waste disposal cart and a lack of designated responsibility for placing these items in isolation rooms.
The facility failed to maintain accurate medical records and properly assess a resident's skin conditions, including dark discolorations and a diagnosis of bullous pemphigoid. Despite ongoing treatment, the resident's clinical records lacked documentation of these conditions, and staff interviews confirmed the oversight.
Failure to Provide Immediate PPE Access for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program that ensured personal protective equipment (PPE) was immediately available near or outside the rooms of all residents on Enhanced Barrier Precautions (EBP). Observations revealed that while appropriate signage was present on the doors of rooms requiring EBP, PPE was not located at or near these rooms. Instead, PPE was stored in supply closets located on specific halls, requiring staff to leave the immediate area of the resident to obtain necessary equipment before performing high-contact activities. In contrast, rooms on contact precautions had PPE readily available at the door or next to the room. Interviews with staff, including the Assistant Directors of Nursing (ADONs), Licensed Vocational Nurse (LVN), Certified Nursing Assistant (CNA), Director of Nursing (DON), and Infection Control Nurse (ICN), confirmed that PPE for EBP was not kept near the residents' rooms but rather in supply closets. Staff expressed uncertainty regarding the specific requirements for PPE placement for EBP, with some believing that having PPE available anywhere in the facility was sufficient. Staff also reported that retrieving PPE from distant supply closets was tedious and time-consuming, and signage did not clearly instruct visitors on PPE use or where to obtain it. Review of the facility's policies and CDC guidelines indicated that gowns and gloves should be made available immediately near or outside the resident's room for EBP. However, the facility's practice did not align with these requirements, as PPE was not stored in the required locations. The deficiency affected all 13 residents on EBP, including those with wounds, indwelling medical devices, or certain infections, as PPE was not immediately accessible for high-contact care activities as stipulated by policy.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than two hours after the allegation was made, as required by law. Specifically, an incident occurred in which a male resident with PTSD, depression, and chronic systolic heart failure reported that another resident, who had dementia and was known to wander, entered his room and struck him on the forehead. The incident took place during the night, and although staff responded to the resident's call for help and performed skin assessments, the event was not reported to the facility administrator or DON until the following morning. The initial response by staff included redirecting the confused resident back to his room and conducting skin assessments, which revealed no physical injuries. However, the LVN who responded to the incident only notified the charge nurse and did not escalate the report to the administrator or DON as required. The administrator and DON were made aware of the incident during their morning meeting, several hours after the event. At first, the resident denied any physical contact, but later stated he had been hit, leading to confusion about the nature of the incident and whether it was reportable. The delay in reporting was further compounded by the fact that the administrator and DON did not receive timely notification from the night staff, and the incident was not reported to the state survey agency until more than 24 hours after it occurred. The facility's own abuse prevention policy and state guidelines require immediate reporting of such incidents, regardless of the presence or absence of injury. The failure to report the alleged abuse in a timely manner constituted a deficiency in the facility's compliance with abuse reporting requirements.
Failure to Administer Prescribed Oxygen Rates
Penalty
Summary
The facility failed to ensure that residents who needed respiratory care received such care consistent with professional standards of practice and the comprehensive person-centered care plan. Specifically, Resident #84 received oxygen at a rate less than prescribed, and Resident #90 received oxygen at a rate higher than prescribed. These discrepancies were observed during a survey, and interviews with staff confirmed the deviations from the prescribed oxygen rates. Resident #84, who has a moderate cognitive impairment and multiple diagnoses including chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia, was observed receiving oxygen at 1.5 liters per minute (LPM) instead of the prescribed 2 LPM. Staff interviews revealed that nurses are responsible for ensuring the correct oxygen rates every shift, but the prescribed rate was not maintained. Despite this, no adverse symptoms were reported for Resident #84 at the time of the observation. Resident #90, who is cognitively intact and has diagnoses including chronic systolic heart failure and COPD, was observed receiving oxygen at 3 LPM instead of the prescribed 2 LPM. Staff interviews indicated that the resident did not exhibit any symptoms at the time of the observation, and the oxygen rate was corrected by the nurse. The facility's policy and training records were reviewed, showing that annual respiratory training is provided to staff, but the prescribed oxygen rates were still not adhered to in these cases.
Failure to Ensure Drug Regimen Free from Unnecessary Drugs
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary drugs, specifically for one resident who was prescribed Rexulti (brexpiprazole), an atypical antipsychotic, without an adequate indication for its use. The resident, a female with end-stage renal disease, hypertensive heart disease with heart failure, and other conditions, did not have a documented diagnosis of dementia, which was the stated reason for the prescription. Despite this, the medication was administered on two occasions, and the resident's care plan did not include any mention of dementia with agitation and psychosis. Interviews with staff revealed that the resident had been experiencing episodes of yelling and anxiety, which led to the in-house Psychiatric NP prescribing Rexulti. However, the NP's progress note and the diagnosis of dementia with psychotic disturbance were not immediately documented in the electronic medical record. The DON admitted to being behind on paperwork and did not upload the diagnosis or progress note in a timely manner. The resident's behavior had been managed with other interventions such as music and aroma therapy, which were unsuccessful, leading to the decision to try Rexulti. The facility's policy requires a psychoactive medication evaluation, consent for use, behavior monitoring, and care planning for the targeted behavior when initiating psychoactive medication therapy. These steps were not adequately followed, as evidenced by the lack of a documented diagnosis and care plan for dementia with agitation and psychosis. The failure to adhere to these protocols resulted in the administration of an antipsychotic medication without proper justification, putting the resident at risk of adverse reactions or harmful side effects.
Failure to Maintain Accurate Medical Records for Oxygen Settings
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards and practices for Resident #83. Specifically, the facility did not correctly transcribe the physician orders related to the oxygen setting for the resident. During an observation, it was noted that Resident #83 was receiving oxygen at 3 L/min via nasal cannula, but there was no corresponding physician order in the resident's clinical record. Interviews with the LVN, ADON, and DON confirmed that the physician order for the oxygen setting was missing from the electronic health records system (PCC). The staff acknowledged that the omission could have been due to a failure to transcribe the order or to discontinue it properly. The facility's policy requires a current list of orders to be maintained in each resident's clinical record, and the absence of this order was a deviation from that policy. Resident #83, a cognitively intact male with multiple diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, and Type 2 Diabetes Mellitus, was readmitted to the facility recently. Despite the resident not being in distress at the time of observation, the lack of a documented physician order for the oxygen setting posed a risk of inadequate treatment or care. The facility's policies on receiving and recording physician orders and oxygen administration were not followed, as confirmed by the staff during interviews. The DON emphasized that oxygen is considered a medication and requires a physician's order, which was missing in this case.
Failure to Provide Proper Waste Disposal for Contact Precautions
Penalty
Summary
The facility failed to maintain an infection prevention and control program for a resident with a diagnosis of ESBL to a wound, Alzheimer's Disease, Vascular Dementia, Parkinson's Disease, Major Depressive Disorder, Chronic Kidney Disease, and Essential Hypertension. The resident was placed on contact precautions, but the facility did not provide a clinical waste covered cart in the resident's room for the proper disposal of contaminated PPE. Observations revealed that the resident's room had a Contact Precautions sign, but no clinical waste covered cart was available, leading to improper disposal of gowns and gloves in small trash cans, which were then sealed and taken out by staff. Interviews with staff members, including a CNA, LVN, ADON, and DON, confirmed the absence of the necessary waste disposal cart and highlighted a lack of designated responsibility for placing these items in isolation rooms. The facility's Infection Prevention and Control Program Policy and procedure, dated 05/23/23, outlined the need for transmission-based precautions, including the proper disposal of contaminated PPE. Despite this policy, the facility did not ensure the availability of a clinical waste covered cart in the resident's room, potentially contributing to the spread of infection. Staff interviews indicated that while in-service training on infection control had been conducted, the necessary equipment was not provided, and there was no clear assignment of responsibility for ensuring that isolation rooms were properly equipped. This deficiency could place residents, staff, and visitors at risk of infection due to improper disposal of contaminated PPE.
Failure to Maintain Accurate Medical Records and Assess Skin Conditions
Penalty
Summary
The facility failed to maintain accurate and complete medical records for Resident #1, who had a diagnosis of bullous pemphigoid and dark discolorations on her bilateral upper and lower extremities. Despite the resident's condition, there was no documentation in her clinical records reflecting these skin conditions. The resident's care plans and weekly skin evaluations also lacked any mention of the dark discolorations, and the diagnosis of bullous pemphigoid was not entered into her physician orders. This oversight was confirmed through interviews with various staff members, including the ADON, LVNs, and the DON, who acknowledged the failure to document and assess the resident's skin conditions properly. Resident #1, an elderly female with severe cognitive impairment and multiple diagnoses, including rhabdomyolysis and functional quadriplegia, had been receiving treatment for her skin condition since January. However, the clinical records did not reflect the dark discolorations on her arms and legs, nor did they include the diagnosis of bullous pemphigoid. The resident's weekly skin evaluations, signed by LVN F, inaccurately reported no abnormal skin areas. Interviews with staff members revealed that they either did not notice the discolorations or failed to document them in the resident's clinical records. The DON admitted that the diagnosis of bullous pemphigoid was not entered into the resident's clinical records, and the MDS/RN missed the opportunity to add the diagnosis during a quarterly assessment. The facility's policies on documentation and skin assessment were not followed, leading to incomplete and inaccurate medical records for Resident #1. This failure to document and assess the resident's skin conditions could potentially result in missed deterioration in her condition and inadequate care.
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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 | 0.7 mi | — | 0 | 0 |
| Treasure Hills Healthcare And Rehabilitation Cente | 0.8 mi | — | 7 | 0 |
| Harlingen Nursing And Rehabilitation Center | 0.8 mi | — | 11 | 1 |
| Golden Palms Rehabilitation And Retirement | 1 mi | — | 5 | 0 |
| Windsor Atrium | 1.2 mi | — | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.