Inspection Reports for
Windsor Atrium
1814 Atrium Pl Dr, Harlingen, TX 78550, United States, TX, 78550
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
13.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
291% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Dec 9, 2025
Visit Reason
The inspection was conducted as a standard annual survey to assess the facility's compliance with regulatory requirements related to resident care, medication management, and medical record maintenance.
Findings
The facility was found deficient in developing and implementing comprehensive, person-centered care plans addressing residents' needs, including medication refusal and fall risk. Additionally, medication carts were left unsecured, and documentation errors were noted in narcotic and medication administration records, potentially risking resident safety and care accuracy. Medical records for some residents were incomplete or inaccurately documented.
Deficiencies (3)
Failed to develop and implement a complete care plan addressing Resident #1's refusal of medication and Resident #4's attempts to get out of bed without assistance.
Failed to ensure all drugs and biologicals were stored in locked compartments; medication cart left unlocked and unattended.
Failed to maintain complete and accurate medical records for residents, including incomplete documentation on Individual Narcotic Records and Medication Administration Records.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 2
Medication doses not signed: 4
Medication dose not initialed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN G | Interviewed regarding Resident #1's refusal of medication and care plan | |
| MDS nurse | Interviewed about care plan responsibilities and deficiencies for Residents #1 and #4 | |
| DON | Director of Nursing | Interviewed about care plan updates, medication cart security, and medication administration |
| LVN A | Responsible for medication cart left unlocked and interviewed about medication administration process | |
| ADON | Assistant Director of Nursing | Interviewed about medication cart security and medication administration documentation |
| CNA E | Certified Nursing Assistant | Interviewed about Resident #4's attempts to get out of bed without assistance |
| CNA F | Certified Nursing Assistant | Interviewed about Resident #4's attempts to get out of bed without assistance |
| LVN D | Interviewed about Resident #4's falls and inability to use call light | |
| LVN B | Interviewed about medication administration and narcotic record documentation for Resident #2 | |
| LVN C | Interviewed about medication administration and documentation for Resident #3 | |
| Administrator | Interviewed about facility meetings, QAPI processes, and medication administration in-services |
Inspection Report
Routine
Deficiencies: 11
Date: Aug 29, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, care planning, infection control, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to obtain consent for psychotropic medication prior to administration, incomplete and untimely care plan updates, failure to provide timely assessment and care for a resident with a fracture, improper use of assistive devices during transfers, inadequate catheter care, failure to maintain proper oxygen therapy settings, unsecured diabetic lancet on medication cart, improper food handling and storage, incomplete medical record documentation, lapses in infection control practices including failure to enforce PPE use by visitors and improper glove use during catheter care, and ineffective pest control.
Deficiencies (11)
Failure to ensure residents were fully informed and consented to psychotropic medication prior to administration.
Failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timely updates.
Failure to provide timely assessment and care for a resident with an acute displaced fracture, including delayed reporting by CNAs.
Failure to use footrests during transfer of a resident, placing resident at risk of injury.
Failure to prevent urinary catheter tubing from touching the floor, risking cross contamination and infection.
Failure to provide respiratory care consistent with physician orders, including incorrect oxygen settings and failure to administer ordered oxygen.
Failure to secure diabetic lancet on medication cart, risking resident access and injury.
Failure to store, prepare, distribute, and serve food in accordance with professional standards, including improper labeling and lack of hand hygiene and glove use during food preparation.
Failure to maintain complete and accurate clinical documentation, including missing progress notes for several months.
Failure to maintain an infection prevention and control program ensuring proper use of PPE by visitors, proper labeling of IV dressings, and appropriate glove use during catheter care.
Failure to maintain effective pest control program, with sightings of live roaches and ants in the facility.
Report Facts
Residents reviewed for consent for antipsychotic medications: 5
Residents reviewed for comprehensive care plans: 5
Residents reviewed for comprehensive care plan revisions: 8
Residents reviewed for quality of care: 5
Residents reviewed for transfers: 3
Residents reviewed for indwelling catheters: 5
Residents reviewed for respiratory care: 5
Medication carts observed: 4
Residents reviewed for medical records accuracy: 4
Residents reviewed for infection control issues: 5
Pest control sightings in June 2025: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN I | Licensed Vocational Nurse | Named in medication consent and fracture assessment findings |
| DON | Director of Nursing | Named in multiple findings including care plan updates, infection control, and medication administration |
| Administrator | Named in oversight and interview regarding missing documentation and infection control | |
| CNA N | Certified Nursing Assistant | Named in fracture delayed reporting finding |
| CNA E | Certified Nursing Assistant | Named in fracture delayed reporting and transfer without footrest findings |
| LVN A | Licensed Vocational Nurse | Named in oxygen therapy and catheter care findings |
| RN J | Registered Nurse | Named in medication consent and lancet storage findings |
| MDS RN | MDS Coordinator | Named in care plan update findings |
| LVN O | Licensed Vocational Nurse | Named in oxygen therapy findings |
| CNA C | Certified Nursing Assistant | Named in catheter care glove use findings |
| CNA B | Certified Nursing Assistant | Named in catheter tubing on floor finding |
| LVN P | Licensed Vocational Nurse | Named in IV dressing labeling finding |
| CNA G | Certified Nursing Assistant | Named in infection control PPE use findings |
| FM | Family member interviewed regarding PPE use | |
| Maintenance Director | Named in pest control findings | |
| DM | Dietary Manager | Named in food handling and glove use findings |
| RN J | Registered Nurse | Named in lancet storage findings |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 26, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate treatment and care for a resident's skin tear.
Complaint Details
The complaint investigation found that LVN A failed to notify the doctor about Resident #1's skin tear in a timely manner, despite being informed by CNA B. The delay in notification lasted two days, increasing the risk of infection. The ADON and DON confirmed the failure to report and monitor the condition appropriately. The facility's Notification of Changes Policy requires prompt notification to the resident, physician, and representative when changes occur.
Findings
The facility failed to ensure that Resident #1 received treatment and care according to professional standards and the person-centered care plan. Specifically, LVN A failed to communicate and provide timely treatment for Resident #1's skin tear, resulting in a delay of two days before the doctor was notified, placing the resident at risk for infection.
Deficiencies (1)
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals for Resident #1's skin tear.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Failed to communicate and provide treatment for Resident #1's skin tear and delayed notifying the doctor. | |
| CNA B | Reported to LVN A that Resident #1 had a skin tear. | |
| ADON | Assistant Director of Nursing | Stated that nurse was supposed to assess Resident #1 and report the skin tear to the doctor and carry out doctor's orders. |
| DON | Director of Nursing | Confirmed LVN A cleansed the skin tear but forgot to notify the doctor, placing Resident #1 at risk for infection. |
Inspection Report
Deficiencies: 2
Date: Jun 21, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards regarding clinical documentation and medical records accuracy, specifically reviewing Resident #1's medical records and medication administration records.
Findings
The facility failed to maintain accurate and complete medical records for Resident #1, including an inaccurately dated medication order for Midodrine and an unsigned medication administration record (MAR) by the Assistant Director of Nursing (ADON). This deficiency could lead to miscommunication, delays in services, or potential decline in resident health.
Deficiencies (2)
Failed to maintain medical records in accordance with accepted professional standards and practices that are complete and accurately documented for Resident #1.
Resident #1's June 2025 MAR order for Midodrine was inaccurately dated and the MAR was not signed by the ADON who administered the medication.
Report Facts
BIMS score: 10
Medication order date: Jun 14, 2025
Blood pressure reading: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON | Assistant Director of Nursing | Obtained the Midodrine order, administered the medication, and failed to sign the MAR |
| LVN-E | Licensed Vocational Nurse | Entered the Midodrine order into the system incorrectly and did not sign the MAR |
| DON | Director of Nursing | Provided information about the medication order transcription error |
Inspection Report
Routine
Deficiencies: 2
Date: Aug 21, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with nursing care standards, specifically regarding wound care treatment for Resident #1, following physician orders.
Findings
The facility failed to ensure that nursing staff treated Resident #1's wound on the left buttock according to the doctor's orders, resulting in potential risks of infection, wound worsening, and pain. Observations and interviews revealed inconsistent wound care and documentation, with the wound care nurse not treating the left buttock wound as ordered.
Deficiencies (2)
Failure to provide appropriate wound care treatment to Resident #1's left buttock wound per physician's orders.
The facility's Physician Visits and Physician Delegation Policy did not address the nurse following physician orders.
Report Facts
Wound measurements: 10
Wound measurements: 30
Wound measurements: 3.8
Dates with no nurse check off for wound care: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| WCN A | Wound Care Nurse | Named in wound care treatment deficiency for Resident #1 |
| WCD | Physician | Provided wound care orders and interviewed regarding Resident #1's condition |
| CNA D | Certified Nursing Assistant | Reported noticing Resident #1's wounds worsening and notifying nurses |
| CNA E | Certified Nursing Assistant | Reported Resident #1 scratched a lot and nurses applied cream |
| RN F | Weekend Wound Care Nurse | Notified of worsening wounds and new orders for Resident #1 |
| DON | Director of Nursing | Interviewed regarding staff statements and wound care oversight |
| ADON A | Assistant Director of Nursing | Interviewed about wound care order verification and oversight |
| LVN B | Licensed Vocational Nurse | Provided wound care assessment and treatment orders |
| CNA C | Certified Nursing Assistant | Assisted wound care nurse during observation |
Inspection Report
Routine
Deficiencies: 1
Date: Jul 25, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with appropriate care standards for residents who are continent or incontinent of bowel/bladder, specifically focusing on catheter care and prevention of urinary tract infections.
Findings
The facility failed to ensure that a resident with an indwelling catheter had the catheter tubing positioned correctly below the bladder, as it was observed draped over the side rail above the body, potentially restricting urine flow and increasing risk of infection. Staff interviews confirmed improper catheter tubing placement despite training, though the resident showed no signs of urinary tract infection at the time.
Deficiencies (1)
Resident #1's catheter urine drainage port was draped over the side rail (above the body) restricting flow of urine to the collection bag.
Report Facts
Residents Affected: 1
Facility Female Urinary Indwelling Catheter Care Competency items: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Confirmed tubing hanging over resident's side rail was part of catheter and stated tubing should not be above the body | |
| CNA B | Stated catheter tubing should not be above resident's body to prevent back flow and complications | |
| DON | Confirmed staff training on catheter care and proper tubing placement below bladder to prevent infections |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 27, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding neglect and failure to follow care plans for residents, specifically focusing on Resident #250 who suffered a fall and fracture due to inadequate assistance during a bed bath.
Complaint Details
The complaint investigation revealed that CNA C failed to follow Resident #250's care plan requiring two-person assistance during bathing, resulting in the resident falling and sustaining a femoral fracture. CNA C was terminated on the same day. The facility also failed to ensure accurate PASARR screening for Resident #33, potentially denying needed specialized services.
Findings
The facility failed to ensure Resident #250 received the required two-person assistance during a bed bath, resulting in a fall and a left femoral fracture. The responsible CNA was terminated, and the facility implemented staff in-service training on care plan adherence and resident assistance. Additionally, the facility failed to ensure accurate PASARR screening for Resident #33, potentially impacting access to specialized services.
Deficiencies (3)
Failure to protect Resident #250 from neglect by not providing two-person assistance during bed bath, resulting in fall and fracture.
Failure to ensure accurate PASARR Level 1 Screening for Resident #33, missing mental illness diagnosis.
Failure to ensure nursing home area was free from accident hazards and provide adequate supervision to prevent accidents for Resident #250.
Report Facts
Residents affected: 4
Residents affected: 3
Date of fall incident: Mar 15, 2024
Date of survey completion: Jun 27, 2024
Employee tenure: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nursing Assistant | Named in neglect and fall incident for Resident #250; terminated for failure to follow care plan |
| LVN H | Licensed Vocational Nurse | Charge nurse on duty during Resident #250 fall incident; reported and assessed resident |
| DON | Director of Nursing | Conducted investigation into Resident #250 fall incident and CNA C's actions |
| Administrator | Facility Administrator | Oversaw investigation and staff in-service following Resident #250 incident |
| MDS T | MDS Assessor | Assigned to Resident #33; noted PASARR screening error |
| MDS R | MDS Assessor | Reviewed Resident #33's medical history and PASARR screening; acknowledged error |
| CNA E | Certified Nursing Assistant | Interviewed regarding training on ADL assistance |
| CNA F | Certified Nursing Assistant | Interviewed regarding training on ADL assistance |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jun 27, 2024
Visit Reason
The inspection was conducted based on complaints and allegations regarding residents' rights to review survey results, neglect resulting in injury, PASARR screening errors, incomplete care plans, inadequate assistance with activities of daily living, and environmental safety hazards.
Complaint Details
The complaint investigation was substantiated with findings of neglect resulting in injury to Resident #250, failure to provide proper care and assistance, and failure to maintain a safe environment. Immediate Jeopardy was identified for Resident #250 on 03/15/2024 but was corrected before the investigation began.
Findings
The facility failed to ensure residents' rights to access survey results, neglected a resident resulting in a fall and fracture due to inadequate assistance, failed to accurately complete PASARR screenings, did not develop comprehensive care plans including fall mat use, and failed to provide proper nail care. The facility also failed to maintain a safe environment and provide adequate supervision to prevent accidents.
Deficiencies (6)
Failed to ensure residents' right to review survey results were readily accessible and failed to post notice of availability.
Failed to protect resident from neglect resulting in a fall and left femur fracture due to CNA providing care alone instead of two-person assist.
Failed to ensure accurate PASARR Level 1 Screening for mental illness, resulting in lack of referral for specialized services.
Failed to develop and implement a comprehensive person-centered care plan addressing fall mat use for a resident.
Failed to provide assistance with nail care for a resident, resulting in long, dirty fingernails and risk of injury.
Failed to ensure a safe environment and adequate supervision to prevent accidents, resulting in a resident falling out of bed and sustaining a fracture.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
BIMS score: 9
BIMS score: 8
BIMS score: 4
Date of fracture: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nursing Assistant | Named in neglect and injury finding for Resident #250; admitted to providing care alone despite two-person assist requirement; terminated on 03/15/2024. |
| LVN H | Licensed Vocational Nurse | Charge nurse on 03/15/2024 who responded to Resident #250's fall and reported incident. |
| DON | Director of Nursing | Conducted investigation of Resident #250 fall; confirmed CNA C's failure to follow care plan; involved in staff in-service. |
| Administrator | Facility Administrator | Provided survey binder; involved in investigation and termination of CNA C; confirmed staff in-service. |
| MDS T | MDS Assessor | Assigned to Resident #33; noted PASARR screening error. |
| MDS R | MDS Assessor | Reviewed Resident #33's diagnoses; acknowledged PASARR screening error and plan to correct. |
| MDS A | MDS Assessor | Noted fall mat for Resident #31 was not care planned. |
| CNA N | Certified Nursing Assistant | Reported CNAs clean nails but do not clip diabetic residents' nails. |
| CNA O | Certified Nursing Assistant | Reported CNAs clean nails and residents visit beauty shop for nail care. |
| LVN P | Licensed Vocational Nurse | Charge nurse; coordinated podiatrist rounds; stated nurses clip fingernails; nervous about negative effects of not clipping nails. |
| LVN Q | Licensed Vocational Nurse | Clipped Resident #57's fingernails; stated nails are clipped every Sunday by nurses. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 9, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to develop and implement baseline and comprehensive care plans for residents, specifically concerning Resident #2's baseline care plan and Resident #1's comprehensive care plan.
Complaint Details
The complaint investigation revealed failures in baseline and comprehensive care planning for residents, including missing code status and transfer instructions for Resident #2, and inaccurate dialysis and transfer information for Resident #1. Interviews with staff including LVNs, CNAs, Social Services, MDS, and the Director of Nursing confirmed these issues and the facility's policies on care planning were reviewed.
Findings
The facility failed to develop and implement a baseline care plan for Resident #2 that included full code status and use of a Hoyer lift, and failed to ensure Resident #1's comprehensive care plan accurately reflected dialysis status and need for mechanical lift transfers. These deficiencies could place residents at risk of not receiving appropriate care and interventions.
Deficiencies (3)
Failed to develop and implement a baseline care plan for Resident #2 including full code status and use of a Hoyer lift.
Failed to develop and implement a comprehensive care plan for Resident #1 that accurately reflected dialysis status and need for mechanical lift transfers.
Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment.
Report Facts
Residents reviewed for baseline care plan: 6
Residents reviewed for comprehensive care plans: 3
BIMS score for Resident #2: 13
BIMS score for Resident #1: 8
Dialysis schedule: 3
Dates of care plan revisions for Resident #1: 2
Inspection Report
Routine
Deficiencies: 8
Date: Apr 6, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, food safety, and care planning at Windsor Atrium nursing home.
Findings
The facility was found deficient in several areas including failure to ensure call lights were within residents' reach, incomplete and inaccurate care plans, inadequate monitoring and documentation of resident weight loss, unclear medication orders and documentation, improper labeling and storage of medications, unsafe food storage and handling practices, incomplete medical record documentation, and lapses in infection prevention and control practices including hand hygiene and signage for COVID-19 precautions.
Deficiencies (8)
Failure to ensure call lights were within reach for residents #35 and #59.
Failure to develop and implement comprehensive, person-centered care plans for residents #60 and #83.
Failure to maintain acceptable nutritional status and monitor weight loss for Resident #60.
Failure to clarify parameters for administering blood pressure medication for Resident #13.
Failure to label medications in accordance with professional principles for Resident #13.
Failure to store, prepare, distribute, and serve food safely; presence of unlabeled, undated, and expired food items in nutrition rooms; incomplete temperature logs.
Failure to maintain complete and accurate medical records including documentation of blood pressure readings for Resident #13.
Failure to maintain infection prevention and control program including improper wound care technique, inadequate hand hygiene between glove changes, and missing signage for COVID-19 precautions.
Report Facts
Residents reviewed for call light issue: 2
Residents reviewed for care plans: 12
Weight loss monitoring gap: 91
Medication administration observation date: Apr 4, 2023
Hand hygiene in-service frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN G | Licensed Vocational Nurse | Responsible for ensuring call lights were within resident reach; stated CNAs needed continuous reminding. |
| RN ADON G | Registered Nurse Assistant Director of Nursing | Oversight of staff and call light placement; clarified medication orders; stated importance of care plans and hand hygiene. |
| CNA A | Certified Nursing Assistant | Described weighing procedures and issues with call light placement. |
| LVN E | Licensed Vocational Nurse | Provided dietary and weight monitoring information; described weighing procedures. |
| DON | Director of Nursing | Provided multiple interviews regarding care plans, infection control, food safety, and medication documentation. |
| MA C | Medication Aide | Observed holding medication due to unclear order; took blood pressure readings. |
| CNA I | Certified Nursing Assistant | Observed failing to sanitize hands between glove changes during incontinent care. |
| MA J | Medication Aide | Observed failing to sanitize hands between glove changes during incontinent care. |
| ES | Environmental Services | Reported housekeeping responsibilities for cleaning nutrition room refrigerators. |
| LVN H | Licensed Vocational Nurse | Discussed importance of hand hygiene and infection control. |
Inspection Report
Routine
Deficiencies: 1
Date: Mar 17, 2023
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically regarding the isolation of COVID-19 positive residents from negative residents.
Findings
The facility failed to maintain an effective infection prevention and control program by not isolating a COVID-19 positive resident (R#27) from a COVID-19 negative resident (R#24) who shared the same room, potentially placing residents at risk for infection.
Deficiencies (1)
Failure to ensure that a positive COVID-19 resident was isolated from negative COVID-19 residents.
Report Facts
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON | Interviewed regarding COVID-19 positive and negative residents sharing a room | |
| Administrator | Interviewed about facility's COVID-19 rooming practices and CDC guidance | |
| MA P | Interviewed about COVID-19 positive resident sharing room with negative resident | |
| DON | Interviewed about moving residents to separate rooms when available |
Viewing
Loading inspection reports...
