Cycle 1
Health 2025-08-29 · Fire 2025-08-29
17 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Harlingen, TX
Windsor Atrium
3-star overall rating with 2-star inspections with $37,457 in total fines with 17 recent health deficiencies
1814 Atrium Place, Harlingen, TX
(956) 230-2300
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
96
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Wellsential Health
Operator or chain grouping
Approved since
2007-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.31
Registered nurse staffing
LPN hours / resident day
1.18
Licensed practical nurse staffing
Aide hours / resident day
2.35
Nurse aide staffing
Weekend hours
3.44
Weekend nurse staffing
RN turnover
29%
Annual RN turnover
Total nurse turnover
50%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.3%
1.7 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.3% |
2.7%
0.4 pts better
|
11.4%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 6.0% |
3.3%
2.7 pts worse
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.8% |
18.9%
5.1 pts better
|
19.6%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 3.4% |
10.8%
7.4 pts better
|
16.7%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.7% |
0.0%
0.7 pts worse
|
0.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.8% |
15.4%
5.6 pts better
|
16.3%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.9% |
16.1%
8.2 pts better
|
14.9%
7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.0% |
15.0%
6 pts worse
|
19.8%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 0.7% |
4.2%
3.5 pts better
|
5.1%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.7% |
12.0%
6.3 pts better
|
12.0%
6.3 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.9% |
88.0%
10.9 pts better
|
79.7%
19.2 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.8% |
25.9%
2.1 pts better
|
23.9%
0.1 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-27 · Fire 2024-06-27
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-04-06 · Fire 2023-04-06
9 health deficiencies
Top issue: Infection Control (2 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-13
E · Potential for more than minimal harm
2024-06-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-13
D · Potential for more than minimal harm
2023-04-06
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-04-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-09
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-12-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-12-09
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-12-10
J · Immediate jeopardy
2025-08-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-30
E · Potential for more than minimal harm
2025-08-29
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-08-30
D · Potential for more than minimal harm
2025-08-29
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-08-30
D · Potential for more than minimal harm
2025-08-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-08-30
D · Potential for more than minimal harm
2025-08-29
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-08-30
D · Potential for more than minimal harm
2025-08-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-30
D · Potential for more than minimal harm
2025-08-29
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-08-30
D · Potential for more than minimal harm
2025-08-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-30
D · Potential for more than minimal harm
2025-08-29
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-08-30
D · Potential for more than minimal harm
2025-08-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-30
D · Potential for more than minimal harm
2025-08-29
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-08-30
D · Potential for more than minimal harm
2025-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-30
D · Potential for more than minimal harm
2025-06-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-06-21
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-06-22
D · Potential for more than minimal harm
2024-08-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-18
D · Potential for more than minimal harm
2024-07-25
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-07-26
J · Immediate jeopardy
2024-06-27
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-03-15
J · Immediate jeopardy
2024-06-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-06-27
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-27
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-27
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-05-09
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-05-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-23
E · Potential for more than minimal harm
2023-04-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-04-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-04-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-04-06
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-04-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-04-06
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-04-06
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-04-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-20
Penalties and ownership
What sits behind the stars
$13,010
2025-08-29
Fine
Fine · fine $13,010
Fine
$14,697
2024-06-27
Fine
Fine · fine $14,697
Fine
$9,750
2023-03-17
Fine
Fine · fine $9,750
Fine
Ownership
Starr County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Campos, Michael
Operational/Managerial Control · Individual
Dekowski, Donovan
Operational/Managerial Control · Individual
Munoz, Thalia
Corporate Officer · Individual
Regency Ihs Of Windsor Atrium LLC
Operational/Managerial Control · Organization
Regency Integrated Health Services LLC
Operational/Managerial Control · Organization
Starr County Hospital District
Operational/Managerial Control · Organization
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