Windsor Atrium

Penalties

• Aug 29, 2025 — Fine ($8,457)
• Jun 27, 2024 — Fine ($14,697)

Inspection findings

1. May 8, 2026 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0756 Pharmacy Service Deficiencies

     Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

     Corrected May 9, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected May 9, 2026 · CMS health inspection

2. Dec 9, 2025 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Dec 10, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0761 Pharmacy Service Deficiencies

     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 Dec 10, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Dec 10, 2025 · CMS health inspection

3. Aug 29, 2025 Health · 12 findings
   • Not serious Scope/severity D

     F0552 Resident Rights Deficiencies

     Ensure that residents are fully informed and understand their health status, care and treatments.

     Corrected Aug 30, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Aug 30, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Aug 30, 2025 · CMS health inspection

   • Serious Scope/severity J

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Aug 30, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Aug 30, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     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 Aug 30, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Aug 30, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     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 Aug 30, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Aug 30, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Aug 30, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Aug 30, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0925 Environmental Deficiencies

     Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

     Corrected Aug 30, 2025 · CMS health inspection

4. Jun 26, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Jun 27, 2025 · CMS health inspection

5. Jun 21, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Jun 22, 2025 · CMS health inspection

6. Aug 21, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Sep 18, 2024 · CMS health inspection

7. Jul 25, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0690 Quality of Life and Care Deficiencies

     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 Jul 26, 2024 · CMS health inspection

8. Jun 27, 2024 Health · 8 findings
   • Not serious Scope/severity D

     F0577 Resident Rights Deficiencies

     Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

     Corrected Jun 28, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Mar 15, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0644 Resident Assessment and Care Planning Deficiencies

     Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

     Corrected Jun 28, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Jun 28, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Jun 28, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Mar 15, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jun 13, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Jun 13, 2024 · CMS fire safety

9. May 9, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected May 23, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected May 23, 2024 · CMS health inspection

10. Apr 6, 2023 Health · 9 findings
    • Not serious Scope/severity D

      F0558 Resident Rights Deficiencies

      Reasonably accommodate the needs and preferences of each resident.

      Corrected Apr 21, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0656 Resident Assessment and Care Planning Deficiencies

      Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

      Corrected Apr 21, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0692 Quality of Life and Care Deficiencies

      Provide enough food/fluids to maintain a resident's health.

      Corrected Apr 21, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0755 Pharmacy Service Deficiencies

      Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

      Corrected Apr 21, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0761 Pharmacy Service Deficiencies

      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 Apr 21, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0812 Nutrition and Dietary Deficiencies

      Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

      Corrected Apr 21, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0842 Resident Assessment and Care Planning Deficiencies

      Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

      Corrected Apr 21, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Apr 21, 2023 · CMS health inspection

    • Not serious Scope/severity D

      K0521 Services Deficiencies

      Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

      Corrected Apr 5, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BAIRD, DANIEL — managing control - governing body, NOT APPLICABLE, since 04/13/2021
• CAMPOS, MICHAEL — operational/managerial control, NOT APPLICABLE, since 12/30/2024
• CAMPOS, MICHAEL — adp of the snf, NOT APPLICABLE, since 12/30/2024
• CASTILLO, CRISOFORO — adp of the snf, NOT APPLICABLE, since 01/01/2025
• CLAPP, BARBARA — managing control - governing body, NOT APPLICABLE, since 06/01/2021
• CORTESE, DAREN — managing control - governing body, NOT APPLICABLE, since 08/10/2021
• DEKOWSKI, DONOVAN — operational/managerial control, NOT APPLICABLE, since 04/01/2017
• DEKOWSKI, DONOVAN — adp of the snf, NOT APPLICABLE, since 04/01/2017
• GIBSON, PATRICIA — managing control - governing body, NOT APPLICABLE, since 08/01/2021
• GUERRA, ADRIAN — managing control - governing body, NOT APPLICABLE, since 05/01/2016
• LUCIO, DELMA — adp of the snf, NOT APPLICABLE, since 01/01/2025
• MANDELBAUM, ELLIOT — managing control - governing body, NOT APPLICABLE, since 01/01/2025
• MUNOZ, THALIA — corporate officer, NOT APPLICABLE, since 01/01/1982
• MUNOZ, THALIA — managing control - governing body, NOT APPLICABLE, since 01/01/1982
• PENA, ELISA — managing control - governing body, NOT APPLICABLE, since 05/01/2022
• REYNOSO, LUIS — adp of the snf, NOT APPLICABLE, since 01/01/2025
• SALINAS, ARCADIO — managing control - governing body, NOT APPLICABLE, since 09/17/2024
• 1814 ATRIUM PLACE DRIVE LLC — adp of the snf, NOT APPLICABLE, since 04/01/2017
• DWD TX HOLDINGS LLC — indirect ownership interest, NOT APPLICABLE, since 04/01/2017
• JACK AND NANCY DWYER WORKFORCE DEVELOPMENT CENTER INC — indirect ownership interest, NOT APPLICABLE, since 04/01/2017
• REG HG OPCO 1, LLC — indirect ownership interest, NOT APPLICABLE, since 04/01/2017
• REG HG OPCO LLC — indirect ownership interest, NOT APPLICABLE, since 04/01/2017
• REG OPERATOR HOLDCO LLC — indirect ownership interest, NOT APPLICABLE, since 04/01/2017
• REGENCY IHS CLINICAL CONSULTING, LLC — adp of the snf, NOT APPLICABLE, since 04/01/2017
• REGENCY IHS MASTER TENANT LLC — adp of the snf, NOT APPLICABLE, since 04/01/2017
• REGENCY IHS OF WINDSOR ATRIUM LLC — direct ownership interest, NOT APPLICABLE, since 04/01/2017
• REGENCY IHS OF WINDSOR ATRIUM LLC — adp of the snf, NOT APPLICABLE, since 04/14/2025
• REGENCY IHS OF WINDSOR ATRIUM LLC — operational/managerial control, NOT APPLICABLE, since 04/01/2017
• REGENCY IHS REHAB LLC — adp of the snf, NOT APPLICABLE, since 04/01/2017
• REGENCY INTEGRATED HEALTH SERVICES LLC — adp of the snf, NOT APPLICABLE, since 04/14/2025
• REGENCY INTEGRATED HEALTH SERVICES LLC — operational/managerial control, NOT APPLICABLE, since 04/01/2017
• REGENCY INTEGRATED HEALTH SERVICES LLC — indirect ownership interest, NOT APPLICABLE, since 04/01/2017
• REGENCY TEXAS HOLDINGS LLC — indirect ownership interest, NOT APPLICABLE, since 04/01/2017
• STARR COUNTY HOSPITAL DISTRICT — adp of the snf, NOT APPLICABLE, since 04/14/2025
• STARR COUNTY HOSPITAL DISTRICT — 5% or greater direct ownership interest, 100%, since 04/01/2017
• STARR COUNTY HOSPITAL DISTRICT — operational/managerial control, NOT APPLICABLE, since 04/01/2017