WINDSOR ATRIUM: Data Analysis and Ratings
CMS Five Star Rating(2 out of 5):
1814 ATRIUM PLACE HARLINGEN, TX 78550
956-230-2300
Data date: March 01, 2019
This is not the most recent data for WINDSOR ATRIUM. For the most recent information, click here.
The Most Important Data about WINDSOR ATRIUM
We've looked at a lot of nursing homes, this is what we think you need to see first and if you don't want to spend a lot of time. (It's the tl;dr section.)
There is no indication of abuse occuring at WINDSOR ATRIUM. (CMS flags facilities where abuse has either happened or is very likely.)
CMS 5-Star Overall Rating:
(2 out of 5):
(The national average overall star rating is 3 stars.)
Current Trend: Worsening
Total Nursing Hours Spent Per Resident Per Day: 3.52
(The national average is 3.74 )
What is this page all about?
Below is everything shred of information that we can find about WINDSOR ATRIUM, along with our best effort to make sense of the data. Our purpose here is to help you to make good decisions when picking a nursing home and to keep you informed once you have chosen a home. We know from personal experience that choosing a nursing home is not something you do once and then you forget about it. In fact, it gets worse. Once you select a nursing home and get through the initial steps of figuring out how to pay for it, then the real worries start. Are they taking good care of me or my loved one? This is the question that will keep you up at night: Can I really trust these people? We wish we could answer this question, we can't. What he can do is churn through the tons of data and try and help you to make sense of it. We hope it helps.
General Data Card
These are the basic data points for the facility.
Data date: March 01, 2019
Address: 1814 ATRIUM PLACE
HARLINGEN, TX 78550
Phone: 956-230-2300
Medicare Provider Number: 676125
Participating in Medicare Since: February 01, 2007
No. of Certified Beds: 120
No. of Residents: 86
Occupancy: 71.67 % (as of 05/21/2023 )
Amount fined in recent period: $0.00
Complaints filed: 1
Ratings History for WINDSOR ATRIUM
Review of WINDSOR ATRIUM Ratings and Inspection Scores
CMS regularly inspects every skilled nursing facility. (The timing is supposed to be annually, but since the beginning of the Covid pandemic, these inspections have not occured as frequently.) The results of the multi-day inspection is reduced to a series of scores which are then translated into the star ratings. The health inspection scores are an absolute value, so you can compare one facility's score directly to another. The Overall Star rating is based on the facility's performance as compared to other facilities in the same state, so you cannot easily compare one facility's Overall star rating to a facility in another state.
Ratings
| Overall Rating | 2: |
| Health Inspection Rating | 2: |
| Quality Rating | 5: |
| Staffing Rating | 1: |
Inspection Scores
| Cycle 1 Score (as of January 26, 2017) | 152 |
| Cycle 2 Score (as of January 07, 2016) | 88 |
| Cycle 3 Score | NA |
| Weighted All Cycles Score | 126 |
It has been 25 months since the most recent inspection.
What Goes Into the Nursing Home's 5-Star Rating
CMS has put a lot of effort into creating its very elaborate 5-Star Quality Rating System specifically to provide a quick way for residents and family members to easily understand how well a nursing home is performing and to make comparing nursing homes easier. The rating system allows people to easily compare facilities across numerous dimensions with the express purpose of identifying the best and best performing nursing homes. The rating system was initially developed in 2008 and the methodologies are regularly reviewed and updated.
The rating system has five separate ratings including:
- Overall rating
- Health Inspection rating
- Staff rating
- RN Staffing rating
- Quality Measures rating
Nursing homes are rated from 1-star to 5-stars with 1-star being the best rating and 5-star being the best rating. For the Health Inspection Rating the nursing homes in each state are ranked based on their weighted three year inspection score. The top 10 percent of nursing homes (those with the lowest scores) are awarded a 5-star rating; the bottom 20 percent (those with the highest scores) are awarded a 1-star rating. In between 1-star and 5-star, the remaining homes are divided equally into three tranches which correspond with the stars 2 to 4. The staff ratings and quality measure ratings follow a similar process but the divisions are based on a national ranking. The division between star ratings is called the “cut-rate”. Cut-rates are redefined periodically and are published by CMS. See the latest cut rates on this table.
Calculating the Overall Star Rating is done differently. According to CMS, the reason for adopting a different system is to give the Health Inspection Rating higher weight in the Overall Rating. So, since there are FIVE ratings and FIVE stars for each rating, there must also be a FIVE step process to calculate the Overall Rating (so symetrical!) :
- Begin with the Health Inspection Rating
- Add one star to the Health Inspection Rating if the Staffing Rating is at least four-stars and is higher than the Health Inspection Rating. (We will call this the "Adjusted Rating".)
- Subtract one star from the Health Inspection Rating if the Staffing Rating is one-star.
- Add a star to the Adjusted Rating if the Quality Measure Rating is 5-stars.
- Subtract one star from the Adjusted Rating if the Quality Measure Rating is 1-star.
Throughout the calculation of the Overall Rating, the rating cannot exceed 5-stars. The Overall Rating is capped at 2-stars if the Health Inspection rating is 1-star. No Overall Rating is awarded if the nursing home does not have a Health Inspection Rating (This effectively means that a nursing home is not rated until the home has been operating for more than two years.)
Changes in a nursing homes star rating can be due to the results of a new health inspection report, the processing of new complaints, the aging of older complaints, a new inspection control survey, a revisit, or the resolution of disputes that change the scope and or severity of deficiencies.
Most Recent Nursing Home Inspections
CMS is required to inspect each senior nursing facility at least annually. These inspections take several days. Additional follow-up inspections as conducted as needed or for certain purposes. Inspections stopped for more than seven months in 2020 due to the Covid pandemic. That stoppage has caused all inspections to be delayed as the inspectors continue to deal with a backlog. The table below shows the latest inspections for WINDSOR ATRIUM including health, fire, and inspection control inspections:
No Inspection Information is Available
Owner and Operator Information for WINDSOR ATRIUM
Our database of owners and operators shows all direct owners of the nursing nurse, any managers and directors, and the most adjacent indirect owners of the facility (that is, if the direct owner is company, then the owners of that company.) Lists of nursing home owners are available and you can search for nursing home owners and operators on our site.
Business Entity Name:
STARR COUNTY HOSPITAL DISTRICT
Owners:
Managers and Directors:
- MICHAEL MOORE (MANAGING EMPLOYEE)
- THALIA MUNOZ (OPERATIONAL/MANAGERIAL CONTROL)
- THALIA MUNOZ (MANAGING EMPLOYEE)
- STARR COUNTY HOSPITAL DISTRICT (OPERATIONAL/MANAGERIAL CONTROL)
- JOSE VAZQUEZ (OPERATIONAL/MANAGERIAL CONTROL)
Analysis of Nursing Hours Spent Per Patient
CMS provides detailed information about how long nursing staff spends with residents. This data includes nursing subcategories of Registered Nurse, Licensed Practical Nurse, and non-nursing Certified Nursing Assistants. More hours spend per patient should can indicate a better facility or it could indicate more complicated situations.
The nursing staff of WINDSOR ATRIUM spends LESS time on average with its residents than the state average and LESS time than the national average for total nursing homes spent per resident.
| Type | Facility | State / National Avg |
|---|---|---|
| Registered Nurse (RN) | ||
| Hours | 0.13 | 0.36 / 0.65 |
| Case Mix | NA | 0.42 / 0.39 |
| Adjusted | 0.11 | NA / NA |
| Licensed Practical Nurse (LPN) | ||
| Hours | 1.07 | 1.02 / 0.88 |
| Case Mix | NA | NA / NA |
| Adjusted | 0.95 | NA / NA |
| Certified Nursing Assistants (CNA) | ||
| Hours | 2.32 | 1.93 / 2.21 |
| Case Mix | NA | NA / NA |
| Adjusted | 2.16 | NA / NA |
| Total Licensed Staff | ||
| Hours | 1.21 | 1.38 / 1.53 |
| Physical Therapist (PT) | ||
| Hours | 0.00 | 0.06 / 0.07 |
| Total Nursing Homes Spent per Resident on Average | ||
| Hours | 3.52 | 3.30 / 3.74 |
| Case Mix | NA | 3.22 / 3.16 |
| Adjusted | 3.21 | NA / NA |
Quality Measures
Quality measures are based both on patient survey information and on the results of actual claims that are filed with CMS. It is not clear what period is covered in the measures.
| Desc. | Perc. | State Avg. / Comparison |
|---|---|---|
| Percentage of short-stay residents who were rehospitalized after a nursing home admission (qm521) | 23.9% | NA |
| Percentage of short-stay residents who had an outpatient emergency department visit (qm522) | 8.6% | NA |
| Percentage of short-stay residents who were successfully discharged to the community (qm523) | 65.3% | NA |
| Number of hospitalizations per 1000 long-stay resident days (qm551) | 2.6% | NA |
| Percentage of long-stay residents whose need for help with daily activities has increased (qm401) | 15.0% | NA |
| Percentage of long-stay residents who self-report moderate to severe pain (qm402) | 2.7% | NA |
| Percentage of high risk long-stay residents with pressure ulcers (qm403) | 0.0% | NA |
| Percentage of long-stay residents who lose too much weight (qm404) | 5.3% | NA |
| Percentage of low risk long-stay residents who lose control of their bowels or bladder (qm405) | 50.0% | NA |
| Percentage of long-stay residents with a catheter inserted and left in their bladder (qm406) | 0.3% | NA |
| Percentage of long-stay residents with a urinary tract infection (qm407) | 1.6% | NA |
| Percentage of long-stay residents who have depressive symptoms (qm408) | 1.7% | NA |
| Percentage of long-stay residents who were physically restrained (qm409) | 0.6% | NA |
| Percentage of long-stay residents experiencing one or more falls with major injury (qm410) | 1.0% | NA |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine (qm411) | 98.1% | NA |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine (qm415) | 95.2% | NA |
| Percentage of long-stay residents who received an antipsychotic medication (qm419) | 11.0% | NA |
| Percentage of short-stay residents who self-report moderate to severe pain (qm424) | 1.6% | NA |
| Percentage of short-stay residents with pressure ulcers that are new or worsened (qm425) | 0.2% | NA |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine (qm426) | 93.6% | NA |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine (qm430) | 91.3% | NA |
| Percentage of short-stay residents who newly received an antipsychotic medication (qm434) | 1.0% | NA |
| Percentage of long-stay residents whose ability to move independently worsened (qm451) | 15.0% | NA |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication (qm452) | 9.6% | NA |
| Percentage of short-stay residents who made improvements in function (qm471) | 74.3% | NA |
WINDSOR ATRIUM Violations, Complaints and Fines
These are complaints and fines that are reported by CMS. Some of the data is not very recent, but we have decided to include it here so that you have as much information as possible.
Amount fined in recent period: $0.00, Complaints filed: 1
| Deficiency | Deficiency Date / Date Corrected |
|---|---|
| Provide proof that residents' personal money that is deposited with the nursing home is secure. (Health) | 01-07-2016 / 02-12-2016 |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. (Health) | 01-07-2016 / 02-12-2016 |
| Provide housekeeping and maintenance services. (Health) | 01-07-2016 / 02-12-2016 |
| Ensure each resident receives an accurate assessment by a qualified health professional. (Health) | 01-07-2016 / 02-12-2016 |
| Ensure services provided by the nursing facility meet professional standards of quality. (Health) | 01-07-2016 / 02-12-2016 |
| Provide care by qualified persons according to each resident's written plan of care. (Health) | 01-07-2016 / 02-12-2016 |
| Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. (Health) | 01-07-2016 / 02-12-2016 |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. (Health) | 01-07-2016 / 02-12-2016 |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. (Health) | 01-07-2016 / 02-12-2016 |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. (Health) | 01-07-2016 / 02-12-2016 |
| Have a program that investigates, controls and keeps infection from spreading. (Health) | 01-07-2016 / 02-12-2016 |
| Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. (Health) | 01-07-2016 / 02-12-2016 |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. (Health) | 08-01-2016 / 08-10-2016 |
| Reasonably accommodate the needs and preferences of each resident. (Health) | 12-13-2016 / 12-27-2016 |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (Health) | 01-26-2017 / 02-16-2017 |
| Provide housekeeping and maintenance services. (Health) | 01-26-2017 / 02-16-2017 |
| Ensure services provided by the nursing facility meet professional standards of quality. (Health) | 01-26-2017 / 02-16-2017 |
| Provide care by qualified persons according to each resident's written plan of care. (Health) | 01-26-2017 / 02-16-2017 |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. (Health) | 01-26-2017 / 02-16-2017 |
| Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. (Health) | 01-26-2017 / 02-16-2017 |
| Store, cook, and serve food in a safe and clean way. (Health) | 01-26-2017 / 02-16-2017 |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. (Health) | 01-26-2017 / 02-16-2017 |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. (Health) | 01-26-2017 / 02-16-2017 |
| Have a program that investigates, controls and keeps infection from spreading. (Health) | 01-26-2017 / 02-16-2017 |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. (Health) | 08-02-2017 / 08-15-2017 |
| Reasonably accommodate the needs and preferences of each resident. (Health) | 09-19-2017 / 09-22-2017 |
| Provide care by qualified persons according to each resident's written plan of care. (Health) | 09-19-2017 / 09-22-2017 |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. (Health) | 09-19-2017 / 09-22-2017 |
| Conduct initial and periodic assessments of each resident's functional capacity. (Health) | 10-19-2017 / 11-10-2017 |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Health) | 10-19-2017 / 11-10-2017 |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. (Health) | 12-14-2017 / 12-20-2017 |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (Health) | 12-14-2017 / 12-20-2017 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Health) | 12-14-2017 / 12-20-2017 |
| Respond appropriately to all alleged violations. (Health) | 01-04-2018 / 01-16-2018 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Health) | 01-25-2018 / 02-02-2018 |
| Provide care by qualified persons according to each resident's written plan of care. (Health) | 01-25-2018 / 02-02-2018 |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. (Health) | 01-25-2018 / 02-02-2018 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Health) | 01-25-2018 / 02-02-2018 |
| Reasonably accommodate the needs and preferences of each resident. (Health) | 02-16-2018 / 03-16-2018 |
| Keep residents' personal and medical records private and confidential. (Health) | 02-16-2018 / 03-16-2018 |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. (Health) | 02-16-2018 / 03-16-2018 |
| Ensure each resident receives an accurate assessment. (Health) | 02-16-2018 / 03-16-2018 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Health) | 02-16-2018 / 03-16-2018 |
| Provide care by qualified persons according to each resident's written plan of care. (Health) | 02-16-2018 / 03-16-2018 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Health) | 02-16-2018 / 03-16-2018 |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. (Health) | 02-16-2018 / 03-16-2018 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Health) | 02-16-2018 / 03-16-2018 |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (Health) | 02-16-2018 / 03-16-2018 |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. (Health) | 02-16-2018 / 03-16-2018 |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. (Health) | 02-16-2018 / 03-16-2018 |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Health) | 02-16-2018 / 03-16-2018 |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. (Health) | 02-16-2018 / 03-16-2018 |
| Implement a program that monitors antibiotic use. (Health) | 02-16-2018 / 03-16-2018 |
| Make sure that a working call system is available in each resident's bathroom and bathing area. (Health) | 02-16-2018 / 03-16-2018 |
| Provide and implement an infection prevention and control program. (Health) | 12-03-2018 / 12-04-2018 |
Hospitals Near WINDSOR ATRIUM
Quite often skilled nursing facilities and hospitals work closely together to help patients recover or manage a terminal illness. Hospitals deals with acute care while nursing homes treat patients for a longer period of time. New residents at skilled nursing homes typically come from a hospital and nursing home residents may be readmitted to a hospital if their recovery does not proceed well. (Hospital readmission rates are closely monitored by CMS.) Consequently it is important that you consider which hospitals are near a nursing home which choosing one. Below is a list of hospitals near WINDSOR ATRIUM.
This information is based on the most recent Hospital data. Historical data is not available.
| Hospital | 5-Star Overall Rating |
|---|---|
|
VHS HARLINGEN HOSPITAL COMPANY LLC 2101 PEASE ST HARLINGEN, TX 78550 |
2 |
|
KNAPP MEDICAL CENTER 1401 EAST EIGHT STREET WESLACO, TX 78596 |
2 |
|
VALLEY REGIONAL MEDICAL CENTER 100 A ALTON GLOOR BROWNSVILLE, TX 78526 |
2 |
|
VALLEY BAPTIST MEDICAL CENTER- BROWNSVILLE 1040 W JEFFERSON ST BROWNSVILLE, TX 78520 |
3 |
|
HARLINGEN MEDICAL CENTER 5501 SOUTH EXPRESSWAY 77 HARLINGEN, TX 78550 |
4 |
|
RIO GRANDE STATE CENTER 1401 RANGERVILLE ROAD HARLINGEN, TX 78550 |
Not Available |
|
PALMS BEHAVIORAL HEALTH 613 VICTORIA LANE HARLINGEN, TX 78550 |
Not Available |
Medical Professionals Associated with WINDSOR ATRIUM
These are the doctors who are affiliated with WINDSOR ATRIUM. The data is from the most recent period. Historical data is not available.
- LUIS REYNOSO ( INTERNAL MEDICINE - DR LUIS REYNOSO PA )
- JOSE VILLALOBOS ( INTERNAL MEDICINE - PADMINI BHADRIRAJU MD P.A. )
- MARK WEISBERG ( INTERNAL MEDICINE - FEMI LAYIWOLA MD PA )
- RAFAEL LOPEZ ( FAMILY PRACTICE - SAN BENITO MEDICAL ASSOCIATES, PLLC )
- STANLEY SY ( PULMONARY DISEASE - BHS PHYSICIANS NETWORK INC )
- SHRIDHAR KOTTA ( INTERNAL MEDICINE )
Detailed Analysis Pages:
Depending on the nursing home, this page can get really long. So, we have also broken up the data onto separate pages to allow you to find what you want more easily. We will keep adding to these pages as we continue to analyze the nursing home database.
CMS Five Star Ratings and Quality Measures for WINDSOR ATRIUM
Five different rating results plus detailed inspection numbers and quality measures for WINDSOR ATRIUM.
Covid Infections at WINDSOR ATRIUM
This report is updated weekly and shows new and historical infection levels.
Nursing Hours Analysis for WINDSOR ATRIUM
How long a nurse spends with a resident can be an important factor in their recovery. This page shows the average nursing hours spent per resident for RNs, LPNs, CNAs, PTs and all licensed staff.
Ownership Details for WINDSOR ATRIUM
A list of all of the registered owners for WINDSOR ATRIUM. This includes direct and indirect owners and managers.
Noted Deficiencies for WINDSOR ATRIUM
A list of all of the deficiencies for the facility. This includes a description, type of deficiency, incident date and when the facility reports that the incident was corrected.
Comparison Ranking of Nearby Skilled Nursing Facilities
How does WINDSOR ATRIUM compare to other skilled nursing facilities? This list shows the competitive set within a 25 mile radius.
Best Nursing Homes in HARLINGEN, TX
Homes that you should consider. A list ranking the best skilled nursing facilities in HARLINGEN based on their weighted inspection score as of March 01, 2019.
Worst Nursing Homes in HARLINGEN, TX
Homes that you avoid if possible. A list ranking the worst skilled nursing facilities in HARLINGEN based on their weighted inspection score as of March 01, 2019.
Other Data Periods:
Data on WINDSOR ATRIUM is available for the following periods:
