Windsor Nursing: Failed to Report Abuse Allegation - TX
CNA A found Resident #1 in what appeared to be an improper restraint situation and reported his concerns to LVN B rather than directly to the administrator. The licensed vocational nurse assessed the resident and determined there were no signs or symptoms of abuse, concluding it was nothing to be concerned about based on his clinical judgment.
The administrator, who serves as the facility's abuse coordinator, was notified later that same morning by the director of nursing. She could not remember the exact date or time she was told about the incident.
"They did not do anything else in response and did not report it because based on the information provided to them from LVN B, Resident was stable, there was nothing to report, and had not been reported as abuse," according to the inspection report.
The administrator acknowledged that CNA A could have reported directly to her, but said he felt safe reporting to LVN B instead. She noted that LVN B did not report the incident to her and could have done so to keep her informed about what was happening.
"If LVN B had found something then he should have reported it to her," the administrator stated during the inspection.
As the designated abuse coordinator, the administrator is responsible for reporting any allegation of abuse to the Texas Health and Human Services Commission. She confirmed that both she and her staff receive training on abuse reporting at least monthly, emphasizing that staff should report to her as soon as possible because she only has two hours to make the required notification to state authorities.
The administrator's understanding of what constitutes abuse appeared inconsistent during the inspection. She stated she considered restraints as abuse, but when it came to being "tucked in," she said "it depended."
The facility's own policy contradicts the administrator's decision not to report the incident. According to the administrator, their policy states that if staff see, suspect, or are even unsure about potential abuse, they must report any abuse to her immediately.
"In this situation, she felt her and the staff followed that policy," the inspection report noted, despite the clear failure to report the allegation to state authorities.
The administrator described how the facility monitors incidents to ensure they identify reportable events within appropriate timeframes. This includes reviewing documentation, conducting rounds, and providing in-services to staff about what should be reported to external authorities.
She acknowledged the serious consequences of failing to report abuse allegations within the required timeframe. "Not reporting allegations of abuse to the Administrator and HHSC within a 2-hour time frame could negatively impact the residents because they would not be investigating or following protocols, and if they were not aware, then they were not doing interventions."
Records showed that CNA A, LVN B, and the director of nursing had all received abuse and neglect training on February 13, 2025. The training covered the "3 R's" of abuse response: recognize, remove, and report.
The facility's written policy, implemented on July 11, 2025, clearly outlines requirements for investigating and reporting suspected abuse. The policy states that "an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur."
The reporting requirements are explicit: all alleged violations must be reported to the administrator, state agency, adult protective services, and other required agencies within specific timeframes. For events involving abuse or resulting in serious bodily injury, reporting must occur "immediately, but not later than 2 hour after the allegation is made."
For events that don't involve abuse and don't result in serious bodily injury, the facility has 24 hours to report.
The inspection found that despite having clear policies, recent training, and an administrator who understood the reporting requirements and potential consequences of delays, Windsor Nursing failed to follow its own procedures when faced with a potential abuse allegation.
The facility's response reveals a troubling gap between written policies and actual practice. While staff received monthly training on recognizing and reporting abuse, the administrator's decision-making process when confronted with a real situation suggests that training may not be effectively translating to appropriate action.
The administrator's statement that she and her staff "followed policy" in this situation directly contradicts both the facility's written procedures and state reporting requirements. The policy requires reporting when staff are "not sure" about potential abuse, yet the administrator chose not to report based on one nurse's clinical assessment that found no immediate signs of abuse.
This case illustrates how nursing homes can fail residents even when they have appropriate policies and training in place. The breakdown occurred not from lack of knowledge about reporting requirements, but from poor judgment about when those requirements should be triggered.
The incident raises questions about whether other potential abuse situations at Windsor Nursing may have gone unreported due to similar decision-making by administrators who substitute their own judgment for the clear directive to report suspected abuse to state authorities.
Federal inspectors classified this as a violation causing minimal harm or potential for actual harm affecting few residents, but the failure to report represents a systemic breakdown in resident protection protocols that could have far-reaching consequences for vulnerable nursing home residents who depend on these reporting systems for their safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Windsor Nursing and Rehabilitation Center of Raymo from 2025-08-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
WINDSOR NURSING AND REHABILITATION CENTER OF RAYMO in RAYMONDVILLE, TX was cited for abuse-related violations during a health inspection on August 11, 2025.
CNA A found Resident #1 in what appeared to be an improper restraint situation and reported his concerns to LVN B rather than directly to the administrator.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.