Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Windsor Arbor View during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and a known fall risk experienced a fall, but the responsible LVN did not document the required change of condition form in the medical record, despite following other fall protocols and being trained on documentation requirements. The DON confirmed that the documentation was missing and that staff are expected to complete all required forms for such incidents.
A resident with severe cognitive impairment was found on the floor with a Foley catheter pulled out. After the catheter was re-inserted by an LVN, the procedure was not documented in the electronic medical record as required by facility policy. Staff interviews and record review confirmed the omission, resulting in incomplete medical documentation.
A resident with severe cognitive impairment and mobility issues exited the facility undetected after a door alarm failed to activate. Despite being identified as an elopement risk and having interventions in place, staff did not hear any alarms and only discovered the resident missing during routine rounds. The resident was later found outside, across the street, wearing only socks. The alarm system had been serviced earlier that day and was reported as operational, but the cause of the failure during the incident was not determined.
A resident with multiple comorbidities was assisted to the floor by two CNAs after her knees gave out during a transfer. Although initially assessed with no pain or visible injury, the resident later reported leg pain, and an x-ray revealed a nondisplaced proximal fibular fracture. The injury was not reported to the state agency within the required 2-hour window, as the administrator waited for a second x-ray to confirm the diagnosis, resulting in a delayed report.
A nurse failed to document and report a resident's guided fall and subsequent assessment, resulting in delayed recognition and treatment of a leg fracture. The incident was not reported or recorded in the clinical record as required, and supervisory staff were not notified until days later, contrary to facility policy for timely and complete documentation.
A resident with multiple health conditions experienced significant weight loss due to the facility's failure to monitor and address nutritional needs as outlined in the care plan. Despite the care plan's instructions to notify the physician of weight loss, the facility did not implement timely interventions, leading to a 6.95% weight loss over a short period.
The facility failed to properly store, label, and date food items in the kitchen, risking food contamination. Observations revealed open and undated milk jugs, cheese, and vegetables, with the absence of a permanent Dietary Manager contributing to the issue. Sister facility managers were assisting, but some problems persisted.
A resident with severe cognitive impairment and multiple health issues was found without access to a call light, which was hanging off the bed and touching the floor. Staff interviews revealed that while procedures were in place to ensure call light accessibility, there was a lapse in execution, as the resident was unaware of the call light's location. This failure to adhere to the facility's policy on call light accessibility could prevent the resident from obtaining necessary assistance.
The facility failed to maintain effective infection control practices, as observed in the care of two residents receiving incontinent care and a resident with a urinary catheter. CNAs did not adhere to proper protocols, such as using one wipe per swipe and sanitizing hands between glove changes. Additionally, a resident's catheter bag was found touching the floor, posing a risk of infection. Despite ongoing training, these lapses indicate a failure to implement the facility's infection prevention policies.
Two residents experienced falls that were not accurately coded in their MDS assessments, leading to deficiencies in the facility's assessment processes. One resident had a fall resulting in a cut lip and chipped tooth, while another had a fall with a head injury and skin tears. The MDS Nurse and DON acknowledged the oversight, which could lead to improper care and services.
Failure to Document Change of Condition After Resident Fall
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Specifically, an LVN did not document a required change of condition form in the electronic medical record after a resident experienced a fall. The LVN worked the shift during which the fall occurred and stated that he followed the fall protocol, including assessing the resident, assisting him up, initiating neuro checks, and notifying the physician, responsible party, and DON. However, upon review, there was no documentation of the change of condition form for the incident, despite the LVN acknowledging he was trained and expected to complete this documentation for every fall. The resident involved had multiple significant diagnoses, including type 2 diabetes, end stage renal disease, heart failure, peripheral vascular disease, hypertension, anxiety disorder, and chronic obstructive pulmonary disease. The resident was identified as being at risk for falls due to a history of falls, decreased mobility, and generalized weakness. Facility policy required that all assessments, observations, and services provided be documented accurately and timely in the resident's medical record. Both the LVN and DON confirmed that the documentation protocol was not followed in this instance.
Failure to Document Foley Catheter Re-Insertion in Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Specifically, after a resident was found on the floor with her Foley catheter pulled out, the nurse responsible for re-inserting the catheter did not document the procedure in the resident's electronic medical record. The facility's policy requires that any insertion or re-insertion of a Foley catheter be documented, including details such as the time, gauge size, and the resident's tolerance of the procedure. The incident involved a female resident with a history of sepsis and vascular dementia, who was severely cognitively impaired. On the day of the event, staff responded to a scream and found the resident sitting on the floor with the Foley catheter removed. A head-to-toe assessment was performed, and no injuries were noted. The resident was unable to communicate what had happened. The nurse on duty at the end of her shift reported that another nurse agreed to re-insert the Foley catheter, but there was no documentation of this procedure in the medical record. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and Director of Nursing (DON), confirmed that the re-insertion of the Foley catheter was not documented as required by facility policy. Review of the facility's documentation policy further supported that all assessments, observations, and services provided must be recorded in the resident's medical record. The lack of documentation was verified through review of the electronic medical record and staff interviews.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Alarm Malfunction
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment exited the facility undetected. The resident, a male with diagnoses including diabetes, hypertension, gait and mobility abnormalities, and lack of coordination, had a BIMS score indicating severely impaired cognition. Although his initial care plan identified him as an elopement risk and included interventions such as distraction and structured activities, a prior wandering evaluation had not classified him as a wandering risk. On the evening of the incident, the resident was moved to a different room due to plumbing issues, and staff last observed him in his room before discovering him missing during routine rounds. Staff did not hear any door alarms when the resident exited through the east exit door, and the alarm system did not activate at the time of his departure. The resident was found outside the facility, across the street, wearing only socks and conversing with two individuals. Multiple staff interviews confirmed that no alarms were heard, and the door alarm was not triggered when the resident left. The maintenance supervisor and an external technician had serviced the door and checked the alarm system earlier that day, confirming it was operational at that time, but the reason for the alarm's failure during the incident remained unclear. The facility's policy required adequate supervision and timely response to alarms for residents at risk of elopement. Despite these protocols, the resident was able to leave the premises without detection or immediate staff response, as the alarm system did not function as intended. Staff were trained on elopement prevention and response, and regular elopement drills were conducted, but these measures did not prevent the incident. The deficiency was identified as past non-compliance, with immediate jeopardy beginning and ending within a specified timeframe.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure timely reporting of an injury of unknown origin for a resident who was later diagnosed with a nondisplaced proximal fibular fracture. The incident began when the resident, who had diagnoses including vascular dementia, muscle wasting, osteoporosis, and weakness, was being assisted from the toilet to her wheelchair by two CNAs. During the transfer, the resident's knees gave out, and she requested to be seated on the floor. Both CNAs and the resident agreed to this, and a nurse was called to assess her. The nurse performed a head-to-toe assessment and found no abnormalities or pain reported by the resident at that time. The resident was transferred back to bed using a mechanical lift, and no incident report or change of condition was completed because the nurse did not consider it a fall. Several days later, the resident began to experience pain in her lower right leg, which she reported to the nurse practitioner (NP) during rounds. The NP ordered an x-ray, which revealed a nondisplaced proximal fibular fracture. The NP accepted the findings but ordered a second x-ray to confirm the injury, which also indicated a fracture. Despite receiving the first x-ray results, the administrator delayed reporting the injury to the state agency, waiting for the results of the second x-ray before submitting the report. The injury was ultimately reported more than 24 hours after the initial diagnosis, exceeding the required 2-hour reporting window for injuries of unknown origin. Interviews with staff confirmed that the incident was not reported promptly due to the initial lack of pain or visible injury and the belief that it was not a fall. The DON acknowledged that the nurse failed to complete an incident report or notify her of the event, and the administrator confirmed the delay in reporting was due to waiting for confirmation from a second x-ray. The facility's policy requires immediate reporting of such incidents, but this protocol was not followed in this case.
Incomplete Documentation Following Resident Fall
Penalty
Summary
A deficiency occurred when a nurse failed to maintain complete and accurate clinical records for a resident who experienced a change in condition. The resident, an older female with a history of vascular dementia, muscle wasting, osteoporosis, and weakness, was being assisted from the toilet to her wheelchair by two CNAs when her knees gave out. She was guided to the floor and subsequently assessed by the nurse, who performed a head-to-toe assessment and noted no immediate pain or injury. However, the nurse did not complete a change of condition report, incident report, or notify supervisory staff at the time of the event, as she did not consider the incident a fall. The resident later reported pain in her right lower leg, which was managed with pain medication. Days after the incident, the resident informed her physician about the pain, leading to an x-ray that revealed a nondisplaced proximal fibular fracture. The nurse's failure to document the incident and the assessment in a timely manner resulted in a delay in further evaluation and treatment. The Director of Nursing and Administrator only became aware of the incident after being notified by the resident's nurse practitioner several days later. Facility policy required that all assessments, observations, and services be documented completely and in a timely manner, with late entries clearly indicated. The nurse's omission of required documentation and failure to notify appropriate staff were identified as deficiencies in maintaining accurate and complete clinical records in accordance with professional standards and facility policy.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, leading to significant weight loss. The resident, a male with multiple diagnoses including Parkinsonism, type 2 diabetes, and dementia, experienced a weight loss of 6.95% over a short period. Despite the care plan indicating the need to monitor and report significant weight loss, the facility did not implement timely interventions when the resident lost 7 pounds in one week, nor did they notify the physician as required by the care plan. The resident's care plan required monitoring for signs of malnutrition and weight loss, with specific instructions to notify the physician if the resident lost more than 3 pounds in one week. However, the facility did not follow these instructions, and the resident's weight loss was not addressed until it became severe. The resident's weight was not consistently recorded, and there was a lack of communication between staff members regarding the resident's nutritional status and weight loss. Interviews with staff revealed that the resident's weight loss was not flagged in the system, and the dietitian was not notified until after the significant weight loss was identified. The facility's failure to adhere to the care plan and monitor the resident's weight effectively resulted in a delay in implementing necessary interventions to prevent further weight loss.
Deficiency in Food Storage and Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen's storage, preparation, and sanitation practices. Specifically, the facility did not ensure that food and drink items in the reach-in freezer, refrigerator, and dry storage area were properly stored, labeled, and dated, with some items being expired. During an initial tour, it was found that two out of six milk jugs in the refrigerator were open and used without an open date, and several bags of cheese and boxes of frozen vegetables were open to air and not sealed properly. The Dietary Aide mentioned that the Dietary Manager had quit about two weeks prior, and the facility Administrator was handling kitchen orders. Interviews with the Dietician and the Administrator revealed that dietary managers from sister facilities were assisting due to the absence of a permanent Dietary Manager. A follow-up observation with a Dietary Manager from a sister facility confirmed that some issues persisted, such as open biscuits in the freezer. The Dietary Manager acknowledged the need for proper labeling and sealing of open foods and mentioned that undated items should be discarded. The facility's policy for food storage requires all refrigerated and frozen foods to be labeled, dated, and stored in moisture-proof containers, which was not consistently followed.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident had access to a call light while in bed, which is a violation of the residents' right to reasonable accommodation of their needs and preferences. The resident in question, a male with severe cognitive impairment and multiple diagnoses including unspecified dementia and anxiety disorder, was observed without the call light within reach. The call light was found hanging off the side of the bed, touching the floor, and the resident was unaware of its location. This situation was confirmed by a Certified Nursing Assistant (CNA) who acknowledged that the resident was supposed to have the call light within reach to call for help when needed. Interviews with staff revealed that there was a lapse in ensuring the call light was accessible to the resident. One CNA mentioned that the call light was within reach during morning care but speculated that the resident might have moved it. Another CNA and a Licensed Vocational Nurse (LVN) stated that they routinely check to ensure residents can reach their call lights, as emphasized by the administration and nursing staff. The facility's policy mandates that staff ensure call lights are within reach and secure, but this was not adhered to in this instance, potentially placing the resident at risk of being unable to obtain assistance when needed.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple deficiencies observed during the care of residents. CNA A did not adhere to proper infection control protocols while providing incontinent care to a male resident diagnosed with benign prostatic hyperplasia. The CNA used the same wipe for multiple swipes during perineal care and failed to change gloves and sanitize hands when transitioning from cleaning the perineal area to the buttocks. This improper technique was acknowledged by CNA A, who admitted to being nervous and aware of the correct procedures. Similarly, CNA B did not follow infection control protocols while providing care to a female resident with muscle wasting and atrophy. The CNA failed to sanitize hands between glove changes and used the same wipe for multiple swipes during the cleaning process. Despite having received recent training on infection control, CNA B did not adhere to the established guidelines, which were reiterated by the lead CNA and the Director of Nursing (DON) during interviews. Additionally, the facility failed to prevent a male resident's urinary catheter bag from touching the floor, which was observed by LVN A. The resident, who had a severely impaired cognition and an indwelling catheter, was at risk of infection due to the catheter bag's contact with the floor. Interviews with LVN A, LVN B, LVN C, and RN A confirmed the potential for cross-contamination and infection due to this oversight. The facility's policy on infection prevention and control, which includes standard precautions and proper hand hygiene, was not effectively implemented in these instances.
Inaccurate MDS Coding for Resident Falls
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in the Minimum Data Set (MDS) coding for falls. Resident #2, who had a history of right-sided hemiplegia and hemiparesis following a cerebral infarction, experienced a fall on October 18, 2023, resulting in a cut on the bottom lip and a chipped tooth. Despite these injuries, the fall was not coded in the Discharge MDS, which was completed on November 20, 2023. The MDS Nurse acknowledged that the fall should have been captured on the Discharge MDS, but it was not considered a significant change due to the absence of major injury. The Director of Nursing (DON) indicated that the injuries sustained during the fall should have warranted a significant change MDS or at least been coded on the Discharge MDS. Resident #3, who had diagnoses including Type 2 Diabetes Mellitus and legal blindness, experienced a fall on April 4, 2024, resulting in a raised area on the left side of the head and skin tears. This fall was not coded in the subsequent MDS assessment. The MDS Nurse stated that the fall should have been coded in the MDS but was not, although it was care planned. The DON confirmed that the fall needed to be coded in the MDS to communicate the resident's needs to other staff. The facility's failure to accurately code these falls in the MDS assessments could lead to improper or incorrect care and services for the residents. The report highlights the facility's failure to adhere to the Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) guidelines, which require falls to be coded in the MDS. The MDS Nurse and DON both acknowledged the oversight in coding the falls, which could result in inaccurate assessments and care plans. The facility's incident logs and care plans documented the falls, but the MDS assessments did not reflect these events, indicating a lapse in the facility's assessment processes.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Edinburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windsor Nursing And Rehabilitation Center Of Edinb | 1.9 mi | — | 0 | 0 |
| Hidalgo Nursing And Rehabilitation Center | 2.8 mi | — | 11 | 0 |
| Edinburg Nursing And Rehabilitation Center | 3.4 mi | — | 11 | 1 |
| Colonial Manor Advanced Rehab & Healthcare | 4.3 mi | — | 3 | 0 |
| Briarcliff Nursing And Rehabilitation Center | 6.2 mi | — | 5 | 0 |
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