The November investigation at Windsor Nursing and Rehabilitation Center of Mcallen revealed conflicting accounts from two certified nursing assistants about whether Resident #1 had fallen. CNA A said no fall occurred. CNA B said the resident had fallen.
The Administrator chose to follow CNA A's version.
"The Administrator stated he opted to follow through with the investigation using CNA A's statement that Resident #1 had not fallen and let State tell him what really happened," according to the federal inspection report. "The Administrator stated he did not follow up with CNA B's statement that Resident #1 had fallen because he just wasn't sure."
The facility's own policy requires immediate investigation when reports of abuse, neglect or exploitation occur. The policy defines an "alleged violation" as any situation reported by staff that "could be indication of noncompliance with the Federal requirements" if not properly investigated.
But administrators never investigated CNA B's account.
During her interview with state inspectors on November 5, CNA B defended her statement. "CNA B stated that a fall is when a resident is on the floor," inspectors documented. "CNA B stated she was not lying about Resident #1 falling. CNA B stated she had no reason to lie."
The Director of Nursing told inspectors she was "unaware as to why CNA B's statement that Resident #1 had sustained a fall was not investigated." She confirmed that both nursing assistants had given contradictory statements about whether Resident #1 had "changed surfaces, in other words, had Resident #1 fallen to the floor."
The DON said CNA A stated no. CNA B stated yes.
"The DON stated the investigation moved forward with CNA A's statement that it was not a fall," the inspection report shows. "The DON stated she could not confirm as to how Resident #1 sustained the fracture."
The facility's response to the conflicting statements was to conduct abuse, neglect and fall prevention training sessions. But administrators never determined what actually happened to cause the resident's fracture.
"The Administrator stated he was not able to determine whether Resident #1 had sustained a fall or not," inspectors wrote after interviewing him on November 4. "The Administrator stated he did not know how Resident #1 sustained the fracture since CNA A had stated he had not fallen."
Federal regulations require nursing homes to immediately investigate any suspected incidents that could indicate abuse, neglect or exploitation. The facility's own policy, dated July 11, 2025, states that "an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur."
The policy defines the facility's responsibility clearly: "It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property."
Yet when faced with two conflicting accounts about a resident sustaining a fracture, administrators chose to accept one version without investigating the other.
The Administrator's statement to inspectors revealed the facility's approach to incident investigation. Rather than conducting the thorough investigation required by policy, he acknowledged he would "let State tell him what really happened."
This abdication of responsibility left fundamental questions unanswered. How did Resident #1 sustain the fracture? Why did two nursing assistants provide contradictory accounts? Was proper care provided during and after the incident?
The inspection found that few residents were affected by the violation, but actual harm occurred. Federal inspectors classified the violation under F 0689, which addresses facilities' obligations to immediately report and investigate suspected violations.
CNA B's insistence that she had "no reason to lie" about witnessing a fall highlights the seriousness of the facility's failure to investigate. Falls among nursing home residents can cause serious injuries including fractures, and proper investigation helps determine whether care was adequate and prevents future incidents.
The facility's policy acknowledges that alleged violations must be investigated even when they are "observed or reported by staff, resident, relative, visitor or others but has not yet been investigated." The policy specifically notes that such reports "could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries or unknown source."
Resident #1's fracture falls into this category of "injuries of unknown source" that trigger mandatory investigation requirements.
The Director of Nursing's admission that she was "unaware as to why CNA B's statement that Resident #1 had sustained a fall was not investigated" suggests a breakdown in the facility's investigation protocols. As DON, she would typically be involved in coordinating the response to potential incidents affecting resident safety.
The Administrator's statement that "he just wasn't sure" about which nursing assistant's account to believe demonstrates a fundamental misunderstanding of investigation requirements. Federal regulations do not allow facilities to simply choose which version of events to accept when staff provide conflicting accounts about potential incidents.
Instead, facilities must conduct thorough investigations that examine all available evidence and interview all relevant witnesses. The investigation should determine what actually occurred, not which account administrators find more convenient to accept.
The facility's decision to conduct training sessions on abuse, neglect and fall prevention suggests administrators recognized that something had gone wrong. But training cannot substitute for proper investigation of specific incidents.
Without determining whether Resident #1 actually fell, the facility cannot assess whether appropriate care was provided during the incident. Falls can cause serious injuries that require immediate medical evaluation. If a fall occurred and was not properly reported or investigated, the resident may not have received necessary medical attention.
The conflicting statements from CNA A and CNA B also raise questions about communication and documentation practices at the facility. When nursing staff provide contradictory accounts about resident incidents, it suggests potential problems with supervision, training, or record-keeping.
CNA B's statement that "a fall is when a resident is on the floor" indicates she understood the definition of a fall. Her insistence that she was "not lying" and had "no reason to lie" suggests she believed she was providing accurate information about what she witnessed.
The Administrator's approach of letting "State tell him what really happened" effectively transferred the facility's investigation responsibilities to government inspectors. This violates the fundamental principle that nursing homes must take immediate action to protect residents and investigate potential problems.
Federal inspectors ultimately determined that the facility had failed to meet its obligations under F 0689. The violation resulted in actual harm to residents, though inspectors found that few residents were affected by the specific failure.
The case illustrates how administrative failures can compromise resident safety even when front-line staff attempt to report incidents properly. CNA B's efforts to report what she observed were undermined by administrators who chose not to investigate her account.
Resident #1 sustained a fracture, but the facility's investigation failure means the circumstances surrounding that injury remain unclear. Without proper investigation, similar incidents could occur in the future, potentially causing additional harm to vulnerable residents who depend on the facility for protection and care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Windsor Nursing and Rehabilitation Center of Mcall from 2025-11-21 including all violations, facility responses, and corrective action plans.
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