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Complaint Investigation

Windsor Arbor View

September 11, 2025 · Edinburg, TX · 218 Baltic
Citations 3
CMS Rating 3/5
Beds 120
Provider ID 676206
Healthcare Facility
Windsor Arbor View
Edinburg, TX  ·  View full profile →
Inspection Summary

Windsor Arbor View in Edinburg, TX — inspection on September 11, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0609
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for More Than Minimal Harm

During a telephone interview on 09/09/25 at 10:57 am, The NP said when he was doing his rounds on 01/30/25, Resident #1 had complained of having pain to her lower right extremity. He said he ordered an x-ray on 01/30/25 and was informed of the results that same day. He said Resident #1's first x-ray showed she had a nondisplaced proximal fibular fracture.

The NP said at that point he accepted the findings of the first x-ray but ordered a second x-ray to confirm the injury.

The NP said that was a normal practice for him when the findings showed a fracture to order a second x-ray to have a second set of eyes confirm the injury.

Record review of the facility's Abuse, Neglect, and Exploitation policy dated 07/11/25 reflected:Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that exhibit and prevent abuse, neglect, exploitation and misappropriation of resident property. VII.

Reporting/Response:A.

The facility will have written procedures that include:1.

Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a.

Immediately by no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/11/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Arbor View

218 Baltic Edinburg, TX 78539

SUMMARY STATEMENT OF DEFICIENCIES

During an observation on 09/10/25, the Maintenance Supervisor was observed testing Door #6, #7, #10,#1, # 2, and #5.

The alarms and the 15 second egress were working.

The non-compliance was identified as Past Non-Compliance.

The Immediate Jeopardy (IJ) began on 06/06/25 and ended on 06/07/25.

The facility corrected non-compliance before the investigation began.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/11/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Arbor View

218 Baltic Edinburg, TX 78539

SUMMARY STATEMENT OF DEFICIENCIES

the first x-ray (right tibia/fibula) indicated a nondisplaced proximal fibular fracture.

She said when Resident #1's NP was notified of the findings that same day, he ordered a second x-ray, and those results were received on 01/31/25 which indicated an age-indeterminate fracture.

The Administrator said LVN E had been counseled for failure to report an incident when Resident #1 was guided to the floor.

She said LVN E had been re-education on falls and reporting incidents as soon as they occur.

The Administrator said a negative outcome of LVN E not reporting Resident #1's incident was her not being treated sooner.Record review of the facility's Documentation in Medical Record policy dated 10/24/22 reflected:Policy: Each residence medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the residents progress through complete, accurate, and timely documentation.Policy Explanation and Compliance Guidelines:1.

Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2.

Documentation shall be complete at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.4.

When documentation occurs after the fact, outside acceptable time limits, the entry shall be clearly indicated as late entry.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Edinburg, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Windsor Arbor View or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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