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Complaint Investigation

Windsor Nursing And Rehabilitation Center Of Mcall

November 21, 2025 · Mcallen, TX · 900 S 12th St
Citations 2
CMS Rating 3/5
Beds 110
Provider ID 455662
Healthcare Facility
Windsor Nursing And Rehabilitation Center Of Mcall
Mcallen, TX  ·  View full profile →
Inspection Summary

Windsor Nursing and Rehabilitation Center of Mcall in Mcallen, TX — inspection on November 21, 2025.

Found 2 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

FF0610
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for More Than Minimal Harm

During an interview on 11/04/25 at 3:10 PM, the DON stated on the day of the reported incident, Resident #1 had a light syncope (a temporary loss of consciousness caused by a decrease in blood flow to the brain) episode.

The DON stated that upon investigation, CNA A and CNA B were asked if any body part of Resident #1 had changed surfaces, in other words, had Resident #1 fallen to the floor.

The DON stated that CNA A had stated no but CNA B had stated yes.

The DON stated the investigation moved forward with CNA A's statement that it was not a fall.

The DON stated she could not confirm as to how Resident #1 sustained the fracture.

The DON stated that CNA B's statement was followed up by conducting abuse/neglect and fall prevention in-services (trainings).

The DON stated she was unaware as to why CNA B's statement that Resident #1 had sustained a fall was not investigated.

The DON stated that the Administrator conducts all investigations.

During an interview on 11/04/25 at 3:33 PM, the Administrator stated he was not able to determine whether Resident #1 had sustained a fall or not.

The Administrator stated that CNA A had stated that Resident #1 had not fallen while CNA B had stated that Resident #1 had.

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.

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 Administrator stated he did not know how Resident #1 sustained the fracture since CNA A had stated he had not fallen.

During an interview on 11/05/25 at 2:36 PM, CNA B stated that a fall is when a resident is on the floor. CNA B stated she was not lying about Resident #1 falling. CNA B stated she had no reason to lie.

Record review of the facility's policy titled Abuse, Neglect and Exploitation, with a date of 07/11/25, revealed:Policy: 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.Definitions: Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries or unknown source, and misappropriation of resident property.V.

Investigation of Alleged Abuse, Neglect and ExploitationA. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Nursing and Rehabilitation Center of McAll

900 S 12th St McAllen, TX 78501

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 11/04/25 at 3:33 PM, the Administrator stated he was not able to determine whether Resident #1 had sustained a fall or not.

The Administrator stated that CNA A had stated that Resident #1 had not fallen while CNA B had stated that Resident #1 had.

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.

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 Administrator stated he did not know how Resident #1 sustained the fracture since CNA A had stated he had not fallen.

During an interview on 11/05/25 at 2:36 PM, CNA B stated that a fall is when a resident is on the floor. CNA B stated she was not lying about Resident #1 falling. CNA B stated she had no reason to lie.

Record review of the facility's policy titled Abuse, Neglect and Exploitation, with a date of 07/11/25, revealed:Policy: 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.Definitions: Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries or unknown source, and misappropriation of resident property.V.

Investigation of Alleged Abuse, Neglect and ExploitationA. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.

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 Mcallen, 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 Nursing and Rehabilitation Center of Mcall or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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