Cycle 1
Health 2025-12-17 · Fire 2025-12-17
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Edinburg, TX
Windsor Arbor View
3-star overall rating with 3-star inspections with $12,740 in total fines with 10 recent health deficiencies
218 Baltic, Edinburg, TX
(956) 316-2533
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
109
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Wellsential Health
Operator or chain grouping
Approved since
2009-02-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
67 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.35
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.93
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.10
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.18
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.70
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.30
CMS adjusted RN staffing hours
Adjusted total hours
2.69
CMS adjusted total nurse staffing hours
Case-mix index
1.58
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,750
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.99
Composite VBP score used to determine payment impact.
Payment multiplier
1.0016
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.51
Baseline 18.73% · Performance 18.41% · Measure score 6.51 · Achievement 6.51 · Improvement 1.37
Healthcare-associated infections
7.45
Baseline 10.06% · Performance 6.04% · Measure score 7.45 · Achievement 6.02 · Improvement 7.45
Total nurse turnover
5.24
Baseline 50.54% · Performance 42.27% · Measure score 5.24 · Achievement 5.24 · Improvement 2.72
Adjusted total nurse staffing
0
Baseline 2.86 hours · Performance 2.75 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.08% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 109 · Observed rate 6.42% · Lower 95% interval 5.97% |
| Discharge to community | 70.76% |
50.57%
20.2 pts better
|
Better than the National Rate · Eligible stays 103 · Observed rate 64.08% · Lower 95% interval 61.71% |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.65% |
95.27%
3.4 pts better
|
Numerator 73 · Denominator 74 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 74 |
| Discharge self-care score | 36.73% |
53.69%
17 pts worse
|
Numerator 18 · Denominator 49 |
| Discharge mobility score | 48.98% |
50.94%
2 pts worse
|
Numerator 24 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 74 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.03% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 59 · Observed rate 3.39% · Lower 95% interval 3.1% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 146 |
| Staff flu vaccination coverage | 97.38% |
42%
55.4 pts better
|
Numerator 186 · Denominator 191 |
| Discharge function score | 36.73% |
56.45%
19.7 pts worse
|
Numerator 18 · Denominator 49 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 20 · Denominator 20 |
| Transfer of health information to patient | 95.92% |
96.28%
0.4 pts worse
|
Numerator 47 · Denominator 49 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.3%
0.5 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.3% · Q3 3.6% · Q4 5.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
2.7%
1.4 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 1.2% · Q4 1.3% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
3.3%
0.4 pts worse
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 6.8% · Q3 3.8% · Q4 2.7% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.6% |
18.9%
9.3 pts better
|
19.6%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 9.6% · Q3 13.8% · Q4 7.9% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.8% |
10.8%
9 pts better
|
16.7%
14.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.5% · Q3 2.7% · Q4 1.4% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 0.0% |
15.4%
15.4 pts better
|
16.3%
16.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.1% |
16.1%
14 pts better
|
14.9%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.9% · Q3 1.3% · Q4 2.8% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.7% |
15.0%
11.3 pts better
|
19.8%
16.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.2% · Q3 3.3% · Q4 8.0% · 4Q avg 3.7% |
| Percentage of long-stay residents with pressure ulcers | 0.7% |
4.2%
3.5 pts better
|
5.1%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 0.0% · Q4 1.7% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
89.7%
10.1 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 99.5% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
12.0%
12 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.5% · Q3 0.7% · Q4 0.7% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.0% |
88.0%
11 pts better
|
79.7%
19.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.3% |
25.9%
9.6 pts better
|
23.9%
7.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.3% · Observed 16.7% · Expected 24.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-25 · Fire 2024-09-25
5 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-06-22 · Fire 2023-06-22
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-06-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-23
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-17
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-12-18
E · Potential for more than minimal harm
2025-12-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-18
D · Potential for more than minimal harm
2025-12-17
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-12-18
D · Potential for more than minimal harm
2025-12-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-18
D · Potential for more than minimal harm
2025-12-17
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-12-18
D · Potential for more than minimal harm
2025-12-17
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-12-18
D · Potential for more than minimal harm
2025-12-02
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-12-03
J · Immediate jeopardy
2025-09-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-07
D · Potential for more than minimal harm
2025-09-11
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-09-11
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-02-06
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-02-07
E · Potential for more than minimal harm
2024-09-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-09-25
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-09-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-07-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-12
D · Potential for more than minimal harm
2023-06-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-25
D · Potential for more than minimal harm
2023-06-22
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-06-25
D · Potential for more than minimal harm
2023-06-22
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-06-25
D · Potential for more than minimal harm
2023-06-22
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-06-25
Penalties and ownership
What sits behind the stars
$12,740
2025-09-11
Fine
Fine · fine $12,740
Fine
Ownership
Starr County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Dekowski, Donovan
Operational/Managerial Control · Individual
Munoz, Thalia
Corporate Officer · Individual
Reyes, Ana
Operational/Managerial Control · Individual
Starr County Hospital District
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Windsor Nursing And Rehabilitation Center Of Edinb
Edinburg, TX
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Hidalgo Nursing And Rehabilitation Center
Edinburg, TX
2-star overall rating with 2-star inspections with abuse icon flag with $7,582 in total fines with 4 recent health deficiencies
#3
Edinburg Nursing and Rehabilitation Center
Edinburg, TX
2-star overall rating with 3-star inspections with $21,472 in total fines with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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