Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mcallen Nursing Center during CMS and state inspections, most recent first.
Unauthorized Video Recording and Social Media Posting of Residents: A visitor recorded two residents in their room and hallway and another resident in the hallway, then posted the video on social media without consent from the residents or their RPs. The residents had severe cognitive impairment, including Alzheimer’s disease, Parkinson’s disease with psychosis, and other chronic conditions, and could not reliably recall or respond about the incident. The AD said the visitor came to donate roses and staff were not aware of the recording, while the ADM confirmed consent existed only for facility photos, not for a visitor’s video.
Two residents with significant cognitive and physical impairments had documented falls that were not incorporated into their comprehensive care plans. Although both residents were care planned for fall risk with various interventions, incident reports showed one resident had an unwitnessed fall and another had multiple witnessed falls that were never added or dated in the care plans. The MDS/RN reported that, following corporate direction, staff stopped updating care plans with dated post-fall interventions and instead relied on incident reports, progress notes, post-fall evaluations, neuro checks, and 24-hour reports, while the DON stated that changes were communicated via in-services and incident reports despite policy requiring each fall to be documented and reflected in the care plan.
A resident with multiple chronic conditions did not have the administration of clonazepam and insulin properly documented by two LVNs on several occasions. Although the medications were reportedly given, the MAR lacked required entries, and there was no supporting documentation in progress notes. Both LVNs acknowledged the omission and confirmed the resident did not refuse medications, contrary to facility policy requiring complete and accurate records.
Two residents were not included in care plan meetings and their care plans were not updated to reflect current smoking status or discharge planning, despite completed smoking evaluations and changes in their needs. Staff confirmed that care plans for smoking and discharge were not implemented in a timely manner, contrary to facility policy.
Surveyors found 17 loose, unlabeled tablets and capsules in each of two medication carts, mixed with blister packs for residents' medications. Nursing staff, including an LVN, ADON, and DON, confirmed there was no official policy on how often to clean medication carts, and could not identify the medications or their intended recipients. Facility policy required removal of medications with missing labels, but this was not consistently followed.
Nursing staff failed to consistently and accurately document blood pressure readings prior to administering blood pressure-altering medications to two residents with complex medical conditions, including heart failure and chronic kidney disease. Multiple instances were found where the same blood pressure values were recorded for several administrations in a row, and required documentation was missing from the clinical record. Staff interviews confirmed that blood pressure readings were sometimes copied from previous entries rather than measured at the time of medication administration, contrary to facility policy and physician orders.
Two residents with significant medical conditions did not have their weekly weights consistently obtained and documented as ordered by their physicians, despite care plans specifying this intervention. Staff interviews revealed inconsistencies in the process for weighing and recording, and nursing leadership confirmed that the required weekly weights were not always completed.
A resident with a stage 4 sacral pressure ulcer and a catheter did not receive proper infection control during wound care, as both the WCN and a CNA failed to wear required gowns and did not perform hand hygiene after removing gloves, despite clear orders and facility policy. Both staff acknowledged forgetting the procedures, and the DON confirmed the lapses.
Two residents with cognitive and behavioral impairments were involved in an incident where one physically struck the other on the head. The aggressive resident, who had a history of behavioral issues and was on one-to-one monitoring, was able to assault another resident in the dining room. The incident was not immediately reported or investigated, and facility policy requiring notification of law enforcement was not followed.
A resident with severe cognitive impairment and behavioral issues struck another resident on the head twice. Although the incident was eventually reported to the state agency, it was not reported to local law enforcement as required by policy and regulation. The administrator chose not to notify law enforcement based on the victim's request, despite facility policy and state law mandating immediate reporting of such abuse allegations.
A resident with cognitive impairments eloped from a facility due to inadequate supervision and failure to follow elopement procedures. The resident, assessed as a low elopement risk, left unnoticed and was found by police nearby. Staff in the break room did not hear the alarm, and the facility's elopement protocols were not properly implemented, leading to the incident.
A resident with a history of exit-seeking behavior and cognitive impairment eloped from the facility unnoticed, despite having a wander guard and previous one-to-one supervision. The resident was found at a nearby apartment complex after being out of the facility for approximately 30 minutes. Staff had redirected the resident earlier in the day but failed to maintain adequate supervision, leading to the incident.
A facility failed to implement a comprehensive care plan for a resident, omitting critical elements such as a wander guard, IV antibiotics for a bacterial infection, and interventions for multiple falls. Despite protocols for incidents, these were not reflected in the care plan, leading to a deficiency in addressing the resident's medical and psychosocial needs.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards. Observations revealed unlabeled food, personal items in a resident's refrigerator, and expired milk. The Dietary Manager and Administrator acknowledged the issues.
The facility failed to maintain hand sink hot water temperatures at a comfortable level of at least 100 degrees F in several resident rooms, with temperatures ranging from 67.6 degrees F to 86.5 degrees F. Residents confirmed they only had access to cold water, and the Maintenance Supervisor acknowledged the issue, noting that staff had to let the water run for 15 to 20 minutes to achieve the desired temperature. This failure compromised the residents' right to a safe, clean, comfortable, and homelike environment.
The facility failed to maintain safe water temperatures in the women's shower room, with observed temperatures reaching 121.4 degrees F. Staff interviews and record reviews confirmed that the hot water was not properly circulated due to empty halls, and there was no policy in place to ensure safe water temperatures, placing residents at risk of burns.
The facility failed to establish an effective infection prevention and control program, leading to deficiencies in sanitizing equipment between residents and improper incontinent care procedures. Staff interviews confirmed the failure to follow established protocols, increasing the risk of infection.
The facility failed to maintain accurate medical records for a resident with multiple serious health conditions, including missing documentation for post-dialysis weight, PEG site care, anticoagulant monitoring, SpO2 saturation, pain assessment, and infection monitoring over several shifts.
The facility failed to complete initial comprehensive MDS assessments within 14 days of admission for two residents, impacting the development of necessary care plans. The DON and a PRN RN acknowledged the oversight, citing the lack of a permanent MDS Coordinator and time constraints as contributing factors.
The facility failed to develop and implement a comprehensive care plan for a resident administered Keppra for mood disorder and psychotic symptoms. Despite physician orders to monitor and document behavioral episodes and adverse drug events, the care plan did not reflect the use of Keppra. Interviews revealed that the oversight was due to the absence of a permanent MDS Coordinator and shared responsibilities among staff.
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in oxygen administration. One resident's oxygen concentrator displayed a warning light, and the nasal cannula was not in place, while another resident received incorrect oxygen levels via a trach mask. Staff interviews revealed a lack of understanding and adherence to oxygen administration protocols.
The facility failed to establish an effective pain management program for a resident with multiple diagnoses, including dementia and a right femur fracture. Staff did not consistently assess or manage the resident's pain, leading to unnecessary discomfort and decreased quality of life. LVNs failed to assess pain levels before administering medication, and the facility's pain management policies were not followed.
The facility failed to maintain a safe environment, with dark discoloration observed on the bathroom ceiling in A Hall and the ceiling in E Hall. Maintenance checks were conducted, but the issues persisted.
The facility failed to ensure a resident's call light was within reach, despite the resident's severe cognitive impairment and functional quadriplegia. Observations and staff interviews confirmed the call light was repeatedly placed out of reach, contrary to the resident's care plan and facility policy.
The facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors for two of the three days reviewed. The daily staffing forms for 2/27/24 and 2/28/24 were not posted in a prominent location and lacked census information. The DON and ADON acknowledged the omissions, and the Administrator confirmed the absence of a policy related to staff posting.
Unauthorized Video Recording and Social Media Posting of Residents
Penalty
Summary
The facility failed to respect residents’ personal privacy and confidentiality when a visitor recorded residents and their private space without the residents’ or their designated representatives’ consent, and the video was later posted on social media. The deficiency involved 3 of 11 residents reviewed for personal privacy and confidentiality: Resident #1, Resident #4, and Resident #7. The report states that the residents were not injured or in distress, but the event involved unauthorized recording and public posting of their images and interactions in the facility. Resident #1 was a female with Alzheimer’s disease, mood disorder due to physiological condition, and cognitive communication deficit. Her MDS reflected a BIMS score of 6, indicating severe cognitive impairment. Resident #1’s care plan identified impaired cognition and a psychosocial well-being problem related to improper social media exposure. During the video, Resident #1 received a rose and a hug from the visitor while in her room. When interviewed, Resident #1 stated she did not know who the lady was and did not remember whether she was asked to take a photo or video. Resident #4 was a female with Parkinson’s disease, chronic kidney disease, muscle wasting and atrophy, mood disorder due to physiological condition, cognitive communication deficit, and unspecified psychosis. Her MDS reflected a BIMS score of 6, indicating severe cognitive impairment. Her care plan also identified impaired cognition and a psychosocial well-being problem related to improper social media exposure. In the video, Resident #4 received a rose and a hug from the visitor in the hallway. Resident #4 could not recall whether she received a rose or whether anyone visited her, and could not provide information about the incident. Resident #7 was a female with Alzheimer’s disease, chronic kidney disease, muscle wasting and atrophy, mood disorder due to physiological condition, cognitive communication deficit, and major depressive disorder. Her MDS reflected a BIMS score of 00, indicating severe cognitive impairment. Her care plan identified impaired cognition and a psychosocial well-being problem related to improper social media exposure. In the video, Resident #7 received a rose from the visitor in the hallway. When interviewed, Resident #7 did not respond to basic questions and was not interviewable. The AD stated the visitor came to donate roses for Mother’s Day, that residents were asked if they wanted to accept the rose, and that the facility was not aware the visitor was recording. The ADM stated the residents or their representatives had signed consent for the facility to take or post photos, but not for a visitor to take photos or video. The facility’s Resident Rights policy stated residents have a right to personal privacy and confidentiality of personal and medical records, including personal privacy in visits.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure that comprehensive care plans were periodically reviewed and revised by a team of qualified persons after each assessment and after falls, as required. For one resident with Alzheimer’s disease, dementia, muscle weakness, reduced mobility, joint stiffness, and bone density disorder, the comprehensive care plan identified fall risk and included multiple fall-related interventions with various initiation and revision dates. However, facility incident/accident reports showed this resident sustained an unwitnessed fall on 11/27/2025 that was not reflected or updated in the resident’s care plan. A second resident, with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, contractures, muscle weakness, lack of coordination, dementia, and mood disorder, also had a care plan identifying fall risk related to CVA, dementia, and right-sided weakness. The care plan contained general fall-prevention interventions and showed an initial date and a revision date. Review of the facility’s incident/accident reports revealed that this resident experienced three witnessed falls on 11/14/2025, 12/16/2025, and 12/30/2025, none of which were reflected or updated in the resident’s care plan. In interviews, the MDS/RN stated that, per direction from a corporate consultant, care plans were no longer updated with dated interventions after each fall, and that staff instead relied on incident reports, progress notes, post-fall evaluations, neuro check forms, the 24-hour report, and previous progress notes for information on interventions and updates. The MDS/RN reported that care plan reviews were done quarterly, annually, and with significant changes in condition, and that dated interventions were not routinely added after each fall, especially when there was no injury or significant change. The DON stated that staff learned of changes to interventions through in-services and incident reports and that care plans were updated when incidents occurred or as needed, but acknowledged, after hearing the facility’s Fall Management System policy, that each fall should be documented, reviewed, and reflected with dates and interventions in the care plan.
Failure to Accurately Document Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Specifically, two LVNs did not document the administration of prescribed clonazepam and insulin on multiple occasions, as evidenced by missing check-offs on the Medication Administration Record (MAR) for several dates. There was no documentation in the progress notes to indicate whether the medications were administered, held, or refused on those dates. The resident involved was an adult male with multiple diagnoses, including Parkinson's disease, type 2 diabetes, intellectual disabilities, autistic disorder, anxiety disorder, and depression. Physician orders required the administration of clonazepam three times daily for anxiety and insulin as per a sliding scale for diabetes. Review of the MAR for the relevant month showed that doses of both medications were not documented as given at several scheduled times. Interviews with the LVNs responsible revealed that they administered the medications as ordered but failed to document the administration on the MAR, attributing the omission to forgetfulness. Both LVNs acknowledged their responsibility to ensure accurate documentation and confirmed that the resident did not refuse medications and was not out of the facility. The facility's policies required documentation of all administered medications and specific procedures for documenting refusals, which were not followed in these instances.
Failure to Update and Involve Residents in Care Planning for Smoking and Discharge
Penalty
Summary
The facility failed to ensure that each resident and/or their representative, as well as the interdisciplinary team (IDT), were invited to participate in care plan meetings for both comprehensive and quarterly review assessments. Specifically, two residents were not included in these meetings as required. Additionally, the care plans for these residents were not revised in a timely manner to accurately reflect their current smoking status, despite both having completed smoking evaluations indicating they were independent and safe smokers. For one resident, the care plan did not include any information about smoking, even though a smoking evaluation had been completed and indicated the resident had recently started smoking. The other resident's care plan also lacked documentation of smoking status and did not address discharge planning, despite the resident having a completed smoking evaluation and being admitted for several months. Both residents' Minimum Data Set (MDS) assessments did not reflect tobacco use or smoking, and their care plans were not updated to include this information until much later. Interviews with facility staff, including the MDS coordinator, DON, and administrator, confirmed that the care plans for smoking were not implemented until after the residents had already begun smoking. Staff acknowledged that discharge planning should have been included in the care plan for one resident but was not. The facility's policy requires comprehensive, person-centered care plans that address all identified needs, but this was not followed in these cases.
Loose and Unlabeled Medications Found in Medication Carts
Penalty
Summary
Surveyors observed that two medication carts, one on B-hall and one on D/E-halls, contained 17 assorted loose tablets and capsules each, stored in the same drawers as blister packs for residents' medications. These loose medications were not labeled, and staff could not determine which residents they belonged to or how long they had been in the carts. The facility's policy required routine inspection and removal of medications with missing labels, but this was not consistently followed. Interviews with nursing staff, including an LVN, the ADON, and the DON, revealed that there was no official policy on how often medication carts should be cleaned, and each nurse was responsible for their own cart. Staff stated that loose medications should be disposed of properly, but there was no documentation or evidence that this was being done regularly. The staff were unable to identify the medications or their intended recipients, and acknowledged that the presence of loose medications could result in residents losing their prescribed doses.
Failure to Accurately Document Blood Pressure Prior to Administration of BP-Altering Medications
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents who were receiving blood pressure-altering medications. Licensed vocational nurses (LVNs) did not consistently document blood pressure readings as required by physician orders and facility policy prior to administering medications such as amiodarone, hydralazine, metoprolol, midodrine, and amlodipine. In multiple instances, the same blood pressure readings were documented for several medication administrations in a row, which is not consistent with normal physiological variation and suggests that actual measurements may not have been taken each time. For one resident with diagnoses including chronic heart failure, hypertension, hypotension, and end-stage renal disease, LVNs failed to correctly document blood pressure readings on numerous occasions when administering medications that required such monitoring. The electronic medication administration record (eMAR) often showed repeated or identical blood pressure values for different times and dates, and in some cases, there were no corresponding entries in the blood pressure summary. Interviews with staff revealed that at times, blood pressure values were copied from previous entries if the nurse misplaced the original documentation, rather than being measured and recorded at the time of medication administration. Another resident with hypertension and chronic kidney disease also had repeated blood pressure values documented for consecutive days when receiving antihypertensive medication, with missing entries in the blood pressure summary. Staff interviews confirmed that the practice of documenting without actual measurement occurred, and that this was not in accordance with facility policy or physician orders. The facility's own guidelines required blood pressure to be checked and documented immediately prior to administration of such medications, but this was not consistently followed.
Failure to Implement Comprehensive Care Plans for Weekly Weights
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that included measurable objectives and timeframes to meet the medical, nursing, mental, and psychosocial needs of two residents. Specifically, the care plans for both residents did not ensure that weekly weights, as ordered by their physicians, were consistently obtained and documented. For one resident with morbid obesity and chronic systolic heart failure, the care plan included a goal to maintain stable weight and interventions to provide a specific diet, but there was no evidence of weekly weights being recorded between two documented dates over a month apart. For another resident with mild protein-calorie malnutrition and dementia, the care plan addressed unplanned weight loss and included interventions such as weekly weights and monitoring for further weight loss. However, weight records showed that weekly weights were not consistently documented, with a gap of over a month between recorded weights. Both residents had active physician orders for weekly weights, but the facility did not ensure these orders were followed. Interviews with staff revealed inconsistencies in the process for weighing residents, with some CNAs stating they always weighed residents as required, while others described weighing residents monthly or passing information between shifts if weights were missed. Nursing leadership acknowledged that residents were not being weighed as ordered and described the process for assigning and recording weights, but the documentation did not support that weekly weights were consistently obtained as required by the care plans and physician orders.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for a resident requiring enhanced barrier precautions due to a stage 4 sacral pressure ulcer and the presence of a catheter. During wound care, both the wound care nurse (WCN) and a certified nursing assistant (CNA) did not wear the required personal protective equipment (PPE), specifically gowns, despite clear physician orders and signage indicating the need for enhanced barrier precautions. Both staff members also failed to perform hand hygiene after removing gloves during the procedure, contrary to facility policy and established infection control protocols. The resident involved had significant medical conditions, including a stage 4 pressure ulcer, hypertension, and type 2 diabetes, and required daily wound care with specific instructions for PPE use. Interviews with the WCN and CNA revealed that both were aware of the correct procedures but forgot to follow them during the observed wound care. The Director of Nursing confirmed that the staff should have worn gowns and performed hand hygiene as required by the facility's infection control policy, which was last reviewed in a recent in-service.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a physical altercation. One resident, who had a history of moderate cognitive impairment, dementia, and muscle weakness, was struck twice on the head by another resident with severe cognitive impairment, behavioral symptoms, and a history of aggression. The incident occurred in the dining room as the aggressive resident was being escorted in a wheelchair and began swinging her arms, making contact with the other resident. The assaulted resident initially denied being hit but later admitted to the incident during the investigation, stating he did not want to report it due to fear of escalation and concerns about his probation status. The aggressive resident had documented behavioral issues, including hallucinations, delusions, and a pattern of physical and verbal aggression toward others. She was already on one-to-one monitoring and awaiting transfer to a psychiatric hospital due to her escalating behaviors. Despite these interventions, the resident was able to physically assault another resident. Staff present during the incident did not immediately report the event, and the facility's investigation was only initiated after a witness reported the incident two days later. No injuries were found on assessment, but the delay in reporting and investigation was evident. The facility's policies required prevention, investigation, and reporting of abuse, neglect, and exploitation. However, the incident was not reported to law enforcement as required by policy, and there was a lack of immediate documentation and witness statements. The failure to promptly identify, report, and investigate the abuse incident, as well as to protect the resident from ongoing verbal abuse, constituted a deficiency in ensuring residents' rights to be free from abuse and neglect.
Failure to Timely Report Resident-to-Resident Abuse to Law Enforcement
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than two hours after the allegation was made, to the administrator and appropriate authorities, including local law enforcement. Specifically, an incident occurred in which a female resident with severe cognitive impairment and behavioral issues struck a male resident on the head twice. The male resident initially denied the incident but later admitted to being hit during the facility's investigation. The incident was not reported to local law enforcement as required by facility policy and state regulations. The male resident involved had a history of moderate cognitive impairment, dementia, and physical limitations, requiring assistance with activities of daily living. The female resident had severe cognitive impairment, hallucinations, delusions, and a documented history of aggressive behaviors. At the time of the incident, she was on one-to-one supervision and awaiting transfer to a psychiatric hospital due to escalating behavioral symptoms. The incident was eventually reported to the state agency, but not to local law enforcement, based on the male resident's expressed fear of legal repercussions due to his probation status. Interviews with facility staff, including the DON and Administrator, confirmed that the administrator was made aware of the incident two days after it occurred and initiated an investigation at that time. Both the DON and Administrator acknowledged that the facility's policy required reporting such incidents to both state and local authorities, but the administrator chose not to notify law enforcement, citing the resident's and his family's request. The facility's own policy and state law mandate immediate reporting of abuse allegations to all appropriate authorities, which was not followed in this case.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident, leading to an elopement incident. The resident, who had a history of Alzheimer's, Bipolar Disorder, PTSD, Major Depressive Disorder, and Unspecified Dementia, was moderately cognitively impaired but functionally independent. Despite being assessed as a low elopement risk, the resident managed to leave the facility unnoticed and was found by police approximately 0.2 miles away. On the night of the incident, the resident was last seen in his room at 11:15 p.m. but was discovered missing at 12:30 a.m. The staff, including CNAs and LVNs, were in the break room and did not hear the alarm when the resident exited through the front door. The alarm was turned off without confirming the resident's whereabouts, and a code silver was initiated only after the resident was found missing. Interviews with staff revealed a lack of awareness and implementation of the facility's elopement procedures. The facility's policy required staff to respond promptly to alarms and to follow systematic procedures for monitoring residents at risk of elopement. However, the staff's failure to adhere to these protocols resulted in the resident's unsupervised departure. The incident highlighted gaps in staff training and awareness regarding the facility's elopement procedures, as not all staff were informed or responsive to the alarms and the necessary protocols for managing such situations.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident who was at risk of elopement. The resident, who had a history of exit-seeking behavior and cognitive impairment, managed to leave the facility unnoticed and was found at a nearby apartment complex. The resident's care plan indicated a risk for wandering and exit-seeking, and interventions such as a wander guard and redirection were in place. However, these measures were insufficient to prevent the elopement. On the day of the incident, the resident was seen attempting to exit the facility, triggering the door alarm. Staff redirected the resident to his room, but he later eloped through a window. The resident was out of the facility for approximately 30 minutes before staff became aware of his absence. Interviews with staff revealed that the resident had been taken off one-to-one supervision the day before the incident, despite ongoing exit-seeking behaviors. The resident's medical history included moderate cognitive impairment, mood disorder, and dementia, which contributed to his exit-seeking behavior. Despite the use of a wander guard and previous one-to-one supervision, the facility's failure to maintain adequate supervision and implement additional interventions led to the resident's elopement. Staff interviews indicated that while they were aware of the resident's behaviors, the existing protocols and supervision were not sufficient to prevent the incident.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs. The care plan did not reflect the use of a wander guard, the administration of IV antibiotics for a bacterial infection, or the falls experienced by the resident on three separate occasions. This oversight could potentially place residents at risk of not receiving the necessary care and services as indicated in their comprehensive care plans. The resident in question was an elderly male with multiple diagnoses, including type 2 diabetes, hepatic encephalopathy, mood disorder, unspecified psychosis, hypertension, dementia with behavioral disturbances, alcohol abuse in remission, muscle weakness, lack of coordination, and cognitive communication deficit. The resident had a moderate cognitive impairment and required supervision for bed mobility and transfers. Despite these needs, the care plan did not adequately document the interventions and precautions necessary to address the resident's condition and incidents. Interviews with various staff members, including LVNs, RNs, the MDS Nurse, the ADON, and the DON, revealed inconsistencies and a lack of clarity regarding the responsibility for updating the care plan. Although the facility had protocols in place for falls and other incidents, these were not consistently reflected in the care plan. The staff acknowledged that the care plan should have included the wander guard, the IV antibiotics, and the interventions for each fall, but these were not documented, leading to a deficiency in the resident's care plan.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards or food service safety. During an observation of the kitchen, it was found that refrigerator #1 contained a plastic container with beans that was not labeled, a personal 4 fl. oz. bottle of water, and an open 2-liter plastic bottle belonging to staff. Additionally, refrigerator #2 contained two gallons of expired milk. These issues were identified during a kitchen inspection at 10:15 a.m. on the specified date. In an interview, the Dietary Manager acknowledged the expired milk and unlabeled beans, stating that the kitchen staff knew the milk was expired but failed to discard it. The Dietary Manager also mentioned that she conducts quarterly or as-needed in-services regarding labeling and dating. The Administrator confirmed that the Dietary Manager had informed her of the issues and that all food items had been discarded. The facility's policy on Frozen and Refrigerated Foods Storage requires proper labeling of cooked foods, including the date placed in the refrigerator and an expiration or use-by date.
Failure to Maintain Adequate Hot Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to ensure the residents' right to a safe, clean, comfortable, and homelike environment by not maintaining the hand sink hot water temperatures at a comfortable level of at least 100 degrees F. Observations revealed that the water temperatures in several resident rooms were significantly below the required temperature, with readings ranging from 67.6 degrees F to 86.5 degrees F. The Maintenance Supervisor acknowledged that the water heater used for both halls E and F took time to flow hot water to the back rooms, and staff had to let the water run for 15 to 20 minutes to achieve the desired temperature. However, it was noted that residents did not typically allow the water to run for that long, resulting in them only having access to cold water. Despite the Maintenance Supervisor's weekly log showing higher temperatures, these were taken after letting the water run for an extended period, which was not reflective of the residents' actual experience. Interviews with residents confirmed that they did not have warm or hot water when using their hand sinks and always received cold water. The Maintenance Supervisor admitted to testing random rooms and letting the water run for several minutes before taking temperature readings. He also mentioned the need for circulating pumps to draw hot water faster to the end rooms. The Administrator stated that staff would notify the Maintenance Supervisor to adjust the water heater valves when temperatures were not within the required range. However, the lack of immediate access to warm or hot water placed residents at risk of not having a comfortable and homelike environment.
Unsafe Water Temperature in Women's Shower Room
Penalty
Summary
The facility failed to maintain water temperatures at a safe level in the women's shower room, which could place residents at risk of injuries and burns. During an observation, the hot water temperature in the women's shower room was found to be 121.4 degrees F, exceeding the safe maximum of 110 degrees F. The Maintenance Supervisor acknowledged that the water heater in the B hall, which also served the C hall, was not circulating hot water properly due to the lack of residents in these halls, causing the water temperature to stay hot. The Logbook Documentation from earlier in the month showed a recorded temperature of 107.6 degrees F, indicating that the issue was not consistently monitored or addressed. The Administrator confirmed that there was no policy for water temperatures and that the Maintenance Supervisor was responsible for ensuring safe water temperatures. Interviews with staff, including a CNA and the DON, revealed that the hot water in the women's shower room would be instantly hot when turned on, and cold water was used to bring it to a comfortable temperature for residents. The CNA mentioned that some residents did not want assistance with their showers, but she would stay in the shower room with them. The DON reiterated that the water temperature should not exceed 110 degrees F to prevent the risk of skin burns. The deficiency was observed and confirmed through multiple interviews and record reviews, highlighting a lapse in maintaining a safe environment for residents.
Infection Control Deficiencies
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, leading to multiple deficiencies. During medication administration, an LVN did not sanitize the blood pressure cuff between uses for three residents. This was observed during med pass sessions, where the LVN completed hand hygiene but neglected to disinfect the blood pressure cuff before and after use on each resident. Interviews with the LVN and other staff confirmed that the protocol requires sanitizing equipment between residents, and failure to do so could lead to infection control issues. The LVN admitted to not following the protocol and was unsure of the last time she attended an infection control in-service. Additionally, during incontinent care for a resident, a CNA failed to use appropriate cleaning procedures. The CNA used a wipe more than once to clean the resident's buttocks, which is against the protocol of using one wipe per swipe and disposing of it immediately. This improper technique was observed during an incontinent care session, and the CNA admitted to remembering this incorrect method from school. Interviews with other staff members, including another CNA and the ADON, confirmed that the correct procedure involves using one wipe per swipe to prevent contamination and infection. The facility's infection control guidelines and incontinence care procedures were reviewed, revealing that the staff did not adhere to established protocols designed to prevent the spread of infections. The guidelines clearly state the need for disinfecting reusable equipment and using proper techniques during incontinent care. The failure to follow these protocols was acknowledged by multiple staff members, including the DON, who emphasized the importance of these measures in preventing infection control issues.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards and practices for one resident. Specifically, the facility did not accurately document various critical health metrics for a resident with multiple serious health conditions, including dementia, type 2 diabetes mellitus, end-stage renal disease, and myocardial infarction. The resident's post-dialysis weight, PEG site care, anticoagulant monitoring, SpO2 saturation, pain assessment, and monitoring for signs of infection were not accurately recorded in the Medication Administration Record (MAR) on multiple shifts over several days. The report details that the resident's post-dialysis weight was not documented on the MAR for a specific date, which is crucial for monitoring potential fluid overload. Additionally, PEG site care was not recorded for one shift, and anticoagulant monitoring was missing for several shifts, which is essential for tracking potential adverse drug events. The resident's SpO2 saturation, pain assessment, and monitoring for signs of infection were also not documented for multiple shifts, which are critical for ensuring the resident's overall health and well-being. Interviews with facility staff, including an LVN, ADON, and DON, revealed that the failure to document these critical health metrics could lead to serious health risks for the resident, such as fluid overload and missed side effects of medications. The facility's policy on medication and treatment administration emphasizes the importance of accurate and timely documentation, yet these procedures were not followed, leading to the identified deficiencies.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete an initial comprehensive resident-centered assessment of each resident's cognitive, medical, and functional capacity for two residents reviewed for comprehensive MDS assessment timing. Specifically, the facility did not complete the Admission MDS assessment within 14 days of admission for two residents. This failure was identified through record reviews and interviews with staff members, including the Director of Nursing (DON) and a PRN RN, who acknowledged the oversight and attributed it to the lack of a permanent MDS Coordinator since January 2024. The DON admitted that the assessments should have been completed within the required timeframe to ensure accurate information for developing care plans. Resident #14, who was admitted with diagnoses including Alzheimer's disease, mood disorder, delusional disorders, major depressive disorder, anxiety disorder, insomnia, and cognitive communication deficit, had an incomplete admission MDS assessment dated 02/13/2024. Similarly, Resident #275, admitted with diagnoses including diabetes, insomnia, schizophrenia, major depressive disorder, dementia, and cognitive communication deficit, also had an incomplete admission MDS assessment dated 02/14/2024. Interviews with the DON and RN F revealed that the assessments were not completed due to time constraints, which hindered the development of necessary care plans to address the residents' needs.
Failure to Develop Comprehensive Care Plan for Resident on Keppra
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #14, who was administered the medication Keppra for behaviors related to mood disorder and psychotic symptoms. Despite the physician's order to monitor the resident for episodes of anger, yelling, and delusions, and to document the interventions and outcomes, the care plan did not reflect the use of Keppra. This oversight was confirmed through record reviews and interviews with the Director of Nursing (DON), Licensed Vocational Nurse (LVN), and Registered Nurse (RN) responsible for care plans. The absence of a care plan for the use of Keppra meant that the resident's care was not individualized to address her specific needs related to the medication's administration and monitoring for adverse drug events (ADEs). Resident #14 had a history of severe cognitive impairment, Alzheimer's disease, mood disorder, delusional disorders, major depressive disorder, anxiety disorder, insomnia, and cognitive communication deficit. The resident's admission records and physician orders indicated the need for Keppra to manage her behavioral symptoms. However, the care plan only included general interventions for behavior problems without specific details on the use of Keppra. Interviews revealed that the facility had not had a permanent MDS Coordinator since January 2024, and the responsibility for updating care plans was shared among the DON, Assistant Director of Nursing (ADON), and RN. The RN admitted to overlooking the development of a care plan for Keppra, and the DON acknowledged that this failure did not provide individualized care for the resident.
Deficiencies in Oxygen Administration and Equipment Maintenance
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in oxygen administration. Resident #299's oxygen concentrator displayed a red warning light indicating a low oxygen flow rate or concentration. Despite the warning, the resident's nasal cannula was not in place, and the staff did not notice the issue during their rounds. The resident's oxygen saturation was checked and found to be within normal limits, but the oxygen concentrator was not immediately replaced, indicating a lapse in monitoring and equipment maintenance. Interviews with the staff revealed a lack of understanding of the warning light's significance and the necessary actions to address it promptly. Resident #177's oxygen was administered at 4.5 Lpm instead of the physician-ordered 5 Lpm via a trach mask. Observations showed that the oxygen setting was incorrect, and staff interviews confirmed that the oxygen levels were not set according to the physician's order. The staff demonstrated a misunderstanding of how to correctly set the oxygen levels, which could lead to insufficient oxygen delivery to the resident. The facility's policies on oxygen administration and safety were not adequately followed, as evidenced by the incorrect oxygen settings and the lack of proper equipment checks. Both residents had significant medical histories, including chronic respiratory conditions and cognitive impairments, which necessitated careful monitoring and adherence to prescribed oxygen levels. The deficiencies in oxygen administration and equipment maintenance could have led to serious respiratory complications for the residents. The staff's lack of knowledge and failure to follow established protocols contributed to the deficiencies observed during the survey.
Failure to Adequately Assess and Manage Pain for Resident
Penalty
Summary
The facility failed to establish an effective pain management program for Resident #9, who had multiple diagnoses including dementia, type 2 diabetes mellitus, hypertension, and pain in unspecified joints and the right knee. The resident was also suffering from a displaced subcapital fracture of the right femur and had a history of osteopenia, osteoarthrosis, osteoporosis, and degenerative arthritis. Despite these conditions, the facility did not adequately assess or manage the resident's pain, leading to unnecessary discomfort and decreased quality of life for the resident. One significant issue was that LVN B did not assess Resident #9's pain level before administering PRN pain medication. During a medication pass observation, Resident #9 complained of severe pain, rating it as 9 or 10 out of 10. However, LVN B administered acetaminophen-codeine without assessing the pain level. This failure to assess pain was confirmed in an interview where LVN B admitted to forgetting to ask due to nervousness from being observed by surveyors. Additionally, other staff members, including LVN C, also failed to properly assess and manage the resident's pain, as evidenced by an incident where regular Tylenol was given despite the resident's pain being at a level of 10 out of 10. Interviews with various staff members, including the ADON, DON, and other LVNs, revealed a lack of consistent practice in assessing and managing pain. Staff members acknowledged the importance of assessing pain levels and following up on the effectiveness of pain medication, but these practices were not consistently followed. The facility's pain management policies were not adhered to, resulting in Resident #9 experiencing ongoing severe pain without adequate relief. This deficiency highlights a significant lapse in the facility's pain management protocols and the need for better adherence to established procedures to ensure residents' well-being.
Ceiling Discoloration in Hallways
Penalty
Summary
The facility failed to provide a safe and functional environment for residents, staff, and the public in two of four hallways observed for environmental conditions. Specifically, the bathroom ceiling on A Hall and the ceiling in E Hall were found to have dark discoloration. Observations revealed multiple discolorations, including light brownish-yellow and black stains, with a smeared substance over some of the black discolorations. Interviews with the ADON and DON confirmed that maintenance checks for stains and issues with ceilings were conducted, but the discolorations were still present during the survey.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to provide services with reasonable accommodation of resident needs and preferences for one resident. Specifically, the staff did not ensure that the call light for a resident on hospice care was within reach. This resident, who had severe cognitive impairment, functional quadriplegia, and other significant medical conditions, was observed on multiple occasions with the call light placed out of reach. Interviews with various staff members, including an LVN, CNA, ADON, and DON, confirmed that the call light should be within reach of the resident to ensure they can call for assistance when needed. However, the call light was repeatedly found on the upper left-hand side of the resident's pillow, making it inaccessible. The resident's comprehensive care plan explicitly stated that the call light should be within reach to prevent falls and ensure timely assistance. Despite this, observations and staff interviews revealed a consistent failure to adhere to this requirement. The facility's policy on call light response also mandated that staff ensure the call light is within reach during each interaction with the resident. The failure to comply with this policy and the care plan placed the resident at risk of not having their needs met in a timely manner.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors with all required information for two of the three days reviewed. Specifically, on 2/27/24 and 2/28/24, the daily staffing information was not posted in a prominent location, and the forms did not include the census. During a tour on 2/27/24, the Surveyor could not locate the daily staff form, and the Director of Nursing (DON) later showed the Surveyor that the form was in a binder tilted sideways in a basket in the hallway by the Administrator's office. The DON admitted that the form should be filled out completely and posted prominently but could not confirm if it was visible to residents or visitors in its current location. On 2/28/24, the DON stated that the staffing form is completed daily by herself, the Assistant Director of Nursing (ADON), or the night staff, but she could not ensure its visibility to residents or visitors. Record review revealed that the forms for 2/27/24 and 2/28/24 lacked census information. The ADON, who filled out the forms for those days, acknowledged the omission but could not explain why the census was not included. The Administrator confirmed that the daily staffing sheet should be posted every day, including weekends, but admitted there was no policy related to staff posting.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 185 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mcallen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grand Terrace Rehabilitation And Healthcare | 1.2 mi | ★★★★★ | 7 | 0 |
| Windsor Nursing And Rehabilitation Center Of Mcall | 1.4 mi | ★★★★★ | 5 | 0 |
| Windsor Las Palmas Nursing And Rehabilitation Cent | 1.6 mi | ★★★★★ | 1 | 0 |
| Mcallen Transitional Care Center | 1.7 mi | ★★★★★ | 5 | 0 |
| Alfredo Gonzalez Texas State Veterans Home | 2.1 mi | ★★★★★ | 14 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.