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 Village Healthcare And Rehabilitation during CMS and state inspections, most recent first.
The facility discharged several residents with significant cognitive and medical needs without documenting a valid reason for discharge or obtaining a physician's discharge order. Discharges were conducted due to unit remodeling, and staff did not provide adequate notice, options, or documentation to residents or their families, contrary to facility policy and regulatory requirements.
The facility did not provide or document required written notifications to residents and their representatives regarding transfers or discharges, instead relying on verbal communication. Multiple residents with cognitive impairments were transferred without written notice, updated care plans, or documentation of involvement of their representatives. Staff interviews confirmed that written notifications were not part of the facility's process, and discharge logs sent to the Ombudsman were inconsistent and lacked detail.
A resident with severe cognitive impairment and high fall risk fell from bed and sustained a traumatic intracranial hemorrhage after a CNA, while providing incontinent care, was momentarily distracted and failed to maintain supervision or physical support. The resident was hospitalized and later placed on palliative care due to the injuries.
A CNA provided care to a resident requiring two-person assistance without help, resulting in the resident falling from bed and sustaining a right humerus fracture. The CNA was aware of the care plan but proceeded alone, and staff interviews confirmed this was not the first occurrence. The resident had significant medical needs and was dependent for all ADLs, as documented in her care plan and MDS.
A CNA provided incontinent care to a resident with moderate cognitive impairment and a history of cerebral infarction and morbid obesity without the required two-person assist, as specified in the care plan and MDS. During the care, the resident was turned and subsequently fell from the bed, sustaining a displaced fracture of the right distal humerus. Staff interviews confirmed the resident's dependence on two-person assistance for all ADLs, and the CNA admitted to previously performing care alone despite knowing the requirements.
A resident with intellectual and developmental disabilities did not receive timely initiation of PASRR-recommended specialized services, including a customized wheelchair and habilitative therapies, due to the facility's failure to submit the required NFSS request within 20 business days after the IDT meeting. Confusion among staff regarding responsibility for the PASRR process contributed to the delay.
Surveyors found that an insulin vial in a medication cart had been kept past the recommended 28-day period after opening, contrary to both facility policy and manufacturer guidelines. Staff interviews confirmed awareness of the 28- to 30-day discard requirement, but the expired insulin remained accessible, indicating a lapse in proper medication storage and labeling.
A CNA failed to follow infection control protocols during incontinent care for a resident with diabetes and incontinence, reusing disposable wipes for multiple cleaning strokes and not sanitizing hands between glove changes. Despite recent in-service training and clear facility policies requiring a new wipe for each stroke and hand hygiene between glove changes, the CNA did not adhere to these procedures, resulting in a breach of the infection prevention and control program.
A resident with dementia and mobility issues experienced a fall resulting in a rib fracture, but the MDS was inaccurately coded as a fall with no injury. The LVN assessed the resident post-fall, and the resident was sent to the ER where the fracture was identified. The MDS coordinator missed updating the MDS to reflect the major injury, potentially leading to inaccurate information being shared with other facilities.
Failure to Document Valid Discharge Reasons and Physician Orders
Penalty
Summary
The facility failed to ensure that there was a valid reason for discharge and that a physician's discharge order was documented for four residents who were discharged. For each of these residents, the medical records lacked documentation of a physician's order for discharge and did not specify a valid reason for the discharge prior to the residents being transferred to other facilities. The records also did not show that the discharges were based on endangerment to the safety or health of the residents or others, as required. Instead, the discharges were attributed to the facility's decision to remodel a locked unit, with no evidence of immediate medical necessity or resident-specific justification. The residents involved had significant cognitive impairments and complex medical histories, including diagnoses such as vascular dementia, Alzheimer's disease, delusional disorders, mood disorders, epilepsy, and chronic kidney disease. Care plans for these residents indicated risks such as elopement, wandering, depression, and the need for supervision with activities of daily living. Despite these vulnerabilities, the facility did not document individualized discharge planning or ensure that the residents or their responsible parties were given adequate notice or choice regarding the transfer. Family members reported being informed of the transfer on the same day it occurred, with some stating they were not given options for alternative facilities or provided with discharge paperwork or instructions. Interviews with facility staff, including the DON, ADON, and administrator, revealed inconsistencies and gaps in the discharge process. Staff were unclear about the required notice period for discharges, the documentation needed, and the involvement of the physician in initiating discharges. The facility's discharge policy required that discharges be appropriate and documented in the medical record, but this was not followed. The lack of proper documentation and communication placed residents at risk for diminished continuity of care and unsafe or improper discharges.
Failure to Provide Required Written Transfer and Discharge Notices
Penalty
Summary
The facility failed to provide and document adequate preparation and orientation for resident representatives to ensure safe and orderly transfers or discharges for five residents reviewed. In each case, the facility did not notify the residents or their responsible parties in writing of the transfers or discharges, nor did they provide the reasons for the moves in a language and manner understood by the recipients. Instead, notifications were made verbally, typically via telephone, and there was no evidence of written documentation or provision of required paperwork to the residents, their families, or representatives. This lack of written notification included the absence of information regarding appeal rights, bed-hold policies, and contact information for the State Long-Term Care Ombudsman or protection and advocacy agencies as required by federal regulations. Record reviews revealed that for each resident involved, there was either no documentation of a discharge care plan, no physician orders for transfer or discharge, or no revisions to care plans to reflect planned discharges. For example, one resident with multiple diagnoses including Alzheimer's disease, dementia, and paranoid personality disorder was transferred to a hospital due to acute mental status changes, but the family was not informed until after the transfer and did not receive any written notification or paperwork. Other residents with severe or moderate cognitive impairment were transferred to other facilities without written notice or documented involvement of their representatives in the discharge planning process. In several cases, care plans referenced pre-discharge planning but had not been updated or revised to reflect the actual discharge events. Interviews with staff, including the ADON, DON, and social services personnel, confirmed that the facility's practice was to notify responsible parties verbally and that written notifications were not part of the facility's process or policy. The Ombudsman also reported inconsistencies in receiving discharge logs and noted that the logs lacked detailed information about the reasons for discharge. The facility's own policy and federal regulations require written notice before transfer or discharge, including specific content such as reasons for the move, effective date, location, appeal rights, and contact information for advocacy agencies, none of which were provided or documented for the residents in question.
Failure to Provide Adequate Supervision During Incontinent Care Resulting in Resident Fall
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide adequate supervision to a resident during incontinent care, resulting in the resident falling from the bed. The resident, an elderly male with diagnoses including unspecified dementia, syncope, anxiety disorder, atrial fibrillation, and adult failure to thrive, was assessed as high risk for falls and required one-person assistance for toileting and bed mobility. The care plan specified the use of mobility bars to aid in repositioning, and the resident was dependent for toileting hygiene and bed mobility due to severe cognitive impairment. During the incident, the CNA was providing incontinent care with the resident positioned on his side. The CNA was momentarily distracted when another CNA entered the room to request assistance with another resident. The first CNA turned away briefly to respond, and in that moment, the resident rolled off the bed and fell to the floor. The CNA was standing next to the bed but was not holding onto the resident at the time of the fall. The fall was witnessed, and the CNA immediately called for nursing assistance. Following the fall, the resident sustained multiple injuries, including a traumatic intracranial hemorrhage, lacerations, and abrasions. The resident was sent to the hospital for evaluation and treatment, but the family opted for palliative care, and the resident later expired. Interviews with staff confirmed that the CNA was not maintaining direct supervision or physical support of the resident during care, despite the resident's high fall risk and dependency. The failure to provide adequate supervision and assistance during care directly led to the resident's fall and subsequent injuries.
Failure to Provide Required Two-Person Assistance Resulting in Resident Injury
Penalty
Summary
A certified nursing assistant (CNA) provided incontinent care to a resident who required two-person assistance for all activities, including toileting and bed mobility, without the required help. The CNA was aware of the resident's care plan and dependency level but chose to proceed alone due to time constraints during lunch. While turning the resident to her right side, the resident slipped off the bed and fell to the floor. The resident, a female with a history of cerebral infarction, morbid obesity, and moderate cognitive impairment, was always incontinent and dependent on two staff for toileting hygiene, as documented in her care plan and Minimum Data Set (MDS). Following the fall, the resident complained of right shoulder pain and was unable to move her right arm. Assessment and x-rays revealed an acute displaced fracture of the right distal humerus. Interviews with staff confirmed that the CNA had previously provided care to the resident alone, despite knowing the two-person assist requirement. Other staff, including another CNA and a registered nurse (RN), responded after the incident, assessed the resident, and facilitated further medical evaluation. The facility's policy required residents to be free from abuse and neglect, including adherence to care plans specifying assistance levels.
Failure to Provide Required Two-Person Assist Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide the required two-person assistance during incontinent care for a resident with a history of cerebral infarction, morbid obesity, and moderate cognitive impairment. The resident's care plan and Minimum Data Set (MDS) both indicated a need for two-person assistance for toileting and hygiene. Despite this, the CNA performed the care alone, stating she did not want to wait for another staff member because it was lunchtime. During the process of providing care, the CNA turned the resident to her right side, resulting in the resident slipping off the bed and falling to the floor. The CNA called for help, and another CNA arrived, followed by a registered nurse (RN) who assessed the resident. The resident complained of right shoulder pain and was unable to move her right arm due to pain. X-rays confirmed an acute displaced fracture of the right distal humerus. Interviews with staff confirmed that the resident was dependent on two-person assistance for all activities of daily living both before and after the incident. The CNA involved admitted to having previously performed care for the resident alone, despite knowing the care plan requirements. The incident was reported to facility leadership, and the event was documented as past non-compliance, with the facility having corrected the issue prior to the survey.
Failure to Timely Initiate PASRR Specialized Services
Penalty
Summary
The facility failed to incorporate the recommendations from the PASRR Level II determination and the PASRR evaluation report for one resident with intellectual and developmental disabilities. Specifically, the facility did not initiate Nursing Facility Specialized Services (NFSS) within 20 business days following the date the services were agreed upon in the Interdisciplinary Team (IDT) meeting, as required by state regulations. The PASRR evaluation had recommended specialized services such as self-monitoring, assistance with ADLs, and independent living skills, but the facility did not ensure timely initiation of these services. Record review showed that the resident had significant medical conditions, including cerebral palsy, muscle weakness, diabetes mellitus, and hypertension, and was dependent on a wheelchair and required substantial assistance with daily activities. The care plan and PASRR documentation indicated ongoing needs for specialized equipment and services, such as a customized manual wheelchair and habilitative therapies. Despite these documented needs and recommendations, the facility did not submit the required NFSS request within the mandated timeframe after the IDT meeting. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for submitting the NFSS request and monitoring the PASRR process. The Director of Rehabilitation (DOR) and MDS staff each believed the other was responsible for initiating the request, and there was a lack of awareness about the 20-day requirement. The administrator acknowledged that the process was not completed within the required timeframe and that oversight of the PASRR process was ultimately his responsibility.
Expired Insulin Vial Found in Medication Cart
Penalty
Summary
Surveyors observed that the facility failed to ensure all drugs and biologicals were stored and labeled in accordance with accepted professional principles, specifically regarding insulin vials in one medication cart on the 200 hallway. During an observation, an insulin vial was found in the cart that had been opened beyond the recommended 28-day period, with the opened date documented as 3/9/2025. Multiple staff interviews confirmed that insulin vials should be discarded after 28 or 30 days from opening, and that expired insulin could result in reduced potency or adverse reactions if administered to residents. A review of the facility's policy indicated that insulin vials are to be stored at room temperature for 30 days, while the manufacturer’s guidelines for Novolog insulin specify a 28-day usage period after opening. The facility's failure to remove the expired insulin from the medication cart demonstrates noncompliance with both internal policy and manufacturer recommendations for medication storage and labeling.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures during incontinent care for a female resident with diabetes mellitus, unsteadiness, muscle weakness, and incontinence. The CNA reused disposable wipes for multiple strokes during perineal care, rather than using a new wipe for each stroke as required by facility policy. Additionally, the CNA did not sanitize her hands between glove changes throughout the procedure, despite being aware of the correct protocol and having recently received in-service training on hand hygiene and perineal care. The resident involved required substantial to maximal assistance with activities of daily living, including toileting hygiene, and was always incontinent of bladder and bowel. During the observed care, the CNA performed initial hand washing and donned gloves, but then used the same side of wipes for multiple cleaning strokes in the perineal and rectal areas, folding the wipes rather than discarding them after each use. The CNA also changed gloves during the procedure but did not sanitize her hands between glove changes, citing a lack of hand sanitizer in her pocket as the reason for this omission. Interviews with the CNA, other staff, and facility leadership confirmed that the expectation and policy were to use one wipe per swipe and to sanitize hands between glove changes. The facility's policies and training materials clearly outlined these requirements, and staff acknowledged understanding of the procedures. Despite this, the observed practice did not align with established protocols, resulting in a failure to implement the infection prevention and control program as designed.
Inaccurate MDS Coding for Resident's Fall with Major Injury
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's status, specifically regarding a fall with a major injury. The resident, who had diagnoses including muscle weakness, unsteadiness on feet, and dementia, experienced a fall resulting in a right rib fracture. However, the Minimum Data Set (MDS) was inaccurately coded, indicating a fall with no injury, despite the resident being sent to the emergency room where the fracture was identified. Interviews with staff revealed that the Licensed Vocational Nurse (LVN) conducted a head-to-toe assessment after the fall but did not recall the exact date of the incident. The resident was found attempting to get back into bed after the fall, and the LVN noted pain at the back of the resident's head. The resident was sent to the ER for further evaluation, where rib fractures were discovered. The MDS coordinator admitted to missing the update on the MDS to reflect the major injury, which could lead to inaccurate information being transferred to other facilities. The Director of Nursing (DON) confirmed that the fall was unwitnessed and that the resident was sent to the hospital for a CT scan, which showed no head injury. However, the rib fractures were not initially coded as a major injury in the MDS. The administrator acknowledged the oversight in reporting the injury on the MDS, emphasizing the importance of accurate documentation, although he believed it did not affect the care provided to the resident.
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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.
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Nursing homes near Mcallen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Briarcliff Nursing And Rehabilitation Center | 1.6 mi | ★★★★★ | 14 | 0 |
| Windsor Nursing And Rehabilitation Center Of Mcall | 2.1 mi | ★★★★★ | 5 | 0 |
| Grand Terrace Rehabilitation And Healthcare | 2.3 mi | ★★★★★ | 7 | 0 |
| Mcallen Nursing Center | 2.9 mi | ★★★★★ | 4 | 0 |
| Mission Nursing & Rehabilitation Center | 3.4 mi | ★★★★★ | 9 | 0 |
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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.