Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Windsor Nursing And Rehabilitation Center Of Mcall during CMS and state inspections, most recent first.
A resident with a suprapubic catheter had the Foley drainage bag hung on the back of his wheelchair above the bladder, with tubing routed through his legs and under the chair. The resident said he did not know the bag was there, and an RN stated she knew it had to be below the bladder but was unsure how to place it in a wheelchair. An LVN later stated the bag should be below the abdomen and not above the bladder, while the DON said Foley training covered placement and care; however, the facility’s skills checklist and perineal care policy did not address proper drainage bag placement.
Food Items Not Labeled or Dated: Surveyors observed multiple food items in the kitchen, freezer, and dry storage that were not labeled or dated when opened or delivered, including spice, bread, hot dog buns, and cranberry sauce. The DM stated staff were responsible for labeling and dating all stored food items, and the facility policy required containers and frozen foods to be labeled and dated.
A resident with severe cognitive impairment and high fall risk sustained a right femur fracture after falling from a shower chair while being assisted by two CNAs. One CNA reported the fall, but the incident was not documented or thoroughly investigated, and the facility relied on conflicting staff statements without ensuring proper supervision or accident prevention.
A resident with severe cognitive impairment and multiple fall risk factors experienced an incident in the restroom where staff gave conflicting accounts about whether a fall occurred. The facility did not obtain statements from all involved staff, failed to document the incident as a fall, and did not conduct a thorough investigation, despite the resident later being diagnosed with a right femur fracture. The Administrator and DON acknowledged uncertainty and did not follow up on all staff reports, contrary to facility policy requiring immediate investigation of alleged neglect.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility failed to ensure proper documentation and justification for the use of psychotropic medications for three residents. One resident received Prozac without an appropriate diagnosis, another was given Gabapentin for anxiety without a documented diagnosis, and a third was prescribed Buspirone for anxiety without the condition being recorded in their chart. Staff interviews revealed gaps in understanding and documentation, contrary to the facility's policy requiring specific diagnoses for psychotropic drug use.
A facility failed to ensure a resident's advance directive was signed by the family representative, risking the resident's end-of-life wishes not being honored. The resident had a DNR order, but the necessary documentation was incomplete. The social worker noted verbal consent but did not obtain the required signature, despite follow-ups. Staff interviews revealed inconsistent procedures for ensuring DNR forms were signed and uploaded, and the facility's policy on advance directives was not followed.
A facility failed to complete a PASRR Level II Evaluation for a resident with mental illness, despite a positive PASRR Level I screening. The resident, diagnosed with Major Depressive Disorder, Bipolar Disorder, and other mental health conditions, was not referred for further evaluation, potentially impacting their access to necessary specialized services. Interviews revealed that the RN MDS was responsible for uploading screenings and acknowledged the oversight, while the DON confirmed the MDS Nurse's responsibility in ensuring evaluations were completed.
A facility failed to ensure a physician documented a rationale for not following a Pharmacy Consultant's recommendation for a gradual dose reduction of Keppra and Trazodone for a resident with dementia and depression. Despite the consultant's suggestion, the physician disagreed without providing a reason, contrary to facility policy. Interviews revealed challenges in obtaining rationales from physicians, and no progress notes were found to justify the decision.
A facility failed to maintain effective infection control practices, as evidenced by two incidents. An LVN did not change gloves or perform hand hygiene after removing a soiled dressing from a resident with a stage 4 pressure ulcer. Another LVN failed to sanitize a stethoscope before checking PEG tube placement for a resident with severe cognitive impairment. Both incidents highlight lapses in adherence to infection control protocols despite regular training.
A resident with severe cognitive impairment experienced swelling in his right leg, which was not reported to the physician by the LVN who was informed of the condition. The issue was discovered the next day by another LVN, who ordered an x-ray revealing a hip fracture. The initial LVN failed to document or notify the physician, leading to his termination.
The facility failed to update care plans for two residents after falls, despite the incidents being captured on the MDS. One resident had a witnessed fall with injury, and another had an unwitnessed fall with serious injury. The care plans were not revised to include new interventions, contrary to the facility's policy requiring updates after significant events.
The facility failed to maintain accurate Medication Administration Records for two residents, resulting in incomplete documentation for anxiety and pain medications. Despite in-service training, staff did not adhere to documentation standards, leading to uncertainty about medication administration. The DON confirmed the lack of documentation and the inability to verify if medications were given.
Improper Foley Drainage Bag Placement
Penalty
Summary
The facility failed to ensure appropriate treatment and services to prevent urinary tract infections for a resident with a suprapubic catheter. Resident #27 was a male with diagnoses including unspecified dementia, hypospadias, and neuromuscular dysfunction of the bladder. His physician’s order directed irrigation of the suprapubic catheter twice daily with 60 mL normal saline, and his MDS indicated he had an indwelling catheter and intact cognition. His care plan identified him as at risk for urinary tract infection related to the Foley catheter. During observation, Resident #27 was sitting in his wheelchair with the Foley drainage bag hooked to a pocket located mid-back on the wheelchair, with the tubing running through his legs and under the wheelchair. The drainage bag was observed resting above his bladder. Resident #27 stated he did not know the bag was hung there. RN L stated the bag should be below the bladder but was unsure of the correct placement in a wheelchair, and later repositioned it. LVN J stated the bag should be below the abdomen and not above the bladder, not touching the floor or wheels. The DON stated nurses were checked off on nursing skills and received in-services as needed, and that Foley training included placement and care. The facility’s skills checklist did not address Foley catheter care or placement, and the perineal care policy did not address proper placement of a Foley drainage bag.
Food Items Not Labeled or Dated
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. During observations on 12/01/25, surveyors found a jar of spice on the kitchen wall that was not labeled or dated when opened, a loaf of bread on the kitchen preparation counter that was not labeled or dated when opened, and 3 packages of hot dog buns in the freezer that were not labeled or dated when opened. Surveyors also observed a can of cranberry sauce in the dry storage room that was not dated when delivered. In an interview on 12/01/25, the DM stated that all staff were responsible for ensuring items were stored, labeled, and dated, and that every item opened should have an open date in the refrigerator, freezer, and dry storage. The DM stated that if food items were not properly labeled and dated, staff may be unaware of when the items were opened, increasing the risk of food spoilage and potential illness for residents. Record review of the Food Storage Policy dated 06/01/19 stated that all containers must be labeled and dated in dry storage and that frozen foods must be stored in moisture-proof wrap or containers that are labeled and dated.
Failure to Provide Adequate Supervision and Accident Prevention During Shower Transfer
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent accidents for a resident with severe cognitive impairment, dementia, and a history of syncope and muscle weakness. The resident required substantial assistance for bathing and was at high risk for falls, as documented in the care plan. During a shower, two CNAs were assisting the resident when one turned away to pick up a soap bottle, and the resident fell from the shower chair, sustaining a right femur fracture. Following the incident, there was inconsistency in staff reporting and documentation. CNA B reported that the resident had fallen to the floor, while CNA A denied a fall occurred. The incident was not documented in the facility's incident reports, and there was no Post-Incident Report (PIR) provided for the fall. The facility's investigation relied on CNA A's statement, and no further investigation was conducted into CNA B's account, despite her insistence that a fall had occurred. The Director of Nursing and the Administrator both acknowledged uncertainty regarding the circumstances of the injury and did not pursue a thorough investigation into the conflicting staff statements. The lack of documentation and failure to investigate the reported fall resulted in the facility not ensuring adequate supervision and accident prevention for the resident, as required by policy and regulatory standards.
Failure to Investigate and Document Alleged Fall and Injury
Penalty
Summary
The facility failed to provide evidence that all alleged violations were thoroughly investigated and did not prevent further potential abuse, neglect, exploitation, or mistreatment while an investigation was in progress for one resident reviewed for neglect. Specifically, the facility did not thoroughly investigate a reported fall that could have been related to a confirmed right femur fracture. Documentation showed that the resident, who had severe cognitive impairment and multiple risk factors for falls, was involved in an incident in the restroom where staff had differing accounts of whether a fall occurred. CNA B reported that the resident fell and was lifted from the floor, while CNA A denied a fall occurred. The facility did not obtain statements from all involved staff, and there was no incident report or documentation of a fall in the facility's records for the relevant period. The resident's medical history included unspecified dementia, need for assistance with personal care, age-related physical debility, syncope, muscle wasting, and muscle weakness. The care plan identified the resident as being at risk for falls due to gait and balance problems, incontinence, poor safety awareness, dementia, and a history of syncope. After the restroom incident, the resident complained of right upper leg pain, and a subsequent x-ray confirmed a right femur fracture, leading to hospital admission for surgery. Despite these events, the facility did not document a thorough investigation or protective measures during the investigation period. Interviews with staff revealed inconsistencies in the accounts of the incident, with the Director of Nursing and Administrator both acknowledging uncertainty about whether a fall had occurred. The Administrator chose to rely on the statement that no fall occurred and did not follow up on the contrary account. The facility's policy required immediate investigation of alleged abuse, neglect, or exploitation, but this was not followed, as evidenced by the lack of comprehensive documentation, failure to obtain all relevant staff statements, and absence of an incident report for the event.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Inadequate Documentation for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were not given psychotropic drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficiency was identified for three residents. Resident #34 was receiving Prozac, an antidepressant, without an adequate indication for its use or an appropriate diagnosis. The resident's care plan indicated the use of antidepressant medication for depression and insomnia, but there was no documented reason for prescribing Prozac specifically for dementia. Interviews with facility staff revealed a lack of understanding and documentation regarding the medication's indication. Resident #59 was administered Gabapentin for anxiety without a documented diagnosis of anxiety in the clinical record. The resident's care plan mentioned physical aggression related to dementia, but anxiety was not listed as an active diagnosis. Despite a pharmacy recommendation for a gradual dose reduction, the healthcare provider disagreed, citing the need for sleep. Interviews with staff indicated uncertainty about the medication's use for anxiety and a lack of documentation supporting its prescription for this condition. Resident #25 was prescribed Buspirone for anxiety, yet there was no documented diagnosis of anxiety in the resident's chart. The care plan included the use of anti-anxiety medication, but the diagnosis was missing from the electronic health records. Interviews with staff revealed that the oversight was due to a failure in updating the resident's chart with the correct diagnosis. The facility's policy requires that psychotropic drugs be prescribed only when necessary to treat a specific condition, as diagnosed and documented, which was not adhered to in these cases.
Failure to Ensure Proper Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's advance directive was properly documented and signed by the family representative, which could lead to the resident's end-of-life wishes not being honored. The resident, who was severely cognitively impaired, had a physician's order for a Do Not Resuscitate (DNR) status, but the necessary documentation was not completed. The social worker noted verbal consent from the family but did not obtain the required signature from the family representative, despite multiple reminders and follow-ups. Interviews with facility staff revealed a lack of consistent procedures for ensuring that DNR forms were signed and uploaded into the system. The social worker was responsible for obtaining signatures and uploading the forms, but there was no clear auditing process to ensure compliance. The facility's policy required that advance directives be executed upon admission, but this was not adhered to in the case of the resident, leading to a deficiency in honoring the resident's rights regarding treatment and advance directives.
Failure to Complete PASRR Level II Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that all Pre-Admission Screening and Resident Review (PASRR) Level I residents with mental illness received a PASRR Evaluation assessment. This deficiency was identified for one resident who had a positive PASRR Level I screening but was not referred for a PASRR Level II Evaluation. The resident, a male with diagnoses including Major Depressive Disorder, Bipolar Disorder, Other specified anxiety disorders, and Delusional Disorders, was admitted to the facility with a history of mental illness. Despite the positive PASRR Level I screening indicating a suspicion of mental illness, the necessary PASRR Level II Evaluation was not completed. Interviews with facility staff revealed that the RN MDS was responsible for uploading PASRR screenings to the portal for LIDDA and acknowledged the oversight in not ensuring the PASRR Level II Evaluation was completed for the resident. The Director of Nursing (DON) stated that the MDS Nurse was responsible for ensuring PASRR screenings were in place before admission and that a positive screening should lead to a PASRR Level II Evaluation. The failure to complete the PASRR Level II Evaluation could result in the resident not receiving necessary specialized services.
Failure to Document Rationale for Medication Regimen
Penalty
Summary
The facility failed to ensure that drug regimen irregularities reported by the Pharmacy Consultant were acted upon for one resident. The Pharmacy Consultant recommended a gradual dose reduction (GDR) for Keppra and Trazodone for a resident, but the physician disagreed with the recommendation without providing a rationale. This lack of documentation could potentially place residents at risk for adverse consequences. The resident involved was a female with a history of unspecified dementia, major depression disorder, and pseudobulbar affect. She was receiving Trazodone for insomnia and Keppra for labile moods. Despite the Pharmacy Consultant's recommendation for a GDR, the physician did not document a rationale for maintaining the current medication regimen, which is a requirement according to the facility's policies. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the facility's process for handling pharmacy recommendations was not followed. The DON acknowledged that it was sometimes difficult to obtain a rationale from physicians, and in this case, no progress notes were found to justify the physician's decision. The facility's policy requires that all recommendations be acted upon and documented, which was not done in this instance.
Infection Control Lapses in Wound Care and Equipment Sanitization
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving residents. In the first incident, a Licensed Vocational Nurse (LVN A) did not change gloves or perform hand hygiene after removing a soiled dressing from a resident's sacral pressure ulcer. This resident, an elderly female with multiple health conditions including a stage 4 pressure ulcer, was at risk due to the improper wound care practice. Despite having received training on wound care and infection control, LVN A admitted to forgetting to change gloves and acknowledged the importance of doing so to prevent cross-contamination. In the second incident, another LVN (LVN D) failed to sanitize a stethoscope before using it to check the placement of a PEG tube during medication administration for a male resident with severe cognitive impairment and multiple health issues, including a feeding tube. LVN D admitted to forgetting to use an alcohol wipe to sanitize the stethoscope, despite having received training on tube feeding procedures and infection control. This oversight occurred during a routine medication administration task, highlighting a lapse in adherence to infection control protocols. Both incidents were observed and documented during a survey, with interviews conducted with the involved staff and the Director of Nursing (DON). The facility's infection prevention and control policy emphasizes the importance of standard precautions, including hand hygiene and the assumption that all residents could potentially be infected. Despite these established protocols and regular training, the lapses in practice by the nursing staff were identified as deficiencies in the facility's infection control program.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to immediately notify the resident's physician regarding a change in condition for a resident who exhibited swelling in his right leg. The resident, who had severe cognitive impairment and required assistance for mobility, was not assessed or documented by the LVN who was informed of the swelling. The LVN did not notify the physician or the next nurse on shift about the condition, despite having spoken to the physician about an unrelated issue on the same day. The situation was discovered when another LVN began her shift the following day and was informed by a CNA about the resident's swelling and pain. Upon assessment, the LVN found the resident in pain, ordered an x-ray, and discovered a hip fracture, leading to the resident being sent to the hospital. The facility's investigation revealed that the initial LVN failed to document the incident or notify the physician, resulting in his termination. The facility did not have a specific policy on Change of Condition Notifications at the time of the incident.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility failed to periodically review and revise the comprehensive person-centered care plans for two residents following significant events. Resident #1 experienced a witnessed fall with injury, which was not reflected in the most recent care plan. Despite the fall being captured on the MDS, the care plan was not updated with new interventions to address the fall. Interviews with the MDS Care Management Specialist, ADON, and DON revealed a lack of clarity and responsibility in updating the care plan, with the DON acknowledging that the fall was not care planned, although interventions were reportedly provided. Similarly, Resident #2 had an unwitnessed fall with serious injury, which was also not updated in the care plan. The resident's care plan did not reflect the fall, although interventions related to musculoskeletal status were initiated after the fall. The MDS Care Management Specialist confirmed that the fall was captured on the MDS but not on the care plan, indicating a potential gap in ensuring proper interventions were in place to prevent further incidents. The facility's policy requires that comprehensive care plans be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. However, the failure to update the care plans for these residents after their falls suggests non-compliance with this policy, potentially placing residents at risk of not receiving necessary care or services tailored to their specific needs.
Incomplete Medication Administration Records
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices, resulting in incomplete and inaccurately documented Medication Administration Records (MAR) for two residents. For one resident, the MAR was missing documentation for the administration of Lorazepam, an anxiety medication, on a specific date at 8:00 pm. The Director of Nursing (DON) confirmed the absence of documentation and was unable to verify if the medication was administered. The resident, however, reported receiving the medication daily and did not recall any missed doses. Another resident's MAR was incomplete for the administration of Gabapentin, a pain medication, on multiple occasions. The MAR had unsigned sections for scheduled doses on several dates and times. The DON identified the staff responsible for administering and documenting the medication but was unable to confirm if the medication was given due to the lack of documentation. Interviews with the staff involved revealed uncertainty about the administration and documentation process, with some staff unable to recall specific details about the resident or the medication administration. The facility's policy required documentation to be completed at the time of service or by the end of the shift, with each entry signed by the person making it. Despite in-service training on medication administration and documentation, the staff did not adhere to these standards, leading to incomplete records. The DON acknowledged the importance of signing off on the MAR to track medication administration and identify potential side effects, but the facility's procedures for ensuring accurate documentation were not effectively implemented.
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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) |
|---|---|---|---|---|
| Grand Terrace Rehabilitation And Healthcare | 0.3 mi | ★★★★★ | 7 | 0 |
| Alfredo Gonzalez Texas State Veterans Home | 1.4 mi | ★★★★★ | 14 | 2 |
| Mcallen Nursing Center | 1.4 mi | ★★★★★ | 4 | 0 |
| Mcallen Transitional Care Center | 1.7 mi | ★★★★★ | 5 | 0 |
| Windsor Las Palmas Nursing And Rehabilitation Cent | 1.7 mi | ★★★★★ | 1 | 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.