McAllen Nursing Center

Inspectors wroteBased on observations, interviews, and record review, 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. On 06/22/26, the facility failed to ensure bread and fresh vegetables were properly labeled and dated. This failure placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident had a right to a dignified existence and to treat each resident with respect and dignity for 1 of 16 residents (Resident #19) reviewed for resident rights. The facility failed to ensure Resident #19's foley catheter bag (a drainage bag that collects urine) had a privacy cover on it to provide respect and dignity. This failure could lead to residents at risk of experiencing feelings of shame and/or embarrassment as well as having their right to privacy violated.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #19) of 13 residents reviewed for comprehensive care plans. The facility failed to include Resident #19's use of a foley catheter (a device that drains urine from your urinary bladder into a collection bag outside of your body) in her care plan. These failures could place residents at risk of not receiving adequate care for a foley catheter device which could potentially lead to infection and deterioration of health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 16 residents' rooms (Resident #17's room) reviewed for food safety. The facility failed to place a thermometer in the refrigerator located in Resident #17's room; therefore, the staff did not monitor the internal temperature and expiration/used by dates of food items. These failures could place residents at risk of foodborne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to respect the residents' right to personal privacy and confidentiality, for 3 of 11 residents (Resident #1, Resident #4, and Resident #7) reviewed for personal privacy and confidentiality. The facility failed to provide personal privacy and confidentiality for Resident #1, Resident #4, and Resident #7 when the residents and their private space were recorded without the resident's or designated representative's consent; and the video was posted on social media on 05/10/26. This failure could place residents at risk of their right to privacy and confidentiality not being honored or respected.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the comprehensive care plans were periodically reviewed and revised by a team of qualified persons after each assessment, including both the comprehensive and quarterly review assessments for 2 of 3 residents (Resident #1 and Resident #2) reviewed for care plans, in that:1. The facility failed to ensure Resident #1's care plan reflected an unwitnessed fall on 11/27/2025.2. The facility failed to ensure Resident #2's care plan reflected witnessed falls on 11/14/2025, 12/16/2025, and 12/30/2025. This failure could place residents at risk of not being provided the necessary care or services and not having personalized care plans updated to address their specific needs.

Inspectors wroteBased on observation, interviews and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 (Resident #1) of 3 residents reviewed for accuracy of records, in that:LVN A failed to document the administration of clonazepam and insulin on 10/11/25 and 10/17/25. LVN B failed to document the administration of clonazepam and insulin on 10/27/25 and 10/28/25. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 (Resident #1 and Resident #2) of 4 residents reviewed for medical records accuracy, in that: The facility failed to provide any documentation in the Progress Notes for Resident #1 and Resident #2 for the resident-to-resident altercation on 07/13/2025. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure each resident and/ or their representative and the IDT were invited to attend/participate in the care plan meetings including both the comprehensive and quarterly review assessments for the resident for 2 of 6 residents (Resident #1 and Resident 2) reviewed for care plan timing and revision. The facility failed to ensure Resident #1 and Resident #2's care plan was revised to accurately reflect current smoking status. The facility failed to develop a care plan for Resident #2 to address his discharge plan. These failures could place the residents at risk of not receiving appropriate interventions and care to meet their needs as indicated on the comprehensive care plans.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 4 (B-hall and D/E-halls) medication carts reviewed for medication storage. 1. The facility failed to store 17 loose tablets/capsules in their appropriate blister packs in the medication cart for B-hall. 2. The facility failed to store 17 loose tablets/capsules in their appropriate blister packs in the medication cart for D/E-halls. These deficient practices could place residents at risk of losing medications leading to medication shortage.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 2 (Resident #2 and Resident #11) of 6 residents reviewed for accuracy and completeness of clinical records. 1. The facility failed to ensure LVN A correctly documented Resident #2's blood pressure 59 times when she administered blood pressure altering medications (amiodarone, hydralazine, metoprolol, and midodrine) between 04/01/25 and 04/23/25. 2. The facility failed to ensure LVN I correctly documented Resident #2's blood pressure 10 times when she administered blood pressure altering medications (amiodarone, hydralazine, metoprolol, and midodrine) between 04/01/25 and 04/23/25. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriaton of resident property, and exploitation for two out of 10 residents (Resident #59 and Resident # 100) reviewed for abuse/neglect. The facility failed to ensure Resident #59 was free of abuse. Resident #59 was hit on the head twice by Resident #100 on 02/22/25. This failure could place residents at risk of serious injury or death.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries or unknown source and misappropriation of residents property, were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, including to the State Agency, in accordance with State Law through established procedures for 1 out of 10 residents (Resident #59 that occurred on 02/24/25 to the local law enforcement agency, for 1 of 10 residents (Resident #59 ) reviewed for reporting of abuse/neglect. The facility failed to report an incident involving Resident #100 and Resident #59 that occurred on 02/24/25 to the local law enforcement agency. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs, as well as describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 6 (Residents #42 and #53) residents reviewed for care plans. 1) The facility failed to ensure Resident #42 was weighed weekly as ordered by the physician. 2) The facility failed to ensure Resident #53 was weighed weekly as ordered by the physician. These failures could place residents at risk of unnoticed weight loss or weight gain resulting in exacerbation of symptoms and increased morbidity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for one of 16 residents (Resident #40) reviewed for infection control practices. 1. The facility failed to ensure the WCN wore proper PPE (gown) during wound care for Resident #40 who required enhanced barrier precautions. 2. The facility failed to ensure CNA E wore proper PPE (gown) during wound care for Resident #40 who required enhanced barrier precautions. 3. The facility failed to ensure the WCN performed hand hygiene after removing a glove during wound care for Resident #40. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate supervision was provided for 1 of 6 residents reviewed for accidents and supervision. (Resident #1) The facility failed to ensure Resident#1 received adequate supervision to prevent elopement. Resident #1 eloped from the facility and was found by the police department approximately 0.2 miles away from the facility. The Immediate Jeopardy template was provided to the facility on [DATE] at 4:38 p.m. While the Immediate Jeopardy was removed on 10/26/2024 at 1:33 p.m., the facility remained out of compliance at a scope of isolated and severity level of potential for more than minimal harm because all staff was not aware of and did not implement the facility's elopement procedures. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 5 residents (R #1) reviewed for supervision. The facility failed to ensure R #1 received adequate supervision as R #1 eloped from the facility without anyone's knowledge on 07/19/24 between 7:30-7:40 PM and was found at an apartment complex approximately 0.2 mile away. R #1 was exit seeking, had increased behaviors, and staff placed R #1 in his room and failed to request additional interventions or increased supervision. R #1 was out of the facility for approximately 30 minutes before the facility became aware that he had eloped. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 07/19/24 and ended on 07/22/24. The facility corrected the non-compliance before the investigation began. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 5 residents (R #1) reviewed for care plans. The facility failed to ensure R #1's care plan reflected the use of the wander guard, the antibiotics R #1 received for ESBL (bacterial infection) in the urine, and falls he experienced on 07/01/24, 07/10/24 and 07/14/24. This failure could place residents at risk of not receiving the care and services as indicated in the comprehensive care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards or food service safety for 1 of 1 kitchen reviewed for sanitation in that: 1. The facility failed to ensure all food items were labeled and dated in refrigerator #1. 2. The facility failed to keep personal drinks out of refrigerator#1 3. The facility failed to ensure expired food in refrigerator #2 was discarded. These failures could place residents at risk of foodborne illnesses.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the residents' right to a safe, clean, comfortable, and homelike environment for (Resident #5, Resident #279, Resident #3, and Resident # 275) of 15 rooms reviewed for water temperatures in that: The facility failed to ensure resident room hand sink's hot water was maintained at a comfortable temperature which was at least 100 degrees F. These failures could place residents at risk for living in an uncomfortable, and unhomelike environment which could cause a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the environment remained as free of accident hazards as is possible for one (women's shower room) of two shower rooms reviewed for accidents. The facility failed to maintain water temperatures at a safe temperature level in the women's shower room. This failure could place residents at risk of injuries and burns.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 4 residents (Resident #18) reviewed for accuracy of records. 1. The facility failed to accurately document on Resident #18's MAR, post dialysis weight on 02/27/24 at 3:30 p.m. 2. The facility failed to accurately document Resident #18's PEG site care on MAR, on 02/26/2024 10-6a shift. 3. The facility failed to accurately document Resident #18's anticoagulant monitoring on [DATE]/26/24 10-6a shift, 02/27/24 6a-2 shift, 02/27/24 2-10p shift, and 02/27/24 10-6a shift. 4. The facility failed to accurately document Resident #18's SpO2 saturation on [DATE]/26/24 10-6a shift, 02/27/24 6a-2 shift, 02/27/24 2-10p shift, and 02/27/24 10-6a shift. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, 4 residents of 5 (Resident #1, Resident #2, Resident #20, and Resident # 226) observed for infection control issues in that: 1. The LVN C did not sanitize the blood pressure cuff between resident use for Resident #1, Resident #2, and Resident #20 when taking resident's blood pressure prior to administering their medications. 2. During incontinent care for Resident #226 on 2/29/24 at 3:33 PM by CNA I failed to use appropriate incontinent care cleaning procedures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services in the facility with reasonable accommodation of resident needs and preferences, for 1 resident (Resident #177) of 12 residents reviewed for accommodation of needs. The facility staff did not provide Resident #177 with a call light that was within reach. This failure could place residents at risk for not having his/her needs met.

Inspectors wroteBased on interview and record review, the facility failed to complete an initial comprehensive resident-centered assessment of each resident's cognitive, medical, and functional capacity for 2 of 4 resident (Resident#14 and Resident # 275 ) reviewed for comprehensive MDS assessment timing. The facility failed to complete the admission MDS assessment within 14 days of admission for Resident #14 and Resident #275. This failure could place residents at risk for not having their needs met.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #14) of 4 residents reviewed for care plans. Resident #14's care plans did not reflect she was administered the medication Keppra (anti-convulsant) for behaviors. This failure placed residents at risk of not having their needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided with professional standards of practice for 2 of 3 residents (Resident #299 and Resident #177) reviewed for oxygen in that: 1. Resident #299 oxygen concentrator displayed a red warning light indicating oxygen flow rate <0.5L/min, or concentration <73 %. 2. Resident #177's oxygen was administered at 4.5 Lpm instead of 5 Lpm via trach mask as ordered by physician. This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased qualify of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish a pain management program designed to help a resident attain or maintain his or her highest practicable level of well-being and to prevent or manage pain, to the extent possible, for 1 resident of 4 (Resident #9) observed for pain management issues in that: 1. LVN B did not assess the pain level for Resident #9, prior to administering the resident her PRN pain medication. 2. The facility failed to adequately treat and assess Resident #9's pain. This failure could place residents at risk for unnecessary pain, discomfort, and decreased quality of life.

Inspectors wroteObservation and interview revealed the facility failed to provide a safe and functional environment for residents, staff and the public in 2 of 4 hallways (A Hall and E Hall) observed for environmental conditions. 1. The facility failed to ensure the bathroom ceiling on A Hall was free of dark discoloration. 2. The facility failed to ensure the ceiling in E Hall was free from dark discoloration. These deficient practices could affect any resident's health and safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors with all required information for 2 (2/27/24, 2/28/24) of 3 days reviewed for nurse staffing information. The facility failed to ensure the daily staffing information was posted in a prominent location on 2/27/24 and 2/28/24 and failed to show the census on each form. This failure could place residents, families and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.