McAllen Transitional Care Center

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, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 4 residents (Resident #2) reviewed for care plans. The facility failed to ensure Resident #2's comprehensive care plan reflected refusals of medications (on 05/16/26, 05/17/26, 05/25/26, 05/29/26, 05/30/26, 05/31/26, 06/03/26, 06/04/26, 06/08/26, 06/09/26, 06/12/26, 06/13/26, 06/14/26, 06/17/26, 06/18/26, 06/22/26, 06/26/26, 06/27/26, 06/28/26, 07/01/26, 07/02/26, 07/06/26, 07/07/26, and 07/15/26) and skin assessments (on 05/20/26, 05/27/26, 06/03/26, 06/10/26, 06/17/26, 06/24/26, 07/01/26, and 07/08/26). [...]

Inspectors wroteBased on 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 of 4 residents (Resident #2) reviewed for accuracy of records. LVN C failed to document progress notes for skin assessment refusals on Resident #2's electronic medical record on 05/20/26, 05/27/26, 06/03/26, 06/10/26, 06/17/26, 06/24/26, 07/01/26, and 07/08/26. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care.

Inspectors wrote:Based on observation, interviews and record review, the facility failed to store food in accordance with professional standards for food service safety for 1 of 1-refrigerator (1 of 1 facility refrigerator) and 1 of 1 freezer (1 of 1 resident freezer reviewed for storage, preparation and sanitation and failed to keep residents room free from pests. -The facility failed to ensure food items in the resident's refrigerator were dated and sealed properly. -The facility failed to ensure food items in the resident's freezer were sealed properly. -These failures could place residents at risk of complications from food contamination.

Inspectors wroteBased on 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 #12) of 6 residents reviewed for comprehensive care plans. The facility failed to include Resident #12 diagnosis of paranoid schizophrenia in his care plan. This failure could place residents at risk for their mental and psychosocial needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #24) of 4 residents who was observed for medication administration. CMA A failed to inform Resident #24 the names of the medications and the indications for the medications that were being administered. This failure could lead to inaccurate administration of medications and ineffective therapeutic effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection for 1 (Resident #47) of 4 residents reviewed for infection control. The facility failed to ensure that LVN B changed her gloves and performed hand hygiene during Resident #47's medication administration. These failures could place residents at risk for contamination and infection.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program so the facility is free of pests for Resident #42, Resident #79' s rooms and 1 of 1 kitchen reviewed for pests. The facility failed to have pest control effectively treat the kitchen for roaches. The facility failed to ensure Resident #42 and #79s room were free from roaches. This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of lifeFindings included: Observation and initial tour of the kitchen with the DM on 03/09/26 at 10:35 am revealed there were pest droppings in the dry storge room floor. During the dry storage observation, the right back corner of the storage room had numerous pests dropping and a small dead roach on the floor. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #1) of 5 residents reviewed for dignity. The facility failed to ensure CNA A did not stand while assisting Resident #1 with lunch on 01/27/26. This failure could place the residents at risk of not having the right to a dignified existence maintained.

Inspectors wroteBased on observations, interviews and record reviews, 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, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident # 2) reviewed for care plans.1. The facility failed to implement the care plan to ensure Resident #2 required assistance with feeding. 2. The facility failed to update Resident #2's Kardex (ADLs: eating and transfer). This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on observations, interviews and record review, 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 1 of 5 residents (Resident #3) reviewed for accuracy and completeness of clinical records. The facility failed to ensure Resident #3's order for a house supplement included the route of administration and dosage and order for liquid protein included the route of administration. This deficient practice could place residents at risk for incomplete or inaccurate clinical records, which could lead to miscommunication, a delay in services, or a potential decline in the resident's health.

Inspectors wroteBased on observations, interviews and record reviews, 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 1 of 3 residents (Resident #1) residents reviewed for EBP. The facility failed to post EBP signage and for Resident #1 when she had a permcath (a flexible tube used for dialysis treatment) to right chest. This failure could place residents at risk of MDRO contamination.

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 for, 1 of 1 resident (Resident #1) observed for infection control issues in that: CNA A did not follow infection control procedures while providing incontinent care to Resident #1 when she failed to apply a PPE gown prior to providing incontinent care, reused wipes when providing care to the perineal area, and did not sanitize hands between glove changes. This deficient practice could place residents at-risk for infection due to improper PPE, sanitizing hands, and incontinent care practices.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 of 1 resident (Resident#66) reviewed for indwelling catheters. The facility failed to prevent Resident#66's urinary catheter bag/tubing from touching the floor. This failure could place residents at risk for cross contamination and urinary tract infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 residents (Resident's #234) reviewed for respiratory care. 1. The facility failed to ensure Resident #234's oxygen was placed on 2 liters per minute via nasal cannula as ordered by the physician. These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 6 residents (R #6) reviewed for supervision. The facility failed to ensure R #6 received adequate supervision as R #6 eloped from the facility without anyone's knowledge on 07/08/24 at around 3:16 AM and went to a corner store approximately 0.5 miles away. R #6 experienced a change of condition (UTI), had increased confusion, and was unsupervised for approximately 1 hour and 15 minutes before the facility became aware that he had eloped. An Immediate Jeopardy was identified on 07/08/24. The Immediate Jeopardy template was provided to the facility Administrator on 07/30/24 at 11:20 AM. While the Immediate Jeopardy was removed on 07/31/24 at 10:30 AM, the facility remained out of compliance pending approval of Plan of Correction. [...]

Inspectors wroteBased on record review and interview the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of resident and misappropriation of resident property for one (resident #1) of 2 residents reviewed. Facility staff failed to notify administration when Resident #1 contacted the police notifying them that facility staff was not responding to his call light when he was calling for help because he had fallen from his bed. This failure could place residents at risk of injury or neglect.

Inspectors wroteBased on interview and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies for one of one facility. The facility did not have a designated seven-day food supply for emergencies for their census of 80 residents who were served from the facility kitchen and 35 staff. The facility's failure could place the resident population at risk for not having resources identified and available to provide the necessary care and services the residents required.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 1 of 8 residents (Resident #38) reviewed for call lights in that: The facility failed to ensure Resident #38's call light was within reach and was positioned where she could use it and was appropriate for her needs. This failure could place residents at risk of being unable to call for assistance.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident, for 1 resident (Resident #88) of 8 residents reviewed for comprehensive care plan revisions in that: The facility failed to review and revise Resident #88's comprehensive person-centered care plan to address the initiation of Aricept, a medication for dementia/Alzheimer's disease, started on 09/13/23. This deficient practice could affect residents and place them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of eight residents (Resident #89) reviewed for comprehensive care plans, in that: Resident #89's hospice care was not reflected in his comprehensive care plan. This failure could place residents at risk for not receiving necessary care and services.