Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mcallen Transitional Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer’s disease, CKD, generalized muscle weakness, and dysphagia, was care planned to require staff assistance with eating. During a meal, a CNA fed the resident while standing beside her instead of sitting at her level, despite facility protocol and staff training requiring staff to sit when assisting with feeding to maintain dignity. Nursing leadership, including the ADON and DON, confirmed that standing while feeding is inconsistent with resident rights and the facility’s dignity policy, although no physical injury or distress was observed.
A resident with quadriplegia, fully dependent on staff for all ADLs, did not have eating assistance included in the care plan or clearly specified in the Kardex. Multiple staff confirmed the resident required a one-person assist for feeding, but this was omitted due to an oversight during care plan updates. The facility's policy required comprehensive, person-centered care plans, but the documentation did not accurately reflect the resident's needs for eating and transfers.
A resident with multiple complex medical conditions received nutritional supplements based on physician orders that lacked required details such as route of administration and dosage. Nursing staff and leadership confirmed the orders were incomplete according to facility policy, though the supplements were still administered as intended.
A resident with an indwelling catheter and multiple chronic conditions did not have Enhanced Barrier Precautions (EBP) signage or a PPE cart outside her room, as required by facility policy. Staff interviews confirmed awareness of the policy but noted the absence of these infection control measures, with the DON attributing the lapse to a possible miscommunication after a room transfer.
A CNA failed to follow infection control protocols while providing incontinent care to a resident with an indwelling catheter, PEG tube, and pressure ulcer. The CNA did not wear a gown at the start of care, inconsistently performed hand hygiene between glove changes, and reused wipes against facility policy. Staff interviews confirmed that these actions did not align with established infection prevention procedures.
A resident with a neurogenic bladder had their Foley catheter bag observed lying on the floor, contrary to the facility's infection control policies. Staff interviews confirmed awareness of the importance of keeping catheter bags off the floor to prevent infections, yet the deficiency occurred. The facility's policies clearly stated the need to position drainage bags below the bladder level without resting on the floor.
A resident with COPD was observed receiving oxygen at 2.5 liters per minute instead of the physician-ordered 2 liters per minute. Staff interviews revealed inconsistencies in monitoring oxygen settings and uncertainty about inservice training frequency. The facility's policy requires adherence to physician orders for oxygen therapy.
A resident with dementia and a UTI eloped from a facility without staff knowledge, traveling to a nearby store in a motorized wheelchair. The front door was not locked or alarmed, allowing the resident to exit unnoticed. Staff were occupied in other areas and did not anticipate the elopement, as the resident had not shown exit-seeking behavior before.
Failure to Maintain Resident Dignity During Assisted Feeding
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was assisted with eating in a manner that promoted dignity, as required by resident rights and facility policy. A female resident with Alzheimer’s disease, chronic kidney disease, generalized muscle weakness, dysphagia, cognitive communication deficit, and a need for assistance with personal care was care planned to require total assistance by one staff member for eating. Her quarterly MDS showed a BIMS score of 2, indicating severely impaired cognition, and documented that she required partial/moderate assistance for eating. During a lunch observation, a CNA was seen feeding this resident while standing to the resident’s left side, despite a chair being available behind the CNA. The CNA remained standing until an ADON moved a chair behind her, at which point she sat down a few minutes later. The resident was not interviewable and was observed to be without injury or distress. In interviews, the CNA, ADON, and DON all stated that facility protocol and training required staff to sit at the resident’s level when feeding to maintain dignity, and the ADON additionally cited aspiration prevention and dignity as reasons staff should not stand while feeding. The DON stated that feeding a resident while standing constituted a dignity issue and that, although there was no negative physical outcome or injury, the resident might have felt uncomfortable or rushed. The facility’s written Resident Rights, Dignity and Respect policy stated that all residents must be treated with kindness, dignity, and respect, and that staff must display respect for residents as affirmation of their individuality and dignity.
Failure to Develop and Implement Comprehensive Care Plan for Dependent Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with quadriplegia, resulting in the omission of necessary interventions for eating assistance. The resident, a male with quadriplegia and muscle atrophy, was entirely dependent on staff for all activities of daily living (ADLs), including eating, transfers, and personal care. Despite this, the resident's care plan did not include eating as an intervention, and the Kardex did not specify the required level of assistance for feeding, although it did provide details for transfers and other ADLs. Observations and interviews with the resident and multiple staff members, including CNAs and an LVN, confirmed that the resident required a one-person assist for eating and a two-person assist with a mechanical lift for all other ADLs. Staff reported relying on the Kardex to determine the level of care needed, but the Kardex lacked clear instructions regarding eating assistance. The omission was attributed to a failure to check off the relevant task during the resident's baseline care plan update upon re-admission. The facility's policy required the interdisciplinary team to develop a comprehensive, person-centered care plan with measurable objectives and timeframes for each resident, based on their comprehensive assessment. However, the care plan and Kardex for this resident were not updated to reflect the actual assistance required for eating and transfers, as confirmed by staff interviews and record reviews. This failure could result in the resident not receiving individualized care and services to meet his needs.
Incomplete Physician Orders for Nutritional Supplements
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident, specifically regarding physician orders for nutritional supplements. The orders for a house supplement and liquid protein did not include essential information such as the route of administration and, in the case of the house supplement, the dosage. These omissions were identified during a review of the resident's medical records, which showed that the supplements were administered without the required details being documented in the orders. The resident involved was an elderly female with multiple significant diagnoses, including sepsis, mild protein-calorie malnutrition, cognitive communication deficit, dementia, chronic kidney disease, and dependence on renal dialysis. She also had a history of pressure ulcers and was at risk for malnutrition, as reflected in her care plan. The care plan included interventions for nutritional support and wound healing, which required accurate and complete physician orders for supplements. Interviews with nursing staff and facility leadership confirmed that the orders were incomplete and did not meet the facility's policy requirements, which specify that orders must include the resident's name, dosage, frequency, route, and diagnosis. Staff acknowledged that the missing information rendered the orders incomplete, although they stated that the supplements were administered as intended. The facility's policy on physician orders was reviewed and found to require the missing elements.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for a resident with an indwelling catheter. Observations revealed that there was no Enhanced Barrier Precautions (EBP) signage posted on the resident's door or room, and no personal protective equipment (PPE) cart was available outside the door, despite the resident having a permcath for dialysis and an indwelling Foley catheter. Interviews with staff, including a CNA, LVN, and the DON, confirmed that facility policy required EBP signage and PPE for residents with indwelling medical devices, but these measures were not in place for this resident. Staff acknowledged the absence of required signage and PPE, and indicated that this was not in accordance with facility policy. Record reviews showed that the resident had multiple diagnoses, including type 2 diabetes, hypertension, and irritable bowel syndrome, and required assistance with personal care. The care plan documented the presence of an indwelling catheter and outlined interventions for its management. Despite these documented needs and the facility's infection control policy, the required EBP measures were not implemented for this resident, and staff were unable to provide a reason for the omission, with the DON suggesting a possible miscommunication due to a recent room transfer.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow established infection prevention and control procedures while providing incontinent care to a resident with multiple risk factors, including an indwelling catheter, PEG tube, and a stage 3 pressure ulcer. The CNA did not don a personal protective equipment (PPE) gown prior to starting care, despite facility policy and the resident's Enhanced Barrier Precautions (EBP) status requiring both gown and gloves for high-contact care activities. The CNA only applied the gown after beginning care and being reminded, which was confirmed by both the assistant director of nursing (ADON) and the CNA during interviews. During the care episode, the CNA also failed to consistently perform hand hygiene between glove changes, only washing hands after every second glove change and not using hand sanitizer between other glove changes as required by facility policy. The CNA was observed to use one wipe per swipe initially, but then began folding and reusing wipes for multiple swipes, contrary to the facility's policy that specifies using a clean portion of the wipe for each cleansing motion and disposing of wipes after use, especially when soiled. The CNA's actions were inconsistent with both the facility's infection control and incontinent care policies, which were reviewed and confirmed by the director of nursing (DON) and other staff. Interviews with the CNA, LVN, ADON, and DON revealed that all staff had received training on infection control, EBP, and proper incontinent care procedures, including the use of PPE and hand hygiene. The CNA acknowledged forgetting to put on the gown due to nervousness and demonstrated confusion about the correct frequency of hand hygiene between glove changes. The DON and ADON confirmed that the observed practices did not align with facility policy and that proper PPE and hand hygiene are essential to prevent the spread of infection, especially for residents on EBP.
Failure to Prevent Catheter Bag Contamination
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections. Specifically, the facility did not prevent the resident's urinary catheter bag and tubing from touching the floor, which could lead to cross-contamination and infection. The resident, a male with a neurogenic bladder, was observed with his Foley catheter bag lying on the floor under his bed. This observation was made despite the care plan indicating that the catheter bag should be positioned below the bladder and away from the floor. Interviews with various staff members, including CNAs, LVNs, and RNs, revealed a general understanding of the importance of keeping catheter bags off the floor to prevent infections. However, the incident still occurred, indicating a lapse in adherence to the facility's infection control policies. Staff members acknowledged the risk of contamination and infection if the catheter bag touched the floor, and they were aware of the facility's policy to keep the bag in a privacy bag attached to the bed. The facility's policies on infection prevention and catheter drainage bags were reviewed, and they clearly stated the need to position drainage bags below the bladder level without resting on the floor. Despite recent in-service training on infection control, the deficiency occurred, suggesting a need for more effective implementation of these policies. The Director of Nursing confirmed that all staff were responsible for ensuring catheter bags were properly positioned and that privacy bags were provided for each resident with a Foley catheter.
Failure to Adhere to Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with chronic obstructive pulmonary disease (COPD) by not adhering to the physician's order for oxygen administration. The resident, a female with a history of COPD, was observed with her oxygen set at 2.5 liters per minute via nasal cannula, contrary to the physician's order of 2 liters per minute. This discrepancy was noted during an observation and confirmed by LVN G, who acknowledged the incorrect setting and adjusted it to the correct rate. The LVN mentioned that the humidifier bottle might have moved the settings and expressed concern about potential harm to the resident if the incorrect order was administered. Interviews with various staff members, including LVN E, RN F, the ADON, and the DON, revealed inconsistencies in the monitoring and verification of oxygen settings. Staff members were aware of the protocol to check oxygen settings at the beginning, during, and at the end of each shift, but there was a lack of clarity on the frequency and timing of inservice training. The DON stated that an increase of 0.5 liters per minute above the prescribed amount would not affect the resident, while other staff members highlighted potential risks of incorrect oxygen administration. The facility's policy on oxygen administration, last revised in April 2016, mandates that oxygen therapy be administered as ordered by the physician.
Resident Elopes Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents, resulting in a resident eloping from the facility without staff knowledge. The resident, who had a history of dementia and was experiencing increased confusion due to a urinary tract infection (UTI), left the facility in a motorized wheelchair and traveled to a nearby corner store. The incident occurred in the early morning hours, and the resident was unsupervised for approximately 1 hour and 15 minutes before the facility became aware of the elopement. The resident's care plan indicated a risk for elopement due to disorientation and confusion related to a UTI. Despite this, the resident was able to exit the facility through the front door, which was not locked and lacked an alarm or chime to alert staff. The facility's investigation revealed that the resident left the building while staff were occupied in other hallways, and no staff were present at the front desk to witness the exit. The resident had not previously demonstrated exit-seeking behavior, and staff did not anticipate the elopement. Interviews with staff indicated that the resident was known to be independent and often moved around the facility at night. However, the staff did not perceive the resident as a risk for elopement, and routine checks were conducted every two hours. The facility's policy on elopement and unsafe wandering was not effectively implemented, as the front door's lack of an alarm system allowed the resident to leave unnoticed.
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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 Mc Allen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windsor Las Palmas Nursing And Rehabilitation Cent | 0.2 mi | — | 0 | 0 |
| Alfredo Gonzalez Texas State Veterans Home | 0.7 mi | — | 12 | 2 |
| Grand Terrace Rehabilitation And Healthcare | 1.4 mi | — | 6 | 0 |
| Windsor Nursing And Rehabilitation Center Of Mcall | 1.7 mi | — | 5 | 0 |
| Mcallen Nursing Center | 1.7 mi | — | 2 | 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 August 2026) and official state health department websites.