Cycle 1
Health 2025-04-10 · Fire 2025-04-10
10 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
McAllen, TX
Village Healthcare and Rehabilitation
2-star overall rating with 2-star inspections with abuse icon flag with $28,970 in total fines with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
615 N Ware Rd, McAllen, TX
(956) 664-8900
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
114
Certified beds
Average residents
93
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2011-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.42
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.21
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.50
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.28
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.96
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.17
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
3.37
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,085
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.1
Composite VBP score used to determine payment impact.
Payment multiplier
0.9994
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.28
Baseline 20.61% · Performance 18.52% · Measure score 6.28 · Achievement 6.28 · Improvement 5.33
Healthcare-associated infections
6.37
Baseline 11.80% · Performance 7.13% · Measure score 6.37 · Achievement 2.37 · Improvement 6.37
Total nurse turnover
5.79
Baseline 39.47% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.17 hours · Performance 3.05 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.45% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 82 · Observed rate 7.32% · Lower 95% interval 6.33% |
| Discharge to community | 57.95% |
50.57%
7.4 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 50% · Lower 95% interval 42.49% |
| Medicare spending per beneficiary | 1.4 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 98.46% |
95.27%
3.2 pts better
|
Numerator 64 · Denominator 65 |
| Falls with major injury | 1.54% |
0.77%
0.8 pts worse
|
Numerator 1 · Denominator 65 |
| Discharge self-care score | 43.24% |
53.69%
10.4 pts worse
|
Numerator 16 · Denominator 37 |
| Discharge mobility score | 59.46% |
50.94%
8.5 pts better
|
Numerator 22 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 3.08% |
2.29%
0.8 pts worse
|
Numerator 2 · Denominator 65 · Adjusted rate 2.38% |
| Healthcare-associated infections requiring hospitalization | 7.13% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 52 · Observed rate 7.69% · Lower 95% interval 4.13% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 167 |
| Staff flu vaccination coverage | 25.37% |
42%
16.6 pts worse
|
Numerator 51 · Denominator 201 |
| Discharge function score | 64.86% |
56.45%
8.4 pts better
|
Numerator 24 · Denominator 37 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 92.59% |
96.28%
3.7 pts worse
|
Numerator 25 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 3.03% |
25.2%
22.2 pts worse
|
Numerator 1 · Denominator 33 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.1
0.3 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.1 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
97.1%
2.6 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.8% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.6% |
97.9%
1.3 pts worse
|
95.5%
1.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.3%
0.5 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.8% · Q3 2.6% · Q4 4.1% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.0% |
2.7%
6.3 pts worse
|
11.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 6.2% · Q3 9.7% · Q4 9.1% · 4Q avg 9.0% |
| Percentage of long-stay residents who lose too much weight | 1.8% |
3.3%
1.5 pts better
|
5.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.9% |
18.9%
11 pts better
|
19.6%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 6.7% · Q3 4.2% · Q4 11.3% · 4Q avg 7.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.3% |
10.8%
9.5 pts worse
|
16.7%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 24.2% · Q3 19.0% · Q4 17.2% · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.9% |
15.4%
3.5 pts better
|
16.3%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 16.2% · Q3 14.0% · Q4 13.5% · 4Q avg 11.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.5% |
16.1%
0.4 pts worse
|
14.9%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 23.0% · Q3 17.5% · Q4 5.3% · 4Q avg 16.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
0.8%
0.1 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.7% |
15.0%
7.3 pts better
|
19.8%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 11.4% · Q3 5.4% · Q4 2.9% · 4Q avg 7.7% |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
4.2%
2.3 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.1% · Q3 2.3% · Q4 3.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
89.7%
9.9 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 99.1% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.5% |
12.0%
0.5 pts better
|
12.0%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.5% · Observed 12.1% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.7% |
1.5%
2.2 pts worse
|
1.6%
2.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 5.7% · Q3 3.8% · Q4 2.1% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.4% |
88.0%
8.4 pts better
|
79.7%
16.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.3% |
25.9%
5.6 pts better
|
23.9%
3.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.3% · Observed 19.7% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-26 · Fire 2024-01-26
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2022-11-10 · Fire 2022-11-10
5 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-06
C · Minimal harm
2025-04-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-04-10
F · Potential for more than minimal harm
2024-01-26
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-03-01
F · Potential for more than minimal harm
2024-01-26
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-01-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-03-01
E · Potential for more than minimal harm
2022-11-10
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-12-02
E · Potential for more than minimal harm
2022-11-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-02
C · Minimal harm
2022-11-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-12-02
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-05
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-11-06
E · Potential for more than minimal harm
2025-11-05
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-11-06
J · Immediate jeopardy
2025-06-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-06
J · Immediate jeopardy
2025-04-10
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-06
J · Immediate jeopardy
2025-04-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-06
D · Potential for more than minimal harm
2025-04-10
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-04-10
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-04-10
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-04-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-06
D · Potential for more than minimal harm
2024-01-26
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-01-29
E · Potential for more than minimal harm
2024-01-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-24
E · Potential for more than minimal harm
2024-01-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-24
D · Potential for more than minimal harm
2024-01-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-01-24
D · Potential for more than minimal harm
2023-10-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-27
D · Potential for more than minimal harm
2022-11-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-11-11
Penalties and ownership
What sits behind the stars
$14,901
2025-06-05
Fine
Fine · fine $14,901
Fine
$14,069
2025-04-10
Fine
Fine · fine $14,069
Fine
Ownership
Fannin County Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Mcallen Community Healthcare, Inc.
Operational/Managerial Control · Organization
Olivares Herrera, Olga
Operational/Managerial Control · Individual
Sanderson, Clark
Corporate Officer · Individual
Yzaguirre, Alexandra
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Briarcliff Nursing and Rehabilitation Center
McAllen, TX
1-star overall rating with 2-star inspections with abuse icon flag with $63,129 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Windsor Nursing and Rehabilitation Center of Mcall
Mcallen, TX
2-star overall rating with 3-star inspections with $37,050 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Grand Terrace Rehabilitation and Healthcare
McAllen, TX
5-star overall rating with 5-star inspections with 4 recent health deficiencies
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