Cycle 1
Health 2024-09-12 · Fire 2024-09-12
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Mcallen, TX
Windsor Nursing and Rehabilitation Center of Mcall
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
900 S 12th St, Mcallen, TX
(956) 682-4171
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
80
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Wellsential Health
Operator or chain grouping
Approved since
1986-07-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.30
Registered nurse staffing
LPN hours / resident day
0.95
Licensed practical nurse staffing
Aide hours / resident day
1.89
Nurse aide staffing
Weekend hours
2.76
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
53%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.3%
1.7 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.7% |
2.7%
About the same
|
11.4%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.3% |
3.3%
2 pts worse
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.4% |
18.9%
11.5 pts better
|
19.6%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 36.0% |
10.8%
25.2 pts worse
|
16.7%
19.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.7% |
15.4%
9.7 pts better
|
16.3%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.1% |
16.1%
7 pts better
|
14.9%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.3% |
15.0%
1.7 pts better
|
19.8%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 1.2% |
4.2%
3 pts better
|
5.1%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.3% |
89.7%
1.6 pts better
|
81.7%
9.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.4% |
1.5%
2.9 pts worse
|
1.6%
2.8 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.6% |
88.0%
8.6 pts better
|
79.7%
16.9 pts better
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-09 · Fire 2023-06-09
7 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2022-03-24 · Fire 2022-03-24
4 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
C · Minimal harm
2024-09-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-09-18
C · Minimal harm
2023-06-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-06-09
F · Potential for more than minimal harm
2022-03-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-05-31
E · Potential for more than minimal harm
2022-03-24
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-05-31
E · Potential for more than minimal harm
2022-03-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-05-31
E · Potential for more than minimal harm
2022-03-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-05-31
E · Potential for more than minimal harm
2022-03-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-05-31
C · Minimal harm
2022-03-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-03-24
Inspection history
Recent health citations
G · Actual harm
2025-11-21
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 2025-11-22
D · Potential for more than minimal harm
2025-11-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-11-22
E · Potential for more than minimal harm
2025-07-09
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 2025-07-18
D · Potential for more than minimal harm
2025-07-09
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-07-18
E · Potential for more than minimal harm
2024-09-12
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 2024-09-27
D · Potential for more than minimal harm
2024-09-12
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-09-12
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-09-12
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-09-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-08-09
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-08-09
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-08-09
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 2024-08-16
E · Potential for more than minimal harm
2024-03-01
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 2024-03-08
D · Potential for more than minimal harm
2024-03-01
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-03-01
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-03-08
D · Potential for more than minimal harm
2023-06-09
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 2023-06-13
E · Potential for more than minimal harm
2023-05-12
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 2023-05-26
E · Potential for more than minimal harm
2022-03-24
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 2022-05-31
E · Potential for more than minimal harm
2022-03-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-05-31
D · Potential for more than minimal harm
2022-03-24
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 2022-05-31
Penalties and ownership
What sits behind the stars
$37,050
2025-11-21
Fine
Fine · fine $37,050
Fine
Ownership
Starr County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Dekowski, Donovan
Operational/Managerial Control · Individual
Munoz, Thalia
Corporate Officer · Individual
Regency Ihs Of Mcallen Manor LLC
Operational/Managerial Control · Organization
Regency Integrated Health Services LLC
Operational/Managerial Control · Organization
Sandoval, Angel
Operational/Managerial Control · Individual
Starr County Hospital District
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Grand Terrace Rehabilitation and Healthcare
McAllen, TX
5-star overall rating with 5-star inspections with 4 recent health deficiencies
#2
Alfredo Gonzalez Texas State Veterans Home
Mcallen, TX
5-star overall rating with 5-star inspections with $12,675 in total fines with 3 recent health deficiencies
#3
Mcallen Nursing Center
Mcallen, TX
2-star overall rating with 2-star inspections with $17,459 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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