F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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:
Residents Affected - Few
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.
The findings included:
Record review of the admission record dated 09/27/23 for Resident #38 reflected resident was admitted to
the facility on [DATE],was a [AGE] year-old female with diagnosis that included dementia (decline in
cognitive abilities), need for assistance with personal care, diabetes (high blood sugar levels), and carpal
tunnel syndrome (neurological disorder on median nerve on hands) and pain in the right knee.
Record review of Resident #38's quarterly MDS dated [DATE] reflected Resident #38's cognitive skills for
daily decision making were independent, required two-person assistance for bed mobility and dressing,
required total dependence on two staff for toilet use and bathing.
Record review of Resident #38's care plans dated 08/23/23 reflected resident was at risk for falls related to
weakness. Interventions included to be sure the call light was within reach and to encourage to use it to call
for assistance as needed, date initiated, 08/23/23.
Observation and interview with Resident #38 on 09/27/23 at 9:26 am revealed Resident #38 was in bed,
she stated she had fallen on 09/26/23 from her bed and was feeling pain in her right shoulder/ hand and
she could not move her left arm. Resident #38's call light was a push button device that was clipped to
resident's pillow on her left side out of sight and out of reach. Resident #38 voiced she could not see or
reach her call light. At 9:35 am LVN K was called into Resident #38's room. LVN K said Resident #38 had
been assessed for pain after the fall the day before and Resident #38 had not voiced any pain to her
shoulders or hands. LVN K said Resident #38 had been asleep earlier in the morning when he did his
rounds with her. Resident #38 usually slept late. LVN K placed Resident #38's call light on her right hand
and asked Resident if she could see it and use the call light. Resident #38 attempted to push the button on
the call light with her right hand and demonstrated she could not press on the push button call light. LVN K
said he would come and place a touch pad call light for Resident #38.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 8
Event ID:
676042
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676042
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/29/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
McAllen Transitional Care Center
2109 South K St
MC Allen, TX 78503
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0558
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview on 09/27/23 at 9:35 am with CNA L revealed he had gone into Resident #38's rooms earlier in the
day and had not seen that her call light was clipped where she could not see it or was not able to reach.
CNA L said Resident #38 could use the call light to ask for help if it was placed within her reach and within
her sight.
Observation and interview on 09/28/23 at 1:42 pm revealed Resident #38 in her bed and her touch pad call
light was placed on her bed below her left outstretched arm and elbow. Resident #38 said she could see
the touch pad call light and she could not move her upper body to see where the call light was placed. CNA
M was called into the room and placed the touch pad call light on Resident #38's right hand that was placed
on her stomach. CNA M said she had placed the call light on Resident #38's left lower elbow beside her
body where Resident #38 could not see or reach. CNA M said she had been in a hurry when she had come
in to check on Resident #38 and had not ensured Resident #38 could see or reach her call light.
Interview on 09/28/23 at 3:40 pm with the DON revealed Resident #38 had been assessed on 09/27/23 and
she was able to show she could use both arms and hands without any pain or discomfort. Resident #38
was able to show she could use her both her hands to reach and push the call light button. The DON said
the call light for Resident #38 should be placed where the resident could see it and be able to use to ask for
help. The DON if the call light was not placed within sight and reach, the resident would not be able to call
for help as needed.
Record review of the facility policy revised May 2017 and titled Call Light/Bell reflected It is the policy of this
facility to provide the resident a means of communication with nursing staff. Place the call device within
resident's reach before leaving the room.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676042
If continuation sheet
Page 2 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676042
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/29/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
McAllen Transitional Care Center
2109 South K St
MC Allen, TX 78503
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being
admitted
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
The findings were:
Review of Resident #88's Progress Notes, dated 09/01/23, revealed he was a [AGE] year-old male,
admitted to the facility on [DATE].
Review of Resident #88's admission MDS assessment dated [DATE] (signed on 09/12/23), revealed
Resident #88 with diagnoses of infection of the skin and subcutaneous tissue, stroke, burn of second
degree of unspecified lower limb, acute kidney failure, rhabdomyolysis (the breakdown of muscle tissue that
releases a damaging protein into the blood that can damage the kidneys), cellulitis, type 2 diabetes
mellitus, heart disease, and anxiety disorder. Resident #88 had a BIMS of 10 which indicated his cognition
was moderately impaired. Resident #88 had adequate hearing and staff could understand him and he
usually was able to understand. Resident #88 required extensive assistance with two+ person assist for bed
mobility, dressing, toileting, required extensive assistance with 1-person physical assistance for eating and
personal hygiene, and activity only occurred once or twice with two+ person physical assist for transfers,
and locomotion Resident #88 was always incontinent of bowel and bladder. MDS did not have diagnosis of
bipolar disorder or Alzheimer's Disease/dementia.
Review of Resident #88's Care Plan dated 09/12/23, revealed Aricept, a medication for dementia, was not
addressed in the Care Plan.
Review of Resident #88's Physician Order dated 09/12/23 reflected Aricept Oral Tablet 5 MG (Donepezil
Hydrochloride) Give 1 tablet by mouth at bedtime for dementia with a start date of 09/13/23.
Review of September 2023 eMAR revealed Aricept Oral Tablet 5 mg was given to Resident #88 by mouth
at bedtime for dementia, 09/13/23 through 09/20/23, and 09/22/23 through 09/28/23.
In an interview on 09/29/23 at 11:47 a.m., LVN A stated if a resident were admitted with orders for the
hospital, he called the physician to reconcile the medications to find out what to continue and what to
discontinue. LVN A stated nurses and MDS can put the diagnosis in the computer on admission. LVN A
stated the admitting nurse will put in medications in the computer. LVN A stated the ADON will do a check
on medications that are put in the computer. LVN A stated if verbal orders are given, it was documented in
Progress Notes or on the form. LVN A stated the nurses and ADON are responsible for checking
medications to diagnosis.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676042
If continuation sheet
Page 3 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676042
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/29/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
McAllen Transitional Care Center
2109 South K St
MC Allen, TX 78503
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
In an interview on 09/29/23 at 12:03 p.m., ADON B stated the charge nurse was the one who does the
initial admission of a resident. ADON B stated the charge nurse does the medications. ADON B stated
proper diagnosis with medication, route, etc. are checked by the charge, the ADON, and the DON. ADON B
stated that he did not input the antipsychotics or that type of medication for residents. ADON B stated the
other ADON (ADON C) would have put the medication in for Resident #88, and she would have done the
check (for the order with diagnosis).
In an interview on 09/29/23 at 02:07 p.m., ADON C stated the admitting nurse will reconcile orders with MD
on admission. ADON C stated ADONs will check admission medications with admission paperwork from
hospital. ADON C stated the MDS also checked medications. ADON C stated the admitting nurse, LVN D
(LVN D was not reachable for interview), was the nurse who took the written note from NP K for the Aricept.
ADON C stated NP K gave a diagnosis of dementia. ADON C stated NP K would bring her notes to the
facility the following month after seeing a resident. ADON C stated she would sometimes ask for them if she
thought it was taking too long to get the records and NP K would fax them to her and then bring her notes
next time she comes. ADON C stated NP K came in on 09/12/23 to reconcile medications and started the
Aricept for dementia for Resident #88. ADON C stated there was no uploaded paperwork from NP K for the
visit. ADON C stated she could try to get surveyor a copy of the paperwork from NP K's visit and notes.
In an interview on 09/29/23 at 02:43 p.m., DON stated when a resident is admitted , they get the transfer
paperwork from the hospital, and they reconcile the medications with the doctor (name, dosage,
frequency). DON stated the psychiatrist (NP K) made a note Resident #88 had dementia on 09/12/23. DON
stated it probably had not been uploaded in the computer yet. DON stated change of condition needed to
be in the computer within 24 hours.
DON stated he does not think there would be a negative effect from giving a resident a medication they did
not have a diagnosis for. He said they try to treat a symptom and if the resident was having a symptom and
getting a medication to treat that symptom, there would not be a negative effect.
Record review of facility's Comprehensive Person-Centered Care Planning, Revised 08/2017, revealed:
Policy:
It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive
person-centered care plan for each resident that includes measurable objectives and timeframes to meet a
resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive
assessment.
4.The comprehensive care plan will be developed by the IDT within seven (7) days of completion of the
Resident Minimum Data Set (MDS) and will include resident's needs identified in the comprehensive
assessment, any specialized services as a result of PASARR recommendation, and resident's goals and
desired outcomes, preferences for future discharge and discharge plans.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676042
If continuation sheet
Page 4 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676042
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/29/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
McAllen Transitional Care Center
2109 South K St
MC Allen, TX 78503
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
The findings were:
Record review of the admission record for Resident #89 reflected resident was admitted to the facility on
[DATE],was a [AGE] year-old male with diagnosis that included epilepsy (neurological condition that causes
unprovoked, recurrent seizures), anxiety disorder (excessive unrealistic worry and tension), hemiplegia and
hemiparesis following cerebral infarction affecting right dominant side (weakness of one entire side of the
body).
Record review of the physician orders for Resident #89 dated 09/26/23 reflected Resident #89 had orders
to admit resident to hospice care, start date 09/02/23.
Record review of the admission MDS dated [DATE] for Resident #89 reflected Resident #89 had severe
cognitive impairment and was receiving hospice care.
Record review of the care plans for Resident #89 last revised on 09/05/23 reflected there was no evidence
a care plan to address hospice care was included.
Interview and observation on revealed Resident #89 in his bed, alert to self and unable to respond to
surveyor greeting due to cognitive impairment.
Interview on 09/26/23 at 3:00 pm with MDS /LVN Coordinator I revealed she was responsible for developing
a care plan for Resident #89's focus care area of hospice as ordered by his physician. MDS /LVN
Coordinator said she had overlooked the development of a care plan for Resident #89 due to the overload
of admissions of residents during the month when Resident #89 received his orders for hospice care.
Interview on 09/29/23 at 3:25 pm with LVN K revealed he would use the care plans developed to get
information such as interventions to provide care to the residents. LVN K said he would make sure that
CNAs received the information on the care plans to provide the care that was required. LVN K said he did
not see a care developed for Resident #89's hospice care.
Interview on 09/29/23 at 3:40 pm with the DON revealed the care plans were reviewed by staff to apply the
interventions that were developed for each resident. The DON said if a care plan for a specific focused area
was not developed, the resident might not review the necessary care as developed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676042
If continuation sheet
Page 5 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676042
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/29/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
McAllen Transitional Care Center
2109 South K St
MC Allen, TX 78503
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Record review of the facility policy titled Comprehensive Person-Centered Care Planning revised on August
2017 reflected It is the policy of this facility that the interdisciplinary team (IDT) shall develop a
comprehensive person-centered care plan for each resident that included measurable objectives and
timeframes to meet a resident's medical, nursing, and psychosocial needs that are identified in the
comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each
resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly
care for each resident and instructions needed to provide effective and person-centered care that meet
professional standards of quality care.
Event ID:
Facility ID:
676042
If continuation sheet
Page 6 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676042
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/29/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
McAllen Transitional Care Center
2109 South K St
MC Allen, TX 78503
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0838
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Conduct and document a facility-wide assessment to determine what resources are necessary to care for
residents competently during both day-to-day operations (including nights and weekends) and
emergencies.
Based 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.
The findings included:
Record review of the facility assessment tool dated 08/31/23 reflected no documentation that addressed
the emergency food supply.
Interview and observation in the facility kitchen on 09/26/23 at 9:15 am with the Dietary Supervisor
revealed he had been the Dietary Supervisor since November 2022. The Dietary Manager said he had no
designated food supply for residents or staff for emergencies. The Dietary Supervisor Manager said he
knew the facility had a contract with a local food supplier to order in case of emergencies. The Dietary
Supervisor said he had not calculated the amount of food supply for seven-day emergency supply, and he
did not know how much food to designate as the seven-day food supply.
Interview on 09/26/23 at 10:30 am with the Administrator revealed he did not have policy or procedure to
calculate how much food to designate as the seven-day food supply for emergencies. The Administrator
said the facility had a storage room for emergency food supplies for seven days for residents only. The
Administrator said he did not know how to calculate how much food was needed for the seven-day food
supply. The Administrator said the assumed the food needed for seven-day supply for emergencies
included the amount for residents only and not for staff on duty. The Administrator said the Dietary [NAME]
was responsible for ensuring food was designated in a different storage room for seven-day emergencies.
The Administrator said the Dietary Supervisor was not aware the Dietary [NAME] had the emergency food
designated in a separate storage room.
Interview on 09/28/23 at 10:50 am with the Dietary [NAME] revealed she would always make sure there
was enough food for a seven-day food supply for emergencies that were stored in a storage room outside
the kitchen. The Dietary [NAME] said she did not know how to calculate how much food was needed for a
seven-day food supply for emergencies for the facility. The Dietary [NAME] said she did not have an
inventory on the storage of food for the seven-day food supply.
Observation on 09/26/23 at 11:00 am with the Administrator revealed a storage room outside the kitchen
had 20 one-gallon cans of vegetables, fruit, beans, and paper goods.
Record review of the facility policy titled Disaster Preparedness Guide 2023 updated January 2023
reflected Ensure uninterrupted operation of food service to residents/patients.
Stock a 7-day supply of non-perishable food supplies.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676042
If continuation sheet
Page 7 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676042
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/29/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
McAllen Transitional Care Center
2109 South K St
MC Allen, TX 78503
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0838
Stock a two-day supply of perishable food supplies.
Level of Harm - Minimal harm
or potential for actual harm
Stock a supply of disposable items-recommendation of at least 3 days of disposable items.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676042
If continuation sheet
Page 8 of 8