01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-12-03 | 4 | 2025-12-03 | 1 |
| Cycle 2 | 2024-09-12 | 10 | 2024-09-12 | 1 |
| Cycle 3 | 2023-06-09 | 4 | 2023-06-09 | 1 |
CMS CCN 4556622026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Windsor Nursing And Rehabilitation Center Of Mcall
900 S 12Th St · Mcallen, TX 78501 · Hidalgo County
Certified beds110CMS provider file
Recent citation rows21current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
21 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 3 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-12-03 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2025-12-052025-12-03 · HEALTHF0812Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-12-052025-12-03 · FIREK0521Severity C · widespread; potential for minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has no plan of correction2025-11-21 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2025-11-22 · complaint2025-11-21 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-11-22 · complaint2025-07-09 · HEALTHF0600Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2025-07-18 · complaint2025-07-09 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2025-07-18 · complaint2024-09-12 · HEALTHF0578Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-09-272024-09-12 · HEALTHF0645Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Correction field: Deficient, Provider has date of correction · 2024-09-272024-09-12 · HEALTHF0756Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Correction field: Deficient, Provider has date of correction · 2024-09-272024-09-12 · HEALTHF0758Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-09-272024-09-12 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-09-27 · complaint2024-09-12 · FIREK0521Severity C · widespread; potential for minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Waiver has been granted · 2024-09-182024-08-09 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2024-08-16 · complaint2024-08-09 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2024-08-16 · complaint2024-08-09 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2024-08-16 · complaint2024-03-01 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2024-03-08 · complaint2024-03-01 · HEALTHF0726Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-03-08 · complaint2024-03-01 · HEALTHF0842Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2024-03-08 · complaint2023-06-09 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2023-06-132023-06-09 · FIREK0521Severity C · widespread; potential for minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2023-06-0903 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-11-21 | Fine | $24,083 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- STARR COUNTY HOSPITAL DISTRICTOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 04/01/2018
- REGENCY IHS OF MCALLEN MANOR LLCOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 10/01/2022
- CSV RHEA MANAGEMENT HOLDCO, LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 10/01/2022
- DWD TX HOLDINGS LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 10/01/2022
- JACK AND NANCY DWYER WORKFORCE DEVELOPMENT CENTER INCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 10/01/2022
- REG LEASED OPCO LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 10/01/2022
- REG OPERATOR HOLDCO LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 10/01/2022
- REGENCY INTEGRATED HEALTH SERVICES LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 10/01/2022
- REGENCY TEXAS HOLDINGS LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 10/01/2022
- BAIRD, DANIELIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/13/2021
- CLAPP, BARBARAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 06/01/2021
- CORTESE, DARENIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 08/10/2021
- GIBSON, PATRICIAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 08/01/2021
- GUERRA, ADRIANIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/01/2016
- MANDELBAUM, ELLIOTIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2025
- MUNOZ, THALIAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/01/2018
- PENA, ELISAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/01/2022
- SALINAS, ARCADIOIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 09/17/2024
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.04per resident day
RN hours0.24per resident day
Weekend nurse hours2.67per resident day
Staff turnover50.0%CMS reported field
06 / LOCAL RECORDS
Open the Mcallen ledger →Other published facilities nearby
Alfredo Gonzalez Texas State Veterans Home160 beds · CMS overall 2/530 citation rowsBriarcliff Nursing And Rehabilitation Center194 beds · CMS overall 1/552 citation rowsGrand Terrace Rehabilitation And Healthcare93 beds · CMS overall 5/516 citation rowsMcallen Nursing Center122 beds · CMS overall 2/535 citation rowsMcallen Transitional Care Center100 beds · CMS overall 4/518 citation rowsVillage Healthcare And Rehabilitation114 beds · CMS overall 3/524 citation rowsWindsor Las Palmas Nursing And Rehabilitation Cent120 beds · CMS overall 5/58 citation rows