Village Healthcare and Rehabilitation
615 N Ware Rd, McAllen, TX 78501 · Hidalgo County · 114 certified beds · avg 93 residents/day · certified since May 1, 2011
Abuse citation flag (CMS)
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jun 5, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: May 6, 2025 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Apr 10, 2025 · F-0600
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 6, 2024 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Apr 10, 2025 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 6, 2024 (Past Non-Compliance)
All citations in the current public record (16)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Nov 5, 2025 | E · Potential for harm, repeated | The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint |
| Nov 5, 2025 | E · Potential for harm, repeated | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint |
| Jun 5, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 10, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Apr 10, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Apr 10, 2025 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. · from a complaint |
| Apr 10, 2025 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Apr 10, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 10, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 5, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint |
| Jan 26, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Jan 5, 2024 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 5, 2024 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Jan 5, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Oct 2, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Nov 10, 2022 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (1 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 1 | 0 | D |
| 2023 | 1 | 0 | D |
| 2024 | 4 | 0 | E |
| 2025 | 10 | 3 | J ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $28,970.
| Date | Type | Amount / length |
|---|---|---|
| Jun 5, 2025 | Fine | $14,901 |
| Apr 10, 2025 | Fine | $14,069 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.92 | 3.46 | 3.95 | bottom 19% in Texas; bottom 11% in the U.S. |
| Registered Nurse hours | 0.38 | 0.44 | 0.69 | bottom 47% in Texas; bottom 19% in the U.S. |
| Weekend total nurse staffing | 2.47 | 3.04 | 3.50 | bottom 14% in Texas; bottom 9% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.25 | 0.34 | 0.48 | bottom 38% in Texas; bottom 22% in the U.S. |
| Total nursing staff turnover (%) | 33.3 | 55.3 | 45.8 | top 9% in Texas; top 20% in the U.S. |
| RN turnover (%) | 0.0 | 54.6 | 42.9 | top 1% in Texas; top 1% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.49, RN 0.45, weekend 2.96. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 4/5 · short-stay residents: 5/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Fannin County Hospital Authority | Organization | 5% or Greater Direct Ownership Interest | 100% | 05/01/2020 |
| Ann Arbor Health Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2020 |
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 05/01/2020 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 07/16/2002 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| McAllen Community Healthcare, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 05/01/2020 |
| McAllen Community Healthcare, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 09/29/2025 |
| Olivares Herrera, Olga | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/11/2007 |
| Olivares Herrera, Olga | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/11/2007 |
| Olivares Herrera, Olga | Individual | ADP of the SNF | NOT APPLICABLE | 04/11/2007 |
| Sanderson, Clark | Individual | Corporate Officer | NOT APPLICABLE | 05/01/2020 |
| Standard Bearer Healthcare Op, LP | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2020 |
| The Ensign Group INC | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2020 |
| Yzaguirre, Alexandra | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/01/2020 |
| Yzaguirre, Alexandra | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2020 |
| Yzaguirre, Alexandra | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2020 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Before a resident is discharged or transferred, how do you make sure the new place can actually meet their needs?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "How do you identify and arrange specialized services for residents with mental health conditions or disabilities?"
- "What is your approach to psychiatric medications — how do you try non-drug options first and work to reduce doses over time?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Briarcliff Nursing and Rehabilitation Center | 1.6 mi | McAllen, TX | ★☆☆☆☆ | 2/5 | abuse |
| Windsor Nursing and Rehabilitation Center of McAll | 2.1 mi | McAllen, TX | ★★★☆☆ | 4/5 | |
| Grand Terrace Rehabilitation and Healthcare | 2.3 mi | McAllen, TX | ★★★★★ | 5/5 | |
| McAllen Nursing Center | 2.9 mi | McAllen, TX | ★★☆☆☆ | 2/5 | |
| Mission Nursing and Rehabilitation Center | 3.4 mi | Mission, TX | ★★★★☆ | 4/5 | |
| Alfredo Gonzalez Texas State Veterans Home | 3.5 mi | McAllen, TX | ★★☆☆☆ | 2/5 | abuse |
| Mission Valley Nursing and Transitional Care | 3.5 mi | Mission, TX | ★★★★☆ | 3/5 | |
| McAllen Transitional Care Center | 3.7 mi | McAllen, TX | ★★★★☆ | 3/5 | |
| Windsor Las Palmas Nursing and Rehabilitation Cent | 3.8 mi | McAllen, TX | ★★★★★ | 5/5 | |
| Colonial Manor Advanced Rehab & Healthcare | 4.8 mi | Pharr, TX | ★☆☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 675689.