Alfredo Gonzalez Texas State Veterans Home
ALFREDO GONZALEZ TEXAS STATE VETERANS HOME in MCALLEN, TX — inspection on February 27, 2026.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
reviewed and reflected residents behaviors and interventions to address them.
The DON stated the
jeopardy to resident health or email communication between the DON and the psychiatric nurse practitioner dated 02/10/26 at safety 9:53am reflected residents (#2,#4, #8, #9, #10, #11) and the behaviors they had and continued email communication from 02/23/26 at 10:08am and 2:09pm reflected residents (#2, #6, #7, #8 #9, #12) and
and 02/23/26Resident #4, #5, #10 and #11 were seen on 02/12/26Resident #8 was seen on 02/23/26Resident #6, #7 were seen on 02/26/26.
Record review of staff development/in-services attendance sheet dated 02/08/26 with an audience documented as All team members covered reporting any incidents of abuse, injury of unknown origin neglect and exploitation immediately to the Administrator and included her phone number. It also covered reporting any resident to resident aggression or Inappropriate touching to the administrator and to redirect resident and keep residents safe.
Also covered was that all residents needed to be put on a one to one and be kept separated.Interviews with CNA A on 02/26/26 at 11:27am, LVN B on 02/26/26 at 7:21pm, CNA C 02/26/26 at 10:28am, LVN D on 02/2626 at 9:56am,, LVN G on 02/27/26 at 6:37am, LVN H on 02/25/26 at 1:20pm, the DON on 02/26/26 at 6:29pm and Administrator on 02/26/26 at 8:06pm reflected they had been trained to report any abuse to the Administrator immediately and were aware to separate and implement one to one monitoring with any resident to resident altercation.Record review of training over abuse guidance: preventing, identifying and reporting dated 02/09/26 reflected the DON and Administrator received the training.
676063 02/27/2026
Alfredo Gonzalez Texas State Veterans Home 301 E Yuma Ave McAllen, TX 78503
During an interview with PA Y on 02/26/26 at 10:31am she stated she would see
antipsychotics were used they usually request mental health providers to follow the resident and stated in her personal opinion antipsychotics should be used carefully with the elderly which was why they consulted with providers with specialties in those areas. PA Y stated antipsychotics could help control aggression and be helpful but stated overall there could be negative impact with use.
Record review of facility's policy titled, Psychotropic Medication & Gradual Dose Reduction with an implementation date of January 2022 and a revised date of January 2023 included a guideline statement that read, Physicians and mid-level providers will use psychotropic medication appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring.
676063 02/27/2026
Alfredo Gonzalez Texas State Veterans Home 301 E Yuma Ave McAllen, TX 78503
attendance sheet dated 02/08/26 with an audience documented as All team members covered
jeopardy to resident health or Administrator and included her phone number. It also covered reporting any resident to resident safety aggression or Inappropriate touching to the administrator and to redirect resident and keep residents safe.
Also covered was that all residents needed to be put on a one to one and be kept
02/26/26 at 10:28am, LVN D on 02/2626 at 9:56am,, LVN G on 02/27/26 at 6:37am, LVN H on 02/25/26 at 1:20pm, the DON on 02/26/26 at 6:29pm and Administrator on 02/26/26 at 8:06pm reflected they had been trained to report any abuse to the Administrator immediately and were aware to separate and implement one to one monitoring with any resident to resident altercation.Record review of training over abuse guidance: preventing, identifying and reporting dated 02/09/26 reflected the DON and Administrator received the training.
676063 02/27/2026
Alfredo Gonzalez Texas State Veterans Home 301 E Yuma Ave McAllen, TX 78503
During an interview with Resident #2 on 02/24/26 at 2:24pm he would only answer that yes he had an incident with Resident #1 and that yes he did get hurt. Resident #2 would not answer any other questions related to the incidents and would respond with, Its none of your business when asked.
During an interview with the Administrator on 02/26/26 at 8:35pm she stated she was the abuse coordinator and was responsible for reporting any incidents of abuse to HHSC within a 2 hour timeframe.
The Administrator stated she was notified by LVN D at 5:00am on 02/08/26 of the altercation between Residents #1 and #2 and the skin tears sustained by Resident #2 earlier that morning at around 4:15am.
The Administrator stated the altercation between Residents #1 and #2 should have been reported within 2 hours.
The Administrator stated she did not report to HHSC until 5:00pm on 02/08/26.
She stated she reported late because she was busy doing her interviews.
The Administrator stated the facility policy reflected reporting any abuse within 2 hours.
The Administrator did not give clear answer when asked if she had followed the facility policy in this situation.
The Administrator stated reporting incidents of abuse within 2 hours was important because depending on the allegation a surveyor may need to arrive to the facility faster.
The Administration stated the negative impact on resident for not reporting within 2 hours would be questionable.
Record review facility policy titled, Abuse Guidance: Preventing, Identifying and Reporting with a implemented date of February 2017 and revised date of January 2024 stated, Report alleged or suspicions of abuse to HHSC by email reporting via TULIP reporting within the designated time frame in accordance with HHSC PL19-17 (Replaces PL 17-19).Are reported immediatelyBut not later than 2 hours after allegation is made, if events that cause the allegation involve abuse or result in serious bodily injury.
676063 02/27/2026
Alfredo Gonzalez Texas State Veterans Home 301 E Yuma Ave McAllen, TX 78503
assessments upon admission and RN supervisors assisting to verify orders are entered at time of
It included stated, A licensed nurse should at least weekly conduct a routine skin
licensed nurse should document the results of weekly skin checks in the resident's medical record.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.