Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Colonial Manor Advanced Rehab & Healthcare during CMS and state inspections, most recent first.
Two residents with dysphagia, severe cognitive impairment, and weight loss were not weighed weekly as ordered. One resident had cancer-related decreased intake and the other had protein-calorie malnutrition and poor oral intake. Staff stated weekly weights were taken by an RA and entered into PCC by the DON, but the record lacked documented weights for specific weeks for both residents, and the DON said the missing weights prevented accurate calculation of weight loss percentages.
A saline flush was observed sitting on top of an unattended medication cart in the 400 hall instead of being stored inside the locked cart. An LVN stated it should have been locked away and could have been taken by a resident, other residents, or visitors, while the DON stated no medication or saline flush should have been left on top of the cart. The facility policy required medications to be stored with proper sanitation, temperature, moisture control, segregation, and security.
A resident with a g-tube and severe cognitive impairment was on enhanced barrier precautions, with care plan directions to wear a gown and gloves during high-contact care. During incontinent care, two CNAs performed hand hygiene for only 15 seconds and did not wear PPE. Both CNAs stated they knew the resident required EBP and that a gown should have been worn, and the DON confirmed staff were required to perform hand hygiene before and after care and follow EBP for residents with feeding tubes.
A resident with chronic pulmonary edema, acute respiratory failure with hypoxia, and pleural effusion had a physician order for continuous O2 at 3 L/min via nasal cannula. During observation, the O2 concentrator was found set at 2.5 L/min, and an LVN adjusted it to the ordered 3 L/min. The resident had moderate cognitive impairment and a care plan noting behaviors of removing the nasal cannula and chewing on O2 tubing. Nursing leadership reported performing routine rounds to check O2 settings, and facility policy required treatments to be administered as ordered, but at the time of observation the O2 flow rate did not match the physician’s order.
A resident with hemiplegia, severe cognitive impairment, and dependence for most ADLs slid from bed onto a floor mat and activated the call light while on the floor. Video evidence showed the call light blinking shortly after the resident reached the floor and remaining unanswered for approximately 1 hour and 45 minutes until a CNA and an LVN entered and assisted the resident. Staff interviews revealed that the room had been noted as pending rounds, some staff saw or believed they saw the call light on but did not enter, and the unit was short-staffed due to call-ins and a no-call/no-show, resulting in a prolonged delay in responding to the resident’s call light despite care plan interventions requiring timely assistance and use of the call light.
Two residents with cognitive and behavioral impairments engaged in a physical altercation in a hallway, with one resident striking the other multiple times before staff intervened. Both had documented histories of aggression and required assistance with daily activities, but the facility did not prevent the unsupervised encounter, resulting in a failure to protect residents from abuse.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The report highlights insufficient environmental safety measures and lack of proper supervision, but does not specify further details about the hazards or individuals involved.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A facility failed to maintain an effective infection control program when a CNA did not follow the protocol of using one wipe per swipe during incontinent care for a resident with severe cognitive impairment. Despite recent in-service training, the CNA used a single wipe multiple times, risking cross-contamination. Interviews with staff confirmed awareness of the correct procedure, highlighting a gap in adherence to the facility's infection control policy.
Two residents in a LTC facility had incomplete documentation of insulin administration in their MARs. Despite receiving their insulin, the responsible LVN failed to transfer the documentation from her personal journal to the electronic MAR. The DON confirmed the documentation lapses, noting that the facility's policy was not followed.
A CNA at a long-term care facility failed to wear gloves while delivering a meal tray to a COVID-19 positive resident under droplet isolation, despite facility policies requiring full PPE. The CNA misunderstood the necessity of gloves, influenced by practices at other facilities, and had not reviewed the specific PPE policy. The facility's DON confirmed the requirement for gloves, gowns, goggles/face shields, and an N95 mask to prevent infection spread.
Missed Weekly Weights for Two Residents With Weight Loss
Penalty
Summary
The facility failed to ensure that two residents with physician-ordered weekly weights were weighed as ordered. Resident #1 was a female with diagnoses including left patella fracture, muscle wasting and atrophy, dysphagia, cognitive communication deficit, rheumatoid arthritis, dementia, and cancers of the breast and lung. Her MDS reflected severe cognitive impairment, weight loss, and dependence for eating. Her care plan identified her as at risk for malnutrition and noted unplanned weight loss related to decreased oral intake and cancer. A physician order required weekly weights beginning 02/18/26, but the weight record showed weekly weights only through 03/26/26, with no weight documented for the week of 03/30/26. Resident #2 was a male with diagnoses including cerebral palsy, dementia, cognitive communication deficit, dysphagia, and protein-calorie malnutrition. His MDS also reflected severe cognitive impairment, weight loss, and the need for substantial to maximal assistance with eating. His care plan identified him as at risk for malnutrition and noted unplanned weight loss related to poor oral intake. A physician order required weekly weights beginning 04/28/26, but the weight record showed weights on 05/01/26, 05/12/26, and 05/27/26, with no weight documented for the weeks of 05/04/26 or 05/18/26. During interviews, the ADONs and DON stated that residents with weight loss were supposed to be weighed weekly and that the weights were taken by an RA and then entered into PCC by the DON. The DON stated she reviewed a binder and did not find weights for the missing weeks for either resident. The DON also stated the facility could not accurately calculate percentages of weight loss without the weekly weights being done or documented appropriately. The facility's Weight Management policy stated that all admission, readmission, weekly, and monthly weights are to be entered into PCC.
Unsecured saline flush left on medication cart
Penalty
Summary
The facility failed to ensure drugs and biologicals used in the facility were stored in locked compartments under proper temperature controls and accessible only to authorized personnel for 1 of 2 medication carts reviewed, the 400 hallway cart. During an observation on 05/12/2026 at 3:45 p.m., a saline flush was found sitting on top of the unattended 400 hall medication cart. During an interview at 3:50 p.m., LVN A stated the normal saline flush should have been inside the medication cart and locked, and said a resident, other residents, or visitors could take it and that it could become contaminated or cause an allergic reaction. During an interview on 05/14/2026 at 4:45 p.m., the DON stated no medication or saline flush should have been left on top of the medication cart and that another resident or any resident or visitor could take it and have an adverse reaction. The facility policy titled Medication Storage stated medications must be stored, dated, and labeled according to manufacturer recommendations and with proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.
Failure to Use EBP and Proper Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to maintain its Infection Prevention and Control Program for Resident #1, a severely cognitively impaired female with dysphagia, a history of cerebral infarction, and a feeding tube. Her care plan identified enhanced barrier precautions due to the g-tube, with interventions to wear a gown and gloves during high-contact resident care activities. During observation of incontinent care on 05/13/26, CNA B and CNA C performed hand hygiene for 15 seconds and did not have personal protective equipment on while providing care to the resident. During interviews, CNA B and CNA C each stated that residents with a tube were required to be on enhanced barrier precautions and that they should have worn a gown but forgot when entering the room. CNA B stated she was aware handwashing should be for at least 20 seconds and that the negative outcome could be the spread of contamination. CNA C also stated she was aware handwashing should be for at least 20 seconds. The DON stated that any resident with a feeding tube was placed on enhanced barrier precautions and that staff were always required to perform hand hygiene before and after care. The facility policy required gown and gloves for high-contact care activities and required hand hygiene with soap and water for at least 20 seconds.
Failure to Administer Oxygen at Prescribed Flow Rate
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered oxygen therapy was administered at the prescribed setting for a resident requiring continuous oxygen. The resident, an older female with chronic pulmonary edema, acute respiratory failure with hypoxia, and pleural effusion, had an active physician order dated 3/17/2026 for continuous oxygen at 3 liters per minute via nasal cannula every shift. The resident’s MDS assessment indicated moderate cognitive impairment and documented oxygen therapy as a treatment performed on admission and while a resident. The care plan identified a behavioral problem in which the resident removed the nasal cannula and chewed on the oxygen tubing, with an intervention to administer medications as ordered. On 3/19/2026 at 10:56 a.m., surveyors observed the resident in bed with oxygen being delivered via nasal cannula from a concentrator set at 2.5 liters per minute instead of the ordered 3 liters. LVN A was observed checking and then adjusting the concentrator setting to 3 liters per minute in response to this finding. Earlier that morning, LVN A reported having checked the oxygen setting and stated it was at 3 liters, with an oxygen saturation of 98% at 9:30 a.m. The ADONs reported that they conducted rounds each morning, including checking oxygen settings, and that managers made Quality of Life rounds to address issues such as oxygen settings. The facility’s policy on Medication-Treatment Administration and Documentation Guidelines required medications to be administered according to the physician’s order, which was not followed at the time the oxygen concentrator was found set below the prescribed rate.
Failure to Timely Respond to Call Light for Dependent Resident on Floor Mat
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with the resident’s person-centered care plan and professional standards of practice by not responding to a call light for an extended period. The resident involved was an older female with hemiplegia and hemiparesis affecting the left non-dominant side, contracture of the left hand, lack of coordination, schizoaffective disorder, and epilepsy. A quarterly MDS showed severe cognitive impairment with a BIMS score of 4, and Section GG documented that she was dependent or required substantial/maximal assistance for nearly all self-care and mobility tasks, including transfers and toileting. Her care plans identified ADL self-care performance deficits and risk for unmet needs, fall risk related to reduced mobility and hemiplegia with a history of falls, and behavior issues including throwing herself on the floor and sliding down to the mat. Interventions included keeping the bed in the lowest position, placing a floor mat next to the bed, ensuring the call light was within reach, and encouraging the resident to use the call light for assistance. On the date of the incident, surveillance video from the resident’s room showed that at 4:37 a.m. she was lying in bed with her feet dangling off the side. At 4:43 a.m., she was observed sliding down from the left side of the bed into a sitting position on the floor mat and pressing the call light within eight seconds of reaching the floor. The wall-mounted call light was seen turned on and blinking. At 4:44 a.m., the resident was seen waving the call light in the air and placing it on top of the bed, and by 4:45 a.m. she had positioned herself lying on the floor. No video footage was available between 4:45 a.m. and 6:36 a.m. A second video segment with a timestamp of 6:36 a.m. showed a CNA entering the room, removing a blanket from the resident’s legs while she remained on the floor, and an LVN entering within about 10 seconds to check the resident. The family member’s own video, viewed by surveyors, similarly showed the resident sliding off the bed onto the mat, pressing the call light, and staff not entering the room until approximately two hours later. Interviews with the resident and staff further described the delay in response to the call light. The resident reported that staff sometimes took a long time to answer her call light and that on this occasion she slid off the bed, sat on the mat, became dizzy, and remained on the floor for about an hour before staff helped her back to bed, though she stated she had no injuries. A family member stated that no one entered the room after the call light was pressed and that the camera in the room only recorded when there was movement, with video showing the resident sliding to the floor and pressing the call light, and a later clip showing staff entering the room roughly two hours afterward. Multiple staff interviews revealed that the call light system required staff to physically enter the room to turn off the light and that there was no electronic log of call light duration. Staff accounts indicated that the resident’s room had been noted as “pending to be seen,” that some staff saw or believed they saw the call light on but did not enter the room, and that staffing on the unit was reduced due to call-ins and a no-call/no-show on the overnight shift. Collectively, these observations and statements show that the resident’s call light remained unanswered for approximately 1 hour and 45 minutes while she was on the floor, contrary to her care plan interventions and the facility’s call light response policy.
Failure to Prevent Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to ensure the right of each resident to be free from abuse, as evidenced by a physical altercation between two residents in the hallway. Both residents involved had significant cognitive impairments and histories of behavioral issues, including aggression and resistance to care. On the day of the incident, one resident was wheeling himself towards the nurse's station when the other resident grabbed his shirt and struck him multiple times on the left shoulder. The altercation escalated, with both residents striking each other before being separated by staff. Video surveillance confirmed that one resident was the initial aggressor, and both residents were assessed by nursing staff immediately after the incident, with no visible injuries or complaints of pain noted at that time. Record reviews revealed that both residents had documented behavioral problems and required varying levels of assistance with activities of daily living due to cognitive and physical limitations. One resident had a history of aggression with staff and was noted to be resistant to care, while the other had a diagnosis of dementia, psychosis, and delusional disorder, with a care plan indicating a risk for aggressive behavior and a need for close monitoring. Despite these known risks, the facility did not prevent the altercation from occurring as the residents encountered each other unsupervised in the hallway. Interviews with staff indicated that they were aware of the residents' behavioral histories and the potential for aggression. Staff described previous incidents of aggression and confusion, as well as the need for interventions to prevent abuse. However, the incident in question demonstrated a failure to implement effective supervision and preventive measures, resulting in a physical altercation between the two residents. The facility's policies and procedures required protections against abuse, but these were not adequately followed to prevent the event.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific nature of the hazards, the supervision lapses, or the condition of any residents involved are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency is based on the observation that when an incident of suspected abuse, neglect, or theft occurred, the required notifications and reporting procedures were not followed as mandated. The report specifically notes the lack of timely communication and documentation to the appropriate authorities regarding both the suspicion and the outcome of the internal investigation.
Infection Control Deficiency in Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of CNA A during incontinent care for a resident. The resident, a female with severe cognitive impairment and total dependence on assistance for personal hygiene, was observed receiving care where CNA A did not adhere to the protocol of using one wipe per swipe. Instead, CNA A used a single wipe multiple times on the resident's buttock area, which could lead to cross-contamination. This practice was contrary to the facility's policy, which mandates the use of one wipe per swipe to prevent infection and cross-contamination. Interviews with CNA A, CNA B, the ADON, and the DON revealed that the staff were aware of the correct procedure and had been in-serviced on incontinent care recently. However, CNA A was unsure of the correct number of times a wipe could be used, indicating a gap in adherence to the training. The facility's policy, last revised in November 2024, clearly outlines the requirement for using a wipe once per swipe, and the failure to follow this protocol was identified as a deficiency in the infection prevention and control program.
Incomplete Medication Administration Documentation
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices, specifically in the documentation of medication administration for two residents. Resident #2, a cognitively intact female with a history of type 2 diabetes mellitus with hyperglycemia, had incomplete documentation in her Medication Administration Record (MAR) for insulin administration on June 3, 2024. The MAR showed three unsigned sections for insulin orders, despite the resident reporting that she received all her insulin and blood sugar checks as ordered. Similarly, Resident #3, also cognitively intact and diagnosed with diabetes mellitus due to an underlying condition with hyperglycemia, had an incomplete MAR for the same date. The MAR had one unsigned section for insulin administration, although the resident confirmed receiving her insulin and blood sugar checks. Licensed Vocational Nurse (LVN) A, who was responsible for administering and documenting the insulin, admitted to documenting the administration in her personal journal but failing to transfer this information to the electronic MAR. Interviews with LVN A and the Director of Nursing (DON) revealed that LVN A was new to the station and unfamiliar with the separate insulin MAR. Despite having been trained on documentation procedures, LVN A did not follow the facility's policy to document medication administration immediately on the MAR. The DON confirmed the documentation lapses and acknowledged that the facility's policy was not followed, as the MAR was left incomplete, which could lead to potential errors in care and treatment.
Inadequate PPE Usage in COVID-19 Isolation Room
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA C, who did not adhere to the required personal protective equipment (PPE) protocols when entering the room of a resident diagnosed with COVID-19. The resident, a cognitively intact female with multiple health conditions including COVID-19, was under droplet/contact precautions. Despite the clear signage and existing orders for transmission-based precautions, CNA C entered the resident's room wearing an N95 mask, eye protection, and a gown, but failed to wear gloves, which are part of the required PPE. CNA C admitted to not wearing gloves during the delivery of a meal tray, under the mistaken belief that gloves were unnecessary if there was no direct contact with the resident. This misunderstanding stemmed from practices observed at other facilities, rather than the specific policies of the current facility. CNA C acknowledged the importance of wearing gloves to prevent infection and cross-contamination, especially in the context of a COVID-positive resident on droplet isolation. The facility had provided training on PPE usage, which CNA C had attended, but he had not reviewed the facility's specific policy on PPE requirements for droplet isolation rooms. The Director of Nursing (DON), who also served as the Infection Control Practitioner (ICP), confirmed that the facility's policy required the use of gloves, gowns, goggles/face shields, and an N95 mask when entering rooms of residents with confirmed COVID-19. The DON emphasized the importance of adhering to these protocols to prevent outbreaks and protect both residents and staff. The facility's policy and training materials clearly outlined the necessary PPE for such situations, but the failure to comply with these protocols by CNA C highlighted a gap in adherence to the infection control measures in place.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pharr
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edinburg Nursing And Rehabilitation Center | 1 mi | ★★★★★ | 13 | 1 |
| Hidalgo Nursing And Rehabilitation Center | 1.5 mi | ★★★★★ | 11 | 0 |
| Mcallen Nursing Center | 2.8 mi | ★★★★★ | 4 | 0 |
| Windsor Nursing And Rehabilitation Center Of Edinb | 3.5 mi | ★★★★★ | 11 | 0 |
| Grand Terrace Rehabilitation And Healthcare | 4 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.