Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Grand Terrace Rehabilitation And Healthcare during CMS and state inspections, most recent first.
Call Light Not Within Reach: A resident with severe cognitive impairment and extensive assistance needs was observed sitting upright in bed without his call light within reach. The ADON later found the call light on the floor behind the headboard, and CNA staff could not recall ensuring it was placed near the resident after providing morning care. The care plan directed staff to keep the call light within reach and encourage its use for assistance.
Failure to Obtain Proper Consent for Antipsychotic Medications: The facility administered antipsychotic medications to two residents without documented RP consent and accepted a consent signed by a resident with severe cognitive impairment. One resident with dementia and severe cognitive impairment received Zyprexa without RP consent, another resident with severe cognitive impairment received Haldol without RP consent, and a third resident with severe communication and cognitive deficits signed consent for Zyprexa despite being documented as severely impaired for daily decision making.
Unnecessary antipsychotic use without adequate indication: Two residents with severe cognitive impairment and no documented psychosis or behavioral symptoms were given antipsychotics despite orders tied to psychosis or altered mental status. One resident with dementia, agitation, and stroke-related deficits received Zyprexa 5 mg HS for psychosis, while another resident with stroke-related deficits, respiratory failure, seizures, and liver disease received Haldol 5 mg for altered mental status. Staff interviews confirmed that altered mental status and dementia were not proper indications for these antipsychotic orders.
Incomplete person-centered care plans for code status and ADL assistance: The facility failed to ensure one resident’s care plan reflected full code status and another resident’s care plan matched the MDS-coded level of ADL dependence. The residents had significant medical and cognitive needs, including respiratory support needs for one resident and severe cognitive impairment with dependence for multiple ADLs for the other, but the care plans did not fully align with the assessed needs and active orders.
A CNA performed incontinent care and dressing for a resident with severe cognitive and physical impairments without the required two-person assistance, as specified in the care plan and MDS. Despite established communication systems and oversight responsibilities among nursing staff, the CNA did not request help, and other staff were unaware the care was performed alone.
A normal saline flush was left unsecured at the bedside of a resident receiving IV medications for a wound infection. After a nurse administered antibiotics, the flush was left on the resident's television stand instead of being properly secured. Facility staff confirmed that medications should not be left at the bedside and must be stored securely, in accordance with facility policy.
A medication cart serving two hallways was left unlocked and unattended by an LVN, contrary to facility policy and professional standards. The LVN admitted to leaving the cart unsecured while answering a call, and the DON confirmed that all staff are expected to lock medication carts when unattended.
A facility failed to include an antibiotic order in a resident's care plan, risking inadequate intervention. The resident, with multiple health issues, was prescribed Azithromycin for pneumonia, but the order was overlooked, especially over the weekend. Staff interviews revealed shared responsibility for care planning, but the oversight occurred due to weekend staffing gaps. The MDS coordinator, ADON, and DON acknowledged the importance of care planning for effective clinical management.
A facility failed to maintain a safe environment due to unrepaired holes in a restroom door frame in a resident's room. Observations showed the holes were not addressed despite staff being aware of the issue. Interviews revealed a breakdown in communication and documentation, as the maintenance staff was not informed, and no record was found in the maintenance log.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure Resident #2 had his call light within reach while he was in bed. Resident #2 was an [AGE] year-old male admitted on 08/21/24 with diagnoses including Type 2 Diabetes Mellitus with Hyperglycemia, Chronic Respiratory Failure with Hypercapnia, Epistaxis, and Gastrotomy Status. His quarterly MDS reflected a BIMS score of 4, indicating severe cognitive impairment, and Section GG showed he used a manual wheelchair and required extensive assistance with dressing, rolling in bed, toileting hygiene, and partial/moderate assistance for sitting to lying on the bed. His care plan dated 03/30/26 included interventions to ensure the call light was within reach and to encourage him to use it for assistance as needed. During observation on 05/07/26 at 10:18 a.m., Resident #2 was sitting upright on his bed and alert, but his call light was not observed near him. When asked where it was, he did not respond. During a later interview, the ADON entered the room and found the call light on the floor behind the headboard, stating it should have been clipped to the bed within the resident's reach. CNA B said she had changed the resident's clothing, brief, and bedding that morning but did not recall ensuring the call light was near him. The DON stated the resident was supposed to have the call light within reach and that if he needed assistance, he could have had a delay in care if unable to reach it.
Failure to Obtain Proper Consent for Antipsychotic Medications
Penalty
Summary
The facility failed to ensure residents were informed of the risks, benefits, and alternatives before antipsychotic medications were administered, and it failed to obtain proper consent for those medications for three residents reviewed. The report states that the facility did not obtain prior consent before giving Zyprexa to one resident, did not obtain prior consent before giving Haldol to another resident, and accepted a consent signed by a resident with severely impaired cognitive skills for Zyprexa. One resident had diagnoses including dementia with agitation, hemiplegia and hemiparesis following cerebral infarction, hypertension, heart failure, generalized anxiety disorder, and emotional lability. The resident’s MDS showed a BIMS score of 03, indicating severe cognitive impairment, and no behavioral symptoms or psychosis indicators were noted. The record showed a physician order for Zyprexa 5 mg at bedtime for psychosis, and the MAR documented administration nightly over multiple days. The record review did not reveal a consent signed by the RP for Zyprexa. Another resident had diagnoses including hypertension, hemiplegia and hemiparesis following cerebral infarction, chronic respiratory failure, heart disease, seizures, alcoholic cirrhosis of the liver, and depression. The resident’s MDS showed a BIMS score of 06, indicating severe cognitive impairment, with no psychosis indicators or behavioral symptoms noted. The record showed orders for Haldol 5 mg for altered mental status, and the MAR documented doses given on multiple days. The record review did not reveal a consent signed by the RP for Haldol. A third resident had diagnoses including paranoid schizophrenia, cerebral infarction, anoxic brain damage, aphasia following cerebral infarction, and cognitive communication deficit. The resident’s MDS showed the resident was rarely or never able to be understood or to understand, and was severely impaired for cognitive skills for daily decision making. The resident signed the antipsychotic consent form, and the record showed Zyprexa 5 mg via PEG tube twice daily was ordered for paranoid schizophrenia and continued for months. During interview, the DON stated the resident would not be able to give consent based on the MDS, but also stated the resident was allowed to sign because he appeared able to follow commands visually. The DON and other staff stated consent was required before antipsychotic administration, and the facility policy stated informed consent was to be completed prior to initiation of new psychoactive medication.
Unnecessary antipsychotic use without adequate indication
Penalty
Summary
The facility failed to ensure that residents were free from chemical restraints not required to treat their medical symptoms for 2 of 8 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with agitation, hemiplegia and hemiparesis following cerebral infarction, heart failure, generalized anxiety disorder, and emotional lability had a BIMS score of 03 and no documented psychosis or behavioral symptoms on the quarterly MDS, yet was placed on a care plan focus for antipsychotic medication related to psychosis and was ordered Zyprexa 5 mg at bedtime for psychosis. The resident’s January and February MARs showed the medication was administered nightly from 01/20/26 through 02/17/26. A progress note stated the resident was seen by a psych NP, had increased appetite and remained depressed with crying spells, and that Namenda and Aricept were stopped while Zyprexa 5 mg PO HS was started for unspecified psychosis, dementia, and aggression. A second resident with diagnoses including hypertension, hemiplegia and hemiparesis following cerebral infarction, chronic respiratory failure, heart disease, seizures, alcoholic cirrhosis of the liver, and depression had a BIMS score of 06 and no documented psychosis or behavioral symptoms on the annual MDS. The resident’s care plan focused on antipsychotic medication use related to altered mental status, and physician orders were written for haloperidol 5 mg daily for altered mental status, first in the morning and later in the evening. The February MAR showed Haldol 5 mg was administered on 02/12/26 and 02/13/26 in the morning and on 02/15/26 in the evening. During interviews, the DON stated altered mental status should not be an indication for an antipsychotic order and said psychosis should not be an indication for an antipsychotic order for a resident who has dementia. LVN A stated antipsychotics needed a correct diagnosis and that orders without a proper diagnosis, especially with Alzheimer’s or dementia, were not proper orders. RN B stated an antipsychotic order cannot have an indication as Alzheimer’s or dementia and that a proper diagnosis and signed consent were needed before administering an antipsychotic. The facility policy stated psychotropic medication was to be prescribed only to treat a specific diagnosed condition documented in the clinical record.
Incomplete person-centered care plans for code status and ADL assistance
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #46 and Resident #18 that matched their assessed needs. The facility’s policy stated the interdisciplinary team would develop and implement a comprehensive person-centered care plan for each resident within 7 days of completion of the MDS and include the resident’s needs identified in the comprehensive assessment, along with the resident’s goals and desired outcomes. Resident #46 was admitted with diagnoses including myasthenia gravis with acute exacerbation, acute respiratory failure, tracheostomy, and dependence on a respirator. His Medicare 5-day MDS showed a BIMS score of 14, indicating intact cognition. His comprehensive care plan did not reflect his full code status, even though his active order stated full code with AED and CPR during sudden cardiac arrest. RN E, MDS D, and the DON all confirmed that his code status was full code and that it was not included on the care plan. Resident #18 was admitted with diagnoses including schizophrenia, cognitive communication deficit, need for assistance with personal care, and lack of coordination. Her quarterly MDS showed a BIMS score of 5 and coded her as dependent for multiple functional abilities, including oral hygiene, toileting hygiene, bathing, dressing, bed mobility, and transfers. Her care plan identified ADL self-care performance deficit and listed 1-person assist interventions for toileting, transfers, bed mobility, and dressing. CNA F stated Resident #18 required a 2-person assist during episodes of aggression, and MDS D and the DON confirmed that the care plan did not match the level of care reflected on the MDS assessment.
Failure to Provide Required Two-Person Assistance During Resident Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) performed incontinent care and dressing for a resident who required two-person assistance, without obtaining help from another staff member. The resident in question had a history of non-traumatic intracerebral hemorrhage, hemiplegia, hemiparesis, severe cognitive impairment, and was documented as totally dependent on two or more staff for activities of daily living such as toileting hygiene and dressing. The resident's care plan and Minimum Data Set (MDS) both specified the need for two-person assistance for these tasks. During the observed incident, the CNA did not request assistance and completed the care alone, despite being aware of the resident's care plan requirements. The CNA stated that it was sometimes difficult to find another staff member to assist during the night shift and admitted to feeling confident in her ability to perform the task alone. The resident's responsible party (RP) was present and noted that this was not the first time the CNA had performed care alone, and that he usually assisted with such tasks. Interviews with other staff, including another CNA, registered nurses (RNs), the assistant director of nursing (ADON), director of nursing (DON), and the administrator, revealed that there were established systems (care plans and Kardex) to communicate care requirements. However, the CNA did not seek assistance from available staff, and the nurses were not aware that the care was performed alone. The facility's process involved verbal communication of changes and oversight by nursing staff, but in this instance, the required two-person assistance was not provided as per the resident's care plan.
Unsecured Medication Left at Bedside
Penalty
Summary
A deficiency occurred when a normal saline flush, intended for intravenous use, was left unsecured at the bedside of a male resident who had been admitted with an infection of an amputation stump and was receiving intravenous medications. The saline flush was observed on the resident's television stand after a nurse administered antibiotics and failed to properly secure the medication. The resident confirmed that the nurse left the saline flush at his bedside. Interviews with facility staff, including an LVN and the DON, confirmed that medications and biologicals, including saline flushes, should not be left at the bedside of any resident. Both staff members acknowledged that such items must be stored securely and only accessible to authorized personnel, as per facility policy and regulatory requirements. Record review of the facility's medication storage policy further supported that all medications must be stored safely and securely, accessible only to authorized personnel.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A deficiency was identified when drugs and biologicals were not stored and labeled in accordance with accepted professional principles. Specifically, one of the medication carts serving the 1 and 2 hallways was observed to be left unlocked and unattended by an LVN. The cart was positioned against the nurse's station and was accessible until the surveyor notified the LVN, who then secured it by locking the cart. The LVN acknowledged responsibility for the cart and stated she was expected to lock it whenever she walked away, but had left it unlocked to answer a call. Further interviews with the DON confirmed that multiple staff, including the DON and ADON, were responsible for ensuring medication carts were locked. The DON reiterated the expectation that staff must lock the cart when leaving it unattended. Facility policy reviewed by the surveyor also required that medications for residents who do not self-administer be stored in a locked cabinet, such as a medication cart, with access limited to authorized personnel.
Failure to Develop Comprehensive Care Plan for Antibiotic Order
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, which included addressing an antibiotic medication ordered by the physician. The resident, a female with multiple diagnoses including pneumonia, end-stage renal disease, type 2 diabetes mellitus, pleural effusion, and acute on chronic diastolic congestive heart failure, was cognitively intact as per her BIMS assessment. The physician had ordered Azithromycin for pneumonia, but this was not included in the care plan, potentially placing the resident at risk of not receiving appropriate interventions. Interviews with facility staff revealed that the responsibility for care planning was shared among the MDS coordinator, nurses, ADON, and DON. However, the antibiotic order was overlooked, particularly because it was received over the weekend when the MDS coordinator was not working. The MDS coordinator acknowledged the oversight and emphasized the importance of care planning for antibiotics to guide nursing staff on monitoring signs and symptoms, contacting the doctor if necessary, and managing lab work. The ADON and DON also recognized the oversight and discussed their processes for reviewing physician orders, which included weekly morning meetings and audits.
Unrepaired Door Frame Holes in Resident Room
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, staff, and the public, as evidenced by the presence of unrepaired gaps and holes in the restroom door frame of one of the rooms. Observations on two separate occasions revealed that the holes, measuring approximately 5 inches wide by 4 inches long and 4 inches deep, were present on both the outer and inner parts of the door frame. Despite the holes not being connected and not allowing visibility into the restroom, their presence indicated a lack of timely maintenance and repair. Interviews with various staff members, including maintenance personnel, certified nursing assistants, and housekeeping staff, revealed a breakdown in communication and documentation regarding maintenance issues. Staff members were aware of the procedure to report maintenance needs either verbally or through documentation in a maintenance binder at the nurse's station. However, the maintenance director and other staff members were not informed about the specific issue in the room, and there was no record of the problem in the maintenance log. The facility's administration, including the administrator and maintenance director, acknowledged the importance of maintaining the building in good repair for the safety and comfort of residents. Despite the facility's policy for routine and non-routine maintenance, the lack of communication and documentation led to the oversight of the necessary repairs in the room. The maintenance log review confirmed that no service requests were documented for the room in question, highlighting a gap in the facility's maintenance reporting and follow-up processes.
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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 Mcallen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windsor Nursing And Rehabilitation Center Of Mcall | 0.3 mi | ★★★★★ | 5 | 0 |
| Mcallen Nursing Center | 1.2 mi | ★★★★★ | 4 | 0 |
| Alfredo Gonzalez Texas State Veterans Home | 1.3 mi | ★★★★★ | 14 | 2 |
| Mcallen Transitional Care Center | 1.4 mi | ★★★★★ | 5 | 0 |
| Windsor Las Palmas Nursing And Rehabilitation Cent | 1.5 mi | ★★★★★ | 1 | 0 |
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