Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 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.
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.
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 | — | 2 | 0 |
| Alfredo Gonzalez Texas State Veterans Home | 1.3 mi | — | 12 | 2 |
| Mcallen Transitional Care Center | 1.4 mi | — | 5 | 0 |
| Windsor Las Palmas Nursing And Rehabilitation Cent | 1.5 mi | — | 0 | 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 August 2026) and official state health department websites.