Pharr, TX

Colonial Manor Advanced Rehab & Healthcare

2-star overall rating with 2-star inspections with $71,122 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

1100 W Minnesota Rd, Pharr, TX

(956) 686-2243

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

123

Certified beds

Average residents

120

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Hamilton County Hospital District

Operator or chain grouping

Approved since

1992-05-19

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

10 facilities

Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.16

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

1.32

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

1.79

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.27

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.47

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

3.01

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.13

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.09

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.15

CMS adjusted RN staffing hours

Adjusted total hours

3.13

CMS adjusted total nurse staffing hours

Case-mix index

1.43

Higher values indicate more complex resident acuity

RN turnover

67%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

45%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,284

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

24.17

Composite VBP score used to determine payment impact.

Payment multiplier

0.9834

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.69

Baseline 22.55% · Performance 20.24% · Measure score 3.69 · Achievement 2.58 · Improvement 3.69

Healthcare-associated infections

Baseline 8.28% · Performance 8.46% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

5.98

Baseline 97.59% · Performance 50.47% · Measure score 5.98 · Achievement 3.23 · Improvement 5.98

Adjusted total nurse staffing

Baseline 3.08 hours · Performance 3.16 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.8%	10.72% 1.1 pts worse	No Different than the National Rate · Eligible stays 72 · Observed rate 15.28% · Lower 95% interval 7.93%
Discharge to community	57.48%	50.57% 6.9 pts better	No Different than the National Rate · Eligible stays 63 · Observed rate 49.21% · Lower 95% interval 47.8%
Medicare spending per beneficiary	1.24	1.02 0.2 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 85 · Denominator 85
Falls with major injury	1.18%	0.77% 0.4 pts worse	Numerator 1 · Denominator 85
Discharge self-care score	48.08%	53.69% 5.6 pts worse	Numerator 25 · Denominator 52
Discharge mobility score	73.08%	50.94% 22.1 pts better	Numerator 38 · Denominator 52
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 85 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	8.46%	7.12% 1.3 pts worse	No Different than the National Rate · Eligible stays 55 · Observed rate 14.55% · Lower 95% interval 4.63%
Staff COVID-19 vaccination coverage	100%	8.2% 91.8 pts better	Numerator 113 · Denominator 113
Staff flu vaccination coverage	41.79%	42% 0.2 pts worse	Numerator 56 · Denominator 134
Discharge function score	61.54%	56.45% 5.1 pts better	Numerator 32 · Denominator 52
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 47 · Denominator 47
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	8.33%	25.2% 16.9 pts worse	Numerator 3 · Denominator 36

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.4	2.1 1.7 pts better	1.9 1.5 pts better	Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.3 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.4	2.1 0.7 pts better	1.8 0.4 pts better	Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	97.1% 2.9 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	97.9% 2.1 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	3.4%	3.3% 0.1 pts worse	3.3% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.0% · Q3 3.9% · Q4 3.7% · 4Q avg 3.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.3%	2.7% 2.4 pts better	11.4% 11.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 0.0% · 4Q avg 0.3%
Percentage of long-stay residents who lose too much weight	7.2%	3.3% 3.9 pts worse	5.4% 1.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 9.1% · Q3 6.2% · Q4 7.1% · 4Q avg 7.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	22.6%	18.9% 3.7 pts worse	19.6% 3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 22.8% · Q3 24.4% · Q4 23.3% · 4Q avg 22.6%
Percentage of long-stay residents who received an antipsychotic medication	23.8%	10.8% 13 pts worse	16.7% 7.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 27.1% · Q3 24.6% · Q4 23.0% · 4Q avg 23.8% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	7.6%	15.4% 7.8 pts better	16.3% 8.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 3.5% · Q3 8.6% · Q4 10.5% · 4Q avg 7.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	13.6%	16.1% 2.5 pts better	14.9% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 21.3% · Q3 9.8% · Q4 11.3% · 4Q avg 13.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.5% 0.5 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	0.8% 0.8 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	12.7%	15.0% 2.3 pts better	19.8% 7.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 15.3% · Q3 9.5% · Q4 7.1% · 4Q avg 12.7%
Percentage of long-stay residents with pressure ulcers	0.9%	4.2% 3.3 pts better	5.1% 4.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.7% · Q3 0.6% · Q4 0.5% · 4Q avg 0.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	89.7% 10.3 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of short-stay residents who had an outpatient emergency department visit	17.5%	12.0% 5.5 pts worse	12.0% 5.5 pts worse	Short Stay · 20240701-20250630 · Adjusted 17.5% · Observed 19.6% · Expected 12.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	6.1%	1.5% 4.6 pts worse	1.6% 4.5 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 6.9% · Q3 6.9% · Q4 4.8% · 4Q avg 6.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	100.0%	88.0% 12 pts better	79.7% 20.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	20.7%	25.9% 5.2 pts better	23.9% 3.2 pts better	Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 23.9% · Expected 27.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-24 · Fire 2025-04-24

9 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-02-17 · Fire 2024-02-17

10 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 3 Health 2022-12-15 · Fire 2022-12-15

20 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-04-24

K226 · Egress Deficiencies

Fire Safety

Have horizontal exits used in accordance with safety requirements.

Corrected 2025-05-23

F · Potential for more than minimal harm 2025-04-24

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-05-23

F · Potential for more than minimal harm 2025-04-24

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2025-05-23

F · Potential for more than minimal harm 2025-04-24

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2025-05-23

E · Potential for more than minimal harm 2024-02-17

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-03-15

E · Potential for more than minimal harm 2022-12-15

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-02-24

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-01-15

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2026-02-12

D · Potential for more than minimal harm 2025-11-20

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-12-19

J · Immediate jeopardy 2025-07-16

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-07-16

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-04-24

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-05-16

D · Potential for more than minimal harm 2025-04-24

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-05-16

D · Potential for more than minimal harm 2025-04-24

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-05-16

D · Potential for more than minimal harm 2025-04-24

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-05-16

D · Potential for more than minimal harm 2025-03-20

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-04-11

E · Potential for more than minimal harm 2024-06-10

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-06-21

D · Potential for more than minimal harm 2024-06-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-06-21

G · Actual harm 2024-02-17

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-03-15

E · Potential for more than minimal harm 2024-02-17

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-03-15

D · Potential for more than minimal harm 2024-02-17

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-03-15

D · Potential for more than minimal harm 2024-02-17

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-03-15

D · Potential for more than minimal harm 2024-02-17

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-03-15

D · Potential for more than minimal harm 2024-02-17

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2024-03-15

D · Potential for more than minimal harm 2024-02-17

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-03-15

D · Potential for more than minimal harm 2024-02-17

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-03-15

E · Potential for more than minimal harm 2024-02-09

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2024-02-12

D · Potential for more than minimal harm 2024-01-12

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-02-09

D · Potential for more than minimal harm 2024-01-12

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-02-09

D · Potential for more than minimal harm 2023-09-15

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2023-09-19

J · Immediate jeopardy 2023-08-17

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2023-08-18

J · Immediate jeopardy 2023-08-17

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-03-09

J · Immediate jeopardy 2023-08-17

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2023-08-18

J · Immediate jeopardy 2023-08-17