Cycle 1
Health 2024-11-20 · Fire 2024-11-20
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
McAllen, TX
Grand Terrace Rehabilitation and Healthcare
5-star overall rating with 5-star inspections with 4 recent health deficiencies
812 W Houston Ave, McAllen, TX
(956) 682-6331
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
93
Certified beds
Average residents
86
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1985-08-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
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
0.53
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.99
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.26
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.78
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
2.77
CMS adjusted total nurse staffing hours
Case-mix index
1.61
Higher values indicate more complex resident acuity
RN turnover
11%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,595
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
3.20
Composite VBP score used to determine payment impact.
Payment multiplier
0.9804
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 21.79% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Baseline 7.46% · Performance 9.02% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.28
Baseline 55.56% · Performance 58.44% · Measure score 1.28 · Achievement 1.28 · Improvement 0
Adjusted total nurse staffing
0
Baseline 2.95 hours · Performance 2.73 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 45 · Observed rate 8.89% · Lower 95% interval 6.11% |
| Discharge to community | 54.25% |
50.57%
3.7 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 45.16% · Lower 95% interval 37.59% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 97.26% |
95.27%
2 pts better
|
Numerator 71 · Denominator 73 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 73 |
| Discharge self-care score | 60.87% |
53.69%
7.2 pts better
|
Numerator 14 · Denominator 23 |
| Discharge mobility score | 56.52% |
50.94%
5.6 pts better
|
Numerator 13 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 73 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 9.02% |
7.12%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 25.81% · Lower 95% interval 4.88% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 131 |
| Staff flu vaccination coverage | 72.25% |
42%
30.2 pts better
|
Numerator 138 · Denominator 191 |
| Discharge function score | 69.57% |
56.45%
13.1 pts better
|
Numerator 16 · Denominator 23 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 36 · Denominator 36 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 47 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
2.1
0.6 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 3.0 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.9 |
2.1
0.8 pts worse
|
1.8
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.8 · 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 | 2.6% |
3.3%
0.7 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.2% · Q3 2.8% · Q4 1.4% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 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 who lose too much weight | 16.4% |
3.3%
13.1 pts worse
|
5.4%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 19.3% · Q3 16.4% · Q4 17.7% · 4Q avg 16.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.4% |
18.9%
9.5 pts better
|
19.6%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 8.3% · Q3 10.1% · Q4 9.4% · 4Q avg 9.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.8% |
10.8%
About the same
|
16.7%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 6.1% · Q3 12.1% · Q4 10.2% · 4Q avg 10.8% · 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 | 25.7% |
15.4%
10.3 pts worse
|
16.3%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.0% |
16.1%
2.9 pts worse
|
14.9%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.1% · Q2 20.0% · Q3 10.9% · Q4 8.7% · 4Q avg 19.0% · 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 | 0.4% |
0.8%
0.4 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.0% |
15.0%
About the same
|
19.8%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.8% · Q2 21.5% · Q3 8.8% · Q4 6.8% · 4Q avg 15.0% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
4.2%
1.8 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 1.0% · Q3 2.3% · Q4 2.8% · 4Q avg 2.4% · 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 | 17.1% |
12.0%
5.1 pts worse
|
12.0%
5.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.1% · Observed 19.7% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.5%
0.1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.1% · Q3 0.0% · Q4 1.5% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.9% |
88.0%
10.9 pts better
|
79.7%
19.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
25.9%
1.1 pts better
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 32.4% · Expected 31.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-31 · Fire 2023-08-31
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-06-09 · Fire 2022-06-09
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-06-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-09
D · Potential for more than minimal harm
2025-12-04
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-11-19
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-11-20
D · Potential for more than minimal harm
2024-11-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-11-08
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-11-10
E · Potential for more than minimal harm
2023-08-31
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-08-31
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-08-31
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 2023-09-01
D · Potential for more than minimal harm
2023-08-31
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-08-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-01
D · Potential for more than minimal harm
2022-06-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-07-08
Penalties and ownership
What sits behind the stars
Ownership
Fannin County Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Operational/Managerial Control · Individual
Guzman, Nefi
Operational/Managerial Control · Individual
Guzman, Nefi
Contracted Managing Employee · Individual
Mcallen Care Associates, Inc.
Operational/Managerial Control · Organization
Sanderson, Clark
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Windsor Nursing and Rehabilitation Center of Mcall
Mcallen, TX
2-star overall rating with 3-star inspections with $37,050 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Mcallen Nursing Center
Mcallen, TX
2-star overall rating with 2-star inspections with $17,459 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Alfredo Gonzalez Texas State Veterans Home
Mcallen, TX
5-star overall rating with 5-star inspections with $12,675 in total fines with 3 recent health deficiencies
Jump out