Inspection·November 20, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed develop a comprehensive person-centered care plan for each resident, consistent with resident needs, that included measurable objectives and time frames to meet residents' physical needs for 1(Resident #66) of 6 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #66. The comprehensive care plan failed to address the antibiotic medication ordered by the physician. This failure could place the residents at risk of not receiving appropriate interventions to meet their current needs. Findings included: 1. Record review of Resident #66's electronic facility face sheet dated 11/19/24, revealed she was an [AGE] year-old female admitted to the facility on [DATE], original admission date of 07/04/2024 with diagnoses of pneumonia, end stage renal disease (final stage of kidney disease), type 2 diabetes mellitus, pleural effusion (excess fluid buildup in the space between the lung and chest), and acute on chronic diastolic congestive heart failure (heart failure in the left ventricle muscle). Record review of Resident #66's quarterly MDS assessment dated [DATE] revealed she scored a 13 on the BIMS assessment which indicated he was cognitively intact. Record review of Resident #66's physician order summary revealed order date 11/16/24 for Azithromycin tablet 250mg by mouth at bedtime for pneumonia for 4 days with an end date of 11/20/24. During an interview on 11/19/24 at 03:11 p.m. with MDS A, she stated she was not the only one responsible for care planning. She stated that the nurses, the ADON, and the DON were also responsible for care planning. She stated that if she sees that the order was not care planned then she will care plan it at that time. MDS A stated that the antibiotic order came in on Saturday and that she did not work on Saturdays or Sundays. She stated that the antibiotic order got overlooked. MDS A stated that it was important for the antibiotics to be care planned because that was how the nurses knew what signs and symptoms to monitor. The care plan will also have information stating when to contact the doctor if the antibiotic was not working, and also if labs needed to be drawn. During an interview on 11/19/24 at 03:18 p.m. with ADON, she stated that the MDS was responsible for care planning. Then she said they should check it in the morning meetings. She stated that they put out the list of antibiotics to review at the time. The ADON stated that maybe the antibiotic order (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455586 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand Terrace Rehabilitation and Healthcare 812 W Houston Ave McAllen, TX 78501 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)