Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Azria Health Rose Vista during CMS and state inspections, most recent first.
Two residents did not receive timely skin care management. One resident with an unstageable heel pressure injury had repeated wound enlargement, drainage, odor, redness, warmth, and eschar while the treatment order remained unchanged and the physician was not contacted when the wound changed. Another resident admitted with MASD to the coccyx had no treatment order in the MAR/TAR, and staff did not obtain a barrier cream order when the skin issue was first identified.
The facility failed to establish and implement a restorative nursing program for residents discharged from PT/OT services. A resident with severe cognitive impairment, multiple falls, and ADL dependence declined in dressing ability after PT/OT discharge, and staff stated the facility did not have a restorative program even though regular exercises could have helped maintain strength and ROM. The DON acknowledged that some residents could benefit from planned restorative exercises, and the facility policy stated restorative nursing services could begin after rehab discharge.
Delayed response to resident call lights was identified for multiple residents, with several reporting waits over 15 minutes and one resident stating she had waited up to an hour for help. Residents with intact cognition and diagnoses including weakness, falls, fatigue, and diabetes described frequent delays, and a CNA said call lights sometimes took longer than 15 minutes because there were not enough staff. Facility records showed call light times ranging from 16 to 49 minutes, while the DON and Administrator stated call lights should be answered within 15 minutes.
Menu Not Followed for Pureed Diets and Butter Service: Residents on pureed diets received meals that did not match the posted menu, including rolls that were not pureed and butter that was not served with meals unless requested. Staff and the CDM acknowledged butter pads were unavailable and that the lunch service did not follow the expected menu for residents with pureed diet orders and dysphagia.
Failure to notify physician and family of a stage 2 pressure ulcer: An LPN documented a resident's sacral pain and an open area over the tailbone with white tissue, but did not notify the resident's family/POA or PCP. The resident had severe cognitive impairment, and the DON later acknowledged the wound was a stage 2 pressure ulcer and that notification had not occurred.
Failure to maintain fall-prevention floor strips for two residents with severe cognitive impairment and repeated falls. One resident had unwitnessed falls and often tried to self-transfer from bed to commode without waiting for help, while the other had an unwitnessed fall that resulted in multiple fractures. Both care plans called for nonskid strips beside the bed, but observations found the strips were not in place.
Incomplete and inaccurate wound documentation: A resident with severe cognitive impairment had sacral pain and an open coccyx area that was later determined to be a stage 2 pressure ulcer, but the EHR contained late and inaccurate wound entries. An LPN documented the area as red but blanching with white tissue present, while later progress notes and skin assessments described the wound as MASD instead of a pressure ulcer. The DON stated several wound assessments were entered late and auto-populated with the description from the date of entry rather than the original assessment.
A CNA failed to use proper hand hygiene and glove changes during peri and catheter care for a resident with a Foley catheter, and another CNA failed to wear a gown while providing toileting and personal care to a resident on EBP. The DON confirmed the expected PPE and hand hygiene practices for these care activities, and the resident on EBP had severe cognitive impairment and a coccyx pressure ulcer.
The facility failed to provide correct portion sizes for 13 residents on carbohydrate controlled diets, serving 4 oz of fried rice instead of the prescribed 2 2/3 oz. Additionally, four residents received full servings of mandarin orange cake instead of half servings. The cook used an incorrect conversion chart, and the facility's policy on therapeutic diets was not followed.
The facility failed to maintain sanitary food storage and labeling practices, with multiple items found unlabeled and undated during inspections. Observations included unlabeled cereal-like contents, macaroni-like substances, and bun-like items, as well as uncovered salad-like substances in the refrigerator. A barrel of old grease was improperly stored in the freezer. The facility's policy requires all foods to be covered, labeled, and dated, which was not adhered to.
A resident with severe cognitive impairment and multiple diagnoses was found lying flat in bed, contrary to a physician's order to keep the head of the bed elevated at 30 degrees. Despite clear instructions in the care plan and progress notes, a CNA was unaware of the requirement, and the facility lacked a specific policy for following physician's orders.
The facility failed to provide proper catheter and peri-care for two residents, leading to potential infection risks. Staff did not follow hand hygiene protocols during care procedures, and catheters were not properly secured, contrary to the facility's infection control policies.
A resident with severe cognitive impairment experienced a fall and subsequent pain, but the facility delayed completing a physician-ordered x-ray for two days, revealing fractures in the wrist and hip. Staff and family interviews confirmed the delay, and the DON emphasized the importance of timely following physician orders.
Failure to Provide Timely Skin Care and Physician Notification for Worsening Pressure Injury and MASD
Penalty
Summary
Timely and adequate skin care was not provided to prevent worsening of pressure-related skin breakdown for two residents. One resident had severely impaired cognitive skills, was totally dependent for toileting hygiene and transfers, and had an unstageable pressure injury to the left heel. The care plan directed staff to float the heel or use heel protectors in bed and to notify the physician with changes or signs of infection. The record showed the heel was first documented as a sore that was scabbed over, then measured repeatedly over time with increasing size, while treatment remained skin prep and heel protectors. Nursing notes and skin assessments documented progression from 2 cm x 1.2 cm to 5 cm x 2 cm, with later findings of drainage, slight odor, swelling, warmth, increased redness, and worsening eschar. The record lacked information showing physician notification of the change in the wound during the earlier period of worsening, and a PCP nurse stated the doctor had not been contacted about the change in status while the wound was getting bigger. The same resident’s heel wound continued to deteriorate, and later documentation described 90% eschar, rolled edges, increased redness, warmth, odor, and discomfort with dressing removal. Staff interviews indicated concern that the treatment order had remained unchanged for a prolonged period and that the wound had worsened significantly. The DON stated the doctor should have been contacted for new treatment orders when there was a change in the wound. Nursing notes also showed that a dressing was applied over the wound on multiple days, although staff stated the skin prep treatment should have been left open to air when no wrapping was ordered. A second resident was admitted with moisture associated skin damage on the coccyx. The baseline and care plan identified impaired ADLs, potential for impaired skin integrity, and the existing MASD, with later care plan language to apply barrier cream as needed and follow wound care orders. However, the MAR/TAR and orders section lacked treatment orders for the developing skin issue, and a skin check documented the MASD present on admission. During care, a CMA assisted the resident to the bathroom, used disposable wipes, and then helped him dress and return to the chair without offering barrier cream. Later, staff observed the coccyx area was red with a slight open slit, and staff stated they would contact the doctor to obtain an order for barrier cream. The DON and Administrator agreed the resident should have received an order for barrier cream as soon as the issue was identified.
Failure to Provide Restorative Nursing Services After PT/OT Discharge
Penalty
Summary
The facility failed to establish and implement a restorative nursing program for residents discharged from PT/OT services to help prevent decline. The facility reported 25 residents who had been discharged from a Medicare-covered Part A stay and remained in the facility. Staff interviews confirmed that the facility did not have a restorative program, and the DON stated that some residents could benefit from regular, planned exercises to help maintain strength. Staff also stated that if a resident had a functional decline, the facility would contact the doctor and request a PT/OT evaluation rather than using a restorative program. Resident #39 had a BIMS score of 8 and required partial assistance with hygiene, dressing, sit-to-stand, and transfers. The resident’s care plan documented unwitnessed falls and identified risks related to weakness, balance problems, medications, and neurodegenerative changes, along with assistance needs related to vascular dementia, emphysema, pulmonary fibrosis, and COPD. The resident was discharged from PT/OT services and later had a decline in ADLs, specifically dressing, which led staff to request an OT evaluation and treatment order. Staff stated that regular exercises could have helped maintain the resident’s upper body strength and ROM, and the facility policy stated that restorative nursing services could be started when residents were discharged from rehabilitative care.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to provide adequate nursing response to resident call lights, with survey findings showing delayed answers for 4 of 18 residents reviewed: Resident #8, Resident #12, Resident #20, and Resident #38. The facility had a census of 69 residents. Resident #12, whose MDS documented a BIMS of 15 with no cognitive impairment, stated that after several residents were added to the census, the facility could use more staff and that at least once a week it takes longer than 15 minutes for the call light to be answered. Resident #20, whose MDS also documented a BIMS of 15, reported waiting longer than 15 minutes for help and said she had waited up to an hour for her call light to be answered. She stated this happened daily depending on staffing, and that staff told her they were running behind because there was a call in and not enough staff. Resident #20 also said she needed help to the restroom after meals and had been incontinent of bowel and bladder because she had to wait for assistance. Resident #8’s MDS documented a BIMS of 13 and diagnoses including diabetes mellitus, fracture of one rib, weakness, repeated falls, and fatigue; he stated call lights can take awhile and sometimes take over 15 minutes, which he knew by reading the clock in his room. Resident #38’s MDS documented a BIMS of 14 and diagnoses including history of falling, muscle weakness, and fatigue; she stated call lights often take over 15 minutes and that she could read the clock to tell. A CNA stated that at times call lights take longer than 15 minutes to answer because there are not enough staff. The Administrator and DON stated they would like staff to answer call lights in a timely manner and that call lights should be answered in 15 minutes or less. A facility document titled Past Calls 11/10/25-11/16/25 showed several call lights lasting from 16 to 49 minutes, and the facility policy titled Answering the Call Light stated to answer the resident call system timely.
Menu Not Followed for Pureed Diets and Butter Service
Penalty
Summary
The facility failed to follow the menu and prepare food to meet the nutritional needs of residents on pureed diets, affecting 4 of 4 reviewed residents with pureed diet orders and all residents who ate the lunch meal on 11/19/25. Residents #6, #13, #26, and #52 each had physician orders for a general diet with pureed texture and MDS documentation showing dysphagia, with severe cognitive impairment documented for Residents #6, #13, #26, and #52. Resident #20, who ate in the front dining room, stated staff rarely provided condiments such as butter and said there was no brown sugar for hot cereal in the morning. The lunch menu for the meal included rosemary herbed baked chicken, roasted red potatoes, cauliflower au gratin, pumpkin cake with whipped topping, dinner roll, and margarine for regular diets, with pureed versions listed for residents on pureed diets, including pureed dinner roll/margarine. During observation, Staff K completed the puree food process, but rolls were not pureed for residents on pureed diets. Observation of the lunch meal also showed no butter served to the front dining room and no butter passed out with meals in the back dining room. A resident in the back dining room requested a pad of butter during the meal. Staff interviews confirmed the meal service did not match the menu. The CDM stated butter was usually placed in the window and given only if a resident requested it, and that the facility had run out of butter pads and did not have any in the building, though liquid butter could be provided in condiment cups. Staff M stated she frequently passed trays in the front dining room and did not serve butter unless residents asked for it, and acknowledged there was no butter available there that day. Staff K acknowledged he did not puree any rolls at lunch, and the CDM, Administrator, and Staff K all stated the facility expected the menu to be followed and rolls to be pureed for residents requiring a pureed diet.
Failure to Notify Physician and Family of Stage 2 Pressure Ulcer
Penalty
Summary
The facility failed to notify the resident's representative/family/POA and the resident's primary care physician of a stage 2 pressure ulcer for one of three residents reviewed. Resident #1 had a BIMS score of 6, indicating severe cognitive impairment. The EHR documented a physician's order for treatment of a pressure ulcer to the coccyx, including cleansing with saline and 4x4, applying xeroform to the wound bed only, and covering with Opti foam, with the order started on 11/4/25. Progress notes documented that at 2:00 AM on 10/31/25, an LPN noted the resident had complaints of sacral pain. The area was described as red but blanching, and directly over the tailbone there was an open area with white tissue. The record did not show family or physician notification by the LPN. The DON later acknowledged that the area found on 10/31/25 was determined to be a stage 2 pressure ulcer and acknowledged that the LPN had not notified the physician or family of the wound.
Failure to Maintain Fall-Prevention Floor Strips
Penalty
Summary
The facility failed to implement established fall-prevention interventions for two residents with repeated falls. Resident #39 had severe cognitive impairment, required assistance with ADLs, and had a history of unwitnessed falls. His care plan identified nonskid strips on the floor near the bed as an intervention after a fall on 6/24/25, but on 11/17/25 the area beside his bed lacked the safety strips. Staff reported that he did not use his call light and often tried to transfer himself from the bed to the commode without waiting for help. The DON and Administrator stated that the facility had gone without a maintenance department for a period of time and that some tasks, including applying safety strips, were not completed. Resident #1 also had severe cognitive impairment and experienced an unwitnessed fall on 10/15/25 that resulted in fractures of the 5th lumbar vertebra, superior rim of the left pubis, sacrum, and surgical neck of the left humerus. The resident’s care plan and risk management assessment documented that non-skid strips were to be applied next to the bed and in front of the recliner, but an observation on 11/18/25 found no non-slip strips on the floor next to the bed. The DON acknowledged the strips should have been in place and stated she did not know they were absent at the time of observation. The Administrator also stated the resident should have had the non-skid strips in place beside the bed.
Incomplete and inaccurate wound documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not documenting a pressure ulcer appropriately in the EHR. Resident #1 had a BIMS score of 6, indicating severe cognitive impairment. On 10/31/25, an LPN documented complaints of sacral pain and noted the area was red but blanching, with an open area directly over the tailbone and white tissue present. However, the resident’s EHR contained inaccurate wound descriptions entered on 10/21/25, 10/23/25, 10/24/25, and 10/28/25, and these entries were documented late. The progress notes and skin assessments completed on 11/1/23 and 11/2/23 after the wound was discovered described the area as MASD rather than a stage 2 pressure ulcer. The DON stated that 10/31/25 was the date the coccyx area was determined to be a stage 2 pressure ulcer and acknowledged that several wound assessments entered by the wound nurse/unit manager were entered late. The DON explained that when late entries were made, the wound description auto-populated based on the date the documentation was entered, which caused the wound to be described as it appeared on the day of entry rather than when it was first assessed. The facility policy required the nurse to document a full assessment of a pressure sore, including location, stage, length, width, depth, presence of exudates or necrotic tissue, and current treatments.
Infection Control and PPE Use During Resident Care
Penalty
Summary
The facility failed to properly use universal infection control measures during peri care and catheter care for a resident with diagnoses including progressive neurological conditions, obstructive uropathy, paraplegia, and Multiple Sclerosis. During observation, a CNA completed hand hygiene and donned gloves and a gown, then performed peri care, replaced the resident’s brief without changing gloves, continued cleaning the catheter tubing and peri area with the same gloves, applied powder to the peri area without hand hygiene, doffed the gloves, and then did not complete proper hand hygiene before donning new gloves to drain the catheter drainage bag. The resident had orders for a 16 fr 10cc Foley catheter to be changed every 30 days and catheter care every shift. The facility also failed to properly wear PPE while providing personal care to a resident on Enhanced Barrier Precautions. An observation showed an EBP sign outside the resident’s room while a CNA assisted the resident with toileting and personal care in the bathroom without wearing a gown. The CNA stated she was not sure why the resident had an EBP sign and acknowledged she did not have a gown on during the care. The resident had severe cognitive impairment with a BIMS score of 6 and had a coccyx pressure ulcer that was documented as a stage 2 wound; the DON stated the resident was in EBP related to the coccyx wound and that EBP required gown and glove use during high-contact care such as dressing, transferring, changing briefs, and assisting with toileting.
Inadequate Portion Control for Therapeutic Diets
Penalty
Summary
The facility failed to serve the appropriate portion sizes of fried rice to 13 out of 15 residents who were on carbohydrate controlled or consistent carbohydrate diets. During a lunch service observation, these residents were served 4-ounce servings of fried rice instead of the prescribed 2 2/3-ounce servings. Additionally, four residents received full servings of mandarin orange cake instead of the required half serving. The facility's cook, Staff A, used the [NAME] Brothers conversion chart to determine serving sizes, but the chart indicated that a #12 scoop, which corresponds to 2 2/3 ounces, should have been used for the fried rice. The facility's policy on therapeutic diets, revised in October 2017, states that therapeutic diets, including diabetic/calorie-controlled diets, should align with residents' treatment goals. The administrator confirmed that staff should adhere to the diet spreadsheets, which were not followed in this instance.
Improper Food Storage and Labeling Practices
Penalty
Summary
The facility failed to maintain sanitary practices in food storage, preparation, and labeling, as observed during a kitchen inspection. Several items were found unlabeled and undated, including plastic containers with cereal-like contents, a bowl of macaroni-like substance, and bags of hamburger and hot dog bun-like items. Additionally, trays with undated and unlabeled plates of yellow, pie-like items, and a tube of ground beef-like meat were found in the Norlake walk-in refrigerator. The inspection also revealed multiple bowls of salad-like substances that were uncovered and in direct contact with the tray surfaces. Further observations noted a barrel of solid, white substance identified as old grease stored improperly on the floor of the walk-in freezer. A follow-up inspection found similar issues, including unlabeled creamy cherry pie and waffle-like items, as well as the barrel of grease now stored on a crate. The facility's policy, revised in 2017, mandates that all foods stored in refrigerators or freezers must be covered, labeled, and dated, and dry foods stored in bins should be removed from original packaging, labeled, and dated. The Administrator confirmed that food removed from identifying boxes must be properly dated, labeled, and stored.
Failure to Follow Physician's Positioning Orders
Penalty
Summary
The facility failed to adhere to a physician's order regarding the positioning of a resident's bed. On November 4, 2024, a resident was observed lying flat on their back, despite a sign at the head of the bed instructing staff to keep the head of the bed elevated above a 30-degree angle at all times. The resident had a severely impaired cognition with a BIMS score of 00 out of 15 and was diagnosed with Alzheimer's disease, non-Alzheimer's dementia, dysphagia, GERD, and gallstones. The resident was dependent on all aspects of ADLs. The physician's order, dated July 19, 2022, required the head-of-bed to be elevated to 30 degrees, which was also reflected in the care plan and progress notes. However, a CNA was unaware of the reason for this requirement, and the facility lacked a specific policy for following physician's orders. The administrator stated that staff should follow the care plan.
Inadequate Catheter and Peri-Care Leading to Infection Risks
Penalty
Summary
The facility failed to provide appropriate catheter and peri-care, leading to potential infection risks for two residents. Resident #16, with moderately impaired cognition and multiple health conditions, was observed with an indwelling catheter. During a care procedure, staff failed to perform hand hygiene or change gloves between handling the trash bin and performing perineal care. Additionally, the catheter tubing was not secured, and there was tension on the tubing, which could lead to trauma. Staff acknowledged the oversight in hand hygiene and securing the catheter. Resident #27, also with moderately impaired cognition and various health issues, had a urinary catheter. During a procedure to drain the urine, staff did not perform hand hygiene or change gloves, even after urine splashed onto a napkin near an alcohol swab. The facility's policy on hand hygiene, which requires handwashing before and after handling invasive devices, was not followed. The staff's actions were inconsistent with the facility's infection control policies. The facility's administrator confirmed that staff should adhere to the hand hygiene policy. The observations and interviews revealed a lack of compliance with infection prevention protocols, specifically regarding hand hygiene and catheter care, which are critical in preventing the spread of infections in the facility.
Failure to Timely Complete Physician-Ordered X-Ray
Penalty
Summary
The facility failed to provide needed services in accordance with professional standards by not completing an x-ray ordered by a physician in a timely manner for a resident with severe cognitive impairment. The resident was found on the floor and subsequently complained of left wrist pain, which was swollen and bruised. Despite obtaining an x-ray order on the morning following the incident, the x-ray was not performed until two days later, revealing fractures in the wrist and hip. Interviews with staff and family confirmed the delay in obtaining the x-ray, and the Director of Nursing (DON) stated that her expectation would be for physician's orders to be followed in a timely manner, ideally within 24 hours for non-stat orders. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and total dependence on staff for mobility and transfers. Progress notes documented the resident's fall, subsequent pain, and the delayed x-ray. Staff interviews revealed that the resident showed no immediate signs of pain but had increased pain medication for comfort post-fall. The facility's policy on medication and treatment orders emphasized the importance of following physician orders promptly, and the DON reiterated this expectation during her interview.
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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 Woodbine
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dunlap Specialty Care | 9.5 mi | ★★★★★ | 0 | 0 |
| Azria Health Longview | 15.2 mi | ★★★★★ | 3 | 0 |
| Elm Crest Retirement Community | 20.8 mi | ★★★★★ | 8 | 0 |
| Avoca Specialty Care | 23.4 mi | ★★★★★ | 18 | 0 |
| Accura Healthcare Of Tekamah | 26.2 mi | ★★★★★ | 14 | 0 |
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