Average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Cordell Nursing And Rehabilitation during CMS and state inspections, most recent first.
A facility failed to maintain a safe, clean, and homelike environment when resident room walls remained damaged and shower/whirlpool areas were visibly dirty. Two resident rooms had damaged sheetrock and missing paint, with no open wall repair work orders, and staff acknowledged the damage had been overlooked or not documented. Multiple bath areas had dust, algae, soap scum, mold, debris, and soiled items, and staff including a CNA, HK, DON, and administrator stated the showers were not clean or sanitary.
The facility failed to maintain an effective QAPI program that identified concerns and implemented actions to correct them. The DON identified 53 residents in the facility, and the administrator could not produce QAPI meeting documentation for the prior year, stating there was no book or other documentation available and that it could not be located, even though meetings had reportedly been held.
The facility failed to ensure a PRN psychotropic medication had a 14-day stop date for a resident receiving Lorazepam for anxiety. The MAR showed the medication was given multiple times, and the DON stated hospice residents were not given stop dates even though the facility policy required PRN psychotropic orders to be limited to 14 days.
A resident with cerebral infarction and spinal stenosis was observed using a power wheelchair independently, and both a CMA and the MDS coordinator confirmed the resident used the device to move around the facility. However, the quarterly MDS assessment incorrectly stated in GG0115 that the resident did not use any mobility devices, despite also documenting that the resident was unable to walk and dependent for chair-to-bed transfers.
Failure to complete PASARR Level II after a new psychosis diagnosis: A resident had a prior PASARR level I showing no serious mental illness, but later received a diagnosis of unspecified psychosis and was also documented with depression and psychotic disorder on an annual assessment. Record review and staff interviews confirmed no new PASARR level II was completed after the new diagnosis, and the DON stated the facility did not have a PASARR policy.
Infection control practices were not followed during catheter care for one resident when a CNA cleaned the peri-area and catheter without changing gloves between tasks. In a separate observation, a resident receiving continuous O2 had the nasal cannula and tubing coiled on top of the concentrator instead of being bagged when not in use, and the infection preventionist confirmed this was not the expected practice.
A facility failed to justify the use of an antibiotic and obtain a wound culture for a resident with a stage three pressure ulcer. The resident was prescribed Keflex for a coccyx wound, but the infection report lacked culture results, and the infection criteria checklist was incomplete. The IPC nurse admitted that the antibiotic stewardship policy was not followed, as no culture was obtained, and the antibiotic was not reviewed after 48 hours.
The facility did not complete annual competency reviews for two CNAs, as required. The personnel files for these CNAs lacked documentation of such reviews, and the DON confirmed there was no policy for annual competency checks. The Administrator verified the absence of these reviews in the files.
The facility failed to adhere to its food storage policy, with observations revealing expired sour cream, undated hot dog buns, and containers of sausage without preparation dates. Staff were unable to confirm the preparation times, indicating non-compliance with labeling and disposal protocols.
The facility failed to submit accurate PBJ staffing data, lacking 24-hour licensed nursing coverage on several dates. The Administrator suggested the issue might be due to unreported agency staff. The facility had 52 residents.
A resident with multiple health issues experienced persistent nausea and vomiting, leading to confusion and abdominal distension. Despite these symptoms and refusal to eat, the facility failed to notify the physician of the change in condition, resulting in the resident being sent to the emergency room. Staff interviews confirmed the lack of physician notification.
A resident with heart failure and high blood pressure reported a missing vape to the Administrator, which had not been communicated by staff as per policy. The resident had informed staff of the theft on a Saturday, but the Administrator was only made aware by a surveyor days later. The facility's policy required such incidents to be reported to the Administrator or DON.
A resident with a history of cardiovascular issues and other conditions experienced nausea, vomiting, and abdominal pain over several days. Despite these symptoms, the facility staff failed to document bowel sound assessments, and the resident was eventually hospitalized with a bowel obstruction. An LPN admitted to assessing the abdomen but did not chart it, and the DON noted the physician was not notified of the change in condition.
The facility did not follow its smoking policy, which requires quarterly smoking assessments. A resident with high blood pressure and high cholesterol was observed smoking without a recent assessment, as the last evaluation was conducted several months prior. The DON acknowledged the policy was not adhered to.
A facility failed to follow proper procedures for the use of bed rails for a resident with severe cognitive impairment. There was no interdisciplinary assessment, physician order, or notification to the resident's representatives about the risks and benefits of side rails. The use of side rails was not documented in the care plan, despite being observed in use. Staff interviews confirmed the oversight, and the DON acknowledged the lack of required assessments and consents.
The facility failed to read and document the second TB skin test results for two residents, one with Alzheimer's and high blood pressure, and another with high blood pressure and anxiety. The IPC nurse could not find the results, indicating a lapse in the facility's TB screening policy.
A facility failed to offer a pneumonia vaccination to a resident according to its policy. The resident, with a history of type two diabetes, a cardiac pacemaker, and high blood pressure, last received a pneumonia vaccination in 2018. The IPC nurse acknowledged not following up to check if the resident was due for another vaccination, despite the policy requiring reevaluation in line with ACIP recommendations.
Unsafe Room Conditions and Unsanitary Shower Areas
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment by allowing resident room walls to remain damaged and by not ensuring shower and whirlpool areas were cleaned between uses. Resident #52’s room had two areas of damaged sheetrock and missing paint where the bed was against the wall, and Resident #52 stated the damage had been present for about 6 years, had been reported to multiple staff, and had never been repaired. Resident #52’s quarterly assessment showed intact cognition with a BIMS score of 15 and dependence for transfers. Resident #9’s room also had damaged sheetrock and missing paint on the wall where the bed was against the wall, and work orders reviewed showed no open wall repair requests for either room. The administrator stated Resident #52 refused to get out of bed for repairs, that attempts to repair Resident #9’s wall were not documented, that the damage in another resident room had been forgotten, and that the facility did not have a policy for maintaining a safe homelike environment. The facility also failed to keep the shower and whirlpool bathrooms clean and sanitary. Observations of the whirlpool bathroom on A hall showed dust on a fan and fake plant, green algae, hair, and soap scum on whirlpool controls, debris and soiled items on the floor, soiled shelves, and a missing access panel exposing soiled floors and dusty plumbing pipes. The shower/bath on C hall had pink mold in a corner, dust and debris on the shower head and pipe, and a soiled storage cabinet with soap scum and debris. The memory care whirlpool bathroom had an access panel leaning against the wall, dirt, debris, hair ties, and resident hair around the floor perimeter, and a broom on the floor. Resident #29, who required partial to moderate assistance with showers and supervision or touching assistance with shower transfers, stated the bathrooms/showers were very dirty and needed to be cleaned. HK #1 and CNA #1 both stated the shower areas were not clean and sanitary, and CNA #1 stated the bathrooms had not been wiped down in a few days and the whirlpool room needed a deep cleaning. The DON and administrator both stated the bath/showers were not clean, sanitary, and did not reflect a clean and sanitary homelike environment.
Missing QAPI Documentation and Ineffective Program Oversight
Penalty
Summary
The facility failed to have an effective quality assessment and assurance program that identified concerns and implemented actions to correct the concerns. The report states the DON identified 53 residents resided in the facility. An undated facility policy titled Quality Assurance and Performance Improvement Program stated that the primary purpose of the program is to establish data-driven, facility-wide processes that improve quality of care. On 09/05/25 at 11:55 a.m., the administrator was asked for quality assurance and performance improvement meeting documentation for the past year, from August 2024 through August 2025. The administrator stated there was no book or other documentation available for that time period, said they had looked for it and could not locate it, and stated that although the meetings had been held, no documentation was available.
PRN Psychotropic Medication Lacked Required Stop Date
Penalty
Summary
The facility failed to ensure a PRN psychotropic medication was limited to 14 days for Resident #40. The resident had a physician's order dated 07/23/25 for Lorazepam 0.5 mg by mouth every 6 hours as needed for anxiety, and the August 2025 MAR showed the medication was administered two times on 08/09/25 and once on 08/14/25. The facility's undated policy titled Initiation of Psychotropic Drugs stated that PRN psychotropic medication orders are limited to 14 days. During interview on 09/05/25, the DON stated the facility had to have a stop date for PRN psychotropic medications and identified 14 days as the stop date, but when asked about Resident #40's order, stated hospice residents do not get stop dates and then acknowledged the order should have had a stop date of 08/06/25.
MDS Assessment Incorrectly Omitted Power Wheelchair Use
Penalty
Summary
The facility failed to accurately code the MDS assessment for Resident #3’s mobility device. Resident #3 was observed moving independently in a power wheelchair in the hall, and the resident stated they used a power wheelchair to move around the facility. The resident’s admission record listed diagnoses including cerebral infarction and spinal stenosis, and the quarterly assessment dated 06/26/25 showed intact cognition with a BIMS score of 15. However, the assessment documented in section GG0115 that the resident did not use any mobility devices, while also stating the resident was dependent for chair-to-bed transfers and unable to walk. CMA #2 and the MDS coordinator both stated the resident used a power wheelchair, and the MDS coordinator acknowledged the quarterly assessment did not document the wheelchair use and was miscoded.
Failure to Complete PASARR Level II After New Psychosis Diagnosis
Penalty
Summary
The facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program for one resident reviewed for PASARR compliance. Resident #41 had a PASARR level I dated 09/09/22 that indicated there was no evidence, history, or diagnosis of a serious mental illness. However, the electronic health record showed that on 11/12/24 the resident was diagnosed with unspecified psychosis not due to a substance or known physiological condition, and an annual assessment dated 07/25/25 listed diagnoses including depression and psychotic disorder, with cognition intact and a BIMS score of 15. The record review showed there was no new PASARR level II completed after the new psychosis diagnosis. During interview, the MDS coordinator stated the resident had a PASARR level I completed on 09/13/22 and confirmed that a PASARR level II was not completed after the new diagnosis of unspecified psychosis. The DON also stated there should have been another PASARR completed because the resident had a new diagnosis of psychosis, and confirmed that a PASARR level II was not completed after the diagnosis. The DON stated the facility did not have a policy on PASARRs.
Infection Control Failures During Catheter Care and Oxygen Storage
Penalty
Summary
The facility failed to ensure proper infection prevention and control during catheter care for one resident and failed to ensure an oxygen nasal cannula was stored in a bag when not in use for another resident. During observation of catheter care, CNA #2 donned gloves and cleaned Resident #4’s peri-area, then used another wet wipe to clean the catheter from the urinary meatus down the tubing approximately five inches without changing gloves. When asked later, CNA #2 stated they did not change gloves and acknowledged they should have changed them after cleaning the resident the first time and before placing the clean brief under the resident. The facility’s policy titled Catheter Care, Urinary, stated to maintain clean technique and isolation precautions as indicated. For Resident #29, who had diagnoses including orthopedic fracture and dementia and was receiving continuous oxygen at 4 L/min via nasal cannula, surveyors observed the oxygen concentrator with the tubing and nasal cannula coiled on top of the concentrator and not placed in a bag on two separate occasions. Resident #29 stated they wore oxygen every night at bedtime. CMA #1 stated they rolled up the tubing and nasal cannula and placed it on the concentrator handle when removing it in the morning. The infection preventionist stated all oxygen tubing and nasal cannulas should be bagged when not in use and confirmed the tubing and nasal cannula were not in a bag and were laying on top of the oxygen concentrator.
Failure to Justify Antibiotic Use and Obtain Wound Culture
Penalty
Summary
The facility failed to ensure that an antibiotic prescribed for a wound was justified and that a wound culture had been obtained for a resident with a stage three pressure ulcer. The resident, who had diagnoses including depressive disorder and high blood pressure, was prescribed Keflex 500 mg TID for seven days for a coccyx wound. However, the resident's infection report was incomplete, lacking documentation of culture results, and the infection criteria checklist was not filled out. A weekly wound observation noted the wound's measurements and condition, but the clinical health record did not show that a wound culture had been obtained. The IPC nurse confirmed that no wound culture had been completed and acknowledged that the antibiotic had not been reviewed after 48 hours to determine if it was justified. The nurse was unsure if the wound was infected, although it was worsening. The IPC nurse admitted that the policy for antibiotic stewardship was not followed, as the nurse responsible for completing the resident infection report and infection criteria checklist did not do so, and the IPC nurse did not follow up to ensure the antibiotic was appropriate.
Lack of Annual Competency Reviews for CNAs
Penalty
Summary
The facility failed to ensure that annual competency reviews were completed for two certified nursing assistants (CNAs) out of three sampled staff members. CNA #2, hired on October 21, 2021, and CNA #3, hired on September 21, 2020, did not have documentation of completed annual competency reviews in their personnel files. During an interview on April 25, 2024, the Administrator confirmed the absence of these reviews after checking the personnel files. Additionally, the Director of Nursing (DON) stated that there was no facility policy in place for conducting annual competency reviews for CNAs, and confirmed that the reviews for CNA #2 and CNA #3 should have been documented in their files.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure proper labeling, dating, and timely disposal of food items in accordance with their Dietary Services Food Storage policy. During an observation of the kitchen, it was noted that two tubs of sour cream were past their 'best if used by' date, a container of green beans was dated several days prior, and a package of hot dog buns lacked a date of receipt. Additionally, two stainless steel containers with ground and pureed sausage were found without any date or time of preparation. Staff were unable to confirm when these items were prepared or how long they had been stored, indicating a lack of adherence to the facility's policy on food storage and disposal.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to ensure the accuracy of the information submitted on the Payroll Based Journal (PBJ) for 24-hour staffing coverage. A review of the PBJ Staffing Data Report for the period from October 1, 2024, to December 31, 2024, revealed that the facility did not have 24-hour licensed nursing coverage on several specific dates. The Administrator, upon request, provided documentation of coverage for these dates and indicated that the discrepancy might have been due to agency staff not being reported correctly. The facility had 52 residents at the time of the report.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to notify a physician of a change in condition for a resident with multiple diagnoses, including atherosclerosis of coronary artery bypass graft, chronic rhinitis, hypertension, and hyperlipidemia. The resident was administered Zofran multiple times for nausea and vomiting over several days, but there was no documentation that the physician was notified of the resident's ongoing symptoms and refusal to eat or take medication. The resident's condition worsened, with symptoms including confusion, abdominal distension, and increased weakness, leading to an eventual transfer to the emergency room. Despite the resident's persistent symptoms and refusal to eat, there was no documentation of physician notification or assessment of bowel sounds from the initial complaint of abdominal discomfort until the resident was sent to the emergency room. Interviews with staff, including an LPN and the DON, confirmed that the physician should have been notified due to the change in condition, but there was no evidence in the records that this occurred.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure staff reported an allegation of misappropriation of property involving a resident. The resident, who had diagnoses including heart failure and high blood pressure, reported to the Administrator that a personal vape was missing from their bag kept in a locked file box. The resident stated they had two vapes stolen since their stay and had informed staff on a Saturday morning, but not the Administrator. The Administrator was only notified of the missing vape by the surveyor on the following Tuesday. Upon investigation, the Administrator learned from a housekeeper that the resident had reported the missing vape on Saturday, but it was not communicated to the Administrator or the Director of Nursing (DON) as per the facility's policy. The policy required such incidents to be reported to the Administrator or the DON in their absence.
Failure to Assess Bowel Sounds Leads to Hospitalization
Penalty
Summary
The facility failed to assess bowel sounds for a resident who complained of abdominal discomfort, leading to a deficiency in care. The resident, who had a history of atherosclerosis of coronary artery bypass graft, chronic rhinitis, hypertension, and hyperlipidemia, was administered Zofran multiple times for nausea and vomiting. Despite these symptoms, there was no documentation of bowel sound assessments from April 15 to April 19, when the resident was eventually sent to the emergency room. A CT scan at the hospital revealed distended loops of small bowel, indicating a bowel obstruction. Throughout the week, the resident experienced nausea, vomiting, and abdominal pain, yet the facility staff did not document any assessment of bowel sounds. An LPN admitted to assessing the resident's abdomen but failed to chart it. The Director of Nursing acknowledged that the staff should have notified the physician due to the change in the resident's condition, but there was no documentation of such notification. This lack of proper assessment and communication contributed to the resident's hospitalization.
Failure to Conduct Quarterly Smoking Assessments
Penalty
Summary
The facility failed to adhere to its smoking policy and procedure, which mandates that a safe smoking assessment evaluation be completed at the time of admission, quarterly, and with any significant change in condition. This deficiency was identified for one resident who was reviewed for smoking. The resident, who had diagnoses including high blood pressure and high cholesterol, had their last documented Smoking Safety Evaluation completed in August 2023. However, during an observation in April 2024, the resident was seen smoking under the patio while wearing a smoking apron, indicating that the quarterly assessment had not been conducted as required. The Director of Nursing (DON) confirmed that the smoking policy was not followed, as the last assessment was not completed within the quarterly timeframe.
Failure to Follow Procedures for Bed Rail Use
Penalty
Summary
The facility failed to ensure proper procedures were followed regarding the use of bed rails for a resident. Specifically, there was no interdisciplinary assessment completed for the use of side rails, no physician order obtained, and the resident's representatives were not notified about the benefits and potential hazards associated with side rails. Additionally, the use of side rails was not included in the resident's care plan. The facility's policies on bed safety and the use of restraints require an interdisciplinary assessment, consultation with the attending physician, and informed consent from the resident or their legal representative before using side rails. Resident #4, who was admitted with diagnoses including COPD, unspecified dementia, and anxiety, was observed with upper bed rails raised on one side of the bed. The care plan and physician order summary did not document the use of side rails, and staff interviews confirmed that the bed rail was not included in the care plan for repositioning. The Director of Nursing acknowledged that there was no interdisciplinary assessment, family notification, or signed consent for the use of the bed rail, and it was not care planned for mobility and repositioning.
Failure to Read Second TB Skin Test Results
Penalty
Summary
The facility failed to ensure that the second tuberculin skin test (TST) was read for two residents, leading to a deficiency in their infection prevention and control program. Resident #50, diagnosed with Alzheimer's disease and high blood pressure, received their second TB skin test, but the results were still pending and not documented in the clinical health record. Similarly, Resident #16, who had high blood pressure and anxiety, also had their second TB skin test results pending and not read. The Infection Prevention and Control (IPC) nurse was unable to locate the results for both residents when asked to review the immunization records, indicating a lapse in the facility's adherence to their tuberculosis screening policy.
Failure to Offer Pneumonia Vaccination as per Policy
Penalty
Summary
The facility failed to ensure that residents were offered the pneumonia vaccination according to its policy. Specifically, one resident, who was part of a sample of five residents reviewed for immunizations, was not evaluated for eligibility for a pneumonia vaccination. The facility's policy, which was undated, stated that the administration of the pneumococcal vaccination should be in accordance with the current Advisory Committee on Immunization Practices (ACIP) recommendations. The resident in question had a medical history that included type two diabetes mellitus, a cardiac pacemaker, and high blood pressure. The resident's clinical health record indicated that their last pneumonia vaccination was in 2018. During an interview, the Infection Prevention and Control (IPC) nurse admitted that they had not followed up to determine if the resident was due for another pneumonia vaccination, despite believing that reevaluation should occur after five years.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 11 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cordell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Corn Heritage Village And Rehab | 12.4 mi | ★★★★★ | 4 | 2 |
| River Valley Skilled Nursing And Therapy | 14.1 mi | ★★★★★ | 3 | 0 |
| Clinton Therapy & Living Center | 14.1 mi | ★★★★★ | 0 | 0 |
| Hobart Nursing & Rehabilitation | 19.6 mi | ★★★★★ | 4 | 0 |
| Corn Heritage Village And Rehab Of Weatherford | 23 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 July 2026) and official state health department websites.