Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Azalea Trail Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Unsecured Oxygen Cylinder Left in Resident Room: A resident with severe cognitive impairment, pneumonia, acute and chronic respiratory failure with hypoxia, and an order for nocturnal O2 had an E-cylinder observed laying unsecured across an extra bed in the room. CNA and RN staff stated cylinders were to be secured in a wheelchair bag or rolling cart and never left on beds or loose in resident rooms; the DON and Administrator confirmed cylinders were required to be secured, and the facility policy required tanks to be stored in a cylinder cart or securely chained.
A resident with severe cognitive impairment and a history of falls had her bed alarm discontinued, but the care plan was not updated to reflect this change or to address a subsequent fall with major injury. Staff interviews confirmed that bed alarms were discontinued facility-wide, but alternative interventions were not clearly documented in the care plan, and the frequency of visual checks was not specified.
Unsecured Oxygen Cylinder Left in Resident Room
Penalty
Summary
The facility failed to provide an environment free of accident hazards for one resident who was reviewed for oxygen use when an oxygen E-cylinder was found unsecured in the resident’s room. The resident was admitted with diagnoses including thrombocytopenia, pneumonia, acute and chronic respiratory failure with hypoxia, encephalopathy, sepsis, acute upper respiratory infection, pain in the left hip, chronic kidney disease, dysphagia, and hypertension. The resident’s MDS assessment showed a BIMS score of 4, indicating severe cognitive impairment, and the resident was coded as using oxygen therapy and requiring a wheelchair for mobility assistance. Physician orders included oxygen at 3 liters via nasal cannula routinely at night from 10:00 p.m. to 6:00 a.m. On observation, the oxygen E-cylinder was seen laying across an extra bed in the resident’s room and was unsecured. A later observation showed the cylinder still laying across the extra bed unsecured. CNA A stated that oxygen cylinders were normally attached to the back of wheelchairs in bags for use while residents were up in wheelchairs and were not supposed to be stored in rooms or left on beds. RN B stated that oxygen cylinders used in resident rooms were to be secured in a black bag on the back of wheelchairs or in a rolling cart, and that empty cylinders were never to be left on beds in resident rooms. The DON and Administrator both stated that oxygen cylinders in resident rooms were required to be secured and that empty cylinders were not to be left unsecured in resident rooms. The facility policy titled LTC Compressed Gases, Safe Handling stated that tanks and cylinders should be stored in a cylinder cart or securely chained in a secure storage area and never left free-standing.
Failure to Update Care Plan After Discontinuing Bed Alarm and Resident Fall
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address all of a resident's medical, nursing, mental, and psychosocial needs. Specifically, the care plan did not reflect the discontinuation of a bed alarm for a resident with a history of falls and severe cognitive impairment, nor did it address a significant fall with major injury that occurred after the alarm was discontinued. The resident, who was dependent on staff for personal hygiene and required maximal assistance with toileting, had a recent history of hip fracture and a severely impaired cognitive level as indicated by a BIMS score of 03. Despite these risk factors, the care plan was not updated to reflect changes in interventions or to document the rationale and monitoring strategies following the discontinuation of the bed alarm and after the resident experienced a fall resulting in a new hip fracture. Interviews with facility staff, including the DON, CNA, and Medical Director, revealed that bed alarms had been discontinued facility-wide based on the belief that they were restraints and not effective in preventing falls. However, there was no documentation in the care plan regarding the discontinuation of the alarm or the implementation of alternative interventions with specific time frames or responsibilities. The acute care plan presented after the fall included frequent visual checks, but did not specify the frequency or timing of these checks. The lack of timely and comprehensive updates to the care plan following significant changes in the resident's condition and interventions contributed to the deficiency.
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 116 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 Grand Saline
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Bradburn | 0.3 mi | ★★★★★ | 18 | 0 |
| Avir At Grand Saline | 0.5 mi | ★★★★★ | 20 | 1 |
| Van Healthcare | 11.3 mi | ★★★★★ | 10 | 0 |
| Avir At Mineola | 12.7 mi | ★★★★★ | 16 | 1 |
| Mineola Gardens Wellness & Rehabilitation | 13.2 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Azalea Trail Nursing And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.