Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Coryell Health Rehab Living At The Meadows during CMS and state inspections, most recent first.
Missing controlled substance count documentation was identified on multiple med carts and nurse carts during shift changes. The facility did not consistently have off-going and on-coming staff count narcotics and sign the narcotic count sheets for several units, and interviews with an LVN, MA, and the DON confirmed that this was required under the facility policy for controlled substance reconciliation.
Kitchen sanitation and food handling deficiencies were identified when the dishwasher had no sanitizer, expired milk cartons remained in a reach-in refrigerator, ice cream cups were stored on the freezer floor, and staff handled food temperatures with un-sanitized thermometer probes. During lunch service, an employee wore gloves throughout multiple tasks without changing them, and a DA entered the kitchen without a hairnet while food was being prepared.
Hand hygiene was not maintained during meal assistance when a CNA repeatedly touched residents, their wheelchairs, clothing, plates, utensils, and his own face and hands without sanitizing between contacts, while also performing nail care at the dining table. The laundry room was also found unsanitary, with heavy lint and debris buildup behind dryers, mixed handling of clean and soiled linen, and no observed sanitizer in use for washing machines after linen from isolation precautions.
Surveyors found a medication cart left unattended and unlocked in a main lobby area while a resident was nearby and staff walked past without securing it. Staff, including an RN, LVN, CNAs, the DON, and the Administrator, all reported they had been trained that medication carts must remain locked when not in use or out of direct view, and that the assigned nurse or medication aide is responsible for securing the cart. The facility’s written policy requires medication carts to be locked at all times when out of the nurse’s view and when not in use. Staff acknowledged that leaving the cart unlocked could allow residents to access medications, with potential for overdose, hospitalization, and pain.
A resident with severe cognitive impairment and a history of skin breakdown developed a blister on her heel, later identified as a pressure ulcer. Despite care plan interventions and physician orders to offload the heel and avoid pressure, an agency CNA placed tennis shoes on the resident after being told not to do so. Communication failures among staff and lack of documented in-service training led to the resident receiving care that did not meet professional standards.
A resident with severe cognitive impairment and chronic pain did not receive a timely pain assessment or appropriate pain management when family reported the resident was in pain. Nursing staff failed to assess and document the resident's pain level at the time of the complaint, despite facility policy and physician orders requiring such assessments. This resulted in the resident's pain not being properly evaluated or managed.
A resident with multiple chronic conditions did not receive an ordered antibiotic for a urinary tract infection as prescribed, due to delays in medication entry and lack of communication among staff. The medication was not administered on the scheduled start date, and there was no documentation explaining the omission. Staff interviews revealed uncertainty about the cause, and the incident was not recorded in the facility's medication error logs.
A facility failed to implement its abuse prevention policies when a nurse allegedly made derogatory comments about a resident's fall, suggesting it was faked. Despite training, staff did not report these comments to the Administrator, the designated Abuse Prevention Coordinator. The resident, with multiple medical conditions and no cognitive impairments, experienced an unwitnessed fall, raising concerns about whether she should be sent to the ER. The failure to report these comments placed residents at risk.
Missing Controlled Substance Count Documentation
Penalty
Summary
The facility failed to establish a system of record of receipt and disposition of controlled drugs in sufficient detail to allow accurate reconciliation for 5 of 8 medication carts reviewed for pharmacy services. Missing narcotic receipt and reconciliation documentation was identified on the Medication Aide Cart and Nurse Cart for Unit 2, the Medication Aide Cart and Nurse Cart for Unit 3, and the Medication Aide Cart for Unit 4 during shift changes. The missing documentation included multiple instances where the off-going or on-coming staff did not complete the narcotic count sheets as required. Review of the Change of Shift Narcotic Count Sheets showed missing narcotic receipt and reconciliation documentation on the Unit 2 Medication Aide Cart and Nurse Cart, the Unit 3 Nurse Cart and Medication Aide Cart, and the Unit 4 Medication Aide Cart on several shifts in February 2026. During interviews, LVN G, LVN E, MA, LVN F, and the DON stated that off-going and on-coming staff were required to count narcotic medications and sign the narcotic count sheet, and that failure to do so could allow drug diversion. The facility's Controlled Substances policy stated that nursing staff count controlled medication inventory at the end of each shift and that the nurse coming on duty and the nurse going off duty make the count together and document any discrepancies.
Kitchen sanitation and food handling deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen and dining room. During an initial tour on 02/10/26, the dishwasher was tested and the chemical strip indicated no sanitizer was being released. The sanitizer container for the dishwasher was empty, and the ND stated sanitizer was empty and needed to be ordered. The walk-in freezer contained multiple single-serve vanilla ice cream cups on the floor, and the reach-in refrigerator in the dining room contained multiple single-serve milk cartons with a best by date of 02/08/26. During observations of lunch preparation and service, CK B took the temperature of chicken gumbo without sanitizing the thermometer probe before use and then wiped the probe with a dry rag before putting it away. CK A removed a thermometer from his pocket to take the temperature of ravioli without sanitizing the probe, left the thermometer open on the prep station, then used it again on pureed ravioli with marinara sauce without sanitizing it. CK A then wiped the probe with a dry rag from the prep station and used it again to take the temperature of soup. During lunch service in the main dining room, CK H wore gloves throughout service while completing several different tasks without changing gloves or washing hands, and he took food temperatures from the steam table, wiped the thermometer probe with a dry rag, and did not sanitize it. During the same observation period, DA entered the kitchen without a hairnet and walked through the food preparation area while food was being prepared for lunch service. DA stated she had just started the day before and forgot to wear a hairnet. Interviews with CK A, CK B, CK H, the ND, and the ADM confirmed expectations that thermometer probes should be sanitized before and after use, gloves should be changed between tasks, hairnets should be worn in the kitchen, expired items should be removed before expiration, sanitizer should be present in the dishwasher, and food should not be stored on the floor. The facility policy and the FDA Food Code sections reviewed reflected requirements for hair restraints, food storage, sanitizer use in warewashing, and glove use limitations.
Hand Hygiene and Laundry Sanitation Failures
Penalty
Summary
The facility failed to maintain an infection prevention and control program related to hand hygiene during lunch service in the secured memory care dining room. A CNA was observed assisting and feeding Residents #35 and #84 without performing hand hygiene, and while seated with Residents #52 and #88 he picked at and cleaned under his fingernails with a paperclip, blew nail debris toward the table, wrote on his hand after sanitizing, wiped crumbs from a table with his bare hand, rubbed his nose and mouth, scratched his hair, and repeatedly touched residents, their wheelchairs, clothing, plates, utensils, and drinks without sanitizing between contacts. He also touched his face, nose, hair, and ear during the meal and continued feeding residents without hand hygiene. During interview, he stated he had been trained in hand hygiene but did not think sanitizing was needed when he did not directly touch the residents' food. Interviews with nursing leadership and the administrator confirmed that staff were expected to perform hand hygiene before and after assisting residents, before feeding, and between resident contacts, and that failure to do so could spread germs and bacteria. The DON stated she intended to contact the agency to request hand hygiene training before the CNA returned to the facility. The ADM stated staff were expected to wash hands with soap and water if visibly soiled and use hand sanitizer before and after donning gloves, providing care, touching a resident, touching their own body, or touching multiple surfaces, and stated the CNA's behavior did not meet expectations. The facility also failed to maintain sanitary laundry room practices. During observation of the only laundry room, one staff member was working with both clean and soiled linen while the area around the dryers was unclean, with thick lint buildup and items including hangers, a wood block, sock/clothing items, and what appeared to be a duster behind the machines. No chemical sanitizer was observed in use or available around the washing machines. The LA stated clothing from TBP or contact isolation rooms was washed in hot water, but the machines were not sanitized afterward and the facility did not use cleaning logs or lint logs. The HSK stated there was no checklist for housekeeping, did not know the machines were supposed to be cleaned from behind, and stated the observed lint and debris did not meet expectations. The MMD stated the washing machines were expected to be sanitized daily and after loads from isolation or special precaution rooms, and that failure to do so could result in cross contamination. The ADM stated the laundry room should be cleaned daily and as needed, but after reviewing the images stated the conditions did not meet her expectations of a sanitary environment.
Unattended, Unlocked Medication Cart Accessible to Residents
Penalty
Summary
Surveyors identified a deficiency related to medication security when medication cart #1 (MC #1) was observed unattended and unlocked in the main lobby area, with a resident present nearby. A subsequent observation showed staff members walking past the still-unlocked cart. The facility’s own policy, titled “Security of Medication Cart” and dated April 2007, states that medication carts must be securely locked at all times when out of the nurse’s view and locked and parked at the nurses’ station when not in use. The report notes that this failure could place residents at risk of overdose, hospitalization, and pain. Multiple staff interviews confirmed that they had been trained to keep medication carts locked and understood the requirement to secure them when not in use or when out of their direct view. RN A, who had worked at the facility for 5 years, acknowledged she left MC #1 unlocked due to an oversight and stated that residents could access medications if the cart was left unlocked. LVN B, CNAs C and D, the DON, and the Administrator each stated that the assigned nurse or medication aide is responsible for locking the cart and that the cart should remain secured when not actively in use. They also stated that residents could access medications from an unlocked cart, with potential for harm, including poisoning or death, if medications were ingested.
Failure to Follow Care Plan and Professional Standards for Resident with Foot Wound
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including dementia, diabetes, chronic pain, and a history of skin breakdown, did not receive care in accordance with professional standards and her person-centered care plan. The resident developed a blister on the back of her left heel, which was later identified as a pressure ulcer. Despite clear instructions and care plan interventions to offload the heel and avoid pressure, an agency CNA placed tennis shoes on the resident after being told not to do so. This action was observed by the resident's family, who had previously communicated with facility staff, including the ADON and LVN, about the need to avoid tennis shoes due to the pressure area. The care plan for the resident included specific interventions such as offloading the heels with cushions or pillows, using a heel boot at all times, and changing dressings as ordered. Physician orders also specified wound care procedures and the use of a heel boot to prevent further pressure. However, there was a breakdown in communication among staff, as the CNA who put the shoes on the resident was not aware of the restriction, and there was no documented in-service training for staff regarding this specific care need. The wound care nurse acknowledged that an order should have been in place to restrict footwear to socks or open-back house shoes, but this was not implemented in a timely manner. Interviews with facility staff, including the Wound Care Nurse, ADON, and DON, revealed that while the issue of inappropriate footwear was discussed among leadership and with the family, the information was not effectively communicated to all direct care staff. The facility's in-service records did not reflect any training or instruction regarding the resident's footwear restriction during the relevant period. As a result, the resident was exposed to unnecessary discomfort and risk of worsening her foot wound due to the failure to follow the care plan and professional standards of practice.
Failure to Assess and Manage Resident Pain as Reported by Family
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with multiple complex medical conditions, including dementia with severe cognitive impairment, chronic pain, congestive heart failure, COPD, and osteoporosis. The resident's care plan included interventions for pain management and skin breakdown prevention, and physician orders were in place for scheduled and PRN pain medications. Despite these measures, there was a failure to assess the resident's pain level when the family reported the resident was in pain and requested pain medication. On the day in question, the resident's family reported that the resident was crying in pain and requested pain medication. The nurse informed the family that the resident had just received medication and could not receive more until a later time. However, upon review, it was found that the resident had not actually received pain medication at the time stated by the nurse. There was no documented pain assessment during the period when the family reported the resident was in pain, and the nurse was unable to specify the resident's pain level at that time. The facility's policy required pain assessment whenever pain was reported or medication was administered, but this was not followed. Interviews with staff confirmed that the expectation was to assess pain whenever a resident complained of pain, and that pain assessments should be documented with each administration of pain medication. The lack of assessment and documentation meant that the resident's pain was not properly evaluated or managed according to professional standards and the facility's own protocols.
Failure to Administer Ordered Antibiotic and Document Medication Omission
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not administering an ordered antibiotic as prescribed. The resident, an elderly female with multiple diagnoses including dementia, diabetes, anxiety, chronic heart failure, COPD, and chronic pain, was admitted with significant health concerns and was at risk for pressure ulcers. A physician's order was written for Cephalexin 500 mg to be administered every 12 hours for a urinary tract infection, with a specified start and stop date. However, review of the Medication Administration Record (MAR) showed that the antibiotic was not given as ordered on the initial date, and there was no documentation in the progress notes explaining why the medication was not administered or why the start of the antibiotic was delayed. Interviews with facility staff, including the hospice nurse, LVN, and DON, revealed a lack of awareness and clarity regarding the missed dose. The hospice nurse was not informed that the antibiotic was unavailable or not delivered, and stated that if she had been notified, she would have arranged for the medication to be provided. The LVN could not recall the specific incident but suggested that pharmacy issues or delays in entering the order into the computer system may have contributed to the missed dose. The DON confirmed that the expectation was for nurses to obtain the initial dose from the emergency kit and to document any issues, but could not find documentation or recall why the antibiotic was not given as ordered. The resident's family reported noticing a foul urine odor and confirmed that hospice had ordered the antibiotic, expecting it to be started promptly. When the family inquired about the medication, they were told by the LVN that the antibiotic had not been administered due to it not being entered into the system. The facility's medication error logs did not reflect this incident, and the facility's policy required immediate documentation of medication orders and administration, which was not followed in this case.
Failure to Report Potential Abuse by Staff
Penalty
Summary
The facility failed to implement its written policies and procedures regarding prohibiting and preventing abuse for one resident. On 4/23/2024, RN-B was allegedly heard making derogatory statements about a resident to multiple staff members, including CNA-A, CSM-C, and CSM-D. These statements included referring to the resident's fall as a 'boy who cried wolf' scenario and suggesting that the resident was faking the fall. Despite these comments, the staff did not report the potential abuse to the Administrator, who was the designated Abuse Prevention Coordinator. The resident involved was an elderly female with multiple medical conditions, including Diabetes Mellitus Type II, Hypertension, Hyperlipidemia, Congestive Heart Failure, Mild Asthma, Generalized Anxiety Disorder, Chronic Pain Syndrome, Disorder of the Connective Tissue, and Osteoarthritis. The resident had a BIMS score of 15, indicating no cognitive impairments. The incident occurred after the resident experienced an unwitnessed fall, and there was a concern about whether the resident should be sent to the ER. Despite the derogatory comments made by RN-B, the staff did not recognize these as potential abuse and failed to report them as required by the facility's policies. Interviews with various staff members revealed that they had received training on abuse and neglect and were aware of the reporting procedures. However, they did not perceive RN-B's comments as abusive at the time and thus did not report them. The facility's policy mandates that any knowledge or suspicion of abuse or neglect must be reported immediately to the Unit Charge Nurse, who is responsible for notifying the Director of Nursing and/or Administrator. This failure to report placed residents at risk of abuse, neglect, or exploitation.
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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 Gatesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillside Medical Lodge | 3.9 mi | ★★★★★ | 8 | 0 |
| Mcgregor Wellness & Rehabilitation | 21.3 mi | ★★★★★ | 6 | 0 |
| St. Joseph's Care Center | 21.3 mi | — | 2 | 0 |
| Avir At Killeen | 21.8 mi | ★★★★★ | 13 | 0 |
| Rosewood Heights | 22.1 mi | ★★★★★ | 5 | 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.