Average — CMS composite of the measures below.
The next survey window likely opens 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 Cuero Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with hypertensive CKD and urinary retention had an admission MDS that documented an indwelling urinary catheter, but H0300 for urinary continence was coded as occasionally incontinent instead of not rated. Observation confirmed the catheter was present, and the MDS nurse stated the code should have been 9 because the resident had an indwelling catheter.
Improper Perineal Care for an Incontinent Resident: A resident with end stage renal disease, moderate cognitive impairment, and total bowel/bladder incontinence was observed receiving perineal care from a CNA who used multiple passes with the same wipe on the penis before cleaning the anal area. The CNA said she forgot to use a new disposable wipe with each stroke, and the DON confirmed this was not consistent with the facility’s perineal care policy.
An opened vial of insulin for a resident in one med cart had no open date on the label, and an LPN stated she forgot to document when it was opened. In another hall, an LPN left a med cart unlocked and unattended while providing IV care to a resident. The DON stated carts should remain locked, and facility policy required the cart to be closed and locked when out of sight.
Unlabeled and undated food was found in a resident’s personal refrigerator, and the facility failed to follow its policy for safe food storage and handling. The resident had Alzheimer’s disease, dementia, type 2 DM, HTN, and severe cognitive impairment, and staff stated night nurses were responsible for daily refrigerator checks and dating/labeling food items.
Incomplete documentation was found for two residents’ records. One resident with severe cognitive impairment and multiple wounds had a scheduled wound treatment left blank on the TAR after the ADON provided care but did not document it. Another resident receiving IV meropenem had a blank MAR entry for a scheduled dose while out on pass, and the DON stated the nurse should have documented it as out on pass rather than leaving it blank.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A CMA failed to disinfect a blood pressure cuff between use on two residents during medication administration, despite being aware of facility infection control protocols and prior training. The DON confirmed that staff are required to clean reusable equipment between residents, as outlined in the facility's infection prevention policy.
The facility's kitchen operations failed to meet food safety standards, with uncovered food items and improper temperature maintenance observed. Cook C and Cook D did not cover food items, and Cook D used wet pans and served food that did not reach safe temperatures. Interviews revealed a lack of adherence to food safety protocols, with Cook D feeling nervous and distracted, and the DM unaware of specific reheating requirements.
A resident with serious mental disorders was not referred for a level II PASARR review due to an incorrect level 1 screening form marking 'no' under mental illness. The error was not identified until a surveyor pointed it out, and the facility lacked a PASARR policy. Interviews revealed that the oversight was attributed to a new LVN, and the DON confirmed the absence of a PASARR policy.
A facility failed to ensure that a physician documented responses to a pharmacist's recommendations for a resident on antipsychotic medication. The resident, with severe cognitive impairment and multiple psychiatric diagnoses, was receiving medications like Lorazepam and Risperidone. Despite recommendations for dose reduction, there was no documented physician response, potentially affecting residents receiving psychotropic medication recommendations.
The facility failed to properly dispose of garbage, as one of the dumpsters was missing a plug, leading to potential infection control issues. The Dietary Manager confirmed that all dumpsters should have plugs to prevent spillage, which could result in germs being carried inside the facility by staff or insects. The facility's policy requires garbage receptacles to be maintained in a clean and sanitary manner.
A resident with dementia eloped from the facility without staff awareness, despite functioning door alarms, highlighting a lapse in supervision. Another resident, requiring substantial assistance for transfers, was improperly handled by staff on two occasions, leading to a fall and a skin abrasion. These incidents revealed deficiencies in adhering to care plans and protocols, posing potential harm to residents.
A resident with Alzheimer's and dysphagia was served a pimento cheese sandwich instead of their prescribed pureed diet, leading to a choking incident. Despite staff awareness of the resident's dietary restrictions, the sandwich was provided based on the family's previous actions. The resident required the Heimlich maneuver and was later hospitalized with pneumonia, suspected to be related to aspiration.
A staff member at an LTC facility misappropriated $100 from a resident, who has Genetic Torsion dystonia, under the guise of purchasing a refrigerator. The staff member did not return with the item and ceased communication with the facility. Despite having completed orientation and a clear background check, the staff member's actions led to a deficiency in protecting resident funds.
A CNA in an LTC facility failed to change gloves after cleaning a resident's bowel movement, touching a clean brief with dirty gloves, which could lead to infection. The resident, with severe cognitive impairment and incontinence, required strict hygiene practices as per their care plan. The CNA admitted to the oversight, and the DON confirmed the need for proper glove-changing procedures.
Inaccurate MDS Coding for Resident with Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure Resident #3’s assessment accurately reflected the resident’s status. Resident #3 was admitted with diagnoses including hypertensive chronic kidney disease and urinary retention, and the admission MDS identified the resident as cognitively intact with a BIMS score of 15 out of 15. In Section H of the MDS, the resident was documented as having an indwelling urinary catheter, but Question H0300 for urinary continence was coded as 1, occasionally incontinent. Record review showed Resident #3’s comprehensive care plan identified an indwelling catheter related to urinary retention, and observation confirmed the resident had an indwelling urinary catheter with the bag secured at the bed frame. During interview, the MDS nurse stated that H0300 should have been coded as 9, not rated, because the resident had an indwelling urinary catheter. The MDS nurse also stated that accurate coding was the MDS nurse’s responsibility and that the facility did not have a policy for MDS accuracy, but followed CMS RAI Manual guidelines.
Improper Perineal Care for an Incontinent Resident
Penalty
Summary
The facility failed to ensure appropriate care for a resident who was incontinent of bowel and bladder and had a care plan intervention to clean the peri-area with each incontinence episode. Resident #39 was a male with end stage renal disease, moderate cognitive impairment with a BIMS score of 8 out of 15, and was dependent for transfers and always incontinent of bowel and bladder. His care plan identified functional incontinence related to impaired cognition and decreased mobility and directed staff to clean the peri-area with each incontinence episode. During observation, CNA-B washed her hands, donned gloves and a gown, opened the resident’s soiled brief, and cleaned the genital area. When cleaning the penis, CNA-B used multiple passes with the same wipe, then turned the resident on his side and cleaned the anal area. CNA-B later stated she had used multiple passes with the same wipe because she was nervous and forgot to use a new disposable wipe with each stroke. The DON stated the CNA should have used a new wipe with each stroke to prevent possible urinary tract infection. The facility policy for perineal care for males directed staff to clean the shaft of the penis using downward strokes and to use a separate section of washcloth or new disposable wipe with each stroke.
Medication carts left unlocked and insulin vial lacked open date
Penalty
Summary
The facility failed to store drugs and biologicals in locked compartments for 2 medication carts reviewed. In the 200 & 400 hall nursing cart, one opened bottle of Resident #8’s NovoLIN R Injection Solution 100 UNIT/ML was observed without an open date on the label. During interview, the LVN stated she had opened the insulin that morning and forgot to write the open date on it. The LVN also stated that, per facility policy, NovoLIN R Injection Solution 100 UNIT/ML should be discarded 42 days after opening, and without an open date staff would not know when to discard it. In the 500 hall, the nursing cart was observed unlocked and unattended while the LVN was providing intravascular care to Resident #102. The LVN stated she forgot to lock the cart and left it unlocked while administering IV medication. The DON stated facility nurses should keep their carts locked at all times for safety and to prevent missing or misuse of drugs by unauthorized personnel. Record review showed the facility policy required the medication cart to be kept closed and locked when out of sight of the medication nurse or aide.
Unlabeled and Undated Food in Resident Refrigerator
Penalty
Summary
The facility failed to have and follow a policy regarding the use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. On 01/20/2026, Resident #41’s personal refrigerator in her room was observed to contain three small plastic containers of food with no dates and no labels. During the observation, RN-C stated the containers appeared to be salad dressings and said the night nurses were supposed to check the refrigerator every day and write dates and labels to prevent possible food-borne illness. Resident #41 was an 88-year-old female with diagnoses including Alzheimer’s disease, dementia, type 2 diabetes mellitus, and hypertension. Her quarterly MDS dated 12/22/2025 showed a BIMS score of 7 out of 15, indicating severe cognitive impairment, and she required assistance with eating and transfers. Her care plan identified her as at risk for nutritional problems related to impaired cognition and poor dentition, with interventions to provide her ordered diet and observe and record intake every meal. The DON stated on 01/22/2026 that facility night nurses were responsible for overseeing and monitoring Resident #41’s personal refrigerator daily, and the facility policy titled Resident Refrigerators stated leftovers shall be dated upon receipt and discarded within three days.
Incomplete Documentation of Wound Care and IV Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents reviewed. For one resident with a history of cerebral infarction, hemiplegia/hemiparesis, type 2 diabetes mellitus, and a stage 4 pressure ulcer of the left ankle, the treatment administration record was left blank on a scheduled wound care date for the right buttocks moisture associated skin damage. The resident’s care plan directed treatment as ordered, and the physician order required cleansing, zinc oxide, and a border foam dressing every other day and as needed. During interview, the ADON stated she had provided the wound care because the wound care nurse left early that day, but she forgot to document the treatment on the treatment administration record. She stated the record should have been accurate. The resident’s quarterly MDS showed severe cognitive impairment with a BIMS score of 0 and dependence for most activities of daily living, and the assessment also noted unhealed pressure ulcer and moisture associated skin damage. For another resident with diagnoses including urinary tract infection, anemia, and hepatitis C, the medication administration record was left blank for a scheduled dose of IV meropenem. The resident’s care plan directed administration of medications as ordered and monitoring/documenting side effects and effectiveness. The DON stated the resident was out on pass for an appointment at that time and the nurse should have documented the MAR entry as 1, meaning out on pass without meds, rather than leaving it blank. The DON stated the MAR should have been accurate.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential resident information or proper record-keeping were not followed as expected. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Disinfect Blood Pressure Cuff Between Residents
Penalty
Summary
A deficiency was identified when a Certified Medication Aide (CMA) failed to follow infection prevention and control protocols during medication administration. Specifically, the CMA was observed taking the blood pressure of one resident, returning the blood pressure cuff to the medication cart without sanitizing it, and then using the same cuff to take the blood pressure of another resident. The CMA did not clean or disinfect the blood pressure cuff between uses, despite facility policy and training that require disinfection of reusable equipment between residents to prevent the spread of infection. During interviews, the CMA acknowledged forgetting to sanitize the cuff and confirmed awareness of the facility's procedures, which had been covered in prior training. The Director of Nursing (DON) also confirmed that staff are expected to disinfect blood pressure cuffs between each resident for infection control purposes. Review of the facility's Infection Prevention and Control Program policy further supported the requirement for cleaning and disinfecting reusable equipment between residents.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen operations. Cook C did not cover a pan of wheat rolls, leaving them exposed to potential contamination. Cook D also neglected to cover food items during meal preparation and used pans that had not been adequately air-dried, instead drying them with paper towels, which could introduce contaminants. These practices were observed during meal preparation and could affect the majority of residents consuming food from the kitchen. Further observations revealed that Cook D did not maintain proper food temperatures. The macaroni and cheese and pureed spinach did not reach the required temperature of 135 degrees for safe service. Despite this, Cook D proceeded to serve these items. Additionally, Cook D was observed using wet pans for food preparation, which were not air-dried as required, and failed to cover various food items on the steam table, including chicken fried steak and cornbread, increasing the risk of contamination. Interviews with Cook D and the Dietary Manager (DM) highlighted a lack of understanding and adherence to food safety protocols. Cook D admitted to feeling nervous and distracted, which contributed to the oversight in maintaining food temperatures and covering food items. The DM acknowledged the importance of reaching and maintaining safe food temperatures to prevent foodborne illnesses but was unaware of the specific reheating requirements. The facility's policy and FDA Food Code guidelines emphasize the need for proper food handling, including maintaining safe temperatures and ensuring equipment is air-dried, which were not followed in this instance.
Failure to Refer Resident for Level II PASARR Review
Penalty
Summary
The facility failed to refer a resident with a serious mental disorder for a level II resident review under the pre-admission screening and resident review (PASARR) program. This deficiency was identified for one of the five residents reviewed for resident assessment. The resident in question, a female with multiple diagnoses including major depressive disorder, delusional disorders, alcohol dependence with alcohol-induced persisting dementia, and generalized anxiety disorder, was not referred for a level II PASARR review despite having a serious mental disorder diagnosis. The resident's PASARR level 1 screening form incorrectly marked 'no' under mental illness, and there was no evidence of a level II screening being completed. Interviews with facility staff revealed that the error in the PASARR level 1 screening form was not recognized until it was pointed out by the surveyor. LVN A was unable to explain why the form was marked incorrectly, while LVN B acknowledged the mistake and stated that the resident should have been referred for a level II review. The facility's Director of Nursing (DON) confirmed that there was no PASARR policy in place at the facility, and the error was attributed to LVN A being relatively new. The lack of a PASARR policy and the oversight in the screening process led to the deficiency being identified during the survey.
Failure to Document Physician Response to Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician documented in the resident's medical record that identified irregularities had been reviewed and what actions, if any, were taken in response to the pharmacist's report for a resident reviewed for antipsychotic use. Specifically, the nursing staff did not ensure that the attending physician responded to the pharmacist's recommendations for the resident. This deficiency could potentially affect residents receiving recommendations for psychotropic medications, leading to unnecessary adverse side effects. The resident in question was admitted with diagnoses including unspecified dementia with psychotic disturbance, bipolar disorder, major depressive disorder, and anxiety disorder. The resident was receiving medications such as Lorazepam, Risperidone, and Valproic Acid as per physician's orders. Despite the consultant pharmacist's recommendations for a trial dose reduction on two occasions, there was no documented response from the primary care physician in the resident's electronic health record. The Director of Nursing confirmed that the pharmacist's recommendations were received, but the physician did not respond to the recommendations, which was required to make necessary changes to the resident's medication regimen.
Improper Garbage Disposal
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey on October 18, 2024. One of the three dumpsters located 10 to 15 feet from the nursing facility was missing a plug at the bottom, which is necessary to prevent spillage. This deficiency was confirmed through an interview with the Dietary Manager (DM), who acknowledged that all dumpsters should have plugs to prevent spillage, which could lead to infection control issues. The DM explained that spillage could result in staff stepping on it and carrying germs inside the facility, or flies landing on it and spreading germs. Additionally, the smell of trash could attract insects, bugs, and rodents, potentially allowing them to enter the facility and resident rooms. The facility's policy on garbage receptacles, revised on June 1, 2019, states that garbage receptacles should be maintained in a clean and sanitary manner, with tight-fitting lids, doors, or covers, and stored in a way that is inaccessible to insects and rodents.
Deficiencies in Resident Supervision and Transfer Protocols
Penalty
Summary
The facility failed to ensure the safety and supervision of two residents, leading to significant incidents. Resident #1, a cognitively intact individual with a history of dementia and bipolar disorder, managed to elope from the facility without staff awareness. Despite the door alarm functioning properly, staff did not notice the resident's exit until a visitor reported finding her in the parking lot. The resident was upset and expressed a desire to go home, resulting in a minor injury to her cheek. This incident highlighted a lapse in monitoring and supervision, as the resident's care plan did not initially account for elopement risk. Resident #3, who suffers from severe cognitive impairment and requires substantial assistance for transfers, experienced two separate incidents due to improper handling by staff. On one occasion, Nurse Aide-E attempted to transfer the resident without using the required mechanical lift, resulting in the resident being lowered to the floor and sustaining a skin abrasion. In another incident, CNA-F used a mechanical lift without a second staff member, causing the resident to slide out of the wheelchair. These actions were contrary to the resident's care plan, which mandated the use of a mechanical lift with two staff members for transfers. The facility's failure to adhere to established care plans and protocols for both residents resulted in potential harm and highlighted deficiencies in staff training and supervision. The incidents involving Resident #3 were particularly concerning, as they demonstrated a disregard for the care plan's requirements, which could have led to more severe injuries. The facility's policies on elopement and mechanical lift usage were not effectively implemented, contributing to these deficiencies.
Failure to Provide Correct Diet Texture Leads to Choking Incident
Penalty
Summary
The facility failed to ensure that a resident received food prepared in a form designed to meet their individual dietary needs, specifically a pureed diet. The resident, who had a history of Alzheimer's with late onset, heart failure, vascular dementia with psychotic disturbance, and dysphagia, was prescribed a pureed diet with honey-thickened liquids due to swallowing difficulties. Despite this, the resident was served a regular texture diet, specifically a pimento cheese sandwich, which posed a choking hazard. The incident occurred when the resident, who had slept through breakfast, was given a pimento cheese sandwich by a CNA after consulting with an LVN. Both staff members were aware of the resident's dietary restrictions but believed it was acceptable to provide the sandwich because the resident's family had previously given him solid foods. The resident choked on the sandwich, requiring the Heimlich maneuver to dislodge the food. The resident was later admitted to the hospital with pneumonia, which was suspected to be related to aspiration. Interviews with facility staff, including the DON, dietician, and speech therapist, confirmed that a pimento cheese sandwich was inappropriate for a resident on a pureed diet. The staff acknowledged the risks associated with not adhering to prescribed dietary textures, such as choking and aspiration. The facility's dietary policy emphasized the importance of providing food textures appropriate to individual resident needs, which was not followed in this case.
Misappropriation of Resident Funds by Staff Member
Penalty
Summary
The facility failed to protect a resident from the misappropriation of funds, which involved a staff member taking $100 from the resident under the pretense of purchasing a refrigerator. The staff member, identified as [NAME] D, did not return with the refrigerator and subsequently did not return to work or respond to any attempts at contact. This incident was confirmed through interviews with the resident and the facility administrator. The resident involved had been admitted to the facility with a diagnosis of Genetic Torsion dystonia, a condition affecting muscle control. The facility's records showed that the staff member had completed orientation, which included training on maintaining resident rights, and had a clear background check. Despite these measures, the staff member misappropriated the resident's funds, leading to the deficiency identified in the report.
Improper Glove Use During Incontinent Care
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bladder, leading to a potential risk of infection. During an observation, a CNA was seen touching a clean brief with dirty gloves after cleaning the resident's bowel movement. This action was contrary to the facility's policy, which requires changing gloves and performing hand hygiene after cleaning fecal material before handling clean items. The CNA admitted to forgetting to change gloves due to nervousness, and the Director of Nursing confirmed that the gloves should have been changed to prevent possible infection. The resident involved was an elderly male with severe cognitive impairment, Alzheimer's disease, and other medical conditions, including type 2 diabetes and hemiplegia. The resident was always incontinent of bladder and bowel and required total assistance for toilet hygiene. The care plan for the resident emphasized the importance of cleaning the peri-area with each incontinence episode to prevent urinary tract infections. However, the failure to follow proper glove-changing procedures during incontinent care compromised the infection control measures outlined in the resident's care plan.
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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 Cuero
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Whispering Oaks Rehab & Nursing | 2.1 mi | ★★★★★ | 0 | 0 |
| Paradigm At Stevens | 15.7 mi | ★★★★★ | 3 | 0 |
| Yorktown Nursing And Rehabilitation Center | 16.6 mi | ★★★★★ | 13 | 0 |
| Yoakum Nursing And Rehabilitation Center | 17.3 mi | ★★★★★ | 5 | 0 |
| Twin Pines North Nursing And Rehabilitation Center | 21.7 mi | ★★★★★ | 4 | 0 |
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