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 Devine Health & Rehabilitation during CMS and state inspections, most recent first.
Failure to change a resident's oxygen nasal cannula per order was identified. The resident had CHF and severe cognitive impairment, and staff observed the tubing dated earlier than expected. An LVN, DON, and Administrator confirmed the cannula had not been changed as ordered, despite the care plan and order summary directing ongoing respiratory care.
A facility failed to monitor a resident's cardiac pacemaker parameters as required by professional standards and the resident's care plan. Despite the resident's history of heart disease and the presence of a pacemaker, there were no physician orders or recorded vital signs for pacemaker monitoring. Interviews with staff confirmed the absence of necessary orders, potentially impacting the resident's cardiac care.
A resident with COPD and a cardiac pacemaker was found with a visibly soiled oxygen nasal cannula, which had not been changed as required by the care plan and facility policy. Staff confirmed the contamination, acknowledging the potential for infection. The facility failed to provide respiratory care consistent with professional standards.
A facility failed to implement a pharmacist's recommendation to monitor a resident for edema, despite the resident receiving a diuretic. The resident, with a history of COPD, heart disease, and a pacemaker, was at risk of fluid overload. The absence of a doctor's order for edema monitoring was confirmed by the DON.
A resident with multiple medical conditions, including diabetes and vascular dementia, had abrasions on her toes requiring daily treatment. The facility failed to update her care plan to reflect these needs, despite existing treatment orders. Interviews with staff highlighted the importance of timely updates to care plans, which was not adhered to in this case.
A controlled medication discrepancy occurred in an LTC facility when a resident's Norco count was incorrect due to LVNs not following protocol for shift change reconciliation. Despite the resident's pain being managed, the audit sheet and blister pack counts did not match. The DON was informed, and an investigation revealed procedural lapses by the staff involved.
The facility failed to maintain safe food temperatures during a lunch meal service, with tater tots served at 130 degrees instead of the required 140 degrees. Despite staff training on food safety, the Dietary Manager and a staff member acknowledged the oversight, which posed a risk to residents' meal satisfaction and safety.
A facility failed to accurately document wound care for a resident with multiple health conditions, including diabetes and vascular dementia. The resident's treatment administration records did not reflect the completion of wound care on a specific date. Interviews revealed that the assigned nurse did not perform the care, and the ADON later initialed the records without having completed the treatment. The facility's policy requires timely documentation of care provided.
Failure to Change Oxygen Nasal Cannula per Order
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for Resident #11, an [AGE]-year-old female admitted on [DATE] with diagnoses including congestive heart failure, senile degeneration of brain, and amnesia. Her MDS dated [DATE] showed a BIMS score of 7, indicating severe cognitive impairment. Her care plan dated 12/30/2025 directed staff to check the oxygen tubing/nasal cannula every night shift every Sunday for change, and the order summary report dated 02/27/2026 included an order to change the nasal cannula as needed. During observation on 2/27/2026 at 9:39 a.m., the resident's oxygen tubing was dated 2/13/2026. In interview, the LVN stated at 11:08 a.m. that the nasal cannula date indicated it should have been changed on 2/22/2026. The DON stated at 11:11 a.m. that the oxygen tubing should have been changed per physician orders to prevent any possible infections, and the Administrator stated at 11:15 a.m. that the oxygen tubing was not changed per physician orders and should have been to help prevent any possible infections. The facility policy titled Oxygen Administration stated that the resident will maintain oxygenation with safe and effective delivery of prescribed oxygen.
Failure to Monitor Pacemaker Parameters
Penalty
Summary
The facility failed to provide treatment and care in accordance with the comprehensive assessment and professional standards of practice for a resident with a cardiac pacemaker. The resident, a female with a history of Chronic Obstructive Pulmonary Disease, Atherosclerotic Heart Disease, and the presence of a cardiac pacemaker, was not monitored for pacemaker parameters as required. The resident's care plan indicated that her heart rate should be maintained within acceptable limits as determined by the physician or pacemaker settings. However, the facility did not have physician orders or medical information necessary to monitor the pacemaker's parameters, and there were no recorded vital signs related to the pacemaker in the resident's Treatment Administration Records (TARs) for October and November 2024. Interviews with facility staff, including an LVN and the Director of Nursing (DON), confirmed the absence of orders for monitoring the pacemaker parameters. The LVN verified the pacemaker's placement in the resident's upper left chest area but acknowledged the lack of monitoring orders. The DON also confirmed the absence of such orders and recognized the potential for harm related to cardiac care. The facility's policy on permanent pacemakers requires checking per the manufacturer's direction and physician's order of frequency, which was not adhered to in this case.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, leading to a deficiency in care. Resident #10, a female with a history of Chronic Obstructive Pulmonary Disease, Atherosclerotic Heart Disease, and a cardiac pacemaker, was observed with a visibly soiled oxygen nasal cannula. The resident's care plan indicated the use of oxygen therapy, and the order summary report required the nasal cannula to be changed as needed. However, the treatment administration records for October and November 2024 showed that the nasal cannula had not been changed, despite the visible contamination. During an observation, the soiled condition of the nasal cannula was confirmed by both a GVN and the DON, who acknowledged the potential for infection due to the contamination. The facility's policy on oxygen administration, dated March 2023, stated that tubing should be changed when it becomes visibly contaminated. The failure to adhere to this policy and the resident's care plan resulted in a deficiency, as the resident was not provided with the necessary respiratory care consistent with professional standards of practice.
Failure to Implement Pharmacist's Recommendation for Edema Monitoring
Penalty
Summary
The facility failed to act upon an irregularity noted by the pharmacist for a resident who was receiving a diuretic. The pharmacist's recommendation to add edema monitoring to the resident's routine orders was not implemented. This oversight was identified during a review of the resident's medical records, which showed no orders for edema monitoring despite the pharmacist's suggestion. The resident in question is an elderly female with a history of Chronic Obstructive Pulmonary Disease, Atherosclerotic Heart Disease, and the presence of a cardiac pacemaker. She was noted to have a moderate cognitive impairment. The facility's Director of Nursing confirmed the absence of a doctor's order for edema monitoring, acknowledging the potential risk of fluid overload due to this omission.
Failure to Update Care Plan for Resident's Wound Care Needs
Penalty
Summary
The facility failed to ensure that a comprehensive person-centered care plan was in place for a resident with multiple medical conditions, including Type 2 Diabetes, Chronic Obstructive Pulmonary Disease, Cirrhosis of the Liver, Chronic Pain, Hemiplegia, and Vascular Dementia. The resident, who was at risk for pressure ulcers and had a history of non-compliance with treatment, had abrasions on her toes that required daily wound treatment. However, the care plan did not reflect these needs, as observed during a review of the care plan record. The resident's care plan, which was last revised several months prior, did not include the necessary interventions for the abrasions on her toes, despite the presence of treatment orders in the Treatment Administration Record (TAR). The resident had abrasions on her toes that were being treated with betadine, as per the orders starting from a specific date. The Wound Care NP confirmed the presence of dry abrasions and the appropriateness of the treatment. However, the care plan was not updated to reflect these treatments and interventions. Interviews with facility staff, including the MDS Coordinator and the DON, revealed that care plans should be updated promptly when there are changes in a resident's care needs. The facility's policy on comprehensive care planning emphasized the importance of developing and implementing a care plan that includes measurable objectives and timeframes. Despite this policy, the care plan for the resident was not updated to include the necessary wound care interventions, potentially placing the resident at risk for not receiving appropriate treatment.
Controlled Medication Discrepancy Due to Inadequate Reconciliation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring that controlled medications were accurately reconciled at the start and end of shifts. This deficiency was identified in the case of a 77-year-old female resident with multiple diagnoses, including Type 2 Diabetes, Chronic Obstructive Pulmonary Disease, Cirrhosis of the Liver, Chronic Pain, Hemiplegia, and Vascular Dementia. The resident was on a pain medication regimen, specifically Norco, which was to be administered four times a day. Despite the resident reporting that her pain was well-managed and she received her medications on time, a discrepancy was found in the controlled medication count. The issue arose when LVN A and LVN C conducted a medication count at the end of a shift, and LVN A noted that the blister pack contained 9 pills, while the audit sheet indicated there should have been 10. LVN B, who was late for her shift, did not participate in the initial count but later discovered the discrepancy when she took over the medication cart. Both LVN A and LVN B acknowledged that they did not follow the facility's protocol, which required both nurses to visually verify the count and sign off on the audit sheet. This failure to adhere to the established procedures led to the medication discrepancy. The Director of Nursing (DON) was notified of the discrepancy, and an investigation was initiated. The investigation revealed that LVN C, who was involved in the initial count, did not return to the facility for a drug test and subsequently was no longer employed there. The facility's policies clearly outlined the procedures for counting and documenting controlled medications, which were not followed by the staff involved. The incident was reported to the appropriate authorities, and the facility conducted an audit of all residents on controlled medications, finding no further discrepancies.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to adhere to professional standards for food service safety during a lunch meal service. An observation revealed that the temperature of tater tots was 130 degrees, below the required 140 degrees for safe serving. Despite this, the staff member, identified as [NAME] A, began serving the food to residents. The Dietary Manager was initially unaware of the correct holding temperature for hot food but later confirmed it should be above 140 degrees. Both the Dietary Manager and [NAME] A acknowledged the mistake and the need to reheat the tater tots to the correct temperature before serving. Interviews with the Dietary Manager and the Administrator confirmed that staff had received training on safe food temperatures, and the expectation was for hot food to be served above 140 degrees. Record reviews showed that [NAME] A had completed a Food Handler Course, and the Dietary Manager had a valid Texas Food Safety Manager Certification. Additionally, an in-service training attendance roster indicated that both had attended training on food temperature safety. Despite these measures, the facility's failure to ensure food was served at the correct temperature posed a risk to residents' meal satisfaction and safety.
Deficient Documentation of Wound Care
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices, specifically in the documentation of treatment administration for a resident. The treatment administration records (TAR) for a resident did not reflect accurate documentation of wound treatments provided on a specific date. This lack of documentation could place residents receiving treatments at risk for not receiving appropriate care. The resident involved was an elderly female with multiple diagnoses, including Type 2 Diabetes, Chronic Obstructive Pulmonary Disease, Cirrhosis of the Liver, Chronic Pain, Hemiplegia, and Vascular Dementia. She was dependent on staff for certain activities and was at risk for developing pressure ulcers. The resident's treatment orders included daily wound care for abrasions on her toes, which were not documented as completed on the specified date. Interviews with staff revealed that the assigned nurse did not perform the wound care and did not communicate this to the Assistant Director of Nursing (ADON), who later initialed the TAR as completed without having performed the care. The ADON admitted to completing a late entry and acknowledged the importance of timely documentation. The Director of Nursing and the Administrator emphasized the responsibility of charge nurses to provide wound care and document it promptly, as per facility policy.
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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 Devine
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lytle Nursing Home | 7.6 mi | ★★★★★ | 0 | 0 |
| Medina Valley Health & Rehabilitation Center | 16.1 mi | ★★★★★ | 11 | 0 |
| Community Care Center Of Hondo | 19 mi | ★★★★★ | 19 | 0 |
| Harbor Valley Health And Rehabilitation | 21.2 mi | ★★★★★ | 19 | 1 |
| The Mission At Blue Skies Of Texas East | 21.7 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.