Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Diboll Nursing And Rehab during CMS and state inspections, most recent first.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet personal care needs.
Surveyors found expired and unlabeled food items in both the kitchen refrigerator and dry storage, including beverages and dry goods, with staff interviews revealing inconsistent practices for checking and discarding expired foods. Facility policy requiring labeling, dating, and timely use of food was not consistently followed, and the Dietary Manager was absent during a scheduled food delivery, leading to missed checks.
The facility did not establish or implement an infection prevention and control program, as required, with surveyors noting the absence of documentation or observed practices related to infection control.
The facility did not have policies and procedures in place to ensure that residents were assessed for and offered influenza and pneumonia vaccinations, as required. Review of practices and documentation showed no established protocols or systematic process for tracking, documenting, or administering these vaccines.
A deficiency was cited when it was found that a working call system was not available in each resident's bathroom and bathing area, preventing residents from being able to call for assistance as needed.
A resident with severe intellectual disabilities and total dependence on staff was housed in a room with a frayed and splintered window frame that had been reported to maintenance but remained unrepaired for about a month. Staff and management acknowledged the hazard, and facility policy requires a safe, clean, and homelike environment, which was not maintained.
A resident with multiple medical conditions, including hemiplegia and heart failure, was observed using an oxygen concentrator with a filter that had significant dust buildup over several days. Despite physician orders and facility policy requiring weekly cleaning, staff did not clean the filter as required. Nursing staff and the DON acknowledged the issue during interviews, confirming the deficiency in providing appropriate respiratory care.
The facility did not obtain the required two witness signatures during the destruction of controlled substances, as only the consultant pharmacist and the DON signed the record. This failure to follow state and federal regulations for documenting the disposal of controlled drugs was confirmed through record review and staff interviews.
The facility failed to have a policy addressing the use and storage of foods brought in by family and other visitors for a resident, as identified during the survey.
The facility failed to maintain food safety and sanitation standards, with a dietary aide improperly wearing a hair net and incomplete dishwasher logs. Leftovers were not labeled or disposed of correctly, and a resident's water pitcher contained contaminated water. Staff interviews revealed a lack of protocol for cleaning water pitchers, and facility policies on cleaning and food storage were not followed.
The facility failed to ensure residents were treated with respect and dignity, as staff members used personal cell phones during care and spoke rudely to residents. During a resident council meeting, several residents reported feeling uncomfortable and disrespected due to staff using cell phones while providing personal care, such as showering. The facility's administrator and DON acknowledged the issue, noting the need for staff education on respect and appropriate cell phone use.
The facility failed to secure the nursing supply storage room and shower room, leaving them open and accessible to residents and visitors. This oversight allowed potential tampering or contamination of sterile supplies and access to toxic cleaners. Staff interviews revealed that the doors should have been locked, but were left open for convenience, posing a risk to safety and sanitation.
The facility failed to provide necessary Medicare/Medicaid coverage notices to three residents, leaving them uninformed about service changes. This was due to a lack of education and communication, and the absence of an MDS nurse. The residents had various medical conditions, including metabolic encephalopathy, anxiety disorder, and acute respiratory failure.
A facility failed to include a resident's feeding tube requirement in their care plan, despite physician orders and the resident's need for specific nutritional management due to cerebrovascular disease. The MDS nurse, new to the role, did not capture this in the care plan, which could impact resident care. The DON and Administrator acknowledged the oversight and its potential effects.
A resident with Alzheimer's requiring total dependence for transfers was improperly moved by two CNAs who manually lifted her without using the required mechanical lift or gait belt. Both CNAs admitted to not following the care plan, which specified the use of a lift, and acknowledged the risk of injury. The facility's policy and training emphasized the use of mechanical aids to ensure safety.
A facility failed to properly store medications and biologicals, leaving topical medications and a wound cleanser on a resident's bedside table. These items, labeled to be kept out of reach of children, were used for the resident's wound care but were not stored securely as required by facility policy. Staff interviews confirmed that medications should not be kept in residents' rooms without proper authorization and storage arrangements.
The facility failed to maintain an effective infection prevention and control program, leading to deficiencies in the care of two residents. A resident with a feeding tube did not receive care with proper PPE by a COTA, who misunderstood the requirements. Another resident with a dialysis port was exposed to infection risk when an LVN failed to remove PPE and sanitize hands after medication administration. The facility's policies on Enhanced Barrier Precautions and medication administration were not followed, increasing the risk of cross-contamination.
The facility failed to maintain a gas stove in safe operating condition, with one burner not lighting due to carbon buildup. The cook and maintenance director were unsure of who was responsible for cleaning the burners, and the administrator acknowledged the lack of clarity in responsibility. The facility's policy required maintaining the range and grill to minimize food hazards.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from facility staff, resulting in unmet care needs. This failure to assist affected residents who were dependent on staff for their daily personal care and routine activities.
Expired and Unlabeled Food Found in Kitchen and Storage Areas
Penalty
Summary
Surveyors observed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an inspection of the kitchen's refrigerator, multiple items were found past their expiration dates, including gallon containers of unsweet tea dated a week prior to the observation, and numerous glasses of unsweet tea, fruit punch, and orange juice that were not labeled or dated. In the dry storage area, several bags of panko breadcrumbs and cookie pieces were also found to be expired. Staff interviews revealed inconsistent practices regarding the responsibility and frequency of checking for expired foods, with some staff indicating it was the Dietary Manager's (DM) responsibility, while others stated it was a shared duty among all kitchen staff. The DM was not present on the day the food truck arrived, and staff were unsure why the routine check for expired foods did not occur as scheduled. Facility policy requires all opened and bulk items to be stored in tightly covered, labeled, and dated containers, and for all refrigerated foods to be labeled, dated, and used within 72 hours. However, record review and staff interviews confirmed that these procedures were not consistently followed. The Administrator acknowledged that both staff and administration are responsible for daily checks of expired foods, but the last documented checks of the refrigerator and dry storage area occurred several days prior to the survey. Staff recognized that failure to remove expired foods could result in residents consuming spoiled items.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. Surveyors identified that the required program was either not established or not effectively carried out, as evidenced by the lack of documentation or observed practices related to infection prevention and control. There were no specific details provided about individual residents, staff, or particular infection control breaches, but the absence of a program itself constituted the deficiency.
Failure to Establish Policies for Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to develop and implement policies and procedures for administering influenza and pneumonia vaccinations. This deficiency was identified through review of facility practices and documentation, which revealed the absence of established protocols to ensure residents were assessed for and offered these vaccinations. There was no evidence that the facility had a systematic process in place to track, document, or provide flu and pneumonia vaccines to eligible residents.
Non-Functioning Call System in Resident Bathrooms and Bathing Areas
Penalty
Summary
A deficiency was identified due to the lack of a working call system in each resident's bathroom and bathing area. This failure means that residents did not have access to a functioning call system in these locations, as required.
Failure to Repair Hazardous Window Frame in Resident Room
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident with severe intellectual disabilities, expressive aphasia, and hypotension. The window frame in the resident's room was observed to be frayed and splintered, with pieces of wood sticking out, on two consecutive days. Staff interviews revealed that the issue had been reported to maintenance about a month prior, and the maintenance log confirmed the report. However, the window frame remained unrepaired during the survey period. The resident was dependent on staff for all activities of daily living and was rarely or never understood, according to her care plan and MDS assessment. Staff, including a CNA and the Maintenance Supervisor, acknowledged the hazard posed by the splintered window frame, noting the potential for injury. The Maintenance Supervisor stated that repairs were typically logged and checked daily, but he was not aware of this specific issue until the survey. The Administrator confirmed awareness of window repairs needed in some rooms but was not aware that this particular window had been on the maintenance log for about a month. Facility policy requires a safe, clean, and homelike environment, but this standard was not met in this instance.
Failure to Maintain Clean Oxygen Concentrator Filters for Resident Requiring Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required oxygen therapy. Specifically, the external filters of the resident's oxygen concentrator were observed to have a significant buildup of white dust over a three-day period. Despite an active physician order to clean the oxygen concentrator filter weekly on Sundays, and a facility policy to follow manufacturer recommendations for cleaning, the filter remained uncleaned. The resident reported that while staff changed the oxygen tubing weekly, she had never seen anyone clean the concentrator filter. Multiple observations confirmed the persistent dust buildup, and both nursing staff and the DON acknowledged the filter was dusty and needed cleaning. The resident involved had a history of hemiplegia following a stroke, type 2 diabetes, heart failure, and GERD, and was receiving oxygen via nasal cannula at 2 L/min during at least one observation. Interviews with staff revealed that the responsibility for cleaning the filters was assigned to weekend nursing staff, but the task was not completed as required. The DON noted difficulty in removing the filter and decided to provide the resident with another concentrator. The administrator confirmed that nursing staff were responsible for cleaning the filters when changing the tubing weekly, but this was not done, resulting in the deficiency.
Failure to Obtain Required Witness Signatures During Controlled Substance Destruction
Penalty
Summary
The facility failed to maintain a system of records for the receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation, as required by state and federal regulations. Specifically, on one occasion, the drug destruction record for controlled substances did not contain the required two witness signatures at the time of disposal. The record for that date was signed only by the consultant pharmacist and the DON, missing the second witness signature as mandated by facility policy and Texas Administrative Code. This lapse was identified during a review of drug destruction records covering a five-month period. Interviews with facility staff confirmed that the DON was responsible for drug destruction and was unsure how the witness signature was missed on the controlled substances sheet. The facility's policy and state regulations require that the destruction of controlled substances be witnessed by two qualified individuals, such as the administrator, DON, acting DON, or a licensed nurse, and that proper documentation be maintained. The absence of the second witness signature on the destruction record constituted a failure to follow these requirements.
Lack of Policy for Visitor-Brought Food
Penalty
Summary
The facility did not have a policy regarding the use and storage of foods brought to residents by family members and other visitors. This lack of policy was identified during the survey, indicating that the facility failed to establish guidelines or procedures for handling outside food items provided to residents by visitors.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in several instances within the kitchen. A dietary aide was seen not wearing a hair net properly, with hair exposed on the neck and facial hair without a beard guard. Additionally, the dishwasher temperature and sanitation log was incomplete, lacking recorded temperatures and sanitation levels, which the dietary aide admitted to not understanding fully. This lack of proper documentation and understanding of the required dishwasher temperature could lead to unsanitary conditions. Further observations revealed improper labeling and disposal of leftovers in the kitchen refrigerator. Containers of thickened water and orange juice, as well as various food items, were found with dates indicating they were past the recommended usage period. Staff interviews confirmed that leftovers should be discarded after three days, and thickened beverages after seven days, but this protocol was not followed, posing a risk of serving expired food to residents. Resident #7, who has Alzheimer's and severely impaired cognition, was found with a water pitcher containing thickened water that had a slimy green substance. Interviews with staff revealed a lack of awareness and protocol regarding the cleaning and changing of water pitchers, which should occur nightly. The absence of a monitoring system for this task was acknowledged by the facility's administrator, who also noted the potential for illness from dirty water pitchers. The facility's policies on mechanical cleaning and food storage were not adhered to, contributing to these deficiencies.
Staff Cell Phone Use and Rudeness During Care
Penalty
Summary
The facility failed to treat residents with respect and dignity, as evidenced by staff members using personal cell phones while providing care and speaking rudely to residents. During a resident council meeting, six out of twelve residents expressed concerns about staff members using their cell phones during personal care tasks, such as showering, which made residents feel uncomfortable and disrespected. Additionally, residents reported that staff often spoke to them in a rude and disrespectful manner, although they did not provide specific names of the staff involved. The facility's administrator acknowledged awareness of these complaints and confirmed that such behavior was unacceptable, as it could negatively impact residents' feelings of self-worth. The Director of Nursing also recognized the issue and noted that staff education on respect and appropriate cell phone use during care was necessary. The facility's policies on cell phone use and resident dignity, dated December 2019 and revised in February 2021, respectively, emphasize the importance of maintaining a respectful and dignified environment for residents.
Unsafe Access to Supplies and Toxic Cleaners
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in two of the four hallways reviewed. Specifically, the nursing supply storage room on the south hallway was found open and accessible, allowing potential tampering or contamination of sterile products and supplies. During an observation, it was noted that the room contained sterile supplies such as foley catheters, lancets, gastric tube feeding supplies, and wound cleansers, with no staff present in the area. A resident was observed walking nearby, indicating the risk of unauthorized access to these supplies. Additionally, the shower room on the north hallway was observed to be open, with a supply closet inside also left open, containing a bottle of spray disinfectant. Interviews with staff revealed that the doors should have been locked to prevent access by residents or visitors, but were left open, likely for convenience by the night shift. The Director of Nursing (DON) acknowledged awareness of the issue and mentioned that staff had been in-serviced, and a punch key lock was ordered to secure the supply room. However, at the time of the survey, the deficiency remained unaddressed, posing a risk of contamination or theft of supplies.
Failure to Provide Required Medicare/Medicaid Notices
Penalty
Summary
The facility failed to inform residents of their Medicare/Medicaid coverage and potential liability for services not covered, as required by regulations. Specifically, the facility did not provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to three residents when they were discharged from skilled services before their covered days were exhausted. This oversight was identified during interviews and record reviews, which revealed that the facility did not issue the necessary notices to residents, leaving them uninformed about changes to their service coverage. The residents involved included a female with metabolic encephalopathy, anxiety disorder, and thrombocytopenia; a male with intestinal adhesions, hypertension, and type 2 diabetes; and another male with acute respiratory failure, bipolar disorder, and dysphagia. The facility's failure to provide the required notices was attributed to a lack of education and communication, as acknowledged by the facility's administrator. The absence of a Minimum Data Set (MDS) nurse at the time contributed to the oversight, resulting in residents not being aware of their remaining benefits.
Failure to Include Feeding Tube in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who required a feeding tube due to cerebrovascular disease. The resident, who had intact cognition as indicated by a BIMS score of 14, was admitted with a diagnosis that necessitated specific nutritional management. Despite the physician's orders for Jevity C 1.5 at 65 ml per hour for 12 hours and a daily bolus feeding, the care plan dated 7/02/2024 did not include the resident's nutritional status or the requirement of a feeding tube. Interviews with the MDS nurse, DON, and Administrator revealed that the MDS nurse, who was new to the role, was responsible for completing the MDS and care plans. She acknowledged the oversight in not including the feeding tube in the care plan, which could impact resident care. The DON confirmed that care plans should be developed on admission, quarterly, and with any changes, and that the omission could affect resident care. The Administrator also emphasized the importance of accurate and comprehensive care plans, noting that the MDS nurse and DON were responsible for ensuring all care needs were reflected in the care plans.
Improper Transfer of Resident Without Required Equipment
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident with Alzheimer's disease, who required total dependence on two persons for transfers. On the day of the incident, two CNAs, CNA E and CNA F, improperly transferred the resident by manually lifting her into a shower chair without using the required mechanical lift or gait belt, as specified in her care plan. Both CNAs acknowledged their failure to follow the proper transfer protocol, with CNA F admitting she should have stopped to get a gait belt, and CNA E stating she forgot her gait belt and did not retrieve it. CNA E also mentioned being aware of the resident's care plan but could not recall the specific transfer instructions at the time. Interviews with the LVN, DON, and Administrator revealed that the facility had established protocols for safe resident transfers, which included the use of mechanical lifts or gait belts. The LVN confirmed that the resident was care planned for a lift and sometimes used a gait belt if she refused the lift. The DON and Administrator emphasized the importance of following care plans to prevent injuries, and both CNAs had previously demonstrated competency in lifting and transferring techniques. The facility's policy on safe lifting and movement of residents also highlighted the elimination of manual lifting when feasible.
Improper Storage of Medications and Biologicals
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were properly stored and inaccessible to unauthorized staff and residents, specifically for one resident. During observations, it was noted that various topical medications and a wound cleanser were left on the bedside table of an 83-year-old female resident. These items included a tube and packets of Zinc Oxide, skin barrier cream, and antifungal skin powder, all labeled to be kept out of reach of children. The resident mentioned that staff used these products for her wound care and left them there afterward. Interviews with staff, including an LVN and the DON, confirmed that medications should not be kept in residents' rooms unless there is a doctor's order and arrangements for safe storage. The LVN acknowledged the risk of harm if residents used or ingested these topicals incorrectly and noted the potential for contamination. The facility's policy requires all drugs and biologicals to be stored in locked compartments, which was not adhered to in this instance.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, which resulted in deficiencies in the care of two residents. Resident #6, a female with cerebrovascular disease and a feeding tube, required Enhanced Barrier Precautions (EBP). However, during an observation, a Certified Occupational Therapy Assistant (COTA) did not wear Personal Protective Equipment (PPE) while providing care to Resident #6. The COTA misunderstood the requirement for PPE, believing it was only necessary for high-risk tasks. The Director of Nursing (DON) also misunderstood the regulations, leading to inadequate training and implementation of EBP. Resident #27, a female with end-stage renal disease and a dialysis port, was also affected by the facility's failure to adhere to infection control precautions. During medication administration, an LVN did not properly remove PPE or sanitize hands after contact with Resident #27, despite signage indicating the need for EBP. The LVN admitted confusion about the procedures, and both the DON and the Regional Nurse Consultant acknowledged that the LVN had broken basic infection control protocols by not doffing PPE and sanitizing hands before exiting the room. The facility's policies on Enhanced Barrier Precautions and medication administration were not followed, contributing to the risk of cross-contamination and infection. The DON and ADON/IP were identified as responsible for ensuring compliance with infection control guidelines, but their oversight and training were insufficient, leading to the observed deficiencies.
Deficiency in Kitchen Equipment Maintenance
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, specifically a gas stove. During an observation, one of the six burners on the stove did not light completely due to excessive carbon buildup. The cook, who had just returned from a month-long break, was unsure who was responsible for maintaining the burners, although she mentioned that the cooks cleaned the covers and grill daily. The maintenance director also expressed uncertainty about who was responsible for cleaning the stove burners and was unaware of the potential consequences of the burners not lighting correctly. The administrator confirmed the lack of clarity regarding responsibility for cleaning the burners and stated that the facility's policy required maintaining the range and grill in a clean manner to minimize food hazards.
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 73 citations issued within 25 miles in the last 12 months — including the 12 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Diboll
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pinecrest Retirement Community | 10.6 mi | ★★★★★ | 2 | 0 |
| Castle Pines Health And Rehabilitation | 11.2 mi | ★★★★★ | 1 | 1 |
| Kennedy Health & Rehab | 11.5 mi | ★★★★★ | 14 | 7 |
| Parkwood In The Pines | 11.9 mi | ★★★★★ | 11 | 0 |
| Corrigan Ltc Nursing & Rehabilitation | 12 mi | ★★★★★ | 12 | 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.