Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Edinburg Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Update Quarterly Care Plan: A resident with quadriplegia, dysuria, neurogenic bladder, urinary catheterization, and HTN had a care plan that was not revised after the quarterly MDS review. The MDS Coordinator and DON said the update was overlooked, even though quarterly care plans were expected to be completed by the MDS team and reviewed after each comprehensive and quarterly assessment.
A facility failed to keep complete and accurate medical records for two residents. One resident with quadriplegia, dysuria, neuromuscular bladder dysfunction, urinary catheterization, and HTN had MAR entries left unsigned after meds and treatments were given, and an LPN said she administered them but overlooked signing. Another resident with hemiplegia/hemiparesis, BPH, neuromuscular bladder dysfunction, DM, and HTN had a telephone order for antibiotics and contact precautions due to ESBL in the urine, but the contact precaution order was not entered into the EMR order summary even though a sign and PPE were posted at the door.
A resident with severe cognitive impairment, hemiplegia, and multiple comorbidities had an MDS significant change assessment in which sit-to-stand and chair/bed-to-chair transfers were incorrectly coded as 88 (not attempted due to medical condition or safety concerns), despite the care plan documenting a need for two staff and a mechanical lift with substantial/maximal assistance. During interviews, the MDS nurse and DON both confirmed the resident was not bedbound, used a wheelchair during the day, and should have been coded as 01 (dependent) for these ADLs, consistent with the facility’s RAI guidance that requires a dependent code when two helpers perform all the effort.
A resident with severe cognitive impairment, dysphagia, and multiple comorbidities had a diet order changed from mechanical soft with regular liquids to a no added salt, pureed diet with nectar thickened liquids following a speech evaluation, but the comprehensive care plan was not updated to reflect this new diet. The existing care plan continued to list a mechanical soft texture and regular liquids despite documentation in the order summary of the revised pureed, nectar-thick diet. Interviews with the MDS nurse, ADONs, DON, and administrator confirmed that the team was responsible for updating care plans, that the diet change had occurred, and that the care plan should have been revised to show the current diet, in accordance with facility policy requiring comprehensive, person-centered care plans with measurable objectives and timeframes.
A resident with Alzheimer’s disease, CKD, and heart failure, and a history of ESBL in the urine and MRSA in a sacral wound, was care planned to remain on Enhanced Barrier Precautions (EBP) with door signage and use of gown and gloves for high-contact care. However, review of the electronic medical record by the MDS-RN and IP showed there was no active EBP order, as a prior order had been discontinued in error, despite staff believing the resident should remain on EBP. This lack of an active order conflicted with facility policy requiring complete and accurate documentation of assessments and services in the medical record.
A resident with Alzheimer's disease and moderately impaired cognition was able to leave the facility multiple times without staff awareness or proper sign-out, including driving a personal vehicle offsite and becoming lost. The care plan did not initially address the resident's access to a vehicle or driving capability, and staff failed to implement adequate supervision or follow sign-out protocols, despite the resident's known cognitive deficits.
A resident with Alzheimer's disease and moderately impaired cognition left the facility in his own vehicle, became lost, and was returned by police. The incident was not reported to the Administrator or the state agency within the required timeframe, despite facility policy mandating such reporting. Documentation and interviews confirmed the event and the lack of timely notification, resulting in a deficiency for failure to comply with reporting requirements.
Multiple residents with histories of aggression and cognitive impairment engaged in verbal and physical altercations, resulting in injuries such as skin tears and scratches. Despite care plans and interventions, staff were not always able to prevent or immediately intervene in these incidents, and residents with supervision needs were involved in altercations in common areas and resident rooms.
Three residents did not have complete, person-centered care plans with measurable objectives and timeframes. Two residents involved in repeated verbal and physical altercations did not have care plans addressing their ongoing verbal conflicts, despite documentation of these incidents. Another resident with a surgical wound did not have wound care interventions included in her care plan, even though wound care was ordered and documented. Staff interviews confirmed these omissions and the facility's policy requires such care planning.
A resident with a history of falls and multiple medical conditions was readmitted after a hospital stay for a hip fracture caused by a fall. The MDS assessment completed upon reentry failed to document the recent fall and resulting major injury, despite clear evidence in medical records. The MDS nurse acknowledged the omission and noted that this affected the resident's care plan risk triggers. The facility lacked a specific policy for MDS accuracy, relying instead on the RAI manual.
A resident with a suprapubic catheter did not have her urine output documented for four days, despite physician orders and care plan requirements to record this information every shift. Staff interviews confirmed awareness of the documentation requirement, but no explanation was provided for the missing entries. The resident had multiple medical conditions requiring close monitoring, and the facility's in-service training did not address documentation of urine output.
A resident with multiple chronic conditions, including severe cognitive impairment and hypotension, received Midodrine outside of the physician-ordered time parameters on several occasions. Despite clear orders to avoid administration after the evening meal, staff administered the medication late in the evening and did not consistently document administration times accurately, contrary to facility policy and physician instructions.
A resident with multiple chronic conditions, including diabetes, dementia, and coronary artery disease, did not have vital signs documented in the MAR for several weeks, despite physician orders and care plan requirements. Staff interviews confirmed issues with the documentation process and acknowledged the importance of accurate record-keeping for medication management.
Surveyors found that the kitchen failed to maintain proper sanitation and food safety standards, with a juicer nozzle containing slimy substances and cucumbers stored uncovered in a refrigerator showing signs of spoilage. The Dietary Manager was unaware of these issues, and cleaning logs indicated the equipment had been marked as cleaned despite the deficiencies.
A resident with chronic respiratory failure and COPD did not receive oxygen therapy as ordered, with the oxygen flow set higher than prescribed and the humidifier left empty. An LVN acknowledged not checking the oxygen settings or humidifier during her shift, and the DON confirmed staff responsibility for these tasks, noting the absence of a facility policy on oxygen administration.
A resident with multiple medical conditions was discharged without a required MDS discharge assessment. Although staff provided clinical information and reports to the receiving facility, the discharge MDS was not completed as confirmed by record review and staff interviews, resulting in a deficiency in the assessment process.
A facility did not develop or implement a comprehensive care plan for a resident with an active PTSD diagnosis, despite documentation in the medical record and facility policy requiring individualized interventions for trauma survivors. Staff did not include PTSD in the care plan because the resident had not displayed symptoms or triggers and was not receiving treatment, even though the diagnosis was present and the resident was severely cognitively impaired.
A facility failed to include a resident's refusal of care, specifically showering, in their care plan. The resident, with multiple diagnoses including dementia, consistently refused showers, but this behavior was not documented or addressed in the care plan. Interviews revealed that the refusal was known to staff, but the care plan did not include interventions to address the resident's needs, leading to a deficiency in meeting the resident's well-being.
Failure to Update Quarterly Care Plan
Penalty
Summary
The facility failed to have the interdisciplinary team review and revise the comprehensive care plan after the completion of the quarterly review assessments for one resident. Record review showed the resident was admitted with diagnoses including quadriplegia, dysuria, neuromuscular dysfunction of the bladder, urinary catheterization, and hypertension. The resident’s MDS assessment reflected a BIMS score of 15, indicating the resident was cognitively intact. Record review of the care plan showed the last quarterly care plan had been completed on 8/26/2025, and it had not been updated after the quarterly assessment completed in March 2026. During interview, the MDS Coordinator stated the care plan was overlooked and that quarterly care plans were updated every three months, with acute changes handled by the ADONs. The DON also stated the care plan should have been updated quarterly and said it may have been overlooked. The facility policy stated the comprehensive care plan would be developed within 7 days after the comprehensive MDS assessment and reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.
Incomplete MAR and Order Documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for 2 residents. For one resident with quadriplegia, dysuria, neuromuscular bladder dysfunction, urinary catheterization, and hypertension, the MAR did not show nurse signatures for medications and treatments given on 5/7/2026 at 7:00 p.m., 5/8/2026 at 9:00 a.m., and 5/8/2026 at 7:00 p.m. The resident was cognitively intact with a BIMS score of 15. During interview, the resident said he received medications and treatments at specific times, and the LVN stated she had administered them but did not sign the MAR because it was overlooked. For the second resident, who had left-sided hemiplegia/hemiparesis, BPH, neuromuscular bladder dysfunction, diabetes mellitus, and hypertension, a telephone order was received for antibiotics and contact precautions due to ESBL in the urine. The LVN documented the change of condition and completed an infection control form, but the physician order summary did not include the contact precaution order. The resident had a BIMS score of 07 indicating severe cognitive impairment, and a contact precautions sign with PPE supplies was observed on the door. The DON stated the nurse was responsible for entering the order into the EMR and that she and the ADON were responsible for ensuring all orders were placed in the EMR. The LVN stated she missed adding the order to the order summary because she had other paperwork to complete. Facility policy required MARs to be signed after administration and documentation to be completed at the time of service, but the records reviewed did not reflect those entries for the two residents.
Inaccurate MDS Coding of ADL Status for Dependent Resident
Penalty
Summary
The facility failed to conduct a comprehensive and accurate assessment using the CMS-specified Resident Assessment Instrument (RAI) for one resident. The resident was an elderly female admitted with diagnoses including cerebral infarction due to embolism, osteoarthritis of the left shoulder, and flaccid hemiplegia affecting the left nondominant side. Her significant change MDS assessment showed a BIMS score of 6, indicating severely impaired cognition. In this assessment, her ADLs for chair/bed-to-chair transfer were coded as 88, meaning the activity was not attempted due to medical condition or safety concerns, while sit-to-lying and lying-to-sitting on the side of the bed were coded as requiring substantial/maximal assistance. However, the resident’s care plan documented that she required two staff for chair/bed-to-chair transfers and substantial/maximal assistance with two staff for lying to sitting on the side of the bed and sit to lying. During interviews and record review, the MDS nurse acknowledged that the code 88 for sit to stand and chair/bed-to-chair transfer was entered in error and stated that the correct code should have been 01, dependent, because the resident required two helpers and was not bedridden. The DON confirmed that the resident liked to sit in her wheelchair during the day, was not bedbound, and that the 88 code on the MDS was incorrect. The DON stated it was the MDS nurse’s responsibility to ensure ADL codes were correct so staff would know the resident’s level of care. Review of the facility’s RAI guidance showed that GG170D (sit to stand) and GG170E (chair/bed-to-chair transfer) should be coded 01, dependent, when two helpers complete all the effort, further demonstrating that the resident’s MDS assessment was not accurately coded for these ADLs.
Care Plan Not Updated to Reflect Resident’s Current Therapeutic Diet
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan that reflected a resident’s current diet order. The resident was an elderly male with multiple diagnoses including cerebral infarction, chronic heart failure, type 2 diabetes, dementia, urinary tract infection, hypertension, muscle wasting and atrophy, dysphagia, and lack of coordination. His MDS assessment showed a BIMS score of 1, indicating severe cognitive impairment, and documented the need for a mechanically altered and therapeutic diet. The care plan, initiated earlier, identified a potential nutritional problem related to diet restrictions and listed interventions of a no added salt, mechanical soft texture diet with regular liquid consistency. Record review showed that the physician’s order for the resident’s diet had been changed to no added salt, pureed texture, with nectar thickened liquids, with a start date of 02/03/26, but the care plan dated 03/11/26 was not updated to reflect this change. Multiple staff interviews, including with the MDS nurse, ADONs, DON, and administrator, confirmed that the resident’s diet had been changed following a speech evaluation and that the care plan should have been updated to show the pureed texture and nectar thickened liquids. Staff acknowledged that the kitchen and staff followed the diet orders rather than the care plan and reported no negative outcome for the resident, but consistently stated it was important for the care plan to contain the current diet information because it communicates the resident’s needs and how to care for him. The facility’s own Comprehensive Care Plans policy required comprehensive care plans with measurable objectives and timeframes to meet residents’ needs as identified in the assessment.
Failure to Maintain Accurate EBP Orders in Clinical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident who required Enhanced Barrier Precautions (EBP). The resident was an elderly female with Alzheimer’s disease, chronic kidney disease, and heart failure, with a severely impaired cognition reflected by a BIMS score of 4 on a quarterly MDS. Her care plan, updated on 01/18/26, identified a need for EBP due to a history of ESBL in the urine and MRSA in a sacral wound, and included interventions such as placing her on EBP, posting signage on the door, and using gown and gloves for high-contact care activities, with additional use of mask and eye protection as indicated. The MDS did not address any care issues that would require EBP. During observations and interviews on 02/04/26, the MDS-RN, Infection Preventionist (IP), and DON each confirmed that the resident had a history of ESBL and MRSA and should remain on EBP, and that signage and supplies were in place. However, review of the electronic medical record by the MDS-RN and IP revealed there was no active physician order for EBP; the prior EBP order had been discontinued on 01/23/26, and the IP did not know why it had been discontinued and stated it may have been in error. The IP acknowledged it was his responsibility to ensure all residents on EBP had an order and that he had missed this during his weekly reviews. The facility’s “Documentation in Medical Record” policy required that each resident’s medical record contain an accurate representation of the resident’s experiences and complete, accurate, and timely documentation of assessments, observations, and services, which was not met in this case because the resident’s ongoing need for EBP was not supported by an active order in the clinical record.
Failure to Supervise Cognitively Impaired Resident with Vehicle Access
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and implement necessary interventions to prevent accidents for a resident with Alzheimer's disease and moderately impaired cognition. The resident, who had a history of forgetfulness and required assistance with activities of daily living, was able to leave the facility multiple times without staff awareness or proper sign-out procedures. On several occasions, the resident left the premises in a personal vehicle, including one incident where he traveled to another city and another where he was found lost and returned by police. Despite these incidents, the resident's care plan did not initially include interventions addressing his access to a vehicle or his ability to drive. The facility's records showed that the resident's cognitive impairment and diagnosis of Alzheimer's were known, and staff were aware that he required supervision and cues for safety. However, after the resident left the facility and drove significant distances without staff knowledge, there were no immediate updates to his care plan to address the risk associated with his access to a vehicle. Interviews with staff and family confirmed that the resident was able to leave the facility unsupervised, and staff were not consistently verifying sign-out and return procedures. The resident's responsible party and staff expressed concerns about his ability to drive safely due to his cognitive deficits. The facility's policy required assessment and care planning for residents at risk of elopement or unsafe wandering, but these measures were not effectively implemented for this resident. Staff interviews revealed gaps in communication and understanding of protocols related to resident supervision and sign-out procedures. The lack of timely interventions and supervision allowed the resident to repeatedly leave the facility and operate a vehicle, despite clear risks associated with his medical condition and cognitive status.
Removal Plan
- Resident #1 received a head-to-toe assessment.
- Resident #1 was placed on 1:1 monitoring.
- The physician was notified and lab orders were obtained with no abnormalities noted.
- The care plan was updated with updated interventions of 1:1 monitoring, documenting exit seeking behaviors, and laboratory studies were completed.
- The vehicle belonging to Resident #1 which was on the premises was removed by resident's Relative Z and moved to her premises.
- Resident #1 has not driven a vehicle.
- The employee monitoring the reception desk was suspended and returned to work.
- Staff member was provided with 1:1 education on following proper out on pass process.
- Nursing administration conducted a facility wide audit of all current residents to determine if any residents were operating personal vehicles that were on the facility's premises.
- The facility completed an audit of all residents wandering evaluations.
- No new residents found at risk for wandering/elopement.
- The center developed and implemented a process to ensure safe and proper leaves of absence for residents: the center developed and implemented a Front Door Safety & Sign-Out Procedure.
- Staff members who assist with front desk reception duties were educated on the new process of Front Door Safety & Sign-Out Procedure to include competency check off.
- The facility initiated 100% reeducation on Elopement Protocols and the supervision of residents and ANE.
- The facility initiated 100% reeducation with the Charge Nurses on the process of Front Door Safety & Sign-Out Procedure.
- The training of direct care staff was completed in person or via telephone.
- Those that were not scheduled completed reeducation prior to accepting assignment for the next scheduled work.
- Verification of 100% of direct care staff education was verified by the Director of Nursing/ designee.
- Employee roster was utilized to validate completion.
Failure to Timely Report Resident Incident to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of an incident involving a resident with Alzheimer's disease, moderately impaired cognition, type 2 diabetes, malnutrition, and hypertension. The resident left the facility in his own vehicle, became lost, and was returned by a police officer. Upon return, the resident was unable to recall the incident, and his responsible party was notified by the police officer. The incident was documented in the resident's progress notes and care plan, which was updated to address the resident's inability to return to the facility without assistance and to remove access to vehicle keys. Despite facility policy requiring all alleged violations involving abuse, neglect, or exploitation to be reported to the Administrator and state agency within specified timeframes, the Director of Nursing (DON) did not notify the Administrator of the incident, citing the resident's safe return and lack of injury as reasons. The Administrator was not made aware of the incident until days later and did not report the event to the state survey agency (HHSC) for similar reasons. Review of the Texas Unified Licensure Information Portal (TULIP) confirmed that no incident report corresponding to this event was submitted by the facility. Interviews with facility staff and the resident's responsible party confirmed the sequence of events and the lack of timely notification to both the Administrator and the state agency. Facility policy specifically required reporting of such incidents within 24 hours, even if the event did not involve abuse or result in serious bodily injury. The failure to report the incident as required constituted a deficiency in the facility's compliance with state regulations regarding the reporting of alleged violations.
Failure to Prevent Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to protect multiple residents from abuse, neglect, and exploitation, as evidenced by several resident-to-resident altercations resulting in physical injuries. Two residents with a history of verbal and physical aggression toward each other engaged in altercations on more than one occasion, leading to minor injuries such as skin tears and scratches. Documentation shows that both residents had care plans identifying their potential for aggression, but despite interventions such as environmental modifications and medication reviews, altercations still occurred in common areas like the hallway and dining room. Staff interviews confirmed that these incidents were witnessed, and that the residents involved would taunt and provoke each other, with staff sometimes intervening only after the altercations had escalated. Another incident involved a resident with severe cognitive impairment who wandered into another resident's room and was struck by an electric wheelchair, resulting in a skin tear. The resident who operated the wheelchair had intact cognition but significant physical limitations and required supervision when using the motorized device. Despite care plans noting the need for supervision and the potential for physical aggression, the incident occurred when the resident with cognitive impairment became confused and entered the wrong room. Staff interviews indicated that the cognitively impaired resident frequently wandered and became confused, and that she had been involved in other incidents that required investigation. The report details that the facility's policies require protections against abuse, neglect, and exploitation, including screening prospective residents and implementing interventions for those at risk. However, the documented events show that these measures were insufficient to prevent resident-to-resident altercations and injuries. Staff accounts reveal that attempts to separate residents or modify their environment did not always prevent further incidents, and that some staff were not immediately available to intervene during altercations.
Failure to Develop and Implement Comprehensive, Measurable Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for three residents. For two residents with a history of escalating verbal altercations that progressed to physical altercations, the care plans did not address the earlier verbal incidents, despite documentation in progress notes and incident reports. The care plans were only updated after physical altercations occurred, omitting interventions or objectives related to the ongoing verbal conflicts that had been documented for months prior. One resident, with diagnoses including cerebral infarction and altered mental status but intact cognition, was involved in multiple verbal and physical altercations with another resident. Despite progress notes and investigation reports documenting these incidents, the care plan failed to address the verbal altercations that preceded the physical events. Similarly, the other resident involved, who had moderate cognitive impairment and multiple mental health diagnoses, also had a care plan that did not address the ongoing verbal altercations, even though these were documented in progress notes and incident logs. Additionally, a third resident with a recent surgical wound following hip fracture repair did not have wound care interventions included in her care plan, despite physician orders for specific wound care and documentation of the surgical wound in her assessment. Interviews with facility staff confirmed that wound care should have been included in the care plan and that its omission could lead to communication breakdowns regarding the resident's care. The facility's policy requires comprehensive care plans to include measurable objectives and interventions for all identified needs, but this was not followed for the residents in question.
Inaccurate MDS Assessment Following Resident Fall with Major Injury
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status, specifically for one resident who had experienced a fall resulting in a major injury. The resident, an elderly female with multiple diagnoses including a displaced intertrochanteric fracture of the left femur, vascular dementia, and a history of falling, was readmitted to the facility following a hospital stay. Hospital records indicated that she had sustained a ground-level fall and subsequently underwent surgery to repair a left hip fracture caused by another unwitnessed fall in her room. Upon review, the resident's admission MDS assessment did not indicate that she had a fall resulting in a major injury, despite clear documentation in hospital and facility records. The MDS nurse responsible for completing the assessment acknowledged that she had coded the fall with major injury on the discharge MDS, but did not answer affirmatively to the fall-related questions on the reentry MDS. The nurse stated that these questions should have been answered "yes" and recognized that failing to do so could affect the resident's care plan, as falls not triggered on the MDS for a new resident would not appear as high risk on the care plan. The facility did not have a specific policy for ensuring the accuracy of MDS assessments and instead referred to the Resident Assessment Instrument (RAI) manual for guidance. The RAI manual requires a thorough review of the resident's history, including falls and fractures in the six months prior to admission, using information from the resident, family, transfer records, and medical documentation. In this case, the required information was available but not accurately reflected in the MDS assessment.
Failure to Document Suprapubic Catheter Output as Ordered
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with a suprapubic catheter, as required by accepted professional standards and physician orders. Specifically, the urine output for the resident was not documented for four consecutive days, despite clear orders to check and record catheter output every shift. The resident's care plan and physician orders both specified the need for regular monitoring and documentation of urine output, but review of the Medication Administration Record (MAR) and progress notes confirmed the absence of this documentation for the specified period. Interviews with the Assistant Director of Nursing (ADON), Director of Nursing (DON), and a CNA revealed that staff were aware of the documentation requirements but could not explain the lack of entries for those days. The resident involved had a history of neuromuscular dysfunction of the bladder, chronic heart failure, and type 2 diabetes, and required substantial assistance with activities of daily living. She had a suprapubic catheter and colostomy bag due to incontinence, and her care plan included specific interventions for catheter care and monitoring. Despite in-service training on catheter changes and PPE, there was no evidence that staff were trained on the importance of documenting urine output. The DON confirmed that no documentation could be found for the missing days and acknowledged the facility followed the Lippincott Manual of Nursing Practice for catheter care procedures.
Failure to Administer Blood Pressure Medication Within Prescribed Time Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering a blood pressure and pulse-altering medication, Midodrine, within the prescribed time parameters as ordered by the physician. The physician's order specified that Midodrine should be given three times daily for hypotension, held if systolic blood pressure was 130 or above, and not administered after the evening meal or within four hours of bedtime. Despite these clear instructions, documentation showed that the medication was administered on multiple occasions late in the evening, well after the designated time frame following the evening meal. Record review indicated that the resident had significant medical conditions, including Type 2 diabetes, dementia with severe cognitive impairment, high blood pressure, coronary artery disease, and acute kidney failure. The resident's care plan included interventions to administer hypotension medications as ordered and to monitor for side effects and effectiveness. However, medication administration records and blood pressure logs revealed that Midodrine was given outside the prescribed parameters on several dates, with administration times ranging from approximately 8:30pm to 9:20pm, despite dinner being served at 5:00pm. Interviews with medication aides and the DON confirmed that staff were aware of the physician's orders and the importance of timely administration and accurate documentation. Both staff members acknowledged that the medication should not have been given after 6:00pm and that accurate documentation was necessary for monitoring the resident's response to the medication. The DON also noted that the facility's system did not alert staff if the medication was given late, and that audits were conducted, but the issue persisted. Facility policies required medications to be administered as ordered and documentation to be accurate and timely, but these were not followed in this case.
Failure to Document Vital Signs in MAR for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to maintain complete and accurate clinical medical records for one resident, specifically by not documenting vital signs in the Medication Administration Record (MAR) over a period of several weeks. The resident in question was an elderly female with multiple diagnoses, including Type 2 diabetes, dementia, high blood pressure, coronary artery disease, and acute kidney failure. Her care plan required monitoring and documentation of blood pressure due to her condition and prescribed medications, including Midodrine, which was to be held if systolic blood pressure was 130 or above. Record review showed that vital signs were not documented in the MAR from 10/01/25 to 10/24/25, despite physician orders and care plan interventions requiring this information. Interviews with medication aides and the Director of Nursing confirmed that there were issues with the documentation system and that staff were aware of the importance of accurate and timely documentation of vital signs. The facility's own policy required factual, complete, and timely documentation in the medical record, which was not followed in this instance.
Failure to Maintain Sanitation and Food Safety in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to maintain proper sanitation and food safety standards in the kitchen. Specifically, the juicer's nozzle dispenser was found to have red, yellow, and white slimy substances present, indicating it was not adequately cleaned. Additionally, the vegetable refrigerator contained an uncovered clear plastic box with a label, holding 12 cucumbers that exhibited brown, white, and black spots, as well as soft spots that made them difficult to handle. The box did not have a lid, and the cucumbers were not properly stored. During interviews, the Dietary Manager (DM) acknowledged difficulties in removing the juicer nozzle for cleaning but stated it was supposed to be cleaned daily. The DM was unaware of the slimy substances and did not recognize the potential negative outcomes for residents. The DM also had not noticed the spoiled cucumbers and stated they would be discarded. Review of cleaning schedules indicated that the juice machine and refrigerators were marked as cleaned, and the facility's food storage policy required all refrigerated foods to be dated, labeled, and tightly sealed in covered containers, which was not followed in this instance.
Failure to Provide Ordered Oxygen Therapy and Maintain Humidifier
Penalty
Summary
A deficiency occurred when a resident with chronic respiratory failure, hypoxia, and COPD, who was dependent on supplemental oxygen, did not receive respiratory care consistent with professional standards. The resident had a physician's order for oxygen at 3 liters per minute (lpm) via nasal cannula, but during observation, the oxygenator was set at 5 lpm and the humidifier was empty. The resident was awake, using the nasal cannula, and did not display signs of respiratory distress at the time of observation. A licensed vocational nurse (LVN) confirmed the oxygen setting was incorrect and the humidifier was empty, acknowledging she had entered the resident's room twice earlier in her shift but failed to check the oxygen settings and humidifier. The Director of Nursing (DON) stated it was the nursing staff's responsibility to ensure oxygen was set as ordered and the humidifier was filled, and also noted that the facility did not have a policy regarding oxygen administration.
Failure to Complete Discharge MDS Assessment for Resident
Penalty
Summary
The facility failed to complete a discharge Minimum Data Set (MDS) assessment for one resident who was reviewed for resident assessments. The resident, a female with multiple diagnoses including hypertension, dementia, aphasia, epilepsy, myocardial infarction, and muscle contracture, was admitted and later discharged to another facility. Record review showed that while her annual MDS was completed, no discharge MDS was found in her records. Interviews with MDS staff confirmed that the discharge MDS was not completed, despite acknowledging that it is a required process for all residents upon discharge. Staff members, including MDS coordinators, the ADON, DON, and the Administrator, indicated that they did not believe the lack of a discharge MDS would negatively affect the resident's care at the receiving facility, as other clinical information and reports were provided during the transfer. However, the absence of the required discharge MDS assessment was confirmed through both record review and staff interviews, constituting a failure to conduct a complete assessment of the resident's functional capacity at discharge as required by regulations.
Failure to Develop Comprehensive Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with an active diagnosis of post-traumatic stress disorder (PTSD). Despite the resident's admission records and quarterly MDS assessment reflecting an active diagnosis of PTSD, the care plan did not include any problems, goals, or interventions related to this condition. Interviews with staff revealed that the diagnosis was not care planned because the resident had not displayed symptoms or triggers since admission and was not receiving treatment for PTSD. The social worker and MDS staff both indicated that, in the absence of observed behaviors or reported triggers, they did not include PTSD in the care plan, even though the diagnosis was present in the medical record. The resident in question was an elderly male with severe cognitive impairment, as indicated by a BIMS score of 5, and additional diagnoses of age-related physical debility and depression. Observations and record reviews confirmed that the resident was bed bound, non-interviewable, and had not exhibited any PTSD-related behaviors since admission. Staff interviews further confirmed that no triggers or symptoms had been identified by the resident, family, or staff, and no interventions had been implemented to address PTSD. The facility's own policy required individualized interventions for trauma survivors, but this was not reflected in the resident's care plan.
Failure to Address Resident's Refusal of Care in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and time frames to meet the resident's physical, mental, and psychosocial needs. The deficiency was identified for a resident who had a history of refusing care, specifically showering, which was not addressed in the care plan. The resident, who had diagnoses including heart failure, neuromuscular dysfunction of the bladder, delusional disorders, dementia, cellulitis, and dermatitis, required substantial assistance with activities of daily living (ADLs) such as toileting, showering, dressing, and personal hygiene. The resident's care plan, initiated in April 2024, did not include a plan for the specific behavior of shower refusal or other ADLs. The bathing logs for November and December 2024 indicated that the resident consistently refused showers, yet this behavior was not documented in the care plan. Interviews with the treatment nurse and CMS nurse revealed that the resident's refusal of care was known, but the behavior was not incorporated into the care plan. The CMS nurse acknowledged that the refusal behavior should have been care planned and that interventions should have been included to address the resident's needs. The facility's policy required comprehensive care plans to describe services to be furnished to attain or maintain the resident's well-being, including services not provided due to the resident's refusal. However, the care plan for the resident did not reflect these requirements, leading to a deficiency in meeting the resident's needs. The CMS nurse and DON recognized the importance of care planning for refusal behaviors to ensure appropriate care and interventions, but this was not executed in the resident's care plan.
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 176 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Edinburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hidalgo Nursing And Rehabilitation Center | 0.6 mi | ★★★★★ | 11 | 0 |
| Colonial Manor Advanced Rehab & Healthcare | 1 mi | ★★★★★ | 6 | 0 |
| Windsor Nursing And Rehabilitation Center Of Edinb | 2.6 mi | ★★★★★ | 11 | 0 |
| Windsor Arbor View | 3.4 mi | ★★★★★ | 11 | 1 |
| Mcallen Nursing Center | 3.8 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Edinburg Nursing And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.