Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mineral Wells Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with BPH, obstructive uropathy, and a recent UTI had an indwelling Foley catheter, but the comprehensive care plan did not address the catheter or its related risk factors. Nursing notes showed the catheter was present after hospital readmission, later required an ED visit after bleeding with Foley placement, and was replaced in the ED. The DON acknowledged the catheter was not added back to the care plan, and the RRS stated the catheter was only listed under enhanced barrier precautions without catheter care approaches.
A resident with urinary incontinence and an indwelling Foley catheter had no order in the MAR specifying the catheter type, size, or clinical indication for use. The record showed BPH, obstructive uropathy, and a recent UTI, while nursing notes documented catheter placement, bleeding after Foley placement, ER replacement of the Foley, and ongoing catheter care orders. The DON stated the order was not entered completely and that the facility had no specific policy for catheter orders.
Staff failed to take the temperature of banana pudding before serving and did not perform required hand hygiene when preparing food, as observed by surveyors. The cook and other staff did not follow established protocols for food safety and hand washing, despite having received prior training and reminders.
A resident with severe cognitive impairment and significant physical limitations was found without access to a working call light, as it was on the floor behind the bed and out of reach. Staff interviews confirmed the call light should have been accessible and attached to the resident, but it was not, and there was no policy in place regarding call lights.
A resident with a right patella fracture was admitted without a physician order for a knee immobilizer, despite hospital instructions and physician notes indicating its necessity. Staff applied the immobilizer based on verbal direction, and the omission was not identified during order reconciliation, resulting in the resident's care plan lacking documentation for the device.
The facility did not post daily nurse staffing information in a prominent and accessible location, with the most recent posting outdated by over a month. The DON was responsible for posting but failed to do so, keeping records in a binder not accessible to residents or visitors. Staff were unclear about who was responsible for ensuring the posting, and the facility's policy requiring daily posting was not followed.
A resident with moderate cognitive impairment was approached by a facility associate (AP) who borrowed money under false pretenses, claiming a personal emergency. The resident and their POA agreed to loan the money, but the AP failed to repay the full amount and avoided further contact. The facility confirmed the misappropriation through an investigation and terminated the AP's employment, notifying the police of the incident.
Failure to Include Indwelling Catheter Care in the Care Plan
Penalty
Summary
Resident #9’s comprehensive care plan did not address his indwelling urinary catheter needs or the associated risk factors. The resident was a [AGE]-year-old male with diagnoses including bowel obstruction surgical aftercare, UTI, edema, type 2 diabetes mellitus, benign prostatic hyperplasia, and obstructive and reflux uropathy. His admission MDS dated 4/05/2026 indicated a BIMS score of 10 out of 15, an indwelling bladder catheter, and diagnoses of BPH and obstructive uropathy. The resident’s nursing notes showed that he was readmitted from the hospital on 4/02/2026 after surgery for a bowel obstruction, and the note documented a catheter with a 16F/10 ml size. On 4/12/2026, he was transferred to the hospital related to bleeding after Foley placement, then returned from the emergency department with the Foley catheter replaced and blood in the catheter drainage bag. On 4/13/2026, he was ordered Amoxicillin-Potassium Clavulanate for UTI, and the order summary included instructions to empty the drainage bag every shift, change the Foley for occlusion or leakage or if the closed system was compromised, keep the Foley bag in a privacy bag while in bed or in a wheelchair, and ensure the catheter strap was in place. The comprehensive care plan, initiated 3/13/2025 and reviewed 4/28/2026, did not include the resident’s current urinary catheter use or the related risk factors. During interview, the resident stated the catheter had been placed while hospitalized because his bladder was not emptying, and observation showed amber urine with a slight amount of sediment in the tubing. The DON stated the resident had a catheter and had wanted it removed, acknowledged the catheter had been replaced in the emergency room, and stated she did not know why the catheter had not been added back to the care plan. The Regional Reimbursement Specialist reviewed the plan and stated the catheter was only included under enhanced barrier precautions, with no catheter care approaches, and that a care plan addressing the indwelling urinary catheter and associated risk factors should have been developed after the catheter was placed.
Missing Catheter Order Details and Clinical Indication
Penalty
Summary
The facility failed to ensure that a resident with urinary incontinence and an indwelling urinary catheter had a clinical condition documented to show the catheterization was necessary. Resident #9 was admitted with diagnoses including benign prostatic hyperplasia, obstructive and reflux uropathy, diabetes mellitus, edema, and a history of urinary tract infection. The resident’s record showed an indwelling bladder catheter on the MDS, and nursing notes documented that the resident was readmitted from the hospital after surgery for a bowel obstruction with a catheter in place, including a notation of catheter type and size in the nursing note. The resident’s order summary did not include an order specifying the type and size of the urinary catheter or the clinical indication for its use. Although nursing notes documented catheter-related events, including transfer to the hospital after bleeding following Foley placement and return from the emergency department with the Foley replaced, the order summary only included catheter care instructions such as emptying the drainage bag, changing the Foley for occlusion or leakage, keeping the bag in a privacy bag, and ensuring the catheter strap was in place. The comprehensive care plan also did not address the resident’s urinary catheter use or associated risk factors. During interview, the resident stated the catheter had been placed while hospitalized because his bladder was not emptying. The DON reviewed the record and stated she did not see an order for the urinary catheter with a diagnosis. She also stated the admitting nurse was responsible for entering orders accurately and completely, and that failing to do so could result in missed care for the resident. The DON further stated there was no specific policy and procedure for catheters or entering catheter orders, and the facility could not find another policy related to entering physician orders into the electronic health record.
Failure to Follow Food Safety and Hand Hygiene Protocols in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to follow professional standards for food service safety in the kitchen. Specifically, the cook did not take the temperature of banana pudding before plating and distributing it for lunch service. The cook acknowledged forgetting to take the temperature, and the Dietary Manager (DM) confirmed that it was the cook's responsibility to do so before food left the kitchen. The DM also admitted she was responsible for monitoring this process but had assumed the task had been completed. Facility policy required that the temperature of all hot and cold foods be checked prior to meal service. Additionally, staff failed to perform proper hand hygiene while preparing food. The Assistant Director (AD) entered the kitchen, handled a can of tomato juice and an empty container, and poured the juice without washing her hands. The DM and the MIT (Management in Training) both stated that all staff should perform hand hygiene upon entering the kitchen, and the AD had previously received training and reminders regarding this requirement. Facility policy also required frequent hand washing by employees.
Failure to Ensure Accessible Call Light for Resident with Cognitive and Physical Impairments
Penalty
Summary
The facility failed to provide a working communication system that was easily accessible for a resident with severe cognitive impairment and significant physical limitations. On the date of observation, the resident's call light was found on the floor behind the bed, out of the resident's reach, and the resident was unaware of its location. The resident required maximal or total assistance for transfers, toileting, dressing, and transferring, and had a care plan intervention specifying that the call light should be within reach and the resident encouraged to use it for assistance as needed. Interviews with staff confirmed that the call light should have been attached to the resident or within reach, and that all staff were responsible for ensuring this. Staff acknowledged that the call light not being accessible could have resulted from new equipment being brought in by hospice, and there was no policy in place regarding call lights. The lack of a working, accessible call light system directly impacted the resident's ability to call for assistance.
Failure to Obtain Physician Order for Knee Immobilizer at Admission
Penalty
Summary
The facility failed to ensure that a physician's order was obtained for a knee immobilizer at the time of admission for a female resident with a recent right patella fracture. Despite hospital records indicating non-operative treatment with a knee immobilizer and weight bearing as tolerated, and a physician progress note stating the brace should be worn at all times, there was no evidence in the facility's records of an order for the knee immobilizer upon admission. The care plan also did not address the use of the knee immobilizer. Multiple observations confirmed the resident was wearing the knee immobilizer during her stay, and interviews with staff revealed that the immobilizer was applied based on verbal instructions rather than a documented physician order. The admitting nurse was responsible for entering orders from the hospital, but this was not completed, and subsequent order reconciliation did not identify the omission. Facility policy required physician orders to be reviewed and approved, but this process failed to ensure the necessary order was in place for the resident's immediate care needs.
Failure to Post Daily Nurse Staffing Information in Accessible Location
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted in a prominent and accessible location for residents and visitors. On one of the reviewed days, the posted staffing information was outdated by 40 days, with the most recent posting dated over a month prior. Interviews revealed that the Director of Nursing (DON) was responsible for posting the daily staffing information but had neglected to do so, instead keeping the records in a binder in her office. Other staff members, including the Assistant Director of Nursing (ADON) and the staffing coordinator, were identified as having roles in posting or monitoring the information, but there was confusion and lack of clarity regarding who was ultimately responsible for ensuring the posting was completed daily. Staff interviews indicated that while employees could access staffing information from a binder, this method was not accessible to residents or visitors, who would not know to look there. The interim administrator confirmed that there was an expectation for daily posting but was unsure of the monitoring process. The facility's documented policy required daily posting of staffing by shift, but this was not followed, resulting in the deficiency.
Misappropriation of Resident's Funds by Facility Associate
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when an associate, referred to as AP, borrowed money from the resident for personal benefit. The resident, who had a moderate cognitive impairment with a BIMS score of 11 out of 15, was approached by the AP who claimed to have no heat at home. Feeling sympathetic, the resident and their Power of Attorney (POA) agreed to loan the AP money with the understanding that it would be repaid on payday. The transactions were conducted via CashApp, with a total of $310 sent to the AP. However, the AP only repaid $80 and subsequently avoided further contact with the resident. The incident was not initially reported to the facility, as it was considered a private matter between the resident, their POA, and the AP. It was only after the AP failed to repay the full amount that the POA informed the facility's Assistant Administrator and Administrator. Upon investigation, the facility confirmed the misappropriation of funds through phone records and terminated the AP's employment. The police were notified, and a report was filed, but the AP's whereabouts remained unknown.
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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 Mineral Wells
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palo Pinto Nursing Center | 0.2 mi | ★★★★★ | 0 | 0 |
| Avir At Keeneland | 19.5 mi | ★★★★★ | 9 | 0 |
| Avir At Weatherford | 19.9 mi | ★★★★★ | 12 | 2 |
| Peach Tree Place | 20.4 mi | ★★★★★ | 6 | 0 |
| College Park Rehabilitation And Care Center | 21.2 mi | ★★★★★ | 3 | 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 October 2026) and official state health department websites.