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 Rockdale Estates & Rehabilitation during CMS and state inspections, most recent first.
QAPI Committee Lacked Required Medical Director Attendance: The facility failed to maintain a QAPI committee with the required members present for most meetings reviewed. Record review showed the Medical Director was absent from seven of eight QAPI meetings, and staff interviews confirmed the MD was not normally present even though the DON stated all department heads were required to attend. The Administrator said the committee met monthly, but he was unaware of any effect on residents from the MD's absence.
A resident with severe cognitive impairment and multiple neurologic diagnoses was verbally abused by a CNA after the resident kicked toward the CNA in her room. Video showed the CNA turn back, point at the resident, and say, “I’m going to f*** you up.” Facility interviews confirmed the statement was made and identified it as verbal and emotional abuse; no physical contact was observed on the video.
A resident with diagnoses including major depressive disorder, PTSD, suicidal ideation, and hemiplegia had PASRR Level I screenings that indicated no mental illness, and no PASRR Level II assessment was completed. The MDSC stated she did not think the resident met criteria for a mental health diagnosis, while the Administrator stated that major depressive disorder and PTSD would trigger a positive PASRR screen and further review.
A resident with bladder neck obstruction, acute kidney failure, and dementia repeatedly pulled on his catheter, disconnected the tubing from the bag, and put the tubing in his mouth. Staff, including CNAs, RN, the ADON, MDSC, and DON, described the behavior as ongoing and discussed it in meetings, but the resident's care plan did not include the catheter-related behaviors or interventions. The facility policy required a comprehensive, person-centered care plan with measurable objectives and interventions, but the plan did not address these needs.
Cold Meal Service and Inadequate Food Temperature Control: Two residents received breakfast trays with food served below the facility’s required hot-holding temperature, and one resident reported breakfast often arrived late and not hot. A test tray showed sausage links and scrambled eggs well below 135 F, while the DTM stated residents had complained about cold food and that trays for multiple halls were being placed together on one cart for delivery. One resident with moderate cognitive impairment and malnutrition risk and another resident with intact cognition both reported the food was cold, though coffee was hot.
A resident with severe cognitive impairment and a history of falls was found walking without her walker, resulting in a fall and significant injuries. Despite the care plan indicating the need for supervision, staff left the resident unattended, leading to the incident.
The facility failed to maintain kitchen sanitation and adhere to food safety practices. The Dietary Manager did not wear a hair net near clean dishes, and the kitchen equipment, including ovens and a fryer, was not cleaned as required. Additionally, the Dietary Manager did not follow proper hand sanitation procedures, risking food contamination.
The facility failed to provide adequate personal hygiene care for three residents, resulting in long, unclean fingernails despite care plans indicating the need for assistance. Observations and interviews revealed inconsistencies in nail care responsibilities among staff, leading to potential risks of infection and injury.
The facility failed to provide individualized activities for three residents with severe cognitive impairments, as required by their care plans. Despite the need for one-on-one activities to support their well-being, there was no documentation of participation for several months. Observations showed residents lying in bed without engagement, and staff interviews confirmed the lack of activity involvement.
QAPI Committee Lacked Required Medical Director Attendance
Penalty
Summary
The facility failed to maintain a quality assessment and assurance committee with the required members present for seven of eight QAPI meetings reviewed. Record review showed the Medical Director was absent from the September 2025, October 2025, December 2025, February 2026, March 2026, April 2026, and May 2026 meetings, and only attended the January 2026 meeting. The report also noted that the committee was expected to include required members and meet at least quarterly. During interviews, the DON stated that all department heads were required to attend QAPI meetings along with the owner/administrator, but said the Medical Director was not usually in the meetings and responded, "Not really," when asked if attendance was required. The ADON/Infection Preventionist stated the committee included the DON, ADON, Wound Nurse, MDSC, Administrator, and Director of Rehabilitation, and said the Medical Director was not normally present. The Administrator stated the committee met monthly and that if a required member could not attend, the meeting would likely be postponed, but he was unaware of any effect on residents related to the Medical Director's absence.
Verbal Abuse Toward a Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure a resident with severe cognitive impairment was free from verbal abuse by a CNA. The resident was an 82-year-old female with diagnoses including post-polio syndrome, sequelae of cerebral infarction, and cerebral aneurysm. Her MDS showed severe cognitive issues, and her care plan identified behaviors of agitation and anxiety. Video from the resident’s room showed the CNA pulling the resident into the room in a wheelchair, then leaving the room as the resident kicked toward her and made an unintelligible statement. The CNA stopped, turned back toward the resident, pointed her finger toward the resident’s upper body, and said, “I’m going to f*** you up.” The video did not show physical contact between the CNA and the resident, but the statement and gesture were documented as verbal abuse and emotional abuse by facility leadership and staff. The incident was reported to the facility after the resident’s family provided the video. The resident was assessed and no immediate visible injuries were noted; bruising on both arms was documented as being in various stages of healing and determined to be pre-existing. Interviews with the ADON, RN, CNA, Administrator, SW, and the resident’s RP confirmed the statement was made and that the CNA knew the comment was inappropriate. The resident later did not recall the event and did not report being hurt or upset during interviews.
PASRR Screening Not Completed Accurately for Resident With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the PASRR Level I screening for one resident with mental health diagnoses was completed accurately and that the resident was provided a PASRR Level II assessment. Resident #19’s record showed diagnoses including major depressive disorder, single episode, unspecified, post-traumatic stress disorder, insomnia, suicidal ideation, and hemiplegia and hemiparesis following unspecified cerebrovascular disease. The resident’s annual MDS reflected a BIMS score of 14, indicating intact cognition, and also showed that he was taking an antidepressant. The PASRR Level I screening completed by the referring facility’s RN case manager on 04/08/2025 indicated that the resident did not have a mental illness, and the PASRR Level I screening entered into the resident’s record by the facility’s MDSC on 05/01/2026 also indicated no mental illness. During interviews, the MDSC stated the resident did not meet criteria for a mental health diagnosis and was not referred because she did not think he met the criteria, while the Administrator stated that diagnoses such as Major Depressive Disorder and PTSD would trigger a positive PASRR screen and require further review. The facility policy stated that a Level I screening is to identify serious mental illness, intellectual disability, or related conditions, and that a Level II evaluation is required when Level I is positive.
Failure to Care Plan Repeated Catheter Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one resident with repeated catheter-related behaviors. The resident was a male admitted with bladder neck obstruction, acute kidney failure, and dementia. Staff reported that he repeatedly pulled on his catheter, disconnected the catheter tubing from the bag, and put the catheter tubing in his mouth. CNA D stated the behavior had been occurring for about a month and a half and that CNAs reported it to nurses several times. She also stated CNAs were not involved in care plans and used the Kardex for resident needs. Record review showed the resident's care plan did not include any focus or interventions for pulling on the catheter, putting the catheter in his mouth, or disconnecting the tubing from the catheter bag. During interviews, the MDSC stated the behavior should have been care planned and said the IDT discussed the resident's catheter behavior on 05/25/2026, but she became distracted. The ADON stated the resident had a behavior of taking his catheter tubing out of his pants and fiddling with every part of the catheter, and said the behavior should be care planned. RN A stated the resident had developed a behavior of drinking the urine out of his catheter and had taken the catheter apart and put the bag in the sink. RN A said these issues were first discussed in the facility daily meeting about 3 weeks earlier when the resident had a UTI diagnosis. The DON stated the resident had been pulling on his catheter and removing the tubing from the bag for about a year and that the behavior had been mentioned at IDT meetings, and she agreed it should have been care planned. The facility policy required a comprehensive, person-centered care plan with measurable objectives and interventions, but the resident's care plan did not address these catheter behaviors.
Cold Meal Service and Inadequate Food Temperature Control
Penalty
Summary
The facility failed to ensure food and drink were palatable, attractive, and served at a safe and appetizing temperature for two residents who were reviewed for dietary services. Resident #79 was a female with diagnoses including major depressive disorder, hypokalemia, and muscle wasting and atrophy, and her quarterly MDS reflected a BIMS of 12, indicating moderate cognitive impairment and risk of malnutrition. Resident #19 was a male with diagnoses including hemiplegia and hemiparesis following cerebrovascular disease, major depressive disorder, insomnia, PTSD, and suicidal ideation, and his annual MDS reflected a BIMS of 14, indicating intact cognition. During observation and interview, Resident #79 stated breakfast often did not arrive until around 9:15 AM and was not hot. On 06/03/2026, a test breakfast tray was observed at 8:55 AM, and the food temperatures were 94.3 degrees Fahrenheit for two sausage links and 91.6 degrees Fahrenheit for scrambled eggs; the pancake was cool to touch. At 9:10 AM, Resident #79 was observed with the breakfast tray and had only eaten a piece of pancake, stating the food was cold and not inspiring, while the coffee was hot. Resident #19 was observed at 9:17 AM with breakfast and had not eaten his eggs; he stated the food was cold but edible. Another resident stated the food was not hot but warm, and the coffee was good and hot. The DTM stated some residents complained that food was cold upon receipt and explained that room trays for multiple halls were now placed together on one cart for delivery. She also stated the facility had tried different plates, but they did not improve food temperature, and the facility had not yet purchased different carts designed to better maintain food temperatures. The facility policy required hot foods to remain above 135 F during service and temperatures to be checked before service.
Failure to Supervise Resident Leading to Fall
Penalty
Summary
The facility failed to provide adequate supervision for a resident with severe cognitive impairment, resulting in a fall with injuries. The resident, who has dementia and a history of falls, was found walking in the hallway without her walker. Despite staff being aware of her tendency to forget her walker and the need for supervision, the resident was left unattended, leading to a fall that caused significant injuries, including a large bruise and an orbital fracture. The resident's care plan indicated the need for supervision and reminders to use her walker, but staff interviews revealed that the resident frequently walked without her walker both in her room and in the hallway. On the day of the incident, a nurse saw the resident walking without her walker, instructed her to wait, and left to retrieve the walker. During this time, the resident continued walking, tripped, and fell, resulting in injuries that required hospital evaluation. Interviews with staff and family members confirmed that the resident often walked without her walker and needed frequent reminders. The facility's fall prevention policy was not effectively implemented, as evidenced by the resident's ability to walk unsupervised and the subsequent fall. The incident highlights a lapse in supervision and adherence to the resident's care plan, leading to preventable injuries.
Deficiencies in Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen. The Dietary Manager was seen entering the dishwashing room and standing by clean plates without wearing a hair net, despite the availability of hair nets at the kitchen entrances. This oversight was acknowledged by the Dietary Manager, who admitted the potential risk of hair contamination on clean dishes, which could lead to foodborne illnesses if ingested by residents. Additionally, the facility did not maintain the cleanliness of kitchen equipment, specifically the ovens and the deep fryer. Observations revealed a significant buildup of black and brownish substances in the ovens and crumbs and oil residue in the fryer. The Dietary Manager admitted that the ovens had not been cleaned weekly as required, and the fryer was not cleaned after each use, contrary to the facility's protocol. This lack of sanitation could result in cross-contamination of food, posing a risk of food poisoning to residents. Furthermore, the Dietary Manager failed to follow proper hand sanitation procedures during food preparation. After touching another person's clothing, which is considered contaminated, she did not change her gloves or sanitize her hands before continuing to handle food. This breach of hygiene protocol could lead to the contamination of food with bacteria from the clothing, potentially causing foodborne illnesses among residents.
Deficiency in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide necessary personal hygiene services to three residents, leading to deficiencies in grooming and nail care. Resident #69, a male with severe cognitive impairment and physical debility, was observed with long fingernails and brown debris underneath, despite records indicating they had been cleaned and trimmed. This discrepancy was noted over several days, highlighting a failure to adhere to the care plan requiring total assistance with personal hygiene. Resident #1, a female with intact cognitive status but blindness in one eye, required extensive assistance with personal hygiene. Despite a care plan indicating her need for assistance, she was observed with long, jagged fingernails and expressed a desire for them to be trimmed. This observation contradicted a weekly skin assessment that reported her nails as clean and trimmed, indicating a lapse in the provision of care as per her documented needs. Resident #59, a male with severe cognitive impairment, was observed with long fingernails and debris, despite requiring substantial assistance for personal hygiene. Interviews with staff revealed a lack of consistent responsibility for nail care, with night shift aides expected to trim nails during bathing. Staff acknowledged the risk of infection from dirty nails, yet the resident's nails remained untrimmed, suggesting a breakdown in communication and execution of care responsibilities across shifts.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to the needs and preferences of residents, as evidenced by the lack of one-on-one activities for three residents. Resident #43, a female with severe cognitive impairment and diagnoses including major depressive disorder and dementia, was not provided with the one-on-one activities she required. Despite her care plan indicating a preference for music and simple activities, there was no documentation of her participation in any activities for several months. Observations showed her lying in bed without any engagement, and staff interviews confirmed the absence of documented activity participation. Resident #46, a male with severe cognitive impairment and multiple diagnoses including vascular dementia and bipolar disorder, also did not receive the one-on-one activities outlined in his care plan. His care plan emphasized the need for diversional activities and assistance with communication, yet there was no record of his participation in activities for three months. Observations found him lying in bed without stimulation, and staff interviews corroborated the lack of activity engagement and documentation. Similarly, Resident #59, a male with severe cognitive impairment and diagnoses such as dementia and cerebral ischemia, was not provided with adequate one-on-one activities. His care plan highlighted the importance of outdoor activities and sensory engagement, but his activity participation was poorly documented, with only minimal engagement recorded in January. Observations and staff interviews indicated a lack of social interaction and activity engagement, which was acknowledged by the Activity Director and the facility's Administrator.
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What surveyors actually found near you
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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 Rockdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Winnie L Nursing & Rehabilitation | 16.1 mi | ★★★★★ | 4 | 0 |
| Legacy Nursing And Rehabilitation | 16.1 mi | ★★★★★ | 8 | 0 |
| Avir At Caldwell | 18.4 mi | ★★★★★ | 18 | 1 |
| Copperas Hollow Nursing & Rehabilitation Center | 20.9 mi | ★★★★★ | 2 | 0 |
| Spjst Rest Home 1 | 22.1 mi | ★★★★★ | 7 | 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.