Average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Skilled Care Of Mexia during CMS and state inspections, most recent first.
A resident with severe dementia and a high risk for elopement was able to leave the facility unsupervised after a visitor mistakenly allowed him to exit, despite posted signage and a care plan with interventions for wandering. Staff did not detect the resident's absence immediately, and he was later found by community members and transported to the hospital for evaluation.
A resident with multiple serious health conditions experienced severe weight loss that was not adequately monitored or addressed by the LTC facility. Despite having a care plan requiring weight monitoring and physician notification, the facility failed to implement effective interventions for the resident's nutritional needs. The resident lost 30 pounds over three months, and the facility did not act upon this significant weight loss, leading to a decline in the resident's health and eventual death from sepsis.
A resident with a history of diabetes and respiratory issues experienced severe weight loss over several months, which the facility failed to identify and address. Despite having a care plan for potential malnutrition, the facility did not implement necessary interventions or notify the physician. The resident's condition worsened, leading to hospitalization for aspiration pneumonia and severe malnutrition. The facility's failure to monitor and manage the resident's nutritional status was identified as a deficiency.
A resident with multiple health conditions experienced severe weight loss that was not accurately reflected in her assessments. The facility failed to implement timely dietary interventions, and staff interviews revealed missed opportunities to address the weight loss. The resident's death was attributed to sepsis, with allegations of neglect related to her nutritional care.
A CNA at a facility failed to knock or request permission before entering a resident's room, violating the resident's right to privacy and dignity. The resident, who has moderately impaired cognition and multiple medical conditions, expressed discomfort with staff entering unannounced. The facility's policy requires staff to knock and request permission, which was not followed in this instance.
The facility failed to label an opened vial of Tuberculin purified protein derivative (PPD) with an open date in the medication storage room refrigerator. An LVN confirmed that all open vials should be dated to ensure medication effectiveness, which is crucial for accurate TB skin test results. The DON and ADM acknowledged the importance of following policy, which states that multi-use vials expire 30 days after opening.
A resident with 13 missing teeth experienced difficulty eating certain foods, such as turkey, due to the facility's failure to adjust her care plan to accommodate her dietary needs. Despite informing the DON and former administrator, the resident's care plan did not reflect her challenges, and staff were not fully aware of the need for dietary modifications. The facility's policy requires a person-centered care plan, but this was not implemented for the resident, leading to the deficiency.
A CNA removed a resident's call light and bedside table from within her reach, preventing her from calling for assistance. The resident, who had multiple diagnoses and required extensive assistance, was left unable to call for help. The incident was reported by two LVNs, and the CNA was suspended and later terminated.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent the elopement of a resident with severe dementia and multiple comorbidities, including Alzheimer's disease, psychotic disorder, and unsteadiness on his feet. The resident was assessed as high risk for elopement, with a documented history of wandering and a care plan that included specific interventions such as distraction, structured activities, and staff notification if exit-seeking behavior was observed. Despite these interventions, the resident was able to leave the facility unsupervised. On the day of the incident, the resident was last seen in the TV area after returning from a smoke break with other residents and staff. The facility's front door was secured with a keypad and posted with signs instructing visitors not to allow residents to exit. However, there was no staff stationed at the door, and a visitor later reported that he had allowed the resident to exit with him, mistakenly believing the resident was another visitor. Staff did not hear any door alarms, and the resident was not immediately noticed missing. The resident was found by community members sitting outside less than 0.2 miles from the facility, confused and with a bandage on his eyebrow, and was subsequently transported to the hospital for evaluation. Interviews with staff and the resident's power of attorney revealed that the resident was generally considered redirectable and not expected to elope, despite his high-risk assessment. Staff described routine in-services on elopement prevention and response, but acknowledged that the resident was able to leave the facility undetected during a period of increased visitor traffic. The facility's elopement risk assessments and care plan interventions were not sufficient to prevent the resident's unsupervised exit.
Failure to Address Severe Weight Loss in Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and times to meet the resident's needs. The resident, who was diagnosed with multiple serious health conditions including diabetes mellitus type 2 with ketoacidosis, pneumonia, acute and chronic respiratory failure, experienced severe weight loss that was not adequately monitored or addressed by the facility. Despite having a care plan that required monitoring of the resident's weight and notifying the physician of any negative findings, the facility did not implement effective interventions to manage the resident's nutritional needs. The resident's weight loss was significant, with a loss of 30 pounds over three months, which was not addressed in a timely manner. The facility's records indicated that the resident's weight was supposed to be monitored monthly, and any significant weight changes were to be reported and addressed. However, the facility failed to identify and act upon the resident's severe weight loss, which was evident at multiple intervals. The resident's nutritional risk assessment highlighted numerous food intolerances and limited food choices, yet the facility did not develop a person-centered intervention to address these issues. Interviews with facility staff revealed discrepancies in the monitoring and recording of residents' weights, and the facility's failure to address the resident's weight loss was attributed to missed opportunities for intervention. The facility's policy required monthly weight reviews and interventions for significant weight changes, but these were not effectively implemented for the resident. The resident's severe weight loss was not discovered until much later, and by then, the resident's health had significantly declined, leading to her death from sepsis.
Failure to Address Severe Weight Loss in Resident
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, resulting in severe weight loss over several months. The resident, who had a history of diabetes mellitus type 2 with ketoacidosis, pneumonia, acute and chronic respiratory failure, experienced significant weight loss that was not identified or addressed at 30-day, 90-day, and 180-day intervals. Despite having a care plan in place to monitor and address potential malnutrition, the facility did not implement necessary interventions or notify the physician of the resident's weight loss. The resident's weight loss was documented as severe, with a loss of 30 pounds over three months, yet the facility failed to take timely action. The resident's nutritional risk assessment indicated numerous food intolerances and limited food choices, which were not adequately managed. Interviews with facility staff revealed discrepancies in weight monitoring and documentation, contributing to the oversight of the resident's nutritional decline. The resident's condition deteriorated, leading to hospitalization for aspiration pneumonia and severe protein-caloric malnutrition. Despite the facility's policy requiring monthly weight reviews and interventions for significant weight changes, these measures were not effectively implemented for the resident. The facility's failure to address the resident's weight loss and nutritional needs was identified as a deficiency, placing the resident at risk for further health complications.
Failure to Address Severe Weight Loss in Resident
Penalty
Summary
The facility failed to ensure that a resident's assessments accurately reflected her status, particularly concerning severe weight loss. The resident, a female with multiple serious health conditions including diabetes mellitus type 2 with ketoacidosis, pneumonia, and chronic respiratory failure, experienced significant weight loss that was not identified in her Quarterly MDS Assessment. Despite having a BIMS score indicating moderate cognitive impairment, the assessment inaccurately recorded her weight loss status, which could have indicated a risk of malnutrition. The resident's care plan included goals and interventions to maintain stable weight and nutritional parameters, but these were not effectively implemented. The facility's records showed that the resident lost 30 pounds over three months, yet the necessary dietary interventions were not initiated in a timely manner. Interviews with facility staff revealed that there were missed opportunities to address the resident's weight loss, and the facility's monitoring of weights was inadequate. The resident's death certificate indicated sepsis as the immediate cause of death, and there were allegations of neglect related to her nutritional care. Interviews with various staff members, including the ADON, DTCN, and MDSC, highlighted a lack of proper monitoring and intervention for the resident's weight loss. The MDSC admitted to errors in data entry regarding the resident's weight loss, and the facility's policy for monitoring weights was not followed. The facility's failure to address the resident's severe weight loss was attributed to human error and inadequate adherence to established protocols, which ultimately contributed to the resident's decline in health.
Failure to Respect Resident Privacy and Dignity
Penalty
Summary
The facility failed to uphold the resident's right to dignity and respect, as evidenced by the actions of CNA A, who entered a resident's room without knocking or requesting permission. This incident involved a female resident with a moderately impaired cognition, as indicated by a BIMS score of 12, and multiple medical conditions including type 2 diabetes mellitus, muscle wasting, chronic pain syndrome, hypertension, muscle weakness, and chronic obstructive pulmonary disease. The resident expressed discomfort with staff entering her room unannounced, as it could occur while she was undressing, leading to a potential invasion of privacy. During interviews, CNA A admitted to not being aware of her actions and acknowledged the importance of knocking before entering a resident's room to avoid startling them. Both the Director of Nursing (DON) and the Administrator (ADM) confirmed that staff are required to knock and request permission before entering a resident's room, as per the facility's Resident Right policy. The policy emphasizes treating residents with respect and dignity, ensuring their quality of life is maintained or enhanced. The failure to adhere to this policy was identified as a deficiency in promoting and maintaining the resident's rights.
Failure to Label Opened Medication Vials
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled in accordance with currently accepted professional principles, specifically in the medication storage room refrigerator. During an observation, it was noted that a vial of Tuberculin purified protein derivative (PPD) was open and not labeled with an open date. This oversight was confirmed during an interview with an LVN, who stated that all open vials should have a date opened either on the vial or on the box. The LVN expressed concern that using an undated vial could lead to uncertainty about the medication's effectiveness, potentially affecting the results of TB skin tests administered to staff and residents. The Director of Nursing (DON) and the Administrator (ADM) both acknowledged the expectation that all open medication vials be dated and timed per the current policy. The DON noted that while the PPD was primarily used on staff, residents also receive a TB skin test upon admission. The lack of an open date on the vial could result in the medication being less effective, exposing individuals to possible contaminants and false test results. The facility's policy, revised in 2012, specifies that multi-use vials like PPD expire 30 days after initial use, underscoring the importance of proper labeling to ensure medication efficacy and safety.
Failure to Accommodate Dietary Needs Due to Missing Teeth
Penalty
Summary
The facility failed to prepare food in a form that met the individual needs of a resident, identified as Resident #20, who had difficulty eating due to missing teeth. Despite having 13 missing teeth, as noted in a dental treatment record, the resident's care plan did not reflect this issue, leading to challenges in consuming certain foods like turkey, meat patties, and chicken. During an observation, the resident struggled to eat turkey served for lunch and requested assistance from a CNA to cut the food into smaller pieces. The resident had previously informed the Director of Nursing (DON) and the former administrator about her difficulties, but no adjustments were made to her care plan. Interviews with staff revealed that the CNA was aware of the resident's difficulties and often assisted by cutting her food. However, the DON was unaware of the resident's concerns and acknowledged that missing teeth should be included in the care plan to ensure proper dietary accommodations. The administrator also stated that a resident would not be care planned for missing teeth unless there was a diet texture change. The facility's comprehensive care planning policy emphasizes the development of a person-centered care plan to meet each resident's needs, but this was not implemented for Resident #20, resulting in the deficiency.
Failure to Ensure Resident's Call Light and Bedside Table Were Within Reach
Penalty
Summary
The facility failed to ensure that a resident had the right to reside and receive services with reasonable accommodation of their needs and preferences. Specifically, a CNA removed the resident's call light and bedside table from within her reach, preventing her from calling for assistance. This action was taken because the resident was banging on her bedside table and pushing her call light, which the CNA believed was disturbing other residents. The incident was reported by two LVNs who witnessed the CNA's actions and intervened to return the call light and bedside table to the resident's reach. The resident involved was an 82-year-old female with diagnoses including exudative age-related macular degeneration, difficulty walking, major depressive disorder, and insomnia. Her care plan indicated that she was at risk for falls and required extensive assistance with bed mobility, transfers, and toileting. The care plan also specified that the resident's call light should always be within reach, and she should be encouraged to call for assistance as needed. Despite these documented needs, the CNA's actions directly contradicted the care plan's interventions. Interviews with the LVNs and the DON confirmed that the CNA's actions were inappropriate and violated the resident's rights. The DON and the facility's administration took immediate steps to address the situation, including suspending the CNA pending an investigation and ultimately terminating her employment. The facility also conducted in-services on abuse/neglect, resident rights, answering call lights, and falls for all staff members to prevent future occurrences of similar incidents.
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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 Mexia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Manor Healthcare Residence | 0.7 mi | ★★★★★ | 6 | 0 |
| Mexia Ltc Nursing And Rehab | 0.8 mi | ★★★★★ | 5 | 0 |
| Teague Nursing And Rehabilitation | 10.7 mi | ★★★★★ | 7 | 0 |
| Groesbeck Ltc Nursing And Rehabilitation | 11.6 mi | ★★★★★ | 0 | 0 |
| Windsor Healthcare Residence | 11.7 mi | ★★★★★ | 4 | 1 |
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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.