Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Manor Healthcare Residence during CMS and state inspections, most recent first.
PASRR Screening Not Accurately Reflected Resident's Mental Health Status: A resident with schizoaffective disorder and vascular dementia had a PASRR Level I that listed dementia and schizoaffective disorder, but the facility did not ensure the screening accurately reflected the resident's status or refer the resident to the state-designated MH/ID authority for Level II evaluation. The MDS Coordinator, ADM, and DON stated PASRRs are used to identify MH/ID needs and that inaccurate screenings can result in missed services.
Medication Administration Errors Due to Late Scheduled Doses: MA A administered all observed scheduled meds late for two residents, resulting in a 100% error rate. One resident had multiple chronic conditions including epilepsy, COPD, and heart failure, and the other had bipolar disorder, CKD, and acute systolic HF. MA A said she was running late, while the DON, other nursing staff, and the facility policy all stated scheduled meds were to be given within one hour before or after the ordered time.
The facility failed to provide a private space for residents' monthly council meetings, compromising their right to privacy. Meetings were held in the Dining Room and front lobby, both lacking privacy, with staff present. The AT Director and ADM acknowledged the issue, with the ADM recognizing the potential discomfort for residents in disclosing concerns without privacy.
The facility failed to ensure resident privacy by not consistently knocking on doors before entering rooms. During lunch tray distribution, staff entered the rooms of five residents without knocking, despite the facility's policy requiring it. Interviews revealed that while some residents were not bothered, others preferred staff to knock to avoid being startled. Staff admitted to lapses in following the protocol, attributing it to task focus or forgetfulness.
The facility failed to store food properly in the kitchen, with items like sausage patties and cookie dough left unsealed and exposed to air, risking foodborne illness. Interviews revealed that staff did not follow the policy requiring food to be labeled, dated, and sealed, despite the potential risks. The Dietary Manager and Administrator were responsible for monitoring these practices, but the deficiency was not identified during routine checks.
PASRR Screening Not Accurately Reflected Resident's Mental Health Status
Penalty
Summary
The facility failed to ensure the PASRR Level I assessment accurately reflected the status of one resident with a mental illness and failed to refer the resident to the appropriate state-designated MH/ID authority for evaluation. Resident #6 was an [AGE]-year-old male who was initially admitted to the facility and later readmitted. His diagnoses included schizoaffective disorder and vascular dementia, moderate, with anxiety. A quarterly MDS assessment reflected a BIMS score of 9, indicating moderately impaired cognition, and no neurological diagnoses, including non-Alzheimer's dementia, were identified on that assessment. Record review showed that the resident's PASRR Level I Screening, completed by the referring nursing facility, reflected diagnoses of dementia and schizoaffective disorder. The facility's comprehensive care plan, revised 11/25/2025, addressed impaired cognitive function/dementia and included interventions such as administering medications as ordered and monitoring/documenting side effects and effectiveness. During interview, the MDS Coordinator stated that if a PASRR is positive it sends an alert to the local authority, and if the PASRR is not completed accurately, someone could miss services they need or can benefit from. The ADM stated that once the facility receives PASRR paperwork, it is reviewed and services are set up based on the resident's needs, and that if the PASRR is filled out incorrectly, the MDS Coordinator corrects it. The DON stated that if the PASRR is not filled out accurately, people with special needs and intellectual disabilities may not have their needs met. The facility did not have a related PASRR policy available when requested, although the admission criteria policy stated that all new admissions and readmissions are screened for mental disorders, intellectual disabilities, or related disorders and that if the Level I screen indicates possible criteria, the resident is referred to the state PASARR representative for Level II screening.
Medication Administration Errors Due to Late Scheduled Doses
Penalty
Summary
The facility failed to ensure that the medication error rate was not five percent or greater. During observation of medication administration on 12/09/2025 beginning at 9:18 AM, MA A administered 31 of 31 medications late for two residents, resulting in a 100% medication error rate. The report states that the medications for both residents were given outside the facility’s stated medication administration timeframe. Resident #15 was a cognitively intact female with diagnoses including Vitamin D deficiency, hypokalemia, hypothyroidism, hypertension, asthma, GERD, epilepsy, chronic right heart failure, COPD, and schizoaffective disorder. Her 8:00 AM medication orders included aspirin, calcium with vitamin D3, cholecalciferol, cyanocobalamin, Farxiga, ferrous sulfate, folic acid, furosemide, guaifenesin, hydrochlorothiazide, Keppra, potassium chloride ER, and sertraline. During observation, MA A began administering these medications at 9:18 AM, and the medication administration audit report showed they were given between 9:19 AM and 10:06 AM. Resident #17 was a cognitively intact female with diagnoses including bipolar disorder, dry eye syndrome, acute systolic heart failure, GERD, vitamin D deficiency, chronic kidney disease, hyperlipidemia, and hypertension. Her morning medication orders included calcium 500 plus D, carboxymethylcellulose sodium ophthalmic solution, Cymbalta, aspirin, ferrous sulfate, folic acid, furosemide, gabapentin, potassium chloride ER, sodium chloride, Topamax, Tricore, Trileptal, and vitamin D3. During observation, MA A began administering these medications at 9:31 AM, and the audit report showed they were given between 9:39 AM and 9:52 AM. MA A stated the medications were late because she was running late that day. The DON, LVN B, MA C, LVN D, and the Administrator all stated the facility timeframe for scheduled medications was one hour before to one hour after the scheduled time, and the policy records also stated medications are to be administered within one hour of the prescribed time unless otherwise specified.
Lack of Privacy for Resident Council Meetings
Penalty
Summary
The facility failed to provide a private space for residents' monthly council meetings, which is a violation of residents' rights to organize and participate in resident/family groups in the facility. During a Resident Council interview, it was observed that the AT Director gathered several residents in the Dining Room, where other residents were watching TV and staff were present, thus compromising privacy. When asked about a more private space, the AT Director suggested moving the meeting to the front lobby area, which was also not private, and there was no effort to redirect staff away from the area. Interviews with the AT Director and the ADM revealed a lack of training and awareness regarding the importance of privacy during Resident Council meetings. The AT Director admitted to not having specific training on privacy issues and expressed an inability to prevent staff from being present. The ADM acknowledged the residents' right to privacy during these meetings and recognized the potential discomfort residents might feel in disclosing concerns without privacy. The facility's Resident Rights Policy, although not dated, supports the residents' right to personal privacy, including during meetings of family and resident groups.
Failure to Ensure Resident Privacy by Not Knocking Before Entering Rooms
Penalty
Summary
The facility failed to ensure the privacy of residents by not consistently knocking on their doors before entering their rooms. This deficiency was observed during the distribution of lunch trays, where staff members CNA A and CNA B entered the rooms of five residents without knocking. The residents involved had various medical conditions, including cognitive impairments, chronic diseases, and physical disabilities, which necessitate a respectful and considerate approach to their care. Interviews with the residents revealed mixed feelings about the lack of knocking. Some residents expressed that it did not bother them, while others indicated a preference for staff to knock to avoid being startled or to be aware of someone entering their room. Despite the residents' varied reactions, the facility's policy clearly states that staff should knock and request permission before entering, as the facility is considered the residents' home. Interviews with staff, including the ADON, CNA A, and CNA B, confirmed that they were aware of the policy requiring them to knock before entering residents' rooms. However, they admitted to lapses in following this protocol, attributing it to being focused on tasks or simply forgetting. The ADM acknowledged that staff had become relaxed in adhering to this policy, despite ongoing training on resident rights and dignity. The facility's Dignity Policy emphasizes treating residents with respect, which includes knocking before entering their rooms.
Improper Food Storage Practices in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety and sanitation in their kitchen, as observed during a survey. Specifically, food items in the kitchen freezer and dry storage area were found to be improperly stored, with several items such as sausage patties, cinnamon rolls, cookie dough, grits, corn tortillas, nonfat dry milk, and corn muffin mix left unsealed and exposed to air. This lack of proper sealing could lead to foodborne illnesses among residents, as the food could become frostbitten, stale, or contaminated by pests. Interviews with the Dietary Manager (DM), Cook (CK C), and Administrator (ADM) revealed that the facility's policy required all food items to be labeled, dated, and sealed to prevent contamination and spoilage. Despite this policy, the staff failed to ensure compliance, with the DM and CK C acknowledging the potential risks of unsealed food. The ADM confirmed that the DM was responsible for monitoring food storage practices, but the ADM's monthly checks did not identify the issue. The facility's Dietary Services Policy and Procedures, dated 2012, also emphasized the need for securely covering unused food, yet this was not followed, leading to the deficiency.
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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) |
|---|---|---|---|---|
| Mexia Ltc Nursing And Rehab | 0.2 mi | ★★★★★ | 5 | 0 |
| Skilled Care Of Mexia | 0.7 mi | ★★★★★ | 3 | 1 |
| Teague Nursing And Rehabilitation | 11.4 mi | ★★★★★ | 7 | 0 |
| Groesbeck Ltc Nursing And Rehabilitation | 11.4 mi | ★★★★★ | 0 | 0 |
| Windsor Healthcare Residence | 11.5 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.