Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
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 Uvalde Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident was admitted with a PICC line, MDR UTI, and a need for contact isolation, but physician orders for IV meropenem, PICC maintenance, and isolation precautions were not in place until several days later. Staff interviews and record review showed the hospital had reported the resident’s IV therapy and isolation needs at admission, yet the facility did not have the needed orders or signage in place when the resident arrived.
A resident admitted after hospitalization for a MDR UTI was receiving IV meropenem through a PICC line and required contact isolation precautions and an indwelling catheter. Although the admission report and nurse-to-nurse handoff documented these needs, the baseline care plan did not include the PICC line or isolation precautions among the resident’s immediate care needs. Staff interviews confirmed the resident arrived with these treatments and precautions in place, and the DON stated the expectation was for a baseline care plan to be developed and implemented within 24 hours of admission.
A resident with PTSD had the diagnosis listed in the face sheet, physician visit, and quarterly MDS, but the care plan did not include PTSD or related interventions. The DON stated she did not see PTSD in the care plan and noted it was important to include the diagnosis so staff could document interventions such as avoiding triggers. Facility policy required person-centered trauma-informed care and individualized interventions, preferences, and triggers to be documented in the care plan.
A resident with klebsiella, a UTI, MDR organism status, an indwelling urinary catheter, and IV access was on contact precautions with signage at the door requiring hand hygiene, gown, and gloves before entry. A CNA entered the room and answered the call light without PPE, and later stated she only used PPE for catheter care. The charge nurse and DON stated staff were expected to wear PPE whenever entering the contact isolation room.
In the laundry department, 1 of 2 commercial washers was out of service for more than 8 months, leaving only 1 washer available for resident laundry. Laundry Aides stated they used the working washer for all residents and that keeping up with timely laundry services was sometimes challenging with only 1 machine.
An open floor drain near the dish machine was observed without a grate, and the FSM confirmed it had no grate and was unsure how long it had been open. In the Hair Salon, the sink drain filter had a glob of hair, and 3 brushes plus a box of hair curlers had hair on them; the AD and HS both confirmed the unsanitary conditions, and the HS stated she might have forgotten to clean the salon after the beautician visit.
A live roach was observed in the kitchen's clean pots and pan storage area, and staff interviews confirmed ongoing pest issues despite regular pest control treatments and a recent change in pest control providers. Record reviews showed that the pest control agreement did not fully cover German roaches, and invoices documented their presence in the dietary area, indicating the facility did not maintain an effective pest control program as required.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, on six specific weekend days within a 90-day period. The absence of RN coverage was due to difficulties in finding RNs, and although the DON occasionally filled in, these instances were not documented. The facility lacked a specific policy for RN coverage, relying instead on CMS guidelines.
The facility failed to maintain an effective infection prevention and control program, with deficiencies in PPE use, hand hygiene, and laundry room practices. CNAs did not wear PPE gowns while transferring a resident on Enhanced Barrier Precautions, and there was no signage or PPE supply cart outside the resident's room. An LVN did not follow proper hand hygiene protocols, and a laundry aide was observed eating in the laundry room, risking cross-contamination of clean linens.
A facility failed to include Enhanced Barrier Precautions (EBP) in a resident's care plan, despite physician orders due to a draining wound. Staff were unaware of the EBP requirement, as there was no signage or PPE available, leading to improper care during a transfer. The MDS nurse admitted to forgetting to add EBP to the care plan, contrary to facility policy.
A resident with respiratory needs was found to have an oxygen concentrator with a filter covered in dust and lint, indicating a failure to maintain cleanliness as per facility policy. Interviews revealed confusion among staff about who was responsible for cleaning the filters, despite the facility's policy requiring weekly cleaning. This oversight could increase the risk of respiratory complications for the resident.
A facility failed to complete dialysis communication forms for a resident with ESRD, leaving vital post-dialysis assessments undocumented. The resident, with cognitive impairment and multiple health issues, did not have vital signs or access site assessments recorded on two occasions. Interviews revealed that staff were expected to perform these assessments, but documentation was neglected, contrary to facility policy.
A facility failed to obtain informed consent for the use of bed rails for a resident with cognitive impairment and multiple health conditions. Despite physician orders for 1/4 bed rails to aid in repositioning, there was no documented consent from the resident or her representative. This oversight was confirmed through record reviews and an interview with the MDS nurse, highlighting a breach in the facility's policy on bed safety.
A LTC facility reported a medication error rate of 6.67% due to two incidents. A resident with diabetes did not receive properly administered insulin because an LVN failed to prime the insulin pen, lacking training on its use. Another resident with dementia received only half the prescribed dose of polyethylene glycol due to an MA's measurement error. The facility's medication administration policy was not adhered to, and specific training was lacking.
The facility failed to employ a qualified Dietary Manager (DM) to oversee food and nutrition services. The DM lacked the necessary certification and education, having not completed a required course. Despite being responsible for kitchen duties, the DM was not enrolled in the necessary coursework, posing a risk of foodborne illness and inadequate nutrition for residents. A dietician visits monthly, but the DM's lack of certification remains a concern.
The facility failed to employ a qualified Director of Food and Nutrition Services, as the current DS lacked necessary certification and experience. The DS was overwhelmed with multiple roles, preventing her from pursuing required training. The administrator and BOM acknowledged the deficiency, which could risk residents' nutrition and safety.
The facility failed to properly store, label, and date food items in their kitchen, with missing temperature logs and expired items found in freezers. Additionally, staff did not wear proper hair restraints during food preparation, risking contamination. These deficiencies could expose residents to foodborne illnesses.
A resident did not receive a prescribed house shake with their lunch meal due to a shortage and subsequent delivery of frozen shakes. Instead, the resident was given milk and applesauce. The dietary aide, LVN, and DON were aware of the issue, but the physician was not notified to authorize a substitute, leading to a deficiency in the resident's dietary plan.
A CNA failed to follow the care plan requiring a two-person assist for a mechanical lift transfer, resulting in a resident falling and experiencing harm. The resident, with a history of diabetes, morbid obesity, and hemiplegia, was dependent on staff for transfers. The CNA attempted the transfer alone, leading to the incident.
A CNA failed to follow a physician's order requiring a two-person assist for a resident's transfer using a mechanical lift, resulting in the resident falling and sustaining a foot fracture. The CNA admitted to transferring the resident alone due to an inability to find assistance, which was against facility policies.
The facility failed to inform a resident and his representatives about the rationale, benefits, and risks of the prescribed medication medroxyprogesterone, which was administered for several months without their knowledge. The resident, with severe cognitive impairment and a history of aggressive sexual behaviors, did not receive necessary education or monitoring for adverse effects, violating the facility's policy on informed consent.
The facility failed to inform physicians and representatives about significant changes in two residents' conditions, including inappropriate sexual behaviors and increased anxiety, preventing timely medical intervention.
The facility failed to protect residents from abuse and neglect, including leaving a resident alone in a dark, locked shower room and not reporting incidents of abuse between residents. This resulted in a deficiency in ensuring residents' rights to be free from abuse, neglect, and involuntary seclusion.
The facility failed to ensure a safe environment and adequate supervision, resulting in a resident being left alone in a dark, locked shower room and falling. Additionally, storage rooms containing medical equipment were left unlocked, posing a risk to residents. Staff were unsure of policies, and incidents were not properly documented.
The facility failed to develop and implement a comprehensive care plan for a resident with a urinary catheter, pacemaker, urostomy, and colostomy. Despite the resident's complex medical needs, there was no care plan addressing the urinary catheter or the pacemaker's location, as confirmed by staff interviews and record reviews.
The facility failed to document necessary orders for a resident's colostomy, urostomy, urinary catheter, and pacemaker, despite the resident's medical history and the presence of these devices. This deficiency was identified through observations, interviews, and record reviews, highlighting a failure to adhere to the facility's policy on physician services.
A resident experienced significant weight loss due to the facility's failure to implement timely nutritional interventions. Despite a care plan indicating unplanned weight loss and the need for a dietitian's review, these actions were delayed, and staff interviews revealed gaps in communication and monitoring.
The facility failed to ensure residents were free from significant medication errors involving Midodrine. One resident was administered the medication nine times despite having blood pressure readings above the prescribed parameters, while another resident received the medication more than 39 times without the required parameters. Interviews revealed a lack of adherence to medication guidelines and insufficient communication with the nursing staff.
The facility failed to report alleged abuse and neglect incidents involving three residents to the administrator and the state agency. Incidents included physical aggression and a resident being left alone in a dark, locked shower room. These incidents were documented in nursing notes but not reported or investigated properly.
The facility failed to investigate and report incidents involving physical aggression between two residents and another incident where a resident was left in a dark, locked shower room alone. Additionally, repeated incidents of sexual harassment were not documented or reported, preventing the leadership from taking appropriate actions to ensure resident safety.
The facility failed to ensure all drugs and biologicals were stored in locked compartments, as an over-the-counter dietary supplement was found on a nightstand in a resident's room. The resident's care plan did not include information on self-administering medications, and interviews with staff confirmed the risks of unregulated access to medications.
A facility failed to maintain an infection prevention and control program when an LVN did not practice proper hand hygiene between handling food items for different residents. This lapse was observed in the main dining room and confirmed through interviews, highlighting a risk of cross-contamination.
Missing Admission Orders for PICC Line and Contact Isolation
Penalty
Summary
The facility failed to ensure that Resident #31 had physician orders for immediate care at the time of admission. Resident #31 was admitted with diagnoses including Klebsiella pneumoniae and a urinary tract infection, and the hospital record showed he had been treated for a multi-drug-resistant organism UTI with IV antibiotics through a PICC line and had been on contact isolation precautions before transfer. The admission MDS also reflected that he had intravenous access, an indwelling urinary catheter, and a multi-drug-resistant organism. Record review and staff interviews showed that the resident arrived with a PICC line and a need for contact isolation precautions, but orders for those needs were not in place until 5/26/2026. The physician orders later entered included contact precautions, meropenem 1 gram IV every 8 hours for 2 weeks, normal saline flushes for the PICC line, monitoring for PICC complications, and securing the PICC line. The resident’s admission report worksheet documented that the hospital RN reported the need for contact isolation precautions and IV meropenem, and nursing notes documented the PICC line on the evening of admission. Staff interviews confirmed that the resident was received as a new admission with a PICC line and a need for isolation precautions, but the facility did not have orders in place for PICC maintenance, antibiotics, or infection control precautions at the time. LVN C stated that on 5/26/2026 she assessed the resident with a PICC line but had no orders to maintain patency, no antibiotics to control the infection, and no contact precautions in place. RN D and LVN B stated they had received report from the hospital and documented the resident’s need for contact isolation, a PICC line, and meropenem, while LVN A stated that standard practice was to secure orders for newly admitted residents to meet their basic immediate needs within 24 hours.
Baseline Care Plan Missing PICC Line and Contact Isolation Needs
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #31 that included the instructions needed to provide effective and person-centered care for his immediate needs. Resident #31 was admitted on 5/22/2026 after a hospitalization for a multi-drug-resistant organism UTI and was receiving IV meropenem through a PICC line. He also required contact isolation precautions and had an indwelling urinary catheter noted in the admission record and MDS. The record showed that the admission report completed by LVN B documented that Resident #31 needed contact isolation precautions and IV meropenem, and nursing progress notes documented that Resident #31 was admitted with a PICC line present in the right antecubital area. However, the baseline care plan dated 5/22/2026 did not include the PICC line or infection control isolation contact precautions among the resident's immediate care needs. During interviews, RN D stated the resident was being discharged from the hospital with a contact isolation room, a PICC line, and an indwelling catheter, and LVN B stated she received report from the hospital RN and documented the resident's need for contact isolation and meropenem. LVN A stated that standard practice was to develop a baseline care plan for newly admitted residents to meet their basic immediate needs within 24 hours, and that a PICC line would require flushing to keep it patent. The DON stated the expectation was for newly admitted residents to receive immediate care needs through a baseline care plan developed and implemented within 24 hours of admission, coordinated by the IDT. The facility policy also stated that care plans would be developed within the timeframe required by applicable regulations and include identified problems and needs, interventions, and responsible disciplines and staff.
Missing PTSD Diagnosis and Interventions in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #4 that included his PTSD diagnosis and related interventions. Record review showed the resident was admitted and later re-admitted with PTSD, and his physician visit and quarterly MDS also listed PTSD as an active diagnosis. However, the care plan dated 4/22/206 did not include PTSD. During interview on 6/10/2026 at 4:48 PM, the DON stated she did not see PTSD in Resident #4’s care plans and said it was important to include the diagnosis so staff could show interventions such as avoiding certain triggers. The facility’s PTSD Management in Long-Term Care policy stated that residents with PTSD should receive person-centered trauma-informed care and that individualized interventions and resident preferences and triggers should be documented. The facility’s Care Plan policy stated care plans should include identified problems and needs, measurable goals and expected outcomes, and interventions and services to be provided.
Failure to Use PPE in Contact Isolation Room
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for Resident #31, who was admitted after hospitalization with diagnoses including klebsiella pneumoniae and a UTI, and who was also documented as having a multi-drug-resistant organism, an indwelling urinary catheter, and intravenous access. The resident’s hospital record showed he had been diagnosed with a multi-drug-resistant organism UTI and treated with IV antibiotics through a PICC line under isolation contact precautions. The admission report form documented that the hospital RN reported the resident needed contact isolation precautions and IV antibiotic meropenem. Resident #31’s physician ordered contact precautions due to bacteremia klebsiella, and the care plan identified infection, antibiotics for urosepsis, multidrug-resistant organism, and risk for adverse reactions, with universal standard precautions to prevent cross contamination and spread of infection. During observation, the resident’s room had contact precaution signage stating that staff must clean hands before entering and when leaving, put on gloves and gown before room entry, and discard them before room exit. Despite this signage, CNA E answered the resident’s call light and entered the room without putting on any PPE. During interview, Resident #31 stated staff sometimes wore gowns and gloves but had not done so when the CNA came in to reposition him. CNA E stated she entered the room without PPE and said she would wear PPE only when providing urinary catheter care, not when she was not providing catheter care. The charge nurse stated CNA E had been trained to wear PPE whenever entering the room and that the resident was cared for under contact isolation precautions. The DON stated the expectation was for all staff entering a contact isolation room to perform hand hygiene and don a gown and gloves before entry and remove PPE before exiting.
Inoperable Commercial Washer in Laundry Department
Penalty
Summary
The facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for the laundry department. Of the 2 commercial washing machines in the laundry area, only 1 was functioning, and the other washer had been out of service for longer than 8 months. During observations and interviews, Laundry Aides stated they were using the 1 working commercial washer to complete resident laundry and that keeping up with timely laundry services was at times challenging with only 1 washer for all residents. The Administrator stated the facility and Owner were aware that 1 of the 2 commercial washers was not working and that the washer was under the manufacturer's warranty, but the facility had been unsuccessful in securing vendor service for the past 8 months.
Unsanitary Hair Salon and Open Kitchen Drain
Penalty
Summary
The kitchen floor drain near the dish machine was observed on 6/09/2026 at 8:08 AM without a grate. The FSM confirmed the drain was open and stated she was not sure how long it had been without a grate. She also stated the facility had no pests and that they were waiting for the Maintenance Supervisor to start working at the facility so she could let him know about it. Later that day, the FSM stated she had told the prior Maintenance Supervisor about it a week or 2 weeks earlier, and that the new Maintenance Supervisor had started on 6/8/2026 after the former supervisor left on 6/5/2026. In the Hair Salon on 6/11/2026 at 11:07 AM, the sink drain filter contained a glob of hair, and 3 brushes in a cabinet had hair on them, along with a box of hair curlers with hair on them. The Activity Director confirmed these observations and stated Housekeeping was responsible for cleaning the Hair Salon sink. The Activity Director also stated the beautician had visited on 6/9/2026. The Housekeeping Supervisor confirmed the hair in the sink drain filter and stated she might have forgotten to clean the Hair Salon after the beautician visited that week.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain effective pest control in the kitchen, as evidenced by the observation of a live roach in the clean pots and pan storage room. Staff interviews confirmed awareness of the pest issue, with dietary and maintenance staff acknowledging the presence of roaches and describing ongoing pest control treatments. The dietary staff reported that pest control services were performed monthly, while the maintenance director noted a recent change in pest control companies due to concerns about the effectiveness of the previous provider. Despite these measures, the presence of a live roach was observed, and staff indicated that the kitchen had experienced stragglers and that a recent drainage backup may have contributed to the pest issue. Record reviews revealed that the facility's pest control agreement did not cover all types of pests, specifically noting that German roaches required different procedures and were not fully included in the standard agreement. Invoices from the pest control company documented the presence of German roaches in the dietary area and indicated that a roach clean-out service was performed, but with no warranty for the service. The facility's pest control policy stated the intent to maintain an effective program, but the observed and documented presence of pests in the kitchen demonstrated a failure to achieve this standard.
Failure to Maintain RN Coverage on Weekends
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified for six specific days within a 90-day review period from January 1st, 2025, through March 31st, 2025. The absence of RN coverage occurred on weekends, specifically on two consecutive Saturdays and Sundays in January and February. Interviews with the Business Office Manager (BOM), Director of Nursing (DON), and Administrator revealed that the facility faced challenges in finding RNs to cover these shifts. Although the DON occasionally filled in during these gaps, these instances were not documented in the timesheets. The facility did not have a specific policy for RN coverage and relied on CMS guidelines.
Infection Control Deficiencies in PPE Use, Hand Hygiene, and Laundry Room Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue involved the improper use of personal protective equipment (PPE) by CNAs while transferring a resident who was on Enhanced Barrier Precautions (EBP) due to an open draining wound. The CNAs did not wear PPE gowns during the transfer, and there was no signage or PPE supply cart outside the resident's room to indicate the need for EBP. This oversight was compounded by the fact that both the CNA and LVN were unaware of the resident's EBP status, which was confirmed by the Director of Nursing (DON) as necessary. Another deficiency was observed when an LVN failed to follow proper hand hygiene protocols after washing her hands in a resident's bathroom. The LVN used her bare hands to turn off the sink faucet, which could lead to contamination and increase the risk of infection. The LVN acknowledged the mistake and the DON confirmed the risk associated with not using a paper towel to turn off the faucet. Additionally, the facility did not enforce proper infection control practices in the laundry room. A laundry aide was observed eating and drinking in the laundry room, which could lead to cross-contamination of clean linens. The DON stated that staff should not eat or drink in the laundry room to prevent contamination of linens, which are meant to remain hygienically clean for resident use.
Failure to Implement Enhanced Barrier Precautions in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included the necessary Enhanced Barrier Precautions (EBP) for infection control. The resident, a male with a history of arterial ulcers and methicillin-resistant Staphylococcus aureus infection, was admitted with a draining wound on the right foot. Despite physician orders indicating the need for EBP due to the open wound, the care plan did not reflect this requirement, leading to a lack of proper signage and personal protective equipment (PPE) availability in the resident's room. Observations revealed that staff members, including CNAs and an LVN, were unaware of the resident's EBP status, as there was no signage or PPE supply cart present. During a transfer after bathing, staff did not wear PPE gowns, indicating a gap in communication and implementation of the necessary precautions. Interviews with staff, including the DON and MDS nurse, confirmed the oversight, with the MDS nurse admitting to forgetting to include EBP in the care plan. The facility's policy on comprehensive person-centered care plans emphasizes the inclusion of measurable objectives and timeframes to meet residents' needs, yet this was not adhered to in the case of the resident. The lack of EBP in the care plan and the absence of proper signage and PPE could lead to confusion among staff and potentially expose the resident to infection, as noted by the DON.
Failure to Maintain Clean Oxygen Concentrator Filter
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident by not ensuring the cleanliness of the oxygen concentrator filter. The resident, a male with a history of wheezing, cough, end-stage renal disease, and atherosclerotic heart disease, was observed to have an oxygen concentrator in his room with a filter covered in lint and dust. Despite the resident's moderate cognitive impairment and reliance on oxygen therapy as needed for shortness of breath, the filter had not been cleaned, which was confirmed by both the resident and staff interviews. Interviews with the LVN, Housekeeping Supervisor, and DON revealed a lack of clarity regarding the responsibility for cleaning the oxygen concentrator filters. The Housekeeping Supervisor acknowledged that the filter appeared dirty and had not been cleaned recently, while the DON stated that nursing staff should be checking and cleaning the concentrators. The facility's policy required that filters be washed every seven days, but this procedure was not followed, potentially putting the resident at risk for respiratory complications.
Incomplete Dialysis Documentation for Resident
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care consistent with professional standards. Specifically, the facility did not complete the dialysis communication forms for the resident on two occasions, leaving vital information such as post-dialysis vitals, assessment for bruit or thrill, and checks for infection or bleeding unrecorded. This oversight was noted for a resident with a history of anoxic brain injury, end-stage renal disease, and type 2 diabetes mellitus with diabetic neuropathy, who was moderately impaired in cognition and required regular dialysis. Interviews with the LVN and the DON revealed that the nursing staff was expected to assess residents before and after dialysis, including taking vital signs and documenting them on the communication form. However, the LVN admitted to forgetting to document the vitals on one occasion, and the form was left blank on another. The facility's policy emphasized the importance of monitoring the dialysis access site for infection and patency, yet these assessments were not documented as required, potentially compromising the resident's care.
Failure to Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure the correct use of bed rails for a resident, specifically by not obtaining informed consent prior to their installation. The resident in question, a female with a history of anoxic brain injury, muscle weakness, and rheumatoid arthritis, was found to have moderately impaired cognition. Despite the presence of physician orders for the use of 1/4 bed rails to promote independence and aid in repositioning, there was no documented informed consent from the resident or her representative. This oversight was confirmed through record reviews and an interview with the MDS nurse, who acknowledged the importance of obtaining consent to ensure the resident and family were aware of the risks associated with bed rail use. The facility's policy on bed safety and bed rails, revised in 2022, mandates that informed consent must be obtained before using bed rails, detailing the medical needs addressed by the rails and the potential risks involved. However, the resident's records showed a lack of consent documentation, and an observation confirmed the presence of bed rails on the resident's bed. This deficiency in practice could potentially affect other residents using bed rails, putting them at risk for injuries due to improper assessment and lack of informed consent.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 6.67% due to errors involving two residents. The first incident involved a resident with a history of Type 2 diabetes mellitus, chronic kidney disease, and other health issues. The resident was prescribed insulin lispro, which was not administered correctly by an LVN who failed to prime the insulin pen before injection. The LVN admitted to not having received training on the use of insulin pens and was unaware of the need to prime them before administration. The Director of Nursing (DON) acknowledged the lack of training and the absence of a specific policy for insulin pen administration. The second incident involved a resident with dementia and chronic pain, who was prescribed polyethylene glycol 3350 for bowel management. An MA administered only half the prescribed dose by filling the cap to the wrong line, resulting in an incomplete dose. The MA believed she had filled the cap correctly but later acknowledged the mistake. The DON noted that aides could use a graduated cup for accurate measurement and emphasized the importance of administering the full dose for the medication's intended effect. The facility's policy on medication administration, revised in 2019, requires medications to be administered safely, timely, and as prescribed. However, the lack of adherence to this policy and the absence of specific training and guidelines for insulin pen use contributed to the medication errors. Manufacturer instructions for insulin lispro emphasize the importance of priming the pen to ensure correct dosing, which was not followed in this case.
Inadequate Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skill sets to manage the food and nutrition services effectively. The Dietary Manager (DM) did not possess the necessary certification, education, or qualifications to serve as the Director of Food and Nutrition Services. During an interview, the DM revealed that she had started a course to become certified as a Dietary Manager but did not complete it after leaving her previous job. Upon being hired at the current facility, she was informed that she would need to pay for her own course, and she had begun making payments but had not yet enrolled in the required coursework. The DM provided documentation of her previous enrollment in an online course from University F, dated February 28, 2022, but there was no evidence of current enrollment. The deficiency was identified during an interview and record review, which highlighted that the DM was responsible for the overall kitchen duties, despite lacking the necessary qualifications. Although a dietician visits the facility once a month, the DM's lack of certification could place residents at risk of foodborne illness and inadequate nutrition. The report references the Food Code, U.S. Public Health Service, U.S. FDA, 2022, which requires that the person in charge be a certified food protection manager, a standard not met by the current DM.
Inadequate Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skill sets to manage the food and nutrition services, as required by regulatory standards. The Director of Food and Nutrition Services (DS) did not possess the necessary certification, education, or qualifications to fulfill the role effectively. The DS was in training and had registered for a Certified Dietary Manager (CDM) course but had not yet started it due to being occupied with multiple roles in the kitchen, including cooking, aiding, washing dishes, and supervising. The DS lacked an associate's or higher degree in food service management and had not previously served as a dietary manager in a long-term care facility. Interviews revealed that the facility's administrator, who had been in the position for just over a week, was aware of the DS's lack of credentials and was working on getting her certified. The Registered Dietitian (RD) visited the facility monthly and believed the DS was in charge of meal preparation but was not involved in her training or duties. The Business Office Manager (BOM) confirmed that the DS was hired as a dietary aide and assumed the DS position without the necessary credentials. The BOM also noted that high turnover in the kitchen prevented the DS from pursuing certification. This deficiency could potentially place residents at risk of foodborne illness and inadequate nutrition.
Food Safety and Hair Restraint Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. Specifically, the facility did not properly store, label, and date food items in three reach-in freezers. In Reach-in Freezer #1, six gallon-sized bags of frozen biscuits were found without a use-by date, and the Dietary Supervisor (DS) acknowledged that these should have been labeled upon receipt. Reach-in Freezer #2 contained an unidentified frozen food item without a date, and temperature logs for both Freezer #1 and Freezer #2 were missing for several days. Additionally, a large box of jelly jars was improperly stored on the floor, posing a risk of cross-contamination. In Reach-in Freezer #3, cooked beans and old cooking oil were found in containers without proper covering or dating, and expired frozen Salisbury steaks and bacon were also present. Furthermore, the facility did not ensure that kitchen staff wore proper hair restraints during food preparation. Observations revealed that the DS, a cook, and a dietary aide were not wearing hair restraints correctly, with hair protruding from their coverings. The cook was seen without a beard cover, and the DS's braid was not fully tucked into her hair restraint. The facility's policy requires all hair to be covered by hair nets, and the U.S. FDA Food Code mandates that food employees wear hair restraints to prevent hair from contacting food. These lapses in food safety practices could potentially expose residents to foodborne illnesses.
Failure to Provide Prescribed Nutritional Supplement
Penalty
Summary
The facility failed to follow the prescribed menu for a resident during a lunch meal, as observed on 10/3/24. The resident, who was on a planned weight gain program due to significant weight loss and low BMI, was supposed to receive a house shake with every meal as per the physician's order. However, during the lunch meal, the resident did not receive the shake because the facility had run out of them the previous night, and the new shipment received that morning was still frozen. Instead, the resident was given two cartons of milk and a serving of applesauce as a substitute. Interviews with the dietary aide, LVN, and DON revealed that the kitchen staff did not notify the physician about the unavailability of the house shake, which was a part of the resident's dietary plan. The dietary aide confirmed the shortage and substitution, while the LVN acknowledged the absence of the shake on the lunch tray but did not take further action to address the issue. The DON stated that while the kitchen staff could offer an alternative, it was ultimately the physician's responsibility to order a substitute if the prescribed item was unavailable. This oversight in communication and adherence to the dietary plan led to the deficiency noted in the report.
Failure to Follow Care Plan for Mechanical Lift Transfer
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, a CNA did not follow the care plan that required a two-person assist to transfer the resident using a Hoyer Lift. This incident occurred when the CNA attempted to transfer the resident alone, resulting in the resident falling and experiencing harm. The resident had a history of diabetes, morbid obesity, contracture of the left knee, hemiplegia, and high blood pressure, and was dependent on staff assistance for transfers. On the day of the incident, the resident requested to be moved from the bed to a wheelchair for dinner. The CNA, unable to find assistance, proceeded to transfer the resident alone using the mechanical lift. During the transfer, the back of the wheelchair reclined abruptly, causing the resident to fall. Another CNA entered the room and assisted in repositioning the resident. The resident reported the fall and expressed anxiety and fear during the transfer. The CNA admitted to transferring the resident alone, which was against the facility's policy. Interviews with staff and record reviews confirmed that the CNA was aware of the requirement for a two-person assist but proceeded alone due to the resident's insistence and the inability to find help. The facility's policies and previous in-service training emphasized the importance of using two staff members for mechanical lift transfers to prevent accidents and ensure resident safety. The failure to adhere to these protocols resulted in immediate jeopardy and placed residents at risk for pain or injuries.
Failure to Provide Adequate Supervision During Transfer
Penalty
Summary
The facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a CNA did not follow the physician's order and the resident's care plan, which required a two-person assist to transfer a resident using a mechanical lift. This failure resulted in the resident's wheelchair reclining unexpectedly, causing the resident to fall and sustain a fracture to the right foot's fifth metatarsal bone. The resident involved had multiple diagnoses, including diabetes, morbid obesity, contracture of the left knee, hemiplegia, and high blood pressure. The resident's care plan and physician's orders clearly indicated the need for a two-person assist with a mechanical lift for transfers. However, the CNA attempted the transfer alone, leading to the resident's injury. The incident was reported by the resident and corroborated by another CNA who entered the room during the transfer. Interviews with the involved staff revealed that the CNA was aware of the requirement for a two-person assist but proceeded alone due to an inability to find assistance. The CNA admitted to transferring the resident by herself, which was against the facility's policies and procedures. The incident was documented in the resident's nurse's notes, and the resident was subsequently sent to the hospital for evaluation and treatment of the injuries sustained during the fall.
Failure to Inform Resident and Representatives About Medication
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments. Specifically, the facility did not inform Resident #14 or his representatives about the rationale, benefits, and risks of the prescribed medication medroxyprogesterone, which was administered from June 2023 to March 2024. This failure was identified during interviews and record reviews, revealing that neither Resident #14 nor his representatives received any education on the medication's purpose, benefits, risks, or potential adverse reactions. Additionally, there was no evidence of monitoring for adverse effects or necessary laboratory tests for Resident #14 during this period. Resident #14, a male with severe cognitive impairment and a history of aggressive sexual harassment behaviors, was prescribed medroxyprogesterone by his primary care physician to reduce these behaviors. However, the nursing staff did not provide the necessary education to Resident #14 or his representatives about the medication. Interviews with the nursing staff and the physician indicated a lack of communication and monitoring for potential adverse effects, such as changes in testosterone levels or breast tenderness. The physician assumed that the nursing staff had informed the resident and his representatives, but this was not the case. Interviews with Resident #14's representatives revealed that they were unaware of the resident's inappropriate sexual behaviors and the prescribed medication. They had not received any information about the rationale, benefits, or risks of medroxyprogesterone. The facility's policy required informed consent before administering any medication, but this was not followed in Resident #14's case. The failure to provide this information denied Resident #14 the right to participate in his care and treatment, potentially placing other residents at risk of receiving medications without their knowledge or consent.
Failure to Notify Physicians and Representatives of Significant Changes
Penalty
Summary
The facility failed to immediately inform the resident, consult with the resident's physician, and notify the resident's representative when there was a need to alter treatment significantly for two residents. Resident #14, who had a history of dementia, psychotic disturbance, mood disturbance, anxiety, and alcohol use, exhibited inappropriate sexual behaviors towards female residents. Despite multiple incidents of Resident #14 making sexual lewd comments and entering Resident #23's shower room, the facility did not inform Resident #14's physician or representatives about these behaviors. This lack of communication prevented timely medical intervention that could have addressed Resident #14's behaviors and ensured the safety of other residents. Resident #23, who also had dementia, mood disturbance, and anxiety, was directly affected by Resident #14's actions. Resident #14 entered Resident #23's shower room on multiple occasions, causing Resident #23 to feel unsafe and anxious. Despite Resident #23 expressing her distress and increased anxiety due to these incidents, the facility failed to inform her physician or representatives. This failure denied Resident #23 the opportunity for timely medical assessment and potential psychiatric evaluation to address her increased anxiety and fear. Interviews with staff and record reviews revealed that the facility had a pattern of not reporting significant changes in residents' conditions to their physicians. The primary care physician for Resident #14 confirmed that he had not received any reports of Resident #14's inappropriate behaviors towards other residents, which would have prompted him to order further interventions. Similarly, the medical director for Resident #23 was unaware of the incidents involving Resident #14, which hindered his ability to provide appropriate care for Resident #23's increased anxiety and fear.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to ensure that residents were protected from abuse, neglect, and involuntary seclusion. Resident #23 was left alone in a dark, locked shower room, which led to her falling and feeling unsafe. Additionally, a male resident was able to access Resident #23 while she was in the shower, causing her distress and fear due to his repeated attempts to enter the shower with her. The facility did not document or report these incidents, failing to protect Resident #23 from potential abuse and neglect. Resident #1 was not protected when she wandered into another resident's room and was hit on the head by Resident #43. The facility did not document or report this incident, and the staff failed to follow the facility's policy on reporting and investigating allegations of abuse. This lack of action left Resident #1 vulnerable to further harm and did not address the aggressive behavior of Resident #43. The facility's failure to document and report these incidents, as well as to provide adequate supervision and protection for the residents involved, resulted in a deficiency in ensuring the residents' right to be free from abuse, neglect, and involuntary seclusion. The facility's policies and procedures were not followed, leading to a lack of appropriate response to the incidents and placing the residents at risk for further harm.
Failure to Ensure Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and provided adequate supervision to prevent accidents for two residents. One resident, who had a history of dementia and moderate cognitive impairment, was left alone in a dark shower room with the door locked, resulting in a fall. The incident occurred because a Licensed Vocational Nurse (LVN) turned off the lights and locked the door without checking if the room was occupied, in an attempt to prevent another resident from entering the shower room. The resident was found on the floor, upset and claiming she fell while trying to reach the light switch or door. The facility did not document this incident in their reports, nor did they document previous incidents of sexual harassment by the other resident towards the affected resident. Additionally, the facility failed to secure storage rooms containing medical equipment such as needles and syringes. Multiple observations revealed that these storage rooms were left unlocked and open, posing a risk to residents. Staff members, including the Administrator and Director of Nursing (DON), were unsure if the doors should be locked, indicating a lack of clear policy or training on securing hazardous materials. This oversight could potentially lead to residents accessing dangerous medical equipment, increasing the risk of injury. Interviews with staff members confirmed that there was a lack of proper incident reporting and documentation. The LVNs involved did not initiate incident reports for the sexual harassment incidents or the fall in the shower room. Furthermore, the facility's policies on accident and incident reporting were not followed, as evidenced by the absence of documentation for the incidents. This lack of adherence to protocols and inadequate supervision contributed to the unsafe environment for the residents involved.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #20, who had a urinary catheter, pacemaker, urostomy, and colostomy. Despite the resident's complex medical needs, there was no care plan addressing the urinary catheter or the location of the pacemaker. This deficiency was identified through observations, interviews, and record reviews. The resident's medical history included a personal history of malignant neoplasm of the bladder, overactive bladder, retention of urine, and urinary infections. The resident was observed with a catheter bag and a pacemaker, but the care plan did not reflect these needs. Interviews with staff, including the MDS nurse and LVN, confirmed that there were no care plans for the urinary catheter or the pacemaker's location. The MDS nurse acknowledged the necessity of care plans for staff to provide appropriate care. Record reviews showed various orders for the resident's urostomy, colostomy, and pacemaker, but these were not incorporated into a comprehensive care plan. The facility's policy on comprehensive person-centered care plans was not followed, leading to a lack of measurable objectives and timeframes to meet the resident's needs.
Failure to Document Orders for Medical Devices and Conditions
Penalty
Summary
The facility failed to ensure that Resident #20 received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, Resident #20 did not have documented orders for his colostomy, urostomy, urinary catheter, or pacemaker. This deficiency was identified through observations, interviews, and record reviews. The resident had a history of malignant neoplasm of the bladder, overactive bladder, retention of urine, and a personal history of urinary infections. Despite having these medical devices and conditions, the necessary orders were not present in the resident's records, which could lead to inadequate care provision. Observations on multiple dates confirmed the presence of the colostomy, urostomy, urinary catheter, and pacemaker. Interviews with the Director of Nursing (DON) and Licensed Vocational Nurse (LVN) highlighted the importance of having proper orders to guide the nursing staff in providing appropriate care. The facility's policy on physician services emphasized the need for orders upon a resident's admission to ensure their immediate care needs are met. However, the lack of documented orders for Resident #20's medical devices and conditions indicated a failure to adhere to this policy, potentially compromising the resident's care.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, resulting in significant weight loss. Resident #13, who has diagnoses including unspecified dementia, chronic obstructive pulmonary disease, and osteoporosis, experienced a continuous significant weight loss of 10.84% between 12/01/2023 and 01/04/2024. Despite the resident's care plan indicating unplanned weight loss and the need for a registered dietitian's review, there is no evidence that these interventions were implemented. The dietitian's recommendation for nutritional supplements was delayed by 23 days before being reviewed by the physician, and the corresponding doctor's order was not initiated until 2/8/2024, well after the significant weight loss had occurred. Interviews with facility staff revealed gaps in communication and documentation regarding the resident's weight loss. The LVN stated that CNAs are responsible for taking weights and notifying nursing staff of significant changes, but there was no indication that this process was effectively followed. The DON confirmed that significant weight loss should be reported to the physician within a week, but this protocol was not adhered to in Resident #13's case. Additionally, the CNA interviewed was unaware of the resident's weight loss status, indicating a lack of awareness and monitoring. The facility's policy on Food and Nutritional Services emphasizes the role of multidisciplinary staff in assessing and addressing residents' nutritional needs, but this policy was not effectively implemented for Resident #13.
Significant Medication Errors with Midodrine Administration
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, specifically involving the administration of Midodrine, a blood pressure medication. Resident #9 was administered Midodrine nine times in February and March 2024 despite having blood pressure readings above the prescribed parameters. The medication was supposed to be held if the systolic blood pressure was greater than 110 mm/Hg. Interviews with the Certified Medication Aides (CMAs) and Licensed Vocational Nurses (LVNs) revealed a lack of awareness and adherence to the medication parameters, and the Director of Nursing (DON) was not informed of these errors. The DON had only been in her position for a week and was not fully aware of the processes in place for medication administration and monitoring. Resident #47 was administered Midodrine more than 39 times between February 13, 2024, and March 9, 2024, without the required parameters to determine whether the medication should be given based on blood pressure readings. The resident's Medication Administration Record (MAR) did not document any vitals with the administration of Midodrine during this period. Interviews with the CMAs and the DON indicated that the CMAs were administering the medication without the necessary parameters and were not notifying the nursing staff of any changes in the residents' conditions. The DON acknowledged that CMAs were not able to assess residents and should notify the nurse for any changes in condition. The facility's policy on administering medications, dated April 2019, stated that medications should be administered in a safe and timely manner as prescribed, and only licensed or permitted personnel should prepare, administer, and document the administration of medications. The policy also indicated that the DON supervises and directs all personnel who administer medications. However, the facility failed to follow these guidelines, leading to significant medication errors for Residents #9 and #47, putting them at risk for adverse health outcomes.
Failure to Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the administrator and the State Survey Agency. This deficiency was observed in three residents. Resident #43 exhibited physical aggression towards Resident #1, but the incident was not reported to the administrator or the state agency. The incident was documented in the nursing progress notes but not in the incident reports or the 24-hour report, leaving the facility leadership unaware and unable to investigate or report the incident properly. Resident #23 was left alone in a dark, locked shower room, and a male resident attempted to access her while she was showering. This incident was also not reported to the state agency. The nursing staff documented the incident in the nursing notes but failed to generate an incident report or document it in the 24-hour report. The facility leadership was unaware of the incident and did not investigate or report it. Interviews with the staff revealed that the facility's policy and expectations were not followed. The Director of Nursing and the Administrator both stated that all allegations of abuse, neglect, exploitation, and mistreatment should be reported to the appropriate authorities and documented properly. However, the record reviews showed that these incidents were not reported, leaving residents at risk for abuse, neglect, exploitation, and mistreatment.
Failure to Investigate and Report Incidents
Penalty
Summary
The facility failed to investigate and report the findings to the state agency for an incident involving physical aggression between two residents. Resident #43, who has severe cognitive impairment and a history of physical aggression, hit Resident #1, who also has severe cognitive impairment, when she wandered into his room. The incident was documented in the nursing progress notes but was not reported to the facility leadership or the state agency, and no incident report was generated. The facility leadership was unaware of the incident and therefore did not investigate or report it as required by policy. The facility also failed to investigate and report an incident involving Resident #23, who was left in a dark, locked shower room alone. Resident #23, who has moderate cognitive impairment and a history of rejecting care, was discovered on the floor of the shower room after another resident, Resident #14, attempted to enter the shower room. LVN A, unaware that Resident #23 was in the shower room, turned off the light and locked the door to prevent Resident #14 from entering. This incident was not documented in the facility's incident reports or 24-hour reports, and the facility leadership was unaware of the incident. Additionally, Resident #23 reported feeling unsafe due to repeated incidents of sexual harassment by Resident #14, who has severe cognitive impairment. Despite these reports, no incident reports were generated, and the incidents were not documented in the 24-hour reports. The facility's failure to document and report these incidents prevented the leadership from taking appropriate actions to ensure the safety and rights of the residents, as required by the facility's abuse and neglect policy.
Failure to Properly Store Medications
Penalty
Summary
The facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments and permitted only authorized personnel to have access to the keys. An over-the-counter dietary supplement was found on a nightstand in a resident's room. The resident, who had a moderate cognitive impairment as indicated by a BIMS score of 12, was not present during the observation, but her husband stated he had brought the medication due to her predisposition to urinary tract infections. The resident's care plan did not reflect any information related to self-administering medications or supplements. Interviews with the LVN and DON revealed that staff are required to remove any medications found in resident rooms, inform the DON, and notify the physician. Both the LVN and DON acknowledged the risks associated with unregulated access to medications, including potential side effects and accidental ingestion. The facility's policy mandates that all drugs and biologicals be stored in locked compartments, accessible only to authorized personnel, and that staff are trained to ensure no hazardous items are available to residents in their rooms.
Failure to Maintain Proper Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, as evidenced by an incident involving a Licensed Vocational Nurse (LVN) who did not practice proper hand hygiene. The LVN served food to a resident, disposed of trash, and then handled another resident's dessert plate without using hand sanitizer or washing hands in between these actions. This lapse in hand hygiene was observed in the main dining room and was confirmed through interviews with the LVN and the Director of Nursing (DON). The LVN admitted to not using hand sanitizer, which was in her pocket, and the DON acknowledged the risk of cross-contamination due to improper hand hygiene practices. The affected resident, identified as Resident #101, has a medical history that includes Parkinson's disease, diabetes type II, osteoarthritis, and pain. The incident was observed and documented on the same day, and subsequent interviews with the LVN, DON, and Administrator highlighted the failure to adhere to the facility's hand hygiene policy. The policy, dated August 2019, emphasizes the importance of hand hygiene as the primary means to prevent the spread of infections, particularly before and after handling food or assisting residents with meals.
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 citations issued around you in the last 12 months — including the 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 Uvalde
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Amistad Nursing And Rehabilitation Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Avir At Camp Wood | 35.5 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Uvalde Healthcare 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.