Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Van Healthcare during CMS and state inspections, most recent first.
Incomplete Care Plans for Catheter Care and EBP Two residents had care plans that did not reflect ordered EBP for high-contact care related to MDRO history and indwelling devices. One resident’s plan also lacked focused interventions for Foley catheter care in line with facility policy and MD orders. Both residents had indwelling catheters, and one care plan noted hospice care and catheter placement, while the other identified catheter-related UTI risk and neurogenic bladder.
Missing narcotic count signatures were found on Medication Cart A/B and C/D halls, showing that change-of-shift narcotic counts were not routinely documented by on-coming and off-going MA staff. Interviews with MA staff, the DON, and the ADON confirmed that narcotic counts were required at each shift change and that both aides were to sign the count sheet to show the count was completed and accurate.
Missing EBP Signage for Residents with Indwelling Catheters: Two residents with indwelling Foley catheters and MDRO history had physician orders for EBP during high-contact care, including gown and glove use for ADLs and catheter-related care. Both residents were observed in bed with catheters in place, but EBP signage and PPE instructions were not posted at the room entry. CNA and LVN interviews confirmed staff knew the EBP protocol but did not know why the signage was absent.
A resident with depression and a later diagnosis of Major Depressive Disorder, Recurrent and Moderate did not have an updated PASARR Level 1 Screening after the mental illness became evident. The resident’s original PASARR showed no evidence of mental illness, while later records, including the MDS, physician note, and psychoactive medication consent for Lexapro, documented depression. The MDS Nurse stated the screening should have been updated, and the ADM, ADON, and DON said they were not aware of the procedure for a newly evident mental illness diagnosis.
A facility failed to place the most recent standard survey in the resident-accessible survey binder. The binder contained older survey results, and the ADM stated the newest survey had been printed but not inserted. The ADM acknowledged residents’ right to review survey results, and 8 residents said they did not have access to the most recent survey and wanted to review it.
The facility failed to provide adequate pharmaceutical services, resulting in medication errors for three residents. A resident received incorrect Vitamin D3 dosage and continued a discontinued diabetic medication for months. Another resident was given incorrect Vitamin C dosage and faced discrepancies in Gabapentin administration. Additionally, insulin was improperly administered to a third resident. These actions violated facility policies and proper medication administration procedures.
The facility failed to maintain accurate clinical records and physician orders for three residents, leading to potential risks in care. A resident lacked documented orders for dialysis treatment, another had unclear antidepressant medication orders resulting in inconsistent dosages, and a third resident's nutritional supplement order did not specify the amount to be administered. These deficiencies highlight issues in record-keeping and medication management.
A facility failed to maintain proper infection control by allowing a resident's urine catheter bag to touch the floor. Observations revealed the bag was improperly hung on a trash can, contrary to facility policy. A CNA and the DON confirmed the bag should have been hung from the bed and placed in a covering bag.
Incomplete Care Plans for Catheter Care and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop and implement comprehensive care plans with measurable objectives and timeframes for 2 of 4 residents reviewed. Resident #7 had diagnoses including aortic stenosis, benign prostatic hyperplasia, orthostatic hypotension, GERD, hyperlipidemia, hypertension, syncope, and UTI, and had a BIMS score of 11 indicating moderately impaired cognition. Physician orders included Enhanced Barrier Precautions for high contact care related to a history of MDRO and an indwelling device, as well as orders related to Foley catheter insertion. However, the care plan reviewed for Resident #7 did not reflect focused interventions for indwelling catheter care in accordance with facility policy and physician orders, and it did not reflect implementation of Enhanced Barrier Precautions for high-contact care related to the history of MDRO and an indwelling catheter. Resident #7 was observed in bed, awake, watching TV, and reported staff assisted with transfers and ADLs. The Foley catheter was noted to gravity with a covered bag and clear urine, and the resident denied UTI symptoms while reporting a history of bladder issues. The care plan had been last reviewed and completed on 12/30/2025 and identified hospice care and placement of an indwelling catheter, but it did not include the focused catheter interventions or the Enhanced Barrier Precautions ordered by the physician. Resident #32 had diagnoses including cerebral ischemic attack/stroke, type 2 diabetes mellitus, polymyositis with myopathy, syncope, dysphagia, vascular dementia, neuromuscular dysfunction of bladder, depression, muscle wasting and atrophy, hypothyroidism, sarcopenia, presence of cardiac pacemaker, poly-osteoarthritis, atrioventricular block, dementia, hypertension, and esophagitis. The resident had a BIMS score of 14 and physician orders for Enhanced Barrier Precautions for high contact care related to a history of MDRO and an indwelling device, along with Foley catheter-related orders for retention. The care plan identified an indwelling catheter and risk for UTI and complications from neurogenic bladder, with interventions for catheter care per facility policy and physician orders and monitoring urine characteristics, but it did not reflect implementation of Enhanced Barrier Precautions for high-contact care related to the history of MDRO and an indwelling catheter.
Missing Narcotic Count Signatures on Medication Carts
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring accurate acquiring, receiving, dispensing, administering, and safekeeping of narcotics on Medication Cart A/B halls and Medication Cart C/D halls. A review of narcotic count signature sheets showed multiple missing signatures for change-of-shift narcotic counts on both carts, including 21 missing signatures on the A/B cart for 21 of 37 change of shifts reviewed, 26 missing signatures on the C/D cart for 26 of 37 change of shifts reviewed, and 24 missing signatures on the A/B cart for 24 of 93 change of shifts reviewed in December 2025. During interviews, MA-E stated narcotic counts were supposed to be completed at every change of shift by the off-going and on-coming Medication Aides and that both aides were to sign the narcotic count sheet after the count was done, but she said the missing signatures looked like the counts had not been done. MA-D stated she counted narcotics at the beginning and end of her shifts but sometimes forgot to sign the sheets, and said without signatures there was no proof the counts had been completed. The DON and ADON stated Medication Aides were responsible for completing and signing narcotic counts at each shift change, and the DON said failure to sign the sheets could lead to missing drugs that could not be accounted for. The facility policy stated the outgoing shift was to count all narcotics with the oncoming shift and that the person accepting the keys and verifying the narcotic counts was assuming responsibility for the medication cart until the next shift change.
Missing EBP Signage for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 2 residents who required Enhanced Barrier Precautions (EBP). Resident #7 was admitted with diagnoses including aortic stenosis, benign prostatic hyperplasia, orthostatic hypotension, GERD, hyperlipidemia, hypertension, syncope, and UTI, and had a BIMS score of 11 indicating moderately impaired cognition. Physician orders directed EBP for high-contact care related to a history of MDRO and an indwelling catheter, including gloves and gowns for dressing, bathing, transferring, hygiene, linen changes, brief changes, and toileting assistance. Resident #32 was admitted with diagnoses including cerebral ischemic attack, type 2 diabetes mellitus, polymyositis with myopathy, syncope, dysphagia, vascular dementia, neuromuscular dysfunction of the bladder, depression, muscle wasting and atrophy, hypothyroidism, sarcopenia, presence of a cardiac pacemaker, poly-osteoarthritis, atrioventricular block, dementia, hypertension, and esophagitis. The resident had a BIMS score of 14 and physician orders for EBP for high-contact care related to a history of MDRO and an indwelling device, with gloves and gowns required for the same types of care activities. Care plans for both residents reflected indwelling catheter use and noted no implementation of EBP for high-contact care. During observations of both residents in their rooms, each was in bed, awake, and clean, with Foley catheters draining to gravity below the bladder and privacy covers in place. However, EBP signage was not posted at the point of entry for either room, and no instructions for required PPE were observed. CNA A, CNA B, and LVN C each stated they were trained on EBP and described the required PPE use for residents with indwelling catheters, but all acknowledged they did not know why the signage was not posted on either door.
Inaccurate PASARR Screening for Resident With Newly Identified Mental Illness
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of mental illness had an accurate PASARR Level 1 Screening after a newly evident diagnosis of Major Depressive Disorder, Recurrent and Moderate was documented. Resident #8’s record showed an admitting PASARR Level 1 Screening completed on 03/01/2019 that indicated no evidence of mental illness, while later records documented depression and a psychiatric diagnosis. The resident’s face sheet listed Major Depressive Disorder, Recurrent and Moderate, and the most recent Quarterly MDS showed a BIMS score of 0, unclear speech, and active diagnoses including depression. Record review showed a psychoactive medication consent for Lexapro signed on 03/16/2019 for treatment of depression, and a physician progress note dated 05/31/2019 documented the diagnosis of Major Depressive Disorder, Recurrent and Moderate. The Quarterly MDS later first indicated a diagnosis of depression. During interviews, the MDS Nurse stated she was responsible for ensuring residents had an accurate PASARR Level 1 Screening and that Resident #8 should have had an updated screening when the diagnosis of Major Depressive Disorder was identified. The ADM, ADON, and DON stated they were not aware of the procedure for PASARR Level 1 Screening for a resident with a newly evident diagnosis of mental illness.
Survey Results Not Posted in Resident-Accessible Binder
Penalty
Summary
The facility failed to post its most recent standard survey in the survey binder accessible to residents, family members, and legal representatives. During observation on 01/12/2026 at 1:23 PM, the survey binder in the facility did not include the results of the most recent standard survey completed on 10/23/2024, although it did include standard survey results from 09/13/2023 and 08/10/2022. During interview on 01/12/2026 at 1:26 PM, the ADM stated he had recently printed the most recent standard survey but had not placed it in the survey binder. He also stated that if the most recent survey results were not placed in the binder, residents would be unable to review them, and acknowledged that residents have the right to review survey results. During a confidential group interview on 01/13/2026 at 11:00 AM, 8 residents stated they did not have access to the most recent standard survey results and wanted to review them. Record review of the facility policy titled Required Facility Postings stated that residents have the right to examine the results of the most recent survey and any plan of correction, and that the facility must make the results available in a place readily accessible to residents and post a notice of their availability.
Medication Administration and Pharmaceutical Service Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of three residents, resulting in medication errors and improper administration. For one resident, the facility did not ensure the availability of medications in the form ordered by the physician. The medication aide administered a different dosage of Vitamin D3 than prescribed and failed to consult the charge nurse. Additionally, the facility continued to administer a discontinued diabetic medication for three months and did not initiate the replacement medication as ordered by the physician. Another resident experienced a similar issue with the administration of Vitamin C, where the medication aide gave a different dosage than prescribed without consulting the charge nurse. There was also a discrepancy in the administration of Gabapentin, as the medication aide was unsure if the resident had been receiving the correct dosage due to conflicting labels. The facility's failure to ensure the correct medications and dosages were administered as per physician orders was evident in these cases. Furthermore, a third resident received insulin injections in an unsafe manner. The LVN massaged the injection site after administering insulin, which is against proper technique as it can increase the rate of absorption. The facility's policies and procedures were not followed, leading to these deficiencies in pharmaceutical services and medication administration.
Deficiencies in Clinical Record Maintenance and Medication Orders
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for three residents, leading to potential risks in their care and treatment. For Resident #3, the facility did not have physician orders for dialysis treatment or care of the dialysis access device, despite the resident receiving dialysis three times a week. The resident's care plan and MDS assessment indicated she was receiving dialysis, but there were no documented orders for this treatment or for the care of the shunt site, which was observed to be uncovered. Resident #7's physician orders for the administration of an antidepressant medication, Venlafaxine, were unclear and inconsistent. The orders included conflicting instructions regarding the dosage, with records indicating both 225mg and 375mg daily doses. The medication administration records showed that the resident received 375mg daily, which was not aligned with the intended prescription. Interviews with the DON and PMHNP revealed confusion over the correct dosage and the use of both generic and brand names for the medication, leading to a risk of medication errors. For Resident #21, the facility failed to specify the amount of a liquid nutritional supplement, Med Pass 2.0, to be administered. The physician's order did not indicate the quantity to be given, and the MAR lacked documentation of the amount provided or consumed by the resident. This oversight was acknowledged by the medication aide, who administered an arbitrary amount without consulting the charge nurse or DON. The lack of clear orders and documentation posed a risk of inadequate nutritional support for the resident, who was at risk for weight changes and malnutrition.
Infection Control Deficiency: Improper Handling of Urine Catheter Bag
Penalty
Summary
The facility failed to maintain an infection prevention and control program, which resulted in a deficiency related to the improper handling of a urine catheter bag for a resident. During observations on two separate occasions, the resident's urine catheter bag was found hanging on a trash can beside the bed, with the bottom of the bag touching the floor. This improper placement was confirmed by a CNA, who acknowledged that the bag should not be touching the floor and should be hung from the bed below the resident's feet. Additionally, the bag should have been placed in a covering bag, as per the facility's policy. The Director of Nursing (DON) also confirmed that the urine catheter bag should have been in a covering bag and noted that the facility had recently purchased new covering bags. The facility's policy on anchoring catheter bags clearly indicated that they should not touch the ground.
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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 Van
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Bradburn | 11.2 mi | ★★★★★ | 7 | 2 |
| Azalea Trail Nursing And Rehabilitation Center | 11.3 mi | ★★★★★ | 1 | 0 |
| Avir At Grand Saline | 11.7 mi | ★★★★★ | 16 | 1 |
| Canton Oaks | 12.8 mi | ★★★★★ | 0 | 0 |
| Mineola Gardens Wellness & Rehabilitation | 13.5 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.