Uvalde Healthcare And Rehabilitation Center
UVALDE HEALTHCARE AND REHABILITATION CENTER in UVALDE, TX — inspection on June 11, 2026.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
residents who did not have their physician orders to meet their immediate needs was that they may
4 days without orders for his isolation contact precautions, antibiotic IV medication, and PICC line
care with their basic needs supported by physicians orders upon their admission.
Specific to Resident #31 the orders would include PICC line care, isolation contact precautions, and IV antibiotics.
The DON stated that the care was developed and implemented with the coordination of the IDT which included the continuity of care between the admissions coordinator and the floor nurses.
The DON stated each member of the IDT had their own unique role and responsibility to ensure each resident received their immediate care needs and LVN A had a unique role in that she was the admissions nurse responsible for assessing Resident #31 with a need for isolation contact precautions, PICC line care, and IV antibiotic medications, for which she was expected to report to the physician and support the physician's orders for the care.
The DON stated the failure could place residents at risk for potential lack of care and the spread of infection by cross contamination.
The DON stated she had reviewed the facility's infection prevention and control surveillance for the period 5/22/2026 through 6/11/2026 which revealed zero incidents of infections throughout the facility with Klebsiella Pneumoniae. A record review of the United States of America's Centers for Disease Prevention and Control's website: https://www.cdc.gov/infection-control/media/pdfs/Guideline-Isolation-H.pdf titled 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings updated September 2024, accessed 6/16/2026, revealed, Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment.
Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination. A record review of the facility's undated, untitled, quality of care policy revealed, Purpose: To ensure that each resident receives the necessary care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being in accordance with comprehensive assessments, individualized care plans, professional standards of practice, and applicable federal and state regulations.
Policy: The facility shall provide care and services consistent with each resident's needs, preferences, goals, and rights.
Care shall be person centered, evidence based, and designed to promote optimal quality of life, prevent avoidable decline, and achieve the best possible outcomes.
The facility will comply with all applicable Federal and state requirements, including those outlined under F-tags related to quality of care and will maintain systems to monitor, evaluate, and improve the quality of services provided.
675532 06/11/2026
Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801
During an interview on 6/10/2026 at 5:42 PM LVN A stated she could not recall the events of 5/22/2026 and stated any documentation she made regarding residents specifically Resident #31 was accurate. LVN A stated standard practice was for a nurse to develop a baseline care plan for newly admitted residents to meet their basic immediate needs within 24 hrs. LVN A was informed that she documented on 5/23/2026 at 12:03 AM that Resident #31 had a PICC line and a record review of Resident #31's baseline care plan did not reflect the PICC line. LVN A stated a PICC line would have been an immediate need for flushing to keep the line patent (in nursing and medical jargon, patent [pronounced PAY-tent] means that a tubular anatomical structure, passage, or airway is open, unobstructed, and clear) with orders for flushes. LVN A did not recall receiving a report from LVN B, but if she had received the report, it would have been a standard practice with information about expectant new residents. LVN A stated she worked the 6:00 PM to 6:00 AM shift and she believed Resident #31 may have arrived on 5/22/2026 sometime between 6:00 PM and 11:00 PM 5/22/2026 evidencing her note on 5/23/2026 at 12:03 AM. LVN A stated the potential risk for residents who did not have their baseline care plan fully completed was that they may not have received the immediate care needed to meet their basic needs.
During an interview on 6/11/2026 at 4:10 PM the DON stated due to the state's investigation, she had recognized that Resident #31 had no baseline care plan.
The DON stated the expectation was for newly admitted residents to receive immediate care with their basic needs with a baseline care plan which was to be developed and implemented within 24 hours of their admission.
The DON stated that the baseline care plan was developed and implemented with the coordination of the IDT which included the continuity of care between the admissions coordinator and the floor nurses.
The DON stated that each member of the IDT had their own unique role and responsibility to ensure each resident received their immediate care needs.
The DON stated the potential risk for residents who did not have their immediate needs care planned could be they would not receive their immediate care needs. A record review of the facility's undated, untitled, care plan policy revealed, Purpose:To ensure that each resident receives individualized, coordinated care based on assessed needs, preferences, goals, and clinical condition.Policy Statement:The facility will develop and maintain a comprehensive, person-centered care plan for each resident.
Care plans will be created, reviewed, and revised by an interdisciplinary team and will reflect the resident's physical, psychosocial, emotional, and functional needs.Procedure:1.
Assessmento A comprehensive assessment will be completed upon admission and as required thereafter.o Assessment findings will identify resident strengths, needs, risks, preferences, and goals.2.
Care Plan Developmento An individualized care plan will be developed within the timeframe required by applicable regulations.o The care plan will include:ˆ Identified problems and needsˆ Measurable goals and expected outcomesˆ Interventions and services to be providedˆ Responsible disciplines and staff.4.
Interdisciplinary Team Involvemento The care plan will be developed and reviewed by the interdisciplinary team, including nursing, therapy, dietary, social services, activities, and other relevant disciplines.5.
Implementationo Staff will provide care according to the documented care plan.o Care plan interventions will be communicated to all appropriate staff.
This policy will comply with all applicable federal, state, and local regulations governing long-term care services.
675532 06/11/2026
Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801
actions that can be measured.
interviews and record review, the facility failed to ensure to develop and implement a comprehensive
measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 (4) residents in that: Resident #4's Care Plan did not include his diagnosis of PTSD and interventions.
This could affect all residents with care plans and could result in a decrease in care.
The Findings:
Record review of Resident #4's face sheet dated 6/10/206 revealed his admit date was on 9/5/2025, re-admitted on [DATE] with diagnoses of PTSD (post-traumatic stress disorder).
Record review of Resident #4's Physician visit dated 5/22/2026 revealed his diagnosis included PTSD.
Record review of Resident #4's Quarterly MDS dated [DATE] revealed his BIMS was 15/15 (cognitively intact), and active diagnosis included PTSD.
Record review of Resident #4's Physician visit dated 5/22/2026 revealed his diagnosis included PTSD.
Record review of Resident #4's care plan dated 4/22/206 revealed it did not include his diagnosis of PTSD.
Interview on 6/10/2026 at 4:48 PM the DON stated she did not see PTSD in Resident #4's care plans.
The DON stated it was important to have the diagnosis PTSD in Resident #4's care plan for staff to show interventions, such as avoiding certain triggers.
Thes DON stated she was responsible for ensuring the resident's diagnoses and care were in the care plans.
Record review of the policy, PTSD Management in Long-Term Care no date, Purpose: To provide guidelines for the identification, assessment, treatment, and support of residents with PTSD while promoting dignity, safety, trauma informed care, and psychological well-being.
Policy, the facility shall provide person centered trauma informed care for residents with a diagnosis or history of PTSD.
Definitions, PTSD; a mental health condition that may develop following exposure to traumatic events.
Trauma informed care; cares that recognizes the impact of trauma and seeks to avoid re traumatization.
Procedures; 2.
Care planning; Develop individualized interventions and document resident preferences and triggers.
Record review of the policy, Care Plan (no date) revealed, To ensure that each resident receives individualized, coordinated care based on assessed needs, preferences, goals and clinical condition.
Policy Statement: The facility will develop and maintain a comprehensive, person-centered care plan for each resident.
Care Plans will be created, reviewed, and revised by an interdisciplinary team and will reflect the residents' physical, psychological, emotional, and functioning needs.
Procedure: 1.
Assessment, Assessment findings will identify resident strengths, needs, risk, preferences, and goals. 2.
The Care plan will include: identified problems and needs, Measurable goals and expected outcomes, interventions and services to be provided and responsible disciplines and staff.
Interdisciplinary Team Involvement: The care plan will be developed and received by the interdisciplinary team, including nursing, therapy, dietary, social services, activities, and other relevant disciplines. 5.
Implementation, staff will provide care according to their documented care plan, care plans interventions will be communicated to all appropriate staff. 6.
Review and revision; Care plans will be reviewed regularly, and revised when: The residence conditions changes, Goals are achieved or no longer appropriate, new needs or risk are identified, regulatory review schedules require updates. 7.
Care plan development, reviews, revisions, and resident participation will be documented in the medical record.
675532 06/11/2026
Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801
she would re-educate CNA E for compliance. LVN C stated the potential risk for residents if staff
isolation room to provide hand hygiene, don a gown, and gloves prior to entering the room and to
contact precaution rooms the potential risk for residents could be the spread of infections. A record review of the facility's undated, untitled, quality of care policy revealed, Purpose: To ensure that each resident receives the necessary care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being in accordance with comprehensive assessments, individualized care plans, professional standards of practice, and applicable federal and state regulations.
Policy: The facility shall provide care and services consistent with each resident's needs, preferences, goals, and rights.
Care shall be person centered, evidence based, and designed to promote optimal quality of life, prevent avoidable decline, and achieve the best possible outcomes.
The facility will comply with all applicable Federal and state requirements, including those outlined under F-tags related to quality of care and will maintain systems to monitor, evaluate, and improve the quality of services provided.
Infection Prevention and Control; staff shall: Follow standard precautions and transmission based precautions; perform hand hygiene according to established guidelines; personal protective equipment; . A record review of the United States of America's Centers for Disease Prevention and Control's website: https://www.cdc.gov/infection-control/media/pdfs/Guideline-Isolation-H.pdf titled 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings updated September 2024, accessed 6/16/2026, revealed, Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment.
Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination.
675532 06/11/2026
Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801
During an observation and interview on 6/8/2026 at 1:00 PM revealed the facility's laundry department had 2 commercial washers of which only 1 functioned.
Laundry Aide F stated she was the laundry staff for the day and used the 1 functioning commercial washer. LA F stated she was able to keep up timely laundry services with the 1 washer but at times keeping up with timely laundry services was challenging with only 1 washer for all the residents. LA F stated the broken washer had been out of service for longer than 8 months.
During an observation and interview on 6/10/2026 at 3:00 PM revealed the facility's laundry department had 2 commercial washers of which only 1 functioned.
Laundry Aide G stated she was the laundry staff for the day and used the 1 functioning commercial washer. LA G stated she was able to keep up timely laundry services with the 1 washer but at times keeping up with timely laundry services was challenging with only 1 washer for all the residents. LA G stated the broken washer had been out of service for longer than 8 months.
During an interview on 6/11/2026 at 4:10 PM the Administrator stated she and the facility's Owner had become aware that 1 of the 2 facility commercial washers was not working and the washer was under the manufactures' warranty; however, the facility was unsuccessful in securing service from the vendor for the past 8 months.
The Administrator stated that for the time being the laundry department was able to keep up timely laundry services.
The Administrator stated she would follow up with the facility's Owner and explore alternate options for repairing the washing machine. A policy was requested (and as of 6/17/2026) a policy had not been provided.
The Administrator stated the facility followed HHSC guidelines.
675532 06/11/2026
Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801
housekeeping support as assigned.
Department Manager: Monitor compliance and address
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.