Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Azria Health Rose Vista during CMS and state inspections, most recent first.
The facility failed to provide correct portion sizes for 13 residents on carbohydrate controlled diets, serving 4 oz of fried rice instead of the prescribed 2 2/3 oz. Additionally, four residents received full servings of mandarin orange cake instead of half servings. The cook used an incorrect conversion chart, and the facility's policy on therapeutic diets was not followed.
The facility failed to maintain sanitary food storage and labeling practices, with multiple items found unlabeled and undated during inspections. Observations included unlabeled cereal-like contents, macaroni-like substances, and bun-like items, as well as uncovered salad-like substances in the refrigerator. A barrel of old grease was improperly stored in the freezer. The facility's policy requires all foods to be covered, labeled, and dated, which was not adhered to.
A resident with severe cognitive impairment and multiple diagnoses was found lying flat in bed, contrary to a physician's order to keep the head of the bed elevated at 30 degrees. Despite clear instructions in the care plan and progress notes, a CNA was unaware of the requirement, and the facility lacked a specific policy for following physician's orders.
The facility failed to provide proper catheter and peri-care for two residents, leading to potential infection risks. Staff did not follow hand hygiene protocols during care procedures, and catheters were not properly secured, contrary to the facility's infection control policies.
A resident with severe cognitive impairment experienced a fall and subsequent pain, but the facility delayed completing a physician-ordered x-ray for two days, revealing fractures in the wrist and hip. Staff and family interviews confirmed the delay, and the DON emphasized the importance of timely following physician orders.
Inadequate Portion Control for Therapeutic Diets
Penalty
Summary
The facility failed to serve the appropriate portion sizes of fried rice to 13 out of 15 residents who were on carbohydrate controlled or consistent carbohydrate diets. During a lunch service observation, these residents were served 4-ounce servings of fried rice instead of the prescribed 2 2/3-ounce servings. Additionally, four residents received full servings of mandarin orange cake instead of the required half serving. The facility's cook, Staff A, used the [NAME] Brothers conversion chart to determine serving sizes, but the chart indicated that a #12 scoop, which corresponds to 2 2/3 ounces, should have been used for the fried rice. The facility's policy on therapeutic diets, revised in October 2017, states that therapeutic diets, including diabetic/calorie-controlled diets, should align with residents' treatment goals. The administrator confirmed that staff should adhere to the diet spreadsheets, which were not followed in this instance.
Improper Food Storage and Labeling Practices
Penalty
Summary
The facility failed to maintain sanitary practices in food storage, preparation, and labeling, as observed during a kitchen inspection. Several items were found unlabeled and undated, including plastic containers with cereal-like contents, a bowl of macaroni-like substance, and bags of hamburger and hot dog bun-like items. Additionally, trays with undated and unlabeled plates of yellow, pie-like items, and a tube of ground beef-like meat were found in the Norlake walk-in refrigerator. The inspection also revealed multiple bowls of salad-like substances that were uncovered and in direct contact with the tray surfaces. Further observations noted a barrel of solid, white substance identified as old grease stored improperly on the floor of the walk-in freezer. A follow-up inspection found similar issues, including unlabeled creamy cherry pie and waffle-like items, as well as the barrel of grease now stored on a crate. The facility's policy, revised in 2017, mandates that all foods stored in refrigerators or freezers must be covered, labeled, and dated, and dry foods stored in bins should be removed from original packaging, labeled, and dated. The Administrator confirmed that food removed from identifying boxes must be properly dated, labeled, and stored.
Failure to Follow Physician's Positioning Orders
Penalty
Summary
The facility failed to adhere to a physician's order regarding the positioning of a resident's bed. On November 4, 2024, a resident was observed lying flat on their back, despite a sign at the head of the bed instructing staff to keep the head of the bed elevated above a 30-degree angle at all times. The resident had a severely impaired cognition with a BIMS score of 00 out of 15 and was diagnosed with Alzheimer's disease, non-Alzheimer's dementia, dysphagia, GERD, and gallstones. The resident was dependent on all aspects of ADLs. The physician's order, dated July 19, 2022, required the head-of-bed to be elevated to 30 degrees, which was also reflected in the care plan and progress notes. However, a CNA was unaware of the reason for this requirement, and the facility lacked a specific policy for following physician's orders. The administrator stated that staff should follow the care plan.
Inadequate Catheter and Peri-Care Leading to Infection Risks
Penalty
Summary
The facility failed to provide appropriate catheter and peri-care, leading to potential infection risks for two residents. Resident #16, with moderately impaired cognition and multiple health conditions, was observed with an indwelling catheter. During a care procedure, staff failed to perform hand hygiene or change gloves between handling the trash bin and performing perineal care. Additionally, the catheter tubing was not secured, and there was tension on the tubing, which could lead to trauma. Staff acknowledged the oversight in hand hygiene and securing the catheter. Resident #27, also with moderately impaired cognition and various health issues, had a urinary catheter. During a procedure to drain the urine, staff did not perform hand hygiene or change gloves, even after urine splashed onto a napkin near an alcohol swab. The facility's policy on hand hygiene, which requires handwashing before and after handling invasive devices, was not followed. The staff's actions were inconsistent with the facility's infection control policies. The facility's administrator confirmed that staff should adhere to the hand hygiene policy. The observations and interviews revealed a lack of compliance with infection prevention protocols, specifically regarding hand hygiene and catheter care, which are critical in preventing the spread of infections in the facility.
Failure to Timely Complete Physician-Ordered X-Ray
Penalty
Summary
The facility failed to provide needed services in accordance with professional standards by not completing an x-ray ordered by a physician in a timely manner for a resident with severe cognitive impairment. The resident was found on the floor and subsequently complained of left wrist pain, which was swollen and bruised. Despite obtaining an x-ray order on the morning following the incident, the x-ray was not performed until two days later, revealing fractures in the wrist and hip. Interviews with staff and family confirmed the delay in obtaining the x-ray, and the Director of Nursing (DON) stated that her expectation would be for physician's orders to be followed in a timely manner, ideally within 24 hours for non-stat orders. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and total dependence on staff for mobility and transfers. Progress notes documented the resident's fall, subsequent pain, and the delayed x-ray. Staff interviews revealed that the resident showed no immediate signs of pain but had increased pain medication for comfort post-fall. The facility's policy on medication and treatment orders emphasized the importance of following physician orders promptly, and the DON reiterated this expectation during her interview.
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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 Woodbine
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dunlap Specialty Care | 9.5 mi | — | 0 | 0 |
| Azria Health Longview | 15.2 mi | — | 3 | 0 |
| Elm Crest Retirement Community | 20.8 mi | — | 8 | 0 |
| Avoca Specialty Care | 23.4 mi | — | 18 | 0 |
| Accura Healthcare Of Tekamah | 26.2 mi | — | 14 | 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 August 2026) and official state health department websites.