Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Coryell Health Rehab Living At The Meadows during CMS and state inspections, most recent first.
Surveyors found a medication cart left unattended and unlocked in a main lobby area while a resident was nearby and staff walked past without securing it. Staff, including an RN, LVN, CNAs, the DON, and the Administrator, all reported they had been trained that medication carts must remain locked when not in use or out of direct view, and that the assigned nurse or medication aide is responsible for securing the cart. The facility’s written policy requires medication carts to be locked at all times when out of the nurse’s view and when not in use. Staff acknowledged that leaving the cart unlocked could allow residents to access medications, with potential for overdose, hospitalization, and pain.
A resident with severe cognitive impairment and a history of skin breakdown developed a blister on her heel, later identified as a pressure ulcer. Despite care plan interventions and physician orders to offload the heel and avoid pressure, an agency CNA placed tennis shoes on the resident after being told not to do so. Communication failures among staff and lack of documented in-service training led to the resident receiving care that did not meet professional standards.
A resident with severe cognitive impairment and chronic pain did not receive a timely pain assessment or appropriate pain management when family reported the resident was in pain. Nursing staff failed to assess and document the resident's pain level at the time of the complaint, despite facility policy and physician orders requiring such assessments. This resulted in the resident's pain not being properly evaluated or managed.
A resident with multiple chronic conditions did not receive an ordered antibiotic for a urinary tract infection as prescribed, due to delays in medication entry and lack of communication among staff. The medication was not administered on the scheduled start date, and there was no documentation explaining the omission. Staff interviews revealed uncertainty about the cause, and the incident was not recorded in the facility's medication error logs.
A facility failed to implement its abuse prevention policies when a nurse allegedly made derogatory comments about a resident's fall, suggesting it was faked. Despite training, staff did not report these comments to the Administrator, the designated Abuse Prevention Coordinator. The resident, with multiple medical conditions and no cognitive impairments, experienced an unwitnessed fall, raising concerns about whether she should be sent to the ER. The failure to report these comments placed residents at risk.
Unattended, Unlocked Medication Cart Accessible to Residents
Penalty
Summary
Surveyors identified a deficiency related to medication security when medication cart #1 (MC #1) was observed unattended and unlocked in the main lobby area, with a resident present nearby. A subsequent observation showed staff members walking past the still-unlocked cart. The facility’s own policy, titled “Security of Medication Cart” and dated April 2007, states that medication carts must be securely locked at all times when out of the nurse’s view and locked and parked at the nurses’ station when not in use. The report notes that this failure could place residents at risk of overdose, hospitalization, and pain. Multiple staff interviews confirmed that they had been trained to keep medication carts locked and understood the requirement to secure them when not in use or when out of their direct view. RN A, who had worked at the facility for 5 years, acknowledged she left MC #1 unlocked due to an oversight and stated that residents could access medications if the cart was left unlocked. LVN B, CNAs C and D, the DON, and the Administrator each stated that the assigned nurse or medication aide is responsible for locking the cart and that the cart should remain secured when not actively in use. They also stated that residents could access medications from an unlocked cart, with potential for harm, including poisoning or death, if medications were ingested.
Failure to Follow Care Plan and Professional Standards for Resident with Foot Wound
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including dementia, diabetes, chronic pain, and a history of skin breakdown, did not receive care in accordance with professional standards and her person-centered care plan. The resident developed a blister on the back of her left heel, which was later identified as a pressure ulcer. Despite clear instructions and care plan interventions to offload the heel and avoid pressure, an agency CNA placed tennis shoes on the resident after being told not to do so. This action was observed by the resident's family, who had previously communicated with facility staff, including the ADON and LVN, about the need to avoid tennis shoes due to the pressure area. The care plan for the resident included specific interventions such as offloading the heels with cushions or pillows, using a heel boot at all times, and changing dressings as ordered. Physician orders also specified wound care procedures and the use of a heel boot to prevent further pressure. However, there was a breakdown in communication among staff, as the CNA who put the shoes on the resident was not aware of the restriction, and there was no documented in-service training for staff regarding this specific care need. The wound care nurse acknowledged that an order should have been in place to restrict footwear to socks or open-back house shoes, but this was not implemented in a timely manner. Interviews with facility staff, including the Wound Care Nurse, ADON, and DON, revealed that while the issue of inappropriate footwear was discussed among leadership and with the family, the information was not effectively communicated to all direct care staff. The facility's in-service records did not reflect any training or instruction regarding the resident's footwear restriction during the relevant period. As a result, the resident was exposed to unnecessary discomfort and risk of worsening her foot wound due to the failure to follow the care plan and professional standards of practice.
Failure to Assess and Manage Resident Pain as Reported by Family
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with multiple complex medical conditions, including dementia with severe cognitive impairment, chronic pain, congestive heart failure, COPD, and osteoporosis. The resident's care plan included interventions for pain management and skin breakdown prevention, and physician orders were in place for scheduled and PRN pain medications. Despite these measures, there was a failure to assess the resident's pain level when the family reported the resident was in pain and requested pain medication. On the day in question, the resident's family reported that the resident was crying in pain and requested pain medication. The nurse informed the family that the resident had just received medication and could not receive more until a later time. However, upon review, it was found that the resident had not actually received pain medication at the time stated by the nurse. There was no documented pain assessment during the period when the family reported the resident was in pain, and the nurse was unable to specify the resident's pain level at that time. The facility's policy required pain assessment whenever pain was reported or medication was administered, but this was not followed. Interviews with staff confirmed that the expectation was to assess pain whenever a resident complained of pain, and that pain assessments should be documented with each administration of pain medication. The lack of assessment and documentation meant that the resident's pain was not properly evaluated or managed according to professional standards and the facility's own protocols.
Failure to Administer Ordered Antibiotic and Document Medication Omission
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not administering an ordered antibiotic as prescribed. The resident, an elderly female with multiple diagnoses including dementia, diabetes, anxiety, chronic heart failure, COPD, and chronic pain, was admitted with significant health concerns and was at risk for pressure ulcers. A physician's order was written for Cephalexin 500 mg to be administered every 12 hours for a urinary tract infection, with a specified start and stop date. However, review of the Medication Administration Record (MAR) showed that the antibiotic was not given as ordered on the initial date, and there was no documentation in the progress notes explaining why the medication was not administered or why the start of the antibiotic was delayed. Interviews with facility staff, including the hospice nurse, LVN, and DON, revealed a lack of awareness and clarity regarding the missed dose. The hospice nurse was not informed that the antibiotic was unavailable or not delivered, and stated that if she had been notified, she would have arranged for the medication to be provided. The LVN could not recall the specific incident but suggested that pharmacy issues or delays in entering the order into the computer system may have contributed to the missed dose. The DON confirmed that the expectation was for nurses to obtain the initial dose from the emergency kit and to document any issues, but could not find documentation or recall why the antibiotic was not given as ordered. The resident's family reported noticing a foul urine odor and confirmed that hospice had ordered the antibiotic, expecting it to be started promptly. When the family inquired about the medication, they were told by the LVN that the antibiotic had not been administered due to it not being entered into the system. The facility's medication error logs did not reflect this incident, and the facility's policy required immediate documentation of medication orders and administration, which was not followed in this case.
Failure to Report Potential Abuse by Staff
Penalty
Summary
The facility failed to implement its written policies and procedures regarding prohibiting and preventing abuse for one resident. On 4/23/2024, RN-B was allegedly heard making derogatory statements about a resident to multiple staff members, including CNA-A, CSM-C, and CSM-D. These statements included referring to the resident's fall as a 'boy who cried wolf' scenario and suggesting that the resident was faking the fall. Despite these comments, the staff did not report the potential abuse to the Administrator, who was the designated Abuse Prevention Coordinator. The resident involved was an elderly female with multiple medical conditions, including Diabetes Mellitus Type II, Hypertension, Hyperlipidemia, Congestive Heart Failure, Mild Asthma, Generalized Anxiety Disorder, Chronic Pain Syndrome, Disorder of the Connective Tissue, and Osteoarthritis. The resident had a BIMS score of 15, indicating no cognitive impairments. The incident occurred after the resident experienced an unwitnessed fall, and there was a concern about whether the resident should be sent to the ER. Despite the derogatory comments made by RN-B, the staff did not recognize these as potential abuse and failed to report them as required by the facility's policies. Interviews with various staff members revealed that they had received training on abuse and neglect and were aware of the reporting procedures. However, they did not perceive RN-B's comments as abusive at the time and thus did not report them. The facility's policy mandates that any knowledge or suspicion of abuse or neglect must be reported immediately to the Unit Charge Nurse, who is responsible for notifying the Director of Nursing and/or Administrator. This failure to report placed residents at risk of abuse, neglect, or exploitation.
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 38 citations issued within 25 miles in the last 12 months — 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 Gatesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillside Medical Lodge | 3.9 mi | — | 8 | 0 |
| Mcgregor Wellness & Rehabilitation | 21.3 mi | — | 6 | 0 |
| Avir At Killeen | 21.8 mi | — | 9 | 0 |
| Rosewood Heights | 22.1 mi | — | 2 | 0 |
| Hill Country Heights | 22.4 mi | — | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Coryell Health Rehab Living At The Meadows.
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 August 2026) and official state health department websites.