Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before 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 Kingsville Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that a CNA did not follow infection control practices during a meal service. The CNA wore a surgical mask below the nose while handling food and leaning over residents, performed hand hygiene with alcohol-based sanitizer for only a few seconds instead of the required ~20 seconds until dry, and handled residents’ drinking cups by the rim where mouths contact the cup. The ADON and the CNA both acknowledged that these practices did not comply with the facility’s hand hygiene and infection prevention policies or CDC guidance on proper mask fit and handling of items that contact residents’ mouths.
The facility failed to maintain effective infection control practices and properly implement Enhanced Barrier Precautions (EBP). During incontinent care for a dependent resident with diabetes and prior stroke, CNAs did not perform hand hygiene or change gloves when moving from dirty to clean areas, handled clean supplies with soiled gloves, manipulated a trash bag on the bed with contaminated gloves, and then handled the same trash bag with bare, clean hands, contrary to facility hand hygiene and perineal care policies. For two other residents with wounds and surgical incisions under EBP orders, PPE such as gowns and gloves was not placed immediately outside or near their rooms, despite care plans and policy requiring EBP signage and readily accessible PPE for high-contact care activities. A CNA reported that PPE was usually kept outside rooms but was unsure where it was for one resident, and the DON stated that PPE did not need to be outside EBP rooms as long as it was available on the hall and that only gowns and gloves were used for EBP, even when splash risk might be present.
A resident with a history of cerebral infarction and Type 2 DM had an active diabetes diagnosis on the MDS, but no corresponding care plan addressing glucose control, diet, or routine diabetic labs and tests. The same resident had an ADL self-care deficit care plan that included floor mats, yet surveyors observed no floor mats in the room while the resident was in bed, and staff acknowledged the intervention was not being used and the care plan had not been updated. These issues occurred despite facility policy requiring comprehensive care plans to describe needed services and be reviewed and revised after each comprehensive and quarterly MDS.
A hospice resident with severe cognitive impairment allegedly told his responsible party that another cognitively intact resident had entered his room and put a finger in his rectum. The responsible party reported this to staff, the resident was moved to another hall, and a hospice RN performed a rectal assessment, but facility documentation only reflected a room change due to noise and did not record the allegation or the reason for the hospice visit. Hospice staff reported that they informed the administrator that an abuse allegation had been made, while several CNAs stated they were told the move was due to another resident touching the victim, yet the DON and ADON on call were not notified of an abuse allegation that day. The administrator later stated she did not view the information from the responsible party as an actual allegation and did not report it to the state agency or initiate a documented investigation until two days later, contrary to the facility’s abuse policy requiring immediate investigation and reporting within two hours for alleged abuse.
A resident with essential HTN and moderate cognitive impairment had an order for carvedilol with instructions to hold the dose if BP was below a specified parameter. Review of the MAR and interviews showed that an LVN administered carvedilol on two occasions when the resident’s documented BP readings were below the ordered threshold. The LVN acknowledged awareness that BP meds should not be given outside ordered parameters without specific provider instructions, and the DON confirmed the doses should have been held. This practice was inconsistent with the facility’s medication administration policy requiring meds to be held when vital signs fall outside prescribed parameters.
A resident with severe cognitive impairment and a history of falls was found to have only one floor mat beside her bed, despite care plan and physician orders requiring two mats for fall prevention. Staff interviews confirmed the responsibility to ensure mats were in place, but the second mat was missing, and the reason was unknown. The facility's policy required individualized fall prevention interventions, which were not followed in this case.
A resident with multiple diagnoses, including hypertension and dementia, received Hydrochlorothiazide outside of prescribed blood pressure parameters, and staff failed to consistently document or clarify blood pressure readings before administration. Nursing staff were unclear about the parameters and did not always follow facility policy, resulting in significant medication errors.
The facility failed to employ a certified dietary manager, placing residents at risk of foodborne illness and inadequate nutrition. The Dietary Manager had not completed the required certification course, and the facility lacked a policy on maintaining licenses or certifications.
The facility failed to adhere to professional standards for food service safety, including the Dietary Manager not wearing a beard hair restraint, unlabeled and undated food items, an uncovered electrical outlet, and dirty ceiling vents in the kitchen. These deficiencies were confirmed through interviews and record reviews, highlighting risks to resident safety and foodborne illness.
The facility failed to maintain an infection prevention and control program, leading to improper care practices for a resident. Two CNAs did not wash or sanitize their hands or change gloves after touching items near the resident before starting incontinent care. One CNA also did not clean between her fingers with hand sanitizer. The resident had multiple diagnoses and required total care. Despite receiving training and passing skills checks, the CNAs did not follow infection control protocols.
The facility failed to transmit encoded, accurate, and complete MDS data to the CMS System for a resident. The Discharge MDS Assessment, completed months earlier, was not exported due to an oversight by the MDS Coordinator. The Administrator confirmed the lack of a policy on MDS transmission timeliness.
Improper Hand Hygiene, Mask Use, and Utensil Handling During Dining Service
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program based on observations in the dining room involving one CNA. During a midday meal service, the CNA was observed wearing a surgical mask positioned below her nose while handling residents’ food and leaning over residents. She performed hand hygiene twice using alcohol-based hand sanitizer but only rubbed her hands together for approximately 3–4 seconds each time before holding her hands in the air and then proceeding to handle residents’ trays and food. The facility’s hand hygiene policy required rubbing all surfaces of the hands and fingers with alcohol-based hand rub until dry, which should take about 20 seconds. The CNA was also observed handling residents’ cups of water and tea by grasping the cups around the tops where residents would place their mouths. In interviews, the ADON stated that wearing a mask beneath the nose was ineffective, that alcohol-based hand sanitizer should be rubbed over all hand surfaces until dry (about 20 seconds), and that cups should not be handled by the rim due to risk of cross-contamination. In a separate interview, the CNA acknowledged she knew the mask was ineffective when worn below the nose, that proper hand sanitizer use required rubbing for about 20 seconds until dry, and that cups should not be grabbed around the rim, but she had not followed these practices. Facility policies and CDC guidance reviewed by surveyors described the infection prevention and control program requirements, proper hand hygiene technique, and correct mask use covering both nose and mouth.
Inadequate Infection Control Practices and EBP Implementation
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, including proper hand hygiene, glove use, and implementation of Enhanced Barrier Precautions (EBP). For one resident, a female with a history of cerebral infarction and type 2 diabetes with hyperglycemia, the care plan identified risk for skin breakdown related to bladder incontinence and dependence in toileting hygiene, with interventions to check for incontinence and clean the perineal area with each episode. During observed incontinent care, two CNAs gathered clean supplies into a clean bag and placed an open trash bag on the resident’s bed for soiled items, then donned gloves after hand hygiene. While removing the resident’s brief, feces were smeared down the resident’s leg. One CNA cleaned the resident’s front and, without performing hand hygiene or changing gloves, accessed the clean supply bag and handed clean supplies to the other CNA, who was cleaning feces from the resident’s backside and between the legs. During the same episode of care, one CNA manipulated the trash bag on the resident’s bed with soiled gloves after dirty gloves had fallen out of the bag onto the bed, placing the soiled gloves back into the bag and pulling the sides of the bag up before returning to incontinent care. After care was completed, one CNA performed hand hygiene in the bathroom while the other CNA fastened a clean brief and pulled up the resident’s clothing without first performing hand hygiene. That CNA then performed hand hygiene and immediately grabbed and tied the trash bag containing soiled items with bare, clean hands and carried it out of the room. In subsequent interviews, both CNAs acknowledged that they should have performed hand hygiene and changed gloves when moving from dirty to clean areas, should not have handled clean supplies with soiled gloves, and should not have handled the trash bag that had been manipulated with dirty gloves using bare, clean hands. The facility’s hand hygiene and perineal care policies required proper hand hygiene and glove changes when soiled, and specified that gloves do not replace hand hygiene. The deficiency also includes failure to ensure appropriate PPE availability and implementation of EBP for two other residents. One male resident with osteomyelitis, local skin and subcutaneous tissue infection, type 2 diabetes, and an active wound infection had physician orders and a care plan for EBP due to diabetic ulcers, requiring gown and gloves for high-contact resident care activities each shift. Another female resident with a displaced trimalleolar fracture and a surgical incision had physician orders and a care plan for EBP due to the surgical incision, with interventions including posting an EBP sign on the door and using gown and gloves for specified high-contact activities, and mask or eye shield as indicated. Observation revealed that these residents’ rooms did not have PPE immediately outside or near the rooms; only one PPE cart was located toward the ends of each hall. A CNA stated that EBP signs were used to indicate when PPE should be worn for certain activities and that PPE was usually located in a bin outside residents’ rooms, but she was unsure where PPE for one resident was and noted PPE was available in the shower room on the hall. In an interview, the DON, who also served as the infection control nurse, stated that hand hygiene should be performed when going from dirty to clean areas but asserted that CNAs could grab the outside of the trash bag with clean, ungloved hands because the outside was considered clean. The DON further stated that EBP was used for residents with wounds or indwelling devices and that EBP rooms did not need PPE outside the rooms as long as it was available on the hall or close by. She indicated that for EBP only gowns and gloves were required for high-contact activities, that face shields and goggles were not used for EBP even for splash back, and that if such eye protection were needed she would place the resident on droplet precautions. She also stated that residents with a known or colonized CDC-targeted MDRO would be placed on contact precautions rather than EBP. CMS and CDC guidance, as well as the facility’s own EBP policy, required that gowns and gloves be made available near or outside the resident’s room and that clear signage and ready access to PPE be ensured when implementing EBP.
Failure to Care Plan Diabetes and Implement Listed Fall Mat Intervention
Penalty
Summary
Surveyors identified that the facility did not develop and implement a comprehensive care plan addressing all identified needs for a resident with multiple diagnoses. Record review showed the resident was an older female with a history of cerebral infarction and Type 2 diabetes with hyperglycemia, with an active diagnosis of diabetes mellitus documented on a recent quarterly MDS. Despite this, the resident’s care plan contained no problem, goals, or interventions related to diabetes, including no care plan direction for glucose monitoring, diet, or routine diabetic labs and diagnostic tests. The facility’s policy required the comprehensive care plan to describe services to attain or maintain the resident’s highest practicable well-being and to be reviewed and revised after each comprehensive and quarterly MDS assessment, but this was not done for the resident’s diabetes. The facility also failed to implement an existing intervention listed on the resident’s care plan. The resident had an ADL self-care performance deficit care plan initiated in 2022 that included floor mats as an intervention. During observation, surveyors noted there were no floor mats in the resident’s room while the resident was in bed. In interviews, the MDS nurse acknowledged that the fall mats on the care plan were supposed to have been removed because they were not being used, but the care plan had not been updated accordingly. The MDS nurse and the ADON both stated that the resident’s diabetes should have been care planned, including diet and labs, and that the MDS nurse typically updated the clinical aspects of the care plan.
Failure to Timely Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its written abuse, neglect, and exploitation policies when a hospice resident with severe cognitive impairment allegedly reported sexual abuse by another resident. The resident was an elderly male on hospice care with COPD, type 2 diabetes, unspecified dementia, depression, anxiety, and a history of stroke, and his admission MDS showed a BIMS score of 3, indicating severe cognitive impairment. On the evening in question, his responsible party (RP) was feeding him when another male resident walked by; the hospice resident became fearful and told the RP that the man who had been at the door had gone into his room and put a finger in his rectum. The RP reported this to facility staff, and the resident was moved to another hall and closer to the nurse’s station that same evening, but the contemporaneous nursing documentation only reflected a room move due to the hall being too loud and did not document the allegation or the reason for the hospice nurse’s visit. Multiple interviews and records showed that the allegation of sexual abuse was known to several individuals on the date it was made, but the facility did not report it to the state agency within two hours as required by its policy, nor did it initiate an immediate, documented investigation at that time. The hospice records documented that the hospice nurse was dispatched for a PRN visit specifically because of a reported sexual assault, that an outcry had been made by the patient to his family, and that the hospice nurse assessed the resident’s anus for trauma with a facility LVN present. The hospice nurse’s narrative stated she had been briefed that the resident reported another resident put a finger in his buttocks, and she documented that the facility administrator and hospice would follow up per protocol. Hospice staff, including the hospice director and hospice social worker, reported that they informed the administrator on the evening of the allegation, and that the administrator stated she was aware of the allegation and was starting the investigation process. However, the administrator later stated she did not consider what she was told by the RP to be an actual allegation of abuse and therefore did not report it at that time. Facility staff interviews revealed inconsistent knowledge and communication about the allegation and the reason for the room change. Several CNAs stated they were told by an LVN or charge nurse that the resident was moved because another resident had touched him or that something had happened between the two residents, while the social worker and one ADON reported they were only told the move was due to noise and anxiety and were unaware of an abuse allegation until days later. The DON stated she was informed by the administrator on the night of the room change only that the RP had concerns about the other resident being loud and causing anxiety, and she did not come to the facility that night. The ADON on call reported she was not notified of the allegation on the date it occurred, despite facility expectations that allegations be reported immediately to administration and on-call leadership. The facility’s abuse policy required immediate investigation and reporting of all alleged violations to the administrator and state agency within two hours when abuse was involved, but there was no timely report to the state survey agency and no contemporaneous, complete documentation of an investigation into the sexual abuse allegation until two days later, when the administrator self-reported after being informed again of the allegation by hospice and internal staff.
Antihypertensive Given Outside Ordered Parameters
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to administration of an antihypertensive medication outside of ordered parameters. The resident was an older male with essential hypertension and a BIMS score of 8, indicating moderate cognitive impairment. His care plan included an intervention to administer antihypertensive medication as ordered. The physician’s order for carvedilol 6.25 mg twice daily specified it should be held if blood pressure was less than 120/60 and pulse less than 60. Review of the December MAR showed that on two occasions carvedilol was administered by an LVN when the resident’s recorded blood pressures were 115/65 and 112/67, which were outside the ordered blood pressure parameters for giving the medication. During interview, the LVN confirmed she signed the MAR indicating she administered carvedilol on those dates and acknowledged she was not supposed to administer blood pressure medications outside specified parameters unless given specific instructions by a physician or nurse practitioner. She stated that administering blood pressure medications outside parameters could cause fatigue, headache, or fainting. The DON, upon review of the MAR, stated it appeared the LVN administered carvedilol despite the blood pressures being outside the stated parameters and confirmed the medication should not have been given on those days. The facility’s Medication Administration policy required staff to obtain and record vital signs when applicable or per physician orders and to hold medications when vital signs were outside the physician’s prescribed parameters, which was not followed in this case.
Failure to Provide Required Fall Prevention Devices for Resident at Risk
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's environment was free from accident hazards and that adequate supervision and assistive devices were provided to prevent accidents. Specifically, a resident with severe cognitive impairment, a history of multiple falls, and a moderate fall risk was observed to have only one floor mat in place beside her bed, despite her care plan and physician's orders requiring two mats as a safety precaution. The resident's care plan and medical orders had been updated following several unwitnessed and witnessed falls, including one with injury, to include the use of two floor mats. Staff interviews confirmed that all staff, including CNAs and nursing staff, were responsible for ensuring the mats were in place, and that the absence of a mat could result in injury. The LVN acknowledged the resident was supposed to have two mats and was unsure why the second mat was missing, noting that the supply clerk was responsible for providing mats. The Administrator and DON also confirmed the requirement for two mats and stated that the main responsibility for ensuring their presence fell on the nurse caring for the resident. Facility policy required individualized fall prevention interventions based on assessed risk, which was not followed in this instance.
Failure to Adhere to Blood Pressure Parameters for Antihypertensive Medication
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was free from significant medication errors related to the administration of Hydrochlorothiazide, a medication prescribed for hypertension. The resident, an older adult male with diagnoses including Wernicke's Encephalopathy, dementia with mood disorder, and essential hypertension, had physician orders specifying that Hydrochlorothiazide should be held if blood pressure was less than 100/60. However, there were inconsistencies in the medication orders, with some periods lacking clear blood pressure parameters, and the facility did not clarify these discrepancies with the provider. Medication administration records revealed that Hydrochlorothiazide was given to the resident even when his blood pressure readings were below the prescribed parameters, such as on occasions when his blood pressure was 124/54 and 98/62. Additionally, there were several days when no blood pressure readings were documented prior to administration of the medication, despite the order requiring this assessment. Interviews with nursing staff indicated a lack of awareness or attention to the blood pressure parameters, and some staff could not recall receiving recent in-service training on this topic, though they mentioned annual skills checkoffs. The facility's medication administration policy required obtaining and recording vital signs when applicable, holding medications for vital signs outside prescribed parameters, and documenting these on the medication administration record. Despite these policies, the staff failed to consistently follow the prescribed parameters for Hydrochlorothiazide, leading to the administration of the medication outside of safe blood pressure ranges and without proper documentation.
Failure to Employ Certified Dietary Manager
Penalty
Summary
The facility failed to employ a certified dietary manager as required, which could place residents at increased risk of foodborne illness and inadequate nutrition. The Dietary Manager, who was hired on 11/20/2015 and rehired on 12/2/2016, had not completed the certified Dietary Manager course that he started in November 2023. During an interview, the Dietary Director admitted that he hoped to complete the course in the next three months and acknowledged that completing the course would help him better manage the kitchen and understand resident diets. The Administrator and Human Resource Director believed that enrolling the Dietary Director in the certified dietary manager course met the facility's requirements. However, the facility did not have a policy on employees maintaining their licenses or certifications. The job description for the Dietary Food Service Supervisor indicated that the supervisor was responsible for the daily operations of the dietary department according to facility policy and federal/state regulations. An additional section in the job description authorized payment for the certified dietary manager course, but the Dietary Director had not yet completed it.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During a kitchen tour, the Dietary Manager was observed not wearing a beard hair restraint, which is essential to prevent hair from contaminating food. Additionally, two bags of sliced strawberries in the freezer and a bag of tostada chips in the kitchen storeroom were not labeled or dated, making it difficult to monitor the freshness and safety of these food items. An electrical outlet in the kitchen was found without an attached cover, posing a safety hazard to employees. Furthermore, a ceiling vent in the dish-room had rust on the attached sprinkler head and dirt on the ceiling surface around the vent, while another ceiling vent in the dish machine room had dirt particles and grease on the vent slats, compromising kitchen sanitation. Interviews with the Dietary Manager, Maintenance Director, and Administrator confirmed the importance of these safety and sanitation measures. The facility's policies on employee sanitation, food storage, and fire containment, as well as the U.S. Public Health Service Food Code, emphasize the need for hair restraints, proper labeling and dating of food items, intact electrical outlets, and clean kitchen equipment and surfaces. The failure to adhere to these standards could place residents at risk for foodborne illness and other safety hazards.
Infection Control Deficiency
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, leading to improper care practices for a resident. During an observation, two CNAs did not wash or sanitize their hands or change their gloves after touching items in close proximity to the resident before starting incontinent care. Additionally, one of the CNAs did not clean between her fingers with hand sanitizer while providing care. Both CNAs confirmed that the environment around the resident was considered dirty and acknowledged that they should have changed their gloves and sanitized their hands prior to providing care. The Director of Nursing (DON) also confirmed that the staff should have followed proper infection control protocols. The resident involved had multiple diagnoses, including Alzheimer's disease, dementia, hyperlipidemia, Parkinsonism, major depressive disorder, anxiety disorder, and delusional disorder. The resident required total care and was frequently incontinent of bowel and bladder. Despite having received infection control training within the year and passing annual skills checks, the CNAs did not adhere to the facility's infection prevention and control policies. The DON and Assistant Director of Nursing (ADON) were responsible for the training and checking of the staff's skills, and the facility's policies emphasized the importance of assuming all residents could be potentially infected or colonized with an organism that could be transmitted during care.
Failure to Transmit MDS Data Timely
Penalty
Summary
The facility failed to transmit encoded, accurate, and complete MDS data to the CMS System for one resident. Specifically, the Discharge MDS Assessment for Resident #42, completed on 12/29/2023, was not exported as of 05/23/2024. During an interview, the MDS Coordinator confirmed the oversight and acknowledged responsibility for the failure. The Administrator also confirmed that the facility had no policy regarding the timeliness of MDS transmission.
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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 Kingsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lone Star Ranch Rehabilitaion And Healthcare Cente | 1 mi | — | 3 | 0 |
| The Premier Snf Of Alice | 22.3 mi | — | 9 | 0 |
| Windsor Nursing And Rehabilitation Center Of Alice | 22.3 mi | — | 11 | 0 |
| Meridian Care Of Alice | 22.6 mi | — | 9 | 4 |
| Robstown Nursing And Rehabilitation Center | 24.7 mi | — | 6 | 0 |
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