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 Mabank Nursing Center during CMS and state inspections, most recent first.
A facility failed to provide proper respiratory care for three residents, leading to deficiencies in oxygen administration and nebulizer mask storage. One resident with COPD had oxygen set at 1 lpm instead of 3 lpm, and her nebulizer mask was improperly stored. Another resident with Alzheimer's had oxygen set between 3-4 lpm instead of 2 lpm. A third resident with dementia and COPD had oxygen set at 2 lpm instead of 3 lpm, and her nebulizer mask was unbagged. Staff acknowledged the importance of following physician orders and proper equipment storage.
The facility failed to implement proper infection control measures for residents with MRSA. A resident with a wound culture indicating MRSA was not placed on contact precautions, and staff frequently entered another resident's room on contact isolation without wearing PPE. These lapses in protocol increased the risk of infection spread, highlighting a lack of adherence to infection control policies.
A facility failed to respect the privacy and dignity of two residents when a Laundry Aide entered their rooms without knocking or introducing herself. The residents, one with intellectual disabilities and the other with severe dementia, were asleep at the time. The facility's policy requires staff to knock and introduce themselves to respect residents' privacy, which was not followed in this instance.
A resident with severe cognitive impairment and multiple care needs was found without access to a call light, as it was placed on the floor out of reach. Staff interviews revealed that the CNA did not place the call light within reach due to concerns about the resident's behavior, despite facility policy requiring call lights to be accessible.
A resident with severe cognitive impairment and incontinence issues was found to have a persistent urine odor in her room and on her person, despite staff efforts to maintain cleanliness. The odor was confirmed by staff and the resident's roommate, who expressed discomfort. Attempts to manage the odor with a diffuser were insufficient, highlighting a deficiency in providing a homelike environment.
The facility failed to develop and implement comprehensive person-centered care plans for two residents. One resident's care plan did not include specific treatments for her non-pressure wounds, while another resident's care plan was not updated to reflect a change in code status from Full Code to DNR. Interviews revealed a lack of communication and responsibility in updating care plans, which could lead to inappropriate care and services.
A resident with quadriplegia and muscle wasting did not receive consistent application of medical devices ('carrots') intended to manage hand contractures. Observations showed the resident without the devices, and staff interviews revealed inconsistencies in care plan implementation. An LVN admitted to not completing the task, and a CNA reported difficulty in placing the devices, often deferring to nurses or therapy staff. The DON confirmed the importance of the devices and that CNAs were trained to use them, but the facility's contracture management policy was not provided.
A resident with an indwelling catheter was observed with their catheter drainage bag on the floor, contrary to facility policy and posing a risk for infection. The resident, who required partial assistance and had a history of bladder dysfunction, was not provided with appropriate catheter care. Staff interviews confirmed the importance of keeping the catheter bag off the floor to prevent contamination, yet this practice was not followed.
A facility failed to ensure trauma-informed care for a resident with a history of trauma, as her care plan did not include this critical information. Despite the social worker's documentation of the trauma history, it was not added to the care plan, leading to potential risks of re-traumatization. Interviews revealed confusion about responsibility for updating the care plan, highlighting a gap in communication and adherence to the facility's trauma-informed care policy.
A medication storage deficiency occurred when a resident's Breo Ellipta inhaler was left unattended on a bedside table. The resident, who required assistance with daily activities and had a physician's order for the medication, was at risk due to the nurse's oversight. Facility staff confirmed that medications should not be left unattended, aligning with the facility's policy requiring drugs to be stored in locked compartments.
A resident's preference for bacon over sausage was not consistently honored, despite being documented on meal tickets. The resident, who was cognitively intact and required supervision with eating, repeatedly received sausage, which she disliked. The dietary manager and staff were aware of her preferences, but there was a lapse in ensuring these were followed, contrary to the facility's policy.
A resident experienced significant changes in condition, including confusion, weakness, and respiratory distress, but the facility failed to notify the physician in a timely manner. The resident was later hospitalized with severe diagnoses and passed away due to respiratory failure related to COVID pneumonia.
A resident with severe cognitive impairment and a history of Alzheimer's experienced a significant change in condition, including confusion and weakness, which the facility failed to recognize. The facility did not ensure increased fluid intake after lab results showed a UTI, and there was a two-day delay in addressing the lab results. Additionally, the resident did not receive oxygen therapy during respiratory distress, leading to hospitalization with sepsis, pneumonia, and dehydration. Staff interviews revealed communication lapses and failure to follow facility policies.
Deficiencies in Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for three residents, leading to deficiencies in oxygen administration and nebulizer mask storage. Resident #3, diagnosed with chronic obstructive pulmonary disease, was observed with oxygen set at 1 liter per minute (lpm) instead of the prescribed 3 lpm. Additionally, her nebulizer mask was improperly stored, being left unbagged on a mini fridge and later found on the floor. These observations were made despite the resident's care plan indicating the need for oxygen therapy and proper storage of respiratory equipment. Resident #66, who has Alzheimer's disease and a history of a femur fracture, was found with her oxygen set between 3-4 lpm, contrary to the physician's order of 2 lpm. The Licensed Vocational Nurse (LVN) responsible for checking the oxygen settings admitted to not knowing the correct settings and acknowledged the importance of adhering to the physician's orders to prevent respiratory distress. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the nurses should ensure oxygen is set according to orders and that nebulizer masks should be bagged to prevent contamination. Resident #19, with diagnoses including dementia and COPD, was observed with her oxygen set at 2 lpm instead of the ordered 3 lpm. Her nebulizer mask was also found unbagged on the nightstand, and her oxygen tubing was on the floor. The LVN and DON acknowledged the importance of following physician orders and proper storage of respiratory equipment to prevent infection and ensure adequate oxygenation. The facility's policies on oxygen administration and nebulizer use emphasize the need for correct oxygen settings and proper storage of equipment, which were not adhered to in these cases.
Inadequate Infection Control Measures for Residents with MRSA
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in implementing contact precautions for residents diagnosed with methicillin-resistant Staphylococcus aureus (MRSA). Resident #39, who had a wound culture indicating MRSA, was not placed on contact precautions. The Wound Care Nurse and the Director of Nursing (DON) did not recognize the need for contact precautions, despite the presence of MRSA, and relied on the wound care doctor and primary care team for guidance. This oversight was acknowledged by the DON, who admitted to not interpreting the wound culture results correctly. Resident #41, who was on contact isolation precautions due to MRSA in the urine, experienced multiple instances where staff failed to adhere to the required personal protective equipment (PPE) protocols. CNA F, CNA B, and Housekeeper E entered Resident #41's room without wearing the necessary gown and gloves, despite the presence of a contact isolation sign on the door. These staff members either misunderstood the requirements or neglected to follow the established protocols, increasing the risk of infection spread. Interviews with staff, including the DON and the Regional Vice President (RVP), highlighted a lack of adherence to infection control policies and a misunderstanding of the necessary precautions. The facility's policies on infection prevention and control, as well as isolation precautions, were not effectively implemented, leading to potential cross-contamination and the spread of infection among residents and staff.
Failure to Respect Resident Privacy and Dignity
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and respect, as evidenced by the actions of a Laundry Aide who entered the rooms of two residents without knocking or introducing herself. This incident involved a female resident with unspecified intellectual disabilities and severely impaired cognition, and another female resident with severe unspecified dementia and behavioral disturbances, both of whom were sleeping at the time. The Laundry Aide admitted to not following protocol because the residents were asleep, despite acknowledging the importance of knocking and introducing herself to avoid making residents feel uncomfortable or invaded. Interviews with the Housekeeping Supervisor, the Director of Nursing (DON), and the Regional President confirmed that the facility's policy required staff to knock and introduce themselves when entering residents' rooms, emphasizing the importance of respecting residents' privacy and treating them with dignity. The facility's policy on Resident Rights, revised in October 2022, mandates that employees treat all residents with kindness, respect, and dignity. The failure to adhere to this policy was observed and documented by the surveyor, highlighting a deficiency in maintaining the residents' quality of life and dignity.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call button was within reach, which is a reasonable accommodation of the resident's needs and preferences. This deficiency was observed when Resident #37 was found sitting in a standard chair with the call light on the floor on the other side of the bed, making it inaccessible. The resident, who is severely cognitively impaired with a BIMS score of 02, requires assistance with activities of daily living and is occasionally incontinent. Despite these needs, the call light was not placed within reach, and the resident was unable to answer questions about its use. Interviews with staff revealed that the CNA responsible for Resident #37 did not place the call light within reach, citing concerns that the resident might pull it out of the wall or throw it, potentially causing a fall. The CNA admitted to not placing the call light next to the resident since the start of her shift. The LVN and DON both emphasized the importance of having call lights within reach for all residents, regardless of cognitive deficits, as a means of communication for assistance. The facility's policy mandates that call lights be easily reachable by residents, yet this was not adhered to in the case of Resident #37.
Facility Fails to Maintain Odor-Free Environment for Resident
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, identified as Resident #19, who was observed to have a persistent urine odor in her room and on her person. Resident #19, an elderly female with severe cognitive impairment due to dementia, was incontinent of bowel and bladder and required assistance with daily living activities. Despite the staff's efforts to maintain cleanliness, the urine odor was noted during multiple observations and interviews, indicating a deficiency in maintaining a homelike environment. Interviews with staff and the resident's roommate confirmed the presence of the urine odor, which was a source of discomfort for the roommate. The staff, including a CNA and an LVN, acknowledged the odor issue and mentioned attempts to manage it with a diffuser, which was found empty during an inspection. The Director of Nursing and the Regional President were aware of the odor problem and expressed a commitment to maintaining an odor-free environment, but the issue persisted, affecting the quality of life for the residents involved.
Failure to Update and Individualize Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in addressing their medical and care needs. For one resident, the facility did not create a care plan specific to her non-pressure wounds, which included wounds on her right foot, right shin, and left posterior ankle. Despite having detailed wound care orders and evaluations, the care plan did not reflect these treatments or the specific locations of the wounds. Interviews with the Director of Nursing (DON) and the Wound Care Nurse revealed that the care plan should have been person-centered and included all treatments and services the resident received. Another resident's care plan was not updated to reflect a change in code status from Full Code to Do Not Resuscitate (DNR). Although the DNR status was documented in the resident's physician orders and electronic medical records, the care plan still indicated a Full Code status, which could lead to inappropriate life-saving measures being administered. Interviews with the Social Worker, DON, and MDS Coordinator highlighted a lack of communication and responsibility in updating the care plan to reflect the resident's current wishes. The facility's policy on comprehensive person-centered care plans emphasizes the need for measurable objectives and timetables to meet residents' needs. However, the failure to update and individualize care plans for these residents indicates a breakdown in the facility's processes for ensuring accurate and current care plans. This deficiency could result in residents not receiving the appropriate care and services tailored to their specific health needs and preferences.
Failure to Implement Contracture Management for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. The resident, who was diagnosed with quadriplegia, traumatic brain injury, and muscle wasting, was dependent on staff for all activities of daily living and had functional limitations in range of motion in both upper and lower extremities. The resident's care plan included the use of medical devices known as 'carrots' to treat hand contractures, but observations revealed that these devices were not consistently placed in the resident's hands as required. During multiple observations, the resident was found without the carrots in his hands, and staff interviews revealed a lack of consistent implementation of the care plan. A Licensed Vocational Nurse (LVN) admitted to signing off on the task without completing it and mentioned that the task could be delegated to Certified Nursing Assistants (CNAs). However, a CNA reported difficulty in placing the carrots due to the resident's contracted hands and usually deferred the task to the nurse or therapy staff. The Director of Nursing (DON) confirmed that CNAs were trained to place the carrots and emphasized the importance of doing so to prevent further contractures and wounds. Despite this, the facility's policy for contracture management was not provided upon request.
Failure to Maintain Catheter Bag Off the Floor
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections. Specifically, the resident's foley catheter drainage bag was observed on the floor, which is against the facility's policy and poses a risk for contamination and infection. The resident, a male with neuromuscular dysfunction of the bladder and benign prostatic hyperplasia, required partial assistance with toileting and had an order for regular catheter bag changes. Despite these measures, the catheter bag was not maintained properly, as observed during a facility visit. Interviews with staff, including an LVN, CNA, DON, ADON, and RVP, confirmed that the catheter bag should not be placed on the floor due to the risk of bacterial contamination and infection. The staff acknowledged their responsibility in ensuring the catheter bag was kept off the floor, yet the deficiency was noted during the survey. The facility's policy on emptying urinary drainage bags also emphasized keeping the bag and tubing off the floor to prevent contamination, which was not adhered to in this instance.
Failure to Provide Trauma-Informed Care for Resident with History of Trauma
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident with a history of trauma. The resident, a female with severe cognitive impairment and diagnoses of anxiety disorder and dementia, did not have her history of trauma documented in her care plan. This omission was identified during a review of the resident's records, which showed that a social worker had noted the history of trauma and abuse by a family member. However, this critical information was not included in the care plan, which is essential for guiding staff in providing appropriate care and preventing potential re-traumatization. Interviews with facility staff revealed a lack of clarity regarding responsibility for updating the care plan with the resident's trauma history. The social worker acknowledged the importance of including this information but was unsure who should add it to the care plan. The Director of Nursing (DON) indicated that the social worker should inform the nursing staff to ensure the care plan is updated. The Regional President emphasized the necessity of having complete and individualized care plans. The facility's policy on trauma-informed care also underscored the need for care plans to include individualized interventions and potential triggers, which was not adhered to in this case.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs were only accessible by authorized personnel, as evidenced by an incident involving a resident's medication being left unattended. On March 10, 2025, a medication named Breo Ellipta, prescribed for a resident with chronic obstructive pulmonary disease (COPD), was observed on the resident's bedside table with 18 puffs remaining. The resident, who was cognitively intact and required assistance with daily activities, had a physician's order for the medication to be administered once daily. However, the medication was left unattended by the nurse responsible for its administration, who admitted to being called away and forgetting to remove the medication from the room. Interviews with facility staff, including a CNA, LVN, and the Director of Nursing (DON), confirmed that medications should not be left at the bedside unattended. The DON emphasized that no residents in the facility were permitted to self-medicate, and leaving medications unattended could result in missed doses or unauthorized access by other residents. The facility's policy on medication storage, revised in April 2019, mandates that all drugs and biologicals be stored in locked compartments, highlighting the deviation from established procedures in this incident.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to accommodate a resident's food preferences, specifically the preference for bacon over sausage, which was not honored. The resident, who was cognitively intact and required supervision with eating, had expressed her dislike for sausage and preference for bacon multiple times to the nursing staff. Despite this, she continued to receive sausage for breakfast on multiple occasions. The resident's care plan and diet history did not reflect her food preferences, although her meal tickets did note her dislike for sausage and preference for bacon. Interviews with the dietary manager and staff revealed that the resident's food preferences were known and documented on her meal tickets. However, there was a lapse in ensuring these preferences were consistently honored, as evidenced by the resident receiving sausage instead of bacon. The dietary manager acknowledged the importance of adhering to residents' food preferences to ensure they eat and maintain their caloric intake. The facility's policy required the documentation of food preferences upon admission and as needed, but this was not effectively implemented in this case.
Failure to Notify Physician of Resident's Condition Changes
Penalty
Summary
The facility failed to immediately inform the resident, consult with the resident's physician, and notify the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status. This deficiency was identified for one resident who experienced a deterioration in health, including head leaning heavily to the left, heavy incontinence, confusion, weakness, and the need for a two-person assist. The facility did not notify the physician of these changes on the specified date. Additionally, the facility failed to notify the physician of the resident's respiratory distress on another date. The resident's vital signs indicated respiratory distress, with an oxygen saturation of 88% and respirations at 30 breaths per minute. Despite these critical changes, the physician was not informed in a timely manner, which could have allowed for an assessment and a plan of care to be decided upon. The resident was later admitted to the hospital with diagnoses including sepsis, pneumonia, COVID-19, influenza, and dehydration. The cause of death was determined to be respiratory failure due to COVID pneumonia. Interviews with facility staff revealed that the nurse practitioner was out of the country during the time of the resident's condition changes, and the physician was not notified of the cumulative changes in the resident's condition.
Removal Plan
- Suspending and then terminating RN A
- In-servicing staff regarding notification of changes
Failure to Provide Timely Care and Follow-Up for Resident with UTI and Respiratory Distress
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, leading to a deficiency in quality of care. The resident, who was severely cognitively impaired and had a history of Alzheimer's, muscle weakness, and anxiety, exhibited significant changes in condition, including head leaning, confusion, and weakness, which were not recognized as a change of condition by the facility on the specified date. Additionally, the facility did not ensure that fluid intake was encouraged or increased after lab results indicated the resident was positive for a urinary tract infection (UTI). The facility also failed to follow up promptly on the resident's lab results, which were positive for a UTI, resulting in a two-day delay in addressing the issue. Furthermore, the facility did not provide oxygen therapy when the resident was in respiratory distress, as evidenced by low oxygen saturation levels and increased respiration rates. The resident's condition deteriorated, leading to hospitalization with diagnoses including sepsis, pneumonia, COVID-19, and dehydration. Interviews with staff revealed a lack of communication and timely notification to the physician regarding the resident's change in condition and lab results. The physician stated that they were not notified of the resident's respiratory distress or lab results, which delayed the necessary medical intervention. The facility's policies on change in condition and lab result communication were not followed, contributing to the deficiency in care provided to the resident.
Removal Plan
- Terminating RN A
- In-servicing staff regarding notification of changes, hydration/keep encouraging hydration/fluids, and indications for oxygen
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 93 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — 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 Mabank
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kemp Care Center | 7 mi | — | 0 | 0 |
| Lakeside Health And Wellness | 7.5 mi | — | 25 | 0 |
| Cedar Lake Nursing Home | 15.5 mi | — | 6 | 0 |
| Sunflower Park Health Care | 17.8 mi | — | 19 | 0 |
| Kerens Care Center | 17.9 mi | — | 1 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mabank Nursing Center.
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.