Colorado City, TX

Mitchell County Nursing And Rehabilitation Center

2-star overall rating with 3-star inspections with 10 recent health deficiencies

971 W I 20, Colorado City, TX

(325) 728-5247

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2009-10-15

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.21

Registered nurse staffing

LPN hours / resident day

0.48

Licensed practical nurse staffing

Aide hours / resident day

1.61

Nurse aide staffing

Weekend hours

0.98

Weekend nurse staffing

RN turnover

Annual RN turnover

Total nurse turnover

36%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.8	2.1 0.3 pts better	1.9 0.1 pts better	Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days	5.7	2.1 3.6 pts worse	1.8 3.9 pts worse	Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	95.7%	97.1% 1.4 pts worse	93.4% 2.3 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	94.0%	97.9% 3.9 pts worse	95.5% 1.5 pts worse	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	9.1%	3.3% 5.8 pts worse	3.3% 5.8 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	11.6%	2.7% 8.9 pts worse	11.4% 0.2 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	0.7%	3.3% 2.6 pts better	5.4% 4.7 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	31.8%	18.9% 12.9 pts worse	19.6% 12.2 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	7.4%	10.8% 3.4 pts better	16.7% 9.3 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened	23.8%	15.4% 8.4 pts worse	16.3% 7.5 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	21.4%	16.1% 5.3 pts worse	14.9% 6.5 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	7.4%	0.5% 6.9 pts worse	1.0% 6.4 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	4.4%	0.8% 3.6 pts worse	1.7% 2.7 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	13.9%	15.0% 1.1 pts better	19.8% 5.9 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	2.9%	4.2% 1.3 pts better	5.1% 2.2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	90.2%	89.7% 0.5 pts better	81.7% 8.5 pts better	Short Stay · 2024Q4-2025Q3

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-20 · Fire 2025-02-20

10 health deficiencies

Top issue: Resident Rights (3 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-01-18 · Fire 2024-01-18

4 health deficiencies

Top issue: Nursing and Physician Services (1 deficiency)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 3 Health 2022-11-30 · Fire 2022-11-30

3 health deficiencies

Top issue: Infection Control (1 deficiency)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-01-18

K343 · Smoke Deficiencies

Fire Safety

Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

Corrected 2024-02-18

C · Minimal harm 2022-11-30

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Not marked corrected

C · Minimal harm 2022-11-30

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-02-20

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2025-03-20

F · Potential for more than minimal harm 2025-02-20

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-03-20

E · Potential for more than minimal harm 2025-02-20

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-03-20

D · Potential for more than minimal harm 2025-02-20

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-03-20

D · Potential for more than minimal harm 2025-02-20

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2025-03-20

D · Potential for more than minimal harm 2025-02-20

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2025-03-20

D · Potential for more than minimal harm 2025-02-20

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-03-20

D · Potential for more than minimal harm 2025-02-20

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-03-20

D · Potential for more than minimal harm 2025-02-20

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-20

D · Potential for more than minimal harm 2025-02-20

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2025-03-20

F · Potential for more than minimal harm 2024-01-18

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2024-02-18

F · Potential for more than minimal harm 2024-01-18

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-02-18

E · Potential for more than minimal harm 2024-01-18

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-02-18

D · Potential for more than minimal harm 2024-01-18

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2024-02-18

E · Potential for more than minimal harm 2022-11-30

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2022-12-30

E · Potential for more than minimal harm 2022-11-30

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2022-12-30

E · Potential for more than minimal harm 2022-11-30

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-12-30

Penalties and ownership

What sits behind the stars

Ownership

Mitchell County Hospital District

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 1967-01-01

Edwards, Helen