La Dora Nursing And Rehabilitation Center

Inspection findings

1. Apr 24, 2026 Fire Safety · 6 findings
   • Not serious Scope/severity F

     E0004 Emergency Preparedness Deficiencies

     Develop and maintain an Emergency Preparedness Program (EP).

     Corrected May 1, 2026 · CMS fire safety

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Apr 27, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected May 20, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Apr 27, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected May 1, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected May 1, 2026 · CMS fire safety

2. Feb 13, 2025 Fire Safety · 12 findings
   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Feb 14, 2025 · CMS fire safety

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     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 Feb 14, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Feb 14, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Feb 14, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected Feb 14, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Feb 14, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Feb 14, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Feb 14, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Feb 14, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Feb 14, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0917 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure electrical receptacles or cover plates have distinctive color or marking.

     Corrected Feb 14, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Feb 14, 2025 · CMS fire safety

3. Jan 16, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Jan 17, 2025 · CMS health inspection

4. Jan 5, 2024 Health · 11 findings
   • Not serious Scope/severity D

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected Jan 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

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

     Corrected Jan 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0694 Quality of Life and Care Deficiencies

     Provide for the safe, appropriate administration of IV fluids for a resident when needed.

     Corrected Jan 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Jan 6, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jan 6, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0211 Egress Deficiencies

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

     Corrected Jan 5, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Jan 5, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Jan 3, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Jan 3, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jan 3, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Jan 3, 2024 · CMS fire safety

Owners and managers (as published by CMS)

• BURNAM, SOON — operational/managerial control, NOT APPLICABLE, since 05/01/2026
• KEETCH, CHAD — corporate officer, NOT APPLICABLE, since 03/01/2011
• RAI, SWEETY — operational/managerial control, NOT APPLICABLE, since 05/01/2026
• RAI, SWEETY — managing control - governing body, NOT APPLICABLE, since 05/01/2026
• RAI, SWEETY — adp of the snf, NOT APPLICABLE, since 05/01/2026
• SANDERSON, CLARK — corporate director, NOT APPLICABLE, since 05/01/2026
• BEDFORD ROAD HEALTH HOLDINGS LLC — adp of the snf, NOT APPLICABLE, since 05/01/2026
• ENSIGN SERVICES INC — adp of the snf, NOT APPLICABLE, since 02/11/2026
• FANNIN COUNTY HOSPITAL AUTHORITY — 5% or greater direct ownership interest, 100%, since 05/01/2026
• LAVACA RIVER HEALTHCARE LLC — adp of the snf, NOT APPLICABLE, since 04/14/2026
• LAVACA RIVER HEALTHCARE LLC — operational/managerial control, NOT APPLICABLE, since 05/01/2026
• STANDARD BEARER HEALTHCARE OP, LP — adp of the snf, NOT APPLICABLE, since 05/01/2026
• THE ENSIGN GROUP INC — adp of the snf, NOT APPLICABLE, since 05/01/2026