GUADALUPE VALLEY NURSING AND REHABILITATION CENTER

1210 EASTWOOD DR
SEGUIN, TX, 78155
8303799308
CCN: 455869
2
Overall
2
Health
2
Staffing
4
Quality
ChainWELLSENTIAL HEALTH
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
NameRole%
MEDINA COUNTY HOSPITAL DISTRICT5% OR GREATER DIRECT OWNERSHIP INTEREST100%
WINDROW, ZACHARYCORPORATE DIRECTORNOT APPLICABLE
BAIN, WILLIAMCORPORATE DIRECTORNOT APPLICABLE
CARTER KRIEGER, LORICORPORATE DIRECTORNOT APPLICABLE
HARDT, TIMOTHYCORPORATE DIRECTORNOT APPLICABLE
JOHNSON, TONYCORPORATE DIRECTORNOT APPLICABLE
WINKLER, JUDYCORPORATE DIRECTORNOT APPLICABLE
YOUNG, CARLTONCORPORATE DIRECTORNOT APPLICABLE
BELL, BILLIECORPORATE OFFICERNOT APPLICABLE
FROSCH, KEVINCORPORATE OFFICERNOT APPLICABLE
REGENCY IHS OF GUADALUPE VALLEY LLCOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
BELL, BILLIEOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
LIMMER, JAMESW-2 MANAGING EMPLOYEENOT APPLICABLE
FROSCH, KEVINW-2 MANAGING EMPLOYEENOT APPLICABLE
BELL, BILLIEW-2 MANAGING EMPLOYEENOT APPLICABLE
Penalties (1)
DateTypeAmount
2024-04-26Fine$75K
Health Deficiencies (55)
2025-12-10 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
E
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
E
F761 · 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.
E
F759 · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
E
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F726 · Nursing and Physician Services Deficiencies
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F656 · 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.
D
F580 · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
2025-06-06 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F583 · Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
2025-01-16 · Health
E
F949 · Administration Deficiencies
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
D
F947 · Nursing and Physician Services Deficiencies
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
D
F946 · Administration Deficiencies
Provide training in compliance and ethics.
E
F945 · Infection Control Deficiencies
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
E
F944 · Administration Deficiencies
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
D
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
E
F942 · Resident Rights Deficiencies
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
E
F941 · Administration Deficiencies
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
E
F940 · Administration Deficiencies
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
E
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
E
F584 · Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
D
F580 · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
D
F561 · Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
D
F558 · Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
2024-12-13 · Health
D
F761 · 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.
D
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
2024-08-30 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
D
F726 · Nursing and Physician Services Deficiencies
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
D
F690 · Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
D
F583 · Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
2024-04-26 · Health
J
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
J
F580 · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
2023-12-15 · Health
D
F805 · Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
2023-09-08 · Health
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F656 · 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.
D
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
2023-06-30 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
2023-04-29 · Health
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
E
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
D
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
2022-10-14 · Health
E
F925 · Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F803 · Nutrition and Dietary Deficiencies
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
D
F761 · 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.
D
F657 · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
D
F656 · 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.
D
F644 · Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
3.14
3.68
RN Hrs/Resident/Day
0.33
0.54
LPN Hrs/Resident/Day
0.79
0.81
CNA Hrs/Resident/Day
2.01
2.33
PT Hrs/Resident/Day
0.01
0.12
Data as of 2026-03-01