Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Village Square Healthcare Center during CMS and state inspections, most recent first.
A resident admitted with psychoactive substance abuse and post-surgical aftercare needs had physician orders and a care plan for daily methadone to treat opioid dependence, along with hydromorphone and oxycodone for pain. For three consecutive days, the methadone was not administered and was documented as not available on the MAR. An LN reported that the facility had not ensured methadone availability at admission, that attempts to obtain it from the methadone clinic were unsuccessful due to lack of transportation, and that the resident became upset, agitated, threw water at staff, called 911, and left AMA. The DON acknowledged that by accepting the admission, the facility had agreed to meet the resident’s needs, but the ordered methadone was not provided.
Controlled medications and narcotic records for multiple residents were removed from medication carts without nurses’ knowledge and later found at another facility during a drug diversion investigation involving an agency nurse. Record review showed numerous discrepancies, including undated or missing pharmacy packing slips, lack of RN/LPN signatures acknowledging receipt of controlled drugs, incomplete documentation of pill quantities, and missed signatures on narcotic records. Although staff described a process for shift-to-shift narcotic counts and use of a narcotic binder, these procedures did not detect that controlled substances and Individual Patient’s Narcotic Records had been taken and left unaccounted for, even as residents with significant pain-related diagnoses were prescribed various oxycodone and tramadol regimens.
A resident with an unstageable sacral pressure ulcer and functional quadriplegia did not have the physician-ordered low air-loss mattress in place for an extended period. Staff, including the TXN and LN, were unaware of the missing mattress and continued to sign off on required checks without verifying its presence, despite care plan and policy requirements for monitoring and use of the mattress for skin management.
Dietary staff did not consistently cover facial hair during food preparation and service, failed to maintain cold food items at or below 41°F on the tray line, and did not remove expired food or properly store items in the freezer to prevent freezer burn. Facility leadership and staff interviews confirmed knowledge of these requirements, but observations showed repeated noncompliance.
Two residents were not provided care in a dignified manner: one was left exposed during incontinence care with the room door open and privacy curtain not drawn, while another was fed by a CNA who stood at the bedside instead of sitting at eye level, contrary to facility policy. Staff interviews confirmed awareness of proper procedures, but these were not followed, resulting in a lack of dignity for the residents.
A resident with COPD and pneumonia, who was cognitively intact, was found to be self-administering an inhaler without the required assessment or physician order. Staff confirmed the resident kept the inhaler at bedside and used it as needed, contrary to facility policy that mandates an interdisciplinary assessment and physician approval before self-administration of medications.
A resident with metastatic prostate cancer and deep vein thrombosis became unresponsive and was transferred to a hospital without notifying the family, despite facility policy requiring such communication. Staff interviews confirmed the oversight, affecting the family's involvement in care planning.
A CNA was observed standing over a resident with schizoaffective disorder while assisting them to eat, contrary to facility policy which requires staff to sit at eye level. The resident, who had no cognitive deficits, threw a pitcher across the room, potentially indicating distress. Interviews with staff confirmed that standing over residents can be intimidating and does not promote dignity.
A resident with a history of heart failure received intravenous fluids over 26 hours instead of the prescribed 20 hours, and the IV tubing was not labeled with the date and time of use. The licensed nurse and DON acknowledged the oversight, which could lead to complications such as inadequate fluid delivery and infection. The facility's policy on IV therapy was not followed.
A resident with a history of heart failure received intravenous fluid (IVF) over 26 hours instead of the prescribed 20 hours, and the IV tubing was not labeled with the date and time of use. The responsible nurse acknowledged the oversight, and the Director of Nursing confirmed the deviation from infection control protocols, as the facility's policy required all parenteral fluids to be used or discarded within 24 hours.
A facility failed to provide a written notice to a resident regarding a room change when another resident was moved for dialysis convenience. The Social Services Director did not inform the affected resident, citing a lack of awareness of the requirement. The facility's policy mandates that roommates be informed of transfers, including reasons, to respect their rights.
The facility failed to provide a comfortable and home-like environment for residents due to malfunctioning televisions and elevated room temperatures. Residents expressed frustration with non-working TVs, which had been an issue for weeks. Additionally, room temperatures often exceeded the facility's policy range, causing discomfort and potential health complications. The facility's Administrator acknowledged issues with the air conditioning system and outdated TV cable boxes, but the problems persisted, affecting residents' comfort.
Failure to Provide Ordered Methadone for Three Consecutive Days
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered methadone for a resident for three consecutive days, despite having accepted the resident for admission with a care plan and physician orders that included daily methadone for opioid dependence and pain management. The resident was admitted with diagnoses including other psychoactive substance abuse and surgical aftercare needs, and was documented as alert and oriented x4 on admission. Physician orders and the care plan specified methadone concentrate 135 mg orally once daily, along with hydromorphone and oxycodone for breakthrough and PRN pain. The medication administration record showed that methadone was not administered on three consecutive days and was marked as not available on each of those days. The facility’s policy stated that it would admit only residents whose needs could be met and that if a non‑contract pharmacy could not provide ordered medications, the provider pharmacy could be contacted to supply them. During interviews, an LN reported that the facility did not administer the resident’s methadone because it was not available for three days and acknowledged that, on admission, the facility should have ensured it could meet the resident’s need for methadone. The LN stated the resident became upset and agitated due to not receiving the medication, threw water at a staff member, called 911, and left the facility against medical advice. Progress notes indicated the LN attempted to contact the methadone clinic and arrange for transport to obtain the medication, but the facility did not have transportation available for the resident to pick up the methadone. The DON confirmed that when the facility accepts a resident, it agrees to meet and provide the resident’s needs. The facility’s failure to secure and administer the ordered methadone as required resulted in the resident not receiving the medication for three consecutive days and experiencing distress.
Unsecured and Unaccounted Controlled Medications and Narcotic Records
Penalty
Summary
The deficiency involves the facility’s failure to ensure that controlled medications and associated Individual Patient’s Narcotic Records (IPNRs) were properly secured and accounted for in the medication carts. Controlled substances and original narcotic sheets were removed from the carts without the knowledge of licensed nurses and were later discovered at another skilled nursing facility during a drug diversion investigation involving an agency nurse. The facility’s Administrator stated that original narcotic sheets and medication bubble packets traced back to this facility were found elsewhere, indicating that controlled medications and records had been taken from the facility without staff awareness. Record review for ten residents showed multiple discrepancies and documentation gaps related to controlled medications. For one resident with liver cancer and a PRN order for Tramadol, the pharmacy packing slip showed 30 tablets received, while the IPNR indicated 26 tablets remaining in the bubble pack. Another resident with chronic back pain and orders for Hydrocodone-Acetaminophen and Oxycontin had multiple controlled prescriptions where the number of tablets dispensed per pharmacy packing slips did not clearly reconcile with the remaining counts documented on the IPNRs. Additional residents with chronic pain, venous ulcers, ischemic colitis, chronic pain syndrome, end-stage renal disease, cervical disc disorder, bilateral knee osteoarthritis, and a leg fracture had controlled medications such as Oxycodone and Oxycodone-Acetaminophen dispensed, but several pharmacy packing slips were undated, lacked licensed nurse signatures acknowledging receipt, or were missing altogether. In some cases, IPNRs showed remaining tablets, in others they showed zero tablets left, and there were missed nurse signatures on the narcotic records. Interviews with the Director of Staff Development and licensed nurses described the facility’s intended process for receiving and counting controlled medications, including signing pharmacy packing lists, maintaining a narcotic binder, and performing shift-to-shift counts where incoming and outgoing nurses verified bubble pack quantities against the narcotic count sheets. However, one nurse stated that when new refills were received, the receiving nurse documented only the number of cards received, not the quantity of pills, and several packing slips in the records lacked any nurse signature to confirm receipt of the medications. Despite these described procedures, the Administrator and DON reported they were unaware of any discrepancies in controlled drug counts until notified of the external drug diversion investigation, indicating that controlled medications and narcotic records had been removed from the carts and left unaccounted for without detection by the facility’s counting and reconciliation processes. The report notes that there were no missed doses for the affected residents, but controlled substances and IPNRs for all ten residents were removed from the medication carts without the knowledge of the licensed nurses and were not accounted for within the facility’s own systems. The combination of missing or unsigned packing slips, incomplete documentation of quantities received, missed signatures on narcotic records, and the discovery of original narcotic sheets and bubble packs at another facility demonstrate that the facility did not maintain secure control and accurate accountability of controlled medications as required.
Failure to Provide Ordered Low Air-Loss Mattress for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a low air-loss mattress, as ordered by the physician and documented in the care plan, was in place for a resident with an unstageable sacral pressure ulcer and functional quadriplegia. Despite orders and care plan directives for the use of a low air-loss mattress to aid in skin management and wound healing, the resident was found to have a regular mattress on her bed. The resident reported concerns about the mattress settings to a CNA, who confirmed the absence of the air-loss mattress. Interviews with the treatment nurse and a licensed nurse revealed that both were unaware the mattress had been missing for weeks, and that nurses had been signing off on the Treatment Administration Record (TAR) for the mattress placement and settings without verifying its presence or function. Record reviews showed that the care plan and physician's orders required monitoring of the low air-loss mattress every shift, but this was not done. The DON acknowledged that the mattress may have been switched to another bed and confirmed the importance of the air-loss mattress for the resident's multiple skin issues. The facility's policy required the implementation of interventions for pressure ulcer prevention and treatment, but these procedures were not followed, resulting in the resident not receiving the prescribed pressure ulcer care.
Dietary Staff Noncompliance with Food Safety and Hygiene Standards
Penalty
Summary
Dietary staff failed to adhere to facility policy and professional standards regarding personal hygiene and food safety. Multiple staff members with facial hair were observed preparing and serving food without appropriate facial hair coverings, despite facility policy requiring beard or mustache covers during meal preparation and service. Interviews revealed inconsistent staff training and enforcement of this policy, with some staff stating they were not told to wear facial hair covers, while others admitted to forgetting. Facility leadership, including the Dietary Director, Registered Dietitian, DON, and Administrator, all stated their expectation that facial hair be covered or staff be clean shaven. Cold food items on the tray line were not maintained at the required temperature of 41°F or below. Observations showed tossed salad and peach yogurt being served at temperatures significantly above this standard, with staff and the Dietary Director failing to intervene or replace the food items. Staff interviews confirmed knowledge of the temperature requirements, but no corrective action was taken at the time of the deficiency. The Dietary Director and other leadership confirmed their expectation that cold foods be held and served at or below 41°F. Additional deficiencies included the storage of expired food items and improper storage of food in the walk-in freezer. Pre-boiled eggs with a use-by date that had passed were found in the refrigerator, and large quantities of corn kernels and chicken breasts were stored in open bags, exposing them to air and potential freezer burn. The Dietary Director acknowledged that food should be stored in airtight, moisture-resistant wrappers, and leadership confirmed the expectation that expired and improperly stored food be removed from storage.
Failure to Maintain Resident Dignity During Personal Care and Feeding
Penalty
Summary
The facility failed to provide care in a dignified manner for two residents during routine care activities. In the first instance, a resident with end stage renal disease and intact cognition, who was dependent on staff for toileting hygiene, was left exposed during incontinence care. The CNA responsible for the resident left the room with the door open and the privacy curtain not drawn, leaving the resident with their pants and incontinence brief down and their buttocks exposed to the hallway. The CNA acknowledged being aware of the need to provide privacy but admitted to rushing and not following proper procedures. The resident reported being left in this state for more than five minutes and expressed discomfort and dissatisfaction with the lack of privacy. In the second instance, another resident with severe cognitive impairment, hemiplegia, and hemiparesis, who was dependent on staff for eating, was fed by a CNA who stood at the bedside rather than sitting at eye level as required by facility policy. The CNA stated she did not sit because there was no chair available in the room. The resident had to turn their head to receive food and drink, and the staff did not position themselves as directed in the care plan. Other staff members, including an LVN and the DON, confirmed that feeding should be done while seated at eye level to maintain dignity, and that a chair should have been obtained if one was not present. Both incidents were observed and confirmed through interviews with staff, residents, and facility leadership. Facility policies reviewed indicated clear expectations for maintaining resident privacy during personal care and for staff to be seated at eye level when assisting residents with eating. The actions and inactions of the staff in these cases did not align with these policies, resulting in a failure to honor the residents' rights to dignity and proper care.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for their ability to self-administer medication, as required by facility policy. The policy stated that if a resident wished to self-administer medication, the interdisciplinary team must complete a specific assessment to determine the resident's capability. In this case, a resident with a history of COPD and pneumonia, who had intact cognition as evidenced by a BIMS score of 15, was observed with an inhaler at their bedside. The resident reported using the inhaler as needed and confirmed that staff were aware of this practice. Record review showed there was no physician order permitting the resident to self-administer the inhaler, nor was there documentation of an assessment for self-administration. Interviews with staff, including a CNA, LVN, and RN, confirmed that the resident kept the inhaler at their bedside and self-administered it without the required assessment or physician order. The facility's DON also confirmed that the necessary procedures for self-administration had not been followed in this case.
Failure to Notify Family of Resident's Health Status Change
Penalty
Summary
The facility failed to notify the family of a resident's change in health status, which was a deficiency identified during a survey. The resident, who had metastatic prostate cancer and deep vein thrombosis, became unresponsive and was transferred to an acute hospital. Despite the facility's policy requiring notification of the resident's representative in such events, the resident's brother, who was the emergency contact and responsible party, was not informed of the transfer. Interviews with the Administrator, Director of Nursing, Licensed Nurses, and the Social Service Director confirmed the oversight in communication. The deficiency was highlighted during an unannounced visit following a complaint about the lack of family notification. Staff members, including a CNA who witnessed the resident's condition change, acknowledged that the family should have been contacted. The facility's policy on notifying the resident's representative during changes in condition was not followed, as confirmed by multiple staff interviews. This failure to communicate affected the family's ability to be involved in care planning and decision-making for the resident.
Failure to Promote Resident Dignity During Feeding
Penalty
Summary
The facility failed to promote dignity for a resident when a CNA was observed standing over the resident while assisting them to eat in bed. The resident, who was admitted with a history of schizoaffective disorder, had a BIMS score indicating no cognitive deficits. During the observation, the resident threw a pitcher across the room, which could suggest emotional distress. The CNA admitted to standing over the resident and acknowledged that she should have been seated at eye level to promote dignity and better communication. Interviews with the nursing staff, including a Licensed Nurse and the Director of Nursing, confirmed that standing over a resident while feeding them can be intimidating and does not promote dignity. The facility's policy on assisting residents to eat specifies that staff should sit at eye level in front of the resident. The CNA involved also noted that the resident sometimes made non-sensical statements and could become physical with staff, which may have contributed to the situation.
Failure to Administer IV Fluids as Prescribed
Penalty
Summary
The facility failed to adhere to a physician's order for the administration of intravenous fluids (IVF) for a resident, resulting in the IVF being infused over 26 hours instead of the prescribed 20 hours. The resident, who was admitted with a history of heart failure, was receiving sodium chloride 0.9% at a rate of 50 ml per hour to address hyperkalemia. Observations revealed that the IV tubing was not labeled with the date and time of use, which is a critical step for infection control. The resident's IVF was started in the morning, and by the following day, a significant amount of fluid remained in the bag, indicating the infusion was not completed within the prescribed timeframe. Interviews with the licensed nurse responsible for the resident's IV care and the Director of Nursing (DON) highlighted the oversight in monitoring the IVF flow rate and the failure to label the IV tubing. The licensed nurse acknowledged that the IVF should have been completed by the early morning of the next day but continued to run beyond the prescribed period. The DON confirmed that the lack of proper labeling and timely completion of the IVF could lead to complications such as inadequate fluid delivery, phlebitis, infiltration, and infection. The facility's policy on IV therapy, which mandates the use or disposal of parenteral fluids within 24 hours, was not followed in this instance.
Failure to Follow Physician's Order for IVF Administration
Penalty
Summary
The facility failed to adhere to a physician's order regarding the infusion of intravenous fluid (IVF) for a resident, resulting in the fluid being administered over 26 hours instead of the prescribed 20 hours. The resident, who had a history of heart failure and no cognitive deficits, was receiving sodium chloride 0.9% at a rate of 50 ml per hour for hyperkalemia. Observations revealed that the IV tubing was not labeled with the date and time of use, which is a critical step for infection control. Licensed Nurse 1, responsible for the resident's IV care, acknowledged that the IVF should have been completed within the specified time frame and that the lack of proper monitoring could lead to complications such as irritation, infection, and inadequate fluid administration. The Director of Nursing confirmed that the IV tubing should have been labeled to prevent infection control issues and that the fluid should have been discarded appropriately. The facility's policy indicated that all parenteral fluids should be used or discarded within 24 hours, highlighting a deviation from established protocols.
Failure to Provide Written Notification of Room Change
Penalty
Summary
The facility failed to provide a written notice and reason for a bed change to a resident, identified as Resident 6, when another resident, Resident 3, required a bed change. Resident 3 was moved from the third floor to the second floor due to the convenience of accessing transportation services for dialysis appointments, as the elevators were not working. This move resulted in Resident 3 sharing a room with Resident 6 for five days until Resident 6 was discharged. However, there was no written notification provided to Resident 6 regarding this room change, which is a violation of the resident's rights. The Social Services Director (SSD) admitted to not providing a written room change notification to Resident 6, stating a lack of awareness of the requirement to notify roommates of bed changes. The facility's policy on room and roommate assignments clearly indicates that roommates should be informed of any new transfers into or out of their room, including the reasons for such transfers. The Administrator confirmed that the expectation was for room change notifications to be given both verbally and in writing to all affected residents and their responsible parties, to ensure awareness and respect for their rights and preferences.
Facility Fails to Maintain Comfortable Environment Due to Malfunctioning TVs and High Temperatures
Penalty
Summary
The facility failed to ensure a comfortable and home-like environment for four residents due to malfunctioning televisions and elevated room temperatures. During an unannounced visit, it was observed that televisions in several residents' rooms were not functioning properly, with issues such as incorrect remotes and poor WiFi signals preventing residents from watching their preferred programs. Residents expressed frustration and dissatisfaction with the non-working TVs, which had been an ongoing issue for at least three weeks. The Director of Maintenance had resigned earlier in the month, which may have contributed to the delay in addressing these issues. Additionally, the facility struggled to maintain appropriate room temperatures, with several areas recording temperatures above the facility's policy range of 71-81 degrees Fahrenheit. Observations and interviews revealed that temperatures in resident rooms and common areas were often in the 80s, with some areas reaching as high as 92.3 degrees Fahrenheit. Residents and staff reported discomfort and potential health complications due to the excessive heat, such as difficulty breathing and irritability. The facility had placed fans in hallways to help circulate air, but this measure was insufficient to maintain a comfortable environment. The facility's Administrator acknowledged the issues with the air conditioning system and the televisions, citing problems with the AC control box and outdated TV cable boxes. Despite attempts to address these issues, the problems persisted, affecting the residents' physical and psychosocial comfort. The facility's policy on maintaining a home-like environment was not adhered to, as evidenced by the malfunctioning equipment and failure to maintain appropriate room temperatures.
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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 San Marcos
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glenbrook | 5.3 mi | ★★★★★ | 18 | 0 |
| Vista View Post Acute | 5.9 mi | ★★★★★ | 2 | 0 |
| Vista Knoll Specialized Care Facility | 6.2 mi | ★★★★★ | 18 | 0 |
| La Paloma Healthcare Center | 6.5 mi | ★★★★★ | 0 | 0 |
| Valley Vista Post Acute | 6.5 mi | ★★★★★ | 24 | 0 |
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