Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Amistad Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Food storage and labeling deficiencies were observed in the kitchen pantry and resident nutrition room. Raisin bread and hamburger buns were left without dates, the buns were open to air, resident foods in the refrigerator were missing required labels and discard dates, and a food vendor delivery was placed in cardboard boxes on the floor. The FSM acknowledged the labeling and storage issues.
A resident reported the 400-hall shower room was dirty and uncomfortable to use. Surveyors observed a wet, black substance between the shower floor tiles and on the moveable shower chair, and a later observation showed the condition was unchanged. The HSKD said shower areas were cleaned daily and shower chairs were deep cleaned monthly, while the DON said showers and chairs were cleaned between residents by the CNA, but the observed shower area and chair still had not been cleaned.
Grievance handling failures for resident complaints: A resident reported missing money to a CNA, but no grievance was filed. Another resident’s representative complained that an LPN missed an ordered nebulizer treatment and was rude and verbally abusive; the complaint was documented as resolved, but no written grievance decision was provided and the LPN continued working for several more days. A third resident called the DON after being left soiled in feces for about 2 hours, but the complaint was not initially entered in the grievance log and was only added later.
Failure to Report Allegations of Abuse, Neglect, and Misappropriation A resident reported that $31 was stolen from her wallet, but the CNA who heard the allegation did not report it to the Administrator. Another resident’s representative alleged missed neb tx administration and verbal abuse by an LVN, and a third resident alleged being left soiled in feces for about 2 hours. The DON and Administrator did not ensure these allegations were reported to the State Agency within required timeframes, despite the facility policy requiring immediate reporting of abuse, neglect, exploitation, mistreatment, and misappropriation allegations.
Failure to Report Allegations of Abuse, Neglect, and Misappropriation: The facility did not timely report allegations involving a resident’s missing money, another resident’s complaint that an LPN missed ordered nebulizer tx and was verbally abusive, and a third resident’s report that he was left soiled for an extended period. Records and interviews showed the allegations were made to staff and leadership, but no timely investigation reports were found in the state portal for the residents involved.
Missed Anticoagulant Orders on Admission: A resident admitted after a suspected CVA with emphysema and cardiomyopathy had hospital discharge orders for apixaban starter pack therapy, but the facility did not ensure the medication was ordered correctly on admission. Review of the MAR showed 4 missed 10 mg doses, and the DON stated the admission nurse transcribed orders while the ADON reviewed them as a second set of eyes.
Infection control practices were not followed for residents on isolation precautions and during catheter care. Two residents had orders for contact-level precautions, but a CNA entered their rooms and handled meal items without gown and gloves despite door signage directing staff to don PPE. For another resident with an indwelling catheter and enhanced barrier precautions, an LPN performed catheter care and touched the resident and catheter tubing without changing gloves or performing hand hygiene.
Kitchen equipment was not maintained in safe operating condition. A plate warmer was plugged in but only held room-temperature plates, and staff said it had not warmed plates since the prior week or earlier. A dishwasher temperature gauge was also faulty, reading 110F while a separate gauge showed the water was 122F during operation. The Maintenance Director said he had not been notified of either issue and found no June maintenance entries for the plate warmer or dishwasher gauge.
Failure to Address Resident's Facial Hair and Dignity: A resident with Parkinson's disease, dementia, and ADL self-care deficits was observed on multiple occasions with long facial hair on her upper lip and chin. She stated she wanted it shaved, said staff had not offered, and reported it made her feel like a man. The DON and an MDS LVN stated grooming includes offering hair removal when residents want it, and a CNA confirmed the facial hair was present.
Failure to include discharge planning in care plans: Four residents with diagnoses including paraplegia, Parkinson's disease, dementia, diabetes, CKD, weakness, and renal dialysis dependence had care plans that did not include discharge or staying-at-facility planning. The MDS nurse was unsure why the plans were missing, and the DON stated all residents should have documented discharge or staying-at-facility planning.
Failure to provide grooming and oral hygiene assistance: A resident with Parkinson's disease, dementia, and moderate cognitive impairment required extensive help with personal hygiene, but surveyors observed long facial hair on her upper lip and chin on multiple occasions and noted she had not cleaned her teeth for 3 days. The resident stated she wanted her facial hair shaved and said staff had not offered to shave her, while the DON and MDS LVN described shaving, oral care, and grooming as part of resident hygiene care.
Two insulin pens in the E-Hall med cart were observed without dates showing when they were opened. An MA said the pens should be dated when removed from refrigerator storage, and the DON confirmed the facility policy requires insulins to be dated immediately upon removal from the refrigerator. Record review of the Medication Labels policy stated medications must be labeled in accordance with facility, state, and federal requirements.
A resident with dementia, DM II, CKD, and muscle wasting was ordered a regular diet with mechanical soft, ground texture, and ice cream with lunch and dinner, but observations showed the ice cream was missing from her meal tray. An LVN confirmed the resident did not receive the ordered ice cream, and the FSM and DON acknowledged that the ice cream should have been served as ordered.
Nonworking Bedside Call Light: A resident with Parkinson’s disease, dementia, weakness, and impaired coordination had a bedside call light that did not work when she pressed it while in bed, and the hall indicator did not light up. A CNA confirmed the failure, while the Maintenance Supervisor and DON were unaware the call light was not working. An email from the ADM noted there was no policy for call lights.
A facility with 200 beds did not employ a qualified full-time social worker, as confirmed by record review and staff interviews. The DON and Acting Administrator acknowledged the absence of a social worker for over a year, with social services being provided by nurses instead. No contract with a licensed social worker was found, and there was no policy on social services.
The facility did not ensure that residents received their mail on Saturdays, as mail delivered on weekends was stored in the admissions office and not distributed until Monday. Staff interviews confirmed that the process for weekend mail delivery was not followed, resulting in delayed access to personal mail for residents.
A resident's personal and medical information was left visible on an unattended medication cart computer screen after an LVN became distracted and failed to lock the screen. The DON observed the exposed information and addressed the issue with the LVN, who acknowledged the privacy breach. The resident involved had a history of stroke, dementia, dysphagia, and UTI.
Two residents with indwelling urinary catheters were observed with their catheter drainage bags touching or dragging on the floor, and one resident received improper incontinence care, including incorrect wiping technique and reuse of wipes. Staff interviews confirmed knowledge of proper procedures, but these were not followed, despite care plans and facility policies requiring catheter bags to be kept off the floor and correct perineal care techniques to be used.
Five loose, unlabeled pills were found in a nurse medication cart, with staff interviews confirming that such incidents could lead to medication errors and that there was no consistent process for checking for and removing loose pills. The facility's policy requires all medications to be properly labeled and stored, but this was not followed.
A resident with severe cognitive impairment, dementia, muscle weakness, and a history of falls did not have her call light within reach, despite her care plan specifying this need. This failure was identified through observation, interview, and record review.
Food Storage and Labeling Deficiencies in Kitchen and Nutrition Room
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed. During an observation in the kitchen pantry, 5 loaves of raisin bread were stored in the manufacturer's clear plastic wrap on a wire rack without any labeled date showing when the bread was received. A package of hamburger buns was also found opened and left open to air on a wire rack without any label showing when the food was received or when it was opened. The FSM stated the food should be labeled with the date received and the date opened, and that opened food should be discarded after 7 days. In the residents' nutrition room on the 100-hall, a refrigerator stored resident foods without the required labels to show when the items were received and when they should be discarded. A plastic to-go container with an enchilada dinner labeled with Resident #62's name had no date on it, and an opened 10.6 ounce container of cottage cheese had no label identifying the resident, the date received, the date opened, or when to discard it. In addition, during an observation of a food vendor delivery, cardboard boxes of food were placed on the floor in the kitchen pantry. The FSM stated this was an oversight and that the food should not have been placed on the floor. The facility's Food Safety policy stated opened food shall be labeled, dated, and stored properly, and perishable opened foods shall be used within 7 days or less.
Dirty 400-Hall Shower Area and Shower Chair
Penalty
Summary
The facility failed to ensure the 400-hall shower area was sanitary and comfortable for residents using it. During an interview, a resident stated the shower room in the 400-hall was dirty and that the lack of cleanliness made the resident feel uncomfortable when bathing. On observation, the 400-hall shower floor had a wet, black substance between the tiles, and the moveable shower chair had a similar wet, black substance on the bottom panel and fabric straps. A second observation the next day showed the condition of the 400-hall shower area was unchanged. The HSKD stated the shower areas were cleaned daily and the shower chairs were deep cleaned with a pressure washer on the last Wednesday of every month, but no log was maintained for this activity. She also stated that if chairs needed additional unscheduled cleaning, staff should notify housekeeping, and that the shower chair in the 400-hall should have received additional cleaning due to its observed condition. The DON stated the showers and shower chairs were cleaned between each resident by the CNA performing showers, and that the shower area and chair should have received additional cleanings. The facility policy titled Infection Control Plan stated non-invasive resident care equipment is cleaned daily or as needed between use by the nursing assistant.
Grievance handling failures for resident complaints
Penalty
Summary
The facility failed to ensure residents could voice grievances without discrimination or reprisal and failed to follow its grievance policy for multiple resident complaints. For Resident #11, who had diagnoses including polyosteoarthritis, chronic pain, difficulty walking, and moderate cognitive impairment, the record showed no grievance was entered for her report that someone stole $31 from her wallet. Resident #11 stated she told CNA G about the missing money, but CNA G said she did not report the complaint because she believed the nurses already knew about it. For Resident #30, who was admitted with emphysema, cerebral infarction, and cardiomyopathy and had intact cognition, the resident’s representative filed a grievance about LVN D not administering the morning nebulizer treatment as ordered and being rude and verbally abusive. The grievance record documented that LVN D was late giving the nebulizer treatment and was coached on medication administration and customer service, and the DON documented that the grievance was resolved in a one-to-one discussion. However, the resident’s representative also sent an email requesting a formal investigation and a written report, and during interview both the resident and representative stated they still had not received a written report of the investigative findings. The report also stated LVN D was allowed to work in the facility for 3 more days after the complaint was made. For Resident #12, who had diagnoses including neuromuscular dysfunction of the bladder, a history of falling, depressive disorders, bowel and bladder incontinence, and moderate cognitive impairment, the resident stated he was left in feces for about 2 hours after dinner and used the Administrator’s cell phone number to call her. The Administrator acknowledged receiving the call and said a CNA then went to the room. The grievance log initially had no entry for this complaint, and the Administrator later corrected the log and added a grievance entry dated for the incident. The Administrator documented that the resident was waiting for someone to change him and that she made sure someone went to take care of his needs.
Failure to Report Allegations of Abuse, Neglect, and Misappropriation
Penalty
Summary
The facility failed to ensure that allegations of abuse, neglect, and misappropriation of resident property were reported to the Administrator and to the State Agency within the required timeframes. The report identified three residents involved in separate allegations: one resident reported that $31 was stolen from her wallet, another resident and her representative alleged missed medication administration and verbal abuse by an LVN, and a third resident alleged being left soiled in feces for longer than 1-2 hours. The facility’s abuse/neglect policy stated that employees must report all allegations to the Administrator and that the Administrator or designee must report qualifying incidents to HHSC within 2 hours if abuse or serious bodily injury is involved, or within 24 hours if not. Resident #11 had diagnoses including polyosteoarthritis, chronic pain, and difficulty walking, and was assessed with moderate cognitive impairment. She told CNA G that someone stole $31 from her wallet kept at her nightstand. During interview, Resident #11 stated she had reported the theft to CNA G, but CNA G did not report the allegation because she believed the nurses already knew about it. A review of the Texas Unified Licensure Information Portal showed no report of alleged abuse, neglect, exploitation, or mistreatment for this resident during the relevant period. Resident #30 had diagnoses including emphysema, cerebral infarction, and cardiomyopathy, and required assistance with activities of daily living. Her representative filed a grievance stating that LVN D had not administered the morning nebulizer treatment as ordered, was rude, and was verbally abusive. The representative also requested a formal investigation and written report. The DON documented that LVN D was late giving the treatment and was rude, and the grievance was resolved internally, but no report was found on the State Agency website. Resident #12, who had diagnoses including neuromuscular dysfunction of the bladder, a history of falling, and depressive disorders, stated he was left in his feces for about 2 hours after dinner and that when a CNA finally responded, the CNA confronted him by saying he got her in trouble and provided rough, hurried incontinent care. The Administrator acknowledged receiving the call from Resident #12 and documented that someone was sent to care for him, but no State Agency report was found for the allegation.
Failure to Report Allegations of Abuse, Neglect, and Misappropriation
Penalty
Summary
The facility failed to report allegations of abuse, neglect, exploitation, mistreatment, and misappropriation of resident property to the administrator or designated representative and to the State Survey Agency within the required timeframe for three residents. The report states that no investigation reports were found on the Texas Unified Licensure Information Portal for the relevant period for Residents #11, #12, and #30, despite allegations being made and documented in the facility records and interviews. Resident #11 was admitted with diagnoses including polyosteoarthritis, chronic pain, and difficulty walking, and was assessed with mild cognitive impairment. She told CNA G that someone stole $31 from her room. During interview, Resident #11 stated she had reported the missing money to CNA G and had not received any information about the loss. CNA G confirmed Resident #11 reported the theft to her, but she did not report it because she believed the nurses already knew about it. Resident #30 was admitted with diagnoses including emphysema, cerebral infarction, and cardiomyopathy, and required assistance with activities of daily living. Her representative filed a grievance alleging LVN D failed to administer ordered nebulizer medication and was rude and verbally abusive. The grievance and email from the representative described that the morning nebulizer treatment had not been given as ordered, that LVN D told the resident she could administer it herself, and that the treatment was eventually given around midday. During interview, Resident #30 and her representative stated they still had not received a written report of the investigation findings and said the resident felt intimidated by LVN D. Resident #12 was admitted with diagnoses including neuromuscular dysfunction of the bladder, a history of falling, and depressive disorders, and was incontinent of bowel and bladder with a care plan calling for frequent toileting assistance. He stated he was left in feces for about 2 hours after dinner on June 17, ignited his call light, and then called the Administrator on his cell phone. He reported that after the Administrator was notified, a CNA entered his room and said, 'you got me in trouble!' before providing hurried incontinent care. The Administrator documented that Resident #12 had been waiting for someone to change him, but the facility record review showed no investigation report had been submitted to the State Agency for this allegation within the required reporting period.
Missed Anticoagulant Orders on Admission
Penalty
Summary
The facility failed to ensure that physician orders for immediate care were in place at the time of admission for Resident #30, who was admitted from the hospital with diagnoses including emphysema, cerebral infarction, and cardiomyopathy. The resident’s admission record showed a hospitalization for a suspected cardiovascular accident, and the care plan documented that the resident was on anticoagulant therapy and medications were to be administered per the medical doctor’s orders. The hospital discharge orders prescribed apixaban starter pack therapy upon admission, and the manufacturer’s dosing instructions indicated 10 mg twice daily for 7 days followed by 5 mg twice daily. Review of the medication orders and MAR from 6/2/2026 through 6/23/2026 showed the resident was not prescribed apixaban as ordered and missed 4 doses of apixaban 10 mg: the morning dose on 6/3/2026, the morning and evening doses on 6/4/2026, and the morning dose on 6/5/2026. During interview, the DON stated the admission nurse was responsible for transcribing physician admission orders and the ADON reviewed them as a second set of eyes, but the DON was not aware the apixaban had been missed.
Infection Control and PPE Noncompliance
Penalty
Summary
The facility failed to maintain an infection prevention and control program for residents on transmission-based precautions. Resident #76 had an order for transmission-based precautions related to a positive test for clostridium difficile and was to remain in a room by themselves with care and services performed in the room. Resident #77 had an order for transmission-based precautions related to shingles and was also to remain in a room by themselves with care and services performed in the room. On 6/25/2026 at 12:26 PM, both residents had signage on their room doors indicating contact level of isolation and instructing staff to don PPE, including a gown and gloves, before entering the rooms. During the observation, CNA C entered Resident #76's room to deliver a lunch tray and later entered both Resident #76's room and Resident #77's room to deliver disposable silverware and assist with setting up Resident #77's lunch tray without donning PPE. In interview, CNA C stated she believed PPE was not required for delivering a lunch tray because close contact care was not being provided. The ADON and an LVN stated that staff should don PPE before entering a room on contact level of isolation precautions, including when delivering a lunch tray. The facility also failed to ensure proper hand hygiene during catheter care for Resident #5, who had an indwelling catheter, a BIMS score of 07, and an order for catheter care every shift. Resident #5's care plan identified enhanced barrier precautions. On 6/26/2026 at 12:10 PM, LVN B performed catheter care, lowered the resident's blankets and undergarments, and then touched the resident's genitals and catheter tubing without changing gloves or performing hand hygiene. LVN B stated he should have changed his gloves and sanitized his hands before initiating the care and said he had forgotten because he was nervous. The DON stated the facility expectation was for staff to perform hand hygiene before beginning care of an indwelling catheter, including touching linens and repositioning a resident.
Kitchen Equipment Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition. During an observation and interview, the kitchen's electrical plate warmer was plugged into the outlet but contained room-temperature plates, and the FSM and another staff member stated it had not warmed plates since the prior week or possibly earlier. The FSM said the plate warmer had been entered into the facility's maintenance care program, which was supposed to alert the Maintenance Director to the needed repair. During another observation and interview, the kitchen dishwasher's temperature gauge read 110F during operation and after operation, while the FSM used a separate temperature gauge and demonstrated that the water temperature during operation was 122F. The FSM stated that the safe operating temperature was over 120F and identified the dishwasher gauge as faulty. The Maintenance Director later stated he had not been notified of the faulty kitchen equipment and found no June 2026 maintenance entries for either the plate warmer or the dishwasher gauge in the maintenance care database. A record review of the facility's preventive maintenance policy stated that the facility would maintain a comprehensive preventive maintenance program for essential operating equipment and document all preventive maintenance.
Failure to Address Resident's Facial Hair and Personal Grooming Preference
Penalty
Summary
The facility failed to ensure Resident #51 was treated with respect and dignity by not ensuring her facial hair was addressed according to her preference. Resident #51 was admitted with diagnoses including Parkinson's disease, muscle weakness, lack of coordination, dementia, and anxiety. Her quarterly MDS documented that she was usually able to make herself understood, usually understood others, and had a BIMS score of 9/15, indicating moderate cognitive impairment. Her care plan identified an ADL self-care performance deficit related to dementia and Parkinson's disease and stated she required extensive assistance with personal hygiene care. Observations on 6/23/2026, 6/24/2026, and 6/25/2026 showed long facial hairs on her upper lip and chin. During interview, Resident #51 stated she wanted her upper lip and chin shaved, was not aware she had facial hair, and said staff had not offered to shave her. She stated the facial hair made her feel like a man and that she did not want facial hair. The DON stated facial hair should be offered to be shaved for both men and women by CNAs and that staff were to provide care and ensure it was in the care plan. A CNA confirmed the resident had long hairs on her upper lip and chin, and an MDS LVN stated grooming included hair removal if residents wanted it.
Failure to Include Discharge Planning in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for 4 of 8 residents reviewed for care plans, specifically Residents #10, #51, #62, and #75. Record review showed that Resident #10 was admitted with paraplegia, lack of coordination, recurrent depressive disorder, and moderate protein-calorie malnutrition, and had a BIMS score of 12/15; his care plan dated 4/27/2026 did not include discharge or staying-at-facility planning. Resident #51 was admitted with Parkinson's disease, muscle weakness, lack of coordination, dementia, and anxiety, had a quarterly MDS showing a BIMS score of 9/15, and her care plan dated 4/16/2026 did not include discharge or staying-at-facility planning. Resident #62 was admitted and re-admitted with muscle wasting, dementia, diabetes II, and chronic kidney disease, had a BIMS score of 7/15, and her care plan dated 6/24/2026 did not include discharge or staying-at-facility planning. Resident #75 was admitted and re-admitted with diabetes II, weakness, lack of coordination, and dependence on renal dialysis, had a BIMS score of 8/15, and her care plan dated 5/5/2026 did not include discharge or staying-at-facility planning. During interview, the MDS nurse stated she was not sure why these residents did not have discharge or staying-at-facility care planning, and the DON stated all residents should have documented discharge or staying-at-facility planning.
Failure to Provide Grooming and Oral Hygiene Assistance
Penalty
Summary
The facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, personal hygiene, and oral hygiene. Resident #51 had diagnoses including Parkinson's disease, muscle weakness, lack of coordination, dementia, and anxiety, and her MDS documented moderate cognitive impairment with a score of 9/15 and a need for extensive assistance with personal hygiene. Her care plan identified an ADL self-care performance deficit related to dementia and Parkinson's disease and directed extensive assistance with personal hygiene care. Survey observations showed Resident #51 had long facial hair on her upper lip and chin on multiple occasions, and during interview she stated she wanted her upper lip and chin shaved, was not aware she had facial hair, and said staff had not offered to shave her. She also stated she did not want facial hair because it made her feel like a man. In addition, the resident had not cleaned her teeth in the last 3 days of surveyor observations. The DON stated facial hair should be offered to be shaved for both men and women and that staff were to provide care and ensure it was in the care plan. The MDS LVN stated grooming included oral care, personal hygiene, brushing teeth, and offering hair removal if residents wanted it.
Insulin Pens in Medication Cart Lacked Open Dates
Penalty
Summary
The facility failed to ensure drugs used in the facility were labeled in accordance with currently accepted professional principles for 1 of 4 medication carts reviewed, specifically the E-Hall medication cart. During observation and interview, 2 insulin pens were found in the E-Hall medication cart without dates showing when they were opened. An MA stated she believed the pens had been removed from refrigerator storage by the overnight nurse because all pens were dated the prior day, and she identified the facility policy as dating all insulins when they are removed from the refrigerator. The DON later confirmed that the facility policy requires insulins to be dated immediately upon removal from the refrigerator and stated the concern was administration of expired insulin to residents. Record review of the facility's Medication Labels policy reflected that medications are to be labeled in accordance with facility requirements, state, and federal laws.
Ordered therapeutic diet item not served with meal tray
Penalty
Summary
Therapeutic diets were not consistently provided as ordered for Resident #62, who had diagnoses including muscle wasting, dementia, diabetes II, and chronic kidney disease. Her record showed a BIMS score of 7/15, supervision or touching assistance needed with eating, and no weight loss on the MDS. Her consolidated orders for June 2026 included a regular diet with mechanical soft, ground texture, and ice cream for lunch and dinner, and her care plan also directed that she receive regular diet, mechanical ground meat texture, and regular consistency ice cream with lunch and dinner due to potential nutrition and weight loss concerns. During lunch observations, Resident #62’s meal card listed a 4 oz ice cream cup, but she did not receive ice cream on her tray. An LVN was observed assisting her with cutting steak, and confirmed that the resident did not have the ordered ice cream on her lunch tray. A later observation again showed the resident was not served ice cream with her lunch meal. The FSM stated that ice cream should be on the tray when the resident is served her meal, and the DON stated the resident should have ice cream on her meal tray and that it had been ordered for weight loss. The facility policy stated that a written order must appear on the medical record before the resident may be served.
Nonworking Bedside Call Light
Penalty
Summary
The facility failed to ensure that a working call system was available at a resident’s bedside. Resident #51 was admitted with diagnoses including Parkinson’s disease, muscle weakness, lack of coordination, dementia, and anxiety. Her quarterly MDS showed she was usually able to make herself understood, usually understood others, and had a BIMs score of 9/15, indicating moderate cognitive impairment. Her care plan identified an ADL self-care performance deficit related to dementia and Parkinson’s disease, noted impaired visual function requiring eyeglasses, and included interventions to keep the call light within reach and encourage its use for assistance. During an observation, Resident #51 pushed the call light while lying in bed and it did not work, and the hall light did not illuminate. The resident stated that sometimes staff did not come when she pushed the call light. A CNA confirmed the call light was not working. The Maintenance Supervisor stated he was not aware the resident’s call light was not working, and the DON stated she was not aware the call light did not work. The DON stated that because the call light did not work, it could cause a decrease in care and staff not being aware residents needed assistance. An email from the ADM also indicated there was no policy for call lights.
Failure to Employ Full-Time Social Worker in Facility Over 120 Beds
Penalty
Summary
The facility, licensed for 200 beds, failed to employ a qualified full-time social worker as required for facilities with more than 120 beds. Record reviews confirmed the facility's licensed capacity and revealed no contract or employment of a licensed social worker. Interviews with the DON and Acting Administrator confirmed that the facility had not had a social worker for over a year, with the Acting Administrator citing recruitment difficulties and a negative reputation following a tragedy. The Acting Administrator also stated that, in the absence of a social worker, nurses were providing social services, but these were not being performed by a licensed social worker. Additionally, the Compliance Nurse confirmed there was no policy on social services in place.
Failure to Distribute Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents had timely access to their mail, specifically on Saturdays. Interviews with staff revealed that while mail was delivered to the facility on Saturdays, it was not distributed to residents until the following Monday. The Receptionist, who was responsible for mail distribution, worked primarily Monday through Friday and confirmed that mail received on Saturdays was stored in the admissions office until she returned. The Admissions Coordinator and Business Office Manager corroborated that no one sorted or delivered mail to residents over the weekend, and the mail remained in the office until the start of the workweek. The facility's policy required daily mail delivery on days mail was received, but this was not followed in practice. A confidential resident reported during a group meeting that they never received mail on Saturdays, which was attributed to the absence of front office staff on weekends. The Administrator acknowledged that mail delivered on Saturdays should be distributed the same day and was unaware of the current process. Attempts to contact the weekend clerical staff for clarification were unsuccessful. The facility's failure to distribute mail on Saturdays resulted in residents not receiving their mail in a timely manner, as required by their rights.
Resident Medical Information Left Exposed on Unattended Medication Cart
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to lock the computer screen on the medication cart, leaving a resident's personal and medical information exposed. The incident was observed on Unit E, where the computer screen displayed the resident's information and was left unattended. The Director of Nursing (DON) also observed the exposed information and subsequently notified the LVN. During an interview, the LVN acknowledged that she became distracted by another resident and forgot to secure the computer screen, admitting that this was a violation of privacy and could allow unauthorized access to sensitive information. The resident whose information was exposed was an elderly female with a history of cerebral infarction, dementia, dysphagia, and urinary tract infection. The facility's policy on resident rights, which includes the right to privacy and confidentiality of personal and medical records, was not followed in this instance. Both the LVN and the DON recognized that the failure to secure the computer screen constituted a breach of confidentiality and resident privacy.
Failure to Maintain Catheter Bag Placement and Proper Incontinence Care
Penalty
Summary
The facility failed to provide appropriate care for two residents with indwelling urinary catheters, specifically by not ensuring that catheter drainage bags were kept off the floor and by not following proper incontinence care procedures. For one resident, observations showed that the catheter drainage bag was repeatedly seen touching the floor while the resident was in the dining room and in the wheelchair. During catheter and incontinence care, a CNA was observed using improper technique, including wiping from back to front and reusing the same area of a disposable wipe multiple times, both of which were acknowledged by the CNA as cross-contamination risks. The CNA admitted to having received recent in-service training on proper catheter and incontinence care, but did not follow the expected procedures during the observed care. Another resident was also observed multiple times with the catheter drainage bag dragging on the floor while in the wheelchair, including while self-propelling through the facility. Staff interviews confirmed that CNAs were responsible for ensuring catheter bags did not touch the floor, and staff acknowledged that failure to do so could result in cross-contamination and infection control issues. The facility's policies and procedures for perineal and catheter care explicitly stated that catheter bags and tubing should be kept off the floor and that clean techniques should be used during perineal care, including wiping from front to back and using a clean area of the wipe for each stroke. Both residents had care plans and physician orders that included specific instructions for catheter care, such as keeping the drainage bag off the floor, using privacy bags, and providing perineal care after each incontinent episode. Despite these documented interventions, staff did not consistently implement them, as evidenced by direct observations and staff interviews. The failure to adhere to established protocols and care plans resulted in deficiencies related to infection control and proper catheter and incontinence care for residents with indwelling urinary catheters.
Unlabeled Loose Pills Found in Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored in accordance with accepted professional principles. During an observation of the 200 hall nurse cart, five pills were found loose in the bottom of the cart, not in labeled containers. This was confirmed through interviews with the Assistant Director of Nursing (ADON), the Acting Administrator, and an LVN, all of whom acknowledged the risk of confusion and the possibility that medications could be given to the wrong patient or that patients might not receive their prescribed medications. The staff also indicated that while narcotics are routinely counted, there is not a consistent process for checking for and addressing loose pills in the medication carts. A review of the facility's Medication Labeling Policy from the Pharmacy Policy & Procedure Manual indicated that all medications must be properly labeled as required by state regulations, and non-prescription drugs must be in their original manufacturer's container. The presence of unlabeled, loose pills in the medication cart demonstrates a failure to follow these established policies and procedures for medication labeling and storage.
Failure to Ensure Call Light Accessibility for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as required by the resident's care plan, which specifically noted the need for the call light to be accessible due to the resident's potential for falls and injuries. The resident in question was a female with diagnoses including polyosteoarthritis, dementia with severe cognitive impairment (BIMS score of 3), and muscle weakness. Despite these conditions and the documented care plan intervention, the call light was not placed within the resident's reach, as observed and confirmed through record review and interviews.
What surveyors are citing around you — mapped
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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 13 citations issued within 25 miles in the last 12 months — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Uvalde
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Uvalde Healthcare And Rehabilitation Center | 1.2 mi | ★★★★★ | 13 | 0 |
| Avir At Camp Wood | 36.3 mi | ★★★★★ | 7 | 0 |
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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.