Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Bandera during CMS and state inspections, most recent first.
Incomplete care plans were identified for three residents. One resident with an indwelling urinary catheter had no care plan interventions to educate or redirect him from wearing the drainage bag above the bladder, and staff observed him doing so while staff acknowledged the habit was not documented or addressed in the care plan. Two other residents had care plans that did not include discharge plans, and the MDS nurse stated the discharge planning was missed in coding.
Accessible Hazards in Shower Rooms and Common Areas: Surveyors found unlocked shower rooms with razors and a disinfecting cleaner left accessible, including used razors in an open sharps container. Acrylic paints were also left unsecured in a drawer in the dining/activity area. In the main dining room, a plugged-in cookie oven and bread machine were left accessible near a resident with dementia and severe cognitive impairment; the AD stated the items were not known to be plugged in and noted a resident could be burned or injured.
A resident council and multiple residents reported cold, bland, and unappealing food, and a meal observation found items on a test tray at improper temperatures, including coleslaw, a Philly cheesesteak sandwich on a hot dog bun, potato wedges, and dessert. Two residents with GERD and other chronic conditions stated meals were consistently cold and unappetizing, and the DM acknowledged the tray temperatures were not within guidelines.
The facility failed to maintain infection control practices for a resident with RSV on droplet precautions and during meal tray delivery on a hall. An SLP and an MA entered the resident’s room after hand hygiene but without gowns, despite the resident’s isolation orders and staff expectations that full PPE included a gown. In a separate event, a CNA passed out meal trays without sanitizing hands before starting or between several rooms, and staff later stated hand hygiene should occur before and after resident-room contact and between tasks.
Unsanitary salon items and shower room water control issues: The salon contained brushes and rollers with hair on them, and the AD confirmed the items were present in the cabinet and drawer. The ADM stated the salon items should be cleaned and disinfected with daily use, but the facility had no salon policy. In the 300/400 hall shower room, staff were using a stained, soaked bed sheet at the entrance to keep shower water from reaching the hall because the shower stalls would not fit a shower bed and the floor did not drain properly.
A resident with an indwelling urinary catheter, a history of recurrent UTIs, sepsis due to pseudomonas, and obstructive/reflux uropathy was observed wearing his drainage bag and tubing secured at his waist above the bladder while ambulating with a rollator. Nursing notes reviewed contained no documentation that staff educated or redirected him to keep the bag below the bladder, and both the CNA and RN stated he routinely used that method and had not been redirected during the observed period. The resident and his representative both stated they had not received education about proper bag positioning, while the DON stated education and redirection had occurred.
Undated Food Items in Kitchen Storage: The facility failed to store food in accordance with professional standards when multiple items in the walk-in cooler, dry storage, and a small refrigerator were found without dates. The DM stated the items needed to be labeled and was unsure why they were not, while another staff member confirmed that all items should have a date such as the date received, opened, or prepared. Facility policy required foods to be covered, labeled, and dated with a use-by date.
Surveyors found that dietary staff did not consistently wear or correctly position required hair and beard restraints while working in the kitchen and handling clean dishes, silverware, meal trays, and beverages. One dietary aide repeatedly wore a beard restraint that failed to fully cover both his mustache and beard, and another aide entered and moved through the kitchen without a hair restraint and then continued food-related tasks with visible facial hair uncovered. In interviews, dietary staff, the dietary manager, the DON, and the administrator all acknowledged that hair nets and beard guards were required at all times in the kitchen to prevent hair from contacting exposed food and to avoid cross contamination, and facility policies and the FDA Food Code similarly required effective hair and beard restraints around exposed food and clean equipment.
A resident with dementia and moderate cognitive impairment told therapy staff that she had been touched in a sexual manner, consistent with prior care plan documentation that she reported someone touching her inappropriately. Therapy staff informed the DON, who interviewed the resident but did not notify the Administrator the same day. The Administrator learned of the allegation the next day and, after internal discussion, did not report the allegation to HHSC, despite facility policy and regulations requiring that all abuse allegations be reported immediately (within 2 hours) to the Administrator and appropriate state agencies.
A resident with a history of recurrent UTIs and an indwelling catheter experienced increased bladder spasms and pain over several days, with frequent requests for pain and antispasmodic medications. Despite these changes and family reports of worsening symptoms, staff did not recognize or report the change in condition, nor did they notify the medical provider or order a urinalysis. The resident was later hospitalized with septic shock due to a UTI, and staff interviews confirmed that the signs and symptoms were not appropriately addressed.
A resident with a history of UTIs and an indwelling catheter experienced increased bladder spasms and dysuria over several days, requiring more frequent administration of pain and bladder spasm medications. Despite these changes, the NP was not notified as required by facility policy. Nursing staff and the DON confirmed that the provider should have been informed of the resident's increased pain and medication use, which could indicate complications such as a UTI or catheter obstruction.
The facility failed to develop comprehensive care plans for two residents, one of whom wished to discharge but lacked documented planning, and another with an implanted defibrillator/pacemaker lacking specific care interventions. This deficiency could risk residents' psychosocial and physical well-being.
The facility failed to provide a comprehensive activity program for residents, particularly in the memory care unit and for those needing in-room activities. A resident with severe cognitive impairment did not receive regular activities, and two residents with complex medical conditions had no in-room activity programs documented. The activities calendar showed a lack of scheduled activities, contrary to the facility's policy requiring an organized program to meet residents' interests and well-being.
A facility failed to monitor vital signs and symptoms in residents receiving blood pressure and diuretic medications. A resident was given amlodipine without checking blood pressure as ordered, and three residents on diuretics were not monitored for heart failure symptoms. Staff interviews revealed inconsistent monitoring and documentation practices, despite facility policies requiring adherence to professional standards.
A resident, who required substantial assistance for personal hygiene, missed 4 out of 20 scheduled showers over six weeks. The facility's policy required showers at least twice weekly, but documentation was lacking, and the DON was unaware of the missed showers, indicating a failure to comply with the care plan and policy.
A resident with a history of chronic UTIs did not have accurate or complete documentation regarding urine sample collection, with inconsistencies in the MAR and missing rationale for discontinuing a urinalysis order. Staff sometimes marked procedures as completed when they were not, and the DON did not document the provider's rationale for stopping the monthly urinalysis, resulting in incomplete clinical records.
A resident with severe cognitive impairment and a history of exit-seeking behavior eloped from a facility, resulting in injury. The resident exited through a hallway door, triggering an alarm that was prematurely silenced by an RN without confirming resident safety. This failure to follow protocol led to the resident being found outside in extreme heat, posing significant risk.
Incomplete Care Plans and Missing Discharge Planning
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents. For one resident with an indwelling urinary catheter, diagnoses included sepsis due to pseudomonas and obstructive and reflux uropathy, and the admission MDS showed a BIMS score of 13/15 with intact cognition. The physician ordered catheter care every shift, but the care plan did not include nursing interventions to educate or redirect the resident from wearing the catheter collection bag above the bladder. Nursing documentation reviewed for the period in question contained no entries showing education or redirection about keeping the bag and tubing below the bladder. Observations showed the resident ambulating with a rollator while wearing the catheter collection bag and tubing secured to the belt at the waist above the bladder, and this was seen on more than one occasion by nursing staff. CNA and RN interviews confirmed the resident routinely dressed himself and wore the bag above the bladder, and both stated they had not provided or documented redirection in the record. The resident stated he had not received education about keeping the bag and tubing below the waist, and the MDS nurse stated the care plan had no interventions addressing this habit and had not been updated to include education or redirection. For two other residents, the care plans did not include discharge plans. One resident had diagnoses of Alzheimer’s disease and lack of coordination, with a quarterly MDS showing a BIMS score of 1/15 and set-up assistance needed for several ADLs. The other resident had diagnoses of low back pain, lack of coordination, and cognitive communication deficit, with a quarterly MDS showing a BIMS score of 15/15, wheelchair use for mobility, and set-up assistance for several ADLs. The MDS nurse stated discharge planning was missing for both residents and said she had missed it in the coding for discharge planning. The ADM stated that residents without discharge plans would not know what the next step would be.
Accessible Hazards in Shower Rooms, Dining Area, and Main Dining Room
Penalty
Summary
The facility failed to ensure that the 100/200 hall shower room and the 300/400 hall shower room were free from accessible hazards. In the 100/200 hall shower room, the door was unlocked and an unlocked cabinet contained 4 razors and a disinfecting cleaner bottle labeled to keep out of reach of children. In the 300/400 hall shower room, the doors were unlocked and there were 11 used razors in an open sharps container. CNA C confirmed both shower rooms were unlocked and stated the shower room cabinets and harmful chemical sprayer should be locked, and that residents could cut themselves with the razors or be harmed by the chemical sprayer. The facility also failed to secure items in the 400 hall dining/activity area. In a drawer, surveyors observed 4-5 acrylic paints in various colors. CNA L confirmed the paints were present in the drawer. CNA L also stated that residents on the 300/400 halls wander in halls and different rooms, and that there were residents on the 100/200 halls who wander in the facility and are redirected by staff. The ADM stated residents should be kept away from hazards and toxins, and stated the facility did not have a policy on acrylic paint. In the main dining room, surveyors observed a cookie oven and a bread machine on a dresser under the TV, both plugged in and operable. The cookie oven did not have a secured oven door and began heating immediately when turned on, and the bread machine did not have a secure lid and had a rapidly spinning mechanism with protruding notches. Resident #20 was observed sitting no more than five feet away. Record review showed Resident #20 had dementia, cognitive communication deficit, insomnia, and metabolic disorders, with a BIMS score of 0 indicating severe cognitive impairment and a care plan addressing communication problems, fall risk, self-care deficit, impaired cognitive function, and impaired thought process. The AD stated she was unaware the items were plugged in and said the negative impact could be that a resident gets burned or injured.
Cold, Unappetizing Meal Service
Penalty
Summary
The facility failed to ensure food and drink were palatable, attractive, and served at a safe and appetizing temperature for two residents and during one meal observation. Resident Council minutes from March and April 2026 documented concerns with cold food, and facility grievances from February and March 2026 also reflected complaints of cold food. The Dining Manager record for a Philly Steak Sandwich showed the item was documented as a roll and New England style hot dog/Frank bun. Resident #9 was a female with diagnoses including GERD, neurogenic bowel disorder, age-related physical debility, and diabetes mellitus. Her quarterly MDS showed a BIMS score of 14. Her care plan identified risks for falls, self-care deficit, incontinence, and diabetes. Resident #48 was a male with diagnoses including GERD, neurogenic bowel disorder, adult failure to thrive, and PTSD. His quarterly MDS also showed a BIMS score of 14, and his care plan identified risks related to self-care deficits, falls, hospice services, and nutritional problems related to terminal prognosis. During interviews, Resident #9 stated the food was cold when received and that there were never any fresh vegetables or fruit, and Resident #48 stated the food was horrible, never tasted good, and was always cold. During a lunch observation, the surveyor checked a test tray after it reached the resident hallway and found coleslaw at 80.4 degrees, a Philly cheesesteak sandwich with a hot dog bun at 123.6 degrees, potato wedges at 108 degrees, and cheesecake at 63.3 degrees. The Dining Manager stated the temperatures were not within guidelines and were in the danger zone for foodborne illnesses, and four residents later stated the food was cold, bland, did not look good, and that the Philly cheesesteak sandwich did not look like a Philly cheesesteak.
Infection Control Failures During Isolation Care and Meal Tray Delivery
Penalty
Summary
The facility failed to maintain an infection prevention and control program for a resident admitted with RSV and placed on strict droplet precautions in a private room. The resident’s admission record, care plan, and physician’s orders documented RSV, strict isolation precautions, and full PPE when in the room. During observation, the room door had droplet precaution signage instructing staff to clean hands and cover eyes, nose, and mouth before entry, but the SLP entered after hand hygiene wearing a surgical mask, face shield, and gloves without a gown. MA P also entered after hand hygiene wearing gloves, a surgical mask, and goggles without a gown to administer medications. During interview, MA P stated she did not wear a gown because she was not trained to do so and the door poster did not mention a gown. RN G stated her expectation was that staff entering the resident’s room would wear a gown along with gloves, a surgical mask, and face shield, and said she did not know why the signage did not call for a gown. The DON and ADON stated they had referred to CDC online resources and developed signage for droplet precautions that did not call for a gown, stating RSV was not transmitted by contact. No policy supporting that statement was presented. The facility also failed to ensure hand hygiene was performed between tray deliveries on the 300 hall. CNA E was observed passing meal trays to residents without sanitizing or washing hands before beginning tray pass and without sanitizing between the first 5 rooms. CNA E later washed hands and sanitized between each of 3 additional trays. CNA E stated staff should sanitize before and after entering a resident room, and LVN D and the DON stated staff should sanitize or wash hands per guidelines, especially between tasks and resident rooms.
Unsanitary salon items and shower room water control issues
Penalty
Summary
The facility failed to ensure the salon was maintained in a sanitary condition. During observation with the AD, 2 brushes were found in a drawer and 4 to 15 rollers were found in a tray in the salon cabinet, with some hair on them. The AD confirmed the brushes and rollers were present with hair on them, and stated the beautician had come in on 5/19/2026 in the afternoon. The ADM stated the hair salon brushes and rollers should be cleaned and disinfected with daily use, and stated the beautician brought in products and supplies and was responsible for her own items. The ADM also stated the facility did not have a policy on the hair salon. The facility also failed to ensure the 300/400 hall shower room was maintained to prevent water from entering the hallway. Observation showed a stained, soaked bed sheet placed at the shower room entrance to stop water from going out into the hall while residents were being bathed. The shower stalls were not large enough to fit a shower bed, and no other shower could accommodate the shower beds. Staff interviews confirmed that bed sheets had been used on the floor for a while because water sprayed out of the shower area and the floor did not drain appropriately. The Maintenance Director and Regional MD stated the floor slope was not significant enough to drain properly, and the LSC surveyor observed that the 300/400 hall shower floor was not sloped and lacked a metal diversion like the 100/200 hall shower room.
Failure to Educate and Redirect Resident on Proper Catheter Bag Positioning
Penalty
Summary
The facility failed to ensure a resident with an indwelling urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. The resident was admitted with diagnoses including sepsis due to pseudomonas and obstructive and reflux uropathy, and was assessed as cognitively intact on admission with a BIMS score of 13 out of 15. The physician ordered catheter care every shift with soap and water, and the care plan included positioning the catheter bag and tubing below the level of the bladder. During observations, the resident was seen ambulating with a rollator while his urinary drainage bag and tubing were secured to his shorts belt at his waist above the bladder. This was observed on two separate occasions, including while the resident walked past CNA K and RN G. The nursing record reviewed for the period from 3/4/2026 through 5/19/2026 contained no documentation that staff educated or redirected the resident to keep the urinary collection bag and tubing below the bladder. In interviews, CNA K stated the resident dressed and toileted himself, drained his own urine collection bag, and routinely wore the bag secured at his waist above the bladder. CNA K stated she had not recommended that he wear the bag below his waist. RN G stated the resident had the same routine, acknowledged concern that it could put him at risk for infection, and stated she could not recall documenting education or redirection and had not redirected him on the days observed. The resident stated he had not received education about keeping the bag and tubing below his waist and bladder, and his representative stated no one had contacted her to provide that education. The DON stated the resident had received education and redirection, but the documentation cited was the updated care plan.
Undated Food Items in Kitchen Storage
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 kitchens reviewed. During observation on 05/19/2026 at 9:20am, two sandwiches in the walk-in cooler were not dated, Quaker Grits packages in dry storage were not dated, and pureed brownies, cottage cheese, and Hershey's chocolate syrup in the small refrigerator near the ice machine were also not dated. During interview, the DM stated the foods needed to be labeled and was not sure why they were not labeled, and stated the brownies and sandwiches had just been made. The DM also stated that staff had been trained on labeling food items in the kitchen. Another staff member stated that all items should have a date on them, such as the date received, opened, or prepared, and confirmed training on dating items in the kitchen. Facility policy required foods to be covered, labeled, and dated with a use-by date, and the FDA Food Code Section 3-501.17 requires date marking on certain items to prevent foodborne illness.
Improper Use of Hair and Beard Restraints by Dietary Staff During Food Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure dietary staff consistently used hair and beard restraints in accordance with professional food safety standards and the facility’s own policies. During multiple observations in the kitchen, one dietary aide was seen wearing a beard restraint that covered his beard but did not cover his mustache, leaving the top lip exposed. Later, the same aide adjusted the beard restraint to cover his mustache, but in doing so pulled it off his chin, leaving his beard exposed while he prepared meal trays. Another dietary aide was observed entering and walking through the kitchen from the back door to the dining room door without any hair restraint, only putting on a hair restraint after entering the kitchen and then failing to apply a beard restraint despite having visible mustache and beard growth on the chin and jaw line. This aide then handled clean dishes and separated washed silverware without a beard restraint. He was later observed assisting at the kitchen door by providing a carafe of juice while his mustache and beard growth on the sides of his face and chin remained uncovered. During the same lunch service, the first dietary aide continued to assist with tray preparation and lunch service with his mustache not covered by the beard restraint. Interviews with dietary staff, the dietary manager, the DON, and the administrator confirmed that hair nets and beard restraints were required to be worn at all times in the kitchen and that beard restraints should cover all facial hair, even minimal chin hair. Staff and leadership consistently stated that failure to wear proper hair restraints could allow hair to get into food, cause cross contamination, and potentially make residents sick or cause foodborne illness. Review of facility policies on Food Safety and Sanitation, Employee Hygiene for Food Safety, and Personal Hygiene and Health Reporting, as well as the FDA Food Code provisions on hair restraints, showed that employees were required to wear hair restraints and beard covers to prevent hair from contacting exposed food, equipment, utensils, and food service areas, which was not followed by the observed dietary staff.
Failure to Timely Report Allegation of Sexual Abuse to Required Authorities
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of abuse to the Administrator and to required external authorities, including the State Survey Agency, as required by regulation and facility policy. A female resident with diagnoses including pneumonia, UTI, and dementia with moderate cognitive impairment (BIMS score 12/15) reported to therapy staff that she had been touched in a sexual manner. Her care plan, initiated and revised in early February, documented behavior problems related to delusions and statements that someone had been in her room touching her inappropriately, and included interventions such as use of two caregivers, female caregivers only, and anticipating and meeting her needs. On the day of the allegation, therapy staff informed the DON that the resident had stated she had been touched in a sexual manner. The DON interviewed the resident, who responded vaguely to questions about when and where she had been touched, saying "here and there," and refused to identify who had done it, stating she was not going to tell. Despite this, the DON did not report the allegation to the Administrator on the day it was received. The Administrator was not informed until the following day during the morning meeting, which was more than two hours after the allegation was made. The Administrator acknowledged that the allegation had been reported to the DON on one day and that she herself was not notified until the next day. She further stated that, after consultation with corporate staff, it was determined the allegation was not reportable and it was not reported to HHSC, despite the facility’s written policy requiring that all suspected abuse be reported immediately (defined as within two hours for allegations involving abuse) to the Administrator and to state agencies according to HHSC reporting guidelines. The facility’s failure to report the resident’s allegation of sexual misconduct by a CNA to HHSC constituted noncompliance with both regulatory requirements and the facility’s own ANE reporting policy.
Failure to Identify and Respond to UTI Symptoms in Catheterized Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with an indwelling urinary catheter received appropriate treatment and services to prevent urinary tract infections (UTIs). The resident, an older female with a history of recurrent UTIs, obstructive and reflux uropathy, and chronic bladder spasms, began experiencing increased bladder spasms and dysuria over several days. Despite her increased requests for pain and bladder spasm medications, staff did not identify these as potential symptoms of a UTI or a change in condition, nor did they notify the nurse practitioner or physician for further assessment or order a urinalysis during this period. The resident's medical records showed a pattern of increased administration of pain and antispasmodic medications, and both family members and staff noted that her pain and discomfort were significantly worse than usual in the days leading up to her hospitalization. Family members reported the resident's increased pain and suspected a UTI to nursing staff multiple times, but no action was taken to escalate care or notify the medical provider. Nursing staff interviewed after the incident acknowledged that increased pain and use of PRN medications should have prompted further assessment and notification of the medical provider, especially given the resident's history of UTIs and catheter use. The resident eventually became lethargic and unresponsive, prompting emergency services to be called. Upon hospital admission, she was diagnosed with septic shock due to a UTI, and a suprapubic catheter was surgically placed. Interviews with staff and family confirmed that the signs and symptoms of a UTI and change in condition were present but not recognized or acted upon in a timely manner, resulting in a significant adverse event for the resident.
Removal Plan
- Resident was being treated for pain/discomfort with PRN medications prescribed to treat chronic pain/bladder spasms and was being monitored by licensed nurse. Resident was sent to hospital for evaluation & treatment.
- Regional Nurse provided in-service to DNS/Admin/Admin in-training/ADNS regarding process for ensuring changes in conditions are identified and reported to the medical provider, notification of PCP of abnormal labs, implementation of orders as provided, and documentation in the EHR of notification of change in condition to MD/NP/PA as well as any prescribed orders and notification to Resident's family or representative.
- Nurse conducting a proper assessment and documenting in the Electronic Health Record (E.H.R.).
- Notifying medical provider of the change in condition (increased pain).
- Adhering to physician's orders and recommendations.
- Communicating pertinent information regarding the status of resident's condition to ensure the well-being of residents during the nurse/shift change report.
- Documentation of the resident's status and delivery of care provided according to the plan of care.
- If the nurse is unable to reach the medical provider, they will place a call to Medical Director to ensure timely notification to the Medical Doctor, Nurse Practitioner, or Physician's assistant (MD/NP/PA).
- Nurses should conduct on-going monitoring of resident related to the change in condition and to ensure that the nurse is communicating the resident's status during change of shift and to ensure proper follow up and necessary interventions are in place and properly documenting findings, interventions and response to care provided within the Electronic Health Record (E.H.R).
- Nurses will conduct on-going monitoring of residents and specifically monitor residents with bowel/bladder issues, and indwelling catheters to identify and recognize sign/symptoms of UTI: such as flank discomfort, urinary frequency, discomfort upon urination, increased confusion, changes in mental status, changes in urine odor, color, amount of urine and hematuria.
- Nurse/Interdisciplinary team (IDT) to review the plan of care and/or updating the plan of care accordingly.
- Abuse and Neglect (ANE) - Identifying Prevention and Reporting.
- Administrator and Director of Nursing conducted an AdHoc Quality Assurance Performance Improvement (QAPI) meeting with the Medical Director to review plan of removal/immediate corrective action plan implemented.
- Director of Nursing/Assistant Director of Nursing conducted 100% audit/assessment/evaluation of all current/active residents, including those with bladder and bowel issues, incontinence and indwelling catheters, to identify any signs or symptoms of a change in condition and validated that the medical provider has reported to the PCP for physician's review and to ensure appropriate plan of care is in place.
- Director of Nursing/Assistant Director of Nursing conducted an audit of all residents to identify any changes in conditions to ensure proper notification of the Medical Doctor (MD) and family representatives and to ensure appropriate interventions were in place.
- Director of Nursing/Assistant Director of Nursing conducted in-service training to all licensed nurses prior to the nurse working his/her next scheduled shift; comprehension verified through follow up questions.
- Director of Nursing/Assistant Director of Nursing will conduct rounds to identify any resident with a change in condition and will ensure appropriate documentation, notifications and appropriate interventions are in place and documented within the electronic health record.
- Director of Nursing/Assistant Director of Nursing will conduct random audits of documentation of progress notes, Medication Administration Record (MARS) (pain meds) as well as staff interviews to identify any signs and symptoms of a resident with a change in condition and will ensure appropriate documentation, notifications and appropriate interventions are in place and documented within the electronic health record.
- Director of Nursing/Assistant Director of Nursing will conduct random interviews with the nursing team members to identify competency/comprehension of identifying signs and symptoms of a urinary tract infection, increased pain, and other signs of a change in condition as well as the process for reporting the identified change in condition to the license nurse, the process for the nurse to conduct an assessment, will ensure appropriate documentation, MD and family notifications as well as ensuring appropriate interventions are in place and documented within the electronic health record.
- The facility will conduct a Quality Assurance Performance Improvement (QAPI) meeting to review the status and compliance notification to Medical Doctor, Nurse practitioner, or physician's assistant (MD/NP/PA) ensuring appropriate intervention and orders are implemented as ordered and appropriate documentation is noted within the Electronic Health Record (E.H.R.).
- Director of Nursing/Designee will ensure all licensed nursing staff will be educated to include nurses on leave/agency/Part time staff (PRN staff) - Nurses will be in serviced prior to working their next shift.
- DNS/Designee will ensure administrative nursing staff in the community will provide in-service/education prior to team members working their assigned shift. The trainings will also be conducted with new hires.
Failure to Notify Provider of Resident's Change in Condition Related to Catheter and UTI Symptoms
Penalty
Summary
The facility failed to immediately notify a resident's nurse practitioner (NP) when there was a significant change in the resident's physical status. The resident, who had a history of urinary tract infections (UTIs) and required an indwelling catheter, began experiencing increased bladder spasms and dysuria over several days. Despite these symptoms and an increased need for pain and bladder spasm medications, there was no documentation or evidence that the NP was notified of the change in the resident's condition. Medical record reviews showed that the resident was administered oxybutynin chloride and phenazopyridine HCl multiple times over a period of days for bladder spasms and dysuria, indicating ongoing and possibly worsening symptoms. Interviews with nursing staff confirmed that the resident's increased pain and medication use should have prompted notification to the NP, as these could indicate complications such as catheter obstruction or a UTI. The NP also stated she would have expected to be notified and for a urinalysis to be conducted if the resident was experiencing increased pain. The resident herself reported experiencing excruciating pain for several days prior to being sent to the hospital, requiring frequent requests for pain medication. Facility policy required that the physician and resident representative be notified of changes in condition or symptoms suggestive of a UTI, but this was not followed. The failure to notify the NP of the resident's change in condition was confirmed through interviews, record review, and review of facility policy.
Deficiency in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which could potentially place them at risk for psychosocial and physical harm. For one resident, the facility did not adequately address her wishes to discharge from the facility. Despite the resident's intact cognition and expressed desire to return home, the facility did not document discharge planning goals or interventions. Interviews revealed that the resident was frustrated with the lack of information regarding her discharge, and although she had improved with therapy, she had no family support or financial means to facilitate her transition back to the community. Another resident with an implanted defibrillator/pacemaker did not have a care plan that included specific interventions for the care and monitoring of his device. The resident was aware of the device's limitations and had a bedside monitor to communicate with his cardiologist. However, the care plan lacked details on the use, care, or monitoring of the device. Interviews with staff indicated a lack of awareness and specific instructions regarding the resident's pacemaker and monitoring device, which could lead to inadequate care and monitoring. The facility's care plan policy emphasizes the importance of developing a plan to maintain the resident's highest practicable well-being. However, the failure to include specific discharge planning for one resident and detailed care interventions for another resident's medical device indicates a gap in the facility's adherence to its policy. This deficiency highlights the need for comprehensive and individualized care plans to ensure residents' needs are met effectively.
Deficiency in Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to the interests and needs of residents, particularly those in the memory care unit and those requiring in-room activities. For Resident #40, who is severely cognitively impaired with a BIMS score of 0, the facility did not provide an activities calendar or regular activities, as observed by CNA G. The CNA reported that activities were infrequent and not conducted daily, which could help mitigate anxious behaviors in the memory care unit. The lack of activities was corroborated by the absence of an activities calendar in the memory care unit. Additionally, the facility did not provide in-room activities for Residents #34 and #48, both of whom have complex medical conditions including CHF, Afib, and COPD, among others. The activity participation logs for these residents showed no data regarding in-room activity programs, and Resident #48's care plan lacked activity interventions. Interviews with the activity director and other staff revealed that in-room activities had not been initiated, and the activities calendar for March 2025 showed a significant lack of scheduled activities. The facility's policy requires an organized program of activities to meet residents' interests and well-being, which was not adhered to in this case.
Failure to Monitor Vital Signs and Symptoms in Residents
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, the facility did not take blood pressure measurements for Resident #37 before administering the blood pressure medication amlodipine, as ordered by the resident's physician. This oversight occurred on multiple occasions between March 1, 2025, and March 19, 2025, where the medication was administered without checking or documenting blood pressure vital signs, contrary to the physician's parameters. Additionally, the facility failed to monitor for signs and symptoms of heart failure in Residents #1, #34, and #79 while they were being treated with diuretic medications. These residents had diagnoses of heart failure and were at risk for complications such as chest pain, shortness of breath, fatigue, dizziness, poor endurance, and edema. Despite these risks, the facility did not adequately monitor the residents for these symptoms, which could lead to a decline in their health. Interviews with facility staff revealed a lack of consistent monitoring and documentation practices. The Director of Nursing (DON) acknowledged the potential adverse effects of not monitoring residents on diuretics, which could result in delayed treatment, physical and functional decline, and possible hospitalization or death. The facility's policies on medication administration and quality of care emphasize the importance of taking vital signs and ensuring treatment aligns with professional standards, yet these were not adhered to in the cases reviewed.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living independently, received the necessary services to maintain personal hygiene. Specifically, the resident, who was moderately cognitively impaired and required substantial assistance for showering, did not receive 4 out of 20 scheduled showers over a period of approximately six weeks. The resident's care plan indicated a need for assistance due to impaired mobility and other health conditions, and the facility's policy required showers to be scheduled at least twice weekly. The deficiency was identified through a review of the resident's records, which showed that the resident missed scheduled showers on four Saturdays. The Director of Nursing was unaware of the missed showers and could not provide documentation to confirm that the showers were given on those dates. The facility's policy emphasized the importance of adhering to the shower schedule based on resident preference, but the lack of documentation and missed showers indicated a failure to comply with this policy, potentially impacting the resident's hygiene and quality of life.
Failure to Maintain Accurate Clinical Records for Urine Sample Collection
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident with a history of chronic urinary tract infections (UTIs). The resident, who had multiple complex medical conditions including vascular dementia, aphasia, and hemiplegia, was under orders for regular urinalysis collection due to recurrent UTIs. The medication administration record (MAR) for January did not accurately reflect the status of urine sample collection on several days, with documentation inconsistencies such as marking the sample as administered when it was not collected, and leaving entries blank. Additionally, there was no documentation or rationale from a medical provider when the order for urine collection was canceled by the Director of Nursing (DON), and the reason for discontinuation was left blank in the records. Record reviews showed that the resident's MAR indicated refusals on some days, an 'administered' status on others, and a blank entry, while progress notes and lab reports confirmed that no urine sample was actually collected in January. Interviews with staff revealed that the resident was often uncooperative with urine collection, and staff would sometimes document the procedure as completed to prevent repeated attempts by other staff. The DON acknowledged that the rationale for discontinuing the monthly urinalysis order was not documented at the time, and that proper documentation protocols were not followed. The facility's own policy required that medical records be maintained in accordance with accepted professional standards, including accurate documentation of care and services provided. The lack of accurate documentation and failure to provide a provider's rationale for discontinuing a medical order resulted in incomplete clinical records for the resident, as evidenced by the discrepancies between the MAR, progress notes, and lab results.
Resident Elopement Due to Inadequate Supervision and Alarm Response
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident identified as being at risk for elopement. The resident, who had severe cognitive impairment due to multiple sclerosis and dementia, was found lying in the grass beside his wheelchair on the opposite side of a two-lane road after eloping from the facility. This incident resulted in a laceration to his right eye and facial bruising. The resident had a history of exit-seeking behavior, as documented in his care plan and progress notes, which indicated multiple attempts to leave the facility unattended. The deficiency occurred when the resident managed to exit the facility through a hallway door, despite wearing a wander guard device. The alarm system was triggered, but the responsible RN prematurely silenced the alarm without confirming the whereabouts of all residents, contrary to the facility's elopement response policy. The RN acknowledged this failure, which led to the resident being outside in extreme heat conditions, posing a significant risk to his safety. Interviews with staff and family members revealed that the resident had been exhibiting exit-seeking behavior multiple times a day, and there were previous incidents where he attempted to leave the facility. Despite these known risks, the facility's response to the alarm was inadequate, as the RN did not follow the proper protocol to ensure the resident's safety. This lapse in supervision and failure to adhere to established procedures directly contributed to the resident's elopement and subsequent injury.
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What surveyors actually found near you
We read the 101 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bandera
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedar Creek Nursing And Rehabilitation Center | 1.3 mi | ★★★★★ | 17 | 0 |
| Avir At Comfort | 19.9 mi | ★★★★★ | 10 | 0 |
| Kendall House Wellness & Rehabilitation | 20.3 mi | ★★★★★ | 7 | 0 |
| Town And Country Nursing And Rehabilitation Center | 20.7 mi | ★★★★★ | 5 | 0 |
| Care Choice Of Boerne | 20.7 mi | ★★★★★ | 17 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.