Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Corpus Christi during CMS and state inspections, most recent first.
Two residents received Midodrine, a medication for hypotension, outside of prescribed blood pressure parameters. Orders either lacked clear parameters or were not followed, and staff administered the medication even when blood pressure readings exceeded the hold thresholds. Despite prior in-service education and pharmacy consultant recommendations, staff admitted to not consistently verifying vital signs before administration, resulting in significant medication errors.
Surveyors found multiple deficiencies in food storage, preparation, and sanitation, including unlabeled and undated food, personal items in food storage areas, improper hygiene practices, malfunctioning equipment, and poor maintenance of the nutrition room. Staff interviews revealed confusion about responsibilities for temperature monitoring and maintenance, and cleaning records did not match observed conditions.
A resident with paraplegia and multiple comorbidities reported being called a 'dummy' by a CNA during a shower, which made her feel uncomfortable. The DON and administrator were informed but did not report the verbal abuse allegation to state or local authorities as required by policy, nor was the accused CNA suspended from all resident contact. Other staff were unaware of the incident, and no in-service training was conducted regarding the event.
A resident with COPD, dyspnea, and on hospice care was admitted with orders for respiratory medications, but the required baseline care plan was initiated and never completed within 48 hours. Interviews with the MDS nurse, DON, ADON, and other staff revealed the care plan was overlooked by the IDT, despite facility policy assigning this responsibility to them.
A resident with end stage renal disease and a newly placed AV fistula did not have a physician's order for assessment of the dialysis access, and staff did not consistently monitor or document the required assessments for thrill and bruit each shift. Nursing staff acknowledged the absence of orders and documentation, despite being aware of the need for such monitoring.
A wound care nurse did not perform hand hygiene after removing gloves and before providing wound care to a resident with stage 4 pressure ulcers. The nurse cited a lack of access to hand sanitizer and nervousness as reasons for the lapse. Facility policy and the DON confirmed that hand hygiene is required after glove removal to prevent infection.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with severe cognitive impairment and high fall risk was left unsupervised and accessed a shower room, resulting in a fall and head injury. The facility failed to secure the shower room and provide adequate supervision, contributing to the incident.
The facility failed to ensure proper documentation and administration of PRN narcotic medications for three residents. An LVN did not sign the MAR when administering these medications, and there was no witnessed waste, leading to discrepancies in medication counts. Interviews revealed a lack of awareness and systems to ensure proper documentation, with the pharmacy director confirming that their audits did not include checking MARs or nursing narcotic count logs.
The facility failed to meet professional standards for food service safety, with deficiencies in labeling, dating, and storing food items. Observations revealed unlabeled and expired items in the walk-in cooler, improper sealing of containers, and personal items stored in the reach-in cooler. Additionally, food temperatures were not consistently recorded, posing a risk of foodborne illness. Interviews with the Dietary Manager highlighted a lack of adherence to the facility's food storage policy and issues with a new cook not following procedures.
The facility failed to ensure call lights were within reach for several residents, including those with severe cognitive impairments and other health conditions. Observations revealed that call lights were often placed out of reach, preventing residents from obtaining assistance when needed. Staff interviews indicated a shared responsibility for ensuring call light accessibility, but inconsistencies were noted, and the facility lacked a specific policy on call light placement.
A facility failed to ensure a safe, clean, and homelike environment for a resident with cognitive impairments. Observations revealed a broken outlet face plate, damaged walls, a dark substance on the ceiling, and an improperly attached sharps container. Staff interviews indicated a lack of awareness and action regarding these issues, and the facility could not provide relevant policies when requested.
The facility failed to provide adequate respiratory care for several residents, including a resident with a tracheostomy who lacked necessary emergency supplies at the bedside. Multiple residents had incorrect oxygen settings, with one resident's oxygen tubing disconnected, leading to low oxygen saturation levels. Nursing staff admitted to not consistently checking oxygen settings and tubing connections, which could delay emergency care and result in inadequate oxygenation.
The facility failed to secure hazardous storage areas in Hall 200, leaving the soiled linen utility closet, oxygen storage room, and central supply storage room unlocked. These areas contained potentially dangerous items such as dirty linens, oxygen canisters, and shaving razors. Staff interviews revealed a lack of awareness and responsibility for securing these areas, and no policy was available to ensure a safe environment.
The facility failed to maintain an effective pest control program, leading to the presence of flies and gnats in the kitchen and dining room. Observations revealed pests in the kitchen's dry storage and food preparation areas, as well as in the dining room. Staff interviews indicated delays in installing an air curtain and a focus on treating roaches and ants, with no specific attention to flies or gnats.
The facility failed to notify the Ombudsman in writing about the transfers of two residents. One resident was discharged home, and another was transferred to a memory care unit without the Ombudsman being informed. The social worker was unaware of the requirement to notify the Ombudsman, despite the facility's policy mandating it.
The facility failed to ensure the 100 hall glucometer was calibrated on ten days in July, risking inaccurate blood glucose readings. Interviews revealed that staff assumed calibrations were done by others, and the DON was unaware of the lapses due to a lack of policy and oversight.
A facility failed to document a physician's order for oxygen therapy for a resident with chronic respiratory conditions, despite the resident receiving continuous oxygen since hospital readmission. Staff interviews revealed a breakdown in the process of reconciling and documenting orders, leading to inaccurate records. Observations confirmed the resident was on oxygen therapy without a documented order, contrary to facility policy.
A facility failed to maintain proper infection control when an LVN performed hand hygiene for only 15 seconds after wound care for a resident with multiple health conditions, including diabetes and dementia. This was below the CDC's recommended 20 seconds, potentially risking cross-contamination. Interviews revealed uncertainty about recent hand hygiene training, highlighting a gap in staff education.
Failure to Administer Blood Pressure Medication Within Prescribed Parameters
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of Midodrine, a medication used to treat hypotension. For one resident, physician orders for Midodrine were initiated without specifying blood pressure parameters, and subsequent orders included parameters to hold the medication if blood pressure exceeded certain thresholds. However, medication administration records showed that Midodrine was given without consistently recording blood pressures, and on multiple occasions, it was administered even when blood pressure readings were above the prescribed parameters. Another resident had physician orders for Midodrine with explicit instructions to hold the medication if blood pressure was greater than specified values. Despite these orders, documentation revealed that the medication was administered several times when blood pressure readings exceeded the hold parameters. The facility's consultant pharmacist had previously identified and communicated these issues, and in-service education was provided to nursing staff regarding the importance of adhering to blood pressure parameters when administering such medications. Interviews with nursing staff and facility leadership confirmed that staff were aware of the medication administration guidelines and the risks associated with improper administration. However, staff admitted to administering Midodrine outside of the prescribed parameters, sometimes due to inattention or being in a hurry. The facility's policy required verification of vital signs prior to medication administration, but this was not consistently followed, resulting in significant medication errors for the residents involved.
Deficient Food Storage, Preparation, and Sanitation Practices
Penalty
Summary
Surveyors identified multiple failures in the facility's food storage, preparation, and sanitation practices during their review of the kitchen and nutrition room. Observations revealed that personal items, such as cans of soda and a Styrofoam cup, were stored in the walk-in refrigerator and placed on the tray line, respectively. Several food items in the walk-in refrigerator and freezer were not labeled or dated, and some boxes of food were left open to air and stored less than 18 inches from the ceiling. The walk-in freezer had a significant accumulation of ice, and there was no internal thermometer present in the walk-in refrigerator. Additionally, one of the juice guns was found to have a thick, red/black sticky substance in and on the inner nozzle, and it was not stored properly. Staff were observed not following required hygiene protocols, such as wearing hairnets when entering the kitchen. The electric stove in the kitchen had two non-functioning burners, and the nutrition room had not maintained freezer temperature logs for several weeks. An expired jar of asparagus was found in the nutrition room, and the cabinet beneath the sink contained standing water, trash, personal items, and evidence of mold. The cabinet floor was also delaminated, indicating ongoing water damage. Interviews with staff revealed confusion and lack of clarity regarding responsibilities for temperature monitoring and maintenance in the nutrition room. Record reviews showed that cleaning checklists were marked as completed, but direct observations contradicted these records, particularly regarding the cleanliness of equipment such as the juice machine. Facility policies required all food to be labeled and dated, refrigerators and freezers to be maintained in good working condition, and staff to wear hair restraints. However, these policies were not consistently followed, as evidenced by the surveyors' findings and staff admissions during interviews.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse involving a resident was reported immediately to the administrator and appropriate authorities, as required by both facility policy and federal regulations. A cognitively intact female resident with multiple medical conditions, including paraplegia, reported that a CNA called her a 'dummy' while she was in a mechanical lift during a shower. The resident expressed that the comment made her feel bad and uncomfortable, and she subsequently informed the DON about the incident. The DON, after being informed by the resident, discussed the matter with the administrator, and together they decided that the CNA would no longer provide care to the resident. However, the incident was not reported to state or local authorities, and no in-service training was conducted regarding the event. Interviews with facility staff revealed a lack of awareness and appropriate action regarding the reporting of the abuse allegation. The administrator initially stated he was not informed about the incident but later acknowledged being told by the DON and admitted that name-calling constituted verbal abuse, which should have been reported. The DON also recognized that name-calling was a form of verbal abuse but did not report the incident, believing that informing the administrator was sufficient. Other staff members, including the ombudsman, social worker, and other CNAs, were either unaware of the incident or had not received any in-service training related to it, despite having regular abuse prevention training. A review of the facility's policy confirmed that all allegations of abuse, including verbal abuse, must be reported immediately to the administrator and appropriate authorities, with 'immediately' defined as within two hours for abuse allegations. The policy also required that the accused employee be removed from resident contact until the investigation was complete, and that the ombudsman be notified. The facility did not follow these procedures, as the incident was not reported to authorities, the accused CNA continued to work in the facility (albeit not with the affected resident), and there was no documentation of disciplinary action or notification to the ombudsman.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to implement a baseline care plan within 48 hours of admission for one resident, as required to ensure effective and person-centered care. The resident, a female with diagnoses including Chronic Obstructive Pulmonary Disease, dyspnea, and dependence on supplemental oxygen, was admitted with orders for respiratory medications and hospice care. Although a baseline care plan was initiated and added to her chart, it was never completed. The Minimum Data Set (MDS) nurse acknowledged that she should have completed the clinical portion of the care plan, while the rest of the Interdisciplinary Team (IDT) was responsible for the remaining sections. However, the care plan was overlooked by all responsible parties. Interviews with facility staff, including the MDS nurse, Director of Nursing (DON), Assistant Director of Nursing (ADON), and a medication aide, confirmed that the care plan was not completed due to oversight. Staff indicated that the resident was well-known to them and had been admitted multiple times, which may have contributed to the oversight. The facility's policy requires the IDT to develop care plans, but in this instance, the process was not followed, resulting in the absence of a completed baseline care plan for the resident.
Failure to Ensure Physician Orders and Monitoring for Dialysis Access
Penalty
Summary
The facility failed to provide dialysis care and services consistent with professional standards of practice for a resident with end stage renal disease and dependence on renal dialysis. Specifically, the facility did not ensure there was a physician's order in place to assess the resident's dialysis shunt or fistula after it was placed. Additionally, the facility did not monitor the resident's dialysis catheter by assessing for the presence of a thrill and bruit each shift, as required for proper monitoring of dialysis access. Interviews with nursing staff and review of the resident's records confirmed that although staff were aware of the need to assess the dialysis shunt, there was no physician order directing this care, and documentation of assessments was not consistently maintained in the resident's progress notes. The lack of orders and consistent monitoring was acknowledged by both the ADON and DON, who stated that the order should have been initiated when the shunt was placed. The facility's own policy emphasized the necessity of physician orders to ensure residents receive appropriate care and services.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
A wound care nurse (WCN) failed to perform proper hand hygiene after removing gloves and before providing wound care to a resident with multiple stage 4 pressure ulcers. Specifically, after sanitizing scissors, the WCN removed her gloves but did not sanitize her hands before donning new gloves and proceeding with wound care. The WCN later stated that she did not have her hand sanitizer in its usual location, which disrupted her routine, and she forgot to perform hand hygiene due to nervousness. The WCN acknowledged the importance of hand hygiene after glove removal to prevent infection and cross-contamination. The resident involved was an adult male with a history of stage 4 pressure ulcers on the sacrum and left big toe, type 2 diabetes, and hypertension. Physician orders required daily wound care, including cleaning and dressing changes. The facility's hand hygiene policy specified that hand hygiene should be performed immediately after glove removal. During interviews, the Director of Nursing (DON) confirmed that staff are expected to sanitize or wash hands for at least 30 seconds after glove removal, but could not recall when the last hands-on in-service for handwashing was conducted.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential resident information or proper record-keeping were not followed as expected. No additional details regarding specific residents, staff actions, or the circumstances leading to the deficiency are provided in the report.
Resident Falls Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, leading to an accident. The resident, who had severe cognitive impairment and was at high risk for falls, was unaccounted for approximately 10 minutes. During this time, the resident was found alone in a shower room, having sustained a head injury from a fall. The resident was subsequently diagnosed with an acute on chronic intracranial subdural hematoma at a local hospital. The resident's care plan indicated a risk for falls due to confusion, gait and balance problems, and poor safety awareness. Despite these known risks, the resident was able to access the shower room unsupervised, where the fall occurred. The facility's failure to secure the shower room and provide adequate supervision contributed to the incident. Interviews with staff revealed that the shower room doors were supposed to be locked, but it was unclear how the resident gained access. The facility had previously used a lock and key mechanism, with the key hanging by the door, which may have allowed the resident to enter the room. The incident highlighted a lapse in the facility's procedures for ensuring resident safety and preventing accidents.
Failure in PRN Narcotic Documentation and Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of three residents, specifically in the administration and documentation of PRN narcotic medications. Licensed Vocational Nurse (LVN-A) did not sign the Medication Administration Record (MAR) when administering PRN narcotics to the residents, and there was no witnessed waste of these medications. This lack of documentation and oversight could lead to residents not receiving the correct dosage of pain medication. Resident #4, a female with a diagnosis of Systemic Inflammatory Response Syndrome, had an order for Hydrocodone-Acetaminophen for pain. Her MAR for September 2024 showed no signatures for the administration of this medication, despite a decrease in the tablet count from 30 to 18. Similarly, Resident #2, a male with a diagnosis of unspecified pain, had only two signatures on his MAR for the same medication, with a significant reduction in tablet count. Resident #3, a male with gout, also had no signatures on his MAR for the administration of Hydrocodone-Acetaminophen, despite a decrease in tablet count. Interviews with facility staff revealed a lack of awareness and systems to ensure proper documentation and verification of narcotic administration. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the absence of checks or audits to verify MARs against narcotic count sheets. The pharmacy director confirmed that their audits did not include checking MARs or nursing narcotic count logs. The facility's Controlled Substance Policy and Pharmacy Medication Administration Policy were not adhered to, as medications were not consistently documented or wasted with a witness.
Deficiencies in Food Storage and Temperature Logging
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies in the storage, preparation, distribution, and serving of food. Observations revealed that food items in the walk-in cooler were not labeled or dated, and some were not discarded after their use-by date. Containers were not tightly sealed, and items meant to be kept frozen were found in the cooler. Additionally, personal items were stored in the reach-in cooler, and food items were not covered when not being actively prepared or served. Further inspection of the dry storage area showed that food items were not labeled or dated, and some were not refrigerated after opening as per the manufacturer's instructions. Containers were not properly sealed, and there were instances of expired food items. The facility also failed to record food temperatures for all meals, with several instances of unsafe temperatures being recorded or not recorded at all. This lack of proper temperature logging could potentially lead to foodborne illnesses among residents. Interviews with the Dietary Manager (DM) revealed that there was a lack of adherence to the facility's food storage policy, which required all food to be labeled, dated, and stored according to state and federal guidelines. The DM acknowledged the responsibility for ensuring that all items were labeled and outdated items were disposed of. However, the DM admitted that the temperature logs were not consistently checked, and there were issues with a new cook not following procedures. The facility's policies on food storage and temperature logging were not consistently followed, leading to the observed deficiencies.
Deficiency in Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that residents had the right to reside and receive services with reasonable accommodation of their needs and preferences, specifically regarding the accessibility of call lights. This deficiency was observed in four residents, who were unable to reach their call lights, potentially placing them at risk of being unable to obtain assistance when needed. The report highlights that the call lights for these residents were not within reach, which could prevent them from calling for help in emergencies or when they required assistance. Resident #254, a severely cognitively impaired individual with multiple health issues including chronic respiratory failure and dementia, was observed unable to reach her call light, which was wrapped around the bed rail. Interviews with staff revealed that ensuring call lights are within reach is a shared responsibility among all staff members, yet this was not consistently practiced. Similarly, Resident #86, who also had severe cognitive impairment, was found with the call light clipped out of reach, although it was later observed within reach during a subsequent check. Residents #26 and #66, both with severe cognitive impairments and other health conditions, were also found with call lights out of reach during initial observations. Staff interviews indicated that regular checks and rounds are supposed to ensure call lights are accessible, but lapses occurred. The facility lacked a specific policy on call light placement, which may have contributed to the inconsistency in ensuring residents' call lights were within reach.
Facility Fails to Maintain Safe and Homelike Environment for Resident
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for a resident, as observed during a survey. The resident's room had several issues, including a broken face plate covering an outlet, damaged walls, a dark substance on the ceiling, and a sharps container that was improperly attached to the wall, allowing it to rotate freely. These deficiencies were identified through observations, interviews, and record reviews. The resident, who has Alzheimer's disease, major depressive disorder with psychotic symptoms, and schizoaffective disorder, was unable to respond to interview questions, indicating a moderate cognitive impairment. Interviews with staff members, including a CNA, LVN, maintenance staff, and the DON, revealed a lack of awareness and action regarding the room's condition. The CNA and LVN acknowledged the room's poor state, with the LVN noting that the room did not pose harm as long as the exposed wire was inactive. The maintenance staff confirmed the wire was an old, disconnected phone line and identified the jagged edges of the broken outlet face plate as a potential danger. The DON admitted to visiting the room daily but only noticed the damage after a second bed was removed, which had previously obscured the view. The facility was unable to provide policies on maintaining a safe, homelike environment when requested.
Inadequate Respiratory Care and Oxygen Management
Penalty
Summary
The facility failed to provide adequate respiratory care for several residents, as observed during a survey. Resident #12, who has a tracheostomy, did not have the necessary emergency supplies such as a suction machine, suction catheters, sterile gloves, and flush solution at the bedside. This lack of preparedness was confirmed by both the resident and the nursing staff, who acknowledged that the absence of these supplies could delay emergency care. The Director of Nursing (DON) admitted that it was their responsibility to ensure these supplies were available to provide a quick response in case of a respiratory emergency. Resident #7 was found with her oxygen tubing disconnected from the concentrator, and the oxygen setting was incorrect at 3 liters per minute instead of the prescribed 2 liters per minute. This resulted in a low oxygen saturation level of 88%, which improved to 91% after the tubing was reconnected. The nurse responsible for Resident #7 admitted to not checking the oxygen settings as required, which could lead to negative outcomes such as cyanosis and inadequate oxygenation. Other residents, including Resident #254, Resident #396, and Resident #36, also experienced issues with incorrect oxygen settings. Resident #254's oxygen was set at 3 liters per minute instead of the prescribed 2 liters, and there was no oxygen sign posted outside the room. Resident #396's oxygen was initially set too high at 5 liters per minute and later too low at 2.5 liters per minute. Resident #36's oxygen was also set incorrectly at 2.5 liters per minute instead of the prescribed 3 liters. These discrepancies were acknowledged by the nursing staff, who admitted to not consistently checking the oxygen settings and tubing connections as required by facility policy.
Facility Fails to Secure Hazardous Storage Areas
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in Hall 200, as observed during a survey. Specifically, the soiled linen utility closet was found partially ajar, containing dirty linens and trash, despite a sign indicating it was for authorized personnel only. Additionally, the oxygen storage room, which contained approximately 50 oxygen canisters, and the central supply storage room, which housed around 40 individual shaving razors, were both unlocked. These rooms were supposed to be secured to prevent unauthorized access to potentially hazardous materials. Interviews with staff revealed a lack of awareness and responsibility regarding the security of these areas. CNA C mentioned that the locking mechanism on the central supply storage room had been non-functional for about a year and expressed uncertainty about the necessity of locking the oxygen storage room. LVN E noted that the oxygen storage room is typically locked in other facilities and acknowledged the potential risk of residents accessing the central supply storage room and injuring themselves. The DON expressed that the soiled linen closet should be secured and acknowledged the potential danger of having razors in the central supply storage room. However, no policy was available to outline the expectations for maintaining a safe environment.
Pest Control Deficiency in Kitchen and Dining Room
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of multiple live flies and gnats in the kitchen and dining room. Observations on July 29, 2024, revealed flies and gnats in the kitchen's dry storage area and food preparation surfaces, as well as flies in the dining room. A resident was observed with a fly swatter on the dining room table, indicating an ongoing issue with flies in the area. Interviews with facility staff revealed that an air curtain had been ordered for the dining room door to prevent pests, but installation was delayed due to an electrical issue. The facility's pest control was contracted to visit twice a month, but recent treatments focused on roaches and ants, with no mention of flies or gnats. The pest control request log showed entries related to roaches and ants, but none for flies or gnats, indicating a lack of attention to the specific pest issue observed.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely written notification of transfer or discharge to the Office of the State Long-Term Care Ombudsman for two residents. Resident #82, a female with multiple health conditions including cellulitis, muscle wasting, and type 2 diabetes, was discharged home without the Ombudsman being notified. The social worker (SW) acknowledged that the discharge was planned and that the resident and her responsible party were informed, but she was unaware of the requirement to notify the Ombudsman. Similarly, Resident #93, a male with cerebral infarction and diabetes, was transferred to another facility without a written notice being sent to the Ombudsman. The SW stated that the transfer was due to the resident's need for a memory care unit and was agreed upon by the family. However, the SW admitted uncertainty about whether a written notice was provided to the resident, his family, or the Ombudsman. The facility's policy requires that a copy of the notice be sent to the Ombudsman at the same time it is provided to the resident and representative.
Failure to Calibrate Glucometer
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate dispensing and administering of drugs and biologicals, specifically in the calibration of glucometers. The deficiency was identified in the 100 hall glucometer, which was not calibrated on ten separate days in July 2024. This lack of calibration could lead to inaccurate blood glucose measurements, potentially affecting the treatment of residents. The record review showed no entries for calibration on specific dates, indicating a lapse in the procedure. Interviews with staff revealed a lack of awareness and responsibility regarding the calibration process. LVN F assumed that the night shift nurse performed the calibrations and did not verify the completion of this task. The DON acknowledged that glucometer checks should be done each shift and that nurses are responsible for ensuring calibration. However, the DON admitted to not reviewing the logs for completion and was unaware of the inconsistency in calibration. Furthermore, the facility did not have a policy addressing glucometer calibration, contributing to the oversight.
Deficiency in Oxygen Therapy Documentation
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices, specifically in the documentation of oxygen administration for a resident. The resident, who was readmitted to the facility with chronic respiratory conditions, including COPD and chronic respiratory failure, did not have an active physician's order for oxygen therapy documented in their Medication Administration Record (MAR) or Treatment Administration Record (TAR). Despite the resident being on oxygen therapy since their return from the hospital, the order was not reconciled or recorded, leading to inaccurate documentation. Interviews with facility staff revealed a breakdown in the process of reconciling and documenting physician orders upon the resident's readmission. The Licensed Vocational Nurse (LVN) and Minimum Data Set (MDS) Nurse acknowledged that the order for oxygen should have been documented and reconciled with the physician. The Director of Nursing (DON) and other staff members admitted that the order was overlooked during the admission process and subsequent reviews, despite the resident's continuous use of oxygen therapy. Observations confirmed that the resident was receiving oxygen therapy at varying levels, but without a documented order, which was only entered after the deficiency was identified. The facility's policy required a physician's order for oxygen therapy, but this was not adhered to, resulting in a lapse in proper documentation and potential risk for the resident and others receiving similar treatments.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN D during wound care for a resident. The resident, a male with a history of type two diabetes, chronic obstructive pulmonary disease, and dementia, required wound care for an arterial ulcer on his left lower leg. During an observation, LVN D was noted to perform hand hygiene for only 15 seconds after removing gloves, which is below the recommended 20 seconds as per CDC guidelines. This lapse in proper hand hygiene could potentially lead to cross-contamination and infection among residents requiring personal care. Interviews with LVN D and the Director of Nursing (DON) revealed that LVN D was aware of the importance of proper hand hygiene but may have counted too fast due to nervousness. The DON confirmed that all staff are expected to adhere to the 20-second handwashing guideline to prevent the spread of infections. However, both LVN D and the DON could not recall when the last hand hygiene in-service was conducted, indicating a possible gap in ongoing staff training and reinforcement of infection control practices.
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What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Corpus Christi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windsor Nursing And Rehabilitation Center Of Corpu | 2.8 mi | ★★★★★ | 10 | 0 |
| Windsor Nursing And Rehabilitation Center Of Morga | 2.9 mi | ★★★★★ | 4 | 0 |
| San Rafael Nursing And Rehabiliation | 3.5 mi | ★★★★★ | 12 | 2 |
| Alameda Oaks Nursing Center | 3.7 mi | ★★★★★ | 8 | 0 |
| Brookdale Trinity Towers | 4.2 mi | ★★★★★ | 11 | 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 July 2026) and official state health department websites.