Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Buena Vida Nursing And Rehab-san Antonio during CMS and state inspections, most recent first.
A resident with stroke, DM2, and severe cognitive impairment had incomplete and inaccurate bathing documentation on the ADL flow sheets. His care plan called for M-W-F bathing, but the EMR did not show entries for multiple scheduled bath days, while staff stated a bed bath was mis-marked as a shower and that a peri-warm wipe down was given instead of a bath because the resident wanted to go to a smoke break. The DON stated the POC was the official record and staff were trained to document baths/showers there.
Surveyors found that the facility failed to properly label and document narcotic sheets for three residents receiving controlled pain medications, resulting in inaccurate accounting of drugs dispensed by the pharmacy. For one resident on APAP/Codeine, an LVN altered the narcotic sheet card count to match the blister pack, revealing that the original documentation did not correspond to the actual medication cards. For two other residents on Tramadol and APAP/Codeine, narcotic sheets lacked any card count labeling, leaving staff unable to accurately track narcotic usage or determine when to reorder. The report notes that this failure could affect residents receiving narcotics for pain and could result in misappropriation of medications or drug diversion.
A resident with depression, anxiety, and moderate cognitive impairment expressed suicidal ideation to CNAs and an LVN but was nonetheless provided two shaving razors without supervision, despite facility policies prohibiting residents from having sharp objects and requiring 1:1 monitoring after suicide threats. The resident later used a razor to inflict a superficial wrist scratch after repeatedly stating she wanted to harm herself, while documentation and interviews showed gaps in recognizing and responding to suicidal ideation and in enforcing razor-control and supervision procedures. Surveyors cited this as past noncompliance at the Immediate Jeopardy level for failure to keep the environment free of hazards and to provide adequate supervision to prevent accidents.
A resident with dementia, psychosis, severely impaired cognition, and a documented history of wandering and exit-seeking was identified as an elopement risk but did not have comprehensive care plan interventions addressing ongoing elopement risk. Progress notes showed repeated pacing, focus on the exit door, and verbalizations about wanting to leave to see a former resident friend. Despite being placed on q15-minute monitoring for elopement risk, the resident was last seen on an upper floor before dinner, then went downstairs unobserved and exited through the front door after a staff member failed to ensure the door was fully closed. Staff were unaware the resident had left because he did not sign out, and he remained out of the building for about 30 minutes until recognized and returned from a nearby convenience store. The RCN later stated that required visual checks every 15 minutes were not carried out as ordered, leading to the elopement.
The facility failed to develop and implement comprehensive care plans addressing elopement risk for four residents who had documented elopement risk scores on Elopement Risk Assessments. One resident with dementia and psychosis had a prior elopement and multiple high-risk scores, yet his care plan only referenced wanting to visit a friend and a psychiatric review, without specific elopement interventions; he also could not describe any procedure for leaving and stated he would walk out the front door without being sure he should tell staff. Another resident with a psychotic disorder and severely impaired cognition, a resident with herpesviral encephalitis and an intact BIMS, and a resident with dementia who wandered daily all had Elopement Risk Assessments indicating risk, but none had elopement-related interventions in their care plans. Leadership acknowledged a recent change in administration, that the new DON had not reviewed all existing care plans, and that Elopement Risk Assessments were supposed to inform IDT discussions and care plan content, consistent with the facility’s comprehensive care planning policy, which was not followed in these cases.
A resident with multiple comorbidities and a history of pressure ulcers did not receive daily wound care or regular skin assessments for nearly a month due to missing wound care orders in the EMR and lack of follow-through by nursing staff. The resident's wounds worsened, leading to infection, osteomyelitis, and ultimately a below-knee amputation. Staff interviews and medical records confirmed that wound care was not performed as ordered, and concerns from outside care teams were not addressed.
A resident with multiple comorbidities and recent below-knee amputation did not receive weekly skin assessments or wound care as ordered, resulting in hospitalization for infection and sepsis. Nursing staff failed to document or complete required assessments, and there was inconsistent awareness and execution of wound care orders, despite facility policy requiring regular monitoring and documentation.
A resident with significant comorbidities developed a Stage IV pressure ulcer on the left ankle, but wound care treatment orders were not entered into the EMR or treatment records for an extended period. As a result, nursing staff were unaware of the required wound care, and no weekly skin or ulcer assessments were completed. The resident's wound deteriorated, leading to infection, sepsis, and amputation, with staff interviews confirming a lack of awareness and missed responsibilities for wound care documentation and treatment.
Three residents requiring enhanced barrier precautions or with indwelling devices did not have proper EBP signage posted at their room entrances, and in one case, a resident's Foley catheter tubing was observed touching the floor. Staff interviews confirmed knowledge of required practices, but these were not consistently followed, resulting in a failure to maintain an effective infection prevention and control program.
A resident with severe cognitive impairment and an indwelling foley catheter was observed in bed with the catheter bag exposed and lacking a privacy cover, contrary to care plan and physician orders. Nursing staff were aware of the missing privacy cover but were unable to locate one, and the facility did not have a specific policy addressing privacy covers for foley bags.
The facility did not post daily nurse staffing information in a visible and accessible location for two consecutive days. Observations showed either outdated or missing staffing posters, despite staff schedules being available. The ADON was responsible for posting this information, and the Administrator confirmed the absence of a formal policy for this process.
Inaccurate MDS coding affected four residents. One resident’s quarterly MDS omitted anticonvulsant use despite active Lamotrigine and Depakote orders, another resident’s MDS incorrectly coded insulin use instead of Trulicity, a third resident’s MDS failed to capture aspirin as antiplatelet therapy and instead recorded anticoagulant use, and a fourth resident’s MDS omitted bipolar disorder despite active Risperdal orders for bipolar. Records also showed related care plans did not consistently match the medication classes or diagnoses documented in the chart.
A facility failed to keep several residents’ comprehensive care plans accurate after assessments. One resident was incorrectly care planned as a smoker despite records and staff confirming he did not smoke, another resident’s dialysis was omitted, two residents’ psychotropic medication plans were inaccurate or incomplete, and one resident was care planned for anticoagulant therapy despite receiving aspirin as an antiplatelet. The DON and MDS Coordinator acknowledged the care plans should have reflected the residents’ current needs and orders.
Missing Signatures on Controlled Medication Reconciliation Logs: The facility failed to ensure controlled substance reconciliation logs were signed for accuracy during shift change for 3 of 5 carts reviewed, including the 2300/2400 hall nurse cart, the 2300/2400 hall medication aide cart, and the 2200/2500 hall medication aide cart. Although sample counts matched the individual controlled substance logs and blister packs, the comprehensive audit logs were missing signatures. Staff and the DON stated the cart handoff audit should be completed by two people and documented on the reconciliation log.
Infection control failures occurred during care for two residents. An ADON provided wound care to a resident on EBP without wearing the required gown at first, then left the room to get one, while the DON confirmed gown use was required for wound care. In a separate event, two CNAs changed gloves during incontinent care for a resident with total bowel incontinence but did not perform hand hygiene between glove changes, and both later acknowledged hand hygiene should have been done to prevent infection.
Accumulated lint was found in 3 of 4 dryers during laundry room observation, with thick lint on the lint trap area and bottom of the dryers. The Laundry Aide said lint traps should be cleaned every 2 hours and documented, but she forgot to document the last cleaning and thought she had cleaned them about 4 times that day. The Laundry Supervisor said the lint traps should be cleaned every 2 hours or after every cycle, and the Administrator said the log was meant to ensure accountability for cleaning the lint.
Failure to Obtain Signed Consent for Psychotropic Medication: A resident with dementia, intact cognition, and active orders for Risperdal had the medication administered as ordered, but the antipsychotic consent form lacked the resident or resident representative signature. The DON stated psychotropic consents should be completed with the appropriate signatures so the resident or representative is informed of the medication’s purpose, side effects, and alternatives before treatment.
A laptop on a med cart was left open in a hallway displaying a resident's appointment details, including the date, time, and location, with no staff present at the cart. The DON stated the laptop was used by all staff and should not have been left open with patient information because it was a HIPAA violation and anyone could access the records.
A resident with schizoaffective disorder, generalized anxiety disorder, epilepsy, insomnia, and disorganized schizophrenia had a PASRR Level 1 Screening that indicated no evidence of mental illness or dementia. The resident’s MDS showed intact cognition and documented anxiety, seizure disorder, and schizophrenia, and the care plan and MD orders included antipsychotic medication for schizophrenia. Staff initially stated there was no qualifying mental disorder and believed the PASRR was correct, then later corrected the PL1 so the resident could be evaluated by the local authority.
A capped lancet was observed lying in the middle of hallway 2300 and remained there for 20 minutes while Housekeeper A walked past it during routine duties. Housekeeper A did not pick it up or notify nursing staff and later stated she did not know what it was or how to dispose of it; the DON stated staff are expected to keep the area clean and remove items from floors and hallways.
Improper Perineal Wiping During Incontinent Care: A resident who was frequently incontinent of bladder and always incontinent of bowel received incontinent care from a CNA who wiped between the gluteal folds toward the urethral and vaginal area after cleansing the urethral area. The CNA stated the correct method was front to back to prevent bacteria from the rectal area reaching the urethral or vaginal area, and the DON confirmed staff should wipe front to back during incontinent care per facility policy.
Incomplete dialysis communication and documentation for a resident with ESRD and DM2. The resident received dialysis several times per week, but multiple dialysis communication forms were missing the dialysis center assessment, the facility post-assessment, or were absent from the dialysis binder. The care plan did not include dialysis-related care areas, and the DON stated the forms should be completed to support continuity of care and monitor the resident’s port site.
Unlabeled medications were found in 2 medication aide carts during observation: two dosing cups with pills in one cart and two loose pills in another. An MA stated pills left in dosing cups could be mistaken for another resident's meds, and another MA said loose pills could not be identified. The DON stated carts should be locked, clean, organized, and free of loose meds, and facility policy required meds to remain labeled in their original containers and not be pre-poured.
Incomplete Documentation of Bipolar Diagnosis: A resident’s medical record was incomplete because bipolar disorder was not added to the active dx list, MDS, or care plan, even though the hospital discharge summary and psych note documented bipolar/behavioral symptoms and active Risperdal orders were written for bipolar. The DON stated notes and hospital discharge paperwork should be reviewed for new dx and care plan updates, and the Regional Compliance Nurse stated there was no specific facility policy for clinical records.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with a history of Bipolar Disorder and other conditions repeatedly violated the facility's smoking policy and exhibited aggressive behaviors towards staff, which were not addressed in the care plan. Despite documentation of these issues in progress notes, the care plan lacked effective interventions. Interviews with staff revealed that the care plan should have been updated to reflect these behaviors, leading to a deficiency in providing appropriate care.
A resident in an LTC facility did not receive medications as prescribed due to errors in administration and documentation by staff. LVNs failed to apply Hydrocortisone gel on time, and an MA documented medications as given when they were not. The MA also administered Lidocaine patches instead of gel and stored prefilled medications improperly. The resident, with a history of cerebral infarction and hypertension, reported not receiving his morning medications, highlighting significant lapses in pharmaceutical services.
A resident with a history of cerebral infarction and hemiplegia did not receive timely ENT and vascular specialist appointments as ordered by their physician. Despite multiple attempts by facility staff, issues such as insurance coverage, staff turnover, and communication breakdowns led to significant delays. The resident expressed frustration over the lack of follow-through, and both the physician and NP were concerned about the impact on the resident's health.
A medication aide in an LTC facility failed to perform hand hygiene between administering medications to two residents, one with asymptomatic HIV and the other with viral hepatitis C. Despite training and satisfactory evaluations in infection control, the aide did not wash hands after handling medication cups and a blood pressure cuff, posing a risk of cross-contamination.
A resident with severe cognitive impairment was found sleeping without bed linen and with a broken footboard for over 24 hours. Despite available linen, the bed remained unmade due to a lack of communication between housekeeping and nursing staff. The facility's records showed no maintenance order for the bed repair, highlighting a failure to uphold the resident's right to a dignified living environment.
A facility failed to maintain accurate medical records for a resident, resulting in discrepancies between the Nurse Kardex and CNAs' electronic records regarding the resident's bathing schedule. The resident, with a history of stroke and cognitive deficits, was documented as missing showers on certain days, while electronic records showed otherwise. Interviews revealed a lack of structured documentation, contributing to the inconsistency.
The facility failed to maintain accurate medication records for two residents, with missing documentation for several prescribed medications in August 2024. Interviews revealed that nursing staff did not consistently document medication administration, and there was a lack of explanation for the omissions. The DON admitted to lapses in routine audits, contributing to incomplete medical records.
The facility failed to provide a safe, clean, and homelike environment for residents, with issues such as loose tiles, rusted bolts, excessive dust, non-functioning lights, broken toilet seats, and water-damaged ceiling panels. A resident expressed distress over the cleanliness, and staff acknowledged the need for repairs to improve safety and quality of life.
The facility failed to provide timely pharmaceutical services, with medications administered late to several residents, affecting their treatment for conditions like anxiety, hypertension, and diabetes. Additionally, an expired insulin pen was found in use, indicating non-compliance with medication storage policies.
Several residents in the facility received cold and unpalatable meals due to delays in meal service. Meals were delivered on open racks and served late, with residents expressing dissatisfaction. The facility's process of checking meal accuracy and limited CNA availability contributed to the delays.
The facility failed to properly store an opened bag of cereal and ensure the dish machine's chlorine sanitizer was at the necessary concentration. An unsealed bag of cereal was found in the dry storage room, risking contamination. Additionally, the dish machine initially showed no chlorine sanitizer during a cycle, which was later corrected by the Dietary Manager. These practices could place residents at risk for foodborne illness.
A resident with left-sided hemiparesis was found in bed with the call light button inaccessible, placed under her left back, preventing her from calling for assistance. The care plan required the call light to be within reach due to her medical conditions, including schizophrenia and severe cognitive impairment. A CNA repositioned the call light, allowing the resident to use it with her right hand. The facility lacked a specific policy for the call light system, relying on CMS and state guidelines.
The facility failed to store drugs and biologicals securely, as the medication room on the second floor was found unattended and unlocked, containing multiple residents' medications. LVN A and MA B were unaware of the situation due to being occupied with other duties. The Administrator and RN C recognized the safety concern, and the facility's policy requires medications to be stored securely.
The facility failed to properly dispose of garbage in Dumpster #2, which was observed to have an open door, missing drain plug, and ants present. The DM and Maintenance Director acknowledged these issues, and it was noted that the facility lacked a policy for maintaining dumpsters. The Food Code requires receptacles to have tight-fitting lids or doors and drain plugs.
A resident's call light system malfunctioned, failing to illuminate the light outside his room, which could risk residents not receiving timely care. The resident, with medical complexities including hemiparesis and anxiety, was unable to alert staff effectively. A CNA confirmed the issue and reported it to maintenance, while the regional DON acknowledged the lack of a specific policy for the call light system.
A survey revealed that a ceiling fan in the Soiled Utility Room on the 2300 hallway had dust and dirt particles in the vent slats, indicating a failure to maintain a sanitary environment. The Maintenance Director acknowledged the issue, which was contrary to the facility's policy on preventative maintenance.
A transcription error occurred in a LTC facility where a resident's Morphine order was incorrectly documented in the EHR. The resident, with multiple chronic conditions and cognitive impairment, was prescribed Morphine with a concentration of 20 mg in 5 ml liquid, but the EHR incorrectly recorded it as 20 mg in 1 ml. Despite the error, staff confirmed the resident received the correct dosage. The facility's medication administration policy was not adhered to, leading to this documentation discrepancy.
A resident's rights were violated when an administrator entered her room without permission and disposed of personal items while she was at a dialysis appointment. The resident, who has a history of major depressive disorder, returned to find belongings valued at $300 missing, leading to emotional distress. Staff confirmed the violation of resident rights, as the resident was not present and had not consented to the removal of her belongings.
A resident's right to personal possessions was violated when a hospitality aide turned off the resident's electronic monitoring device without permission. The resident, who had a history of dementia and other conditions, was observed on video during the incident. Staff interviews revealed no awareness of the camera being turned off, and the facility's policy on resident rights was not upheld.
A resident's personal belongings were misappropriated by a former administrator who entered the room without permission while the resident was at dialysis. The resident returned to find items valued at $300 missing, leading to emotional distress. Witnesses confirmed the resident was upset, and the facility's policy on resident rights was violated. The facility attempted to replace the missing items, but the incident highlighted a breach of resident rights.
Incomplete Bathing Documentation and ADL Flow Sheets
Penalty
Summary
The facility failed to maintain complete and accurately documented clinical records for one resident, specifically the Nursing Assistant ADL Flow Sheets for bathing from 4/13/2026 to 5/12/2026. The resident was a male admitted with diagnoses including cerebral infarction, type 2 diabetes mellitus, and need for assistance with personal care. His quarterly MDS dated 4/1/2026 showed a BIMS score of 07, indicating severe cognitive impairment, and his functional abilities included supervision or touching assistance with bathing and personal hygiene/toileting. His care plan directed staff to assist with bathing and to check, trim, and clean nails on bath day as necessary, with bathing scheduled for Monday, Wednesday, and Friday on the day shift. Record review showed the resident’s ADL completed bath activity for the last 30 days did not reflect the scheduled bathing days, and there were seven showers, baths, or sponge baths documented in the electronic medical record during that period. However, there were no showers, baths, sponge baths, or refusals entered for seven scheduled M-W-F bath days, including 4/15/2026, 4/17/2026, 4/22/2026, 4/24/2026, 4/29/2026, 5/4/2026, and 5/8/2026. During interviews, CNA A stated baths were recorded in the POC and sheets and said the resident received a bed bath on 4/11/2026 that was mis-marked as a shower; CNA B stated the resident received a peri-warm wipe down instead of a bath because he wanted to go to a smoke break. LVN C, LVN D, the ADON, and the DON all stated staff were trained to document baths/showers in the POC, and the DON stated the POC was the official record.
Inadequate Narcotic Sheet Labeling and Accounting for Controlled Medications
Penalty
Summary
Surveyors identified a deficiency in the facility’s pharmaceutical services related to the accounting and documentation of controlled medications for three residents. The facility failed to ensure that narcotic sheets were labeled in a way that accounted for all medications dispensed by the pharmacy, as required for accurate acquiring, receiving, dispensing, and administering of drugs and biologicals. This issue was found during review of the narcotic book on the 2200/2500 hallway medication cart and through interviews with nursing staff. For one male resident with dementia, muscle weakness, spinal stenosis, impaired mobility, gait and balance problems, and potential for uncontrolled pain, the narcotic sheet for APAP/Codeine 300-30 mg was not labeled to accurately reflect all medications dispensed. During observation, an LVN changed the narcotic sheet notation from “card 1 of 2” to “card 2 of 2” to match the numbering on the blister pack, indicating that the original documentation did not correspond to the actual medication card count. The LVN stated that the numbers on the narcotic sheet did not match what was written on the blister pack and acknowledged that this discrepancy affected the ability to accurately track narcotics and determine when to reorder. For a female resident with muscle weakness and wasting, polyneuropathy, cognitive communication deficit, hip fracture, and potential for uncontrolled pain, the narcotic sheet for Tramadol 50 mg lacked any labeling for card count, with no documentation indicating how many cards had been dispensed. Similarly, for another male resident with cognitive communication deficit, pain, muscle weakness and wasting, lack of coordination, hemiplegia/hemiparesis, ADL self-care deficit, limited physical mobility, and potential for uncontrolled pain, the narcotic sheet for APAP/Codeine 300-30 mg also had no labeling for card count. In both cases, the LVN reported that without proper labeling and documentation, staff could not accurately keep track of the narcotics or know when to reorder because the numbers were wrong or missing. The report states that this failure could affect residents who take narcotics for pain and could result in misappropriation of medications or drug diversion.
Failure to Control Razor Access and Supervise Suicidal Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident environment as free of accident hazards as possible and to provide adequate supervision to prevent accidents for one resident with depression, anxiety disorder, and mild to moderate cognitive impairment. The resident was admitted with diagnoses including mild cognitive impairment, depression, and anxiety disorder, and her admission MDS showed a BIMS score of 8/15, indicating moderate cognitive impairment. She was ambulatory and required partial/moderate assistance for personal hygiene, including shaving. Her medication regimen included Buspirone for anxiety and Sertraline for depression, and her mood assessment reflected minimal depression. The care plan dated 2/6/2026 identified that the resident wanted to end her life and included interventions such as notifying the physician, counseling by social work and staff, refocusing to positive topics, psychological consult, and emergency room evaluation and treatment, but it did not mention a history of suicidal ideation. On 2/4/2026, during the dinner period, the resident told a CNA that she wanted to kill herself and did not want to be there anymore. CNA C reported this statement to LVN B, and CNA A stayed with the resident while this was reported. Despite the resident’s suicidal statement, CNA A had previously provided the resident with two shaving razors so she could shave her legs and did not supervise her use of the razors, contrary to facility policy that residents are not supposed to have sharp objects and that staff must stay with residents who use shavers and dispose of them in sharps containers after use. Staff interviews later confirmed that residents were not to be left alone with razors and that razors were to be supervised and then discarded by staff. The facility’s suicide-threat policy required that suicide threats be taken seriously, immediately reported to the nurse supervisor or charge nurse, the physician be notified, and that a staff member remain 1:1 with the resident until the immediate danger had changed. On 2/5/2026, the resident was discovered with a razor in her hand and a superficial scratch on her left wrist after having expressed multiple times that she wanted to harm herself. Documentation indicated that she had suicidal ideation, had voiced wanting to kill herself in the dining room, and then gone to her room. The transfer form and SBAR documented suicidal ideation and a superficial scrape to the left wrist, and that she was sent out for evaluation of suicidal thoughts. The resident later stated in an interview that she had asked a CNA for a razor to shave her legs and received two shavers with no supervision, that she was upset because a male resident had broken her heart, and that she did scratch herself due to a broken heart. The administrator and ADON reported that the resident had been provided two razor blades by CNA A and that staff were supposed to stay with residents using shavers and ensure no sharp objects were left with residents. The surveyors determined that the facility failed to ensure the resident’s environment was free of hazards and that she was adequately monitored, resulting in an Immediate Jeopardy situation beginning on 2/4/2026 and ending on 2/8/2026. The noncompliance was identified as Past Noncompliance (PNC) at the Immediate Jeopardy level. The report states that this failure could result in residents experiencing suicidal ideations being at risk for harm, injuries, and death.
Removal Plan
- Revised Resident #1's comprehensive care plan to address statements and actions indicating she wanted to end her life
- Placed Resident #1 on 1:1 supervision until EMS arrived
- Notified the physician and Resident #1's responsible party/family
- Social worker met with Resident #1
- Referred Resident #1 to psychological services
- Ordered a urine test for Resident #1
- Sent Resident #1 to the emergency room for evaluation and treatment
- Suspended CNA A pending investigation and disciplined the employee
- Submitted a self-report of the incident to HHSC
- Assessed other residents in the facility for suicidal ideations
- Removed sharp objects/razors from resident rooms and bathrooms
- Conducted a facility-wide sweep to ensure no razors or sharp objects were present to ensure resident safety
- In-serviced all staff on Abuse/Neglect and Exploitation
- In-serviced all direct care staff on Razors
- In-serviced all staff on Suicidal Ideation
- Ensured staff who had not received the required education were not allowed to work until in-services were provided
- Discussed the incident involving Resident #1 with QAPI and during Adhoc meetings
Failure to Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for a cognitively impaired resident who was known to be at risk for wandering and exit-seeking. The resident was an adult male with dementia, adjustment disorder, alcohol abuse, and psychosis, with a BIMS score of 06 indicating severely impaired cognition. Prior assessments identified him as an elopement risk, with multiple Elopement Risk Assessments scoring in the elopement risk range. His prior MDS indicated daily wandering behavior, and progress notes documented repeated expressions of wanting to leave the facility to visit a former resident friend, including a statement that he wanted to walk to another city to see this friend. Staff notes also described the resident pacing in front of the exit door, focusing on the door instructions, and stating he "just want[ed] out" to see his friend. Despite these indicators, the resident’s care plan did not include comprehensive interventions addressing his ongoing elopement risk. The care plan documented that the resident wanted to go across the street to visit his friend and that he had previously left the facility without notifying staff to go to a corner store, but there was no detailed care planning related to continued elopement risk. Progress notes showed that the resident had been placed on 1:1 monitoring after a resident-to-resident altercation and was later placed on every 15-minute monitoring due to anxiety, agitation, and exit-seeking behaviors. However, during the period leading up to the elopement, staff documentation reflected that the resident continued to pace, use the elevator between floors, and focus on the exit door, indicating ongoing exit-seeking behavior. On the day of the elopement, the resident was identified as high risk for elopement and was to be monitored every 15 minutes. RN B documented that the resident was in the hallway on the second floor prior to dinner and that the CNA invited him to join other residents in the dining room while the nurse was watching the dining room and feeding residents. During this time, the resident went downstairs unobserved and exited through the front door. Staff were not aware that he had left the facility because he did not sign himself out. The resident remained out of the facility for approximately 30 minutes and was later found at a nearby convenience store and returned by a former employee. The RCN reported that the elopement occurred after a staff member failed to ensure the front door was fully closed upon entering for a scheduled shift, and that the resident should have been visually checked every 15 minutes as ordered, but RN B failed to ensure those observations were conducted. These actions and inactions resulted in the resident eloping from the facility without staff knowledge or supervision.
Failure to Care Plan for Identified Elopement Risks
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans addressing elopement risk for four residents identified as being at risk. For one male resident with dementia, adjustment disorder, alcohol abuse, and psychosis, the care plan noted that he wanted to go across the street to visit a friend and that he had previously left the facility without notifying staff to go to a corner store. The care plan included reminders about safety concerns and a psychiatric review for anxiety and agitation related to missing his friend, but there was no care planning addressing his ongoing elopement risk despite multiple Elopement Risk Assessments scoring him as an elopement risk. His record also showed a documented elopement incident, and during observation and interview he was unable to recall the incident or state the facility’s procedure for leaving, indicating he would simply walk out the front door and was unsure if he should tell staff. Another female resident with a diagnosis of psychotic disorder with delusions had an annual MDS showing severely impaired cognition and no documented wandering behavior, but her most recent Elopement Risk Assessment scored her as an elopement risk. Her care plan did not contain any interventions or planning related to elopement risk. During observation, she was seen interacting with staff in a common area but was unable to participate meaningfully in an interview due to her mental status and did not answer interview questions, instead focusing on her personal history. A male resident with herpesviral encephalitis had an admission MDS indicating intact cognition and no wandering behavior, but his Elopement Risk Assessment score also indicated elopement risk, with no corresponding elopement-related care planning in his care plan. He was observed alone in an unoccupied wing inspecting a handrail, with no staff present, and reported he had never attempted to leave the facility before ending the interview. Another male resident with dementia had an annual MDS showing severely impaired cognition and daily wandering behavior, and his most recent Elopement Risk Assessment also indicated elopement risk, yet his care plan contained no elopement-related planning. He was observed sleeping in bed and declined to participate in an interview. Facility leadership, including the RCN and ADO, reported that there had been a leadership change, that the DON was new and had not yet reviewed all care plans, and that Elopement Risk Assessments were intended to alert the IDT so that risks and interventions, including possible secured unit placement, could be determined and incorporated into care plans. The facility’s comprehensive care planning policy stated that risks identified in the MDS or otherwise should be assessed and considered for care plan development, but this was not done for the four residents’ elopement risks.
Failure to Provide Wound Care and Skin Assessments Resulting in Neglect and Amputation
Penalty
Summary
A facility failed to protect a resident's right to be free from neglect by not providing daily wound care or regular skin assessments over a period of nearly one month. The resident, who had significant medical conditions including quadriplegia, kidney disease, cirrhosis, and a history of pressure ulcers, was dependent on staff for mobility and personal hygiene. Despite being at high risk for pressure ulcers and having documented wounds, the facility did not ensure that wound care orders were entered into the electronic medical record (EMR), nor did nursing staff consistently provide or document wound care and skin assessments as required by facility policy. The resident had multiple wounds, including a Stage IV pressure ulcer on the left ankle and a surgical wound following a right below-knee amputation (BKA). Wound care physician assessments and outpatient clinic notes documented the presence and worsening of these wounds, with evidence of infection, necrosis, and exposed bone. Nursing staff interviews revealed a lack of awareness or follow-through regarding wound care orders, with some staff stating they did not provide care due to missing orders in the EMR. The Assistant Director of Nursing (ADON) acknowledged responsibility for entering wound care orders but admitted to missing this task, resulting in the absence of documented wound care for the left ankle. The resident's condition deteriorated, with observations of soiled dressings, malodor, and purulent drainage. The lack of wound care and monitoring led to the development of osteomyelitis and septic shock, necessitating hospitalization and a left BKA. Interviews with staff, the wound care physician, and the hospital case manager confirmed that wound care was not performed as ordered, and concerns raised by outside care teams were not addressed by facility staff. Facility policies required weekly skin assessments and prompt notification of physicians for changes in wound status, but these were not followed, resulting in neglect and significant harm to the resident.
Failure to Provide Ordered Wound Care and Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure that a resident with surgical wounds received necessary treatment and services consistent with professional standards of practice. Specifically, the resident did not receive weekly skin assessments during a specified month, and care to the right surgical wound was not provided as ordered by the physician. Documentation showed that the treatment administration record was not initialed as completed on multiple occasions, and there were no weekly skin or pressure ulcer assessments documented until after the resident was admitted to the hospital. The resident, who had a complex medical history including lung cancer, quadriplegia, kidney disease, hepatitis C, cirrhosis, and encephalopathy, was at high risk for pressure ulcers and had multiple unhealed pressure ulcers documented on assessment. Despite care plan interventions requiring weekly wound assessments and monitoring, staff failed to complete these assessments and did not consistently follow physician orders for wound care. Interviews with nursing staff revealed a lack of awareness regarding wound care orders and inconsistent documentation and monitoring of the resident's surgical site. The resident was ultimately admitted to the hospital with an infection of the right below-knee amputation site, presenting with low blood pressure, significant ulcers, and signs of sepsis and osteomyelitis. Hospital records confirmed the presence of infected wounds and critical illness requiring urgent intervention. Facility policy required weekly skin assessments and timely documentation, but these were not followed, as confirmed by staff interviews and record reviews.
Failure to Provide Pressure Ulcer Treatment and Assessment
Penalty
Summary
A resident with multiple complex medical conditions, including quadriplegia, kidney disease, cirrhosis, and a history of bilateral below-knee amputations, developed a Stage IV pressure ulcer on the left ankle. Despite being at high risk for pressure ulcers and having a care plan in place that required regular wound assessments and treatments, there were no wound care treatment orders for the left ankle documented in the facility's records for the entire month of September. Additionally, there were no weekly skin or pressure ulcer assessments recorded during this period until after the resident was admitted to the hospital. Multiple wound care physician assessments documented the presence and progression of the Stage IV ulcer, with specific treatment plans outlined in the physician's notes. However, these orders were not transcribed into the facility's electronic medical record (EMR) or treatment administration records, resulting in the nursing staff being unaware of the required wound care interventions. Interviews with nursing staff revealed a lack of awareness regarding the resident's wound care needs, with several nurses and CNAs stating they did not know about the wound or did not perform any wound care. The wound care nurse, who was responsible for entering physician orders into the EMR, acknowledged missing the transcription of these orders, and as a result, wound care was not provided as required. The resident's condition deteriorated, with observations of soiled dressings, malodor, and exposed bone, ultimately leading to infection, sepsis, and the need for a left below-knee amputation. The facility's own policies required prompt notification of the physician and initiation of treatment orders in the absence of existing orders, as well as weekly skin and ulcer assessments, none of which were followed. The deficiency was identified through record review, staff and resident interviews, and direct observation, confirming that the facility failed to provide necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection.
Failure to Implement and Communicate Enhanced Barrier Precautions and Proper Device Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for three residents who required enhanced barrier precautions (EBP) or had indwelling devices. One resident with a Foley catheter did not have a sign posted at the room entrance indicating the need for EBP, despite the care plan specifying this intervention. Staff interviews confirmed that the resident was on EBP and that signage was required, but the sign was not present during observation. Another resident with a Foley catheter was observed with the catheter tubing touching the floor while sitting in a wheelchair at the nurse's station. The care plan for this resident included an intervention to keep the drainage bag off the floor, but this was not followed. Staff acknowledged that catheter tubing should not touch the floor and that all nursing staff were responsible for ensuring proper catheter care to prevent infection. A third resident with a gastric tube also did not have an EBP sign posted at the room entrance, although the care plan required it. PPE supplies were present outside the room, but staff were unsure about the responsibility for posting EBP signs. Interviews with staff and the administrator confirmed the importance of EBP signage and proper catheter care, and that training had been provided, but the required practices were not consistently implemented.
Failure to Ensure Privacy for Foley Catheter Bag
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple medical conditions, including diabetes, stroke, and hydronephrosis, was observed lying in bed with a foley catheter bag attached to the side of the bed without a privacy cover. The contents of the foley bag were visible from the open bedroom door. The resident's care plan and physician orders specified that the foley bag should be in a privacy bag while in bed or in a wheelchair. Despite this, the privacy cover was not in place during the observation. Interviews with staff revealed that the nurse assigned to the resident was aware of the missing privacy cover and had attempted to locate one but was unsuccessful, subsequently notifying the interim DON. The nurse confirmed that it was the responsibility of nursing staff to ensure privacy covers were used and that she had received training on this requirement. The administrator also confirmed that all foley catheter bags should have privacy covers or be positioned to maintain privacy, and that staff had been trained accordingly. However, the facility did not have a specific policy on privacy covers for foley bags, relying instead on a general resident rights policy.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nursing staffing information in a prominent and accessible location for residents, staff, and visitors on two consecutive days. On the first day, the staffing poster displayed at the receptionist desk was outdated, showing a date from several weeks prior. On the following day, the display holder was observed to be empty during two separate observations, with no current staffing information available. Record reviews confirmed that staff schedules existed for both days, listing the numbers of licensed nurses, medical assistants, and certified nurse aides scheduled, but this information was not posted as required. During an interview, the Administrator confirmed that the Assistant Director of Nursing (ADON) was responsible for updating and posting the daily staffing information and had been directed to do so. The Administrator acknowledged the importance of posting this information for families, visitors, and regulatory compliance. It was also noted that the facility did not have a formal policy for posting staffing information but stated that regulatory guidelines were followed.
Inaccurate MDS Coding for Medications and Diagnoses
Penalty
Summary
The facility failed to ensure resident assessments accurately reflected resident status for 4 of 6 residents reviewed. For Resident #7, the quarterly MDS did not include anticonvulsant use even though the resident had active orders and was receiving Lamotrigine and Depakote. The record also showed the care plan listed Depakote and Lamotrigine under antipsychotic medications and did not include monitoring for anticonvulsant medications. Resident #7 had diagnoses including dementia, schizophrenia, diabetes mellitus, anxiety, hypertension, bipolar disorder, depression, and hyperlipidemia, and the MDS documented severe cognitive impairment with a BIMS of 6. For Resident #8, the quarterly MDS inaccurately coded insulin injections during the 7-day look-back period even though the order summary did not include insulin. The resident had diagnoses including schizoaffective disorder, diabetes mellitus, dementia, depression, anxiety, insomnia, hypertension, and cerebral infarction. The record showed the resident was receiving Trulicity as ordered, and the care plan addressed diabetes medications and monitoring for side effects and effectiveness. For Resident #10, the MDS did not include antiplatelet medication use and instead inaccurately recorded anticoagulant therapy. The resident’s MAR showed Aspirin 81 mg daily for heart health, and the record did not show an anticoagulant order; the care plan stated the resident was on anticoagulant therapy and did not include monitoring for antiplatelet therapy. For Resident #35, the quarterly MDS did not include the diagnosis of bipolar disorder even though the resident had active Risperdal orders for bipolar and was receiving the medication as prescribed. The resident’s diagnoses included dementia with behavioral disturbance, benign prostatic hyperplasia, and hypothyroidism. The care plan addressed adverse medication effect and behavior monitoring but did not specify the medication class to monitor, and bipolar disorder was not included on the diagnosis list. During interview, the MDS Coordinator stated that incorrect or missing MDS information could cause staff to miss medication side effects and not know whether behaviors were mania or altered mental status, and the DON stated the MDS should be accurate, complete, and detail-oriented.
Incomplete and inaccurate comprehensive care plans
Penalty
Summary
The facility failed to revise the comprehensive care plan after each assessment for 5 of 6 residents reviewed for care planning. The report identified inaccurate or incomplete care plans for residents with needs related to smoking status, dialysis, psychoactive medication monitoring, blood thinning medication, and psychiatric diagnoses. The facility’s policy stated that each resident’s care plan would be reviewed after Admission, Quarterly, Annual, and/or Significant Change MDS assessments and revised based on changing goals, preferences, needs, and current interventions. For one resident admitted with diagnoses including frontotemporal neurocognitive disorder, pneumonia, and schizophrenia, the record showed a smoking assessment that did not indicate whether he was a current or former smoker, while the care plan listed him as a smoker with goals related to smoking safely. Progress notes documented that he did not smoke, and staff interviews confirmed he was not a smoker. For another resident with end stage renal disease and diabetes, the MDS and physician orders showed he was receiving dialysis three times weekly, but the care plan did not include dialysis-related care areas. The DON stated dialysis should be care planned for continuity of care and to ensure staff monitored the resident and dialysis site, and the MDS Coordinator stated the care plan should have been updated to include dialysis. For two residents receiving psychotropic medications, the care plans were not accurate to the medications ordered and the monitoring needed. One resident’s care plan listed Depakote and lamotrigine under antipsychotic medications, even though both are anticonvulsants, and it did not include Zyprexa in the antipsychotic section. Another resident’s care plan listed adverse medication effect and behavior monitoring but did not specify the medication class to monitor, and it did not include bipolar disorder in the diagnosis list. For a resident whose MAR showed aspirin therapy, the care plan stated he was on anticoagulant therapy even though no anticoagulant was ordered, and it did not include monitoring for antiplatelet therapy. The DON stated the care plan needed to be accurate because it was the communication between staff regarding the resident’s care and included information necessary for the Kardex.
Missing Signatures on Controlled Medication Reconciliation Logs
Penalty
Summary
The facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 3 of 5 carts reviewed: the 2300/2400 hall nurse cart, the 2300/2400 hall medication aide cart, and the 2200/2500 hall medication aide cart. During observation and record review, controlled medications in the carts were inventoried with staff and the sample counts matched the individual controlled substance logs and the pills remaining in the blister packs, but the comprehensive controlled medication reconciliation logs used during shift change were missing signatures. On the 2200/2500 hall medication aide cart, Medication Aide B stated the card audit should be performed and the reconciliation log signed in the presence of the staff member receiving or relinquishing the cart, and that an unsigned log would leave the next person without knowing whether the count was correct. On the 2300/2400 hall medication aide cart, Medication Aide C stated the log should be signed to make sure the medication count was right and that without a signature it would not be known if the log was accurate. On the 2300/2400 hall nurse cart, LVN D stated a missing signature could mean the medication count might be wrong and that the log should be verified during shift change. The DON stated that when a cart is handed off, two people should perform the controlled medication audit together while looking at both the log and the blister packs, and the facility policy required a physical inventory of all controlled medications at each shift change documented on an audit record.
Infection Control Failures During Wound Care and Incontinent Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program when staff did not follow required precautions during resident care. Resident #3 was admitted with diagnoses including liver cell carcinoma, malnutrition, malignant neoplasm of bone and articular cartilage, and alcoholic cirrhosis of the liver. His quarterly MDS showed severely impaired cognition and multiple pressure injuries, including a stage 4 pressure injury, unstageable pressure ulcers, and deep tissue injuries. His care plan identified enhanced barrier precautions, including the use of gloves and a gown for wound care, and physician orders directed daily wound treatment for multiple wounds. During observation, the ADON began wound care for Resident #3 and cleansed a right foot wound with skin prep, then removed her gloves and stated she forgot a PPE gown and went outside the room to put one on. She later stated she needed a gown to provide wound care because the resident was on EBP and to prevent wound drainage from getting on her. The DON stated staff should be wearing a gown while providing wound care to Resident #3 because he was on EBP, and that the gown helped protect staff and resident from infection. The facility also failed to ensure hand hygiene was performed between glove changes during incontinent care for Resident #34. Resident #34 had diagnoses including type 2 diabetes, bacteremia, schizoaffective disorder, generalized anxiety disorder, epilepsy, insomnia, and disorganized schizophrenia. Her MDS showed intact cognition, frequent bladder incontinence, and total bowel incontinence, and her care plan included checking her every 2 hours and assisting with toileting as needed. During observation, two CNAs provided incontinent care, removed their gloves, put on new gloves, and did not perform hand hygiene between glove changes. They stated they did not have hand sanitizer when they started and wanted to be quick because the resident was in pain, and they acknowledged they should have performed hand hygiene to prevent infection. The DON stated staff was expected to perform hand hygiene between glove changes for infection control.
Accumulated lint in dryers
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for 3 of 4 dryers reviewed because lint was not properly disposed of and maintained in a timely manner. During observation of the laundry room, four dryers were in use and three dryers had a layer of thick lint about 0.5 inch thick accumulated on the top of the lint trap and on the bottom of the dryer. A facility log titled Dryer Cleaning showed entries completed at 11:00 a.m., 1:00 p.m., and 3:00 p.m., but the Laundry Aide stated she forgot to document when she last cleaned the lint traps and thought she had cleaned them about 4 times that day. The Laundry Aide stated the lint traps should be cleaned every 2 hours and documented after each cleaning. The Laundry Supervisor stated staff should clean the lint traps every 2 hours or after every cycle and that the lint trap is vacuumed with a shop vac. The Administrator stated staff should complete the log but was unsure how often the lint traps needed to be cleaned, and stated the log was intended to ensure accountability for cleaning the lint. A facility sign-off sheet stated dryer filters would be inspected and cleaned free of lint every two hours and that the laundry employee would confirm and sign off that this had been completed every two hours.
Failure to Obtain Signed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was informed of and participated in treatment decisions, including being informed in advance of the risks, benefits, and alternatives to proposed care, and choosing the option preferred. Resident #35 was admitted with diagnoses including dementia with behavioral disturbance, benign prostatic hyperplasia, and hypothyroidism. The resident’s MDS documented a BIMS score of 14, indicating intact cognition, and also noted the use of antipsychotic, antidepressant, and opioid medications. The resident had active orders for Risperdal 1 mg, including 0.5 tablet by mouth daily and 1 tablet by mouth at bedtime for bipolar disorder, and the July 2025 MAR showed the medication was being administered as ordered. Record review of the resident’s medication consents included a Texas Health and Human Services Form 3713 Nursing Facility Consent for Antipsychotic or Neuroleptic Medication Treatment for Risperdal, but Section II of the form did not contain a resident or resident representative signature. During interview, the DON stated that for new psychotropic medication orders, consents were expected to be complete with doctor and resident signatures and obtained within 24 to 48 hours for the medical record. The DON also stated the consent should be signed by the resident if they were their own responsible party, or by the designated representative if they were unable to sign themselves, so they would be informed of the medication’s potential side effects, understand why it had been prescribed, and decide whether to take it. The facility policy titled Unnecessary Medications stated residents have the right to be informed of and participate in their treatment and that, prior to initiating or increasing a medication, the resident, family, and/or resident representative must be informed in advance of the benefits, risks, and alternatives.
Failure to Protect Resident Record Confidentiality
Penalty
Summary
The facility failed to respect a resident's right to confidentiality in personal and medical records when a laptop used for medication cart documentation was left open in the hallway displaying Resident #25's appointment information, including the date, time, and location of a medical appointment. During observation, no staff were at the cart with the laptop, and no staff returned before it timed out and turned off on its own. The DON stated that the laptop was used by all staff and that it should not have been left open displaying patient information because it was a HIPAA violation and anyone could access patient health records. The facility policy titled Resident Rights states that the resident has a right to personal privacy and confidentiality of his or her personal and medical records.
PASRR Screening Not Accurately Completed for Resident With Mental Illness
Penalty
Summary
The facility failed to coordinate assessments with the PASRR program to the maximum extent practicable for one resident reviewed for PASRR. Resident #34 was admitted and readmitted with diagnoses including schizoaffective disorder, generalized anxiety disorder, epilepsy, insomnia, and disorganized schizophrenia. The resident’s quarterly MDS reflected intact cognition for daily decision making and documented anxiety, seizure disorder, and schizophrenia. The care plan included a need for antipsychotic medications, and the physician ordered Risperdal daily for schizophrenia. Record review showed the resident’s PASRR Level 1 Screening, completed prior to admission, indicated in section C0100 that there was no evidence of mental illness or dementia. During interview, the MDS Coordinator stated the resident did not have a qualifying mental disorder for PASRR services and believed there were no errors on the PASRR screening because it had been completed before admission. In a later interview, the MDS Coordinator stated the PASRR had been corrected to answer yes to the mental illness question so the resident could be evaluated by the local authority to determine whether the resident could qualify for services. The facility policy stated that if the PL1 is coded as suspicion of MI, ID, or DD, then a PE is required.
Capped Lancet Left on Hallway Floor
Penalty
Summary
The facility failed to keep hallway 2300 free of an accident hazard when a capped lancet was observed lying in the middle of the floor. During an observation on 8/28/2025 at 11:07 AM, the capped lancet was seen on the floor of hallway 2300, and it was still there 20 minutes later at 11:27 AM. Between those observations, Housekeeper A was seen walking up and down hallway 2300 past the capped lancet while cleaning restrooms and resupplying rooms with soap and paper towels. Housekeeper A did not pick up the lancet or notify nursing staff during the observation period. When interviewed, Housekeeper A stated she did not know what the capped lancet was, that it should be cleaned up, and that if she found something on the floor that she did not know how to dispose of, she should ask the nurse. The DON stated her expectation was that staff keep a clean house and pick up trash or anything that could injure a resident, and ask a nurse for guidance if they did not know how to dispose of an item. The facility policy titled Fall Policy stated that preventing falls includes removing clutter from floors and hallways.
Improper Perineal Wiping During Incontinent Care
Penalty
Summary
The facility failed to ensure appropriate incontinent care was provided to a resident who was frequently incontinent of bladder and always incontinent of bowel. Resident #34 had diagnoses including type 2 diabetes, bacteremia, schizoaffective disorder, generalized anxiety disorder, epilepsy, insomnia, and disorganized schizophrenia. Her quarterly MDS assessment reflected intact cognition for daily decision making. Her care plan included bowel incontinence interventions to check her every 2 hours and assist with toileting as needed. During an observation, CNA F provided incontinent care and, after cleansing the resident's urethral area, wiped between the gluteal folds toward the urethral and vaginal area. During interview, CNA F stated she should wipe from front to back or away from the front area to prevent bacteria from the rectal area from reaching the urethral or vaginal area, and stated the resident was at risk of a UTI. The DON stated staff needed to wipe from front to back during incontinent care to prevent infection. The facility policy for Perineal Care stated to wipe from the clean urethral area to the dirty rectal area, using a clean area of the washcloth or wipe for each stroke.
Incomplete Dialysis Communication and Documentation
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was deficient for one resident who received dialysis. The resident had diagnoses including end stage renal disease and type 2 diabetes mellitus, and the quarterly MDS reflected severely impaired cognition for daily decision making and that he received dialysis while a resident. His care plan addressed malnutrition risk and monitoring meal intake and weights, but it did not include any care areas for dialysis. The physician’s order directed dialysis every Monday, Wednesday, and Friday beginning 8/1/25 with no end date. Record review of the dialysis communication forms showed inconsistent and incomplete documentation. One form was complete, while multiple later forms were missing either the dialysis center assessment, the facility post assessment portion, or were not present in the resident’s dialysis binder at all. During interview, the resident stated he went to dialysis a few days a week and that staff assessed his port and he had no concerns or issues. The DON stated the dialysis communication forms should be completed in entirety for continuity of care, to ensure the resident was stable pre and post dialysis, and to monitor the resident’s port site. The facility policy stated the site should be assessed for bleeding, bruising, lack of pulsations, and aneurysm, and that the resident’s departures and returns from the dialysis center, vital signs, general appearance, orientation, and other baseline data should be documented.
Unlabeled Pills Found in Medication Carts
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with accepted professional principles in 2 of 5 medication carts reviewed. During an observation of the 2200/2500 hall medication aide cart, two dosing cups containing pills were found sitting in the top drawer of the cart. During an observation of the 2300/2400 hall medication aide cart, two loose pills were found lying in the bottom of the second drawer of the cart. During interviews, Medication Aide B stated that pills left in dosing cups in the medication cart could be mistaken for another resident's pills and given to the wrong resident, and that unlabeled medications should be brought to the nurse and disposed of. Medication Aide C stated that loose pills in the cart could not be identified and she did not know what could happen if a resident received one. The DON stated the expectation was that medication carts be kept locked, clean, and organized with no spills or loose medications, and that pills should be labeled appropriately and match chart orders. Facility policies reviewed stated medications are labeled according to facility, state, and federal requirements, contents are not transferred from one container to another, medications are stored in their original containers, and medications are not pre-poured.
Incomplete Documentation of Bipolar Diagnosis
Penalty
Summary
Medical records were not kept in accordance with accepted professional standards for one resident reviewed for accuracy of records. Resident #35, a [AGE]-year-old male admitted on 7/01/2025, had documented diagnoses including dementia with behavioral disturbance, benign prostatic hyperplasia, and hypothyroidism. Record review showed the resident’s MDS dated [DATE] included a BIMS score of 14 and documented antipsychotic, antidepressant, and opioid use, but did not include bipolar disorder as a diagnosis. The resident’s active diagnosis list also did not include bipolar disorder. Further review showed the resident’s order summary contained active Risperdal orders for bipolar, and the care plan documented behaviors but did not list bipolar disorder in the diagnosis section. The hospital discharge summary documented bipolar disorder, and a psychiatric progress note dated 7/5/2025 listed bipolar/behavioral symptoms and continued Risperidone, Olanzapine, Paroxetine, and Trazodone. During interview, the DON stated the expectation was for notes to be reviewed and all diagnoses added to the medical record, and that hospital discharge paperwork should be reviewed for new diagnoses and care plan updates. The Regional Compliance Nurse stated there was no specific facility policy for clinical records.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Update Care Plan for Resident's Noncompliance and Aggressive Behaviors
Penalty
Summary
The facility failed to ensure that a comprehensive person-centered care plan was developed and implemented for a resident, which resulted in unmet needs related to smoking policy noncompliance and aggressive behaviors. The resident, a male with a history of Bipolar Disorder, Chronic Viral Hepatitis C, Depression, and Anxiety, was admitted to the facility and had a BIMS score indicating no cognitive impairment. Despite being aware of the facility's smoking policy, the resident repeatedly violated it by smoking in non-designated areas and during non-smoking times, which was not addressed in the care plan with effective interventions. Additionally, the resident exhibited verbally disruptive and aggressive behaviors towards staff and others, which were not adequately addressed in the care plan. The resident's aggressive actions included throwing objects at staff, making verbally abusive threats, and attempting to physically harm staff members. These behaviors were documented in progress notes, but the care plan did not reflect interventions to manage or mitigate these behaviors. Interviews with facility staff, including the DON, Social Worker, and MDS Nurse, revealed that the care plan should have been updated to reflect the resident's noncompliance with the smoking policy and aggressive behaviors. The facility's policy required care plans to be updated with changes in resident condition or behavior, but this was not done, leading to a deficiency in providing appropriate care and interventions for the resident.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident, leading to multiple medication administration errors. On two separate occasions, Licensed Vocational Nurses (LVN) did not administer Hydrocortisone gel to the resident's face within the scheduled administration time. Additionally, a Medication Aide (MA) documented that medications were administered to the resident when they had not been, and prepared medications were stored in unlabeled cups in the medication cart. The resident involved was an elderly male with a history of cerebral infarction, hemiplegia, hypertension, and depression. His care plan included specific interventions for hypertension and potential uncontrolled pain, requiring precise medication administration. However, the resident reported not receiving his morning medications, including a face cream, and expressed frustration over the issue. The MA responsible for administering the medications admitted to signing off on the Medication Administration Record (MAR) before actually administering the medications, which is against the training received. Further investigation revealed that the MA was administering Lidocaine patches instead of the prescribed Lidocaine gel, and had prefilled medications stored in the cart, which could lead to errors. Interviews with the Director of Nursing (DON) and the resident's physician highlighted the importance of accurate documentation and adherence to medication administration protocols. The facility's policies and training records indicated that staff were trained on the correct procedures, but these were not followed, resulting in the deficiencies observed.
Failure to Schedule Specialist Appointments for Resident
Penalty
Summary
The facility failed to ensure that a resident received timely treatment and care in accordance with professional standards of practice. Specifically, the facility did not schedule an ENT appointment for the resident as ordered by the physician in April 2024, nor did it schedule a vascular appointment ordered in October 2024. These failures were identified during a review of the resident's records and interviews with staff and the resident. The resident, a male with a history of cerebral infarction, hemiplegia, and depression, was admitted to the facility and required referrals to an ENT for dysphagia and a vascular specialist for an abdominal aortic aneurysm. Despite multiple attempts by the facility's staff to schedule these appointments, issues such as insurance coverage, staff turnover, and communication breakdowns led to significant delays. The resident expressed frustration over the lack of follow-through, noting that his communication and swallowing had improved with speech therapy but believed further improvement could have been achieved with specialist intervention. Interviews with various staff members, including the ADON, LVNs, and the Admissions Director, revealed a lack of clarity and responsibility regarding the scheduling of appointments. The ADON and other staff members were unaware of the status of the referrals, and there was confusion about who was responsible for scheduling. The resident's physician and NP expressed concern and frustration over the delays, emphasizing the importance of timely specialist evaluations for the resident's health conditions.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically during medication administration. This deficiency was observed when a medication aide, identified as MA B, did not perform hand hygiene after administering medications to one resident and before administering medications to another. This lapse in protocol was noted during a medication administration observation, where MA B handled medication cups and a blood pressure cuff without washing hands in between interactions with two residents. The first resident, a male with severe cognitive impairment and an asymptomatic HIV infection, received his medications without incident. However, MA B did not perform hand hygiene before proceeding to check the blood pressure and administer medications to the second resident, who also had severe cognitive impairment and was diagnosed with viral hepatitis C. Interviews with MA B and the Director of Nursing (DON) confirmed that staff had been trained on the importance of hand hygiene to prevent cross-contamination and infection. Despite this training, MA B acknowledged the failure to adhere to hand hygiene protocols during the observed medication administration. The facility's policy on infection control emphasizes hand hygiene as the primary means of preventing infection transmission, and MA B had previously been evaluated as satisfactory in infection control practices. However, the observed failure to perform hand hygiene between residents posed a risk of cross-contamination and infection spread.
Failure to Maintain Resident's Bed and Linen
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for a resident, as observed in one of the resident rooms. The deficiencies included a broken footboard on the resident's bed and the absence of bed linen, which were not addressed for over 24 hours. The resident, an 81-year-old male with severe cognitive impairment due to dementia, was found sleeping without linen and with a broken footboard. Despite being alert and oriented to person and place, the resident did not report the issues to the staff, expressing sadness over the situation. The facility's records showed no maintenance order for the broken footboard, indicating a failure in communication between nursing staff and maintenance. Additionally, the housekeeping supervisor confirmed that there was sufficient linen available, yet the resident's bed remained without linen for over a day. The Director of Nursing acknowledged the dignity issue related to the lack of bed sheets, and the maintenance director confirmed the absence of a work order for the bed repair. The facility's policy on resident rights emphasizes the right to be treated with respect and dignity, which was not upheld in this instance.
Inaccurate Documentation of Resident's Bathing Schedule
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, as evidenced by discrepancies between the Nurse Kardex and the CNAs' electronic record system (POC) regarding the resident's bathing schedule. The resident, a 47-year-old male with a history of nontraumatic intracranial hemorrhage, anxiety, cognitive deficits, and dysphasia, was documented in the Kardex as not receiving showers on specific dates in October 2024, while the POC indicated that showers were given on all scheduled days. This inconsistency in documentation could lead to an inaccurate overall view of the resident's care and services. Interviews with the resident, the resident's representative, and facility staff revealed that the resident did not receive a shower on one of the scheduled days, which was confirmed by both the resident and the representative. The Director of Nursing (DON) acknowledged the lack of a structured system for documenting shower days and PRN showers, which may have contributed to the discrepancies. The DON and staff members, including an LVN and a CNA, were unable to explain the differences between the Kardex and the POC, highlighting a failure in proper documentation practices within the facility.
Incomplete Medication Documentation for Two Residents
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices, specifically in documenting medication administration for two residents. For one resident, the Medication Administration Record (MAR) for August 2024 showed missing documentation for prescribed medications, including Gabapentin and HYDROcodone-Acetaminophen. The resident reported that nursing staff refused to administer Gabapentin due to a perceived high dosage, and there were multiple instances where pain medication was not documented as administered, nor were pain assessments recorded. Another resident's MAR also exhibited missing documentation for several medications, including Lasix, Lisinopril, Meloxicam, and others, on various dates in August 2024. Interviews with the resident and nursing staff revealed that medications were not consistently documented, and there was a lack of explanation for the missing entries. Nursing staff acknowledged the importance of documenting medication administration and the implications of missing entries, which could suggest that medications were not given. Interviews with the Director of Nursing (DON) and other nursing staff highlighted a systemic issue with documentation practices. The DON admitted that routine audits on MAR documentation were not consistently performed, leading to gaps in the records. The facility's policy required immediate charting of administered medications and documentation of any withheld or refused doses, but this was not adhered to, resulting in incomplete and inaccurate medical records for the residents involved.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several maintenance and cleanliness issues observed during a survey. In one room, there were loose tiles around the toilet, a rusted bolt securing the toilet, and an excessive accumulation of dust and debris on top of the mirror and paper towel dispenser. Additionally, the vent across from the bathroom had a large accumulation of dust. A resident in this room expressed distress over the dirt and dust, which was corroborated by the Corporate RN and the Maintenance Director, who acknowledged the need for tile replacement and additional cleaning. Further observations revealed additional deficiencies, including a non-functioning light in the Secured Unit shower room, a broken toilet seat hinge in another room, and broken window blinds, water marks on ceiling panels, and a separated ceiling exhaust fan in yet another room. In one bathroom, two out of three lights were not functioning, and the toilet was not properly secured, allowing it to move. These issues were acknowledged by the Maintenance Director and the Administrator, who recognized the need for repairs to improve resident safety and quality of life.
Medication Administration Delays and Expired Insulin Pen Found
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident, as evidenced by the late administration of medications to 10 out of 24 residents reviewed. The medications were administered by MA B and RN H, who were responsible for ensuring timely medication administration. The delays ranged from 53 minutes to nearly three hours, affecting medications critical for managing conditions such as anxiety, hypertension, diabetes, and chronic pain. These delays were not reported to supervisors, indicating a lapse in communication and protocol adherence. Resident #3, for example, received her medications, including baclofen, torsemide, buspirone, and gabapentin, significantly later than prescribed. Similarly, Resident #4's clonazepam was administered late, which is crucial for managing her anxiety disorder. Resident #19's insulin was administered late, after her breakfast, due to a lack of communication between the DON and RN H, who took over the nursing duties late and without a proper handover. Additionally, the facility stored an expired insulin injection pen for Resident #24, which was discovered during an observation. The insulin pen was used beyond its recommended 28-day period, posing a risk of ineffective diabetes management. The facility's policies on medication storage and administration were not adhered to, as evidenced by the expired insulin and the late administration of scheduled medications, which should have been administered within one hour of the scheduled time.
Cold Meals Served to Residents
Penalty
Summary
The facility failed to provide meals that were palatable, attractive, and at a safe and appetizing temperature for several residents. Observations revealed that meals were served cold to seven residents, including those with diagnoses such as muscle wasting and protein-calorie malnutrition. The meals were delivered on open, uncovered racks, and there were significant delays in serving the meals to the residents, resulting in cold and unpalatable food. Specific instances included Resident #25 receiving a breakfast meal 1 hour and 2 minutes after delivery, and Resident #13 receiving a meal 58 minutes after delivery, both of which were cold and unpalatable. Other residents, such as Resident #61 and Resident #37, also reported receiving cold meals. The delays in meal service were attributed to the process of checking meal accuracy and the limited number of CNAs available to serve the meals. Interviews with residents and staff highlighted ongoing issues with meal service, with residents expressing dissatisfaction with the temperature and appeal of their meals. The facility's admission packet promised enjoyable meals, yet observations and resident feedback indicated a failure to meet this standard. The facility administrator acknowledged the issue and expressed an intention to improve meal service quality and timeliness.
Deficiencies in Food Storage and Dish Sanitization
Penalty
Summary
The facility was found to have deficiencies in food storage and sanitation practices in the kitchen. During an observation, an opened bag of corn flakes cereal was discovered in the dry storage room, stored in a zip-locked bag that was not sealed. This improper storage method could lead to spoilage and contamination from pests. The Dietary Manager (DM) acknowledged that the bag should have been sealed and stated that it was the responsibility of all dietary staff to properly seal, label, and date food items. All staff were reportedly up to date on food handler certification. Additionally, the facility failed to maintain the appropriate concentration of chlorine sanitizer in the dish machine. Observations revealed that the dish machine, which uses a chemical sanitizer, did not have any chlorine present during the sanitizing cycle, as indicated by a test strip that did not change color. The DM later adjusted the sanitizer container and manually pumped sanitizer into the machine, achieving the correct chlorine level. The DM suggested that an air bubble in the line might have caused the issue. A review of the facility's policy and the Food Code indicated that the dish machine should be tested for proper temperature and sanitizer concentration before use, but no discrepancies were noted in the temperature/sanitizer log for the month.
Failure to Accommodate Resident Needs with Call Light Accessibility
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident, specifically Resident #24, who was left in her bed with the call light button underneath her left back. Resident #24 was semi-paralyzed on her left side and unable to reach the call light button, which was essential for her to request assistance. This oversight was observed during a survey on 07/09/2024, when Resident #24 expressed that she did not know where her call light was and could not use her left side to reach it. The call light was found underneath her left side back, and she stated she could not turn to access it. Further investigation revealed that the care plan for Resident #24, who had a history of falls, dementia, and generalized muscle weakness, required that her call light be within reach. A CNA observed the situation and repositioned the call light so that Resident #24 could hold it with her right hand. Additionally, the Maintenance Director was unaware of any issues with the call light system, and the regional DON confirmed that the facility lacked a specific policy for the nurse call light system, relying instead on CMS and state agency guidelines.
Unattended and Unlocked Medication Room
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and that only authorized personnel had access to the keys. This deficiency was observed in the medication room on the second floor, which was left unattended and unlocked. The room, located at the beginning of the resident's hallway, contained multiple residents' medications and had a key latch door handle that was unlocked. During interviews, LVN A, the nurse on duty for the second floor, stated she was busy serving residents' breakfasts and was unaware that the medication room was unattended and unlocked. Similarly, MA B, who was administering medications to residents, was also unaware of the situation. The Administrator and RN C acknowledged that having an unattended and unlocked medication room posed a safety concern for residents. A review of the facility's policy on medication storage, dated 2003, indicated that medications and biologicals should be stored safely, securely, and properly.
Improper Garbage Disposal Practices
Penalty
Summary
The facility failed to properly dispose of garbage and refuse for one of its two dumpsters, specifically Dumpster #2. Observations revealed that the door of Dumpster #2 was not completely shut, it lacked a drainage plug, and there were ants present, indicating a pest issue. During interviews, the Dietary Manager (DM) acknowledged that the door was open, which created an unsanitary condition and could lead to rodent proliferation. The Maintenance Director confirmed the absence of a drain plug and the presence of ants. Additionally, the facility did not have a policy in place for maintaining the dumpsters and the surrounding area. A review of the Food Code by the U.S. Public Health Service and the FDA highlighted the requirement for receptacles to have tight-fitting lids or doors and drain plugs in place.
Call Light System Malfunction
Penalty
Summary
The facility failed to ensure that a working call system was available in each resident's bathroom and bathing area, specifically affecting one resident. On a specific date, a resident utilized his call light, which did not illuminate the nurse call light directly outside and above his room door. This malfunction could place residents at risk for harm by not receiving care and attention when their nurse call light system malfunctions or is out of reach. The resident, who was admitted with diagnoses including left-sided hemiparesis and general anxiety disorder, was assessed as medically complex and needed support for his conditions. His care plan emphasized the importance of having a working and reachable call light. During an observation and interview, it was noted that the call light panel at the nurses' station sounded an alarm and illuminated the light designated for the resident's room, but the light outside the room was not functioning. The resident expressed that he needed assistance, and no one was coming to his aid. A CNA confirmed the malfunction and stated she would report it to the maintenance director, who later acknowledged being unaware of the issue. The regional DON confirmed that the facility's call light system should be available and functioning for all residents, although there was no specific policy for the system in place.
Environmental Deficiency in Soiled Utility Room
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During an observation on the 2300 resident hallway, a ceiling fan in the Soiled Utility Room was found to have dust and dirt particles in the vent slats. This deficiency was identified during a survey conducted with the Maintenance Director, who acknowledged the issue. The facility's policy on Preventative Maintenance/Work-Order Request, dated 2003, states that the facility will repair or replace damaged or broken equipment or building amenities as needed.
Transcription Error in Morphine Order for Cognitively Impaired Resident
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically in the transcription of a Morphine order. The resident, who was cognitively impaired with a BIMS score of 3, had a history of chronic systolic heart failure, COPD, anxiety, depression, dementia, and chronic pain. The resident's MAR indicated a Morphine order of 20 mg in 1 ml liquid, but the actual medication bottle prescribed contained a concentration of 20 mg in 5 ml liquid. This discrepancy was not reflected in the electronic health record (EHR), leading to a transcription error. Interviews with facility staff, including an RN and the DON, confirmed awareness of the transcription error, although they stated the resident received the correct dosage. The hospice patient care manager and the hospice MD also acknowledged the transcription error, noting that the pharmacy sent a higher concentration than ordered. Despite the error in documentation, the primary care physician confirmed that the resident received appropriate doses of Morphine for pain management. The facility's policy on medication administration emphasizes adherence to the five rights of medication, which was not followed in this instance.
Violation of Resident Rights During Unauthorized Room Cleaning
Penalty
Summary
The facility failed to honor a resident's right to be present and to consent when Administrator A entered the resident's room and disposed of personal items without the resident's permission. This incident involved a cognitively intact female resident with a history of end-stage renal disease, anxiety, and major depressive disorder. The resident was not present during the room cleaning, which occurred while she was at a dialysis appointment. Upon returning, the resident discovered that some of her personal belongings, valued at approximately $300, had been thrown away, leading to emotional distress and feelings of worthlessness. The facility's internal investigation revealed that Administrator A, along with housekeeping staff, entered the resident's room to dispose of trash and expired food items. However, the resident had not given permission for this action, nor was she informed of the specific date when the cleaning would occur. Witnesses, including LVNs and a hospitality aide, confirmed that the resident was visibly upset and crying at the nurse's station after discovering the missing items. The facility's Corporate RN acknowledged that the administrator's actions could be considered a violation of resident rights, as the resident was not present and had not consented to the removal of her belongings. Interviews with various staff members, including the ADON, DON, and the current administrator, confirmed that entering a resident's room without permission and disposing of personal items is a violation of resident rights. Despite attempts to recover or replace the missing items, the resident remained upset and expressed a lack of trust in the staff. The former administrator admitted to entering the room without the resident's presence, citing safety and infection control concerns, but failed to respect the resident's rights to personal possessions and to be free from interference.
Failure to Respect Resident's Personal Possessions
Penalty
Summary
The facility failed to respect the dignity and personal possessions of a resident, specifically concerning the resident's electronic monitoring device. On a specific date, a hospitality aide was observed turning off the resident's camera without permission. This action was captured on video, showing the aide adjusting the resident's position in bed and then moving towards the camera to turn it off. This incident was part of a broader concern raised by a family member who alleged that staff would turn off the resident's monitoring device and neglect the resident. The resident involved was an elderly male with a history of hemiplegia, dementia, and paranoid personality disorder. He was moderately impaired according to his BIMS score and had a care plan addressing sexual acting out behaviors and non-compliance with medications. Despite these challenges, the resident was his own responsible party. The facility's records indicated that the resident had been sexually inappropriate with staff, but there was no documentation of the camera being turned off in the nurse's notes. Interviews with various staff members, including LVNs and hospitality aides, revealed a lack of awareness or acknowledgment of the camera being turned off. The Director of Nursing mentioned that the resident's roommate had been unplugging the camera, leading to the decision to room the resident alone. The facility's Resident Rights policy emphasized the right to retain and use personal possessions, which was not upheld in this instance.
Misappropriation of Resident's Belongings by Former Administrator
Penalty
Summary
The facility failed to protect a resident's personal belongings from being misappropriated by a former administrator. The incident involved a cognitively intact resident who was undergoing dialysis treatment. During the resident's absence, the former administrator entered the resident's room without permission and removed personal items, including clothing and figurines, which the resident valued at $300. The resident returned to find her belongings missing, leading to emotional distress and feelings of worthlessness. The facility's internal investigation revealed that the former administrator, along with housekeeping staff, entered the resident's room to dispose of trash and expired food items. However, the resident was not informed of the specific date of the cleaning, nor was she present during the process. Witnesses, including nursing staff and aides, confirmed that the resident was visibly upset and cried for an extended period after discovering her belongings had been discarded. The facility's policy on resident rights was violated, as staff are required to obtain permission before entering a resident's room and removing items. Interviews with staff and the resident highlighted the emotional impact of the incident, although no long-term psychosocial harm was observed. The facility attempted to rectify the situation by purchasing replacement items for the resident. Despite these efforts, the incident underscored a breach of resident rights and the need for adherence to policies regarding the handling of personal property.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 934 citations issued within 25 miles in the last 12 months — including the 17 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.
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 San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pecan Valley Rehabilitation And Healthcare | 0.1 mi | ★★★★★ | 9 | 0 |
| Southeast Nursing & Rehabilitation Center | 0.5 mi | ★★★★★ | 16 | 1 |
| Highland Nursing Center | 1.1 mi | ★★★★★ | 20 | 0 |
| The Rio At Mission Trails | 2.4 mi | ★★★★★ | 19 | 0 |
| Normandy Terrace Nursing & Rehabilitation Center | 2.5 mi | ★★★★★ | 18 | 1 |
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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.