Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Coronado At Stone Oak during CMS and state inspections, most recent first.
Surveyors found that staff failed to consistently document ADL-bathing care and refusals in the EMR for four residents, despite established bathing schedules and a facility policy requiring complete, accurate, and timely charting. Several scheduled bath days had no corresponding entries, even though residents and families reported that showers were being provided with or without staff assistance. CNAs and RNs stated they were responsible for documenting showers and refusals in the POC/EMR, while leadership acknowledged that documentation was often missed due to workflow issues and other disruptions.
A resident with CAD, heart failure, renal insufficiency, and pneumonia had a care plan and physician order for daily weights with instructions to notify the MD if weight increased by 3 lbs overnight or 5 lbs in a week. EMR review showed the resident’s weight increased by 4 lbs overnight, meeting the notification threshold. However, there was no documentation in progress notes that the MD was notified, and contemporaneous nutrition and nursing notes did not address the weight change. The DON confirmed that staff did not notify the MD despite the resident’s CHF and the facility’s change of condition policy requiring evaluation, MD/responsible party notification, and documentation for significant status changes.
Nursing staff failed to obtain informed consent and conduct required assessments for the use of quarter side rails for three residents with cognitive impairment and mobility needs. In each case, documentation was incomplete or missing, and staff interviews confirmed that neither valid consent nor proper assessment was in place prior to side rail use, contrary to facility policy.
A resident with multiple medical conditions and a need for nightly Bipap therapy was not accurately assessed on the admission MDS, despite clear evidence from observations, nursing notes, and interviews that the device was used. Facility staff, including the DON and MDS nurse, were unaware of the omission, and the resident's care plan and physician's orders did not consistently reflect the Bipap use.
A resident's need for nightly Bipap respiratory support and diagnosis of shortness of breath were not included in the comprehensive care plan or MDS assessment, despite clear evidence of use and staff awareness. The omission was confirmed through observations, record reviews, and staff interviews, with the DON and MDS nurse acknowledging the oversight and its potential to result in missed care.
A resident with a Stage 3 pressure ulcer and multiple comorbidities was receiving wound care per physician orders, but an LVN incorrectly documented that the resident had no wounds during a nursing assessment. The LVN later acknowledged the documentation error, and the DON confirmed the importance of accurate record-keeping for proper care.
A resident with severe cognitive impairment and multiple medical conditions was found using a petroleum-based lip balm while receiving oxygen therapy. Staff interviews revealed a lack of awareness regarding the flammability of the product and its incompatibility with oxygen use, despite facility policy and safety guidelines prohibiting such substances near oxygen equipment.
A resident with multiple medical conditions used a Bipap machine nightly without a physician's order since admission. Staff and the DON confirmed the absence of the required order, and facility policy mandates written physician authorization for such treatments. The deficiency was identified through record review, observations, and staff interviews.
Two residents with significant medical histories were not seen by their primary care physicians within the required 60-day interval, as documented in their records. Instead, both were last seen by a FNP, and the DON confirmed the lack of physician visits, contrary to facility policy and regulatory requirements.
Surveyors observed that expired medications were not removed from two medication carts and a medication room, including several over-the-counter drugs and an open box of Preparation H. The DON acknowledged that expired medications should not be present for administration, and facility policy prohibits the use of outdated drugs.
Two residents' prescribed Flonase nasal sprays were left unsecured in their rooms, either on bedside tables or in dresser drawers, rather than being stored in the medication cart as required. Nursing staff assumed the residents could self-medicate without verifying physician orders, and the DON confirmed that no such orders existed. Facility policy requiring secure storage of all medications was not followed.
A resident with a Stage III sacral wound and dressing was not placed on Enhanced Barrier Precautions (EBP) as required by facility policy, despite having orders for wound care and staff training on EBP. Observation found no EBP signage or PPE bin at the room, and staff interviews revealed a lack of awareness regarding the need for EBP for open wounds with dressings.
A facility failed to update physician's orders for wound care for two residents, resulting in inaccurate medical records. One resident's stage 2 sacrum wound and another's DTI heel wound had healed, yet treatments were still signed off as completed. The wound treatment nurse had left, and new nurses required more training. The facility lacked policies for updating and discontinuing orders.
A resident in a LTC facility did not have her oxycodone-acetaminophen administration consistently documented in the eMAR, as required by facility policy. Despite the resident's ability to communicate her needs, nursing staff failed to record the administration and effectiveness of the medication, citing busyness and oversight. This lack of documentation prevented proper assessment of the medication's effectiveness on the resident's pain.
The facility failed to maintain cleanliness in the Willow Unit's nutrition room, with observations revealing a dirty refrigerator, freezer, and ice machine. The Dietary Manager and Administrator confirmed the lack of clarity on cleaning responsibilities, leading to potential risks for foodborne illnesses and contamination.
A resident alleged abuse by a CNA during pericare, but the ADM failed to report the allegation to authorities within the required 2-hour timeframe, violating the facility's abuse prevention protocol.
A facility failed to report an allegation of abuse involving a resident and a CNA within the required 2-hour window. The ADM delayed reporting the incident to the authorities, violating the facility's policy and regulatory requirements. The resident, admitted for orthopedic aftercare, alleged abuse during pericare, causing pain and distress.
The facility failed to develop a comprehensive care plan for a resident with autoimmune disease-induced skin conditions. Despite the resident's wounds being observed and documented, they were not included in the care plan, and new orders from the wound care doctor were not incorporated. Interviews revealed a lack of proper assessment and updating of the care plan, and the facility's care plan policy was not provided upon request.
A facility failed to ensure proper use of a mechanical lift during a resident transfer, leading to potential safety hazards. The CNA did not apply the brakes or widen the legs of the lift and maneuvered it by pulling on the sling due to limited space. The resident had multiple diagnoses and was dependent on staff for all ADLs. The CNA admitted to not receiving training on the lift, and the ADON confirmed the correct procedures were not followed.
The facility failed to ensure the bed's dimensions were appropriate for a resident's size and weight, leading to a significant gap between the mattress and the side rails. This posed a safety hazard for a resident who was moderately cognitively impaired and dependent on staff for all ADLs. Staff were unaware of the safety requirements for bed rails and mattress dimensions.
Incomplete EMR Documentation of ADL-Bathing Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for residents’ ADL-bathing in accordance with its own charting and documentation policy. For four residents reviewed, the electronic medical record (EMR) 30‑day task records for ADL-bathing did not contain entries indicating that a bath was provided or refused on certain scheduled bath days, despite established bathing preferences. The facility’s policy requires that each resident’s medical record contain an accurate representation of the resident’s experiences, with complete, accurate, and timely documentation of services provided, including care such as bathing, to be recorded at the time of service or no later than the end of the shift. One resident, a female admitted on 1/15/2026, had a documented bathing preference of Monday, Wednesday, and Friday evenings, but her 30‑day ADL-bathing task record lacked any bath or refusal entry for a scheduled Monday. During interview, she stated she was able to take showers on her scheduled days, did so independently, and had not missed any showers. Another female resident admitted on 12/31/2026, with the same Monday, Wednesday, and Friday evening bathing preference, had no bath or refusal entries for two scheduled days. She reported she was able to take showers on her scheduled days with assistance from one staff member. A third resident, a [AGE]‑year‑old female admitted on 1/21/2026 with a Monday, Wednesday, and Friday daytime bathing preference, had no bath or refusal entry for a scheduled Monday. During interview, he initially stated he had not received a shower, but his family member corrected him, stating he had received one, and he then agreed, adding he was unsure if he had missed a shower. A fourth [AGE]‑year‑old female resident admitted on 12/10/2026, with a Tuesday, Thursday, and Saturday evening bathing preference, had multiple dates with no bath or refusal entries in the EMR. She stated she was able to take showers on her scheduled days with staff assistance and commented that she paid for three times a week and did not take bed baths, though she could. CNAs and RNs interviewed confirmed they were responsible for documenting showers and refusals in the EMR/POC, and the DON and Administrator acknowledged that missing documentation occurred, citing reasons such as login issues, crisis situations, and staff moving from task to task and losing track, despite the written policy requiring complete, accurate, and timely documentation.
Failure to Notify Physician of Significant Weight Gain in Resident With Heart Failure
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and facility policy for change in condition notification related to a resident with heart failure. The resident, an older female with diagnoses including coronary artery disease, heart failure, renal insufficiency, and pneumonia, had a care plan that included monitoring for changes in condition and weighing as ordered for altered cardiovascular status. A physician order directed staff to obtain a daily weight before breakfast and to notify the physician if the resident gained 3 lbs overnight or 5 lbs or more in one week. Electronic medical record review showed the resident’s weight increased from 92.6 lbs on 1/19/2026 to 96.6 lbs on 1/20/2026, a 4 lb overnight gain that met the threshold for required physician notification. Progress notes from 12/29/2025 to 1/29/2026 did not contain any documentation that the physician was notified of this significant weight gain. A nutrition note dated 1/20/2026 referenced a current weight of 92.6 lbs from the prior day, and a skilled nursing note on 1/20/2026 documented vital signs within normal limits with no concerns noted, without addressing the weight change. During interview, the DON acknowledged that staff did not notify the physician of the 4 lb weight gain and stated that the congestive heart failure was the reason for the 3 lb weight gain notification parameter. The facility’s Change of Condition Policy required licensed nurses to evaluate significant changes in status and notify the physician and responsible party, and to document the notification and any new orders, which was not done in this case.
Failure to Obtain Consent and Assess for Bed Rail Use
Penalty
Summary
The facility failed to ensure the correct use of bed rails and to assess residents for the risk of entrapment from bed rails for three residents observed with side rails. For one resident with non-traumatic brain dysfunction and moderate cognitive impairment, documentation for informed consent regarding the use of quarter side rails was not signed by the patient or their representative. The resident's care plan indicated the use of side rails as enablers for bed mobility, but interviews revealed the resident was unable to use the rails independently and required total assistance. The unit manager acknowledged that the required assessment and valid consent were not completed, and that reassessments had not been performed as required every three months. Another resident with unspecified dementia and moderate cognitive impairment also had quarter side rails in use, with the care plan specifying their use as enablers. However, the informed consent document for this resident was not signed by the family representative, rendering the consent invalid. The unit manager confirmed that the necessary consent was not obtained prior to the use of side rails for this resident. A third resident, with dementia and a history of femur fracture, was observed with quarter side rails in use on both sides of the bed. The resident required assistance with bed mobility and reported holding onto the side rails when repositioning. Review of the electronic health record revealed that neither a consent nor an assessment for the use of side rails was present. The unit manager confirmed that both the assessment and informed consent were missing for this resident. Facility policy requires assessment for risk of entrapment and informed consent prior to the use of side rails, but these steps were not completed for the three residents identified.
Failure to Accurately Document Bipap Use on Admission Assessment
Penalty
Summary
The facility failed to provide an accurate assessment that reflected a resident's use of a Bipap machine on her admission Minimum Data Set (MDS). Despite multiple sources of information indicating the resident used a Bipap machine nightly—including the resident's own statements, nursing notes, skilled assessments, and direct observations of the machine at her bedside—the admission MDS did not document this respiratory support therapy. The resident had a history of significant medical conditions, including a displaced bicondylar fracture of the right tibia, diabetes, morbid obesity, and shortness of breath, and was admitted from a short-term general hospital. She was cognitively intact and required moderate assistance with activities of daily living. Interviews with facility staff, including the Director of Nursing (DON), charge nurse, and MDS nurse, revealed a lack of awareness that the resident's Bipap use was not reflected on the admission MDS. The DON and MDS nurse acknowledged that not having this information accurately documented could result in missed care. The facility's records, including the resident's care plan and physician's orders, also did not consistently reflect the use of the Bipap machine, despite its presence and use being confirmed through observations and interviews.
Failure to Update Care Plan for Resident's Bipap Use and Respiratory Needs
Penalty
Summary
The facility failed to ensure that a comprehensive, person-centered care plan was reviewed and revised by the interdisciplinary team after each assessment for a resident who required a Bipap machine at night. Despite multiple observations and interviews confirming the resident's nightly use of the Bipap machine, this need was not reflected in the resident's comprehensive care plan or the Minimum Data Set (MDS) assessment. The resident's diagnosis of shortness of breath was also omitted from the care plan, and there was no physician's order for the Bipap documented in the medical record. Nursing assessments and notes indicated the use of respiratory support, but this information was not incorporated into the care planning process. Staff interviews revealed a lack of awareness among the interdisciplinary team regarding the resident's use of the Bipap machine, with the MDS nurse and admitting nurse both stating they were unaware of this need at the time of care plan development. The Director of Nursing acknowledged that the omission of the Bipap from the care plan could result in missed care. Facility policy requires individualized care plans with measurable objectives and timetables to address all resident needs, but this was not followed in this case.
Failure to Accurately Document Pressure Ulcer in Resident Assessment
Penalty
Summary
A resident with multiple medical conditions, including fractures, chronic kidney disease, diabetes mellitus, and edema, was admitted to the facility and identified as having a Stage 3 pressure ulcer on the sacrum upon admission. The resident's care plan included interventions for pressure ulcer management, and physician orders were in place for wound care treatments to be administered on specific days. Documentation in the Treatment Administration Record confirmed that the resident received the ordered wound treatments as scheduled. However, on one occasion, an LVN completed a nursing assessment and incorrectly documented that the resident had no wounds present, despite being aware of the existing pressure ulcer. This error in documentation was acknowledged by the LVN during an interview, who stated it was a mistake and recognized the importance of accurate record-keeping for continuity of care. The DON also confirmed that accurate documentation is a professional standard necessary for proper care delivery. The facility's policy requires that all treatments be administered based on written physician orders and that documentation be accurate.
Flammable Lip Balm Found Near Resident Receiving Oxygen Therapy
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis following cerebral infarction, acute respiratory failure with hypoxia, diabetes mellitus, neuromuscular dysfunction of the bladder, and allergic rhinitis was observed receiving oxygen therapy at 2L/min via nasal cannula. During observation, a tube of Carmex lip balm containing 45.3% white petrolatum was found on the resident's bedside table. The resident reported using the lip balm for moisture. Facility records indicated that the resident was severely cognitively impaired and required extensive assistance with activities of daily living. Interviews with the DON and an LVN revealed that staff were unaware of the flammable nature of the lip balm and its incompatibility with oxygen therapy. The DON acknowledged that the resident should not have had the Carmex while on oxygen and that oxygen can react with oily substances, potentially causing burns. Facility policy and NFPA guidelines both specify that oil-based products should be kept away from oxygen in use, but these precautions were not followed, resulting in the presence of a flammable substance near the resident's oxygen supply.
Failure to Obtain Physician Order for Bipap Use
Penalty
Summary
The facility failed to ensure that a resident who required respiratory care, specifically the use of a Bipap machine at night, received such care in accordance with professional standards and the resident's care plan. The resident, who was admitted with multiple diagnoses including a displaced bicondylar fracture of the right tibia, diabetes, morbid obesity, and shortness of breath, had been using a Bipap machine nightly since admission. Despite this, there was no physician's order for the Bipap documented in the resident's electronic medical record, order summary, or care plan. Multiple observations confirmed the presence and use of the Bipap machine in the resident's room, and interviews with the resident and nursing staff confirmed nightly use of the device. Interviews with the DON and nursing staff revealed that a physician's order is required for treatments such as Bipap, and the absence of such an order was not identified at the time of admission or during subsequent care. The admitting nurse was unaware that the resident had a Bipap machine at the time of admission and did not obtain an order. The facility's policy requires a written physician's order for all treatments, but this was not followed in this case, resulting in the resident using the Bipap without proper medical authorization or documentation.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that residents were seen by their primary care physicians at least once every 60 days, as required by federal and state regulations. For two residents, one with epilepsy and a history of traumatic brain injury and another with cancer and a history of CVA, record reviews showed that neither had documentation of a primary care physician visit in the past six months. Instead, both residents were last seen by a Family Nurse Practitioner, with no evidence of a physician visit during the required timeframe. Interviews with the Director of Nursing confirmed the absence of documentation for physician visits for both residents, and the DON acknowledged that the primary care physician is ultimately responsible for the residents' healthcare and is obligated to see them at least every 60 days. The facility's policy also requires the attending physician to visit residents in accordance with applicable regulations, which was not met in these cases.
Expired Medications Not Removed from Medication Carts and Room
Penalty
Summary
The facility failed to provide pharmaceutical services that meet the needs of each resident by not removing expired medications from two medication carts and one medication room. During observations, surveyors found that medication cart #1 contained five expired over-the-counter medications, including Geridryl 25mg, Meclizine 12.5mg, Glucosamine Relief 500mg, Heart Burn Relief (Famotidine 20mg), and Aspirin 325mg. Medication cart #2 contained one expired over-the-counter medication, Sodium Bicarbonate. Additionally, the medication room on the [NAME] Unit had an open box of Preparation H with an expiration date that had passed. The DON confirmed in an interview that expired medications may not be effective, could interact negatively with other medications, and could cause illness if administered. Facility policy states that discontinued, outdated, or deteriorated drugs or biologicals should not be used and must be returned to the pharmacy or destroyed. These findings were based on direct observation, interviews, and record reviews.
Failure to Secure Medications in Locked Storage
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and only accessible to authorized personnel, as required by professional standards and facility policy. During observations, it was found that two residents' prescribed Flonase nasal sprays were left unsecured, either on bedside tables or in dresser drawers within their rooms, rather than being stored in the medication cart. Both residents did not have physician orders permitting self-administration or keeping medications at the bedside. One resident, who was cognitively intact but required moderate assistance with activities of daily living (ADLs), had her Flonase left on her bedside table and later stored in her dresser drawer by nursing staff. The resident reported that the nurse would leave the medication at her bedside and sometimes place it in the drawer. The Director of Nursing (DON) confirmed that the medication should have been locked in the medication cart, as there was no order for self-medication or bedside storage. Nursing staff admitted to assuming the resident could self-medicate without verifying orders and acknowledged being trained not to leave medications unsecured. A second resident, who was severely cognitively impaired and required extensive assistance with ADLs, also had her prescribed Flonase left on her bedside table and later stored in her dresser drawer. Similar to the first case, the DON confirmed that the medication should have been secured in the medication cart. Nursing staff again reported assuming the resident could self-medicate without checking for proper orders and placed the medication in the dresser drawer to keep it out of sight. Facility policy required all drugs and biologicals to be stored safely and securely, which was not followed in these instances.
Failure to Implement Enhanced Barrier Precautions for Resident with Open Wound
Penalty
Summary
The facility failed to implement and maintain an infection prevention and control program by not placing a resident with an open sacral wound and dressing on Enhanced Barrier Precautions (EBP) as required. The resident, who was admitted with multiple diagnoses including fractures, chronic kidney disease, diabetes, and edema, had a Stage III pressure sore to the sacrum documented on admission. Medical records showed that wound care orders were in place and treatments were administered as scheduled. However, during observation, there was no EBP signage on the resident's door, nor was there a bin with personal protective equipment (PPE) present, despite facility policy and training indicating these measures were necessary for residents with open wounds requiring dressings. Interviews with the treatment nurse revealed a lack of awareness that EBP was required for open wounds with dressings, and the DON was not aware that the resident was not on EBP. The facility's own policy and previous staff in-service training specified that EBP, including signage and PPE, should be implemented for wound care involving any skin opening requiring a dressing. Despite these protocols, the required precautions were not followed for this resident, as confirmed by both observation and staff interviews.
Incomplete and Inaccurate Medical Records for Wound Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to deficiencies in care. For one resident, the physician's orders for wound treatment to a stage 2 wound on the sacrum were not updated to reflect that the wound had healed. Despite the resident and a CNA confirming that no treatment was needed, the treatment administration record showed that treatments were signed off as completed by an LVN from March 17th to the 19th. The LVN admitted that the physician's order should have been discontinued and was unaware of when the wound had healed. Similarly, another resident's physician's orders for wound treatment to a DTI area on the left heel were not updated after the wound had healed. The treatment administration record indicated that treatments were signed off by an LVN, even though the resident no longer required them. The LVN acknowledged that the wound was healed and that the orders should have been discontinued. The wound treatment nurse, who was responsible for updating these orders, had left the facility, and the staff were adjusting to taking over his duties. Interviews with the ADON and DON revealed that the new nurses required additional training in signing off on doctor's orders. The DON confirmed that the wound treatment nurse was responsible for discontinuing orders once wounds healed, but this had not been done. The facility lacked specific policies for following and discontinuing doctor's orders, contributing to the oversight in updating the residents' medical records.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, specifically in the accurate documentation of medication administration. The resident, who was admitted with diagnoses including major depressive disorder, orthopedic aftercare, and a stage 2 pressure ulcer, was prescribed oxycodone-acetaminophen for pain management. Despite the resident's intact cognition and ability to communicate her needs, the facility's nursing staff did not consistently document the administration of this medication in the electronic Medication Administration Record (eMAR). This lack of documentation occurred on multiple occasions, as confirmed by the Director of Nursing (DON) and the resident's Controlled Drug Receipt/Record/Disposition Form. Interviews with the DON and nursing staff revealed that the failure to document was due to oversight and busyness, with some staff admitting to not filling out the eMAR appropriately. The facility's policy requires that the administration of each PRN medication, including the time, reason, and effectiveness, be documented. However, this was not consistently done, preventing the assessment of the medication's effectiveness on the resident's pain. The resident reported that the medication helped reduce her pain, and she did not request it daily, indicating that the medication was effective when administered. The deficiency in documentation could potentially put residents at risk for unmanaged pain and anxiety.
Failure to Maintain Cleanliness in Nutrition Room
Penalty
Summary
The facility failed to store, distribute, and serve food in accordance with professional standards for food service safety in the Willow Unit's nutrition room. Observations revealed that the refrigerator had a red sticky substance from spilled liquids on the shelves, door, and bottom shelf where nutritional supplements were stored. The freezer had food particles, stains from spilled liquids, and a strand of hair on the floor of the freezer compartment where packages of food were stored. Additionally, the ice machine had a large amount of white hard water stains from the vent and a black residue on the inside above the ice outlet. These conditions were confirmed by the Dietary Manager, who was unsure whether the dietary staff or nurses were responsible for cleaning these areas. During an interview, the Administrator stated that it was the dietary staff's duty to keep the refrigerator and freezers clean, while maintenance was responsible for cleaning the ice machine due to its technical components. The Administrator also mentioned that the ice machine had issues, possibly related to a seal problem. The facility's policies for food storage and ice machine maintenance were reviewed, revealing that all refrigerator units should be kept clean and in good working condition, and ice machines should be maintained to ensure a safe and sanitary supply of ice. However, these policies were not adhered to, leading to potential risks for foodborne illnesses and contamination for the residents receiving snacks from the nutrition room.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement written policies and procedures that prohibit and prevent abuse of residents, as evidenced by the case of a resident who alleged abuse by a CNA. The resident, admitted for orthopedic aftercare following a surgical amputation, reported to an LVN that the CNA was abusive during pericare. The LVN reported the allegation to the ADON and the ADM, who then suspended the CNA pending investigation. However, the ADM did not report the allegation to the appropriate authorities within the required 2-hour timeframe, instead reporting it several hours later. This delay in reporting is a violation of the facility's abuse prevention protocol, which mandates immediate reporting within 2 hours. Interviews with the involved staff revealed that the resident was alert and oriented and able to make her needs known. The resident specifically complained about being frightened and mishandled during pericare. Despite the ADM's claim that the allegation was not confirmed until after interviewing the resident, the facility's policy requires immediate reporting of any suspected abuse. The failure to adhere to this policy could potentially affect any resident and contribute to further instances of abuse.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, within 2 hours after the allegation was made, as required by their policy. Specifically, an allegation of abuse involving a resident and a CNA was reported by an LVN at 12 PM but was not reported to the appropriate authorities until 6 PM, which is beyond the 2-hour window mandated by the facility's Abuse Prohibition Protocol. The ADM, who is the Abuse Coordinator, did not report the incident to HHSC until 4 PM, despite being informed of the allegation earlier in the day. This delay in reporting is a violation of the facility's policy and regulatory requirements. The resident involved had been admitted to the facility for orthopedic aftercare following a surgical amputation. The resident alleged that the CNA was abusive during pericare, causing pain and distress. The LVN who overheard the allegation reported it to the ADON and the ADM immediately, but the ADM did not take timely action to report the incident to the authorities. The CNA was suspended pending investigation but returned to work the following day. Interviews with the staff confirmed the timeline of events and the delay in reporting the abuse allegation.
Failure to Develop Comprehensive Care Plan for Resident with Skin Conditions
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for Resident #67, who had multiple skin conditions induced by an autoimmune disease. Despite the resident's quarterly MDS assessment and care plan indicating a risk for pressure ulcer development, there was no documentation of her other skin conditions. The resident had wounds on her left forearm and both legs, which were not included in her care plan. The MDS Coordinators acknowledged that these conditions should have been included but were not, due to a lack of proper assessment and updating of the care plan. The resident's skin conditions were observed during an interview, and it was noted that she had significant blisters, scabs, and oozing wounds, which were not adequately documented or addressed in her care plan. Interviews with the DON and MDS Coordinators revealed that the resident's skin conditions had been present intermittently and were not properly managed due to the resident's refusal to shower and the failure to update the care plan with new orders from the wound care doctor. The MDS Coordinators admitted that they had not read the wound doctor's assessment or included the new orders in the care plan. Additionally, the facility's care plan policy was not provided upon request, indicating a lack of adherence to proper procedures for updating and maintaining comprehensive care plans for residents with complex medical needs.
Improper Use of Mechanical Lift During Resident Transfer
Penalty
Summary
The facility failed to ensure proper use of a mechanical lift during a transfer for a resident, leading to potential safety hazards. During an observation, CNA I did not apply the brakes or widen the legs of the mechanical lift while transferring a resident from the bed to a wheelchair. The CNA also maneuvered the lift by pulling on the sling due to limited space, which could have caused the lift to tilt and the resident to fall. The resident involved had multiple diagnoses, including seizure disorder, schizophrenia, and congenital myopathies, and was dependent on staff for all activities of daily living (ADLs), including transfers. The resident's care plan specified the use of a mechanical lift for transfers, but the CNA did not follow the proper procedures. The CNA admitted to not receiving training on the mechanical lift at the facility and was unsure about the correct operation, including the importance of widening the legs and locking the wheels for stability. The Assistant Director of Nursing (ADON) confirmed that the legs should be widened and the wheels locked to prevent the lift from tilting, especially for a resident of the involved resident's size. The ADON also noted that the resident's mother had insisted on the room's furniture arrangement, which limited the space for maneuvering the lift. Despite this, the ADON acknowledged that the CNA's actions were a safety hazard. The facility's guidelines for mechanical lift safety clearly stated that the wheels should be locked during transfers, but this protocol was not followed, leading to the identified deficiency.
Inappropriate Bed Dimensions and Safety Risks
Penalty
Summary
The facility failed to ensure the bed's dimensions were appropriate for a resident's size and weight, leading to a significant gap between the mattress and the side rails. This deficiency was observed in a resident who was moderately cognitively impaired, had functional limitations in both upper and lower extremities, and was dependent on staff for all activities of daily living. The resident's weight was noted as 254 pounds, and he was 69 inches tall. The care plan indicated the use of quarter rails as enablers to promote independence, but the mattress did not fit the bed frame properly, resulting in a gap of 7 to 10 inches between the mattress and the side rails, which posed a safety hazard. Cushions were wedged between the mattress and the side rails, but this did not mitigate the risk of injury effectively. Staff interviews revealed a lack of awareness regarding the safety requirements for bed rails and mattress dimensions. The Assistant Director of Nursing (ADON) and the Maintenance Supervisor (MS) were not familiar with the acceptable dimensions between a mattress and side rail that were considered safe. The ADON eventually replaced the mattress with a larger one that fit better, but this was after the surveyor had noted the deficiency. The facility's Administrator admitted to not knowing the specific safety dimensions and had to consult the corporate office for guidance. The deficiency was identified through observations, interviews, and record reviews, highlighting a significant lapse in ensuring resident safety related to bed rail use and mattress compatibility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stone Oak Care Center | 0.8 mi | ★★★★★ | 9 | 0 |
| Sonterra Health Center | 1.3 mi | ★★★★★ | 0 | 0 |
| The Enclave | 1.6 mi | ★★★★★ | 20 | 0 |
| Estates At Shavano Park | 5.6 mi | ★★★★★ | 20 | 0 |
| San Antonio Wellness & Rehabilitation | 6.4 mi | ★★★★★ | 4 | 0 |
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