Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Corpus Christi Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple comorbidities, and a mechanically altered diet had missing documentation of meal intake percentages in the EHR on several days, despite a care plan requiring monitoring and documentation of meal intake and tolerance. CNAs reported they assisted the resident with meals on those days but failed to record the meal percentages, citing heavy workload on the unit. The dietician noted the resident’s BMI was within normal limits and reported no current nutritional concerns, while the DON confirmed that facility policy requires accurate, complete documentation of all care, including meal assistance.
A resident with multiple medical conditions, including cognitive and physical impairments, was observed in bed calling out for assistance because the call light was placed out of reach. Staff interviews confirmed unawareness of the call light's inaccessibility, despite the resident's care plan and facility policy requiring the call system to be accessible at all times.
The facility did not consistently perform or document daily glucometer accuracy checks for multiple nurse carts, as required by internal expectations, with staff interviews confirming lapses in both testing and recordkeeping. The DON acknowledged the expectation for daily testing but could not provide a written policy, and the manufacturer's guidelines only required weekly checks.
A resident with multiple chronic conditions experienced a change in code status from full code to DNR and was admitted to hospice, but the care plan was not updated to reflect this change. The care plan continued to list interventions appropriate for a full code, such as initiating CPR, despite new physician orders and documentation indicating DNR status. Staff interviews confirmed the oversight and acknowledged the potential for confusion among nursing staff.
A wound care nurse failed to follow proper wound cleansing technique for a resident with a venous stasis ulcer, repeatedly using the same blood-soaked gauze to clean both the center and outside of the wound. This practice, confirmed by interviews with the nurse, ADON, and DON, did not align with professional standards, which require cleansing from clean to dirty areas and discarding contaminated gauze after use.
A resident with an indwelling urinary catheter was observed with the catheter drainage bag and tubing resting on the floor, contrary to facility protocols and infection control practices. Staff confirmed that the drainage bag should be kept off the floor and below the bladder, but this was not followed, despite the resident's medical history of urinary tract infection and related conditions. The facility lacked a specific catheter care policy and relied on a general incontinent care checklist.
The facility did not ensure that a witness signature was obtained during the destruction of controlled medications, such as Hydrocodone-APAP, Tramadol, and Acetaminophen-Codeine, for multiple residents. An ADON destroyed these medications without a second licensed nurse present to witness and sign the narcotic sheet, contrary to facility policy. Staff interviews confirmed that the standard procedure was not followed, and record reviews showed repeated instances of missing witness signatures during medication disposal.
A resident with moderate cognitive impairment and her representative were not provided documented opportunities to participate in care plan meetings during her stay. Staff interviews confirmed that required quarterly meetings and documentation did not occur, despite facility policy mandating such records.
A long-term care facility failed to properly place PPE carts for residents on Enhanced Barrier Precautions, leading to potential cross-contamination risks. Observations showed PPE carts were either missing or incorrectly placed inside rooms, contrary to guidelines. Staff interviews revealed confusion over PPE protocols, with guidance from the corporate office contributing to the issue. The deficiency was identified through record reviews, observations, and staff interviews, highlighting a systemic issue in infection control practices.
A resident with dementia was pinched by her cognitively intact roommate after touching the roommate's personal items, resulting in bruising. The facility failed to prevent the altercation despite having policies in place to protect residents from abuse. Staff were aware of the residents' behaviors but did not anticipate or prevent the incident.
The facility failed to ensure that nursing staff demonstrated the necessary competencies in managing narcotics, as LVN-D and LVN-E did not count narcotics correctly or maintain control of the narcotic keys. This oversight, observed through record reviews and staff interviews, revealed inconsistencies in narcotic counts and key management, posing potential risks to residents and staff. The facility's Medication Administration Policy was not adhered to, leading to confusion and potential drug diversion.
The facility failed to secure medication carts, as observed with two unlocked carts in the 100 and 400 halls, posing a risk of unauthorized access to medications. Staff interviews revealed that the carts were likely left unlocked by the night shift, despite in-service training on the importance of locking them. The facility's policy mandates that medication carts be locked when not in use, but this was not adhered to, leading to the deficiency.
Two medication carts on the 100 hall were left unlocked and unattended by a CMA due to a staff shortage, posing a risk to residents. The CMA was responsible for two carts because an on-call LVN did not cover the absent staff member's duties. The facility's policy requires carts to be locked or within the staff's line of sight, which was not adhered to in this instance.
The facility failed to develop and implement comprehensive care plans for four residents, omitting their smoking status and necessary Smoking Safety Screens. Interviews and record reviews revealed that staff were unaware of the requirement for smoking assessments, leading to non-compliance with the facility's smoking policy.
The facility failed to maintain logs for glucometer control solution testing, affecting the care of 28 insulin-dependent residents. The absence of these logs could lead to inaccurate blood glucose readings, as confirmed by staff interviews and observations.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, leading to numerous unlabeled, undated, and improperly stored food items in both the kitchen and nutrition room. Staff interviews revealed a lack of adherence to food safety protocols and facility policies.
The facility failed to maintain an infection prevention and control program, leading to improper handling of residents' cups and bowls during meal service. Staff, including the ADON, HR personnel, and a CNA, were observed touching the rims of cups and bowls with bare hands, indicating a lack of training on proper meal service procedures and infection control practices.
The facility failed to treat two residents with respect and dignity by not maintaining a clean and odor-free environment. One resident's room had a strong odor of urine, and his floor mat and mattress were saturated with urine. Despite multiple reports from staff, the issue persisted for months, leading to a diminished quality of life for the residents involved.
The facility failed to ensure a safe, clean, and comfortable environment for two residents, leading to significant issues with cleanliness and odor. One resident's room had a strong odor of urine, and his floor mat and mattress were saturated with urine. Despite multiple reports and observations, the facility's staff did not adequately address the issue, leading to prolonged discomfort for the residents.
The facility failed to ensure proper disposal of garbage and refuse for three dumpsters, which were observed to be overflowing and left open, with one leaking an unknown liquid. Both the Maintenance Supervisor and the Administrator acknowledged the importance of keeping the dumpsters closed to prevent infection risks, as per the facility's policy.
The facility failed to follow their smoking policy for a resident with dementia, schizophrenia, and heart failure, who was observed smoking without a required smoking apron. The resident's care plan indicated the need for one-on-one supervision and a smoking apron, but staff oversight led to non-compliance.
Failure to Document Meal Intake Percentages in Clinical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident in accordance with its medical record documentation policy and accepted professional standards. Record review showed that the resident, who had Alzheimer’s disease, dementia, muscle wasting and atrophy, lack of coordination, and required assistance with personal care and ADLs, had no documented meal intake percentages in the electronic health record on 02/28/2026, 03/17/2026, and 03/23/2026. The resident’s Significant Change MDS reflected a BIMS score of 1, indicating severe cognitive impairment, and the resident was on a mechanically altered diet. The care plan included monitoring and documenting meal intake and tolerance, and recording meal intake percentages, but the meal percentage logs for the identified dates were blank. During interviews, three CNAs each stated they had assisted the resident with meals on the dates in question but admitted they forgot to document the meal percentages due to the heavy workload and demanding needs on the hallway. All three CNAs acknowledged the importance of documenting meal percentages and confirmed that they had received recent education on documentation. The dietician reported that the resident’s BMI was 27.9 and within normal limits for age and weight range, and stated there were no concerns about the resident’s nutritional status, weight, or muscle wasting at that time. The DON confirmed that it was the facility’s expectation that all clinical staff document care provided, including meal assistance, in the electronic health record and acknowledged that the lack of documentation for this resident’s meal percentages occurred on the identified dates.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs and preferences by not ensuring that a resident's call light was within reach. Observation revealed that the resident, who had multiple diagnoses including COPD, memory deficit, cerebral infarction, dysphagia, cognitive communication deficit, altered mental status, and vascular dementia, was in bed calling out into the hallway because the call light was placed on the bedside table out of her reach. The resident attempted to use the bed remote instead of the call light, as she could not find the call light within her reach. The resident's care plan specifically indicated that she was at high risk for falls and required the call light to be within reach to request assistance as needed, as well as prompt responses to all requests for help. Interviews with staff revealed that the LVN was unaware the resident could not reach the call light and was unsure how long the resident had been without it. The CNA who assisted the resident to bed stated that the call light was placed next to the resident earlier and was not aware of anyone moving it. The facility's policy required the call system to be accessible to residents while in bed or other sleeping accommodations. The deficiency was identified through observation, interview, and record review, confirming that the call light was not within the resident's reach as required by her care plan and facility policy.
Failure to Maintain Complete Glucometer Accuracy Testing Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for glucometer accuracy testing and documentation, as required by accepted professional standards. Specifically, the glucometer logbooks for the 100, 200, 300, and 400 hall nurse carts were missing recorded test results on several dates. Interviews with staff revealed that it was the night shift nurses' responsibility to test the glucometers and record the results daily, but on multiple occasions, this was not done. One nurse admitted to testing the glucometers but forgetting to record the results, while another nurse stated she forgot to test the glucometers during her shift. The Director of Nursing (DON) confirmed that daily testing and documentation were expected, although there was no written facility policy specifying this frequency, and the manufacturer's guidelines only required weekly testing. Record review and staff interviews confirmed that the required daily accuracy checks and documentation for glucometers were not consistently performed or recorded. The absence of these records could impact the safe administration of insulin to residents, as accurate glucometer readings are necessary for proper dosing. The DON was unable to provide a facility policy outlining the required frequency for glucometer testing when requested by the surveyor.
Failure to Update Care Plan After Change in Code Status
Penalty
Summary
The facility failed to update and implement a comprehensive care plan for a resident following a significant change in condition, specifically when the resident's code status changed from full code to Do Not Resuscitate (DNR). Despite physician orders and documentation indicating the change to DNR and the resident's admission to hospice, the care plan continued to reflect the previous full code status. The care plan still included interventions such as initiating CPR and calling 911, which were no longer appropriate for the resident's current wishes and medical orders. Interviews with facility staff revealed that the MDS nurse was responsible for updating care plans after changes in condition, but the update was missed. The Director of Nursing acknowledged that the care plan should have been revised to reflect the new code status and that the oversight could have led to confusion among staff regarding appropriate actions in an emergency. The facility's policy required care plans to be updated to reflect resident-specific interventions and needs, but this was not followed in this instance.
Improper Wound Cleansing Technique Leading to Cross-Contamination Risk
Penalty
Summary
The facility failed to ensure that wound care was provided in accordance with professional standards of practice and the resident's person-centered care plan for one resident with a venous stasis ulcer. During an observed wound care procedure, the wound care nurse cleansed the resident's wound using a folded gauze soaked in wound cleanser, scrubbing the center of the wound in an up and down motion, then moving to the outside, and then returning to the center, repeating this process for approximately 1-2 minutes. The nurse continued to use the same blood-soaked gauze to clean both the outside and center of the wound multiple times, rather than discarding it after it became contaminated. Interviews with the wound care nurse, ADON, and DON confirmed that the proper technique should have involved cleansing from the inner part of the wound to the outer area (clean to dirty), discarding the dirty gauze after use, and not reusing contaminated gauze. The nurse acknowledged that her actions could have caused cross-contamination and introduced bacteria into the wound. The resident involved had multiple diagnoses, including peripheral vascular disease, hemiplegia, hemiparesis, type 2 diabetes with skin ulcer, and chronic venous hypertension with ulcer, and was cognitively intact at the time of the incident.
Failure to Maintain Proper Catheter Care and Prevent UTI
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter did not receive appropriate care to prevent urinary tract infections. During observation, the resident's catheter drainage bag and tubing were found resting on the floor, despite facility protocols requiring that these items be kept off the floor and below the level of the bladder. Staff interviews confirmed awareness that the catheter bag and tubing should not touch the ground to prevent infection, and that the drainage bag should be hung on the bed frame below the bladder. The facility's own Incontinent Care skills checklist also specifies that the drainage bag must be kept off the floor at all times. The resident involved was an 82-year-old female with a history of urinary tract infection, acute pyelonephritis, and hydronephrosis. She required substantial to total assistance with bed mobility, toileting, and personal hygiene, and had an indwelling urinary catheter as documented in her care plan. Despite these needs and the established protocols, the failure to maintain proper catheter care was observed and acknowledged by both nursing staff and facility administration. The facility did not have a specific Catheter Care/Maintenance policy and relied on the Incontinent Care skills checklist.
Failure to Obtain Witness Signature During Controlled Medication Destruction
Penalty
Summary
The facility failed to ensure the proper disposal of controlled medications by not obtaining a witness signature on the narcotic sheet during the destruction of medications for nine residents. Specifically, the Assistant Director of Nursing (ADON) was found to have destroyed tablets of Hydrocodone-APAP, Tramadol, and Acetaminophen-Codeine without a witness present, as required by facility policy. Record reviews showed that for each instance, the narcotic sheets lacked the required witness signature, despite the destruction of the medication being documented. Interviews with staff, including other ADONs and Licensed Vocational Nurses (LVNs), confirmed that the standard practice was to always have a witness present when destroying controlled substances. The Director of Nursing (DON) acknowledged that instructions were given to audit and destroy medications with damaged blister packs, but it was discovered that the ADON destroyed these medications without a witness. The facility's policy clearly states that two licensed nurses must be present and sign the controlled substances record when a controlled medication is destroyed. The residents involved had active or discontinued orders for controlled pain medications, and the destruction events occurred over several months. The lack of a witness signature on the narcotic sheets was consistently observed across multiple residents and medications, indicating a pattern of non-compliance with established procedures for controlled substance disposal.
Failure to Document Resident and Representative Participation in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that a resident and her representative were given the opportunity to participate in the development and implementation of her person-centered care plan. Record review showed no documentation of any care plan meetings involving the resident or her representative during her stay, despite the care plan being initiated and interventions updated throughout her admission. The resident had moderate cognitive impairment due to unspecified dementia, and her representative reported only one care plan meeting occurred during a seven-month stay, with no evidence of quarterly meetings as required. Interviews with facility staff, including the DON, LMSW, and CMS Nurse, confirmed that care plan meetings should have been held and documented quarterly, after changes in condition, or as needed. However, none of the staff could locate documentation of these meetings for the resident, and only recalled participating in a single meeting. Facility policy required that care plan meeting discussions be documented in the nursing progress notes, but this was not done for the resident in question.
Improper Placement of PPE Carts in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper placement and availability of Personal Protective Equipment (PPE) carts for residents requiring Enhanced Barrier Precautions (EBP). Observations revealed that PPE carts were either missing or incorrectly placed inside the rooms of residents on contact isolation, contrary to guidelines that require PPE to be available immediately outside the resident's room. This deficiency was noted for four residents who were on EBP due to various conditions such as urinary tract infections, wounds, indwelling devices, and feeding tubes. Interviews with staff, including CNAs, LVNs, the Infection Control Preventionist (ICP), and the Director of Nursing (DON), highlighted a lack of clarity and consistency in the implementation of PPE protocols. Staff members were under the impression, based on guidance from the facility's corporate office, that PPE could be stored centrally rather than outside each resident's room. This misunderstanding led to PPE carts being placed inside rooms, which could result in contamination and cross-contamination when supplies were removed from the room. The facility's failure to adhere to CDC guidelines and its own policies regarding the placement of PPE carts was further compounded by inadequate staff training and supervision. Despite being in-serviced on the correct procedures, staff continued to improperly place PPE carts, increasing the risk of cross-contamination and infection spread within the facility. The deficiency was identified through a combination of record reviews, observations, and staff interviews, which collectively demonstrated a systemic issue in the facility's infection control practices.
Resident-to-Resident Altercation Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure that a resident was free from abuse, resulting in a resident-to-resident altercation. A resident with Alzheimer's disease and unspecified dementia, who was severely cognitively impaired, was pinched by her roommate, another resident, after she put her fingers into the roommate's cup of ice. The incident led to bruising on the resident's left arm. The roommate, who was cognitively intact and had a history of bipolar disorder, anxiety, and depression, admitted to pinching the resident because she was upset about her personal items being touched. The facility's records indicate that the incident was reported by a CNA who was informed by the roommate about the pinching. The roommate expressed that she was not thinking clearly when she pinched the resident and did not believe she had pinched her hard. The facility's investigation revealed that the roommate was possessive of her belongings and had previously been verbally aggressive, although no prior physical aggression was noted. The facility's staff, including the ADON and social worker, were involved in assessing the situation and monitoring the resident's injuries. The facility's policies on abuse, neglect, and exploitation were reviewed, highlighting the requirement for staff training and the development of care plans to prevent such incidents. Despite these policies, the facility's failure to prevent the altercation and protect the resident from harm was evident. The incident was documented in the facility's logs, and staff interviews indicated that while they were aware of the residents' behaviors, they did not anticipate or prevent the physical altercation.
Narcotic Management Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure that licensed nursing staff demonstrated the necessary competencies and skill sets to manage narcotics properly. Specifically, LVN-D and LVN-E were not competent in counting narcotics correctly and maintaining control of the narcotic keys. On a particular day, LVN-D did not count her narcotics with LVN-E before leaving her shift, and LVN-E failed to secure the narcotic key on her person, leaving it in a cabinet at the nurse's station. This oversight had the potential to lead to medication errors or drug diversion, posing risks to residents, visitors, and staff. The report includes multiple observations and interviews that highlight the deficiencies in narcotic management. Record reviews showed that staff had been in-serviced on job duties, including the necessity of conducting narcotic counts at every shift change. However, controlled count sheets for February and March revealed inconsistencies, such as multiple narcotics being counted on a single sheet and adjustments being made to the counts. Interviews with various staff members, including LVN-D, LVN-E, ADON-A, ADON-B, and the DON, confirmed that the proper procedures for narcotic counts and key management were not followed, leading to confusion and potential risks. The facility's Medication Administration Policy mandates that only licensed nurses or certified medical aides may carry keys to the medication cart, and controlled substance keys must always be in the possession of the designated nurse. Despite this policy, the report indicates that the keys were left unattended, and the narcotic counts were not conducted with the required accuracy and accountability. This failure to adhere to established protocols could result in narcotics being stolen or misused, endangering the safety of residents and staff.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that drugs and biologicals were secured and stored according to accepted professional principles, as observed with two medication carts. The 400 hall and 100 hall medication carts were found unlocked and unattended, with residents passing by, posing a risk of unauthorized access to medications. The 100 hall med-cart was noted to be unlocked at the nurse's station without any staff present, and the 400 hall med-cart was similarly found unlocked in the hallway. Interviews with staff revealed that the carts were likely left unlocked by the night shift, and there was an acknowledgment that unlocked carts could lead to unauthorized access to medications. Staff interviews indicated that the med-carts should always be locked when not in use, and there was a history of in-service training on this policy. Despite this, the carts were found unlocked, and staff members, including the DON and ADON, recognized the potential harm that could result from such lapses. The facility's Medication Administration Policy clearly stated that medication carts must be locked at all times when not in use, yet this protocol was not followed, leading to the observed deficiencies.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments, as observed with two medication carts on the 100 hall. These carts were left unlocked and unattended by a Certified Medication Aide (CMA), identified as CMA B, for a duration of four minutes. This lapse occurred while CMA B was attending to a resident in a room, taking their blood pressure. CMA B was responsible for two medication carts due to a staff member calling in sick, which led to an oversight in securing the carts. CMA B acknowledged the proper procedure of locking the carts when not in view but cited the demands of the residents as a reason for the oversight. The Director of Nursing (DON) confirmed the facility's policy that all medication carts must be locked or within the line of sight of the staff member responsible. The DON clarified that the on-call staff, LVN H, was supposed to cover the duties of the absent staff member, not CMA B. However, LVN H allowed CMA B to manage the medication carts on the 100 hall due to her own workload on another hall. The Administrator later stated that LVN H was suspended for not fulfilling her on-call duties, which contributed to the situation. Additionally, it was noted that one of the medication carts had a locking issue, which has since been addressed.
Failure to Implement Comprehensive Care Plans for Smoking Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet the residents' medical, nursing, and mental and psychosocial needs. Specifically, the care plans for four residents did not reflect their smoking status nor included a Smoking Safety Screen. This deficiency was identified through observations, interviews, and record reviews of the residents' care plans and electronic health records. The residents involved had various medical conditions and required different levels of assistance with activities of daily living (ADLs), but none had a smoking assessment documented in their care plans or health records. Resident #10, admitted with diagnoses including stroke, muscle wasting, and seizures, had a care plan dated 03/23/23 that did not mention smoking or include a Smoking Safety Screen. Similarly, Resident #68, with diagnoses such as diabetes and COPD, had a care plan dated 09/28/23 that also lacked smoking-related information. Resident #70, with conditions including heart failure and end-stage renal disease, had a care plan dated 02/27/23 that did not address smoking. Lastly, Resident #91, who had an amputation and an indwelling catheter, had a care plan dated 05/11/23 that did not include smoking assessments. Interviews with the residents and staff revealed a lack of awareness and understanding regarding the necessity of smoking assessments and their inclusion in care plans. The Activity Aide and LVN A were unaware of the requirement for smoking assessments, and the ADON acknowledged that the oversight could have been missed. The facility's policy on resident smoking, dated 10/24/22, mandates that all residents be assessed for tobacco use during admission and quarterly assessments, with safe smoking measures documented in the care plan. However, this policy was not followed, leading to the identified deficiencies.
Failure to Maintain Glucometer Control Solution Testing Logs
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, specifically in the area of blood glucose monitoring for 28 insulin-dependent residents. The facility did not maintain a log documenting the control solution testing results for the glucometers, which is essential to verify that the meters and test strips were functioning properly. During an inspection, it was observed that the glucometer logs were not available at the nurse's station or on the medication carts. Interviews with the ADON and DON confirmed that the logs were not kept, and the facility did not have a specific Glucometer Policy, relying instead on the Glucometer Manual. This lack of documentation could lead to false glucometer readings, potentially affecting the care provided to the residents. Further observations and interviews revealed that the night shift nurses were responsible for checking the glucometer controls, but no logs were maintained to confirm this. An RN performed a control solution test during the inspection, and it was the first entry documented in the quality control log. Staff members acknowledged that without these logs, they could not determine if the glucometers were providing accurate readings. The DON and ADON both stated that the absence of logs could negatively impact the accuracy of blood glucose readings, and they would follow the glucometer manual for control solution testing moving forward.
Failure to Adhere to Food Safety Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation and initial tour of the kitchen, it was found that there were unlabeled and undated sippy cups in the refrigerator, a juice gun with its nozzle touching the outside of a cabinet, open containers of spices, and unsealed bags of dry cereals that were neither dated nor labeled. Additionally, some steam table wells were crusted with a whitish substance. In the nutrition room, there were also unlabeled and undated food items, including ice cream, yogurt, milk, salad, and an electrolyte drink. Expired items such as instant oatmeal and tube feeding containers were also found. Interviews with staff revealed a lack of adherence to food safety protocols, with some staff unaware of who was responsible for the nutrition room and others acknowledging the potential risks of improper food storage and labeling practices. The facility's policies on food storage and labeling were not being followed, as evidenced by the numerous unlabeled, undated, and improperly stored food items found during the survey. The facility's policy on potluck meals and foods from home also emphasized the importance of labeling and dating food items, which was not being adhered to. The lack of in-service training for kitchen staff further contributed to the deficiencies observed. These failures could place residents at risk of foodborne illnesses.
Inadequate Infection Control Training During Meal Service
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, which led to improper handling of residents' cups and bowls during meal service. Specifically, the Assistant Director of Nursing (ADON), Human Resources (HR) personnel, and a Certified Nursing Assistant (CNA) were observed touching the rims of residents' cups and bowls with bare hands during lunch service. This practice was identified as a potential source of cross-contamination and infection risk for the residents. Interviews with the involved staff revealed a lack of training on proper meal service procedures and infection control practices. The ADON admitted that there had been no training on how to properly serve food to residents, and both the CNA and HR personnel confirmed they had not received such training and were unaware of the correct procedures. The Administrator, who was new to the facility, also did not know if any meal service training had been conducted for the staff. The facility's Infection Prevention and Control Program policy, dated 05/13/23, mandates that all staff receive training relevant to their specific roles and responsibilities, including infection prevention and control practices. However, the observations and staff interviews indicated that this policy was not being followed. The lack of training and adherence to infection control procedures during meal service could lead to cross-contamination and the spread of infections among residents. The deficiency was noted during a lunch dining observation and confirmed through multiple staff interviews, highlighting a significant gap in the facility's infection control training and practices.
Failure to Maintain Clean and Odor-Free Environment
Penalty
Summary
The facility failed to treat two residents with respect and dignity by not maintaining a clean and odor-free environment. Resident #35's room had a strong odor of urine, and his floor mat and mattress were saturated with urine. The room's floor was sticky, and the laundry hamper was full of urine-soaked clothes. Despite multiple reports from staff about the foul odor, the issue persisted for at least two to three months. The facility's housekeeping and nursing staff were aware of the problem but failed to address it adequately, leading to a diminished quality of life for the residents involved. Resident #35, an elderly male with severe cognitive impairment and multiple health issues, including dementia and urinary incontinence, was found lying on a urine-soaked mattress. The resident's behavior of urinating in various places in the room, including the floor, trash can, and laundry hamper, was documented but not effectively managed. Staff interviews revealed that the resident's room had been deep cleaned multiple times, but the odor and unsanitary conditions persisted. The resident expressed feelings of discomfort and self-worth issues due to the smell and the lack of timely care from the staff. Resident #14, who shared the room with Resident #35, also suffered from the foul odor. Although non-verbal, Resident #14 indicated through gestures that the smell bothered him and that he wanted to move to another room. The facility's ambassador program, which was supposed to ensure the cleanliness and comfort of residents' rooms, failed to address the ongoing issue despite multiple reports during morning meetings. The facility's policies on promoting resident dignity and maintaining a clean environment were not followed, leading to the deficiency observed by the surveyors.
Failure to Maintain Clean and Comfortable Environment
Penalty
Summary
The facility failed to ensure a safe, clean, and comfortable environment for two residents, leading to significant issues with cleanliness and odor. Resident #35's room had a strong odor of urine, and his floor mat and mattress were saturated with urine. The room's floor was sticky, and the resident's laundry hamper was full of urine-soaked clothes. Despite multiple reports and observations of the foul odor and unsanitary conditions, the facility's staff did not adequately address the issue, leading to prolonged discomfort for the resident. Resident #35, who had severe cognitive impairment and a history of urinary incontinence, expressed that the smell bothered him and that he felt neglected by the staff. Resident #14, who shared the room with Resident #35, also experienced the negative effects of the unsanitary conditions. Although non-verbal, Resident #14 indicated through gestures that the smell bothered him and expressed a desire to move to another room. The facility's staff, including the Administrator, Director of Nursing (DON), and housekeeping personnel, were aware of the odor and the unsanitary conditions but failed to take timely and effective action to resolve the issue. The facility's ambassador program, which involved daily room visits by department heads, also failed to address the persistent odor and cleanliness problems. Interviews with various staff members, including CNAs, housekeeping staff, and the Administrator, revealed a lack of consistent and effective communication and follow-up regarding the residents' living conditions. The facility's policies on promoting resident dignity and maintaining a clean environment were not adequately followed, resulting in a diminished quality of life for the affected residents. The failure to provide timely and appropriate care and cleaning interventions contributed to the ongoing issues in Resident #35's and Resident #14's room.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse for three dumpsters (A, B, and C). Observations revealed that all three dumpsters had their lids open and were overflowing, with one leaking an unknown liquid onto the ground. This situation was confirmed through interviews with the Maintenance Supervisor (MS) and the Administrator (ADM), who both acknowledged that the dumpsters should have been kept closed and not overflowing to prevent infection risks. The facility's policy on garbage receptacles, revised in June 2019, mandates that outdoor receptacles should have tight-fitting lids and doors, and should be kept closed to minimize the risk of attracting insects and rodents and to prevent biohazards from spreading. The MS emphasized the importance of keeping the dumpster lids and doors closed to prevent biohazards from leaking or flying out, which could lead to the spread of disease through gnats, bugs, and rodents. The ADM reiterated that the dumpsters should only be open when in use and that all staff members were responsible for ensuring the lids and doors were closed and the area around the dumpsters was kept clean. The facility's failure to adhere to these guidelines could place residents at risk of infection from improperly disposed garbage.
Failure to Follow Smoking Policy for Resident
Penalty
Summary
The facility failed to follow their established smoking policy for a resident who required a smoking apron while smoking. Resident #30, who has diagnoses including dementia, schizophrenia, and heart failure, was observed smoking without a smoking apron. The resident's care plan indicated the need for one-on-one supervision and the use of a smoking apron due to moderate cognitive impairment and safety concerns. During an observation, the Activity Aide provided the smoking apron only after being questioned, revealing a lapse in adherence to the care plan and smoking policy. Interviews with the resident and staff confirmed that the resident was aware of the requirement to wear a smoking apron but did not consistently comply. The Activity Aide, who was not typically responsible for supervising smoking, was not fully educated on the resident's care plan requirements. The Assistant Director of Nursing (ADON) acknowledged the oversight and indicated that the Activity Aide was trying to help due to staff being busy. The facility's policy on resident smoking outlined the need for safe smoking measures and proper documentation, which were not fully adhered to in this instance.
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What surveyors actually found near you
We read the 138 citations issued within 25 miles in the last 12 months — including the 3 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Corpus Christi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wooldridge Place Nursing Center | 0.8 mi | ★★★★★ | 11 | 0 |
| Mirador | 1.2 mi | ★★★★★ | 0 | 0 |
| Cimarron Place Health & Rehabilitation Center | 1.2 mi | ★★★★★ | 3 | 0 |
| The Palms Nursing & Rehabilitation | 2.5 mi | ★★★★★ | 37 | 0 |
| San Rafael Nursing And Rehabiliation | 4.9 mi | ★★★★★ | 12 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.