Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Estates At Shavano Park during CMS and state inspections, most recent first.
A facility failed to ensure that three residents were free from significant medication errors involving midodrine. The residents had orders for midodrine for hypotension with instructions to hold the medication when SBP was above 120, but staff repeatedly gave the drug when SBP exceeded the ordered parameter and also withheld doses when BP was low. The affected residents had diagnoses including HTN, hypotension, and dementia, and one resident had moderate cognitive impairment while the others had no or no noted cognitive impairment.
Unsecured medications and an unlocked med cart were observed in the facility. A resident with an indwelling urinary catheter had three bottles of normal saline left unattended in the room, another resident had Calmoseptine ointment left unattended in the restroom, and the 300-hall nursing cart was observed unlocked and unsupervised in the hallway. Staff acknowledged the saline and ointment were medications that should have been stored in a nursing cart.
Kitchen staff were observed failing to follow food safety standards, including not wearing proper hair and beard restraints, storing wet dishes so they could not air-dry, leaving food items in the walk-in refrigerator unlabeled and undated, and keeping dry storage items on the floor. Staff also served microwaved soup to a resident without checking the temperature before it left the kitchen, and the soup was later measured at 135 F.
Staff failed to follow infection control practices during resident care and isolation precautions. Two staff members entered residents’ droplet precaution rooms wearing only a surgical mask instead of the PPE posted on the door, a CNA changed gloves during incontinent care without washing or sanitizing hands, and a MA used a blood pressure cuff on one resident without cleaning it after it had been used on another resident.
Failure to Evaluate and Document Self-Administration of Nasal Spray: A resident with intact cognition and diagnoses including COPD and allergic rhinitis was observed receiving his scheduled meds, but he self-administered his nasal spray without a documented self-administration evaluation or record. The resident said he had been taking it himself, wanted to continue doing so, and had not been evaluated; the med aide said she reported it to nursing, while the LVN and DON stated the physician should have been contacted and the resident's ability assessed and documented per policy.
The facility failed to limit PRN lorazepam orders for two residents to 14 days and to ensure required practitioner review before renewal. One resident with anxiety disorder and a stroke history had an indefinite PRN lorazepam order that was administered several times, and another resident with Alzheimer’s disease and anxiety had a PRN lorazepam order without a duration listed. Nursing leadership confirmed the orders should have had end dates and that the facility policy required documentation and evaluation for extended PRN psychotropic use.
A resident admitted with PE, PVD, and ESRD on dialysis had a baseline care plan that did not include dialysis, wound care, or oxygen needs. Staff observed the resident on 3 L O2 via NC and receiving wound care, and the resident reported dialysis on M/W/F, while the MDS Coordinator and DON acknowledged the baseline care plan did not reflect these services.
A facility failed to keep two residents' comprehensive care plans current. One resident with severe cognitive impairment and total bowel and bladder incontinence had a care plan that addressed bladder incontinence but omitted bowel incontinence care. Another resident with a gastrostomy tube had a physician order changed from continuous enteral feeding to bedtime bolus feeding, but the care plan still listed the old continuous-feeding regimen and related flush schedule.
A resident with severe cognitive impairment, bowel incontinence, and an indwelling urinary catheter did not receive appropriate incontinent care when a CNA cleaned the groin, genital area, and catheter with multiple passes of one wipe before cleaning the buttocks. The resident’s care plan called for cleaning the catheter and peri-area with each incontinence episode, and the facility policy stated not to reuse the same washcloth or water to clean the urethra. The CNA and DON both stated a new wipe should have been used with each stroke to prevent infection.
A resident with an intact BIMS and an order for PRN nebulizer treatment had a nebulizer mask left uncovered on the bedside nightstand instead of stored in a plastic bag when not in use, and the ADON and DON stated it should have been covered to prevent infection. Another resident was observed on oxygen via NC even though the chart had no physician order or oxygen care plan, and an LVN and DON acknowledged the missing order.
A resident's room refrigerator contained a plastic container of food that was not labeled or dated. The resident did not know what the food was or when it was brought in, and the ADON and DON stated staff should have labeled and dated food brought by family. The facility policy required perishable foods to be stored in a refrigerator in a re-sealable container and labeled with the resident's name, item, and use-by date.
Incomplete and Inaccurate Resident Clinical Record: A resident with cerebral infarction, dysphagia, and gastrostomy status had a Liquid Protein order documented via G-tube even though staff stated the resident was receiving food and meds by mouth, with only bolus feeding via G-tube at bedtime. The LVN-U and DON both acknowledged the order was incorrect and remained unchanged after other orders were changed from via G-tube to PO, leaving the medical record inaccurate.
A resident with a history of respiratory failure, CHF, and pneumonia was receiving supplemental oxygen as documented in her care plan and vital signs records, but the MDS assessment failed to indicate oxygen use. The MDS Nurse relied on MARs, which did not show oxygen administration, and did not initially check other records, resulting in an inaccurate assessment.
A resident with a history of respiratory and cardiac conditions was given oxygen therapy at 2 LPM via nasal cannula without a physician's order. The care plan and clinical records documented ongoing oxygen use, but no order was present. Staff interviews confirmed the absence of an order and acknowledged that facility policy requires one before administering oxygen.
A licensed nurse failed to fully cover a wound with the prescribed dressing and did not date or initial wound dressings for two residents during wound care, contrary to facility policy. These actions were observed during care for residents with complex medical needs, including diabetic foot ulcers and stage four pressure ulcers. Interviews revealed uncertainty among staff regarding competency assessments and wound care procedures.
Two residents requiring contact or enhanced barrier precautions did not receive care in accordance with infection control protocols. Staff failed to post required isolation signage for a resident with C. diff and did not perform hand hygiene between glove changes during wound care for both residents. Open wound care supplies were also placed directly on a resident's bed, and facility policies for hand washing and use of personal protective equipment were not consistently followed.
A resident with a history of respiratory and cardiac conditions was receiving supplemental oxygen, as documented in her care plan and clinical records. However, the MDS assessment failed to indicate oxygen use because the MDS Nurse relied on the MARs, which did not reflect oxygen administration, instead of reviewing all relevant clinical documentation. Facility leadership confirmed the responsibility for accurate MDS completion and acknowledged the potential for an inaccurate care plan due to this omission.
A resident with a history of respiratory and cardiac conditions was given oxygen therapy at 2 LPM via nasal cannula without a physician order, despite this intervention being included in the care plan and documented in clinical records. Staff interviews and facility policy confirmed that a physician order was required for oxygen administration, but none was present while the resident received ongoing oxygen therapy.
The facility failed to maintain proper infection control as several residents' Foley catheter bags were observed touching the floor, posing a risk of contamination. Despite having care plans and staff training, the catheter bags of five residents were improperly positioned, indicating a systemic issue in catheter care management.
A facility failed to accurately code a resident's diagnosis of anxiety on the MDS assessments, despite the resident receiving buspirone for anxiety. The MDS RN confirmed the discrepancy, which could risk improper care. The DON acknowledged the potential impact on the resident's well-being.
A facility failed to maintain a medication error rate below 5%, with an observed rate of 11.54% due to untimely administration of medications. Two residents experienced delays in receiving their prescribed medications, bumex and gabapentin, which were administered significantly later than scheduled. Interviews with staff revealed a misunderstanding of the facility's policy on medication administration timing, contributing to the high error rate.
A resident with a history of hemiplegia, atrial fibrillation, and hypertension received Amlodipine Besylate and Carvedilol outside of physician-ordered parameters, with medications administered despite vital signs being outside specified limits. Multiple LVNs were involved, and the DON was unaware of these errors, indicating a lack of communication and adherence to medication administration policies.
A resident with hemiplegia and hemiparesis was not provided with a required divided plate during a meal, leading to difficulties in eating. Despite the resident's care plan and dietary orders specifying the need for a divided plate, the facility failed to provide it, and staff did not intervene until prompted by a state surveyor. The facility's policy mandates the provision and supervision of assistive devices, which was not adhered to in this instance.
A resident with intact cognition was referred to using a 'sippy cup' on their meal ticket, despite their meal plan specifying a two-handle cup or mug with a lid. Staff interviews revealed that this terminology was commonly used by the dietary department and kitchen staff. The dietary manager acknowledged the inappropriate terminology only after state surveyors raised the issue, and subsequently changed it to '2 handle cup or mug with lid'.
Medication Errors With Midodrine Orders
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors involving midodrine for Residents #14, #23, and #27. Midodrine was ordered for these residents for low blood pressure, with instructions not to give the medication when the systolic blood pressure was greater than 120. Record reviews showed that staff administered the medication when the residents’ systolic blood pressures were above the ordered parameter on multiple occasions, and also withheld doses when the blood pressure readings were below the threshold for administration. Resident #14 was admitted with diagnoses including hypertension, hypotension, and dementia. The resident’s physician ordered midodrine 10 mg three times daily for low blood pressure, with a hold parameter for systolic blood pressure greater than 120. Review of the October and November 2025 MARs showed numerous instances in which staff either gave midodrine when the systolic blood pressure was above 120 or did not give it when the blood pressure was low. The record identified multiple staff members involved in these administrations and omissions, including medication aides and LVNs. Resident #23 was admitted with diagnoses including hypertension, hypotension, and dementia and had a BIMS score of 10. The physician ordered midodrine 10 mg three times daily with the same hold parameter. The March 2026 MAR showed eight administrations of midodrine when the systolic blood pressure was above 120, including one dose given by the ADON. Resident #27 was admitted with diagnoses including hypertension, hypotension, and dementia and had a BIMS score of 15. The physician ordered midodrine 5 mg twice daily with the same hold parameter. The March 2026 MAR showed eight doses given when the systolic blood pressure was above 120, all documented as administered by the same medication aide.
Unsecured Medications and Unlocked Medication Cart
Penalty
Summary
Drugs and biologicals were not consistently stored in locked compartments or left in proper control when three bottles of normal saline were found unattended in Resident #2’s room. Resident #2 was an [AGE]-year-old male admitted on 01/23/2026 with diagnoses including lack of coordination, urinary tract infection, and muscle weakness. His admission MDS dated 01/27/2026 showed a BIMS score of 12 out of 15, indicating moderate cognitive impairment, and he had an indwelling urinary catheter with an order for a Foley catheter. On 03/10/2026 at 9:53 a.m., the resident was observed sleeping in bed with three bottles of normal saline on the window frame. During interview later that morning, an LVN stated the saline was for flushing the resident’s catheter and acknowledged that the bottles had been left unattended and should have been stored in a nursing cart to prevent possible inappropriate use. A moisture barrier ointment was also left unattended in Resident #70’s restroom, and the 300-hall nursing cart was observed unlocked and unattended. Resident #70 was an [AGE]-year-old female admitted on 09/18/2026 with diagnoses including lack of coordination, difficulty walking, and type 2 diabetes mellitus. Her quarterly MDS dated 12/26/2025 showed a BIMS score of 15 out of 15, indicating intact cognition, and her care plan identified her as at risk for additional pressure ulcers related to decreased mobility. On 03/10/2026 at 10:33 a.m., an ointment tube of Calmoseptine was observed in the resident’s restroom while the resident was not in the room. The wound care nurse later stated the ointment was a medication and should have been stored in a nursing cart. On 03/12/2026 at 8:41 a.m., the 300-hall nursing cart was observed parked in the hallway, unlocked, and unsupervised.
Kitchen Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During observation, the Dietary Manager was not wearing a proper beard restraint while working in the kitchen, and Dietary Aide P and Dietary Aide R were observed without proper hair or beard restraints. The Dietary Manager stated that hair restraints covering all hair were to be worn in the kitchen and that it was his responsibility to ensure staff wore them properly. The kitchen also had multiple storage and sanitation issues. A box of 8-ounce cup lids and a case of canned soup were observed on the floor in dry storage. In the walk-in refrigerator, an opened jar of grape jelly, a bag with two eggs, a container of red sauce, a large pan covered with aluminum foil, a large bottle of soy sauce, and seven trays of cups with liquid were stored without labels identifying the items or dates to be used by. An opened gallon of milk was also observed in the refrigerator without a label showing the date opened or a use-by date. In the dish storage area, eight bowls were stacked right side up with liquid pooling inside them, and the facility failed to store wet dishes to allow for air-drying. Food preparation and temperature monitoring were also deficient. [NAME] Q prepared a pureed entree by portioning out nine servings into a bowl and then placing the pureed entree back into the same bowl that had held the whole portions. [NAME] W opened a can of soup, heated it in the microwave, and placed it on a resident's tray without taking the temperature before it left the kitchen. The soup was later returned to the kitchen and found to be 135 F when checked. The Dietary Manager stated the cook should have taken the temperature before serving and that the failure could have caused the resident to burn themselves from food that was too hot or caused illness because food did not get hot enough to kill bacteria.
Infection Control Lapses With PPE, Hand Hygiene, and Equipment Cleaning
Penalty
Summary
The facility failed to maintain infection prevention and control practices for residents on droplet precautions when staff entered isolation rooms without the PPE posted on the door. Resident #72, who had Alzheimer’s disease and severe cognitive impairment, had an order for droplet precautions related to influenza. During observation, LVN A entered the resident’s room wearing only a surgical mask, then exited the room and spoke with a CNA before removing the mask. LVN A stated she had not worn gloves or a gown and acknowledged that the signage indicated PPE should include a mask, gown, gloves, and eye protection. A similar failure occurred with Resident #3, a male with diagnoses including orthopedic aftercare following toe amputation and diabetes, who also had an order for droplet precautions related to influenza. During observation, NP B entered the resident’s room wearing only a surgical mask and exited into the hallway without doffing it. NP B stated she had not recognized the signage and had not donned the appropriate PPE for the resident’s isolation precautions. The DON stated staff were expected to don and doff PPE as posted and as trained for residents under isolation precautions. The facility also failed to ensure hand hygiene was performed after glove removal during incontinent care and failed to ensure equipment was disinfected between residents. During incontinent care for Resident #19, a 101-year-old female with heart failure, UTI, hypertension, and frequent bowel and bladder incontinence, CNA-T cleaned the resident, changed gloves, and continued care without washing or sanitizing her hands. CNA-T stated she should have sanitized or washed her hands when changing gloves. For Resident #82, a 74-year-old female with pulmonary embolism, peripheral vascular disease, and dependence on renal dialysis, MA-M brought a blood pressure cuff from another resident’s room and took the resident’s blood pressure without cleaning the cuff. MA-M stated she forgot to clean it and should have done so to prevent possible infection.
Failure to Evaluate and Document Self-Administration of Nasal Spray
Penalty
Summary
The facility failed to ensure the interdisciplinary team determined whether a resident could safely self-administer medication when the resident was observed taking his own nasal spray for allergies. The resident was a 77-year-old male with diagnoses including lack of coordination, COPD, and allergic rhinitis. His quarterly MDS showed a BIMS score of 15/15, indicating intact cognition, and his care plan included resident rights and freedom of choice. He had a physician order for Nasal Mist Inhalation Aerosol Solution 0.9% one puff in each nostril daily for allergies, scheduled for 8:00 a.m. Record review showed no self-administration evaluation form and no self-administered medication record for the nasal spray. During observation, the medication aide administered the resident's morning medications except for the nasal spray. The resident stated he gave himself the nasal spray every morning, had done so at home, wanted to administer it himself instead of nurses, and said nobody had evaluated him for this medication. The medication aide said the resident had told her he wanted to self-administer and that she had reported it to nurses, but she could not recall when or to whom. The LVN stated nobody had reported the resident's self-administration and said nurses should have contacted the physician, evaluated the resident's ability, and documented it on the self-administered medication record. The DON stated the resident had the right to self-administer and was able to do so, but the facility should have contacted the physician, evaluated his ability, and documented it per policy; the failure occurred because of lack of communication between nurses and the medication aide.
PRN lorazepam orders exceeded required duration limits
Penalty
Summary
The facility failed to ensure PRN lorazepam orders for two residents were limited to 14 days and were not renewed without the required practitioner evaluation. For Resident #54, the record showed diagnoses including generalized anxiety disorder and cerebral infarct, a BIMS score of 14, and a care plan addressing PRN anti-anxiety medication use. The physician ordered lorazepam 0.5 mg every 12 hours as needed on 10/21/2025 with no end date, and the MAR showed the medication was administered several times in January and February 2026. Staff interviews confirmed the order remained indefinite and that it should have had an end date and been limited to 14 days per professional standards. For Resident #6, the record showed diagnoses including hemiplegia/hemiparesis, Alzheimer’s disease, and anxiety disorder, with a BIMS score of 4 indicating severe cognitive impairment. The resident’s care plan included PRN anti-anxiety medication use, and the physician ordered lorazepam 0.5 mg every 4 hours as needed starting 01/20/2026 with no duration listed. The MAR for March 2026 showed the resident did not receive lorazepam, and staff stated verbal redirection was effective when anxiety occurred. Interviews with nursing leadership confirmed both PRN lorazepam orders should have been limited to 14 days. The LVN, ADON, and DON acknowledged the indefinite order for Resident #54 and the over-14-day order for Resident #6, and stated the orders lacked the required duration or documented rationale. The facility policy stated PRN psychotropic medication orders beyond 14 days require practitioner documentation of the rationale and that PRN antipsychotic medication orders will not be renewed beyond 14 days unless the practitioner evaluates the resident for appropriateness.
Baseline Care Plan Missing Dialysis, Wound Care, and Oxygen Needs
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a 74-year-old female resident admitted with pulmonary embolism, peripheral vascular disease, and dependence on renal dialysis. Her physician orders included dialysis every Monday, Wednesday, and Friday at 2:45 PM chair time with pickup at 1:45 PM, and wound care for the left lower leg using gauze and Vashe solution, Xeroform gauze, an abdominal pad, Kerlix gauze, and tape. Observation on 03/12/2026 showed the resident receiving 3 liters of oxygen per minute via nasal cannula and wound care from the wound care nurse, and the resident stated she had dialysis every Monday, Wednesday, and Friday. Record review showed the resident's baseline care plan, dated 03/07/2026, did not include dialysis, wound care, or oxygen. The LVN-U stated the resident had been receiving oxygen therapy, dialysis, and wound care since admission, and the MDS Coordinator stated it was her mistake that the baseline care plan did not reflect those needs. The MDS Coordinator and DON both stated the baseline care plan should have included oxygen therapy, dialysis, and wound care because the resident was receiving those services since admission.
Care Plans Not Updated for Bowel Incontinence and Tube Feeding Changes
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #46 that reflected bowel incontinence care. The resident was a 91-year-old female with a history of cerebral infarction, muscle weakness, and hemiplegia/hemiparesis. Her quarterly MDS assessment showed a BIMS score of 0 out of 15, indicating severe cognitive impairment, and she was dependent for transfers and always incontinent of bowel and bladder. Her comprehensive care plan, dated 09/09/2024, addressed bladder incontinence related to hemiplegia and hemiparesis and included interventions for monitoring signs and symptoms of urinary tract infection, but it did not include any care related to bowel incontinence. The facility also failed to revise and update Resident #4's comprehensive care plan after the resident's gastrostomy feeding tube order changed from continuous feeding to bolus feeding only at bedtime. Resident #4 was a 90-year-old female with diagnoses of cerebral infarction, dysphagia, and gastrostomy status, and her quarterly MDS assessment showed a BIMS score of 3 out of 15 with feeding tube use for nutrition. The physician order, started 02/27/2026, directed enteral feed at bedtime with 2 bolus cans of Fibersource 1.2, but the care plan still reflected Fibersource 1.2 at 55 mL/hour for 22 hours with water flushes every 4 hours and a morning downtime schedule for tube feeding orders.
Incontinent Care and Catheter Hygiene Not Performed Correctly
Penalty
Summary
The facility failed to ensure appropriate care for a resident who was incontinent of bowel and had an indwelling urinary catheter. Resident #37 was a male with diagnoses including lack of coordination, urinary tract infection, and obstructive and reflux uropathy. His quarterly MDS reflected a BIMS score of 6, indicating severe cognitive impairment, and he was assessed as having an indwelling urinary catheter and frequent bowel incontinence. His care plan, dated 11/01/2024, included the intervention to clean the catheter and peri-area with each incontinence episode. During observation on 03/12/2026, CNA-V provided incontinent care by opening the resident’s dirty brief, cleaning the groin and genital areas, and cleaning the indwelling urinary catheter with multiple passes of one wipe before cleaning the buttocks. During interview, CNA-V stated she used multiple passes of one wipe because she was nervous and said she should have used a new wipe with each stroke to prevent infection. The DON also stated the CNA should have used a new wipe with each stroke to prevent infection. The facility policy on perineal/incontinence care stated not to reuse the same washcloth or water to clean the urethra.
Respiratory Care Not Properly Managed for Two Residents
Penalty
Summary
Resident #57, a 100-year-old female with diagnoses including lack of coordination, atrial fibrillation, and atherosclerotic heart disease, was assessed as cognitively intact and was receiving oxygen therapy. Her care plan included as-needed oxygen therapy for ineffective gas exchange, and she also had a physician order for ipratropium-albuterol nebulizer treatment as needed for shortness of breath or wheezing. On 03/10/2026, she was observed sleeping in bed with oxygen at 2 liters per minute via nasal cannula, and a nebulizer was on the nightstand at the bedside with the mask lying uncovered on the nightstand rather than being stored in a plastic bag when not in use. The ADON and DON both stated the mask should have been covered in a plastic bag when not used to prevent infection. Resident #82, a 74-year-old female with diagnoses including pulmonary embolism, peripheral vascular disease, and dependence on renal dialysis, was observed receiving oxygen at 3 liters per minute via nasal cannula. The resident stated she had oxygen since coming to the facility, but her baseline care plan did not include oxygen and the physician order record contained no order for oxygen therapy. An LVN-U stated the resident had been receiving oxygen since admission and that the nurse did not know there was no physician order for it. The DON stated the resident needed oxygen due to her respiratory status and acknowledged there was no known reason for the missing order.
Unlabeled and Undated Food in Resident Refrigerator
Penalty
Summary
The facility failed to have a policy regarding the use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 1 of 20 residents reviewed for food and nutrition services. Resident #41, a 77-year-old male with diagnoses including lack of coordination, COPD, and allergic rhinitis, had a BIMS score of 15 out of 15 and required setup or clean-up assistance with eating. His comprehensive care plan identified a nutritional problem or potential nutritional problem related to protein-calorie malnutrition and included monitoring for signs and symptoms of dysphagia. During observation of Resident #41's room, a small refrigerator contained one plastic container with food that was not labeled or dated. The resident stated that family members might bring food, but he did not know what the food was or when it was brought. The ADON confirmed the container appeared to be chicken salad and stated the facility nurses should have labeled and dated the food when the resident's family brought it from outside, and that night nurses should have checked the refrigerator every night. The DON also stated the nurses should have labeled and dated the container when the family brought the food from outside. The facility policy titled Foods Brought by Family/Visitors stated perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator and labeled with the resident's name, the item, and the use-by date.
Incomplete and Inaccurate Resident Clinical Record
Penalty
Summary
Clinical records were not maintained in accordance with accepted professional standards for one resident. Resident #4, a 90-year-old female with diagnoses including cerebral infarction, dysphagia, and gastrostomy status, had a quarterly MDS assessment showing a BIMS score of 3 out of 15 and severe cognitive impairment. Her record showed a physician order for Liquid Protein in the morning, 30 mL daily, via gastrostomy tube to provide 15 grams of protein per 100 kilocalories. Record review also showed the resident was receiving all medications by mouth. During interview, the LVN-U stated the Liquid Protein order was incorrect and inaccurate because the resident was receiving all food and medications by mouth, with only bolus feeding via gastrostomy tube at bedtime. The DON stated the order remained unchanged because nurses had changed the resident’s medication orders from via gastrostomy tube to by mouth but did not change this Liquid Protein order, and stated that an inaccurate medical record might affect inaccurate care due to confusion. The facility policy required all services provided to the resident or changes in the resident’s medical or mental conditions to be documented in the medical record.
Failure to Accurately Document Oxygen Therapy on MDS Assessment
Penalty
Summary
The facility failed to ensure that the assessment accurately reflected a resident's status by not indicating that the resident received oxygen on her Quarterly MDS assessment. The resident, who had a history of acute respiratory failure with hypoxia, congestive heart failure, pneumonia, and high blood pressure, was observed and documented as receiving supplemental oxygen via nasal cannula. Her care plan included interventions for oxygen therapy, and vital sign records confirmed oxygen administration during the MDS look-back period. However, the MDS assessment did not reflect this, as the section for oxygen use was not checked. The MDS Nurse stated that she relied on the Medication Administration Records (MARs), which did not indicate oxygen use, and did not initially review the vital signs section that documented oxygen administration. Upon review, the MDS Nurse acknowledged the oversight and confirmed that the resident did receive oxygen during the look-back period. Interviews with facility leadership confirmed that the MDS Nurse was responsible for ensuring the accuracy of assessments, and that inaccurate documentation could result in an inaccurate plan of care.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A deficiency was identified when a resident with a history of acute respiratory failure with hypoxia, congestive heart failure, pneumonia, and high blood pressure was administered oxygen at 2 liters per minute via nasal cannula without a physician's order. The resident's care plan included oxygen therapy, and clinical records documented ongoing oxygen administration on multiple dates. However, review of the physician's order summary revealed no order for oxygen administration, despite the resident receiving it regularly. Observations confirmed the resident was receiving oxygen, and staff interviews acknowledged the absence of a physician's order for this treatment. Facility staff, including an LVN and the Executive Clinician, confirmed that oxygen therapy should only be provided with a physician's order and that the lack of such an order could result in unmonitored treatment. The Executive Director also stated that all treatments, including oxygen, require a physician's order and proper documentation in the clinical record and care plan. The facility's own policy on oxygen administration requires verification of a physician's order prior to providing oxygen, which was not followed in this case.
Failure to Ensure Nurse Competency in Wound Care Procedures
Penalty
Summary
The facility failed to ensure that licensed nurses possessed and demonstrated the necessary competencies and skills to provide proper wound care for two residents. Specifically, the Assistant Director of Nursing (ADON) did not fully cover a resident's wound bed with calcium alginate dressing as ordered by the physician, and on two separate occasions, did not date or initial wound dressings after providing care to two different residents. These actions were observed during wound care procedures and were not in accordance with the facility's wound care policy, which requires dressings to be labeled with the date, time, and staff initials. One resident involved was a female with a history of enterocolitis due to clostridium difficile, diabetes mellitus, and peripheral vascular disease, who had a diabetic foot ulcer requiring daily wound care. During wound care, the ADON failed to fully cover the wound with the prescribed dressing and did not label the dressing on a subsequent day. The second resident was a male with diagnoses including unsteadiness, malnutrition, colostomy status, and a stage four pressure ulcer. The ADON also failed to date and initial the dressing after wound care for this resident. Interviews with facility staff revealed a lack of clarity regarding responsibility for staff competency assessments and uncertainty about whether wound care competencies were included in staff checks. The ADON acknowledged not realizing the errors at the time and recognized that not labeling dressings could result in confusion for subsequent staff. The facility's wound care policy and competency documentation indicated requirements for proper wound care procedures, including labeling of dressings, which were not followed during the observed incidents.
Failure to Maintain Infection Control Practices During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for two residents who required specialized precautions due to their medical conditions. For one resident with a diagnosis of Clostridium difficile (C. diff) and a diabetic foot ulcer, the facility did not post appropriate contact isolation signage upon or immediately after notification of the isolation order. During wound care procedures for this resident, the Assistant Director of Nursing (ADON) did not perform hand hygiene between glove changes, and open wound care supplies were placed directly on the resident's bed, contrary to infection control protocols. The resident was unaware of the need for contact precautions, and the required signage was not present at the time of initial observation. For the second resident, who had a stage four pressure ulcer and a colostomy, the ADON also failed to sanitize her hands between glove changes while providing wound care. Both residents had care plans and physician orders that specified the need for enhanced barrier precautions, including the use of gowns and gloves during high-contact care activities. Facility policy required hand washing with soap and water after contact with residents with infectious diarrhea, such as C. diff, and after removing gloves, but these procedures were not consistently followed by staff during the observed care events. Interviews with facility staff, including the ADON, the Vice President of Clinical Services, and the Administrator, confirmed that the expected standard was for staff to wash their hands before and after care, as well as between glove changes, especially for residents on isolation precautions. The lack of proper signage and failure to adhere to hand hygiene protocols during wound care for both residents were directly observed and documented by surveyors, constituting a deficiency in the facility's infection prevention and control practices.
Failure to Accurately Document Oxygen Therapy on MDS Assessment
Penalty
Summary
The facility failed to ensure that the assessment accurately reflected a resident's status by not indicating that the resident received oxygen therapy on the Quarterly MDS assessment. The resident, who had a history of acute respiratory failure with hypoxia, congestive heart failure, pneumonia, and high blood pressure, was observed and documented as receiving supplemental oxygen via nasal cannula. The care plan included interventions for oxygen therapy, and the electronic clinical record showed oxygen administration during the MDS look-back period. However, the MDS assessment did not reflect this, as the section for oxygen use was not checked. The MDS Nurse stated that the omission occurred because she relied on the Medication Administration Records (MARs), which did not indicate oxygen administration, rather than reviewing the vital signs section that documented oxygen use. Upon review, the MDS Nurse acknowledged that the resident did receive oxygen during the look-back period and that the MDS should have been marked accordingly. Interviews with facility leadership confirmed that the MDS Nurse was responsible for ensuring assessment accuracy and that an inaccurate MDS could result in an inaccurate plan of care.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A resident with a history of acute respiratory failure with hypoxia, congestive heart failure, pneumonia, and high blood pressure was observed receiving oxygen at 2 liters per minute via nasal cannula. The resident's care plan included an intervention to administer oxygen at this rate to maintain blood oxygen saturations above 92%. However, review of the physician's order summary and clinical records revealed there was no physician order for oxygen administration, despite documentation and observation confirming the resident was receiving oxygen therapy on multiple dates. Interviews with facility staff, including an LVN, the Executive Clinician, and the Executive Director, confirmed that oxygen therapy should only be administered with a physician's order and that the resident did not have such an order in place. The facility's own policy on oxygen administration also requires verification of a physician's order prior to providing oxygen. The lack of a physician order for ongoing oxygen therapy constituted a failure to provide respiratory care consistent with professional standards of practice.
Improper Foley Catheter Bag Management
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by the improper handling of Foley catheter bags for several residents. Observations revealed that the catheter bags of five residents were found touching the floor on multiple occasions. This improper positioning of the catheter bags was noted during various times and locations, including dining rooms and hallways, indicating a systemic issue in the facility's handling of catheter care. Resident #27, a female with intact cognition, was observed twice with her Foley catheter bag on the floor. Despite having a care plan for her indwelling catheter due to stage 4 pressure injuries, there were no specific interventions for managing the catheter bag. Similarly, Resident #38, with moderately impaired cognition and a neurogenic bladder, was observed with her catheter bag touching the floor. Resident #9, who has severe cognitive impairments and a history of pressure injuries, was also seen with her catheter bag dragging on the floor on two separate occasions. Resident #2, with intact cognition but suffering from hemiplegia and a traumatic brain injury, was observed with his catheter bag dragging on the floor under his wheelchair. Resident #49, with moderately impaired cognition and obstructive uropathy, was seen with his catheter bag making contact with the floor. Interviews with staff, including LVNs and CNAs, confirmed that the catheter bags should not touch the floor due to infection risks. However, the facility's policies and training did not effectively prevent these occurrences, as evidenced by the repeated observations of catheter bags improperly positioned.
Inaccurate Coding of Resident Diagnosis on MDS
Penalty
Summary
The facility failed to ensure that the quarterly comprehensive assessment accurately reflected the status of a resident, specifically regarding the coding of the resident's diagnosis. The resident, who was receiving buspirone for anxiety as per physician's orders, had a diagnosis of Adjustment Disorder with Anxiety. However, the Minimum Data Set (MDS) assessments did not reflect this diagnosis, despite the medication administration records indicating the use of an anti-anxiety medication. This discrepancy was confirmed by the MDS RN, who acknowledged that the MDS assessments did not accurately reflect the resident's diagnosis. The failure to accurately code the resident's diagnosis on the MDS assessments could place the resident at risk for improper or incorrect care and services necessary for their well-being. The facility's policy requires that all persons completing any portion of the MDS Resident Assessment Form must sign the document, attesting to the accuracy of the information. The Director of Nursing (DON) acknowledged that these failures could impact the resident's physical, mental, and psychosocial well-being.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 11.54% due to three errors out of 26 opportunities. These errors involved two residents and one medication aide (MA). The errors were primarily related to the untimely administration of medications, which were not given within the prescribed time window. Specifically, medications for two residents were administered significantly later than scheduled, which could potentially affect the therapeutic outcomes. Resident #52, a male with chronic kidney disease, hypertensive heart disease with heart failure, and hypertension, was affected by the untimely administration of medications. His care plan included interventions for fluid overload and pain management, requiring the administration of diuretics and analgesics as ordered. On the day of the observation, the resident's medications, bumex and gabapentin, were administered almost two hours past the scheduled time of 7:00 AM. Similarly, Resident #18, a female with type 2 diabetes mellitus and neuropathy, experienced a delay in receiving her medication. Her care plan also required timely administration of gabapentin for neuropathy pain. The medication was administered over two hours late. Interviews with staff, including the MA and the Director of Nursing (DON), revealed a misunderstanding or misapplication of the facility's policy, which allows for a one-hour window before and after the scheduled time for medication administration. However, the observed delays exceeded this window, contributing to the facility's high medication error rate.
Medication Administration Errors in Resident Care
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the administration of medications outside of physician-ordered parameters. The resident, who had a history of hemiplegia, atrial fibrillation, and hypertension, was prescribed Amlodipine Besylate and Carvedilol with specific instructions to hold the medications if the systolic blood pressure was less than 110 or the heart rate was less than 60 beats per minute. Despite these parameters, the medications were administered multiple times when the resident's vital signs were outside the specified limits. The medication administration records revealed that Amlodipine Besylate was given to the resident on several occasions when the heart rate was below 60 beats per minute, and Carvedilol was administered when either the heart rate was below 60 or the systolic blood pressure was below 110. These errors occurred over a period of time and involved multiple licensed vocational nurses (LVNs), indicating a pattern of non-compliance with the physician's orders. Interviews with the nursing staff and the Director of Nursing (DON) highlighted a lack of awareness and communication regarding the administration of medications outside of parameters. The DON was not informed of these occurrences, and the expectation was that any deviation from the prescribed parameters should be reported to the physician and monitored for adverse effects. The facility's policy on medication errors emphasized adherence to physician's orders and professional standards, which was not followed in this case.
Failure to Provide Required Assistive Eating Equipment
Penalty
Summary
The facility failed to provide special eating equipment for a resident who required it, specifically a divided plate, which was necessary for the resident's assistance while eating. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, was observed struggling with a regular, flat, undivided plate during a meal. This struggle included spilling coleslaw after attempting to pick up the bowl it was in. Despite the resident's care plan indicating the need for a divided plate, the appropriate equipment was not provided, and staff did not intervene until prompted by a state surveyor. The resident's medical records indicated a need for a divided plate and other assistive devices as part of their dietary orders. The facility's policy stated that assistive devices should be provided, maintained, and supervised for residents. However, during the meal observation, the resident did not receive the required divided plate, and the staff failed to notice or correct this oversight. The Director of Nursing acknowledged that the assistive device should have been on the tray and that the nurse responsible for checking meal tickets should have ensured the correct equipment was provided.
Inappropriate Terminology on Meal Tickets Affects Resident Dignity
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as evidenced by the use of inappropriate terminology on meal tickets. A resident, who had intact cognition and required setup or clean-up assistance with eating, was referred to using a 'sippy cup' on their meal ticket. This terminology was used despite the resident's meal plan specifying the use of a two-handle cup or mug with a lid. The resident expressed that while the term did not personally bother them, they understood how it could be bothersome to others. Staff interviews revealed that the term 'sippy cup' was commonly used by the dietary department and kitchen staff, and it was printed on meal tickets without correction. The dietary manager acknowledged the inappropriate terminology only after state surveyors raised the issue, and subsequently changed the term to '2 handle cup or mug with lid' on meal tickets. The facility's policy on Quality of Life - Dignity emphasized the importance of caring for residents in a manner that promotes dignity and respect, which was not adhered to in this instance.
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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 Shavano Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Heights On Huebner | 3.2 mi | ★★★★★ | 17 | 0 |
| Patriot Heights Health Care Center | 3.8 mi | ★★★★★ | 3 | 1 |
| The Heights At Medical Center | 4.3 mi | ★★★★★ | 0 | 0 |
| Wurzbach Nursing And Rehabilitation | 4.5 mi | ★★★★★ | 2 | 0 |
| Remington Transitional Care Of San Antonio | 4.7 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.