Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Frank M. Tejeda Texas State Veterans Home during CMS and state inspections, most recent first.
A CNA verbally abused a resident by scolding her for using the call light repeatedly and stating she had counted the calls. The resident, who had dementia, MDD, anxiety, bipolar disorder, schizophrenia, and required assistance with ADLs and transfers, said the CNA spoke to her like a small child and she did not want her to return. The CNA admitted the comment was verbally abusive, and the ADM and ADON agreed it could cause emotional harm and discourage call light use.
Two residents reported financial concerns that were not timely reported as alleged violations to the administrator and State Survey Agency as required. One resident with intact cognition and dementia-related diagnoses filed a grievance after learning from her daughter that her credit card had been charged for a grocery curbside order she did not make; a staff member later admitted using the resident’s stored card information on a personal phone for a personal purchase while the resident was hospitalized. Another cognitively intact resident reported $57 missing from a locked drawer, stating the key had been kept in a visible, unlocked drawer. In both cases, the concerns were documented as grievances, but the social worker and administrator did not treat them as reportable allegations of misappropriation or theft under facility policy and regulatory requirements, and they were not reported to state authorities within mandated timeframes.
Two residents reported financial and property concerns that were not treated as reportable abuse-related allegations. One resident with DM2 and dementia, but intact BIMS, filed a grievance after learning her credit card had been charged for a grocery curbside order she did not make; a staff member later documented that the resident’s saved card was used in error for the staff member’s personal order. Another cognitively intact resident reported $57 missing from a locked drawer, with the key kept visibly in an unlocked drawer; a SW documented that the drawer was intact and no money was found. The DON and Administrator acknowledged that these grievances were not reported to the State Survey Agency and were not investigated as alleged violations, despite facility policies requiring prompt reporting and investigation of suspected misappropriation and theft of resident property.
A facility failed to keep hazardous items and smoking materials secured when an unlocked bin outside a room contained germicidal wipes with caution labels, a resident with intact cognition had a box of cigarettes on his bed, and another resident had a cigarette lighter on his bedside table. Staff stated the wipes, cigarettes, and lighter should have been kept locked or secured, and facility policy said residents should not keep personal cigarettes, lighters, or matches.
An open multidose vial of Lidocaine HCL injection 1% was found on the 300 Hall med cart without an open date. The LVN said nurses are trained to check for open, undated, or expired meds and stated the vial should have been dated because it is only good for 28 days once opened. The PCN said the vial was not on the list of meds requiring a date, but also acknowledged it should have been listed as a multidose vial. The DON stated the Lidocaine should not have been on the cart because it had been used for a Rocephin injection and no residents were prescribed Rocephin.
MDS Assessment Did Not Reflect CPAP Use: A resident with obstructive sleep apnea had CPAP ordered nightly, documented on the MAR as applied every night, and reported using it every night since admission, but the quarterly MDS did not reflect CPAP use. The MDS nurse stated she missed it and that it should have been coded under non-invasive mechanical ventilator; the DOCR, DON, and ADM stated the MDS needed to accurately show the resident’s care needs.
Improper Perineal Care During Incontinent and Catheter Care: A resident with an indwelling catheter and urinary retention received incontinent care from a CNA who used a back-and-forth wiping motion on the buttocks instead of wiping front to back. The CNA acknowledged the error, and the DON stated staff should wipe front to back with a clean wipe each pass; the facility policy also required one wipe per swipe and front-to-back cleansing.
A facility failed to provide pharmaceutical services to meet resident needs when 2 male intermittent catheters with a use-by date remained on a 400 Hall med cart during survey observation. RN A stated the catheters should have been removed, and the DON and ADM acknowledged that supplies on med carts must be checked for use-by and expiration dates and that expired items need to be removed.
A resident’s personal refrigerator contained fried chicken in an unlabeled, undated storage bag, and it remained there on repeat observation. The resident said the food had been in the refrigerator for about 2 days. The CNA and nurse confirmed the item was unlabeled and undated, and the nurse stated all staff were responsible for removing such items from residents’ refrigerators. The DON confirmed perishable items should be labeled and dated, and the facility policy required routine checks for unsafe or expired food.
An LPN failed to fully sanitize her hands and did not change gloves after cleansing a resident’s wound before applying ointment. The resident had quadriplegia, CKD, DM2, a stage 4 pressure ulcer, osteomyelitis, an indwelling catheter, and an ostomy. The DON stated staff should sanitize all hand surfaces and change gloves after wound cleansing to avoid cross contamination.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, as the facility did not ensure adequate safeguards against physical, mental, sexual abuse, physical punishment, or neglect by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility failed to maintain effective infection control practices for three residents. A resident was not placed under contact precautions as ordered, and improper glove use was observed during wound care. Another resident's medication administration involved cross-contamination risks due to improper handling of a water cup. Additionally, a resident self-administering eye drops was not instructed to sanitize hands, leading to potential infection spread.
A resident's annual MDS assessment failed to accurately reflect their tobacco use, despite their care plan indicating smokeless tobacco use and observations by staff. The responsible RN acknowledged the oversight, attributing it to the resident's past use of a vape cigarette. The facility uses the RAI manual for MDS updates, which was not followed correctly in this case.
A facility failed to update a resident's care plan to accurately reflect their current tobacco use, which stated the resident smoked and used a vapor cigarette, while they had quit smoking and only used dip tobacco. The resident was cognitively intact, and the oversight was acknowledged by the DON and RN responsible for care plan updates.
A resident with multiple health conditions, including diabetes and chronic kidney disease, did not receive proper incontinent care, leading to a deficiency in preventing urinary tract infections. CNAs failed to clean the resident's urinary meatus and did not re-clean after the resident urinated, contrary to facility policy. The DON confirmed the oversight, highlighting a lapse in following infection control protocols.
A facility failed to label a bottle of Ciprofloxacin 0.3% ophthalmological solution with an open date, as required by professional principles. This medication, prescribed for a resident with chronic allergic conjunctivitis, was observed without the necessary labeling, which was confirmed by a Medication Aide. The DON stated that medications should be labeled with open dates to ensure they are not used beyond their effective period.
Verbal Abuse Toward Resident During Call Light Use
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a CNA. The resident was a female admitted with diagnoses including hypertension, dementia, major depressive disorder, anxiety, muscle weakness, bipolar disorder, and schizophrenia. Her care plan addressed cognitive impairment, falls, Parkinson's disease, aggressive behaviors, anxiety, and DNR status, and her MDS showed a BIMS score of 15, indicating she was cognitively intact. She required minimal to moderate assistance with ADLs and used a mechanical lift for transfers. During an interview, the resident's RP reported that the CNA told the resident she had been on the call light 34 times and that the CNA knew she could hear her. The CNA later stated she told the resident she had been on the call light 32 times, that she counted, and that it was an excessive amount of time because she had to care for other residents. The CNA acknowledged she had recently received in-service training on abuse and neglect and stated she understood that what she said was verbally abusive. The resident later stated she did not know why the CNA was so angry and did not want her to return because the CNA spoke to her like she was a small child. The ADM and ADON both stated the behavior was verbally abusive and could cause emotional harm and make residents afraid to use the call light.
Failure to Timely Report Alleged Misappropriation and Theft of Resident Property
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, misappropriation, or mistreatment, including injuries of unknown source, were reported within required timeframes to the administrator and appropriate state officials. For one resident, an unauthorized use of a credit card by a staff member for a personal purchase was not identified or treated by the administrator as an alleged violation of misappropriation of funds, despite being brought forward through the grievance process. For a second resident, an allegation of missing money from a locked drawer was not reported by the social worker to the administrator as an alleged theft or misappropriation, and the administrator did not report the allegation to the State Survey Agency within 24 hours as required. Resident #1 was an older female with type 2 diabetes mellitus, unspecified dementia, and a cognitive communication deficit, but with a BIMS score of 14 indicating intact cognition and no documented memory concerns. She was dependent on staff for toileting hygiene but independent in other ADLs. She was sent to the ER on 02/28/2026 and admitted with Flu A, returning to the facility on 03/02/2026. On 03/06/2026, she submitted a grievance stating that her daughter had informed her that her credit card had been charged for $152 at a grocery store curbside service, and that she had not made a purchase that day. The grievance was received by the Social Services Director. Subsequent documentation showed that the Health Information Manager admitted using the resident’s credit card "in error" for a personal curbside order because the resident’s card information had been stored in the staff member’s personal phone wallet from prior food orders placed for the resident. The Health Information Manager’s written statement confirmed that the resident’s credit card had been used on 02/28/2026 for a personal grocery order while the resident was in the hospital, and that the staff member contacted the responsible party and arranged reimbursement. The DON acknowledged being notified of the grievance and that the staff member had used the resident’s credit card without authorization, and also acknowledged that the incident was not reported to the State, though she stated it perhaps should have been. The administrator stated she was aware of the grievance, reviewed it, and knew that the staff member had used the resident’s credit card stored on a personal cell phone for a personal purchase, but she did not consider it an alleged violation requiring reporting because she believed it was unintentional and did not rise to that level. No employee coaching record related to this incident was provided upon request. Resident #2 was an older male with atherosclerotic heart disease, a history of transient ischemic attack, and seizures, with a BIMS score of 13 indicating intact cognition and no documented memory concerns, and was independent in self-care and mobility. He submitted a grievance reporting that $57 was missing from a locked drawer in his room, stating that he remembered the drawer being locked and that the key was kept in another, unlocked drawer with his socks where it was visible. The social worker documented examining the drawer, finding it intact and not openable without a key, and confirmed that no money was found. The resident was educated on key use, his right to keep the key on his person, to maintain a spending log, and his right to file a police report, which he declined at that time. The administrator later acknowledged being aware of this grievance of missing money but stated that it was not brought to her as an allegation of theft and that she did not view it as a specific allegation requiring reporting to the State Agency. She described that many male residents loan money to others and was unsure whether the missing money grievance was confirmed. The DON reported she had not been notified of this grievance and would need to follow up with the social worker. Facility policies on abuse, misappropriation, and grievances stated that all alleged or suspected violations, including theft or misappropriation of resident property, must be promptly reported to community management and appropriate state agencies, and that residents have the right to be free from abuse and exploitation and to keep personal property secure from theft or loss. Despite these policies, the allegations involving unauthorized use of a resident’s credit card and missing resident funds were not treated and reported as required alleged violations. The facility’s written guidance defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent, and defined an alleged violation as any observed or reported situation that, if verified, could be noncompliance with federal requirements related to mistreatment, exploitation, neglect, abuse, or misappropriation. The same guidance required that all alleged or suspected violations and all substantiated incidents of abuse be promptly reported to appropriate state agencies. Nonetheless, the administrator and social worker did not report the two residents’ allegations of unauthorized credit card use and missing money to the State Survey Agency within the required timeframes, resulting in the cited deficiency for failure to timely report suspected abuse, neglect, exploitation, or misappropriation.
Failure to Investigate and Report Alleged Misappropriation and Theft of Resident Property
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and report alleged violations of abuse, neglect, and exploitation, specifically misappropriation of funds and theft of property, for two residents. For the first resident, an older female with type 2 diabetes mellitus, unspecified dementia, and a cognitive communication deficit, the quarterly MDS showed a BIMS score of 14, indicating intact cognition without noted memory concerns. Her care plan documented impaired cognitive function/dementia or impaired thought process, and she was dependent on staff for toileting hygiene but independent in eating, showering, and mobility. A grievance form dated 03/06/2026 documented that this resident reported her daughter had informed her that the resident’s credit card was charged $152.00 at a grocery store curbside service, and the resident stated she had not made a purchase on that date. The grievance noted that the resident still had the credit card in her wallet and that her daughter was canceling the card. Further documentation for this resident included a written statement dated 03/10/2026 from the Health Information Manager, who reported that on 02/28/2026 she placed a curbside grocery order and, in error, used the resident’s credit card that had been previously saved in her phone wallet after prior authorized purchases for the resident. She acknowledged that this error resulted in a $152.42 charge to the resident’s card, described contacting the responsible party, and described arrangements to reimburse the funds. The Director of Nursing later stated in interview that she recalled the grievance about unauthorized use of the credit card but did not report it to the State Survey Agency or conduct an investigation because she viewed it as an unintentional occurrence. The Administrator, who served as the Abuse and Neglect Coordinator, similarly stated that she did not consider the incident to rise to the level of an alleged violation, did not report it to the State Survey Agency, and did not investigate further. For the second resident, an older male with atherosclerotic heart disease, a history of transient ischemic attack, and seizures, the quarterly MDS showed a BIMS score of 13, indicating intact cognition and organized thinking, and he was documented as independent in self-care and mobility. His care plan indicated he was able to participate in activities of his choice within his physical and cognitive abilities. A grievance form dated 03/13/2026 documented that this resident reported $57 missing from a locked drawer in his room, stating he remembered the drawer being locked and that the key was kept in another, unlocked drawer with his socks where it was visible. The social worker documented examining the drawer, noting it was not broken and could not be opened without a key, and that the key was visible in the other drawer; no money was found. The grievance response included education to the resident about key use, his right to keep the key on his person, to maintain a spending log, and his right to file a police report, which he declined at that time. The DON stated she was not notified of this grievance and was unaware whether the incident was investigated further by the Administrator. The Administrator stated that the grievance was handled by the social worker, that she was not familiar with the details, and that she did not view all grievances involving money as reportable allegations, so she did not report or investigate this matter as an official allegation. Facility documents, including the Code of Conduct, Grievances policy, Statement of Resident Rights, and Abuse Guidance, described expectations that staff respect resident rights, not take resident property, and immediately report any suspected abuse, neglect, or theft of resident property to supervisors and community management. The Abuse Guidance defined misappropriation of resident property as wrongful use of a resident’s belongings or money without consent and defined an alleged violation as any reported situation that, if verified, could be noncompliance with federal requirements related to mistreatment, exploitation, neglect, abuse, or misappropriation of resident property. The same guidance stated that all alleged or suspected violations and all substantiated incidents of abuse would be promptly reported to appropriate state agencies per state and federal requirements. Despite these written policies, the facility did not treat the unauthorized use of the first resident’s credit card or the second resident’s report of missing funds from a locked drawer as alleged violations requiring investigation and reporting to the State Survey Agency, resulting in the cited deficiency.
Accessible Hazardous Items and Smoking Materials Left Unsecured
Penalty
Summary
The facility failed to keep the resident environment free of accessible accident hazards when an ADON was observed disinfecting personal protective eyewear outside a room and placing a canister of germicidal wipes back into an unlocked isolation bin by the door. The canister had a caution label for possible eye irritation and flammability, and the ADON stated the wipes could be hazardous for residents with dementia and should have been under lock. The DON later confirmed the wipes should have been kept away from residents for safety because residents with dementia could misuse them and be injured. The facility also failed to secure smoking materials for two residents. Resident #157, a male with diagnoses including anemia, dysphagia, and flaccid bladder, had a BIMS of 15 and a care plan and smoking assessment directing that smoking materials be kept under supervision for safekeeping. A box of cigarettes with three cigarettes was observed on his bed, and the assigned CNA confirmed it was there; the assigned nurse removed it and stated cigarettes should be locked up. Resident #110 was observed asleep with a cigarette lighter on the bedside table, accessible from the hallway, and the DOR stated the lighter should have been secured. The facility policy stated residents should not keep personal cigarettes, lighters, or matches.
Undated Open Lidocaine Vial on Medication Cart
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with accepted professional principles on the 300 Hall medication cart. During observation on 03/04/2026 at 3:15 p.m. with LVN B, a vial of Lidocaine HCL injection 1% was found open in the cart with an expiration date of 11/27, but no open date on the vial. LVN B stated nurses are trained to check medication carts for open, undated, or expired medications and said she did not know why the Lidocaine vial had not been dated. She also stated an open multidose vial needed to be dated because it would only be good for 28 days. During interview, PCN stated the Lidocaine was not on the list of medications requiring a time and date once opened, but also stated it should have been on the list because it was a multidose vial and once opened was only good for 28-day use. The DON later stated the Lidocaine 1% should not have been on the medication cart because it was used when a Rocephin injection was given and no residents were prescribed Rocephin. Record review showed the facility policy required medications and biologicals to be labeled in accordance with accepted professional standards and drug-labeling regulations, and CDC guidance stated that once a multi-dose vial is opened, it should be dated and discarded within 28 days.
MDS Assessment Did Not Reflect CPAP Use
Penalty
Summary
The facility failed to ensure Resident #7’s quarterly MDS assessment accurately reflected his status by omitting that he received CPAP therapy. Resident #7 was a male resident with diagnoses including paraplegia, PTSD, major depressive disorder, and obstructive sleep apnea. His care plan directed staff to administer CPAP as ordered, and his active orders showed CPAP was to be used every night while sleeping for obstructive sleep apnea. His MAR for 12/1/2025 through 12/31/2025 reflected that CPAP was applied every night, and the resident stated during interview that he used CPAP every night since admission. During record review and interviews, the MDS nurse stated she missed the CPAP and said it should have been noted under non-invasive mechanical ventilator. She stated she was accountable for the accuracy of the MDS and that an inaccurate MDS could result in missed care for a resident. The DOCR, DON, and ADM also stated that the quarterly MDS needed to reflect that the resident received CPAP and that MDS accuracy was important to show what care the resident required. The CMS RAI Manual was reviewed and reflected that the assessment must accurately reflect the resident’s status.
Improper Perineal Care During Incontinent and Catheter Care
Penalty
Summary
The facility failed to ensure appropriate incontinent care and catheter care for a resident who was incontinent of bladder and had an indwelling catheter. Resident #50 had diagnoses including Parkinson's disease, dementia, chronic kidney disease, hyperlipidemia, and urinary retention. The resident's quarterly MDS indicated a BIMS score of 15, showing the resident was cognitively intact, and the resident was documented as always continent of bowel and having an indwelling catheter. The care plan identified the need for a catheter due to neuromuscular dysfunction of the bladder and included monitoring for signs and symptoms of infection. During observation, while CNA D was providing catheter/incontinent care, he used a back-and-forth motion to wipe the resident's buttocks instead of wiping front to back. In interview, CNA D stated he should have wiped front to back and changed the wipe before another pass to prevent possible infection, and said he was nervous and made a mistake. The DON stated staff should not use a back-and-forth motion during incontinent care and should wipe front to back with a clean wipe each pass to prevent fecal matter from entering the urinary tract and causing infection. The facility policy on perineal care stated to use one wipe per swipe and wipe front to back.
Expired Catheters Left on Medication Cart
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 1 medication cart, the 400 Hall medication cart, out of 6 carts reviewed. During observation on 03/05/2026 at 11:24 a.m., surveyors found 2 male intermittent catheters on the 400 Hall medication cart with a use-by hourglass symbol dated 11/09/2025. The report states the hourglass symbol is a standardized international symbol used on medical devices to show the final date the manufacturer guarantees the product's safety and effectiveness. During an interview on 03/05/2026 at 11:30 a.m., RN A stated the 2 male intermittent catheters should have been removed from the cart because the use-by date signified the device could have a loss of integrity. During interviews on 03/06/2026, the DON stated supplies on medication carts needed to be checked for use-by dates and expiration dates, and the ADM stated expired items needed to be removed from medication carts and checked accordingly to ensure proper use, effectiveness, and function. The facility policy titled Medication Management stated medications are stored, dispensed, and destroyed in a manner to ensure safety and conformance with state and federal laws.
Unlabeled and Undated Food Stored in Resident Refrigerator
Penalty
Summary
The facility failed to ensure the safe and sanitary storage of a resident’s personal food items in the room refrigerator. During observation, fried chicken was found in the refrigerator in an unlabeled and undated storage bag, and the same item remained present on a later observation. The resident stated the fried chicken had been in the personal refrigerator for about 2 days. The assigned CNA and nurse both confirmed that the refrigerator contained fried chicken in an unlabeled and undated bag. The CNA stated she did not know who was responsible for checking the resident’s personal refrigerator for expired food. The nurse stated all staff were responsible for removing undated and unlabeled food items from residents’ personal refrigerators and said the resident risked food-borne illness by possibly consuming food that was unlabeled and undated. The DON also confirmed that perishable food and drinks in residents’ personal refrigerators should be labeled and dated, and that staff were responsible for removing undated, unlabeled food items daily. The facility policy reviewed stated the refrigerator should be routinely checked to identify unsafe foods and discard items that appeared to have gone bad or were expired.
Infection Control Lapses During Wound Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for one resident reviewed for infection control. During observed wound care for a resident with quadriplegia, hypertension, chronic kidney disease, a stage 4 pressure ulcer of the right buttock, osteomyelitis, and type 2 diabetes mellitus, the LVN did not sanitize between her fingers while performing hand hygiene. The resident’s record showed he was cognitively intact, dependent on staff for care, and had an indwelling catheter and an ostomy. During the same wound care observation, the LVN cleansed the wound and then applied ointment around the wound bed without changing gloves or sanitizing her hands after the wound cleansing. In interview, the LVN stated she should have sanitized between her fingers and should have changed her gloves after cleaning the wound because the gloves were soiled. The DON stated staff should sanitize all surfaces of their hands and that the nurse should have changed gloves after cleaning the wound to avoid cross contamination of the ointment.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. For Resident #23, the facility did not implement contact precautions as ordered by the physician. Despite the presence of a contact isolation sign, Resident #23 was observed in the day room with other residents, indicating a failure in communication and implementation of isolation protocols. Additionally, during wound care, LVN D did not change gloves or sanitize hands after cleansing the wound, which could lead to the spread of infection. For Resident #90, improper infection control practices were observed during medication administration. MA G was seen handling a cup of water with her fingers inside the cup, which could result in cross-contamination. Despite being trained in infection control, MA G admitted to forgetting the proper procedure while managing multiple tasks simultaneously. Resident #135's supervised self-medication administration of eye drops also demonstrated lapses in infection control. MA C did not instruct the resident to sanitize hands before applying the eye drops and failed to observe the resident's technique, which included wiping excess medication with soiled hands. This oversight could lead to cross-contamination and further infection, as the resident's hands were not cleaned before or after the procedure.
Inaccurate Tobacco Use Assessment for Resident
Penalty
Summary
The facility failed to ensure that the assessment accurately reflected the resident's status for one resident whose assessments were reviewed. Specifically, the resident's use of tobacco was not identified on the resident's annual Minimum Data Set (MDS) assessment. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, had a comprehensive care plan indicating the use of smokeless tobacco. However, the MDS assessment incorrectly coded the resident as not using tobacco, which was an oversight by the responsible RN. This error occurred despite the resident's care plan clearly stating the use of smokeless tobacco and the resident being observed using it in the facility's smoking area. The RN responsible for completing the MDS acknowledged the error, attributing it to the resident's previous use of a vape cigarette, which had been discontinued two years prior. The Director of Nursing (DON) was unaware of the discrepancy in the annual assessment, although she had observed the resident using smokeless tobacco. The facility utilized the Resident Assessment Instrument (RAI) manual for MDS and care plan updates, which was available to staff digitally. The coding instructions in the RAI manual specify that any form of tobacco use during the look-back period should be coded as 'yes,' indicating a failure to adhere to these guidelines in this instance.
Failure to Update Resident's Care Plan for Tobacco Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and time frames to meet the resident's mental, nursing, and psychosocial needs. Specifically, the facility did not update the care plan to accurately reflect the resident's current tobacco use. The resident, who was cognitively intact with a BIMS score of 15, had a care plan that incorrectly stated they smoked tobacco and used a vapor cigarette, while in reality, they had quit smoking and only used dip tobacco. The Director of Nursing (DON) acknowledged that the care plan should have been updated to reflect the resident's current use of smokeless tobacco. The MDS LVN, responsible for updating care plans, missed this change. The facility's RN stated that care plans were updated every three months or as needed, but the smoking section was overlooked. The facility used the RAI manual as their policy for MDS and care plan updating, which was available to staff digitally.
Inadequate Incontinent Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident, leading to a deficiency in preventing urinary tract infections. The resident, who had a history of Type 2 diabetes mellitus, hypothyroidism, hypertension, chronic kidney disease, and Guillain-Barre syndrome, was frequently incontinent of bladder and bowel and required extensive assistance with activities of daily living. During an observation, it was noted that CNA A did not clean between the labia or the urinary meatus while providing incontinent care. Additionally, after the resident urinated while being turned on her side, CNA A and CNA B did not clean the genital area again before placing a clean brief on the resident. Interviews with CNA A and CNA B revealed that they did not clean the resident thoroughly due to concerns about being too invasive and acknowledged the oversight of not cleaning the urinary opening. The Director of Nursing confirmed that the urinary meatus area should have been cleaned and that the resident should have been cleaned again after urination. The facility's policy on perineal care, which includes cleaning from front to back, was not followed, contributing to the risk of infection and skin breakdown for the resident.
Medication Labeling Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles, specifically regarding the labeling of an ophthalmological solution for a resident. During an observation, it was noted that a bottle of Ciprofloxacin 0.3% ophthalmological solution, prescribed for a resident with chronic allergic conjunctivitis, was not labeled with an open date. This oversight was confirmed by a Medication Aide, who acknowledged that the medication had been previously opened and should have been marked with an open date to track its expiration. The Director of Nursing (DON) confirmed that the facility's expectation was for all medications to be labeled with their open dates, as medications like eye drops are only effective for 30 days after opening. The facility's policy, revised in January 2023, also required medications to be labeled with expiration dates in accordance with professional standards and regulations. The lack of an open date on the medication bottle could prevent staff from determining the expiration date, potentially leading to the administration of expired medications.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Floresville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harmony Care At Floresville | 0.5 mi | ★★★★★ | 18 | 0 |
| Prairie Meadows Rehabilitation And Healthcare Cent | 0.8 mi | ★★★★★ | 23 | 3 |
| Country Care Manor | 15.2 mi | ★★★★★ | 6 | 0 |
| Bluebonnet Nursing And Rehabilitation | 21.9 mi | ★★★★★ | 38 | 0 |
| Southeast Nursing & Rehabilitation Center | 23.4 mi | ★★★★★ | 16 | 1 |
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