Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hacienda Oaks At Beeville during CMS and state inspections, most recent first.
Incomplete Care Plans for Call Light Use and PTSD Triggers: A resident with hemiplegia, dementia, CHF, depression, and anxiety had a care plan that did not include her soft touch call light, even though it was in use and within reach. Another resident with PTSD, vascular dementia, and other chronic conditions had a care plan that listed general calming interventions but did not document his specific PTSD triggers, despite assessments and staff interviews showing he was private, sometimes agitated, and had not disclosed triggers.
Insufficient Resident Room Square Footage: The facility failed to provide the required 80 sq ft per resident in all 48 resident rooms. Surveyors reviewed the bed classification form, measured the rooms with a laser device, and found that the 2-bed rooms measured 151 to 160 sq ft and the 3-bed rooms measured 219 to 234 sq ft, which did not meet the required space per resident. The ADM provided a waiver request and stated there had been no changes to the rooms.
Medication Given Outside Blood Pressure Parameters: A resident with HTN and moderate cognitive impairment had an order for valsartan with instructions to hold if SBP was below 110. An LVN administered the medication when the resident's BP was 105/59, outside the ordered parameters. The LVN acknowledged that giving BP medication outside parameters could harm the resident, and the DON stated the dose should not have been given.
A resident admitted for hospice respite care did not have a baseline care plan completed within 48 hours that included essential information such as hospice status and DNR code status, despite these being present in physician orders. Staff interviews confirmed the omission was due to oversight, and the facility's policy requiring timely and comprehensive baseline care planning was not followed.
A resident with a documented diagnosis of dementia and severely impaired cognition did not have dementia addressed in their care plan, despite this need being identified in assessments. Facility staff confirmed the omission and acknowledged that the care plan should have included interventions for dementia, as required by policy.
A resident's care plan was not updated by the interdisciplinary team to reflect the discontinuation of blood pressure medication, resulting in outdated information remaining in the plan. Despite the resident no longer having an active order for antihypertensive medication, the care plan continued to address potential complications related to its use. Staff interviews confirmed that the care plan review process failed to ensure accuracy after the resident's medication was stopped.
A nurse administered medication to a resident with multiple diagnoses, including Parkinsonism and dementia, in the middle of the dining room without obtaining the resident's permission. The medication was given publicly, disregarding the resident's right to privacy and dignity, despite facility policies and staff training requiring privacy during medication administration.
Staff failed to keep a linen cart covered while distributing clean laundry and did not follow proper hand hygiene during wound care for a resident with a stage 4 pressure ulcer. During wound care, a nurse did not sanitize hands between glove changes and allowed the resident’s open wound to come into contact with a soiled brief, contrary to facility infection control policies.
Surveyors found that all resident rooms failed to meet the required minimum square footage per resident, with measurements showing insufficient space in both double and triple occupancy rooms. The administrator confirmed the room sizes had not changed and requested a waiver for the deficiency.
Two residents with cognitive impairments and urinary catheters were observed with uncovered catheter bags, contrary to their care plans and facility policy. The facility's policy requires catheter bags to be covered to maintain resident dignity, but hospice staff used their own supplies without covers, leading to this deficiency.
Incomplete Care Plans for Call Light Use and PTSD Triggers
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents so that the plans reflected all identified needs and included individualized, measurable interventions. For one resident with hemiplegia/hemiparesis, unspecified dementia, peripheral vascular disease, CHF, major depressive disorder, and anxiety disorder, the care plan addressed impaired physical functioning and included interventions for two-person assistance with transfers, incontinent care, and repositioning, but it did not reflect the use of a soft touch call light that was present in the resident's room and within reach during observation. The MDS Nurse stated the soft touch call light should have been added to the care plan as an intervention. For another resident with type 2 DM with hyperglycemia, hyperlipidemia, HTN, alcoholic cirrhosis, vascular dementia, non-compliance with treatment, and PTSD, the care plan included a focus on behaviors associated with PTSD and listed interventions such as creating a calm and safe environment, reducing stimuli, encouraging expression of feelings and concerns, and identifying specific triggers or situations that exacerbate anxiety. However, the resident's psychosocial assessment stated he did not like to be bothered, did not like to talk about his past, and preferred to be left alone, while the trauma-informed care assessment showed he acknowledged a traumatic event but denied nightmares, avoidance, hypervigilance, numbness, guilt, or other PTSD symptoms. Staff interviews reflected that he did not disclose triggers, and the MDS Nurse stated that until the day of the interview there were no triggers listed anywhere in the chart. Interviews with the SSA, DON, RN, and CNAs showed that staff were aware the resident was private, quiet, and sometimes agitated, but they did not have documented PTSD triggers to guide care. The SSA stated the care plan needed updating because asking him to express triggers and concerns could trigger him, and the MDS Nurse later documented that asking too many questions aggravated him. The facility's comprehensive care plan policy required person-centered care plans with measurable objectives and timeframes that include all services identified in the comprehensive assessment, including trigger-specific interventions for trauma survivors, but the two residents' care plans did not fully reflect the assessed needs described in the record.
Insufficient Resident Room Square Footage
Penalty
Summary
The facility failed to provide the required 80 square feet per resident in 48 of 48 resident rooms. Record review of the Health and Human Services Form 3740 Bed Classifications dated 06/29/26 showed 44 rooms with 2 beds and 4 rooms (23, 24, 51, and 52) with 3 beds. During the survey investigation beginning at 11:30 a.m. on 06/29/26, an agency laser measuring device was used to measure all existing rooms, and the 2-bed rooms measured between 151 and 160 square feet while the 3-bed rooms measured between 219 and 234 square feet. None of the rooms provided the required square footage per resident. During interview and record review at 3:00 p.m. on 06/29/26, the ADM provided a letter requesting a room size waiver for rooms 1 through 52 and stated there had been no changes to the rooms.
Medication Given Outside Blood Pressure Parameters
Penalty
Summary
Resident #1, a [AGE]-year-old male admitted on 05/04/26 with essential primary hypertension and a BIMS score of 10 indicating moderate cognitive impairment, had an active order for valsartan 40 mg by mouth in the morning for hypertension, with instructions to hold the medication if systolic blood pressure was less than 110. The care plan included a focus on potential for altered tissue perfusion related to hypertension and an intervention to administer medications as ordered by the physician. On 05/08/26, the MAR showed valsartan was administered by LVN A when Resident #1's blood pressure was 105/59, which was outside the physician's hold parameter. During interview, LVN A stated she normally checked blood pressure before giving blood pressure medications and acknowledged that administering medication outside ordered parameters could harm the resident, but she did not remember the specific administration. The DON reviewed the MAR and stated the valsartan should not have been given at that time because it was outside the physician's parameters. The facility policy on medication administration stated that vital signs should be obtained and recorded when applicable or per physician orders, and medications should be held when vital signs are outside prescribed parameters.
Failure to Complete Baseline Care Plan with Hospice and DNR Status
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for a resident who was admitted for hospice respite care. The baseline care plan did not include essential information such as hospice status and Do Not Resuscitate (DNR) code status, despite these being present in the resident's physician orders and relevant to her care. The resident had significant medical conditions, including hemiplegia, hemiparesis following a cerebral infarction, chronic viral hepatitis C, type 2 diabetes, and dysphagia, and was admitted and discharged under hospice care. The resident was rarely or never understood, as indicated by the MDS assessment, and required person-centered care planning to address her complex needs. Interviews with facility staff, including the ADON, DON, SS nurse, and MDS coordinator, revealed that the omission of hospice and DNR status from the baseline care plan was due to oversight and lack of proper documentation. Staff acknowledged that the information should have been included and that the baseline care plan is used to guide care and inform staff of critical care instructions. The facility's policy required the development and implementation of a baseline care plan to provide effective and person-centered care, but this was not followed in this instance.
Failure to Include Dementia Diagnosis in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that addressed all of a resident's needs, specifically omitting the diagnosis of dementia from the care plan for one resident. Record reviews showed that the resident had a documented diagnosis of unspecified dementia, which was listed as a secondary admission diagnosis and was also identified as an active diagnosis in the Minimum Data Set (MDS) assessment. The MDS assessment further revealed a severely impaired cognition score and triggered the need for care planning related to cognitive loss/dementia. Despite these findings, the resident's care plan did not include any focus or interventions related to dementia. Interviews with facility staff, including the ADON, MDS coordinator, and DON, confirmed that the responsibility for updating and reviewing care plans was shared among them. All acknowledged that the resident's dementia diagnosis should have been included in the care plan, as required by facility policy and the MDS triggers. The facility's policy mandates that all identified needs from the comprehensive assessment, including those triggered by the MDS, must be addressed in the care plan with measurable objectives and timeframes. The omission was attributed to a failure in the process of updating and reviewing the care plan, as confirmed by staff interviews and record reviews.
Failure to Update Care Plan Following Discontinuation of Blood Pressure Medication
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly reviews, to accurately reflect the resident's current condition. Specifically, the care plan continued to include interventions related to blood pressure medication use, despite the resident no longer having an active order for such medication. The resident, an elderly female with diagnoses of unspecified dementia and hypertensive chronic kidney disease, had her blood pressure medication discontinued several months prior, but this change was not reflected in her care plan. Interviews with facility staff, including the ADON, MDS nurse, and DON, revealed that while the interdisciplinary team was responsible for reviewing and updating care plans, the process failed in this instance. The staff acknowledged that the care plan should have been updated to remove references to blood pressure medication, but it was overlooked. The facility's own policy required care plans to be reviewed and revised after each assessment, but this was not followed, resulting in the care plan containing outdated and inaccurate information regarding the resident's medication status.
Failure to Ensure Resident Privacy During Medication Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) administered medication to a male resident with Parkinsonism, dysphagia, cognitive communication deficit, bipolar disorder, and dementia in the middle of the dining room without obtaining the resident's permission. The resident, who had moderately impaired cognition as indicated by a BIMS score of 08, was observed being spoon-fed his crushed medication mixed with pudding in a public area filled with other residents. This action was taken without regard to the resident's privacy or dignity, as required by facility policy and standard practice. Interviews with the LVN, another nurse, and the Director of Nursing (DON) confirmed that medications should not be administered in public areas without the resident's consent, as it could cause embarrassment or loss of dignity. The facility's policies and recent in-service training also emphasized the importance of providing privacy during medication administration and not interrupting meal services for this purpose. Despite these guidelines, the LVN failed to ensure privacy for the resident during medication administration.
Infection Control Lapses in Linen Handling and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple lapses in infection control practices. During an observation, a laundry aide was seen distributing clean laundry from an uncovered linen cart in a resident hallway. Both the laundry aide and the laundry supervisor were unaware that the linen cart was required to remain covered at all times during transport and distribution, contrary to facility policy. The Director of Nursing confirmed that the cart should have been covered to prevent cross-contamination and unauthorized access to residents' clothing. Additionally, a nurse did not perform proper hand hygiene during wound care for a resident with a stage 4 pressure ulcer. The nurse failed to wash or sanitize hands after removing gloves and before donning new gloves while providing wound care. During the same episode, the resident’s wound was left uncovered and came into contact with a visibly soiled brief when the resident was repositioned. Both the nurse and the Assistant Director of Nursing acknowledged that these actions were not in accordance with infection control protocols and could lead to contamination of the wound. The resident involved had significant medical conditions, including a stage 4 pressure ulcer, severe chronic kidney disease, and vascular dementia. Physician orders required specific wound care procedures, including cleansing, application of dressings, and maintaining a sterile environment. The facility’s own policies on infection prevention, hand hygiene, and wound management outlined the need for proper handling of linens, consistent hand hygiene, and protection of wounds from contamination, all of which were not followed during the observed incidents.
Resident Rooms Below Required Square Footage
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in all 48 resident rooms, as determined by direct measurement during a survey. Specifically, rooms with two beds measured between 149 and 156.5 square feet, and rooms with three beds measured between 220.1 and 220.9 square feet, which does not meet the regulatory requirement of at least 80 square feet per resident in multiple occupancy rooms. This deficiency was identified through observations, interviews, and record reviews, including a review of the facility's bed classification documentation. The administrator confirmed that no changes had been made to the rooms and provided a letter requesting a waiver for the room size requirement for all affected rooms.
Failure to Cover Catheter Bags Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity and privacy of two residents by not ensuring their urinary catheter bags were covered. Resident #1, who has Alzheimer's Disease, a pressure ulcer, major depressive disorder, and neuromuscular dysfunction of the bladder, was observed in the dining room with an uncovered catheter bag. Despite having a care plan that included a privacy cover for the catheter, the resident was unaware of the need for a cover and stated it did not bother him. Similarly, Resident #2, who suffers from pressure ulcers, severe protein-calorie malnutrition, chronic kidney disease, vascular dementia, and neuromuscular dysfunction of the bladder, was found with an uncovered catheter bag while eating lunch in her room. Her care plan also indicated the use of a catheter bag cover, but she was unsure why her bag was uncovered. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the catheter bags were uncovered because hospice staff had changed the bags and used their own supplies, which did not include covers. The facility's policy requires all catheter bags to be covered to protect residents' dignity and rights, but the catheter care policy did not specify the need for a cover. The Administrator confirmed that it is expected for all residents with catheters to have covers on their bags, aligning with the facility's policy and resident rights to a dignified existence.
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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 Beeville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Beeville | 1.1 mi | ★★★★★ | 2 | 0 |
| Palma Real | 21.8 mi | ★★★★★ | 7 | 0 |
| Live Oak Nursing And Rehabilitation Center | 23.1 mi | ★★★★★ | 6 | 0 |
| Kenedy Health & Rehabilitation | 27 mi | ★★★★★ | 13 | 0 |
| La Bahia Nursing & Rehabilitation | 29 mi | ★★★★★ | 8 | 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 October 2026) and official state health department websites.