Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Jourdanton Nursing And Rehabilitation during CMS and state inspections, most recent first.
Food Storage and Handling Deficiencies: The kitchen failed to store food in accordance with professional standards when surveyors observed an open bag of broccoli exposed in the freezer, a tub of peanut butter with residue around the rim, an unsecured open bin of flour, and a box of oranges with mold on 5 oranges. The DM and RD stated that food should be stored properly to prevent contamination and that moldy food should not be kept or served.
Improperly secured dumpster doors were observed on 1 of 2 dumpsters, with 2 side doors and 1 top door left open. A staff member acknowledged the doors should be closed to keep animals out, and the DM and RD stated open dumpsters could attract rats and roaches and lead to pest contamination of food. The facility policy required outside dumpsters to have tightly fitting lids, doors, or covers and to remain covered when not being loaded.
A resident with dementia and severe cognitive impairment was observed lying in a low bed with a floor mat, and when he asked for water he could not locate his call light because it was under the floor mat. A CNA stated the call light should have been clipped to the sheet and within reach, but she had not checked its placement; the DON stated staff should constantly check call light placement so residents can ask for assistance.
Failure to Disburse Resident Trust Funds: A resident with intact cognition and bowel/bladder incontinence was not given access to $250 from her trust account to buy incontinent supplies. The BOM said the withdrawal request was forgotten by the staff member who normally cashed trust fund checks, and when that staff member quit, no alternate process was in place to cash the check. The ADM acknowledged the resident had a right to access her funds and that the delay left her without the money she needed.
A MA left a laptop open, unlocked, and unattended on the MA cart at the nurse's station with the EMAR visible to people passing by, including residents nearby. MA B closed the laptop after being alerted and stated it should not have been left open and unattended. The DON later confirmed the lapse, noted the MA had prior privacy training, and referenced facility HIPAA policy that identifies leaving a secured application unattended while logged on as a violation.
Respiratory care was not properly provided for two residents with COPD and oxygen/nebulizer needs. One resident’s nebulizer mask and mouthpiece were found loose in drawers instead of stored in bags, and staff confirmed they should have been bagged. Another resident’s oxygen concentrator had a vent cover with white buildup while she was receiving continuous O2, and staff noted the filter/vent had not been checked or cleaned as expected.
Failure to document hospital transfer and change in condition: A cognitively intact resident with depression, TBI, COPD, and anxiety was sent to the hospital after reporting confusion and fear that someone was hurting her and trying to get her. The chart lacked documentation of the transfer, the change in mental status, and who was notified, and the DON confirmed the record was incomplete.
A resident with chronic pain and cognitive impairment did not receive scheduled doses of Lyrica for several days because nursing staff failed to follow up with the pharmacy or consult the PCP for a one-time order from the Pyxis, despite the medication being available in-house. The resident received PRN pain medications during this period, but not the prescribed routine pain management.
CNAs failed to fully close the privacy curtain while providing perineal care to a resident with cognitive impairment and multiple medical conditions, resulting in a lack of privacy and potential exposure to others in the room. Both CNAs acknowledged the oversight, despite having received recent resident rights training, and the DON confirmed that privacy should have been maintained according to facility policy.
A resident with cognitive impairment and multiple diagnoses experienced a fall resulting in a superficial abrasion, but the incident was not accurately coded as a fall with injury on the admission MDS assessment. Although the fall and injury were documented elsewhere, the MDS assessment reflected the fall as without injury, contrary to the resident's actual condition.
A resident at risk for pressure injuries did not receive weekly skin assessments as required by their care plan and facility policy, with two weeks lacking documented assessments. The resident, who had multiple medical conditions and required assistance with mobility, did not have an active order for weekly skin assessments, and staff interviews confirmed the assessments were not completed or documented. The facility's policy required weekly full-body skin assessments by a licensed nurse, which was not followed in this instance.
A CNA did not retract the foreskin of an uncircumcised male resident during incontinent care, resulting in inadequate cleaning of the area. The resident, who had multiple chronic conditions and was always incontinent, had a care plan requiring proper incontinence care due to a history of skin issues. Facility policy and staff training required foreskin retraction for hygiene, but this step was omitted during the observed care.
Two residents did not have complete documentation of Cefdinir administration in their medical records, with multiple scheduled doses left blank in the MAR. Staff interviews revealed confusion about whether blanks indicated missed doses or missed documentation, and in some cases, 'see progress note' was entered without a corresponding note. Facility policy requires accurate and timely documentation of medication administration, which was not followed in these instances.
CNAs did not wash their hands before providing incontinent care to a resident with multiple chronic conditions and failed to sanitize hands between glove changes, contrary to facility policy. Both staff admitted to forgetting proper hand hygiene, and the DON confirmed the required procedures and training.
The facility did not thoroughly investigate or report multiple allegations of abuse, neglect, or mistreatment involving several residents, including incidents of rough handling by staff, missed medication administration, resident-to-resident altercations, and an allegation of physical abuse by staff. Required investigation documentation and timely reporting to the state were not completed, and staff interviews confirmed the absence of investigation records.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
Two residents experienced deficiencies in medical record documentation: one was not accurately recorded as wearing a required wander guard device, despite staff knowing it was not in place, and another did not have timely documentation of IV antibiotic administration on the MAR, with the ADON entering the information days later in a nursing note.
Two residents with severe cognitive impairment and significant ADL needs did not have peri-care documented in their medical records for two shifts, despite staff interviews confirming care was provided. The omission occurred because CNAs were occupied with other tasks and failed to record the care in the electronic system, resulting in incomplete records and a lack of evidence for services rendered, contrary to facility policy and professional standards.
A resident sustained a head laceration and a fractured clavicle after not being properly secured in a transport van. The incident occurred when the van driver made a sudden stop, causing the resident to slide out of her wheelchair. The resident, who had a history of traumatic brain injury and other conditions, was cognitively intact. Witnesses confirmed the resident was not secured with a lap belt or cross body strap during transport.
A resident did not receive the prescribed large protein portions at meals, despite being under his ideal body weight and having a physician's order for a therapeutic diet. Observations showed insufficient protein portions during meals, and interviews revealed a communication breakdown between nursing and dietary staff. The facility's policy for notifying diet changes was not adequately followed.
A medication cart was left unlocked and unattended in a common area and a hallway, containing medications and scissors, with staff, residents, and visitors nearby. RN A, responsible for the cart, admitted to leaving it unlocked while attending to other tasks. The DON claimed visual contact with the cart but acknowledged it was unattended when assessed by a surveyor. Facility policies require carts to be locked when not in use.
A resident with a stage 4 pressure injury received wound care from an RN who failed to perform hand hygiene between glove changes, violating infection control protocols. The RN, new to the facility, admitted to not using hand sanitizer after glove removal, as required by training and policy. This lapse was observed during a survey, indicating a deficiency in the facility's infection prevention program.
The facility did not meet the required minimum square footage per resident in all rooms, with each two-person room providing only 77 square feet per bed instead of the required 80 square feet. The Administrator acknowledged the deficiency and wished to continue the current room size waiver.
A facility failed to use an AED during CPR for a resident with a full code status, despite having the equipment available. The resident, with a history of serious medical conditions, was found unresponsive, and CPR was initiated by staff. However, the AED was not utilized, contrary to facility policy.
Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During observation, a freezer contained a box folded closed with the corners tucked under one another, leaving a gap in the center that exposed an open bag of broccoli to the air. In the dry food storage area, which was being used as an office, a closed tub of peanut butter had peanut butter around the rim of the tub, and a bin of flour was found with the top not secured and opened. The observation also identified a box of oranges with the remainder of the oranges in the bottom, and 5 of the oranges had mold. During interview, the DM stated that food should be stored properly in the freezer to maintain integrity and prevent freezer burn and cross contamination, that the flour bin needed to be secured to prevent insects from getting inside and contaminating the food, that containers such as the peanut butter needed to be clean after use to prevent pests or rodents, and that expired or moldy food should be discarded because it can cause food borne illness. The RD stated that food should be stored properly to prevent cross contamination and food borne illness, and that rotten or moldy food should not be kept or served to residents.
Improperly Secured Dumpster Doors
Penalty
Summary
The facility failed to dispose of garbage and refuse properly for 1 of 2 dumpsters on the premises, as dumpster #1 had three doors left open. During observation on 1/13/2026 at 10:00 AM, dumpster #1 was found with 2 sliding side doors open and one black top door open. A staff member stated she knew the dumpster doors should be closed so animals could not get into the dumpsters and that garbage pickup occurred every Monday. Interviews with the DM and RD stated it was important to keep dumpster doors closed because open dumpsters could bring rats and roaches to the facility and allow rodent and pest contamination that could cause food borne illness to residents. Record review of the facility policy titled Disposal of Garbage and Refuse, dated 12/1/2025, stated refuse containers and dumpsters kept outside the facility shall have tightly fitting lids, doors, or covers and shall be kept covered when not being loaded.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure Resident #23 had reasonable access to his call light. Resident #23 was admitted with dementia and, on the quarterly assessment, was documented as severely cognitively impaired and dependent for most ADLs by one staff member. During observation, he was lying in a low bed with a floor mat on the right side of the bed and asked for water, but he stated he did not know the location of the call light. The call light was observed on the floor underneath the floor mat. During a later observation, the call light was still on the floor underneath the floor mat. A CNA stated the call light should have been on top of the bed and clipped to the sheet, and that she should have checked its placement but did not. The CNA also stated the call light should be within reach so the resident could call for assistance. The DON stated nursing staff should constantly check call light placement so residents can ask for assistance and get their needs met.
Failure to Disburse Resident Trust Funds
Penalty
Summary
The facility failed to manage and account for the personal funds of a resident who had deposited money with the facility, resulting in the resident not receiving her allowance so she could purchase incontinent supplies. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction and borderline personality disorder. Her quarterly MDS showed a BIMS score of 15 out of 15, indicating no cognitive impairment, and she was incontinent of bowel and bladder. Her care plan identified urinary incontinence and noted a history of bladder incontinence related to dementia. During observation and interview, the resident stated she had not received her allowance for the month and had planned to use it to buy incontinence supplies. She reported speaking with the BOM about withdrawing $250. The BOM stated the resident requested the withdrawal, but the MS who had been cashing trust fund checks forgot to cash it and then quit his job, leaving no one else to cash the check. The BOM and ADM acknowledged the resident had $250 available in her account and had the right to access her funds as soon as possible, but the money was not disbursed. The facility policy stated the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.
Unattended EMAR Left Visible at Nurse's Station
Penalty
Summary
The facility failed to ensure that each resident had a right to secure and confidential personal and medical records when a laptop computer on the medication administration cart was left open, unlocked, and unattended with the screen turned on and the EMAR visible. During an observation and interview on 1/13/26 at 9:15 a.m., the MA cart was positioned at the nurse's station facing outward toward people passing through the area. The laptop was on the cart facing away from the nurses station, and the screen was open to resident EMARs while unattended. A resident was standing to the right of the cart talking on the phone, and another resident was standing to the left of the cart talking to an LVN seated behind the nurse's station. When MA B approached at 9:16 a.m., MA B closed the laptop screen and stated she should not have left it open and unattended. The DON later stated MA B should not have left the computer screen on and unattended and that MA B had been trained previously on resident records privacy. The DON also stated staff were re-trained the same day on 1/13/26. Review of the HIPAA Privacy Rule pre/posttest for MA B dated 9/22/25 showed that protected health information includes identifiable health information in electronic format, written on paper, and communicated verbally. The facility policy for HIPAA sanctions stated that leaving a secured application unattended while logged on is an example of a violation.
Respiratory Equipment Not Properly Stored or Maintained
Penalty
Summary
Safe and appropriate respiratory care was not provided for Resident #11, a male with COPD, vitamin B12 deficiency, legal blindness, and moderate cognitive impairment with a BIMS of 9. He had an order for Budesonide inhalation suspension by nebulizer every shift. During observation, a nebulizer machine was found plugged in on a nightstand, with the oxygen tubing in a drawer and the nebulizer mask lying loose in the drawer under a knit hat, not enclosed in a container or bag. On the opposite nightstand, another nebulizer machine was inside a drawer with a nebulizer mouthpiece laying loose in the drawer and not stored in a container or bag. During the same observation, LVN A stated the nebulizer masks should be in bags and not loose in the drawers, and that the oxygen tubing ends should not be sticking out of the drawer. LVN A also stated the resident had refused his nebulizer treatment that day and she was unsure when he last received it. The DON later stated the nebulizer masks should be in bags and that staff were trained and aware. The DON stated that not storing the nebulizer mask or mouthpiece in bags could cause cross contamination issues. The facility policy on nebulizer therapy stated that once completely dry, the nebulizer cup and mouthpiece are to be stored in a zip lock bag. Safe and appropriate respiratory care was also not provided for Resident #49, a female with COPD who received continuous oxygen therapy and had no cognitive impairment on admission MDS. She had an order for continuous oxygen at 2 to 4 liters and for maintenance of the oxygen concentrator, tubing, and humidifier bottle per facility policy. During observation, she was receiving oxygen via nasal cannula at 2 liters per minute, and the vent cover on the back of the oxygen concentrator was observed to be full of white buildup. The resident stated staff had changed the tubing and plastic bottle a day or so earlier, but she did not see them clean the vent cover. LVN A later stated the vent cover looked like lint and that she had not checked it. The DON stated night nurses were responsible for changing the tubing, humidifier bottle, and filter, and that if the filter was dirty it could cause infection or other respiratory complications. The facility policy on oxygen concentrators stated to follow the manufacturer's recommendations for cleaning filters and servicing the device.
Failure to Document Hospital Transfer and Change in Condition
Penalty
Summary
The facility failed to safeguard medical record information against loss, destruction, or unauthorized use and failed to maintain accurate medical records for 1 of 4 residents reviewed for change in condition. Resident #2, a cognitively intact female with diagnoses including depression, traumatic brain injury, COPD, and anxiety, was re-admitted to the facility on 1/13/2026. Her record also showed care planning for heightened perception of events, deep vein thrombosis, antidepressants, traumatic brain injury, and falls. Review of Resident #2’s progress notes for January 1-16, 2026 did not show documentation of her transfer to the hospital or a change in condition explaining why she was sent out. The only related documentation noted was a call from the RP expressing concern about the resident’s behavior after the resident reported that someone was hurting her and people were trying to get her. The RP stated the resident was sent to the hospital because she called confused and afraid, and the DON confirmed the transfer was for a change in mental status and that the record lacked documentation of why the resident was out of the facility, the change in condition, and who was notified.
Failure to Provide Timely Pain Medication Due to Inadequate Pharmacy Coordination
Penalty
Summary
Nursing staff failed to provide a resident with routine and emergency pharmaceutical services as required by physician orders. Specifically, the staff did not ensure timely administration of Lyrica, a pain medication, from 10/10/25 to 10/15/25. The medication was not administered for five consecutive days, and documentation showed either missing initials or notes indicating the medication was pending delivery. During this period, the resident received PRN pain medications, but not the scheduled Lyrica as ordered. The resident had a history of unspecified cirrhosis of the liver and type 2 diabetes, with frequent pain episodes documented in his care plan and MDS assessment. The care plan required staff to administer medications as ordered and notify the physician as needed. Despite these directives, nursing staff did not contact the pharmacy promptly to inquire about the delayed delivery of Lyrica, nor did they consult the resident's primary care provider (PCP) to obtain a one-time order for the medication from the facility's Pyxis system, even though the medication was available in-house. Interviews with facility leadership, including the ADON and DON, confirmed that staff did not follow established policies for medication reordering and notification of changes in treatment. Both leaders stated that staff should have reordered medications in advance, followed up with the pharmacy within 24 hours of a missed delivery, and notified the PCP to ensure continuity of care. The nurse responsible for the resident's care acknowledged not considering obtaining the medication from the Pyxis or contacting the PCP, resulting in the resident not receiving prescribed pain management for several days.
Failure to Provide Privacy During Incontinent Care
Penalty
Summary
Certified Nursing Assistants (CNAs) H and I failed to provide adequate privacy for a resident during incontinent care by not fully closing the privacy curtain. This lapse occurred while the resident, who had a history of vascular dementia, schizoaffective disorder, hypertension, type 2 diabetes mellitus, and irritable bowel syndrome, was receiving perineal care. The resident's care plan included interventions for impaired skin integrity and required proper incontinence care due to a history of excoriation and consistent incontinence of bowel and bladder. During the observed care, the privacy curtain remained open, allowing the resident to be visible to his roommate and potentially to anyone entering the room. Both CNAs acknowledged during interviews that they had not closed the curtain and admitted to forgetting due to nervousness, despite having received resident rights training within the past year. The Director of Nursing confirmed that privacy should have been maintained during care, as outlined in the facility's resident rights policy.
Failure to Accurately Code Fall with Injury on MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected their status, specifically by not coding a fall with injury on the admission Minimum Data Set (MDS) assessment. The resident, a male with diagnoses including encephalopathy, intracranial injury with loss of consciousness, and dementia, experienced an unwitnessed fall resulting in a superficial abrasion on the left iliac crest. Despite documentation of the fall and injury in the post-incident assessment and skin check, the MDS assessment completed shortly after the incident recorded the fall as having occurred without injury. Interviews with facility staff, including the MDS Nurse, DON, and Administrator, revealed that the error in the MDS assessment was attributed to the injury not being reflected in the assessment documentation. Staff indicated that care provision was based on physician orders and other documentation rather than the MDS assessment. The facility's policy requires that each resident's medical record accurately represent their experiences and include complete, accurate, and timely documentation.
Missed Weekly Skin Assessments for At-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to complete weekly skin assessments for a resident identified as being at risk for pressure injuries, as required by the resident's care plan and the facility's own policy. Specifically, the weekly skin assessments were not documented for two out of ten weeks. The care plan, which was last reviewed and updated, included an intervention for weekly skin assessments due to the resident's risk factors such as incontinence. However, there was no active order for weekly skin assessments in the resident's medical record, and the electronic medical record did not reflect completed assessments for the specified weeks. The resident in question was a cognitively intact male with diagnoses including encephalopathy, acute cholecystitis, and sepsis. He required partial to moderate assistance with mobility and was at risk for developing pressure injuries, though he did not have any present at the time. Documentation review showed that during the weeks in question, there were no progress notes describing the resident's skin status, and the assigned LPN could not recall completing the required assessment. The DON confirmed that unless an order was entered, the weekly skin assessment would not appear on the Medication or Treatment Administration Record, which contributed to the missed assessments. Interviews with staff indicated that while the resident received frequent care such as incontinence brief changes and shower assistance, which could have allowed for informal skin monitoring, the formal weekly skin assessments required by policy and care plan were not completed or documented. The facility's policy clearly outlined the need for weekly full-body skin assessments by a licensed or registered nurse, with specific documentation requirements, which were not met in this case.
Failure to Retract Foreskin During Incontinent Care for Uncircumcised Resident
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to retract the foreskin of an uncircumcised male resident while providing incontinent care. Observation revealed that the CNA did not properly clean underneath the foreskin, which is necessary for adequate hygiene. The CNA acknowledged during an interview that he did not retract the foreskin and was unclear about the reason, despite being aware that this step was required. The Director of Nursing (DON) confirmed that staff are trained to retract the foreskin for proper hygiene and infection prevention, and that skills are checked annually and as needed. The resident involved had a history of vascular dementia, schizoaffective disorder, hypertension, type 2 diabetes mellitus, and irritable bowel syndrome, and was always incontinent of bowel and bladder. The care plan for the resident included interventions to maintain proper incontinence care due to a history of excoriation on the scrotum related to moisture, friction, or incontinence. Facility policy on perineal care specified that the foreskin should be gently retracted if applicable, but this was not followed during the observed care.
Failure to Accurately Document Medication Administration in Medical Records
Penalty
Summary
The facility failed to maintain complete, accurate, and systematically organized medical records for two residents regarding the administration of the antibiotic Cefdinir. For one male resident with diagnoses including encephalopathy, acute cholecystitis, and sepsis, there were ten undocumented occasions of scheduled Cefdinir administration. Review of the Medication Administration Record (MAR) showed multiple blank entries for scheduled doses, particularly for morning administrations, while evening doses were documented as given. Staff interviews revealed uncertainty about whether blanks indicated missed doses or simply missed documentation, with one LPN admitting she may have failed to record the administration despite believing the medication was given. There were also instances where 'see progress note' was entered in the MAR, but no corresponding progress note was found in the resident's record. For a female resident with severe cognitive impairment and diagnoses including sepsis, acute respiratory failure with hypoxia, and pneumonia, there was one occasion where the scheduled administration of Cefdinir was left blank in the MAR. All other scheduled administrations were documented as given. The staff member responsible for this administration was noted to have given other medications at the same time, but no documentation was provided for the antibiotic dose in question. Attempts to interview the staff member were unsuccessful. Facility policy requires that the MAR be signed after medication administration and that any discrepancies be corrected and reported to the nurse manager. The policy also mandates that each resident's medical record accurately reflect the resident's experiences through complete, accurate, and timely documentation. The failure to document medication administration as required resulted in incomplete medical records for both residents.
Failure to Follow Hand Hygiene Protocols During Incontinent Care
Penalty
Summary
Certified Nursing Assistants (CNAs) H and I failed to perform proper hand hygiene before providing incontinent care to a resident with multiple diagnoses, including vascular dementia, schizoaffective disorder, hypertension, type 2 diabetes mellitus, and irritable bowel syndrome. The resident was always incontinent of bowel and bladder and had a care plan addressing impaired skin integrity due to a history of excoriation. During observation, both CNAs did not wash their hands after entering the resident's room and before starting care. Additionally, CNA H did not sanitize his hands between changing gloves after cleaning the resident's buttocks and before handling clean briefs. During interviews, both CNAs acknowledged they had not washed their hands before care and that CNA H did not use sanitizer between glove changes, stating they forgot but understood the importance of hand hygiene. The facility's policy required handwashing before and after direct resident contact and the use of alcohol-based hand rub before moving from a contaminated to a clean body site and after removing gloves. The Director of Nursing confirmed the expectation for staff to follow these procedures and stated that infection control training and skills checks were provided at least annually.
Failure to Investigate and Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate and report allegations of abuse, neglect, exploitation, or mistreatment for multiple residents, as required by federal regulations. In several cases, there was no evidence that a comprehensive investigation was conducted or that the results were reported to the state survey agency within five working days. For example, one resident reported to a family member that a CNA was rough during repositioning, causing her contracted legs to hit the wall. Although the incident was reported to the former Social Worker and Administrator, there was no documentation of an investigation or submission of findings to the state. Another resident with severe cognitive impairment and multiple medical conditions, including a recent surgery and infection, experienced missed doses of IV antibiotics due to a pulled PICC line and a failure to enter medication orders promptly. Nursing notes documented behavioral issues and repeated attempts to remove medical devices, but the facility did not provide investigation reports for these incidents. The ADON confirmed that the previous Administrator handled self-reports and that no investigation documentation was available for review. Additional incidents included a resident-to-resident altercation resulting in reopened skin tears and an allegation by a cognitively impaired, blind resident that a staff member struck him. In both cases, intakes were submitted to the state agency, but no provider investigation reports were available. Interviews with staff revealed a lack of familiarity with official reporting requirements and an inability to locate investigation documentation. The facility's own Abuse Prevention Program policy requires thorough investigation and timely reporting, but these procedures were not followed in the cited cases.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Incomplete Documentation of Safety Device Use and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, resulting in deficiencies related to documentation of safety devices and medication administration. For one resident with severe cognitive impairment and a history of wandering, the care plan required the use of a wander guard device to mitigate elopement risk. Despite this, documentation on the Treatment Administration Record (TAR) indicated the resident was wearing the device, even though direct observation and staff interviews confirmed the device was not in place. A nurse admitted to marking the TAR as if the device was present without verifying, and the device had been removed by the resident the previous night. In another case, a resident with multiple complex medical conditions, including a recent surgery and ongoing IV antibiotic therapy, did not have timely documentation of cefazolin administration on the Medication Administration Record (MAR). The Assistant Director of Nursing (ADON) administered the medication but failed to document it at the time of administration, instead entering a late note in the nursing progress notes several days later. The ADON acknowledged the omission and explained the circumstances, including a delay in entering the order and obtaining the medication from the backup supply. Both incidents were confirmed through record review, staff interviews, and direct observation. Facility policies required accurate and timely documentation of both safety device use and medication administration, but these were not followed in the cases described. The lack of accurate documentation could result in improper care or lack of awareness of residents' needs, as evidenced by the events described in the report.
Failure to Document Peri-Care Provided to Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents regarding the documentation of peri-care provided on two specific shifts. For both residents, the electronic medical record did not contain documentation by the assigned CNAs that peri-care was given on the night and day shifts in question. Interviews with the CNAs revealed that peri-care was provided, but documentation was omitted due to being occupied with other resident care tasks. There was no documentation indicating that the residents refused care, nor was there any record that peri-care was not necessary during those shifts. Resident #1 was a 65-year-old female with diagnoses including schizoid affective disorder, GERD, and epilepsy, and was severely cognitively impaired. She required extensive assistance for toileting and was incontinent of bowel and bladder. Her care plan and assessments indicated a need for substantial assistance, and her skin assessment noted excess moisture in abdominal folds. Resident #2 was a 71-year-old male with cerebral palsy, post-polio syndrome, and dementia, also severely cognitively impaired and requiring substantial assistance for toileting. Both residents' care plans and assessments supported the need for regular peri-care and documentation thereof. Interviews with nursing staff and administration confirmed that documentation of peri-care is required for continuity of care and as evidence that services were provided. The facility's policy also mandates that all services provided to residents be documented in the medical record to facilitate communication among the care team. The absence of documentation for peri-care on the specified dates for both residents constituted a failure to maintain medical records in accordance with accepted professional standards.
Resident Injury Due to Improper Securing in Transport Van
Penalty
Summary
The facility failed to ensure the safety of a resident during transportation, resulting in an accident. On 9/19/2024, a resident was not properly secured in the facility transport van, leading to a head laceration and a fracture of the right clavicle. The incident occurred when the van driver made a sudden stop, causing the resident to slide out of her wheelchair and sustain injuries. The resident had a history of traumatic brain injury, transient ischemic attack, depression, and alcohol abuse, and was cognitively intact with a BIMS score of 15. The incident was documented in the Facility Incident Report, which noted that the transport driver failed to buckle the resident before the trip. The driver admitted in a written statement that the resident slid out of the wheelchair when he had to stop abruptly, resulting in the resident's head sliding under the backseat and causing a laceration. The driver immediately transported the resident to the local hospital emergency room for treatment. Interviews with a CNA and the resident's family member confirmed that the resident was not secured with a lap belt or cross body strap during the transport. Both witnesses described the sudden stop and the subsequent injury to the resident. The facility's failure to secure the resident properly in the transport van constituted a deficiency in ensuring the resident's right to be free from accidents and hazards.
Failure to Provide Therapeutic Diet as Ordered
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered by a healthcare provider for a resident who was under his ideal body weight. The resident was supposed to receive large protein portions at all meals, as indicated in his nutritional assessment and physician's orders. However, observations revealed that the resident did not receive the prescribed large protein portions during meals, including a lunch where he was served a slice of meatloaf and a turkey sandwich with insufficient protein portions. Interviews with the Dietary Manager and the Director of Nursing (DON) revealed a lack of communication regarding the resident's dietary needs. The Dietary Manager was unaware of the diet change and stated that nurses are responsible for informing kitchen staff of such changes. The DON confirmed that nursing staff update diet orders in medical records and communicate changes to the kitchen staff but could not explain why the resident did not receive the large protein portions. The facility's policy requires written and verbal notifications of diet changes, but this procedure was not adequately followed, leading to the deficiency.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, and that only authorized personnel had access to the keys for one of the three medication carts reviewed for medication storage. Specifically, the Treatment Cart was left unlocked and unattended in the common area in front of the nurse's station and again in the 200-hallway opposite of a resident's room. The cart contained scissors, prescription, and over-the-counter medications related to skin and wound care, and there were staff, residents, and visitors in the immediate vicinity during both instances. RN A, who was responsible for the Treatment Cart, admitted to leaving it unlocked while stepping into the DON's office and again while beginning a procedure in a resident's room. RN A acknowledged being trained not to leave the cart unlocked when unattended but was unsure if the items in the cart could cause harm if misused. The DON stated she had visual contact with the cart through a window when it was at the nurse's station but conceded that the cart was unattended when the surveyor assessed it. The facility's policies require medication carts to be locked when not in use and not left unattended if open, which was not adhered to in these instances.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a resident with a stage 4 pressure injury. During a wound care procedure, a registered nurse (RN) did not perform hand hygiene between glove changes, which is a critical step in preventing cross-contamination and infection. The RN, who was new to the facility and had prior experience in acute care settings, admitted to not using an alcohol-based hand sanitizer after removing gloves, as required by both her training and the facility's hand hygiene policy. The resident involved was an elderly female with a history of a stage 4 pressure injury on the right buttock, which had been present since November 2023. The resident's medical records indicated moderate cognitive impairment and a need for frequent wound care. The RN's failure to adhere to proper hand hygiene protocols during the wound care procedure was observed by surveyors, highlighting a lapse in the facility's infection control practices. This deficiency could potentially contribute to increased bacterial load and delayed healing of the resident's wound.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in all the resident rooms reviewed. Observations revealed that all rooms were two-person rooms, each measuring 11 feet by 14 feet, totaling 154 square feet per room. This resulted in only 77 square feet per bed, falling short of the required 80 square feet per resident in multiple occupancy rooms. Interviews with the maintenance director and the Administrator confirmed that the rooms were under the required size, and no changes had been made to the rooms. The Administrator expressed a desire to continue the current room size waiver. A review of the CMS-3740 Bed Classification form indicated that all rooms were certified for two beds each.
Failure to Use AED During CPR for Full Code Resident
Penalty
Summary
The facility failed to provide a full code resident with the use of an AED during CPR, as per facility policy, for one of the residents reviewed for Advanced Directives. The resident, who had a history of multiple medical conditions including diabetes, congestive heart failure, and end-stage renal disease, was found without respirations by a CNA during a routine check. The CNA immediately alerted the nurse, who confirmed the absence of respirations and pulse and began CPR. However, the AED, which was available at the nurses' station, was not utilized during the resuscitation efforts. Interviews with the involved staff revealed that neither the CNA nor the LVN thought to use the AED during the emergency. The facility's policy clearly states that the AED should be used during a code or CPR to attempt to restore normal cardiac rhythm. The oversight in not using the AED was identified as past non-compliance, which had been corrected before the state's investigation began.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 14 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Jourdanton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Heights Of Atascosa | 3 mi | ★★★★★ | 1 | 0 |
| Pleasanton South Nursing And Rehabilitation | 4 mi | ★★★★★ | 11 | 0 |
| Pleasanton North Nursing And Rehabilitation | 4.3 mi | ★★★★★ | 2 | 0 |
| Devine Health & Rehabilitation | 26.6 mi | ★★★★★ | 6 | 0 |
| Lytle Nursing Home | 26.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.