Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 La Bahia Nursing And Rehabilitation during CMS and state inspections, most recent first.
Medication administration errors exceeded the allowed rate when the DON gave multiple meds late or not as ordered for three residents. One resident with GERD and bronchitis received benzonatate, Maalox Max, and sucralfate late or after breakfast; another resident with Guillain-Barre Syndrome received gabapentin nearly 2 hours late; and a third resident with DM and ESRD received sevelamer carbonate after breakfast and gabapentin 2 hours late. The DON said she took over med pass because two nurses did not come to work and acknowledged meds were expected to be given within a 1-hour window of the ordered time.
A facility failed to maintain infection prevention and control practices during catheter care, meal delivery, and laundry handling. A resident with an indwelling urinary catheter had the drainage bag placed above the bladder, on the bed, and on the floor, while the catheter tubing and meatus were not cleaned during care. A CNA also delivered meals to two residents without hand hygiene between tray deliveries. In the laundry department, there was no physical barrier between dirty and clean areas, and clean mops, rags, and new linens were stored on the dirty side.
A facility failed to transmit a discharge MDS to CMS for a resident who died while on hospice. The resident had multiple chronic conditions, including liver disease with ascites, DM2 with diabetic neuropathic arthropathy, CHF, and Alzheimer's disease. The MDS Coordinator stated she did not complete the required discharge MDS, and record review showed no discharge MDS documentation was present.
A resident with urinary retention, a hx of UTI, and an indwelling urinary catheter was admitted back to the facility after hospitalization for UTI and sepsis. The baseline care plan did not include catheter-related focuses, goals, or interventions within 48 hours of admission, despite physician orders for catheter support and monitoring. The resident reported concerns about catheter care practices, and the DON acknowledged the immediate needs were not care-planned within the required timeframe.
Care Plan Not Updated for Ordered Diet Texture: A resident with Parkinson's disease, functional quadriplegia, dysphagia, and severely impaired cognition had physician orders for a regular diet with finger foods and ground texture meats, but the care plan did not include the ground meat need. During dinner observation, the resident was served ground food, and the DON acknowledged the care plan had not been revised to match the current orders and care provided.
A resident with urinary retention, a history of UTIs, and an indwelling catheter was observed receiving catheter care that did not follow professional standards. A CNA held the drainage bag above the bladder, placed it on the bed and then the floor, failed to clean the catheter tubing, and did not retract the foreskin to clean the meatus; the resident also reported staff had not used PPE or cleaned the tubing during prior care.
A resident with severe cognitive impairment and at risk for falls was found with the call light on the floor, making it inaccessible. The resident preferred to scream for help, and the facility lacked a specific policy to ensure call light accessibility. The DON acknowledged the importance of this task, which is monitored by charge nurses and overseen by the ADON.
A facility failed to update a resident's care plan to include a wine bottle in the resident's personal refrigerator. The resident, an 86-year-old female with intact cognition, mentioned the wine was left by family and did not consume it. Staff interviews revealed a lack of awareness and communication about the wine, with the MDS nurse admitting to not updating the care plan, posing a risk of uninformed staff. The facility's policy on comprehensive care plans was not followed.
The facility failed to properly dispose of garbage, as observed with dumpster #1, which had its lid completely open, exposing the contents. This was noted during an observation with the Dietary Director, who acknowledged the risk of pest access. Interviews confirmed the issue, and a review of policies and regulations highlighted the requirement for covered receptacles.
A resident with multiple medical conditions experienced several falls, but the facility failed to update the care plan with new interventions. Despite the responsibility of the DON and MDS CM to revise care plans after significant changes, the care plan was not updated after four of the six falls, contrary to facility policy.
A resident with severe cognitive impairment and high fall risk fell during a solo mechanical lift transfer by a CNA, despite the requirement for a two-person assist. The CNA, who had been trained on proper procedures, attempted the transfer alone, resulting in the resident experiencing back pain after being struck by the lift's support bar.
The facility failed to report an injury of unknown origin involving a resident who suffered a brain bleed and a back fracture. Despite being aware of the resident's condition, the Administrator and DON did not report it to the state agency within the required two-hour window, waiting instead for hospital documentation. This failure to follow the facility's policy on immediate reporting of serious injuries could contribute to further abuse and neglect.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent. Surveyors found a medication error rate of 17.65%, based on 6 errors out of 34 opportunities, involving 3 residents and the DON, who was one of the staff members reviewed for medication administration. The report states that the DON administered medications to Residents #5, #25, and #43 late or not according to the physician orders. Resident #5 was admitted for LTC with diagnoses including GERD and bronchitis, and had a BIMS score of 8, indicating mildly impaired cognition. Physician orders included benzonatate 100 mg three times daily at 8:00 AM, Maalox Max 5 mL twice daily at 6:30 AM and 4:30 PM, and sucralfate 1 gram before meals and at bedtime. During observation, the DON administered benzonatate 55 minutes late, Maalox Max 2 hours and 25 minutes late, and sucralfate after breakfast. Resident #25 had Guillain-Barre Syndrome and a BIMS score of 14, indicating no cognitive impairment. The physician ordered gabapentin 400 mg three times daily at 8:00 AM, 2:00 PM, and 8:00 PM for nerve pain. During observation, the DON administered gabapentin at 10:57 AM, 1 hour and 57 minutes late. Resident #43 had type II diabetes and end stage renal disease, and was ordered sevelamer carbonate 800 mg three times daily with meals and gabapentin 100 mg three times daily at 7:30 AM, 12:00 PM, and 5:00 PM. During observation, the DON administered sevelamer carbonate after breakfast and gabapentin at 10:31 AM, 2 hours late. In interview, the DON stated she took over medication administration because two nurses did not come to work and said the expectation was that residents receive medications as prescribed and within a 1-hour window before and after the ordered time.
Infection Control Failures in Catheter Care, Meal Delivery, and Laundry Separation
Penalty
Summary
The facility failed to maintain infection prevention and control practices during catheter care for a resident with an indwelling urinary catheter. The resident had diagnoses including hemiplegia and hemiparesis affecting the right side, urinary retention, and a history of urinary tract infections. The resident’s record showed he was ordered to receive indwelling catheter support, with monitoring for leakage, blockage, sediment buildup, or low output. During an observation, CNA C assisted the resident with transfer and incontinent care while the resident was in bed, but held the urine collection bag above the resident’s abdomen, placed the bag on the bed, failed to clean the catheter tubing, failed to retract the foreskin to clean the meatus, and then placed the urine collection bag on the floor before emptying it. CNA C stated she had received training for indwelling urinary catheter care but did not know the potential negative outcome of the care provided. The facility also failed to ensure hand hygiene was performed between resident meal deliveries. During an observation in the dining room, CNA B collected meal trays from a cart and delivered them to residents, including one resident and then another, without performing hand hygiene in between. CNA B stated he did not recognize that he had not practiced hand hygiene between delivering meal trays and could not state any potential negative outcome from not doing so. The DON stated the expectation for staff delivering meals was to perform hand hygiene in between serving each resident. The laundry department was also observed to lack separation between dirty and clean areas. The department consisted of an entry room to the dirty laundry area, a dirty clothes washer room, and a clean dryer room and clean clothes storage room, but there was no physical barrier between the dirty washer room and the clean dryer room. Clean mops, rags, and new bed linens were stored in the entrance room on the dirty side. A laundry aide stated the mop heads and rags were stored there to dry and that the blankets were new, while a housekeeper stated she retrieved clean mop heads and rags from the drying rack in the laundry department’s first entry room and stocked them in the janitor’s closet. The DON and Administrator acknowledged the infection prevention and control concerns described in the report.
Failure to Transmit Discharge MDS After Resident Death
Penalty
Summary
The facility failed to ensure that a discharge MDS assessment was electronically transmitted to the CMS system for a resident who died. Record review showed the resident was an older male with diagnoses including alcoholic cirrhosis of the liver with ascites, Type 2 diabetes mellitus with diabetic neuropathic arthropathy, unspecified combined systolic and diastolic heart failure, and Alzheimer's disease. Nurses' notes documented that he expired with a hospice nurse at his bedside, and the Significant Change MDS indicated hospice care had been initiated within the prior 14 days. During interview, the MDS Coordinator stated she failed to complete a Discharge MDS following the resident's death. Record review also showed there was no documentation of a Discharge MDS for the resident. The facility's MDS Transmission policy stated that required MDS records must be transmitted to CMS' QIES ASAP system, and that tracking information for entry and death in facility records must be transmitted within 14 days of the event date.
Baseline Care Plan Not Developed for Indwelling Catheter Needs
Penalty
Summary
The facility failed to develop and implement a baseline care plan for Resident #10 within 48 hours of admission that included the instructions needed to provide effective and person-centered care. Resident #10 was admitted with diagnoses including hemiplegia and hemiparesis affecting the right side, urinary retention, and a history of urinary tract infections. The record showed the resident was readmitted to the facility on 1/30/2026 after a recent hospitalization related to a UTI, sepsis related to urinary retention, and discharge with an indwelling urinary catheter and antibiotics. The baseline care plan dated 1/30/2026 did not include any focuses, goals, or interventions for the resident’s indwelling urinary catheter. The physician’s orders directed catheter support, catheter changes if occluded or if the closed system was compromised or leaking, and monitoring for leakage, blockage, sediment buildup, or low output. During interviews, the resident stated concern about another UTI and reported observing staff not using gowns or gloves during catheter care, raising the urine collection bag above waist level, and not cleaning the catheter collection tube. The DON stated the resident’s immediate needs were to be developed and implemented within 48 hours of admission, and acknowledged the potential negative outcome that indwelling catheter care would not have been care-planned within that timeframe.
Care Plan Not Updated for Ordered Diet Texture
Penalty
Summary
The facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after assessments for one resident. Resident #9 was admitted on 12/20/2025 with diagnoses including Parkinson's disease, functional quadriplegia, and dysphagia. The quarterly MDS assessment dated 12/24/2025 showed severely impaired cognition with a BIMS score of 04 out of 15. Physician orders dated 2/10/2026 directed a regular diet with finger foods and ground texture meats. A review of Resident #9's care plan dated 2/10/2026 showed no focus, goal, or interventions for the resident's need for ground meats. During observation on 2/11/2026 at 5:20 PM, Resident #9 was seated in a wheelchair at the dining room table and was being assisted with dinner by RN A, and was served ground buffalo chicken. RN A stated the resident was served finger foods and ground meats as prescribed by the physician and SLP. The DON stated the care plan should be revised after new physician orders such as a diet texture change, and acknowledged the care plan had not been revised to accurately reflect the care provided.
Improper Catheter Care During Incontinent Care
Penalty
Summary
The facility failed to ensure appropriate catheter care for a resident with an indwelling urinary catheter and a history of urinary retention and UTIs. The resident had diagnoses including hemiplegia and hemiparesis affecting the right side, urinary retention, and a history of UTIs, and had been hospitalized for a UTI and sepsis related to urinary retention before returning to the facility with an indwelling catheter. The resident stated staff had not used gowns or gloves during catheter care, had raised the urine collection bag higher than his waist, and had not cleaned the catheter collection tube. During an observation, CNA C provided incontinent care and catheter care but held the urine collection bag above the resident’s abdomen/bladder, placed the bag on the bed, failed to clean the catheter tubing, and did not retract the resident’s foreskin to clean the meatus. After care was completed, the bag was placed on the floor before the urine was emptied into a collection bottle. The CNA stated she had received training for indwelling urinary catheter care but did not know the potential negative outcome of the care provided. The DON stated catheter care was expected at every incontinent care episode and at a minimum per physician’s orders every shift, and that catheter care included cleaning the catheter tubing.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for the resident's needs and preferences. The resident, who has severe cognitive impairment and is at risk for falls, was observed with the call light on the floor, making it inaccessible. The resident expressed a preference to call for help by screaming, indicating a lack of awareness or ability to use the call light effectively. Interviews with the assigned CNA and the Director of Nursing (DON) revealed that there was no specific policy in place to ensure call lights are accessible to residents. The CNA was unaware of how the call light ended up on the floor, and the DON acknowledged the importance of call light accessibility to prevent potential falls. The DON mentioned that charge nurses monitor this task during morning rounds, with oversight by the Assistant Director of Nursing (ADON).
Failure to Update Care Plan for Resident's Personal Refrigerator Contents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included addressing the presence of a wine bottle in the resident's personal refrigerator. The resident, an 86-year-old female with diagnoses including heart failure, hyperlipidemia, and cerebral ischemia, had a BIMS score indicating intact cognition. During an interview and observation, the resident mentioned that the wine was likely left by family after a birthday party and stated she did not consume alcohol. However, the care plan did not reflect the presence of the wine bottle, which was a significant oversight. Interviews with facility staff, including an LVN, the MDS nurse, and the DON, revealed a lack of awareness and communication regarding the wine bottle. The LVN was unaware of the wine's presence and stated that families were responsible for managing personal refrigerators. The MDS nurse admitted to not updating the care plan to include the wine bottle, acknowledging the risk of staff being uninformed. The DON confirmed that the care plan should have been updated and noted that the MDS nurse was responsible for overseeing care plans, with the ADON conducting random audits. The facility's policy on comprehensive care plans was not adhered to, leading to this deficiency.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, specifically with one of the two garbage dumpsters, identified as dumpster #1. During an observation, it was noted that the lid of dumpster #1, measuring 3 x 5 feet, was completely open, exposing the garbage inside. This observation was made in the presence of the Dietary Director, who acknowledged that an open lid could allow pests access to the garbage and potentially the facility. The Dietary Director confirmed that staff are trained to keep the dumpster lids closed at all times. Interviews with the Dietary Director and the Administrator further highlighted the issue, with both acknowledging the potential for pest control problems due to the open dumpster lid. A review of the facility's Dietary Services Policies and Procedures Manual, as well as relevant food safety regulations, confirmed that trash receptacles must be covered at all times when not in use, and that outdoor receptacles should have tight-fitting lids. The failure to adhere to these guidelines was identified as a deficiency in the facility's waste disposal practices.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident that included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. The care plan did not describe the services necessary to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Specifically, the facility did not revise the care plan with updated interventions after the resident experienced multiple falls. The resident, who was admitted with several medical conditions including heart failure, a femur fracture, obstructive and reflux uropathy, diabetes mellitus type 2, and hemiplegia following a stroke, had a history of falls. Despite documented falls on several occasions, the care plan was not updated to include new interventions to address these incidents. The care plan had not been revised to reflect interventions for four of the six falls that occurred over a period of several months. Interviews with facility staff revealed that the Director of Nursing (DON) and the MDS Case Manager (CM) were responsible for updating care plans. However, they acknowledged that interventions following the resident's falls were not documented in the care plan. The facility's policy required care plans to be reviewed and revised after significant changes, but this was not adhered to, resulting in a lack of updated interventions to prevent further falls.
Improper Mechanical Lift Transfer Leads to Resident Fall
Penalty
Summary
The facility failed to ensure a safe environment for a resident, leading to an accident involving a mechanical lift. A CNA attempted to transfer the resident using a mechanical lift by herself, despite the requirement for a two-person assist. This resulted in the resident falling and experiencing back pain after being struck by the lift's support bar. The CNA had previously been trained on the necessity of a two-person assist for mechanical lifts but proceeded alone due to being in a hurry. The resident involved was an 88-year-old female with severe cognitive impairment, dementia, chronic kidney disease, heart failure, and a history of falls. Her care plan specified the need for two-person assistance during transfers due to her high fall risk and physical limitations. Despite these documented needs, the CNA attempted a solo transfer, which was against the facility's policy and training. Interviews with facility staff, including the DON and LVN, confirmed that the CNA was aware of the two-person requirement and had been trained accordingly. The CNA admitted to attempting the transfer alone and acknowledged her mistake. The facility's policies clearly outlined the procedures for safe transfers, which were not followed in this instance, leading to the resident's fall and subsequent pain.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin involving a resident who suffered a brain bleed and a back fracture. The resident, who had a history of type 2 diabetes mellitus with diabetic nephropathy, dementia, and end-stage renal disease, was sent to the hospital from dialysis due to nausea and vomiting. Hospital records revealed a wedge compression fracture and a non-traumatic cerebrovascular accident, but the facility did not report these injuries to the state reporting agency (HHSC) within the required two-hour window because they were waiting for documentation to substantiate the injuries. The Administrator and DON were aware of the resident's condition but did not report it immediately. The Administrator stated that they needed confirmation from the hospital before reporting, despite the facility's policy requiring immediate reporting of serious injuries. The DON also acknowledged the need to report within two hours but deferred to the Administrator for the actual reporting. The facility's policy on abuse and neglect clearly defined the need for immediate reporting of injuries of unknown origin, but this protocol was not followed. Interviews with the Administrator, DON, and other staff revealed that the facility had started an investigation but had not received the necessary medical records from the hospital. The resident's responsible party was also not informed of any incidents at the nursing home. The facility's failure to report the injuries promptly could affect any resident and contribute to further abuse and neglect.
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Illustrative
What surveyors actually found near you
We read the 13 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Goliad
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Yorktown Nursing And Rehabilitation Center | 21.9 mi | ★★★★★ | 13 | 0 |
| Twin Pines North Nursing And Rehabilitation Center | 26.4 mi | ★★★★★ | 4 | 0 |
| Mission Ridge Rehab & Nursing Center | 26.5 mi | ★★★★★ | 9 | 1 |
| Riverside Oaks | 27.1 mi | ★★★★★ | 19 | 0 |
| The Courtyard Rehabilitation And Healthcare Center | 27.4 mi | ★★★★★ | 14 | 2 |
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