Below 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 Meridian Care Monte Vista during CMS and state inspections, most recent first.
A resident with hepatic encephalopathy and CKD stage 4 missed multiple ordered doses of rifaximin 550 mg because the medication was unavailable, and the MAR showed the doses as pending delivery, pending pharmacy, or no supply. The record had no documentation that the physician or RP was notified, and interviews confirmed the RP was not informed until later and the LVN did not notify the physician or RP when the medication ran out.
A resident with hepatic encephalopathy and CKD stage 4 did not receive ordered rifaximin 550 mg BID because the medication was unavailable and was documented as pending delivery, pending pharmacy, or no supply for multiple doses. Nursing staff contacted the pharmacy and faxed the order, but the physician and RP were not notified at the time, and the ADONs were not aware the medication was unavailable until later.
A resident with ALS, a tracheostomy, and a documented OOH DNR and DNR physician orders was found unresponsive by a CNA, who notified an LVN. After assessment by two LVNs revealed loss of pulse and respirations, a Code Blue was called, and RT staff initiated suctioning and ambu-bag ventilation while an LVN performed chest compressions. Staff were unsure of the resident’s code status, relied on an outdated crash cart binder that contained incorrect DNR information, and continued resuscitation while the LVN searched the EMR for verification. EMS arrived, continued CPR, and obtained a pulse before being informed by the LVN that the resident was actually a DNR, despite existing documentation and the responsible party’s prior completion of DNR forms. The facility lacked a specific policy for Out-of-Hospital DNRs, relying only on a general resident rights policy regarding refusal of treatment.
The facility failed to fully inform residents and/or their RPs and obtain complete consent for psychotropic medications. One resident with ALS, depression, and anxiety had no consent for buspirone and incomplete consents for diazepam and Lexapro, with missing treatment details, side effect disclosure, and physician signatures. Another cognitively intact resident with depression and anxiety had no consent for Atarax and an incomplete duloxetine consent with missing clinical details and physician signature. Interviews showed the RP and residents were not fully informed, and staff acknowledged the forms were incomplete.
Unlocked Medication Room Door: The facility failed to keep one door to the 100-hall med room locked, even though the room contained OTC meds, insulin and other Rx meds in a refrigerator, and resident snacks. An LVN stated the hallway door should have been locked at all times and that only licensed staff held the keys; the DON said she was unaware a second door was being used for the med room. The facility policy stated meds and biologicals are stored in locked compartments with access limited to authorized personnel.
Infection control lapses were observed during care for three residents. An LVN touched a privacy curtain and then the resident’s skin without changing gloves or sanitizing hands during incontinent care for a resident with severe cognitive impairment and multiple diagnoses. An RT provided trach care for a resident on EBP without wearing a gown, and an LVN performed wound care for a resident with a thoracic wound without placing a disposable cloth under the wound as a barrier.
A facility failed to keep hazardous disinfecting wipes out of residents’ reach during wound care. An LVN used sanitizing wipes to clean a side table, then left the wipes container on top of her cart while she went into the room and closed the door, losing line of sight with the container during care. The wipes were labeled as a moderate eye irritant, a physical or chemical hazard, and flammable. The DON stated hazardous products should be kept under lock when not in use, and the facility policy required following manufacturers’ storage instructions.
A resident admitted with HTN, OSA, and heart disease did not have a baseline care plan developed within 48 hours of admission. The resident had intact cognition per BIMS, and the ADON confirmed that no baseline care plan had been completed during the stay, despite facility policy requiring a baseline plan of care to meet the resident’s immediate needs within 48 hours.
Care Plan Missing Anemia Interventions: A resident with severe cognitive impairment, PEG tube dependence, and diagnoses including anoxic brain damage and type 1 DM had low Hgb and Hct values and a physician order for ferrous sulfate via G-tube for anemia, but the care plan did not include anemia or iron supplementation interventions. The MDS Coordinator stated the care plan lacked a plan of care for anemia, and the DON stated comprehensive care plans were important for staff to evaluate the nursing process.
A resident with severe cognitive impairment and bowel/bladder incontinence received improper peri-care when a CNA used the same wipe across multiple areas, did not separate the labia, and did not clean the anal area. The CNA acknowledged the errors and said she had been trained on infection control and incontinent care, while the DON stated staff should not make multiple passes with the same wipe and should clean the labia and rectal area thoroughly.
Incorrect Ferrous Sulfate Dose Administered: A resident with severe cognitive impairment, anoxic brain damage, diabetes, and a PEG tube received ferrous sulfate via G-tube in the wrong concentration. An LPN administered 5 ml of 220 mg/5 ml solution instead of the ordered 300 mg/5 ml formulation, and later stated it was a medication error and that this was what had been given to the resident.
A resident with depression, anxiety, and cyclothymic disorder was ordered PRN Atarax for itching with an indefinite end date, and no consent for the medication was found in the chart. The ADON stated the drug was being used off label for itching and did not need a specific end date, while the DON said the system flagged psychotropics at 14 days and that the use was discussed with the psychologist, physician, and pharmacy.
The facility did not update its Emergency Preparedness Plan annually, failed to correct a persistent fire alarm system trouble signal, and allowed overgrown vegetation and dead branches to accumulate near the building, including the smoking area. The Administrator was unaware of the annual review requirement for the emergency plan, and the Maintenance Director acknowledged ongoing issues with the fire alarm and grounds maintenance.
A resident with ventilator dependence, oxygen dependence, CHF, COPD, atrial fibrillation, and prior cerebral infarction was found unresponsive, pulseless, and apneic while listed as full code. Staff gave conflicting accounts of the response, but interviews and EMS findings showed CPR was not consistently initiated or maintained, the AED and crash cart were not obtained, and CPR was stopped when staff believed the resident was DNR despite the full code order.
The facility did not report multiple allegations of abuse, neglect, or mistreatment involving four residents, including emotional distress, neglect of a G-tube dressing, rough incontinent care, and verbal abuse. These incidents were documented in grievance reports but were not reported to the state agency as required, despite residents having significant cognitive and physical impairments.
The facility did not thoroughly investigate or report multiple allegations of abuse, neglect, or mistreatment involving four residents, including incidents of poor treatment, neglect of care, rough handling, and verbal abuse. Despite documentation of grievances and internal discussions among leadership, required reporting to the state agency was not completed, and there was no evidence that further potential harm was prevented during the investigation process.
Medication carts containing drugs, including narcotics, were left unattended and unlocked in two separate hallways for several minutes, with staff unable to account for the responsible personnel. Facility policy requires carts to be locked when not attended, but in both instances, the carts were accessible to unauthorized individuals while residents and CNAs were present in the area.
A resident with complex medical needs, including a sacral pressure injury, did not have daily wound care consistently documented in the treatment administration record as required by physician orders and facility policy. Several dates lacked evidence of wound care being provided, and staff interviews confirmed the expectation for timely documentation. The resident's representative also reported inconsistent care and had to provide dressings personally.
A resident with intact cognition and multiple chronic conditions was repeatedly told by staff that his family member would be called if he refused to change clothes, a practice used to gain compliance with care. This approach, which was included in the care plan at the family member's request, made the resident feel threatened and sad, and was acknowledged by the DON and administrator as a violation of the resident's rights to self-determination and choice.
Two residents' rights were not protected when an LVN diverted Norco pain medication by being the sole staff member to call in refills and receive pharmacy deliveries, bypassing required verification procedures. Audits later revealed missing medication cards, and staff interviews confirmed that established protocols for receiving and securing narcotics were not consistently followed.
A resident with complex medical needs was discharged to a hospital without the facility sending the required discharge notice to the state LTC ombudsman. Interviews with the ombudsman, SW, DON, and administrator confirmed that no notification was made, and the facility's records did not contain evidence of such notice.
A facility exceeded the acceptable medication error rate with a 7.69% error rate due to late administration of medications to a resident with GERD and constipation. A new RN administered carafate and enulose over an hour late, citing unfamiliarity with the residents and procedures. The facility's policy mandates timely medication administration to ensure therapeutic effectiveness.
The facility's kitchen failed to meet food service safety standards by improperly storing plastic containers without air-drying, inadequately labeling and dating chopped beef brisket in the cooler, and failing to properly label and seal French fries in the freezer. These actions could lead to foodborne illness due to bacterial growth and deterioration in food quality.
A resident with severe cognitive impairment and multiple medical conditions was left exposed during catheter care when two CNAs failed to fully close the privacy curtain. The incident was observed by surveyors, and the CNAs admitted the oversight. The facility's DON confirmed that privacy should have been maintained, and staff had received training on resident rights.
A resident with a cognitive communication deficit did not have their needs fully addressed in their care plan, as required by facility policy. Despite having a history of hemiplegia, hemiparesis, major depressive disorder, and aphasia, the care plan lacked a focus on communication needs. Staff interviews confirmed the omission, and the resident used a communication card not documented in the care plan.
A resident with severe cognitive impairment and legal blindness was found to have hazardous cleaning supplies in their bathroom, posing a risk of contact with dangerous substances. Facility staff confirmed the presence of these materials, which were not supposed to be in resident rooms, as per facility policy.
A resident with a history of cancer, diabetes, and dementia displayed signs of depression and isolation but was not referred to mental health services, despite multiple documented reports of these symptoms. The facility's policy required providing behavioral health services to maintain residents' well-being, which was not followed.
A medication cart was left unlocked by an RN during medication administration, contrary to facility policy and training. The cart, containing various medications, was out of the RN's sight, posing a risk of misappropriation or accidental ingestion. The DON confirmed the breach of protocol, despite the RN having passed a proficiency checklist.
The facility failed to maintain an effective infection prevention and control program. An RN did not sanitize a blood pressure cuff between two residents, risking cross-contamination. Additionally, two CNAs did not wear gowns while caring for a resident on enhanced barrier precautions, despite signage. Both incidents occurred despite staff having received infection control training.
The facility failed to properly dispose of garbage in Dumpster #1, which was overflowing and missing a drainage plug, with trash scattered around the area. Interviews revealed that trash was picked up twice a week, and the dumpster had been recently replaced. The facility's waste disposal policy and the U.S. Public Health Service Food Code require sealed and covered waste containers with drain plugs, which were not followed.
A resident with severe cognitive impairment suffered a fracture to her left tibia, which was not reported to the state agency as required. The injury was discovered after the resident returned from an Adult Day Care program, and despite the presence of a significant bruise and swelling, the facility did not classify it as an injury of unknown origin. The facility's staff relied on the resident's limited communication about the bus, leading to a failure to report the incident within the required timeframe.
A resident with intellectual disabilities and diabetes did not have a comprehensive care plan, missing crucial details like LIDDA contact information, Adult Day Care specifics, and transportation arrangements. Interviews revealed a lack of communication and coordination among staff, with the MDS Coordinator unavailable and the DON acknowledging the oversight. The facility's policy required comprehensive care plans, but the necessary updates were not made.
Failure to Notify Physician and Resident Representative of Missed Rifaximin Doses
Penalty
Summary
The facility failed to immediately consult the resident’s physician and notify the resident representative when Rifaximin 550 mg, ordered every 12 hours for hepatic encephalopathy, was not available and doses were missed. Resident #1 was admitted with diagnoses including hepatic encephalopathy and chronic kidney disease stage 4, had a BIMS score of 15, and had a care plan identifying a risk for altered neurological status related to a history of hepatic encephalopathy with interventions to give medications as ordered and monitor for side effects and effectiveness. The MAR showed that Rifaximin 550 mg was not documented as administered and was instead marked as 9=Other/See Nurse Notes for 31 doses during the period reviewed, with notes indicating the medication was pending delivery, pending pharmacy, or no supply. The record contained no documentation that the physician or resident representative was informed of the missed doses during that period. During interviews, the resident representative stated she was not made aware until the facility informed her, an LVN stated she did not notify the resident representative or physician because she thought the ADONs would do so, and the DON stated her expectation was that staff would contact the pharmacy, check the emergency medication kit, and notify the DON, physician, and family if the medication was unavailable.
Missed Rifaximin Doses Due to Medication Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with hepatic encephalopathy and chronic kidney disease stage 4 by not ensuring the ordered rifaximin 550 mg was available and administered as prescribed. The resident’s care plan directed staff to give medications as ordered and noted that the resident received rifaximin orally per MD orders. The physician order summary directed rifaximin 550 mg by mouth every 12 hours for hepatic encephalopathy, with administration times of 8:00 a.m. and 8:00 p.m. The MAR showed that nursing staff did not document rifaximin as administered during the identified period and instead recorded 9=Other/See Nurse Notes for 31 doses. The corresponding notes stated the medication was pending delivery, pending pharmacy, or there was no supply. Pharmacy staff stated the medication was no longer covered by the resident’s insurance and that prior authorization may be needed. Nursing staff stated they had contacted the pharmacy and faxed the order, but the physician and responsible party were not notified at the time because they believed the ADONs would do so. The ADONs stated they were not aware the medication was unavailable or that prior authorization was needed until later, and the DON stated she was not aware the resident did not have rifaximin available.
Failure to Honor Resident’s Documented DNR Status During Code Blue Event
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s Out-of-Hospital Do Not Resuscitate (OOH DNR) order and documented DNR status when the resident was found unresponsive and staff initiated resuscitation. The resident was an older female with diagnoses including depression, anxiety disorder, ALS, and a tracheostomy, and had a BIMS score of 15, indicating she was cognitively intact. Her care plan, physician orders, and an OOH DNR form signed by the physician and two witnesses all documented that her code status was DNR. Despite this, when she was found unresponsive in her room, staff proceeded with CPR and other resuscitative measures after determining she had no pulse and had stopped breathing. According to interviews and record review, an agency CNA discovered the resident unresponsive and notified an LVN, who assessed the resident and noted she was pale but breathing, with a weak pulse. Another LVN entered, performed a sternal rub and other stimuli without response, while the first LVN rechecked pulses at multiple sites and then reported finding no pulse and that the resident had stopped breathing. At that point, a Code Blue was called. Respiratory therapy staff removed the breathing circuit from the tracheostomy, suctioned the airway, and began manual ventilation with an ambu bag. Another LVN began chest compressions. During this period, staff questioned whether the resident was a DNR or full code, and there was hesitation because the LVN leading the response was unsure of the resident’s code status. Staff reported that the crash cart binder, which they relied on to verify code status, was not up to date and contained DNR information for residents who were no longer in the facility. The LVN in charge stated she attempted to verify the resident’s status by checking the crash cart binder and then the electronic medical record, but resuscitation had already been initiated and continued while this verification was pending. EMS arrived and continued compressions, and a pulse was recovered before the LVN informed EMS that the resident was actually a DNR based on the documentation she eventually located. The resident’s responsible party later confirmed that a DNR had been completed at the hospital and again at the facility, and stated that the resident did not want CPR, including having her ribs cracked, and that the facility did not abide by the resident’s wishes. The facility did not have a specific policy for Out-of-Hospital DNRs, only a general resident rights policy stating that residents have the right to refuse treatment.
Removal Plan
- Provided in-service training to staff on resident rights, including: Timely Emergency Services & Professional Standards for CPR; How to Identify the Resident Code Status; and Abuse & Neglect.
- Required all new hires to complete the in-service trainings on resident rights, code status, and CPR-related standards.
- Implemented a process for night shift nurses to print the daily resident census, highlight residents with DNR status, and place the dated census sheet in each crash cart binder along with a copy of each resident’s DNR.
- Implemented a process for morning-shift ADONs to check crash cart binders for accuracy and needed DNR code status updates.
- Implemented DON review of resident code status and crash cart binder accuracy.
- Implemented use of a Standard of Care (SOC) spreadsheet that includes a DNR column and records the date of any code status change; tracked by the corporate nurse.
- Implemented audits of printed reports for new admissions to verify code status and ensure crash cart binders are updated accordingly.
- Implemented a process for the Social Worker to deliver newly executed DNR documentation to the DON for updating the electronic medical record and adding the DNR to the crash cart binder and SOC tracking.
- Implemented a DON audit of resident charts for DNR documentation.
- Implemented corporate nurse audits of SOCs.
Incomplete Consent and Notification for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents and/or their responsible parties were fully informed in advance of the risks, benefits, and treatment alternatives for psychotropic medications, and failed to obtain complete consent documentation for several medications. The deficiency involved two residents reviewed for resident rights and centered on missing or incomplete consent forms for buspirone, diazepam, Lexapro, Atarax, and duloxetine. Resident #52 had diagnoses including amyotrophic lateral sclerosis, depression, and anxiety disorder, and her assessment showed a BIMS score of 15, indicating she was cognitively intact. Her medication record showed buspirone 7.5 mg twice daily, diazepam 2.5 mg daily, and Lexapro 20 mg daily. The record contained no consent for buspirone. The consent for diazepam was incomplete, with blanks for length of treatment, psychiatric condition or maladaptive behavior, medication dose and frequency, and physician or Medical Director signature. The consent for Lexapro was also incomplete in the same areas and lacked physician or Medical Director signature. During interview, the resident could not say whether she had received medication information, and her RP stated she had been called for consents for anxiety medications but was not told of potential side effects and was only told the resident needed the medication. Resident #4 had diagnoses including moderate recurrent major depressive disorder, generalized anxiety disorder, and cyclothymic disorder, and her assessment showed a BIMS score of 14. Her medication record showed Atarax 10 mg every 8 hours as needed for itching and duloxetine 60 mg daily for depression. The record contained no consent for Atarax, despite a physician order alert stating this class of medication required consent. The consent for duloxetine was incomplete, with blanks for length of treatment, psychiatric condition or maladaptive behavior, medication dose and frequency, and physician or Medical Director signature. The resident stated she did not know if she had received information about her medication treatments. Staff interviews confirmed that consents were being handled inconsistently, that some forms were prefilled, that physician signatures were missing, and that the DON and ADON had oversight responsibilities but the forms reviewed for these residents were incomplete or absent.
Unlocked Medication Room Door
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in a manner that permitted only authorized personnel to have access to the keys for 1 of 2 medication rooms reviewed, the 100 hall medication room. During an observation on 2/11/2026 at 2:11 p.m., the medication room on the first floor 100 hallway was found to have two doors, with the door inside the nurse's station locked and the hallway door unlocked and able to be opened. Visible from the doorway were multiple over-the-counter medications, a medication refrigerator, a resident snack refrigerator, and resident snacks. A cabinet on the bottom shelf containing prescription medication was visible through a crack and was locked. No staff were present in the hallway or at the nurse's station at the time of the observation. During interview, LVN H stated she was not aware the hallway door to the medication room was unlocked and said it was supposed to be locked at all times. She stated the room contained over-the-counter medications, insulin in the refrigerator, other prescription medications in the refrigerator, and snacks meant for residents. She also stated residents were not allowed in the room and only staff with keys could enter, and that only licensed staff held the keys. The DON stated she was not aware there was a second door being used to the 100-hall medication room and said the medication room should remain locked at all times. Record review of the facility policy, Medication Labeling and Storage dated February 2023, stated all medications and biologicals are stored in locked compartments and only authorized personnel have access to keys.
Infection Control Lapses During Resident Care
Penalty
Summary
The facility failed to maintain its infection prevention and control program for three residents during observed care activities. Resident #3 had diagnoses including dementia, chronic kidney disease, tracheostomy status, gastrostomy status, type 2 diabetes mellitus, and hypertension, and was assessed as severely cognitively impaired and always incontinent of bowel and bladder. During incontinent care, an LVN touched the privacy curtain with gloved hands and then, without changing gloves or sanitizing hands, touched the resident’s skin while assisting with care. The LVN stated she did not think about the curtain being considered dirty and acknowledged she should have changed gloves and sanitized her hands to prevent cross contamination and infection. Resident #5 had anoxic brain damage, tracheostomy status, gastrostomy status, and type 1 diabetes mellitus, and was nonverbal with severely impaired cognition. The resident’s care plan required Enhanced Barrier Precautions during high-contact care activities, including tracheostomy care. During observation, an RT began providing tracheostomy care without first putting on a gown. The RT stated he knew the resident was on Enhanced Barrier Precautions but forgot to put on a gown and confirmed it was a risk of contamination for the resident. Resident #43 had chronic kidney disease, tracheostomy status, type 2 diabetes mellitus, and an open wound of the back wall of the thorax. The resident’s record noted surgical wounds and multiple skin impairments requiring treatment. During wound care, an LVN did not place a disposable cloth under the wound as a barrier. After the wound was cleaned, the wound and surrounding skin were close to the surface of the air mattress. The LVN stated she did not use a disposable cloth, and the DON stated staff should place a disposable cloth under the wound to prevent potential contamination with linen or the mattress.
Hazardous Wipes Left Accessible During Resident Care
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 2 units reviewed for the physical environment, because hazardous products were not kept out of residents’ reach. During observation on 02/12/2026 at 1:18 p.m., while an LVN was providing wound care for a resident, she used sanitizing wipes to clean a side table and then left the wipes container on top of her cart before going into the room to continue care. She closed the door and lost line of sight with the wipes, which remained on top of the cart for the duration of the care from 1:18 p.m. to 1:25 p.m. At 1:25 p.m., the wipes container was observed to have a caution label stating it could cause moderate eye irritation, should avoid contact with eyes, and was a physical or chemical hazard and flammable. During interview, the LVN stated she had left the wipes on top of her cart after entering the room and did not know they should be kept in her cart and away from residents. The DON stated hazardous products should be kept under lock when not in use to prevent resident access and confirmed that residents with dementia and impaired cognition were on the second floor and that some residents could use their wheelchairs independently. Record review of the facility policy on cleaning and disinfection of environmental surfaces stated manufacturers’ instructions would be followed for proper use of disinfecting products, including storage.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan for Resident #68 within 48 hours of admission. Resident #68 was admitted with diagnoses including essential hypertension, obstructive sleep apnea, and heart disease, and the discharge MDS showed a BIMS score of 15, indicating intact cognition. Review of the resident’s full clinical record showed that he resided at the facility from 11/13/2025 to 11/18/2025, and no baseline care plan was developed during that admission. During interview, the ADON confirmed that no baseline care plan had been developed for the resident during her tenure, stated she did not know why it had not been completed, and stated it should have been. The facility policy stated that a baseline plan of care to meet the resident’s immediate needs shall be developed for each resident within 48 hours of admission.
Care Plan Missing Anemia Interventions
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one resident that included measurable objectives and timeframes to meet her medical, nursing, mental, and psychosocial needs. Resident #5 was a [AGE]-year-old female admitted with diagnoses including anoxic brain damage, type 1 diabetes mellitus, and dependence on supplemental oxygen. Her annual MDS showed severe cognitive impairment, inability to obtain a BIMS score, short- and long-term memory problems, dependence on staff for care, and a PEG tube. Her care plan, last revised on 12/19/2025, did not address anemia or include appropriate interventions. Record review showed physician orders for ferrous sulfate via G-tube for anemia and lab results with low hemoglobin and hematocrit values, including hemoglobin 9.6 and hematocrit 32.7 on 1/12/2026 and hemoglobin 9.8 and hematocrit 33.1 on 2/02/2026. During interview, the MDS Coordinator stated the care plan did not contain a plan of care for anemia or iron supplementation and that she did not routinely review labs unless brought to her attention. The DON stated care plans were interdisciplinary and that accurate, complete comprehensive care plans were important so staff could evaluate the nursing process. The facility policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident.
Incontinent Care Not Provided Properly During Perineal Care
Penalty
Summary
The facility failed to ensure incontinent care was provided in accordance with appropriate treatment and service practices for a resident who was always incontinent of bowel and bladder. The resident had diagnoses including dementia, bipolar disorder, chronic kidney disease, tracheostomy status, gastrostomy status, type 2 diabetes mellitus, and hypertension. The resident’s significant change MDS showed a BIMS score of 7, indicating severely impaired cognition, and the care plan identified a risk for skin integrity related to bowel and bladder incontinence with an intervention to provide peri-care after each incontinent episode. During observation, CNA B provided incontinent care but did not change the wipe between cleaning across the abdomen and the right groin, did not separate the resident’s labia, and did not clean the resident’s anal area. In interview, CNA B stated she did not change the wipe between areas, should have cleaned between the labia and the anal area, and thought she could use the same wipe if folding it. The DON stated staff should not make multiple passes with the same wipe, should separate the labia when cleaning, and should clean the anal area. The facility policy titled Perineal care stated to separate the labia and wash the rectal area thoroughly.
Incorrect Ferrous Sulfate Dose Administered
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when Resident #5 did not receive the correct dose of ferrous sulfate as ordered. Resident #5 was a [AGE] year-old female admitted on [DATE] with diagnoses including anoxic brain damage, type 1 diabetes mellitus, and dependence on supplemental oxygen. Her annual MDS assessment showed severe cognitive impairment, inability to obtain a BIMS score, dependence on staff for care, and a PEG tube. Her care plan last revised on 12/19/2025 did not address anemia or iron supplementation. The physician order dated 9/17/2026 directed ferrous sulfate 5 ml of 300 mg/5 ml (60 Fe) via G-tube twice daily for anemia. During observation on 2/11/2026 at 8:13 a.m., an LVN dispensed and administered 5 ml of liquid ferrous sulfate 220 mg/5 ml solution via feeding tube instead of the ordered 300 mg/5 ml solution. During interview, the LVN stated the bottle used was 220/ml instead of 300/5 ml for Resident #5 and said it was a medication error, adding that it was what they had been giving the patient. The DON stated medications should be dispensed and given as ordered, the label should be verified against the medication on hand, and any discrepancies should be clarified with the physician.
PRN Atarax Ordered Without Required Stop Date or Consent
Penalty
Summary
The facility failed to ensure that Resident #4 was not given a psychotropic drug unless it was necessary to treat a specific condition as diagnosed and documented in the clinical record. Resident #4 was a cognitively intact female with diagnoses including moderate recurrent major depressive disorder, generalized anxiety disorder, and cyclothymic disorder. Her care plan stated she was receiving Atarax per MD orders for itching and refusal to shower, and her February 2026 order summary showed Atarax (hydroxyzine) 10 mg by mouth every 8 hours as needed for itching with a start date of 1/15/2026. The physician order in PCC listed the end date as indefinite, and no consent for Atarax was found in the resident’s medical record. During interview, the resident stated she did not know if she had received information about her medication treatments. The ADON stated consents should be obtained for psychotropic medications including antipsychotics, hypnotics, and antianxiety medication, but said Atarax did not need consent because it was prescribed off label for itching and would not need a specific end date. The DON stated the computer flagged psychotropics at 14 days and that Atarax use for the resident was discussed with the psychologist, physician, and pharmacy. The facility policy stated PRN antipsychotic medications would not be renewed beyond 14 days unless the practitioner evaluated the resident and documented the rationale for continued use.
Deficiencies in Fire Safety Systems, Emergency Preparedness, and Grounds Maintenance
Penalty
Summary
The facility failed to maintain a safe environment by not correcting impairments related to the fire alarm system, not maintaining outside areas free of fire hazards, and not ensuring the Emergency Preparedness Plan was evaluated and updated annually. During inspection, the Emergency Preparedness Plan was found to have last been reviewed and signed in 2005, with no documentation of a more recent review. The Administrator, newly employed for one week, was unaware of the requirement for annual review and update of the Emergency Preparedness Plan and had not yet reviewed it. The facility housed 52 residents, including 17 who were dependent on ventilators for maintaining oxygen levels. Observations revealed the fire alarm annunciator near the Nurse Station displayed a trouble signal indicating a low battery, and the Maintenance Director confirmed ongoing issues with the fire alarm control panel, including a DC battery charge failure. Service tags on the panel indicated recent attempts to address the issue, but the trouble signal persisted. Additionally, the outside inspection showed overgrown vegetation, dead tree branches, dead brush, and leaves along the rear of the building, particularly near the smoking area, with multiple trees leaning against the roof. The Maintenance Director acknowledged responsibility for grounds maintenance and awareness of the overgrown vegetation but cited workload as a reason for the delay in addressing these hazards.
Failure to Provide CPR and Emergency Response for a Full Code Resident
Penalty
Summary
Facility personnel failed to provide basic life support, including CPR, to a resident who was found unresponsive with no pulse and no respirations while listed as full code. The resident had a history that included dependence on a ventilator, dependence on supplemental oxygen, paroxysmal atrial fibrillation, acute systolic congestive heart failure, chronic obstructive pulmonary disease with acute exacerbation, and cerebral infarction. The resident’s care plan and physician orders reflected full code status, with instructions to begin CPR after absence of vital signs, call 911, notify the physician, and ensure staff were aware of the code status. When the resident was found unresponsive, staff actions were inconsistent. One note stated aides found the resident not breathing and immediately started CPR while EMS was called, while another note stated CPR was begun after code status was checked. During interviews, staff described that CNA staff found the resident unresponsive and pulseless, left the room to find the charge nurse, and then returned with an LVN who began CPR. The LVN stated she performed compressions while calling 911, but also left the room to check the resident’s code status on the computer. Staff reported that the respiratory therapist bagged the resident, and that CPR was stopped when staff were told by the ADON that the resident was DNR, despite the resident being documented as full code. EMS reported that when they arrived, no care appeared to have been provided before their arrival, and the resident was pulseless and apneic. EMS began CPR, found the resident in asystole, and later stopped efforts after contacting the medical director. Staff interviews also showed that the AED was not obtained, the crash cart was not obtained, and CPR was not continued until EMS arrived. The facility policy stated that a licensed staff member certified in CPR/BLS shall initiate CPR when a person is found unresponsive and not breathing normally unless a DNR order exists or there are obvious signs of irreversible death, and if DNR status is unclear, CPR is to be initiated until it is determined that there is a DNR or a physician’s order not to administer CPR.
Failure to Timely Report Allegations of Abuse, Neglect, or Mistreatment
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the appropriate authorities within the required timeframes. Specifically, the facility did not report four separate allegations of abuse, neglect, or mistreatment involving four different residents. These allegations included a nurse allegedly treating a resident poorly and causing emotional distress, a nurse neglecting to change a gastric tube stoma dressing and instructing the resident to do it herself, rough incontinent care resulting in discomfort to an amputated leg, and verbal abuse where a staff member insulted a resident. Record reviews and interviews revealed that these allegations were documented in grievance reports but were not reported to the state agency as required by facility policy and state regulations. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that the grievances were reviewed by the interdisciplinary team, including the previous administrator, but the allegations were not recognized or reported as abuse, neglect, or exploitation (ANE) to the state agency. The current administrator also confirmed that the grievances should have been reported but were not, either due to lack of recognition or assumption that another staff member had reported them. The residents involved had varying degrees of cognitive and physical impairment, including diagnoses such as cerebral vascular accident, seizures, end-stage renal disease, severe obesity, amputation, adjustment disorder with depressed mood, and Parkinson's disease. Their care plans indicated significant needs for assistance with activities of daily living and communication. Despite these vulnerabilities, the facility did not follow established procedures to report the allegations, as confirmed by the absence of corresponding reports in the state’s incident database.
Failure to Investigate and Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated and reported as required. For four out of ten residents reviewed, there was no evidence that allegations of abuse, neglect, or mistreatment were properly investigated or that further potential harm was prevented during the investigation process. The facility also did not report the results of these investigations to the state agency, as required by policy and regulation. One resident with severe cognitive impairment and a history of stroke and seizures was alleged by her representative to have been treated poorly by a nurse, resulting in the resident crying, which was noted as rare for her. Another resident, who was cognitively intact and dependent on a gastrostomy tube for nutrition, alleged that a nurse neglected to change her tube dressing and instructed her to do it herself, contrary to her care plan requiring staff assistance. In both cases, grievance reports were documented, but the DON stated she did not recall the reports and had not reported the investigation results to the state agency. A third resident, with end-stage renal disease, severe obesity, and an above-knee amputation, alleged rough incontinent care by a staff member, resulting in soreness to her amputated leg. The ADON recalled discussing the allegation but did not report the results to the state agency. A fourth resident, with severe cognitive impairment and a history of depression and Parkinson's disease, alleged verbal abuse by a CNA. The ADON and administrator discussed the allegation but did not recognize it as reportable. A review of the state incident database confirmed that none of these allegations were reported as required. The facility's policy mandates immediate reporting of such allegations, but this was not followed.
Unattended and Unlocked Medication Carts
Penalty
Summary
Facility staff failed to ensure that medication carts containing drugs and biologicals, including narcotics, were securely locked and attended as required by facility policy and professional standards. On two separate occasions, a medication cart on the 100-hall and a respiratory therapy medication cart on the 200-hall were observed left unattended, unsupervised, and unlocked in the hallways. The 100-hall cart was left unlocked for 10 minutes while residents and CNAs walked by, and the 200-hall cart was left unlocked for 5 minutes with similar hallway traffic. In both cases, the responsible staff members were not present, and the carts were accessible to unauthorized individuals. Interviews with facility staff, including the ADON, LVN, and RT, confirmed that the carts were left unlocked due to human error and lack of awareness of the assigned nurse's whereabouts. The facility's policy requires medication carts to be locked when not in use or out of the nurse's view, and to be parked securely when unattended. The DON acknowledged that the expectation is for all medication carts to be locked when not attended by nursing staff.
Incomplete Documentation of Wound Care in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was admitted with multiple complex diagnoses, including Guillain-Barre disease, respiratory failure, and a tracheostomy. Specifically, the resident was prescribed daily wound care for a sacral pressure injury, but the November treatment administration record (TAR) lacked documentation of wound care on several specified dates. The care plan and physician's orders indicated the need for daily and PRN wound care, yet the TAR showed blanks for the prescribed treatment on multiple days. Interviews with facility staff confirmed the expectation that all care should be documented as soon as it is provided, and the Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the missing documentation in the resident's record. The resident's representative reported that the facility neglected general care and wound care, stating that the resident did not consistently receive the prescribed wound care and that the representative had to provide dressings personally. The DON stated that the wound was improving according to the wound care physician's documentation but was unaware of the missing entries in the TAR. The facility's policy requires accurate maintenance of medical records, but the lack of documentation for wound care on the specified dates resulted in incomplete and unorganized records for the resident.
Failure to Support Resident's Right to Refuse Care Without Coercion
Penalty
Summary
Staff failed to promote and facilitate a resident's right to self-determination and choice, specifically regarding the right to refuse care. The resident, an adult male with diagnoses including hypertension, chronic kidney disease, and coronary artery disease, and with intact cognition as evidenced by a BIMS score of 15, was subjected to staff telling him that his family member would be called if he refused to change his clothes. This approach was used as a means to gain compliance with care, as confirmed by both the DON and a CNA, and was described as a threat by the resident himself. The care plan included a directive to call the family member upon refusal of care, per the family member's request. The resident reported feeling sad and infantilized by this practice, expressing concern that his family member would be angry and stop visiting if called. The DON acknowledged that staff had become accustomed to using the threat of calling the family member to compel the resident to comply with care, and recognized this as a violation of the resident's rights. The administrator also confirmed that such actions were not permitted, even if requested by the family, as they infringed upon the resident's right to refuse care and could cause psychosocial harm.
Failure to Prevent Diversion of Pain Medication
Penalty
Summary
The facility failed to protect the rights of two residents to be free from misappropriation of property, specifically regarding the diversion of pain medications. Both residents had orders for Norco, with one resident rarely taking the medication and the other receiving it on a scheduled basis for pain management. The medications were administered and refilled exclusively by one LVN, who was also the only person to receive the medications from the pharmacy. This allowed the LVN to divert medications when they were delivered, as she was responsible for calling in refills and receiving the deliveries without adequate oversight. The deficiency was identified after an audit revealed several cards of Norco were unaccounted for, prompting further investigation. The audit involved both the in-house and hospice pharmacies, and it was discovered that the LVN had diverted the medications upon delivery. The process in place at the time did not ensure that medications were properly secured or that there was a reliable verification system involving multiple staff members when narcotics were received from the pharmacy. Interviews with staff indicated that the standard procedure required two nurses to verify and sign for narcotics upon delivery, but this process was not consistently followed in the cases involving the two residents. The lack of adherence to established protocols for receiving and securing medications enabled the LVN to divert the narcotics without detection for an extended period.
Failure to Notify State Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to send a copy of a resident's discharge notice to the Office of the State Long-Term Care (LTC) Ombudsman prior to the resident's discharge, as required. Record review and interviews confirmed that a resident with diagnoses including Guillain-Barre disease, respiratory failure, and a tracheostomy was admitted for LTC and later discharged to a hospital for elevated care, with no expectation of return. There was no evidence in the medical record that a discharge notice was sent to the state ombudsman. Interviews with the state ombudsman, social worker (SW), director of nursing (DON), and administrator revealed that none were aware of a notification being made to the ombudsman regarding the resident's discharge. The SW stated she had been directed not to coordinate with the ombudsman and had no evidence of a report for the discharge. The facility's policy indicated that for resident-initiated discharges, notification to the ombudsman was not required, but the discharge in question was not clearly documented as resident-initiated.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.69% due to two errors out of 26 opportunities. These errors involved a resident who was administered medications late. Specifically, RN A administered a 10 gram carafate tablet and 30 milliliters of 10 gm/15mL enulose solution to the resident at 5:29 p.m., which was one hour and twenty-nine minutes past the scheduled time of 4:00 p.m. The resident involved had a medical history of biliary cirrhosis, fibromyalgia, and gastro-esophageal reflux disease (GERD) with esophagitis. The resident's care plan included interventions to manage GERD and constipation, with specific medication orders for carafate and enulose to be administered at designated times to optimize therapeutic effects. The late administration of these medications could potentially affect their effectiveness, particularly the carafate, which was intended to be given before meals. RN A, who was new to the facility and unfamiliar with the residents and their medications, attributed the delay to his lack of familiarity with the medication administration procedures. The Director of Nursing (DON) confirmed that RN A was a new staff member and suggested that the late administration was due to his inexperience. The facility's policy requires medications to be administered within one hour of their prescribed time, emphasizing the importance of timely administration for optimal therapeutic effect.
Food Storage and Labeling Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. The first issue identified was the improper storage of plastic storage containers in the dish room. Three opaque plastic containers were stacked on top of each other without any separation to allow for air circulation, resulting in visible moisture between the containers. This practice contradicts the facility's policy and the U.S. FDA Food Code, which require equipment and utensils to be air-dried before being stacked or stored to prevent bacterial growth. The second deficiency involved the improper labeling and dating of a container of chopped beef brisket in the walk-in cooler. The container, which was partially full, was labeled with the date it was received, but not with the date it was opened or a use-by date. This oversight could lead to the proliferation of bacteria, as the facility's policy mandates that all opened food items be labeled with both the date opened and the use-by date to ensure food safety. The third issue was the improper storage and labeling of French fries in the reach-in freezer. A package of food wrapped in brown paper and loosely covered with plastic wrap was found without a label indicating its contents. The package was dated but not properly sealed, which could result in freezer burn and deterioration of food quality. The facility's policy requires all frozen foods to be covered, labeled, and dated to ensure they are consumed by their use-by dates or discarded if necessary.
Failure to Ensure Resident Privacy During Catheter Care
Penalty
Summary
The facility failed to ensure personal privacy for a resident during catheter care, as observed by surveyors. Two CNAs did not completely close the privacy curtain while providing catheter care, leaving the resident exposed and visible from the room's door. This incident occurred while other staff members were present in the room providing care for the resident's roommate. The CNAs acknowledged during an interview that the privacy curtain was not fully closed, although it should have been. The resident involved had a history of severe cognitive impairment and was dependent on staff for activities of daily living. The resident's medical conditions included dysphagia, type 2 diabetes mellitus, cerebral palsy, and spina bifida, and they had an indwelling catheter due to a neurogenic bladder. The facility's Director of Nursing confirmed that privacy should have been maintained during care and that staff had received training on resident rights within the year. The facility's policy on dignity emphasized the importance of maintaining resident privacy during personal care and treatment procedures.
Incomplete Care Plan for Resident with Communication Deficit
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which is a requirement to ensure that all residents' needs are met. Specifically, the care plan for a resident with a cognitive communication deficit was incomplete, as it did not address the resident's communication needs. This oversight was identified during a review of the resident's records, which showed that the resident had a history of hemiplegia, hemiparesis, major depressive disorder, and aphasia following a cerebral infarction. Despite these conditions being documented, the care plan lacked a focus section on the resident's communication deficit, which is crucial for staff to provide appropriate care. Observations and interviews with staff revealed that the resident used a communication card to express needs, but this method was not included in the care plan. The MDS LVN responsible for care plans acknowledged the omission and could not explain why the communication deficit was not included. The Director of Nursing also confirmed that the communication impairment should have been reflected in the care plan to ensure the resident's needs were met. The facility's policy requires that care plans include measurable objectives and timeframes to address residents' physical, psychosocial, and functional needs, which was not adhered to in this case.
Hazardous Materials Found in Resident's Bathroom
Penalty
Summary
The facility failed to maintain a safe environment for a resident with severe cognitive impairment and legal blindness. During an observation, it was found that the resident's bathroom contained several cleaning supplies with hazardous warnings, such as disinfecting sprays, isopropyl alcohol, bleach, multipurpose cleaner, and germicidal alcohol wipes. These items were stored behind a shower curtain, making them accessible to the resident, who was diagnosed with unspecified dementia with psychotic symptoms, legal blindness, and anxiety disorder. The presence of these hazardous materials in the resident's bathroom posed a risk of contact with potentially dangerous substances. Interviews with facility staff, including an RN and the DON, confirmed the presence of these cleaning supplies in the resident's bathroom. The RN acknowledged that the supplies should not have been there, given the resident's legal blindness and dementia diagnosis. The DON stated that cleaning supplies should not be present in resident rooms to prevent contact with hazardous materials. It was noted that a family member of the resident might have brought the supplies into the room, which was against the facility's policy of providing a safe and homelike environment.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, leading to a deficiency in maintaining the resident's highest practicable physical, mental, and psychosocial well-being. The resident, who was admitted with diagnoses including malignant neoplasm of the lung, type 2 diabetes mellitus, and unspecified dementia, displayed signs and symptoms of depression. Despite these symptoms being documented in multiple progress notes over several months, the resident was not offered mental health services. The resident's quarterly MDS indicated moderate cognitive impairment, and the resident consistently reported feelings of depression, isolation, and loneliness. Interviews and record reviews revealed that the resident expressed feelings of being a prisoner and not understanding why they were residing at the facility. The Director of Nursing (DON) acknowledged being unaware of the lack of referral to mental health services and confirmed that the resident had expressed feelings of depression and isolation. The facility's policy on Behavioral Health Services, revised in February 2019, stated that the facility would provide necessary behavioral health services to maintain residents' well-being, which was not adhered to in this case.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by professional principles. During a medication administration round, RN C left the Hall 200 Medication Cart unlocked while entering a resident's room and closing the door, leaving the cart out of sight. The unlocked cart contained blister packs, bottles, and vials of medications intended for residents, which could lead to misappropriation or accidental ingestion. In an interview, RN C acknowledged leaving the cart unlocked and admitted to forgetting the requirement to keep it locked. The Director of Nursing (DON) confirmed that the medication cart should have been locked and that nursing staff had been trained on drug diversion prevention, including keeping carts locked when not in use. The facility's policy on medication cart security also mandates that carts be securely locked when out of the nurse's view. Despite RN C having passed a proficiency checklist for medication administration, this oversight occurred.
Infection Control Deficiencies in Equipment Sanitization and Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving improper care practices. In the first incident, a registered nurse (RN) did not sanitize a blood pressure cuff between using it on two different residents. The RN acknowledged the oversight and recognized the potential risk for cross-contamination. The Director of Nursing (DON) confirmed that the RN should have sanitized the equipment between uses, as per the facility's policy on cleaning and disinfection of resident-care equipment. In the second incident, two certified nursing assistants (CNAs) failed to wear gowns while providing care to a resident who was on enhanced barrier precautions. Despite signage indicating the need for such precautions, the CNAs were unaware of the requirement. The DON confirmed that gowns should have been worn to prevent cross-contamination, in accordance with the facility's policy on enhanced barrier precautions. Both the RN and the CNAs had received infection control training within the year, and the facility conducted regular skills checks.
Improper Garbage Disposal Practices
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, specifically with Dumpster #1. Observations revealed that the dumpster was overflowing with trash, preventing the lid from closing completely, which left an 18-inch gap. Additionally, the dumpster was missing a drainage plug on the right side, and there was trash and debris scattered around the area, including plastic bags, an empty cardboard case of soda, a plastic glove, an empty water bottle, and a cigarette butt. Interviews with the Food Service Director (FSD) and the Maintenance Director confirmed that trash was typically picked up twice a week, and the dumpster had been recently replaced. The Maintenance Director acknowledged the missing drain plug and its importance in preventing animals from accessing the dumpster. The facility's waste disposal policy and the U.S. Public Health Service Food Code require that waste containers be emptied regularly, sealed, and covered with tight-fitting lids, and that drain plugs be in place, which were not adhered to in this instance.
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 fracture to her left tibia. The resident, who had moderate intellectual disabilities, autistic disorder, and severe cognitive impairment, was unable to communicate how the injury occurred. Despite the presence of a significant bruise and swelling on her leg, the facility did not report the incident to the state reporting agency (HHSC) within the required two-hour timeframe. The resident was wheelchair and bedbound, requiring maximum assistance for activities of daily living and was dependent on staff for transfers. The injury was discovered after the resident returned from an Adult Day Care program, where she traveled via a public bus service without staff supervision. The facility's Director of Nursing (DON) and other staff members were aware of the injury but did not classify it as an injury of unknown origin, as the resident reportedly mentioned the bus in relation to the injury, despite her severe cognitive impairment. Interviews with facility staff revealed that there was confusion and a lack of clarity regarding the origin of the injury. The DON and Administrator did not report the injury to the state agency, as they did not suspect abuse or neglect, relying instead on the resident's limited communication about the bus. The facility's policy required reporting injuries of unknown origin, but the staff did not adhere to this policy, resulting in a failure to report the incident as required.
Deficient Care Plan for Resident with Intellectual Disabilities
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with moderate intellectual disabilities, autistic disorder, and type 2 diabetes mellitus with diabetic polyneuropathy. The care plan did not include essential details such as the name and contact information of the LIDDA representative, the next scheduled IDT meeting, or specifics about the Adult Day Care services the resident attended three times a week. Additionally, the care plan lacked information on the community bus service used for transportation to the Adult Day Care, including the schedule, interventions for transport, and contact information. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's care plan. RN B described the process of preparing the resident for Adult Day Care but noted that there was no daily or written communication with the Adult Day Care facility. The receptionist and LVN A confirmed that the care plan did not include necessary transportation and contact information. The MDS Coordinator, who was responsible for care plans, was unavailable for interviews, and the DON acknowledged that the care plan should have included the missing information. The facility's policy on comprehensive person-centered care plans emphasized the need for measurable objectives and timetables to meet residents' needs. However, the DON admitted that the care plan for the resident's Adult Day Care and transportation was not updated when the activity was initiated. The Administrator and LIDDA also provided insights into the lack of communication and coordination between the facility and the Adult Day Care, highlighting the deficiency in ensuring continuity of care for the resident.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 899 citations issued within 25 miles in the last 12 months — including the 18 immediate-jeopardy cases — 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 San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| San Pedro Manor | 0.2 mi | ★★★★★ | 1 | 0 |
| St. Francis Nursing Home | 0.2 mi | ★★★★★ | 5 | 0 |
| San Antonio North Nursing And Rehabilitation | 0.7 mi | ★★★★★ | 15 | 0 |
| Memorial Medical Nursing Center | 0.7 mi | ★★★★★ | 9 | 0 |
| The Sarah Roberts French Home | 2 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 July 2026) and official state health department websites.