Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mirador during CMS and state inspections, most recent first.
Kitchen Food Storage and Sanitation Failures: The DM entered the kitchen without a hairnet, and surveyors observed dirty juice dispenser nozzles, corrosion and buildup on the hot chocolate and latte dispenser, a dirty ice machine with black-brown substance on the lid, and an unlabeled spray bottle in the chemical storage area. Multiple foods were expired, unlabeled, undated, or left open in the refrigerator, walk-in cooler, ice cream cooler, and bread shelf, and several clean-dish items were corroded or damaged. The CNM stated hairnets should be worn in the kitchen and foods should be labeled, dated, and sealed appropriately.
A resident with acute kidney failure, COPD, muscle weakness, and moderate cognitive impairment had a care plan and MD order for fall mats x2 while in bed, but an observation found the resident in bed with no mats present. The ADON and DON stated the mats were used to prevent injury, should be placed next to the bed whenever the resident was in bed, and may not have been put back after the resident returned from the hospital.
A resident with COPD and other diagnoses was observed receiving oxygen through a kinked nasal cannula while the O2 concentrator was set above the ordered 2 L/min. No Oxygen in Use sign was posted at the room door. The ADON and DON stated that kinks or incorrect settings would prevent delivery of the ordered oxygen and could cause medical complications.
A resident with HTN and a history of TIA received carvedilol even though her HR was below the ordered hold parameter of less than 60. The MAR showed the med was given three times while HR readings were 55, 56, and 55, and the DON confirmed it should have been held. The DON and an MA stated carvedilol lowers BP and HR and should not be administered outside physician parameters.
A medication cart contained a used bottle of timolol eye drops for a resident with cataracts, but the bottle was not labeled with the date opened. An MA stated she had used the bottle several times and could not tell whether it had expired, and the DON stated the date opened should have been recorded and that the drops expire about 28-30 days after opening.
Infection control failures occurred during wound care for a resident with a stage 3 sacral pressure injury and an EBP order. The ADON performed wound care without a gown, did not perform hand hygiene before touching the bedside table or after contact with the dirty brief, used ABHS for only a few seconds, and tried to glove while hands were still wet. CNA-C was also in the room without a gown while assisting with the resident’s positioning. The ADON later stated EBP applied to wound care and that hand hygiene and glove changes should have occurred after touching the soiled brief and before handling the resident’s linens.
Two residents requiring Enhanced Barrier Precautions and Contact Precautions did not have their care plans updated to reflect these needs, despite physician orders and posted signage. Staff interviews revealed that care plans were not routinely used or accessed, and the MDS nurse acknowledged the oversight due to competing priorities. Facility policy required comprehensive, person-centered care plans, but these were not updated as needed.
A resident with hemiplegia, dependent on staff for ADLs, fell from bed during peri care when a CNA failed to maintain proper alignment and supervision. After the fall, the CNA moved the resident back to bed before a nurse could assess for injuries, contrary to facility protocol. The resident sustained a femur fracture and a dislodged feeding tube, requiring hospital evaluation and nonsurgical management.
A CNA failed to provide adequate supervision and safe positioning for a resident with significant cognitive and physical impairments during incontinent care, leading to the resident falling from the bed, sustaining a femur fracture, and dislodging a feeding tube. The CNA did not use proper PPE despite the resident being on contact isolation for C. difficile, and had a history of not following infection control protocols. The incident was captured on in-room surveillance and resulted in the resident being transferred to the hospital.
A CNA failed to follow infection prevention and control protocols while providing incontinent care to a resident on contact isolation for C. diff. The CNA did not wear a gown, wore a face mask improperly, and neglected hand hygiene before and during care, including not changing gloves between dirty and clean tasks. The resident was highly dependent and had multiple medical conditions, including a current C. diff infection. Despite available PPE and documented training, the CNA's actions violated facility policies and placed the resident at risk.
A resident with multiple health issues experienced significant changes in condition, including lethargy and decreased oxygen saturation, but the facility failed to notify the physician promptly. Despite family concerns and worsening symptoms, communication was limited to text messages, which were not seen in time, leading to delayed medical intervention and the resident's eventual death.
A facility failed to maintain the confidentiality of residents' medical records when an RN left an electronic health record screen unlocked, displaying sensitive information about four residents. The screen was visible to non-staff members, potentially exposing private details such as names, pictures, and health information. Staff acknowledged the importance of locking screens to protect privacy, but the administrator could not confirm if the information was confidential, referring to the facility's Resident Rights policy.
Kitchen Food Storage and Sanitation Failures
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 the initial kitchen observation, the DM entered the kitchen without a hairnet. The juice dispenser nozzles and backsplash were dirty with sticky spots, runs, and drips. The hot chocolate and latte dispenser nozzle had build-up and corrosion, and the backsplash and drip tray were dirty and sticky. The ice machine had corrosion on the outside and a black-brown substance across the inside of the lid. In the chemical and cleaning storage area, there was an unlabeled spray bottle containing a small amount of clear liquid. In the area where clean dishes were stored, multiple pitchers were corroded and appeared melted, and multiple pans had dings and scraped Teflon. Food storage issues were also observed throughout the kitchen. Inside the kitchen refrigerator there was an unlabeled and undated pan of a thick creamy substance, an unlabeled and undated tray with 28 individual cups of shredded cheese, sour cream, and bacon bits, and a jar of sliced jalapenos that had expired on 09/06/2025. The refrigerator also had a black-brown substance along the rubber seal. Inside the walk-in cooler were expired dessert topping sauce, simple syrup, homemade croutons, cut carrots, and cornbread muffin mix, along with an opened, unlabeled, and undated bag of French fries, an opened, unlabeled and undated bag of breaded meat, and an unsealed bag of granola. In the ice cream cooler, multiple containers of ice cream had lids off or not completely on. On the bread shelf, there were multiple open, unlabeled and undated packages of bread and an expired package of croissants. The CNM stated hair nets should be worn when entering the kitchen and that foods should be labeled, dated, and sealed appropriately to prevent cross-contamination and prevent residents from getting sick. The DM stated staff cleaned the kitchen daily and deep cleaned weekly, but did not know what the slimy black-brown substances on the ice machine and refrigerator were.
Care plan for fall mats not implemented
Penalty
Summary
The facility failed to ensure the comprehensive care plan was developed and implemented for Resident #16, including measurable objectives and timeframes to meet identified medical, nursing, mental, and psychosocial needs. Resident #16 was a female with diagnoses including acute kidney failure, COPD, and muscle weakness, and her annual MDS showed a BIMs score of 08, indicating moderate cognitive impairment. Her care plan dated 01/29/26 included a fall intervention for fall mats x2 while she was in bed, and the physician order summary also listed fall mats x2 while the resident was in bed as an order dated 05/19/26. During an observation on 06/29/26 at 11:00 AM, Resident #16 was lying in bed with the bed in its lowest position, but no fall mats were noted on the floor next to the bed or anywhere else in the room. The ADON stated the mats were used to prevent injury if a resident fell and that it was staff responsibility to put them back after the resident returned to bed. The DON stated the mats were likely removed and cleaned when the resident went to the hospital and were not put back upon return, and that the mats should be on the floor next to the bed whenever the resident was in bed.
Incorrect Oxygen Delivery Setup and Missing Room Signage
Penalty
Summary
Resident #16, a female with diagnoses including COPD, acute kidney failure, and muscle weakness, had a care plan focus for impaired airway clearance with continuous/PRN oxygen at 2 L/min via nasal cannula. During an observation, she was lying in bed with the nasal cannula in place, but the tubing was caught between the door frame and the bathroom door, causing it to kink. The oxygen concentrator was also observed to be set at 3.5 L/min instead of the ordered 2 L/min, and there was no Oxygen in Use sign posted at the door to her room. Record review showed the physician order for continuous/PRN oxygen at 2 L/min via nasal cannula matched the care plan. In interviews, the ADON stated that incorrect concentrator settings or kinks in the nasal cannula would prevent delivery of the oxygen concentration ordered by the physician and could lead to hypoxia or other medical complications. The ADON also stated the facility did not have a policy for posting Oxygen in Use signage and believed community signage was sufficient. The DON stated that incorrect oxygen settings or a kinked oxygen tube would not deliver the ordered oxygen and that higher liters per minute than ordered could lead to medical complications.
Medication Error: Carvedilol Given Despite Low Heart Rate
Penalty
Summary
The facility failed to ensure Resident #25 was free from significant medication errors when carvedilol was administered despite the resident’s heart rate being below the physician’s ordered parameter of less than 60. Resident #25 was a female with diagnoses including Essential Hypertension and Transient Cerebral Ischemic Attack, and her care plan included giving Coreg and Lisinopril as ordered. Her active order for carvedilol 12.5 mg twice daily included the instruction to hold the medication if heart rate was less than 60. Review of the June 2026 MAR showed carvedilol was given on the morning of 06/27/26 with a heart rate of 55, on the evening of 06/27/26 with a heart rate of 56, and on the evening of 06/28/26 with a heart rate of 55. During interview, the DON stated the medication should have been held on all three occasions. The DON and MA B stated carvedilol lowers blood pressure and heart rate and should be held when outside physician parameters; the facility policy also stated vital signs are checked and verified prior to administering medications when necessary.
Unlabeled Timolol Eye Drops in Medication Cart
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in locked compartments and labeled according to accepted professional principles for medications in 1 of 4 medication carts reviewed. During observation of the Side 2 Medication Aide Cart, a used bottle of timolol eye drops for Resident #5 was found with a sticker that said "Date Opened:" but no date was entered. The bottle label identified it as timolol eye drops for Resident #5, but there was no way to determine when the bottle had first been opened. Resident #5 was an [AGE] year-old female with diagnoses including age-related nuclear cataract and impaired visual function related to cataracts. Her active order was for timolol 0.5% solution eye drops, 1 drop in the left eye twice daily. The MA stated she had administered the eye drops from the bottle in the cart several times, did not know when the bottle was first used, and could not tell whether it had expired. The DON stated the date opened should have been written on the label and that the timolol eye drops expired approximately 28-30 days after opening; the DON also stated there was a possibility Resident #5 received expired medication.
Infection Control Failures During Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for Resident #18 during wound care. Resident #18 was a male admitted on 03/26/2026 with a current order for treatment of a stage 3 pressure injury to the sacrum, including cleansing with DWS or Vashe, applying Medi-honey, covering with calcium alginate, applying skin prep to the surrounding wound edges, and securing with a foam dressing on Tuesday, Thursday, and Saturday day shifts. The resident also had an order for Enhanced Barrier Precautions every shift for wounds. During an observation of wound care, CNA-C was already in the resident’s room with gloves on but without a gown, and she held the resident in place while the ADON performed the wound care. The ADON entered the room, retrieved the bedside table, and cleaned the table and reviewed the wound care order without performing hand hygiene, although she was wearing gloves. She then washed her hands, put on gloves, and began wound care, but never donned a gown. While cleansing the wound, the ADON pulled the resident’s dirty brief aside, and the brief repeatedly slid up against the wound area. The ADON continued to move the brief without performing hand hygiene and re-gloving in between contacts. After cleansing the wound, the ADON performed hand hygiene with ABHS for approximately 3 to 4 seconds and attempted to put on gloves while her hands were still visibly wet. She discarded one glove and started over, then touched the dirty brief again to move it out of the way and continued wound care. When wound care was finished, she used the same gloves to put the resident’s brief back on and pull up the blankets without performing hand hygiene and changing gloves in between. CNA-C later stated she forgot to put on a gown and acknowledged that she should have worn one during wound care. The ADON stated she was also the Infection Control Nurse, that EBP was for high-contact care such as wound care and bathing, and that she should have placed a barrier between the brief and wound or pulled the brief down, performed hand hygiene after touching the dirty brief, and performed hand hygiene before pulling up the sheets and blankets.
Failure to Update Care Plans for Infection Control Precautions
Penalty
Summary
The facility failed to develop and implement person-centered, comprehensive care plans with measurable objectives and timeframes for two residents who required specific infection control precautions. For one resident with an indwelling Foley catheter, the care plan did not include the need and physician order for Enhanced Barrier Precautions (EBP), despite the presence of an EBP sign outside the resident's room and a physician order for EBP. For another resident with a diagnosis of C. Diff, the care plan did not reflect the need and physician order for Contact Precautions, even though a Contact Isolation sign was posted and an order for Contact Precautions was present in the medical record. Interviews with staff revealed that certified nursing assistants (CNAs) and nurses did not routinely use or access care plans to guide resident care, relying instead on other tools such as the Kardex. The registered nurse (RN) and director of nursing (DON) both acknowledged that care plans should have included the required precautions and that staff should have known how to access and use them. The minimum data set (MDS) nurse, responsible for updating care plans, admitted that the care plans for these two residents were overlooked due to a recent gastrointestinal outbreak and other competing priorities, despite being aware of the need for updates. Facility policy required that care plans incorporate goals and objectives to achieve the resident's highest level of independence and that the interdisciplinary team (IDT) develop comprehensive, person-centered care plans based on resident assessments. However, the care plans for these two residents were not updated to reflect current infection control needs, as required by policy and physician orders.
Failure to Follow Fall Management Protocols Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to ensure a resident received treatment and care in accordance with professional standards and the resident’s care plan. The resident, an elderly female with a history of cerebrovascular disease and right-sided hemiplegia, was dependent on staff for activities of daily living, including bed mobility and transfers. During the provision of perineal care, the CNA assisted the resident in turning and repositioning in bed. The resident’s legs became misaligned, and after the CNA removed the fitted bed sheet, the resident’s legs dangled off the bed, leading to her falling to the floor. The incident was captured on in-room surveillance video, which showed the resident hitting her head and sustaining a fall after the CNA stepped away from the bedside. Following the fall, the CNA immediately picked up the resident from the floor and placed her back on the bed without waiting for a nurse to perform a head-to-toe assessment, as required by facility protocol. The charge nurse was notified after the resident had already been moved, and upon arrival, found the resident on the bed rather than on the floor. The nurse questioned the CNA about moving the resident, emphasizing that residents who have fallen should not be moved prior to a nursing assessment to prevent exacerbation of potential injuries. The nurse conducted an assessment and, due to the unwitnessed nature of the fall, sent the resident to the emergency room for further evaluation. Medical records from the hospital revealed the resident sustained a nondisplaced right femur fracture and a dislodged feeding tube as a result of the fall. The resident required nonsurgical management of the fracture and the use of a Hoyer lift for transfers. The facility’s policy on post-fall procedures required staff to evaluate for injuries and obtain vital signs before moving a resident, which was not followed in this case. The CNA involved had received relevant in-service training and competency assessments prior to the incident, but failed to adhere to established protocols during the event.
Failure to Provide Adequate Supervision and Safe Positioning During Incontinent Care Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide adequate supervision and safe positioning for a resident during incontinent care, resulting in the resident falling from her bed. The resident, an elderly female with multiple diagnoses including cerebrovascular disease, metabolic encephalopathy, right-sided weakness, dysphagia, malnutrition, abnormal posture, rheumatoid arthritis, seizures, and a history of traumatic brain injury, required substantial to total assistance with activities of daily living (ADLs) and was always incontinent of bladder and bowel. Her care plan and assessments indicated significant cognitive and physical impairments, including dependence on staff for transfers and repositioning, and a need for close supervision during care. On the day of the incident, the CNA was observed on in-room surveillance video providing perineal care while the resident was on her side. The CNA instructed the resident to roll, and although the resident attempted to comply, her body was not properly aligned or secured on the bed. The CNA removed bed linens and, while doing so, the resident's legs slipped off the bed. The CNA then turned away from the resident, at which point the resident's body followed her legs off the bed, resulting in a fall. The resident struck her head and sustained a right distal femur fracture and dislodgement of her feeding tube. The CNA immediately picked the resident up from the floor and placed her on the bed, contrary to standard protocol for post-fall management. Interviews and record reviews revealed that the CNA had a history of not following proper infection control and peri care procedures, including not using appropriate personal protective equipment (PPE) and not maintaining hand hygiene. The CNA had received annual competency training and signed off on relevant in-services, but had been previously counseled for similar issues. At the time of the incident, the resident was on contact isolation for C. difficile, and the CNA was not wearing full PPE. The incident was witnessed by staff and documented in facility records, with the resident subsequently transferred to the hospital for evaluation and treatment.
Failure to Follow Infection Control Protocols During Incontinent Care for Resident on Contact Isolation
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow infection prevention and control protocols while providing incontinent care to a resident on contact isolation for Clostridium difficile (C. diff). The CNA entered the resident's room without donning a gown, wore his face mask improperly under his chin, and did not perform hand hygiene before putting on gloves. During the care, the CNA did not change gloves or sanitize hands when moving between dirty and clean tasks, such as wiping, assisting with turning, removing clothing, and changing linens. The CNA also used the same gloves to remove clean wipes from their container, further breaching infection control practices. The resident involved was an elderly female with multiple complex medical conditions, including cerebrovascular disease, gastrostomy status, dysphagia, right-sided paralysis, esophageal stricture, malnutrition, rheumatoid arthritis, seizures, and a history of traumatic brain injury. She was totally dependent on staff for all activities of daily living, including toileting, dressing, and hygiene, and was always incontinent of bladder and bowel. At the time of the incident, she was on antibiotic therapy and under contact isolation for a confirmed C. diff infection, with appropriate signage and PPE supplies available outside her room. Despite documented policies, procedures, and regular in-service training on infection control, hand hygiene, and PPE use, the CNA had a history of non-compliance with these protocols, including previous counseling for similar issues. Staff interviews confirmed that infection control training was provided and that PPE and hand hygiene expectations were well known. The incident was observed via in-room surveillance video and corroborated by staff interviews and record reviews, establishing that the CNA's actions directly violated established infection control policies and placed the resident at risk for cross-contamination and infection.
Failure to Notify Physician of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to notify the physician when a resident experienced a significant change in their physical status. The resident, an elderly male with a history of multiple fractures, atrial fibrillation, heart failure, and other conditions, showed signs of lethargy, vomiting, decreased oxygen saturation, and irregular lung sounds. Despite these significant changes, the facility did not adequately communicate with the physician, leading to a delay in medical intervention. The resident's condition deteriorated over several hours, with family members expressing concern about his lethargy and other symptoms. The nursing staff, including RN A and LVN B, were involved in monitoring the resident but failed to effectively communicate the severity of the situation to the physician. The resident eventually required resuscitation efforts, and despite these efforts, he expired. The facility's communication with the physician was limited to text messages, which were not promptly seen or responded to, contributing to the delay in appropriate medical response. Interviews with staff and the physician revealed that there was a lack of clear communication and timely notification regarding the resident's condition. The physician indicated that he would have expected to be contacted directly when the resident's condition worsened, especially given the full code status and the family's wishes regarding resuscitation. The facility's policy on notifying physicians of significant changes in a resident's condition was not followed, leading to a critical lapse in care.
Failure to Maintain Resident Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical records, affecting four residents. On a specific date, RN A did not lock her electronic health record computer screen, which displayed sensitive information about the residents. This screen was visible to community residents and visitors, potentially exposing the residents' private information. The information displayed included names, pictures, and the ability to access further confidential details such as date of birth, primary physician, and health-related documentation. The residents involved had various medical conditions. One resident was a female with cerebral infarction, hemiplegia, hemiparesis, and vascular dementia, with a severe cognitive impairment. Another resident was a female with acute respiratory failure, heart failure, and dyspnea, who was cognitively aware but reliant on staff for activities of daily living (ADLs). A male resident had Alzheimer's disease and dementia, unable to complete an interview and dependent on staff for ADLs. The fourth resident was a female with Alzheimer's disease and chronic obstructive pulmonary disease, also with severe cognitive impairment and reliant on staff for ADLs. During interviews, staff members acknowledged the importance of locking the electronic health record screen to protect residents' privacy. RN A admitted to forgetting to lock the screen when attending to a resident's request for pain medication. The facility's administrator was unable to definitively confirm whether the displayed information was considered confidential, referring instead to the facility's Resident Rights policy. The policy guarantees residents' rights to privacy and confidentiality, which were not upheld in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Corpus Christi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cimarron Place Health & Rehabilitation | 0.8 mi | ★★★★★ | 4 | 0 |
| Corpus Christi Nursing And Rehabilitation Center | 1.2 mi | ★★★★★ | 2 | 0 |
| Wooldridge Place Nursing Center | 2 mi | ★★★★★ | 14 | 0 |
| The Palms Nursing & Rehabilitation | 2.1 mi | ★★★★★ | 35 | 0 |
| San Rafael Nursing And Rehabilitation Center | 4.4 mi | ★★★★★ | 19 | 0 |
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