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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pearsall Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with CKD stage 5 and ESRD had an MDS that did not indicate dialysis in Section O, even though the resident had active orders for dialysis, a care plan for dialysis-related needs, and staff confirmed he was receiving dialysis at an outside clinic on a regular schedule. The MDS nurse stated dialysis should have been triggered on the assessment and described the omission as an oversight/data entry error.
Insulin Pen Not Primed Before Administration: An LVN administered Lantus to a resident with diabetes without priming the insulin pen first. The resident had orders for Lantus 30 units BID, and the LVN stated he was not familiar with priming the pen. The DON stated the pen should be primed before use to ensure the resident receives the appropriate dose.
A resident with dysphagia and a hx of stroke was ordered a slow-flow adaptive drinking cup with fluids, and the care plan and meal ticket also identified the need for the device. During a meal observation, a CNA served cranberry juice in a regular cup instead, and the resident drank from it and immediately coughed. The CNA, an LVN, the SLP, and the DON all acknowledged the resident should have received the ordered adaptive cup.
Missing Hospice Election and Certification Documents: The facility failed to coordinate hospice care planning and ensure a resident’s hospice binder contained the election/cancellation/update form and the physician’s certificate of terminal illness. A resident with schizophrenia, metastatic breast cancer, and severe cognitive impairment was receiving hospice services, and the DON stated the hospice company was responsible for the binder after the missing forms were identified and faxed.
An LVN failed to follow hand hygiene and insulin pen preparation practices during a medication pass for a resident with diabetes. After washing his hands, he turned off the faucet with his bare hand, then administered insulin without cleaning the insulin pen’s rubber seal with alcohol first. The DON stated both actions were a break in infection control, and the facility policy required proper hand hygiene and noted that gloves do not replace hand hygiene.
A resident with multiple medical conditions was discharged home with family, but the MDS discharge assessment was incorrectly coded as a discharge to a short-term general hospital. Staff and administrative interviews confirmed the error, which was inconsistent with the resident's documented discharge destination.
A resident with severe cognitive impairment and frequent urinary incontinence did not receive complete incontinence care when a CNA failed to clean the buttock area during a care episode. The omission occurred despite the resident's care plan and facility policy requiring thorough cleaning, and was acknowledged by the CNA and confirmed by the ADON.
The facility did not employ a Food Service Supervisor with the required certification, education, or completed coursework in food safety management, and the consultant RD provided only limited consultative hours. The administrator was aware of the deficiency and could not provide evidence of compliance with federal food code requirements for food protection manager certification.
Surveyors found that the facility did not maintain proper food storage and temperature control in the kitchen, with a cooler operating above the required temperature and expired food items not discarded as per policy. Additionally, staff failed to properly sanitize blender components used for pureed diets, not following the required contact time for sanitizing solution. These failures could place residents at risk for foodborne illness.
A resident with severe cognitive impairment and psychosis was admitted and began receiving an antipsychotic medication, but the baseline care plan did not include this medication within the required 48-hour timeframe. The omission was confirmed by staff interviews and record review, showing that the medication was only added to the care plan several days after admission, contrary to facility policy.
A resident with multiple mental health diagnoses had a care plan that did not include required PASRR services, despite being evaluated and qualified for them. Staff interviews revealed uncertainty about whether the resident had refused these services, but it was later confirmed the resident had not refused and was awaiting service implementation. The facility's policy requires such services to be documented in the care plan, but this was not done.
A nurse failed to provide a scheduled wound care treatment for a resident with a Stage IV sacral pressure ulcer, as ordered by the physician. The omission was confirmed through record review, observation, and staff interviews, revealing that the required dressing change was not completed and not documented, in violation of facility policy.
A medication cart contained a package of sertraline with outdated dosage instructions after a physician order was changed from 150 mg to 50 mg for a resident. The required change direction label was not applied to the medication package, contrary to facility policy, which could have led to confusion among staff and medication errors.
Two residents experienced lapses in infection prevention and control when a CNA placed a bed wedge that had fallen on the floor back onto a resident's bed without cleaning it, and an RN failed to change gloves or perform hand hygiene between removing an old PEG tube bandage and applying a new one. Both staff acknowledged the breaches, which were not in accordance with facility infection control policies.
The facility failed to obtain informed consent from the responsible parties of three residents before admitting them to a locked unit, violating resident rights and leaving them uninformed about their care and treatment options.
The facility failed to ensure that a nurse aide employed for more than four months was enrolled in or had completed an approved training course. Despite attempts to contact the aide, there was no documentation confirming certification, placing residents at risk.
A facility failed to ensure a resident's Out-of-Hospital Do Not Resuscitate (OOH DNR) order was valid, as it lacked the necessary physician's signature and details. The Social Worker admitted to uploading the incomplete document, resulting in the resident being identified as full code status against the family's wishes.
A resident's annual MDS assessment failed to include a diagnosis of depression, despite the resident being treated with Paroxetine. This clerical error was confirmed by the MDS Coordinator and acknowledged by the RN and DON, highlighting a risk of inadequate care due to incomplete assessments.
The facility failed to ensure that a resident's care plan was comprehensive and updated to reflect her current condition, including her psychiatric diagnosis, locked unit status, allergies, code status, and medications. The care plan also lacked interventions for her dementia diagnosis, despite her severe cognitive impairment and multiple health issues.
A facility failed to ensure proper incontinent care for a resident, as CNA did not clean between the vaginal folds after an incontinent episode, risking infection. The resident had severe cognitive impairment and multiple diagnoses, requiring substantial assistance for toileting. The facility's policy and skills checklist were not followed, as confirmed by the CNA and DON.
A resident was administered Paroxetine without an active diagnosis of depression due to a clerical error in the MDS Assessment and lack of review by the charge nurse. The facility's policy on psychotropic medication was not followed, leading to the risk of unnecessary medication administration.
The facility failed to ensure proper labeling and storage of medications for two residents, as observed in the 100-hall and 500-hall medication carts. The medication packages did not match the current dosage orders, and change direction stickers were not used due to a shortage. The DON confirmed that staff should have notified her to order more stickers in advance.
The facility failed to ensure that the Activity Director, who was preparing food for residents, had a food handlers' certificate. The Administrator was aware of this practice but did not enforce the requirement, leading to potential risks of food-borne illness and inadequate nutrition due to improper food handling practices.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, leading to the presence of unlabeled and past-dated food items in the kitchen and activities refrigerators and freezers. The Activity Director prepared food without a food handler's certificate, and weekly audits were not properly documented, increasing the risk of food-borne illness for residents.
The facility failed to ensure a safe environment by leaving hazardous materials and potential choking hazards unsecured on three hallways. Unsecured bleach wipes were found on the 100 hallway, an unlocked utility area and hazardous material room were observed on the 200 hallway, and an unlocked supply room with small objects and food items was found on the 300 hallway, a secure unit for residents with cognitive concerns.
MDS Did Not Reflect Resident’s Dialysis Treatments
Penalty
Summary
The facility failed to ensure Resident #17’s MDS assessment accurately reflected that the resident was receiving dialysis treatments. Resident #17 was a [AGE]-year-old male admitted with diagnoses including diabetes, hyperlipidemia, peripheral vascular disease, and chronic kidney disease stage 5. The most recent MDS assessment reflected kidney disease and moderate cognitive impairment for daily decision-making, but Section O did not indicate that the resident required dialysis. Record review showed the resident had active orders for dialysis-related care, including checking the left upper arm shunt every shift for signs and symptoms of infection or bleeding and receiving dialysis at a clinic on Monday, Wednesday, and Friday. The comprehensive care plan also identified that the resident required dialysis treatments related to end stage renal disease. During interviews, staff stated the resident had been receiving dialysis before admission and continued while in the facility. The MDS nurse reviewed the assessment and stated dialysis should have been triggered on the MDS and that it was an oversight and data entry error.
Insulin Pen Not Primed Before Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when LVN B administered Lantus insulin to Resident #97 without priming the insulin pen first. Resident #97 was a cognitively intact male with diagnoses that included diabetes, peripheral vascular disease, acquired absence of left toes, and acquired absence of the right leg below the knee. His orders included Lantus 100 unit/mL insulin, 30 units subcutaneously twice daily, and his care plan identified diabetes with interventions for administering medications as ordered. During observation, LVN B obtained the insulin pen from the medication cart, inserted a needle into the rubber seal without cleaning it first, did not prime the pen, dialed the dose to 30 units, and injected the resident. When interviewed, LVN B stated he was not familiar with priming an insulin pen and did not fully know the technology behind priming it, despite having skills training within the year that included insulin use. The DON stated that an insulin pen should be primed before administration and checked for air bubbles because priming ensures the resident receives the appropriate dose. The Lantus package insert also stated to perform the safety test before each injection to ensure an accurate dose.
Failure to Provide Ordered Adaptive Drinking Cup
Penalty
Summary
The facility failed to provide Resident #24 with the physician-ordered slow-flow adaptive drinking cup during the noon meal. Resident #24 had diagnoses including dysphagia and a history of stroke. The physician order dated 06/11/2024 required a slow-flow adaptive drinking cup with fluids, and the care plan dated 11/11/2025 identified the adaptive drinking cup as needed to promote safe swallowing and reduce the risk of aspiration. The meal ticket also indicated that Resident #24 required a slow-flow adaptive drinking cup with meals. During observation of meal service on 07/13/2026 at 12:15 pm, CNA D served cranberry juice in a regular drinking cup instead of the ordered adaptive cup. Resident #24 independently lifted the regular cup, drank the juice, and immediately coughed after swallowing. CNA D stated the resident should have been provided a slow-flow adaptive drinking cup and acknowledged the incorrect cup was served. LVN C stated she was responsible for making sure residents had what was ordered by the doctor and said the resident should have had a sippy cup. The SLP stated Resident #24 required thin liquids with small sips when drinking, and the DON stated staff are educated regarding adaptive equipment needs and that the slow-flow adaptive drinking cup is intended to regulate fluid intake and promote safer swallowing.
Missing Hospice Election and Certification Documents
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services, and failed to ensure that the resident’s hospice documents were present in the hospice binder. Resident #23 was a [AGE]-year-old female admitted to the facility on 04/01/26 with diagnoses including schizophrenia, malignant neoplasm of the right breast, secondary malignant neoplasm of axilla and upper limb lymph nodes, and mild intellectual disabilities. Her Significant Change MDS showed a BIMS score of 5, indicating severe cognitive impairment, and her comprehensive care plan showed hospice services were initiated on 06/15/26. The Physician Order Summary dated 07/16/26 showed she was admitted to [Hospice Company] for malignant neoplasm of the right breast with an order date of 06/12/26. Record review of the hospice binder for Resident #23 on 07/15/26 at 3:00 PM showed there were no forms under the tab for Form 3071 and Form 3074. During initial rounds on 07/13/26 at 10:45 AM, Resident #23 was observed visiting with a hospice employee in her room, and during interview on 07/15/26 at 10:55 AM she confirmed she had a visitor from hospice and stated she was pleased with services from the facility and hospice and received help when needed. During interview on 07/15/26 at 3:30 PM, the DON stated she would have to ask the hospice company why Forms 3071 and 3074 were not in the hospice binder because they are responsible for the binder; the DON then called the hospice company and they faxed the forms to her. The facility’s hospice policy stated that when a resident participates in hospice, a coordinated plan of care between the facility and hospice agency is developed and the resident’s care plan should be revised and updated with changes.
Infection Control Lapses During Insulin Administration
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when an LVN failed to follow hand hygiene and insulin administration practices during a medication pass for a resident with diabetes. Resident #97 was cognitively intact, had diagnoses including diabetes, peripheral vascular disease, acquired absence of left toes, and acquired absence of the right leg below the knee, and was ordered Lantus insulin 30 units subcutaneously twice daily. During observation, the LVN washed his hands in the resident’s bathroom and turned off the faucet with his bare hand instead of using a paper towel, then returned to the medication cart and administered insulin without cleaning the rubber seal of the insulin pen with alcohol first. During interview, the LVN stated that after washing hands the faucet should be turned off with a paper towel because the handle could be contaminated and germs could be reintroduced, and he acknowledged he did not realize he had turned it off with his bare hand. He also stated he was not sure the rubber seal on the new insulin pen had to be cleaned with alcohol before use, despite having skills training within the year. The DON stated the nurse should have wiped the rubber seal with alcohol before inserting the needle and should have used a paper towel to turn off the faucet because it was cross contamination and a break in infection control. The facility’s hand hygiene policy stated all staff must perform proper hand hygiene procedures and that gloves do not replace hand hygiene.
Inaccurate MDS Discharge Assessment Coding
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the resident's status for one resident whose Minimum Data Set (MDS) records were reviewed. Specifically, the Discharge MDS assessment for this resident was incorrectly coded, indicating that the resident was discharged to a short-term general hospital, when in fact, documentation and staff interviews confirmed the resident was discharged home with family. This discrepancy was identified through review of the resident's face sheet, progress notes, and staff interviews, which consistently indicated the resident's actual discharge destination was home, not a hospital. The resident involved had a medical history including type 1 diabetes mellitus with ketoacidosis, major depressive disorder, and anemia. The error in the MDS assessment was acknowledged by both nursing staff and the facility administrator during interviews, who confirmed that the coding did not match the resident's actual discharge status as documented in the clinical record.
Incomplete Incontinence Care Provided to Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide complete incontinence care to a male resident with severe cognitive impairment, dementia, and multiple other diagnoses, including muscle wasting, hypertension, and anemia. The resident was frequently incontinent of urine and occasionally incontinent of bowel, with a care plan specifying incontinence care at least every two hours and cleaning of the perineal area with each episode. During an observed care episode, the CNA removed the resident's soiled brief and cleaned the suprapubic, groin, and genital areas, but did not clean the resident's buttock area before applying a new brief. The CNA later acknowledged forgetting to clean the buttock area due to nervousness, despite having received peri-care training and passing a skill checkoff earlier in the year. The Assistant Director of Nursing (ADON), who was acting as the Director of Nursing (DON) at the time, confirmed that the buttock area should have been cleaned to prevent possible infection. Facility policy also required cleansing of the entire buttock area during incontinence care. This lapse in care was identified through observation, interviews, and record review.
Lack of Qualified Food and Nutrition Services Leadership
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skill sets to manage the food and nutrition service in accordance with regulatory requirements. The Food Service Supervisor (FSS) did not possess the necessary certification, education, or qualifications to serve as the Director of Food and Nutrition Services. Specifically, the FSS was not a certified dietary manager or certified food service manager, did not have an associate's or higher degree in food service management or hospitality, and had not completed a course of study in food safety management covering essential topics such as foodborne illness, sanitation procedures, and food purchasing/receiving. Although the FSS had over two years of experience in the role, she had not achieved certification due to the lack of a consistent consultant Registered Dietitian (RD) to serve as a preceptor. Interviews revealed that the consultant RD provided only 12-16 hours of consultative services per month and was not employed full-time at the facility. The facility administrator confirmed awareness of the FSS's lack of required credentials and was unable to provide evidence of completed coursework in food safety management. Record reviews referenced federal food code requirements for accredited food protection manager certification, which were not met by the current FSS.
Deficient Food Storage, Temperature Control, and Sanitization Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. Surveyors observed that reach-in cooler #1 was not maintained at or below the required temperature of 41 degrees F, with thermometer readings showing 51-52 degrees F. The temperature log for the cooler indicated a lower temperature, but no time was recorded, and staff could not confirm when the temperature was taken. Additionally, there was a failure to record the temperature of the cooler on a subsequent day, as required by facility policy. Further deficiencies were identified in the storage of food items. An opened package of pork chorizo sausage and a package of sliced salami were found in the coolers past their use-by dates, contrary to facility policy and federal food code requirements. Staff interviews confirmed that these items should have been discarded and that all staff had been trained on proper food storage procedures. The facility also failed to properly sanitize the compartments of a blender used to prepare pureed diets. Staff were observed submerging blender components in sanitizing solution for less than the required contact time specified by the manufacturer's instructions and facility policy. There was inconsistency among staff regarding the correct submersion time, with the actual practice not meeting the required 60 seconds. These failures could place residents at risk for foodborne illness, as noted in the report.
Failure to Include Antipsychotic Medication in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission that included all necessary instructions for effective and person-centered care for a resident. Specifically, the baseline care plan did not address the resident's use of an antipsychotic medication, Olanzapine, which had been ordered and administered for psychosis. The omission was confirmed through record review, which showed that the antipsychotic medication was not included in the baseline care plan until several days after admission, despite being present in the physician's orders and medication administration record from the time of admission. Interviews with the MDS nurse and the DON confirmed that the admitting nurse was responsible for completing the baseline care plan and that the omission of the antipsychotic medication was an oversight. The resident in question had severe cognitive impairment, as indicated by a BIMS score of 2, and diagnoses including dementia and unspecified psychosis. The facility's policy required that baseline care plans be developed within 48 hours of admission and include all physician orders, but this was not followed in this instance.
Failure to Include PASRR Services in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple mental health diagnoses, including major depressive disorder, schizoaffective disorder, insomnia, anxiety disorder, and unspecified psychosis. The resident's care plan included interventions related to antipsychotic medication use and mental health services but did not reflect the requirement for PASRR (Preadmission Screening and Resident Review) services, despite documentation that the resident had been evaluated and qualified for such services. Interviews with staff revealed confusion regarding whether the resident had refused PASRR services, but it was later clarified that the resident had not refused and was awaiting implementation of these services following a recent evaluation. The facility's policy requires that the care plan include any specialized services recommended by PASRR, as well as documentation if services are refused, but this was not reflected in the resident's care plan at the time of the survey.
Failure to Provide Prescribed Wound Care for Stage IV Pressure Ulcer
Penalty
Summary
A deficiency occurred when a nurse failed to provide prescribed wound care to a resident with a Stage IV sacral pressure ulcer on the evening of 05/07/2025. The resident, who was dependent for transfers and had intact cognition, had physician orders for wound cleansing and dressing changes three times daily. Review of the Treatment Administration Record showed no documentation of the 8:00 p.m. wound care on that date, and observation the following morning revealed the sacral wound dressing was soiled and had not been changed as scheduled. The nurse assigned to the resident on the evening in question confirmed during an interview that she did not complete the wound care due to being busy and forgetting, and the Director of Nursing corroborated this account after speaking with the nurse. The facility's policy required topical treatments and dressings to be applied as per physician orders, but this was not followed for the resident's Stage IV pressure ulcer. The omission was identified through record review, staff interviews, and direct observation, which confirmed that the required wound care was not provided as ordered, resulting in a lapse in necessary treatment and services for wound management.
Failure to Update Medication Label Following Order Change
Penalty
Summary
A deficiency was identified when a medication cart in the 300 Hall was found to contain a package of sertraline for a resident with a label indicating a dosage of 50 mg, along with instructions to give one tablet daily with an additional 100 mg to equal 150 mg. However, the current physician order for the resident was for sertraline 50 mg, one tablet by mouth daily, with no end date. During medication administration, the medication aide administered only 50 mg of sertraline to the resident, in accordance with the current order, but the medication package still displayed outdated instructions referencing the previous 150 mg dosage. The facility's policy requires that when there is a change in a physician's order, a direction change sticker or equivalent must be affixed to the medication label to alert staff to the updated instructions. In this case, the required change direction label was not present on the medication package, and the Director of Nursing confirmed that staff should have placed the sticker to prevent confusion and ensure the correct dosage was administered. This lapse in labeling could have led to medication errors, as the medication label did not reflect the current physician order.
Infection Control Failures in Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for two residents. In the first instance, a certified nursing assistant (CNA) was observed providing peri and Foley catheter care to a resident with a history of cerebral infarction and neuromuscular bladder dysfunction, who was on Enhanced Barrier Precautions due to a Foley catheter and ulcers. During care, the CNA removed a bed wedge from the resident's bed, which then fell to the floor. The CNA subsequently picked up the wedge from the floor and placed it back onto the resident's bed without cleaning or sanitizing it, despite the resident's increased risk for infection. In the second instance, a registered nurse (RN) provided PEG tube site care to a resident with dementia, cerebral infarction, and dysphagia requiring tube feeding. The RN removed the resident's old gauze bandage from the PEG tube site and, without changing gloves or performing hand hygiene, applied a new bandage. The RN acknowledged that he should have changed gloves and sanitized his hands between removing the old bandage and applying the new one, as per infection control protocols. Both staff members involved were aware of the correct procedures and acknowledged during interviews that their actions did not align with facility policy or infection control standards. Facility policies reviewed confirmed the requirement for cleaning reusable equipment after contamination and for performing hand hygiene before and after glove use, especially during wound care and when handling potentially contaminated items.
Failure to Obtain Informed Consent for Locked Unit Admission
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments. Specifically, the facility did not obtain informed consent from the responsible parties of three residents (Resident #44, Resident #47, and Resident #95) before admitting them to a locked unit. This failure included not informing the residents or their representatives of the risks, benefits, and treatment options available, which is a violation of resident rights. Resident #44, a severely cognitively impaired female with multiple diagnoses including dementia and anxiety, was admitted to a locked unit without the facility obtaining informed consent from her responsible party. The medical records clerk admitted to being behind on uploading consents, and the Director of Nursing (DON) confirmed that a consent form was required but not found. Resident #47, a severely cognitively impaired female with multiple psychiatric diagnoses, was also admitted to a locked unit without proper informed consent. Interviews with staff revealed that the resident was her own representative, but she did not know what medications she was taking and had no emergency contact or guardian listed. Staff members signed consent forms on her behalf without proper documentation or attempts to find a responsible party. Resident #95, a severely cognitively impaired male with dementia and other medical conditions, was admitted to a locked unit without the facility obtaining informed consent from his family or responsible party. The Assistant Director of Nursing (ADON) and Medical Records Clerk both acknowledged that the consent was missing from the resident's electronic record, and the DON confirmed that obtaining consent was their policy but had not been followed in this case.
Failure to Ensure Nurse Aide Certification
Penalty
Summary
The facility failed to ensure that a nurse aide (NA G) who had been employed for more than four months was either enrolled in or had completed an approved training course. NA G was hired on 04/24/2023, and as of 03/29/2024, there was no documentation confirming that NA G had taken the certification test. Interviews with the HR representative, LVN, and DON revealed that none of them knew why NA G had not taken the certification test, and attempts to contact NA G had been unsuccessful. This failure placed residents at risk of receiving care from an individual whose skill level was not verified.
Failure to Ensure Valid DNR Documentation
Penalty
Summary
The facility failed to ensure a resident's right to formulate an advance directive was honored, specifically for one resident who had an Out-of-Hospital Do Not Resuscitate (OOH DNR) order. The resident, a male with severe cognitive impairment and multiple health conditions including dementia, diabetes, and chronic kidney disease, was identified as DNR status. However, the OOH DNR document was found to be invalid as it lacked the physician's signature, printed name, license number, and date, which are required to make the document valid. Interviews with the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Social Worker (SW) revealed that the SW was responsible for ensuring the OOH DNR paperwork was completed correctly. The SW admitted to uploading the incomplete document into the electronic record, acknowledging the oversight. The facility's policy mandates that the resident's code status be communicated accurately, but this failure resulted in the resident being identified as full code status, contrary to the family's wishes.
Failure to Accurately Assess Resident's Depression Diagnosis
Penalty
Summary
The facility failed to complete an accurate assessment for Resident #78, who was being treated for depression with Paroxetine. The resident's annual MDS assessment did not reflect the diagnosis of depression, despite the resident having an active prescription for an antidepressant. This discrepancy was identified during a record review and confirmed through interviews with the RN, MDS Coordinator, and DON. The MDS Coordinator admitted to a clerical error in the assessment, which led to the omission of the depression diagnosis. The resident's face sheet and care plan indicated the use of antidepressant medication for depression, but this was not captured in the MDS assessment. The RN and DON acknowledged the risk of inadequate care due to incomplete assessments. The facility's policy on psychotropic medication requires that resident symptoms and therapeutic goals be clearly documented, which was not adhered to in this case.
Failure to Update Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to ensure that Resident #44's care plan was comprehensive and updated to reflect her current condition. Specifically, the care plan did not include information about her psychiatric diagnosis, the locked unit she resided in, her allergies, her code status, or medications for her psychiatric diagnosis. Additionally, while the care plan mentioned her dementia diagnosis, it did not contain any interventions to address it. This deficiency was identified during a review of Resident #44's records and an interview with the Director of Nursing (DON), who acknowledged that the care plan was missing critical information necessary for providing appropriate interventions. Resident #44, a [AGE] year-old female, was admitted with multiple diagnoses including dehydration, dementia, muscle weakness, generalized anxiety disorder, seizures, insomnia, and cognitive communication deficit. Her Admission MDS indicated that her cognition was severely impaired and that she was receiving antianxiety medications and antidepressants. Despite these significant health issues, her care plan, last revised on 03/26/24, lacked essential details and interventions. The facility's policy on comprehensive care plans, dated 10/24/22, mandates that care plans be developed within 7 days of the comprehensive MDS assessment and include all necessary information to meet the resident's medical, nursing, and psychosocial needs, which was not adhered to in this case.
Failure to Provide Proper Incontinent Care
Penalty
Summary
The facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. Specifically, CNA G did not properly clean the vaginal area of Resident #47 after an incontinent episode. During the observation, it was noted that CNA G did not separate and clean between the vaginal folds, which is necessary to remove germs and prevent infections. This was confirmed by CNA G during an interview, where she acknowledged the correct procedure and admitted to not following it during the care of Resident #47. Resident #47 is a [AGE] year-old female with a history of severe cognitive impairment and multiple diagnoses, including mood disorder, bipolar disorder, schizophrenia, and sleep apnea. The resident's care plan indicated that she was always incontinent of urine and required substantial assistance for toileting. The facility's policy and skills checklist for perineal care clearly outlined the correct procedure for cleaning the vaginal area, which CNA G failed to follow. The Director of Nursing (DON) confirmed the necessity of cleaning the vaginal folds to prevent infections during an interview.
Failure to Administer Psychotropic Medication for Diagnosed Condition
Penalty
Summary
The facility failed to administer a psychotropic medication to treat a specific, diagnosed condition for one resident. Resident #78 was being administered Paroxetine, an antidepressant, since January 12, 2024, without having an active and current diagnosis of depression. The resident's Annual MDS Assessment, dated January 31, 2024, did not indicate depression, insomnia, or adjustment disorder as active diagnoses. Despite this, the resident's Comprehensive Person-Centered Care Plan noted the use of anti-depressant medication for insomnia and adjustment disorder. Interviews with the RN and MDS Coordinator revealed that the MDS Assessment had a clerical error, missing the indication of depression, and the charge nurse did not review the MDS for accuracy. The DON was unaware of the resident being treated for a diagnosis not assessed, highlighting the risk of unnecessary medication administration. The facility's policy on psychotropic medication, dated August 15, 2022, requires that resident symptoms and therapeutic goals be clearly identified and documented. This policy was not followed in the case of Resident #78, leading to the administration of Paroxetine without a proper diagnosis. The MDS Coordinator admitted to a clerical error in the assessment, and the charge nurse did not verify the accuracy of the MDS. The DON acknowledged the risk associated with this practice, which could result in residents receiving unnecessary medications.
Failure to Properly Label and Store Medications
Penalty
Summary
The facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for two of four medication carts reviewed. Specifically, the facility did not provide change direction labels for two medication packages that had their medication orders changed. This was observed in the 500-hall medication cart for a resident's Divalproex with instructions for 250 mg, and in the 100-hall medication cart for another resident's Divalproex with instructions for 125 mg. The labels on these packages did not match the current dosage orders, which could lead to medication misuse and diversion. During an interview, a CMA stated that they usually use change order stickers to alert staff to medication changes, but they had run out of stickers. The Director of Nursing (DON) confirmed that staff should place a change in direction sticker on any medications with a change in the order and that they should have notified her in advance to order more stickers. The facility's policy on labeling of medication, dated 10/01/2019, states that only the dispensing pharmacy or registered pharmacist can modify, change, or attach prescription labels, and that drugs should be kept in containers labeled by a pharmacist or in the original manufacturer's container.
Failure to Ensure Dietary Staff Competency
Penalty
Summary
The facility failed to ensure that all dietary staff, including the Activity Director, had the appropriate competencies and skillsets to carry out the functions of food and nutrition service. The Activity Director was observed preparing food for residents without having a food handlers' certificate. The Activity Director had been working at the facility for two years and had been preparing food for residents and staff community events for the last year. The Administrator was aware of this practice but did not require the Activity Director to obtain a food handlers' certificate, believing it was unnecessary since she was not a dietary staff member. This oversight could place residents at risk of food-borne illness and inadequate nutrition due to improper food handling practices. During the survey, it was observed that the Activity Director had exclusive access to certain refrigerator and freezer units containing various food items, some of which were expired, past-dated, or unlabeled. The Activity Director admitted to not auditing the work of her activity aides who were responsible for weekly inspections of these units. The facility's policy on food preparation and handling, as well as food storage, was not followed, as evidenced by the lack of proper labeling, dating, and sealing of refrigerated foods. The Administrator acknowledged the potential risks associated with untrained staff preparing food but had not enforced the requirement for a food handlers' certificate for the Activity Director.
Failure to Adhere to Food Safety Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety. Observations revealed that reach-in freezer unit #5 contained several unlabeled food items, including bags of diced meat, meat tenders, meatballs, and meat cutlets. The Dietary Manager (DM) was unaware of these unlabeled items and stated that it was her expectation that all items in the kitchen be labeled. Additionally, the activities refrigerators and freezers contained past-dated food items and unlabeled meat, which were only accessible by the Activity Director and her aides. The Activity Director admitted to preparing food from these units without a food handler's certificate and without proper documentation of weekly audits by her aides. The Administrator was also unaware of the unlabeled and past-dated items and acknowledged the potential risk of food-borne illness associated with these deficiencies. The facility's policies on food preparation, handling, and storage were not followed, as evidenced by the presence of unlabeled and past-dated food items. The Activity Director's lack of a food handler's certificate and the absence of proper documentation for weekly audits further contributed to the deficiency. The facility's failure to ensure that all food items were labeled and discarded once past their printed date placed residents at increased risk of food-borne illness and inadequate nutrition. The Administrator confirmed that all food in the facility should be labeled and discarded according to the facility's policies and state and federal guidelines.
Facility Fails to Secure Hazardous Materials and Potential Choking Hazards
Penalty
Summary
The facility failed to ensure the resident environment was free of accident hazards on three of its hallways. On the 100 hallway, a container of unsecured bleach wipes labeled 'Danger' and 'Keep Out of Reach of Children' was found on an incontinent care cart. Both a CNA and an LVN confirmed that the bleach wipes were usually stored on the cart and acknowledged the potential risk of residents coming into contact with the hazardous material. On the 200 hallway, the utility area and a room marked for hazardous material were found unlocked. Although the room did not contain hazardous materials at the time, it did have supplies for storing such materials. An RN confirmed that the unlocked doors could allow residents, staff, or visitors to access potentially harmful materials. On the 300 hallway, which is a secure unit for residents with cognitive concerns, a supply room containing small objects and food items was found unlocked. The room contained items like gambling chips and potato chips, which could pose choking hazards. An LVN confirmed the presence of these items and noted that many residents in the secure unit required mechanical soft or puree diets to prevent aspiration and choking. The Administrator and DON acknowledged that these unsecured items could be dangerous and confirmed that the facility did not have a policy regarding the physical environment.
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What surveyors actually found near you
We read the 6 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pearsall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Devine Health & Rehabilitation | 22.3 mi | ★★★★★ | 6 | 0 |
| Lytle Nursing Home | 29.9 mi | ★★★★★ | 0 | 0 |
| Community Care Center Of Hondo | 31.8 mi | ★★★★★ | 19 | 0 |
| Avir At Cotulla | 32.1 mi | ★★★★★ | 14 | 0 |
| Jourdanton Nursing And Rehabilitation | 34.8 mi | ★★★★★ | 25 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.