Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pecan Valley Rehabilitation And Healthcare during CMS and state inspections, most recent first.
Two residents with Type 2 DM did not receive insulin according to physician orders, as MARs showed multiple bedtime Insulin Glargine and NovoLOG doses documented more than one hour after the scheduled times over several months. Despite facility protocols and in-service education requiring adherence to the one-hour window, immediate documentation, and reporting of medication errors to nursing leadership and providers, there were no progress notes identifying these late administrations as errors, no documented provider notification, and no evidence of management follow-up in the clinical records. Interviews with medication aides, an RN, ADONs, the DON, and the Administrator confirmed the established expectations for timely administration and documentation, but also revealed that leadership was either unaware of or had not acted on the repeated late insulin entries associated with a specific LVN.
Two residents with Type 2 DM receiving ordered bedtime insulin had multiple doses administered significantly later than the scheduled times, as shown on their MARs, without any corresponding progress notes documenting the late administrations as medication errors or any notification to the physician or management team. Despite facility policy, staff training on the six rights of medication administration, and leadership expectations that all medication errors and related notifications be documented immediately in the EMR, the residents’ clinical records did not contain entries explaining or reporting these late insulin administrations.
Admission MDS Not Completed Timely: A resident admitted with an open leg wound, DM2 with hyperglycemia, bipolar disorder, and morbid obesity did not have a completed admission MDS within the required timeframe. The record showed only the preferences section was finished while the rest remained in progress, even though the resident had intact cognition on BIMS and a care plan had already been started. The MDS LVN acknowledged the assessment was due but not completed, and the DON said staffing/workload issues made it difficult for the two MDS LVNs to keep up.
Discharge MDS Not Completed or Transmitted Timely: A resident with epilepsy, DM2, acute respiratory failure, and a prior stroke was sent to the hospital after sudden loss of consciousness, hypotension, and agonal breathing. The MDS record showed an admission MDS, but no discharge MDS was completed or transmitted to CMS within the required timeframe; the MDS LVN acknowledged missing it, and the DON said staffing/workload issues made timely completion difficult.
A resident with stroke-related hemiplegia, aphasia, dysphagia, and severe cognitive impairment did not have her ordered right-hand splint in place. The care plan and order called for splint use and shift monitoring of the hand, but during observation the right hand was curled under her shirt while staff said therapy had ended, restorative hand care was never set up, and the splint had been paused.
Unlabeled, Undated Food Left in Resident Refrigerator: Surveyors found cooked beef and white pasta in an unlabeled, undated container in a resident's personal refrigerator, and the same food remained there on a later check. The resident said her daughter often leaves food in the refrigerator, the CNA did not know who checked for expired food, and the LVN said nursing was responsible for removing unlabeled or undated items. The DON confirmed perishable items in resident refrigerators should be labeled and dated.
A Dietary Manager was observed preparing food while wearing a hair restraint that only partially covered her hair, leaving the rest of her head exposed. The DM, DON, and Administrator all stated that full hair coverage is expected to prevent contamination, but the DM did not have a properly fitting restraint at the time, resulting in a deficiency related to kitchen sanitation standards.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment was not maintained to minimize risks, and supervision protocols were insufficient.
Two residents voiced grievances regarding missed medications and prolonged wait times after a medical appointment, but staff failed to document or report these concerns to facility leadership as required by policy. As a result, the grievances were not recognized or addressed by the facility.
A resident with heart failure and other cardiac conditions missed a scheduled cardiology appointment for an echocardiogram after her representative did not arrive on time to escort her. Despite attempts to contact the representative, an LVN dismissed the ambulance and did not arrange for staff to accompany the resident, resulting in the missed appointment. Facility leadership was not informed of the incident at the time, and no alternative arrangements were made.
A facility failed to maintain accurate clinical records for a resident with stage 4 pressure ulcers, as wound care was not documented on five occasions. Despite wound care being provided, staff interviews revealed lapses in documentation due to oversight and system errors, potentially affecting care continuity.
The facility failed to appoint a licensed administrator responsible for daily management. OM L, who managed daily operations, was not licensed but in the process of obtaining a license. The administrator was not present full-time and was available remotely. OM M, who previously managed operations, was also unlicensed. The facility lacked a specific policy for administration, relying on regulations.
A facility failed to maintain accurate medical records for a resident with severe cognitive impairment and multiple medical conditions. Oral hygiene care was not documented on several days, despite being performed using a sponge stick instead of a toothbrush. The CNA responsible documented the task incorrectly, leading to a deficiency in record-keeping. The DON confirmed that all care tasks should be documented daily.
A LTC facility failed to maintain proper infection control practices, as observed in three incidents. A CNA did not change gloves or wash hands after touching a privacy curtain before providing care to a resident with an indwelling catheter. An LVN left a used lancet on a resident's bedside table, posing an infection risk. Additionally, a medication aide wiped the tip of an eye dropper with a tissue, potentially contaminating the medication. These actions were acknowledged by the staff involved and confirmed by the DON.
A CNA failed to sit while assisting a resident with severe cognitive impairment and dysphagia during a meal, contrary to facility policy and training. The resident, who requires supervision for eating, was observed lying in bed with her lunch tray, and the CNA stood over her while feeding, leading to the resident pushing her tray away. The DON confirmed that staff should sit to avoid making residents feel towered over.
A resident's privacy was compromised during wound care when LVNs did not fully close the privacy curtain, exposing the resident in front of a roommate. Additionally, an LVN failed to lock her laptop screen, leaving residents' information visible. The DON confirmed the need for privacy during care and secure handling of medical records.
A resident's quarterly MDS assessment inaccurately documented the absence of anticoagulant medication, despite records showing the resident was prescribed and receiving Eliquis for deep vein thrombosis. The MDS nurse confirmed the error, acknowledging the medication should have been coded as an anticoagulant.
A resident with severe cognitive impairment and total dependence on staff for bathing did not receive scheduled showers on two occasions. Facility records lacked documentation of showers or baths during a specific period, and staff interviews confirmed the resident did not receive the necessary hygiene care. The facility's policies require documentation of all hygiene activities and refusals, but this was not adhered to, resulting in a deficiency.
The facility failed to properly label and date milk containers in the walk-in cooler, as observed during a survey. The whole milk and Lactose-Free milk containers were labeled with the dates they were received, not the dates they were opened or the use-by dates, contrary to food safety standards. This oversight could lead to bacterial growth, posing a risk of foodborne illness to residents.
The facility failed to properly dispose of garbage, with dumpster #1 overflowing and unable to close, and dumpster #2 missing a drainage plug and having an open door. This was observed during a survey, and staff interviews confirmed the trash had not been picked up as scheduled, violating the facility's policy based on the Texas Food Establishment Rules and the U.S. Food Code.
Late and Undocumented Insulin Administration for Two Diabetic Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate and timely administration and documentation of insulin for two residents with Type 2 Diabetes Mellitus. For the first resident, a male with diabetes, CVA, legal blindness, and a left below-knee amputation, the MARs for February through April 2026 showed repeated late administration of ordered insulin doses. His orders included Insulin Glargine 22 units subcutaneously at bedtime and NovoLOG on a sliding scale before meals (and previously at bedtime). Documentation showed that on multiple dates in February and March, insulin doses scheduled for 8:00 p.m. were recorded as administered more than one hour late, such as at 9:41 p.m. and 9:19 p.m. in February and at 9:22 p.m. and 9:42 p.m. in March. In April, the same bedtime Insulin Glargine order was documented as given at 9:02 p.m. and 9:01 p.m. instead of the scheduled 8:00 p.m. For this first resident, the facility’s records did not contain progress notes identifying these late administrations as medication errors, nor any documentation of provider notification or management notification related to the late insulin doses between February 1 and April 30, 2026. The resident’s care plan identified a history of Type 2 Diabetes Mellitus, and the MDS documented that he required insulin injections and had intact cognition. Despite this, there was no corresponding clinical documentation explaining the deviations from ordered administration times or any nursing assessment or follow-up related to the late insulin administration. The second resident, a female with diabetes, major depressive disorder, and bipolar disorder, also had physician orders for insulin that were not followed as written. Her orders included Insulin Glargine-yfgn 20 units subcutaneously at bedtime, to be held if blood sugar was less than 150, and NovoLOG FlexPen on a sliding scale before meals and at bedtime, also to be held if blood sugar was less than 150. The April 2026 MAR showed that the Insulin Glargine-yfgn scheduled for 6:00 p.m. was documented as administered at approximately 9:00 p.m. on multiple dates, and the NovoLOG FlexPen scheduled for 8:00 p.m. was also documented as given around 9:00 p.m. on several dates. As with the first resident, there were no progress notes identifying these late administrations as medication errors, no documentation of provider notification, and no indication that facility management was informed. Interviews with medication aides, an RN, ADONs, the DON, and the Administrator confirmed that the facility’s protocol required medications to be administered within one hour before or one hour after the scheduled time, and that doses given outside this window were considered medication errors requiring immediate reporting, provider notification, and progress note documentation. Staff stated that late doses should be documented with reasons in the progress notes and reported to the DON or ADON. The ADONs and DON acknowledged that they could pull reports to identify out-of-range administration times, and that late doses should trigger follow-up. However, the ADONs reported they were not aware of the late insulin administrations and had not counseled the nurse involved, and Human Resources confirmed that the LVN associated with numerous late entries had not been counseled. The DON stated she was aware of late entries by this LVN and attributed some late documentation to the LVN not interrupting residents, but there was no evidence of corrective documentation or reporting in the residents’ records. Facility policies and in-service materials emphasized the right time and immediate documentation as part of the rights of medication administration, but these were not followed in the cases reviewed.
Failure to Document Insulin Medication Errors and Notifications in Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for two residents with diabetes who required insulin therapy. For the first resident, a male with Type 2 Diabetes Mellitus and an intact BIMS score of 15, the Medication Administration Record (MAR) for April showed an active order for Insulin Glargine 22 units subcutaneously at bedtime. On two dates in April, this insulin was documented as administered more than an hour after the scheduled time of 8:00 p.m. by the same LVN. However, a review of this resident’s progress notes from February through April did not reveal any documentation identifying these late administrations as medication administration errors or any notification to the provider or facility management. For the second resident, a female with Type 2 Diabetes Mellitus, diabetic neuropathy, major depressive disorder, and bipolar disorder, and a BIMS score of 11 indicating intact cognition, the Order Summary showed an active order for Insulin Glargine-yfgn 20 units subcutaneously at bedtime with instructions to hold if blood sugar was less than 150. The April MAR reflected multiple instances where this insulin was administered several hours after the scheduled time of 6:00 p.m., again by the same LVN. A review of this resident’s progress notes from late March through April did not show any entries identifying these late administrations as medication errors or any documentation of notification to the physician or facility management. Interviews with the ADONs and the DON confirmed that facility practice and expectations required all medication errors, including late medication administration, and related notifications to the physician and management team to be documented immediately in the electronic medical record. They stated that such documentation in progress notes was necessary to explain late entries for medication administration and to maintain accurate medical records. In-service education records on “Rights of Medication Administration” and “Insulin Administration” showed staff had been instructed that documentation should occur immediately after medication is administered, including the right documentation as one of the six rights of safe medication administration. Despite these policies and trainings, the clinical records for the two residents lacked the required progress notes and documentation of medication errors and notifications.
Admission MDS Not Completed Timely
Penalty
Summary
The facility failed to complete and transmit an admission MDS assessment for Resident #45 within 14 days of admission. Resident #45 was a female admitted with diagnoses including an open wound on the lower left leg, Type 2 diabetes with hyperglycemia, bipolar disorder, and morbid obesity. The electronic health record showed the admission MDS was initiated, but only Section F, Preferences for Routine & Activities, was completed; all other sections remained marked In Progress. The Complete By date for the assessment was 01/21/2026, and a BIMS completed by the speech therapist on 01/09/2026 showed a score of 15/15, indicating intact cognition. The resident’s EHR also showed a comprehensive care plan was initiated on 01/09/2026 and included code status, medications, cognitive function, self-care deficits, pain, and activity preferences. During interview, the MDS LVN stated she was responsible for completing the admission MDS for Resident #45 and acknowledged it was due on 01/21/2026 but was not completed in a timely manner. The administrator stated the facility had two MDS LVNs who were sometimes assigned other duties, and the DON stated the census had increased and the two MDS LVNs were having difficulty keeping up with assessments in a timely manner.
Discharge MDS Not Completed or Transmitted Timely
Penalty
Summary
The facility failed to ensure an encoded, accurate, and complete discharge MDS was electronically completed and transmitted to the CMS system within 14 days after completion for Resident #20. Resident #20 was a Medicare A resident admitted with diagnoses including epilepsy, Type II diabetes, acute respiratory failure, and cerebral infarction due to occlusion of the left middle cerebral artery. On 01/07/2026, the resident had a sudden loss of consciousness in the dining room with hypotension and agonal breathing, and the MD ordered transfer to the ER; EMS arrived and transported the resident to the hospital. A progress note on 01/09/2026 documented the resident could not be rounded on because of the hospital transfer for loss of consciousness and increased oxygen demand. Record review of the resident’s electronic MDS assessments showed an admission MDS with an ARD of 11/01/2025, but there was no evidence of a discharge MDS completed or transmitted to CMS. During interview, the MDS LVN stated the discharge MDS should have been initiated the day the resident left or the day after and acknowledged she missed it. The administrator stated the facility had two MDS LVNs who were sometimes assigned other duties, and the DON stated the census had increased and it was difficult for the two MDS LVNs to keep up with assessments in a timely manner.
Failure to Maintain Right-Hand Splint for Resident With Limited ROM
Penalty
Summary
The facility failed to ensure Resident #53 received appropriate treatment and services to maintain or improve ROM when her right hand splint was not in place. Resident #53 was a female with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, aphasia following cerebral infarction, dysphagia following cerebral infarction, and frontal lobe and executive function deficit following cerebral infarction. Her annual MDS documented severe cognitive impairment for daily decision making, and her care plan identified altered musculoskeletal status related to impaired ROM to the right hand with an intervention noting that she had a right-hand splint per restorative and/or therapy and that the right hand was to be monitored every shift for signs of breakdown or skin changes. During observation with a family member, Resident #53 was seen with a rubber hand spacer on the left hand while the right hand appeared curled under her shirt hem. The family member stated the splint had been paused when therapy stopped a few months earlier. PT staff stated the resident had been discharged from PT and OT after reaching her potential and that restorative nursing should have taken over the splint, with nursing and therapy monitoring it because there was an order to do so. The restorative aide stated the facility was only doing lower-extremity stretching and did not have a hand therapy program set up. The DON stated therapy had been managing the resident’s PT, OT, and SLP, but a restorative plan was supposed to have been rolled over to the restorative aide after skilled therapy ended; however, the restorative aide plan was never set up.
Unlabeled, Undated Food Left in Resident Refrigerator
Penalty
Summary
The facility failed to ensure the safe and sanitary storage of residents' food items in 1 of 5 residents' refrigerators reviewed. In the personal refrigerator in Resident #104's room, surveyors observed cooked beef and white pasta in an unlabeled, undated storage container at 9:35 a.m. on 1/27/2026, and the same unlabeled, undated food items were still present during a later observation at 11:30 a.m. Resident #104 stated she could not recall how long the food had been in her refrigerator and said her daughter often leaves food there for her to eat when she visits. CNA E confirmed the refrigerator contained the cooked beef and white pasta in an unlabeled and undated container and stated she did not know who was responsible for checking the resident's personal refrigerator for expired food. LVN F confirmed the food items were unlabeled and undated and stated nursing was responsible for removing such items from residents' personal refrigerators. She also stated that Resident #104's family member sometimes brings food for herself during visits and leaves leftovers in the resident's refrigerator. The family member confirmed she leaves leftover food in the refrigerator to eat when she visits and recalled being told to notify nursing staff so food could be labeled and dated, but said she forgets. The DON confirmed that perishable food and drinks in residents' personal refrigerators should be labeled and dated and that nursing was responsible for removing undated, unlabeled food items daily.
Improper Use of Hair Restraints by Dietary Manager During Food Preparation
Penalty
Summary
During a kitchen observation, the Dietary Manager (DM) was seen wearing a hair restraint that only partially covered her hair, specifically covering her ponytail but not the rest of her head, while preparing meals. The DM acknowledged that her expectation was for all staff to wear hair restraints in the kitchen and recognized the importance of fully covering hair to prevent contamination. She admitted that her hair restraint was too small to cover her entire head and ponytail, but did not have a proper restraint in place at the time of the observation. Interviews with the DM, the Director of Nursing (DON), and the Administrator confirmed that the facility's expectation is for all kitchen staff to have their hair fully covered by a hairnet or hat to prevent hair from falling into food. The facility's policy and the FDA Food Code both require effective hair restraints to prevent hair from contacting exposed food and clean equipment. The deficiency was identified during a review of the kitchen's sanitation practices, specifically regarding the improper use of hair restraints by the DM during food preparation.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Document and Address Resident Grievances
Penalty
Summary
The facility failed to ensure that residents' grievances were properly documented, reported, and addressed according to its grievance policy. In two separate cases, residents voiced concerns to staff members regarding their care and services, but these grievances were neither documented nor reported to facility leadership as required. One resident, who had a history of blindness, diabetes, and chronic kidney disease, alleged that he did not receive his medications over a weekend. Although he communicated this concern to a medication aide, the aide did not document the grievance or report it to the Director of Nursing (DON). The medication aide stated she verbally informed a weekday nurse, but the nurse did not recall receiving such a report and confirmed that she would have documented and escalated the issue if she had been informed. In another instance, a resident with atherosclerotic heart disease, dementia, and mobility difficulties was left at a doctor's office for several hours without transportation back to the facility. The resident and his representative reported this grievance to a case manager, who did not document the complaint or report it to the DON. The case manager recalled discussing the incident with the resident's representative but did not complete a grievance report. Facility leadership, including the Administrator and DON, confirmed they had not received reports of either grievance and emphasized that all grievances should be documented and reviewed according to policy. A review of the facility's grievance policy indicated that residents have the right to voice concerns regarding care, treatment, staff behavior, and other issues without fear of reprisal, and that the facility is responsible for making prompt efforts to resolve such grievances. However, the lack of documentation and reporting in these cases resulted in the grievances not being recognized or addressed by facility leadership, contrary to the established policy.
Failure to Provide Chaperone Results in Missed Cardiology Appointment
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the resident's preferences. The resident, an elderly female with diagnoses including heart failure and cardiomegaly, was scheduled for a cardiology appointment for an echocardiogram. The resident required assistance with personal care and could not attend appointments alone. On the day of the appointment, transportation arrived as scheduled, and the resident was prepared and waiting in her wheelchair for her representative, who was supposed to escort her. Despite multiple attempts by the LVN to contact the resident's representative, the representative did not arrive on time. After waiting for 20 to 40 minutes and being unable to reach the representative, the LVN dismissed the ambulance and did not attempt to arrange for a staff member to accompany the resident, citing a lack of available staff. The incident was not reported to supervisors, and no further efforts were made to ensure the resident could attend the appointment. The resident ultimately missed the scheduled cardiology appointment. Interviews with facility leadership revealed that the expectation was for residents to be supported in attending medical appointments, and that the DON and ADON were not informed of the situation at the time. The facility's policy requires sufficient and qualified staff to meet residents' needs and to intervene in situations where neglect may occur. The failure to provide a chaperone or alternative support for the resident resulted in a missed medical appointment, contrary to the facility's stated procedures and expectations.
Incomplete Documentation of Wound Care for a Resident
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for one resident, leading to incomplete and inaccurately documented wound care records. Specifically, the wound administration records (WAR) for a resident with stage 4 pressure ulcers on the sacrum and right ischium did not accurately reflect the wound care provided on five different treatment days in November and December 2024. This lapse in documentation could result in inaccurate records of the care provided. The resident in question was admitted with multiple serious health conditions, including end-stage renal disease, diabetes, and severe pressure ulcers. The resident's care plans included specific interventions for wound care, which were not consistently documented as completed in the electronic clinical records. Interviews with the wound care nurse and other staff revealed that wound care was provided on the specified dates, but the documentation was either forgotten or not properly completed in the electronic system. The facility's policy on charting and documentation emphasizes the importance of maintaining accurate clinical records to reflect the quality of care provided, guide treatment plans, and serve as valid information for legal defense. However, the failure to document wound care accurately could lead to other staff being unaware of the care provided, potentially impacting the continuity and quality of care for the resident.
Facility Lacks Licensed Administrator for Daily Management
Penalty
Summary
The facility failed to ensure that the governing body appointed a licensed administrator responsible for the management of the facility. During interviews, it was revealed that the Operations Manager (OM) L, who was responsible for the daily management of the facility, did not possess an administrator license but was in the process of obtaining one. The facility had an administrator who did not work full-time at the facility and was not present on a daily basis. The administrator assumed the position in February 2024 but was unsure of the exact date and was available at home if needed. Further interviews and record reviews indicated that OM M had taken over leadership from the previous administrator and was also not a licensed administrator. OM M was responsible for the daily operations until OM L took over in October 2024. The facility did not have a specific policy regarding the administration of the facility, relying instead on following regulations. The previous licensed administrator was employed until January 2024, and the current administrator's hire date was in March 2024.
Incomplete Documentation of Oral Hygiene Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, identified as Resident #67, who was reviewed for clinical records. The deficiency was identified through interviews and record reviews, revealing that oral hygiene care was not documented on several specific dates in October 2024. The resident, a female with severe cognitive impairment and multiple medical conditions including dysphagia, cerebral infarction, and diabetes, was assessed as needing partial to moderate assistance with oral hygiene. Despite this, the oral hygiene log showed no documentation of care being provided on multiple days. Interviews with staff, including a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA), revealed discrepancies in documentation practices. The CNA responsible for Resident #67's care admitted to performing oral hygiene using a sponge stick instead of a toothbrush, due to the resident's discomfort, but incorrectly documented the task as 'non-applicable' in the log. The Director of Nursing (DON) confirmed that oral hygiene should be documented daily, and any task not documented could be considered as not done. The facility's policy on charting and documentation emphasizes the importance of maintaining a concise account of the resident's treatment and care.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies. During incontinent care for a resident with severe cognitive impairment and an indwelling catheter, a CNA did not change gloves or wash hands after touching a privacy curtain, which was considered dirty. This lapse in protocol was acknowledged by the CNA and confirmed by the Director of Nursing (DON), who noted the risk of cross-contamination and infection. In another instance, a used lancet was found on a resident's bedside table after an accu-check test, posing a safety and infection control concern. The LVN responsible for the test acknowledged that the lancet should have been disposed of in a sharps container immediately. This was corroborated by a Medical Records Specialist who was present during the procedure. The facility's policy on sharps disposal mandates immediate disposal of contaminated sharps into designated containers. Additionally, while administering eye drops to a resident, a medication aide wiped the tip of the eye dropper with a tissue, potentially contaminating the medication. The aide admitted to being nervous and acknowledged the mistake, while the DON confirmed that the dropper tip should not touch any surface to avoid contamination. The aide had previously demonstrated competency in medication administration, including eye drops, during training.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity during meal assistance. Specifically, a CNA did not sit down while feeding a resident with severe cognitive impairment and dysphagia, which is contrary to the facility's policy and training. The resident, who has a PEG tube and requires supervision or assistance for eating, was observed lying in bed with her lunch tray on an overbed table. The CNA stood over the resident while feeding her, which led to the resident pushing her tray away. The CNA, who had been working at the facility for about three years, acknowledged that he was accustomed to standing while feeding the resident but was aware that he should sit to be at the resident's level. The Director of Nursing confirmed that staff should sit while assisting residents with feeding to avoid making them feel towered over. The CNA had previously met the competency requirements for assisting with meals, which included sitting in a chair facing the resident. The facility's policy on resident rights emphasizes treating residents with respect and dignity.
Privacy Breach During Wound Care and Record Handling
Penalty
Summary
The facility failed to ensure personal privacy for a resident during wound care and in the handling of medical records. Licensed Vocational Nurses (LVNs) A and B did not fully close the privacy curtain while providing wound care to a resident, leaving the resident's buttock exposed in the presence of a roommate. The resident confirmed that the privacy curtain had been too short for some time, resulting in multiple instances of care without full privacy. LVN A acknowledged the oversight and confirmed that the privacy curtain should have been completely closed. Additionally, LVN A failed to secure the resident's medical records by not locking her laptop screen, which displayed residents' information. This lapse was observed after care was provided, and LVN A confirmed that the screen should have been locked to protect resident information. The Director of Nursing (DON) confirmed that privacy should be maintained during nursing care and that laptop screens should be locked when not in use. The facility's policy on HIPAA compliance also mandates that computer screens should not be left open with patient information.
Inaccurate MDS Assessment of Anticoagulant Use
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's medical status, specifically regarding the administration of anticoagulant medication. The quarterly Minimum Data Set (MDS) assessment for a resident, who had been diagnosed with cerebral infarction and deep vein thrombosis, incorrectly documented that the resident was not receiving an anticoagulant. However, a review of the resident's physician orders and medication administration record for October 2024 showed that the resident was prescribed and had been receiving Eliquis, an anticoagulant, for deep vein thrombosis. During an interview, the MDS nurse responsible for completing the assessment confirmed the error, acknowledging that Eliquis is an anticoagulant and should have been coded as such in the MDS. The nurse admitted to not knowing why the medication was not correctly documented and confirmed having access to the Resident Assessment Instrument (RAI) for reference. This oversight in the MDS assessment could potentially place residents at risk for inadequate care due to the inaccurate documentation of their medical treatment.
Failure to Provide Scheduled Hygiene Care
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living, received the necessary services to maintain good personal hygiene. Specifically, the resident did not receive a shower or bath as scheduled on two occasions. The resident, who has severe cognitive impairment and is totally dependent on staff for bathing, was scheduled to receive showers three times a week. However, the facility's records showed no documentation of showers or baths being given during a specific period, and staff interviews confirmed the resident did not receive the scheduled hygiene care. Interviews with staff revealed that the resident sometimes refused to get out of bed for showers, and such refusals should have been documented in the Point of Care (POC) system. The facility's Director of Nursing (DON) emphasized the importance of documenting all hygiene activities and refusals, as lack of documentation could imply that care was not provided. The facility's policies require nursing assistants to provide ADL assistance based on individualized care plans and to report any changes in the resident's performance to a licensed nurse. Despite these policies, the failure to document and provide scheduled hygiene care was identified as a deficiency.
Improper Labeling and Storage of Milk in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, specifically in the storage, labeling, and dating of milk containers in the walk-in cooler. During an observation, it was noted that a one-gallon container of whole milk and a one-gallon container of Lactose-Free whole milk were improperly labeled. The whole milk container, which was opened and had approximately one cup remaining, was labeled with the date 10/25, while the Lactose-Free milk container, also opened with about one quart remaining, was labeled 10/15. These labels indicated the dates the milk was received by the facility, not the dates they were opened or the use-by dates, which is against the facility's policy and food safety standards. An interview with the dietary staff (DS) revealed that the staff responsible for storing opened food items in the cooler did not properly label and date the milk containers with the date opened and the use-by date. This oversight could lead to the proliferation of bacteria, posing a risk of foodborne illness to residents consuming meals or snacks from the kitchen. The facility's policy, based on the Texas Food Establishment Rules (TFER) and the U.S. FDA Food Code, requires that refrigerated, ready-to-eat, time/temperature controlled for safety food be clearly marked with the date the original container is opened and the date by which it should be consumed, sold, or discarded, not exceeding the manufacturer's use-by date.
Improper Garbage Disposal Practices
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed with two dumpsters. Dumpster #1 was overflowing with trash, preventing the lid from closing and leaving a significant gap. Additionally, a piece of cardboard was found on the ground in front of the dumpster, and flies were observed circulating between the dumpsters. During an interview, the Director of Services (DS) acknowledged that the lid should have been closed and noted that the trash had not been picked up recently, despite the facility's policy of daily trash removal. The DS mentioned that both the dietary and nursing departments used these dumpsters. For dumpster #2, the right sliding door was found open, and a drainage plug was missing. The DS confirmed that the door should not have been open, as it created an unsanitary condition and could lead to rodent infestation. The Operations Manager (OM) also noted that the trash had not been picked up for over a day, which could attract pests. The facility's policy, based on the Texas Food Establishment Rules and the U.S. Food Code, requires that receptacles be kept covered with tight-fitting lids or doors and have drain plugs in place.
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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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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Buena Vida Nursing And Rehab-san Antonio | 0.1 mi | ★★★★★ | 26 | 5 |
| Southeast Nursing & Rehabilitation Center | 0.6 mi | ★★★★★ | 16 | 1 |
| Highland Nursing Center | 1 mi | ★★★★★ | 20 | 0 |
| The Rio At Mission Trails | 2.3 mi | ★★★★★ | 19 | 0 |
| Normandy Terrace Nursing & Rehabilitation Center | 2.6 mi | ★★★★★ | 18 | 1 |
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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.