Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Pleasanton South Nursing And Rehabilitation during CMS and state inspections, most recent first.
Food Storage and Kitchen Sanitation Deficiencies: Surveyors found multiple undated, unlabeled, and uncovered food items in the kitchen refrigerator, along with staff drinks stored with resident food, personal belongings touching pantry food items, and several soiled or improperly maintained kitchen areas and equipment. The plate warmer was unplugged during lunch service, and a container of caramel sauce labeled to refrigerate after opening was open and not refrigerated.
A facility failed to ensure MDS assessments accurately reflected residents’ medication status for multiple residents. The assessments omitted or incorrectly recorded anticoagulant, antiplatelet, antidepressant, hypoglycemic, and pain medication use, despite active orders and MAR documentation showing the residents’ actual medication regimens. The DON and Regional Support Nurse stated MDS accuracy is expected and that the MDS coordinator is responsible for checking assessments for accuracy.
Unlocked supply closets on Hall E and Hall F were observed accessible to residents and contained potentially hazardous items, including flammable hand sanitizing wipes and germicidal wipes labeled hazardous to humans and domestic animals. An LVN and the Maintenance Director both confirmed the closets were unlocked and should have been secure, and the DON stated staff were expected to ensure hazardous materials were stored securely.
Incomplete resident diagnosis lists on facesheets: Two residents had provider-documented diagnoses that were not entered into the facility’s diagnosis list and therefore did not populate onto their facesheets. One resident with a fracture, major depression, and moderate cognitive impairment also had adjustment disorder and other specified persistent mood disorders omitted; another resident with stroke-related deficits, brain cancer, diabetes, and moderately impaired cognition also had pain, bilateral cataracts, poor visual acuity, and adjustment disorder with mixed disturbance of emotions and conduct omitted. The DON confirmed the facesheet was the primary record used to share resident information with outside providers.
A resident with severe cognitive impairment, hemiplegia, and COPD had a call bell found on the floor under the bed and out of reach while the resident was leaning out of bed and stated wanting to get up but could not reach it. A Medication Aide confirmed the call bell was out of reach, and the DON stated staff were expected to keep call bells within reach so residents could call for assistance when needed.
Two residents who died while on hospice care did not have complete or accurate documentation in their medical records regarding their deaths, pronouncement of death, notifications to family, hospice, law enforcement, or the disposition of their bodies. Nursing staff acknowledged the lack of documentation, and the DON confirmed that facility policy requires thorough recordkeeping of such events.
A resident with advanced medical conditions died while on hospice care, and the facility failed to notify the family immediately as required. The nurse on duty did not inform the family after being told by hospice staff to wait, and there was no follow-up to ensure notification occurred. Facility policy required immediate notification of family or representatives in such events, but this was not followed.
A resident with cerebral palsy, major depressive disorder, and anxiety disorder did not receive timely specialized services and equipment as recommended by the PASARR Level II evaluation, due to the facility delaying initiation of therapy and provision of a new wheelchair until Medicaid approval was obtained, despite requirements to begin services within 20 business days of the IDT meeting.
A facility failed to provide routine drugs and biologicals to residents, with one resident sharing her prescribed supplement with another without a nurse present, and another resident not receiving prescribed doses of Velphoro due to delivery and insurance issues. The facility's policies on medication administration were not followed, potentially impacting resident health and safety.
A resident's tube feeding bag was improperly labeled, lacking the correct date, resident's name, and administration details, contrary to the facility's policy. The ADON acknowledged the error during a survey observation.
The facility did not provide the required minimum of 80 square feet per resident in 43 rooms, affecting all residents in those rooms. Measurements showed that the space per resident ranged from 75.48 to 79.56 square feet, below the mandated requirement. The administrator plans to request a room waiver for these rooms, which are all double occupancy.
A resident with dementia, identified as an elopement risk, exited a facility unnoticed and was found by police at a nearby restaurant. Despite having a care plan intervention to involve her in group activities, the resident managed to leave after receiving her medications. The facility's exit doors were equipped with alarms and keypads, but staff failed to notice her departure, indicating a lapse in supervision.
A CNA in a LTC facility failed to wear a gown while providing care to a resident with MRSA due to a lack of available gowns in the PPE supply unit. Despite being aware of the need for gown and glove use under Enhanced Barrier Precautions, the CNA prioritized the resident's immediate needs over retrieving a gown from the supply closet. The DON confirmed the resident's precautionary status and the requirement for proper PPE use during high-contact activities.
Food Storage and Kitchen Sanitation Deficiencies
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 observations, surveyors found multiple food items in the three-door refrigerator that were undated, including a 40-ounce package of honey ham, a 32-ounce container of liquid eggs, a 6-ounce container of raspberries, a 1-pound block of margarine, two 3-quart containers of apple juice, and a 5-pound container of sour cream. Surveyors also observed a clear carafe of yellow liquid that was uncovered, unlabeled, and undated, a tray of approximately 24 cups of liquid that was unlabeled and undated, and a tray of approximately 24 cups of milk that was unlabeled and undated. A plastic container of food thickener was also unlabeled and undated. Additional observations showed an open 16-ounce can of energy drink on the table where residents' food was prepared, a 16-ounce bottle of soda and two 24-ounce cans of energy drink stored in the refrigerator used for resident meals, and personal belongings of kitchen staff hanging on the pantry shelves and touching food items intended for resident meals. Surveyors also found the plate warmer was not plugged in during lunch service, the small kitchen sink was stained with brown liquid, the dish sanitation machine had a sand-like residue on the top and sides, the microwave door was soiled on the inside, and a 12-ounce container of caramel sauce labeled to refrigerate after opening was open and not refrigerated. The Dietary Aide and Dietary Manager confirmed these conditions, and the Dietary Manager stated that food items should have been labeled and dated, staff personal belongings and drinks should not have been in the refrigerator or pantry, and the sink, microwave, and dish machine should have been unsoiled.
MDS Assessments Did Not Match Residents’ Medication Records
Penalty
Summary
The facility failed to ensure resident assessments accurately reflected residents’ medication status for 6 of 7 residents reviewed. The deficiency involved MDS assessments that did not match the residents’ active medication orders and MARs, including omissions of anticoagulant, antiplatelet, antidepressant, hypoglycemic, and pain medication information, as well as one assessment that incorrectly documented scheduled pain medication when no such order existed. Resident #7’s quarterly MDS did not document anticoagulant use even though the resident had an active order for Apixaban and was receiving it via G-tube twice daily for paroxysmal atrial fibrillation. Resident #10’s admission MDS did not document scheduled pain medication use despite an active order for Acetaminophen-Codeine 300-30 mg every 6 hours for wound pain and administration during the look-back period. Resident #47’s quarterly MDS did not document hypoglycemic medication use despite an active order and administration of Ozempic, and it also documented scheduled pain medication use even though there was no active scheduled pain medication order. Resident #53’s quarterly MDS documented PRN pain medication use during the look-back period, but the MAR showed no PRN Acetaminophen or Acetaminophen-Codeine was administered or refused during that period. Resident #54’s quarterly MDS did not document anticoagulant or antiplatelet medication use despite active orders and administration of Xarelto and Clopidogrel. Resident #63’s quarterly MDS did not document antidepressant use despite an active order and administration of Prozac, and it documented scheduled and PRN pain medication use even though the MAR showed only PRN Tylenol with no doses administered or refused during the look-back period. The Regional Support Nurse and DON stated that MDS sections must be accurate and that the MDS coordinator is responsible for checking assessments for accuracy; the facility policy titled Resident Assessment - RAI stated the assessment will include medications.
Unlocked Supply Closets Contained Hazardous Materials
Penalty
Summary
The facility failed to ensure the resident environment was as free of accident hazards as possible on Hall E and Hall F when supply closets on both hallways were observed open and unlocked. On Hall F, the front supply closet was unlocked and contained hand sanitizing wipes labeled "Flammable Keep Out of Reach of Children" and two containers of germicidal wipes labeled "Hazardous to Humans and Domestic Animals." An LVN confirmed the closet was unlocked, accessible to residents, and contained the listed materials, and stated it was usually locked and should have been secure. On Hall E, the supply closet next to the Administrator's office and across from the dining room was also observed unlocked and contained germicidal wipes labeled "Hazardous to Humans and Domestic Animals." The Maintenance Director confirmed the closet was unlocked, accessible to residents, and contained the listed materials, and stated it was usually locked and should have been secure. The DON stated her expectation was for all staff to assist in ensuring potentially hazardous materials were stored securely so that residents would not come into contact with them.
Incomplete resident diagnosis lists on facesheets
Penalty
Summary
The facility failed to maintain complete and accurate medical records for 2 of 25 residents reviewed because diagnoses documented in provider notes were not included on the residents’ lists of diagnoses and therefore were not populated onto their facesheets. For Resident #27, the record showed admission diagnoses including a right humerus fracture, major depressive disorder, and iron deficiency anemia secondary to blood loss, and the admission MDS showed a BIMS score of 9 indicating moderate cognitive impairment. The care plan identified psychosocial well-being concerns related to recent admission and major depression, with behaviors including agitation, yelling, cursing, and refusing care. A psychological provider note documented adjustment disorder and other specified persistent mood disorders, but these diagnoses were not included on the resident’s diagnosis list or facesheet. For Resident #28, the record showed admission diagnoses including hemiplegia and hemiparesis following cerebral infarction, malignant neoplasm of brain, and type 2 diabetes mellitus, and the quarterly MDS showed a BIMS score of 9 indicating moderately impaired cognition. The care plan identified resistive and noncompliant behaviors, including refusal of medications and verbal aggression. A physician note documented pain, bilateral cataracts, and poor visual acuity, and a psychological provider note documented adjustment disorder with mixed disturbance of emotions and conduct, but these diagnoses were not included on the resident’s diagnosis list or facesheet. The DON confirmed that the facesheet was populated from the diagnosis list and was the primary mechanism used to convey resident information to outside providers such as hospitals and medical specialists, and confirmed that the missing diagnoses should have been included.
Call Light Out of Reach for Resident With Severe Cognitive and Mobility Impairments
Penalty
Summary
The facility failed to ensure a working call system was available within reach for a resident in the bathroom and bathing area, as Resident #60's call light was found out of reach under the resident's bed. Resident #60 had diagnoses including unspecified sequelae of cerebral infarction, hemiplegia and hemiparesis following cerebral infarction, and COPD. The resident's Quarterly MDS showed a BIMS score of 4, indicating severe cognitive impairment, and the care plan identified extensive assistance needs for turning and repositioning, personal hygiene, oral care, and toileting, with encouragement to use the bell to call for assistance. During observation, Resident #60 was in bed leaning with the top half of the body out of the bed, and the call bell was on the floor under the bed and out of reach. The resident stated wanting to get up and being unable to reach the call bell. A Medication Aide confirmed the call bell was in the floor under the bed and out of reach, and the DON stated the expectation was for all staff to ensure resident call bells were within reach at all times so residents could call for assistance when needed. The facility policy stated the purpose was to ensure the facility was adequately equipped with a call light at each resident's bedside.
Failure to Document Resident Deaths and Notifications in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents who died while under care. For one resident, a female with diagnoses including malignant neoplasm of the brain, epilepsy, and altered mental status, the medical record lacked documentation of the physician discharge summary, pronouncement of death, notification of local law enforcement, and disposition of the body. The only progress note entry after her death was made by an LVN, who stated that hospice was notified and instructed not to call the family until their arrival, with no further documentation of subsequent actions or notifications. For the second resident, a male with diagnoses including senile degeneration of the brain, chronic respiratory failure, and anxiety disorder, the medical record did not contain documentation of the resident's death, pronouncement of death, notification of required entities, or disposition of the body. The progress notes only reflected the resident's move to a private room due to decline and a later entry about equipment pickup, with no entries about the death event itself. Interviews with nursing staff revealed that the RN on duty at the time of death pronounced the resident, notified the DON, family, hospice, and funeral home, and received a police case number, but failed to document these actions in the medical record. The DON confirmed that staff are expected to document all notifications, the resident's decline, expiration, vital signs, and interactions with hospice or law enforcement, as well as the pronouncement of death and disposition of the body. The facility's policy requires that each resident's medical record accurately reflect their experiences and include sufficient information to provide a complete picture of their progress, but this was not followed in these cases.
Failure to Notify Family of Resident Death
Penalty
Summary
The facility failed to notify the resident representative of a significant change in a resident's status, specifically failing to inform the family when a resident expired. The resident, a female with diagnoses including malignant neoplasm of the brain, epilepsy, and altered mental status, was on hospice care at the time of her death. Documentation showed that the resident was found without respirations, and hospice was notified. The hospice nurse reportedly instructed the facility nurse not to notify the family until hospice arrived. The nurse did not notify the family, nor did he follow up to ensure the family was informed. The facility's progress notes did not document any further communication with the family, and the time of family notification was unclear in hospice records. Interviews revealed that the nurse typically would notify the family immediately but deferred to hospice's instructions in this instance. The DON was uncertain about the facility's policy regarding family notification when hospice was involved and assumed hospice had reasons for delaying notification. The hospice representative stated that hospice would never instruct a facility not to notify next of kin and considered immediate notification important. Facility policies reviewed required immediate notification of family or representatives in the event of significant changes, including death, but this was not followed in this case.
Failure to Timely Implement PASARR Recommendations and Specialized Services
Penalty
Summary
The facility failed to incorporate recommendations from the PASARR Level II determination and evaluation report into a resident's assessment, care planning, and transitions of care. Specifically, the facility did not initiate necessary specialized services within 20 business days following the IDT meeting where services were agreed upon. This delay was attributed to the facility waiting for the resident's Medicaid approval before starting therapy services and providing a new wheelchair, despite the PASARR office's communication with facility leadership regarding the requirement to begin services within the specified timeframe. The resident involved was a female with diagnoses including cerebral palsy, major depressive disorder, and anxiety disorder, and had moderate cognitive impairment as indicated by her BIMS score. Interviews with facility staff revealed that although the IDT meetings and communication with the PASARR office occurred, services such as therapy and equipment provision were delayed until Medicaid eligibility was confirmed. The facility's policy required screening and timely implementation of services as outlined in the PASARR evaluation, but these were not followed due to the pending Medicaid status.
Deficiencies in Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide routine drugs and biologicals to its residents, specifically failing to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for three residents. Resident #44 was observed sharing her prescribed nutritional supplement with Resident #52 in the dining room while the nurse was not present. This sharing occurred despite Resident #52 not having a physician's order for the supplement. The nurse, LVN A, acknowledged witnessing the sharing and stated that Resident #44 usually consumed her supplement without issue and did not typically sit with other residents. Resident #51 did not receive her prescribed doses of Velphoro, a medication used to manage phosphate levels in patients with End Stage Renal Disease (ESRD), over several days. The medication was documented as not administered due to pending delivery and insurance approval issues. Despite the lack of medication, there were no reported abnormal lab results or adverse effects on Resident #51. The facility's Director of Nursing (DON) was aware of the situation and noted that the delay was due to awaiting approval from the resident's renal dialysis physician and insurance. The facility's policies on administering medications and pharmacy services were not adhered to, as medications were not administered in accordance with prescriber orders, and there was a failure to ensure timely delivery and administration of medications. The sharing of medications between residents, as observed with Residents #44 and #52, was not permitted by state law or facility policy. These deficiencies highlight lapses in the facility's pharmaceutical services, potentially impacting the health and safety of the residents involved.
Improper Labeling of Tube Feeding Bags
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles, specifically for a resident receiving tube feeding. During an observation, it was noted that the tube feeding bag for a resident was not labeled with the correct date, resident's name, time hung, or the date and time to be taken down. This discrepancy was identified for a resident who was admitted with hospice care and had several diagnoses, including cerebral infarction, adult failure to thrive, moderate protein-calorie malnutrition, and cachexia. The resident was dependent on staff for all care and had a gastrostomy feeding tube. The facility's policy on enteral feedings required that the enteral nutrition label be checked against the order before administration, including details such as resident name, type of formula, date and time prepared, and rate of administration. However, during the survey, it was found that the feeding bag was incorrectly labeled with a date from the previous year and lacked essential information. The Assistant Director of Nursing (ADON) acknowledged the error and indicated that the bags should have been labeled correctly with the current date, resident information, formula, and administration rate.
Facility Fails to Meet Minimum Square Footage Requirements
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in 43 of 43 resident rooms reviewed. The rooms in question, identified as A2 through A8, A10, B3 through B11, C2 through C5, C7, C9, C10, D2 through D7, E2 through E4, E6 through E8, and F1 through F8, did not meet the square footage requirement. Measurements of these rooms revealed that the floor space per resident ranged from 75.48 to 79.56 square feet, which is below the mandated 80 square feet per resident. This deficiency was identified through interviews and record reviews, including a previous room waiver dated 09/06/2024. The administrator acknowledged the issue during an interview and indicated plans to request a room waiver for the same rooms as the previous year. The facility's Form 3740, Bed Classifications, confirmed that all resident rooms were double occupancy, further contributing to the space deficiency. The lack of adequate space could potentially affect residents' living conditions and their ability to perform activities of daily living.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure the environment was free of accident hazards and that each resident received adequate supervision to prevent accidents. This deficiency was identified when a resident with dementia, who was assessed as an elopement risk, managed to exit the facility without staff knowledge. The resident was later found by local police at a restaurant located 0.3 miles from the facility. The staff were unaware of the resident's absence until they received a call from the police. The resident, who used a walker and had a BIMS score of 5, was identified as an elopement risk in her care plan and elopement risk assessment. Despite this, there were no exit-seeking behaviors noted prior to the incident. The resident's care plan included an intervention to involve her in group activities, but this was insufficient to prevent her from leaving the facility unnoticed. Interviews with the Director of Nursing (DON) and the Administrator revealed that the resident had received her medications around 9:00 PM and was last seen entering her room. It was speculated that the resident might have followed another resident's family out of the facility. Observations of the facility's exit doors showed they were equipped with keypads and alarms, which were functioning properly at the time of the survey. However, the incident highlighted a lapse in monitoring and supervision, as staff did not notice the resident's departure.
Infection Control Breach Due to PPE Unavailability
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a certified nursing assistant (CNA) who did not adhere to established protocols. The CNA, identified as CNA-AB, provided incontinent care to a resident diagnosed with MRSA without wearing a gown, which is a requirement under Enhanced Barrier Precautions (EBP). The resident, a 76-year-old female with severe cognitive impairment, was on contact precautions due to multiple health issues, including MRSA, pressure ulcers, and a recent hip surgery. Despite the presence of a contact precautions sign and a PPE supply unit outside the resident's room, no gowns were available, leading the CNA to proceed without the necessary protective equipment. The CNA acknowledged awareness of the need for both gown and gloves during high-contact activities but chose not to retrieve a gown from the medical supply closet to avoid upsetting the resident. The Director of Nursing (DON) confirmed the resident's EBP status and the requirement for gown and glove use during such care activities. The DON also noted that the PPE supply should have been adequately stocked, and it was the staff's responsibility to ensure this. The CNA had previously received training in infection control procedures, as indicated by her training record. The facility's policy on Enhanced Barrier Precautions, dated August 2022, clearly outlines the necessity of gown and glove use during high-contact resident care activities.
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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 Pleasanton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pleasanton North Nursing And Rehabilitation | 0.3 mi | ★★★★★ | 2 | 0 |
| The Heights Of Atascosa | 1.9 mi | ★★★★★ | 1 | 0 |
| Jourdanton Nursing And Rehabilitation | 4 mi | ★★★★★ | 25 | 0 |
| Harmony Care At Floresville | 24 mi | ★★★★★ | 18 | 0 |
| Frank M. Tejeda Texas State Veterans Home | 24.2 mi | ★★★★★ | 12 | 0 |
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