Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 River City Care Center during CMS and state inspections, most recent first.
Food service staff failed to keep temp logs complete, store food properly, and maintain a clean prep area. Surveyors found missing night temps for 2 freezers and 1 refrigerator, sliced cheese left unsealed and exposed to air, onions and bell peppers without a discard/use-by date, and an open personal beverage in the food prep area while lunch was being prepared. The DM and staff acknowledged the storage and contamination concerns.
A resident with burns and moderate cognitive impairment had an MDS showing setup or clean-up assistance for eating, but the care plan did not document that need. Another resident with depression and anxiety had a cleaning agent in his room, but the care plan did not reflect whether he was allowed to keep it there, and staff were unsure how to handle it until it was removed from bedside.
A resident with intact cognition and diagnoses including major depressive disorder and generalized anxiety disorder had a cleaning solution left at his bedside, despite his care plan not allowing cleaning supplies or chemical agents in his room. An LVN later removed the item and confirmed it was not permitted, while a CNA said she had seen it but assumed it was allowed. The ADM and DON gave conflicting statements about whether the resident could keep the item, and the facility did not have policies on accidents, hazards, or prohibited items.
Meal tray tickets did not consistently match resident preferences or allergy information. One resident with dementia was served apple juice instead of the orange juice listed on the tray ticket, and staff said tray tickets should be followed to meet resident needs. Another resident with a documented lactose allergy had a tray ticket that did not reflect the allergy, and staff interviews showed the allergy was not consistently communicated to dietary even though the resident reported still receiving milk on meal trays.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Surveyors found that drugs and biologicals were not properly stored or labeled, including loose unidentified pills in a medication cart, an insulin vial without an open date, a narcotic lock box in the medication fridge that was not securely affixed, and treatment cart keys stored in an unlocked container on the cart. Staff interviews confirmed these practices did not meet facility policy or professional standards.
Surveyors identified failures in kitchen sanitation and food storage, including dirty ceiling and wall vents, undated opened food items in both the refrigerator and storage room, and a dish machine that did not record sanitizer levels after cycles. These issues were confirmed by interviews and were not in accordance with facility policies for cleaning and food labeling.
A resident with an indwelling urinary catheter was observed with the catheter bag touching the floor and not placed in a dignity bag, contrary to physician orders and facility policy. Staff interviews confirmed the bag should have been kept off the floor and inside a dignity bag to prevent contamination, but this was not done at the time of observation.
Surveyors found that the facility did not provide the required 80 square feet per resident in most multi-occupancy rooms, as confirmed by direct measurements and record review. The facility had previously operated under a room size waiver, which had expired, and a new waiver request was pending at the time of the survey. No changes had been made to the number or size of the affected rooms.
A resident with moderate cognitive impairment and a history of wandering was able to leave the facility unsupervised, traveling to a distant location before being found. The care plan did not address elopement risk prior to the incident, and staff interviews revealed inconsistent understanding and application of elopement risk assessments and supervision protocols, resulting in a failure to prevent the resident's unsupervised departure.
The facility failed to store, prepare, distribute, and serve food according to professional standards, with issues including improper labeling, expired food, and unsanitary practices by staff. Observations revealed unlabeled and expired food items, open containers, and staff not adhering to sanitary practices, such as keeping personal drinks on food prep tables and licking fingers while handling dietary preference sheets.
The facility failed to respect resident dignity and privacy, as staff entered rooms without knocking and stood while feeding residents due to a lack of chairs. This affected multiple residents, including one who expressed dislike for staff entering without knocking.
The facility failed to update care plans to include enhanced barrier precautions for residents with indwelling urinary catheters, feeding tubes, and other conditions requiring such precautions. Observations revealed a lack of precautionary signs and PPE storage in residents' rooms, and staff interviews confirmed the oversight.
A resident with Parkinson's disease and other conditions did not receive scheduled doses of Methadone due to the facility running out of the medication. Despite notifying the DON and ADON, the medication was not refilled in time, leading to missed doses and potential withdrawal symptoms.
The facility failed to maintain an infection prevention and control program, leading to multiple deficiencies. Staff did not utilize enhanced barrier precautions for residents with indwelling catheters and feeding tubes, and proper hand hygiene was not followed. Observations and interviews revealed a lack of understanding and training among staff regarding infection control protocols.
The facility failed to ensure a resident's Out-of-Hospital Do Not Resuscitate (OOH DNR) order was properly completed and valid. The OOH DNR was not signed by a witness, a second physician, or a notary public, rendering it invalid. Despite the resident being identified as DNR status, the incomplete form could lead to the resident's end-of-life wishes not being honored.
A facility failed to ensure accurate PASRR Screening for a resident with bipolar disorder. The resident's diagnosis was not reflected in the initial PASRR Level 1 Screening, and the DON admitted that a new Level 1 should have been resubmitted after the diagnosis was added. This oversight could result in the resident missing out on necessary PASRR services.
The facility failed to ensure that two residents with indwelling urinary catheters received appropriate care, as their catheter drainage bags were observed touching the floor, contrary to care plan instructions and facility policy.
A facility failed to ensure a resident with a feeding tube received appropriate care, as RN F did not elevate the head of the bed to at least 30 degrees during medication administration. The resident, who had severe cognitive impairment and multiple diagnoses, was observed lying flat, contrary to care plan and physician orders. The DON confirmed the expectation to elevate the head of the bed to prevent aspiration.
A facility failed to provide appropriate respiratory care for a resident with COPD, heart disease, and cognitive decline. The resident's oxygen concentrator was set below the physician's order and had a dirty filter. Staff were unaware of the need to check and clean the filters, leading to potential risks for the resident.
The facility failed to ensure proper dialysis care and communication for a resident with end-stage renal disease. The resident's care plan was not consistently followed, and pre-dialysis vitals were not documented, despite the resident's refusal. The DON confirmed the lack of documentation and the absence of a dialysis policy.
The facility had a medication error rate of 7.14%, involving two residents who received incorrect dosages of Vitamin D due to Med Aide D following incorrect information on the medication bottle cap instead of the label or orders. The DON confirmed that staff are expected to check medication orders and labels for accuracy.
The facility failed to ensure proper storage and administration of medications. An LVN left a medication cart unlocked and unattended, and a resident was found with medications left at the bedside. Both incidents were confirmed by staff interviews, highlighting a breach in medication safety protocols.
The facility failed to maintain accurate medical records for a resident requiring Methadone for pain management. Med Aide Q documented administering doses that were not given, and the resident reported not receiving scheduled doses. The DON acknowledged discrepancies between the narcotic log and the MAR.
The facility failed to provide mandatory behavioral health training for the DON, whose personnel record showed no evidence of such training. The DON was unsure why the training was not completed and how it could affect residents. A policy for training was requested but not provided.
The facility failed to ensure that 46 out of 49 multiple occupancy resident rooms provided a minimum of 80 square feet per resident. The Administrator acknowledged the issue and expressed a desire to continue with the room waiver for all non-compliant rooms. The facility had a census of 42 residents at the time of the survey.
The facility failed to ensure a resident's care plan accurately reflected her current status, documenting her as ambulatory and able to propel her wheelchair despite being totally dependent on staff for mobility and other ADLs. This discrepancy was confirmed through interviews and observations, highlighting a significant risk of inadequate care.
The facility failed to ensure that a treatment cart was locked when left unattended, which could result in unauthorized access to medications and potential harm. A nurse admitted to not locking the cart after use, and the DON emphasized the importance of this safety measure.
Food Storage, Temperature Logs, and Personal Beverage in Prep Area
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen. During observation and interview on 05/28/26 at 08:39 AM, surveyors found that the May 2026 temperature log was missing the night temperatures for 2 freezers and 1 refrigerator for 05/27/26. [NAME] B stated it was important to keep the temperature logs up to date to ensure no food went bad. The Dietary Manager also stated temperatures needed to be documented to ensure proper food storage, and that all kitchen staff could ensure temperatures were recorded but he oversaw everything. During a later observation and interview on 05/28/26 at 08:42 AM, surveyors found a bag of sliced cheese in the walk-in refrigerator that was not sealed and was exposed to air. In the same refrigerator, there was also a bag of onions and bell peppers with no discard or use-by date. The Dietary Manager and [NAME] B stated foods stored in the refrigerator should have a discard date and be in a sealed bag to ensure the foods used for residents' meals were not old or became hard. During an observation and interview on 05/28/26 at 11:34 AM, surveyors observed an open clear cup of a personal beverage in the food preparation area while [NAME] B was prepping lunch. [NAME] B, the Dietary Manager, and Dietary Aide D stated the beverage should not have been in the food preparation area because it could cause cross contamination, and Dietary Aide D confirmed the beverage belonged to him.
Incomplete Care Plans for Eating Assistance and Cleaning Agent Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #2 and Resident #3 that reflected their assessed needs and preferences. Resident #2, a male with diagnoses including burns of various body parts and a BIMS score of 11 out of 15 indicating moderate cognitive impairment, had a quarterly MDS assessment that showed he needed setup or clean-up assistance for eating. However, his care plan, last reviewed on 12/07/25, did not document the type of assistance he needed for eating. CNA C stated Resident #2 was able to feed himself, and the MDS nurse confirmed the eating assistance needed was not documented in the care plan and said it was important for staff to know how the resident ate so they could help him appropriately. Resident #3, a male with diagnoses including major depressive disorder and generalized anxiety disorder and a BIMS score of 13 out of 15 indicating intact cognition, had a care plan last reviewed on 05/14/26 that did not reflect his use of a cleaning agent in his room for personal cleaning. During observation, the cleaning agent was found on the side of his bed, and LVN A confirmed it was in his room and removed it. She stated he had been educated multiple times not to keep it in his room and was unsure whether it was in his care plan. CNA E said she had seen the cleaning agent in his room and would have found it helpful if the care plan documented whether he was allowed to have it there. The ADM and DON later stated he was okay to have the cleaning agent in his room because he was alert and oriented and liked to clean his room on his own, and they planned to document that staff should remove it from his room as needed and keep it behind the nurse's station for his use.
Cleaning Solution Left at Resident Bedside
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for Resident #3 by allowing a cleaning solution to remain at the bedside on 05/28/26 and 05/29/26. Resident #3 was a [AGE]-year-old male admitted on [DATE] with diagnoses including major depressive disorder and generalized anxiety disorder. His quarterly MDS, dated 05/09/26, showed a BIMS score of 13 out of 15, indicating intact cognition. His care plan, last reviewed on 05/14/26, did not reflect that he could have cleaning supplies or chemical agents in his room for personal use. Observation on 05/28/26 at 08:12 AM showed the cleaning agent on the side of Resident #3's bed. On 05/29/26 at 08:33 AM, an LVN confirmed the cleaning agent was still at the bedside and removed it, stating he was not allowed to have it in his room. A CNA stated she had seen the cleaning agent in the room but assumed it was allowed because she was new and expected other staff familiar with the resident to remove it. During interviews, the ADM and DON stated the resident was okay to have the cleaning agent because he was alert and oriented, but they also stated they would place it in his care plan and keep cleaning agents behind the nurse's station. The ADM further stated the facility did not have policies regarding accidents and hazards or prohibited items, including chemicals and cleaning supplies.
Meal Tray Tickets Did Not Match Resident Preferences or Allergy Information
Penalty
Summary
The facility failed to ensure that residents received foods that matched their documented preferences and allergy information. One resident with dementia and severe cognitive impairment had a breakfast tray ticket that listed orange juice, but apple juice was served instead. During observation and interview, the resident stated she liked orange juice and was okay with the apple juice that day, and she also said that sometimes she did not receive everything on her tray ticket. Staff acknowledged that the tray ticket did not match the meal served and stated that tray tickets should be followed to meet resident needs and preferences. A second resident with diagnoses including burns and a documented lactose allergy had a lunch tray ticket that did not reflect the lactose allergy listed in the medical record and care plan. The resident stated he was lactose intolerant and reported that he still received milk on meal trays. He said he knew not to consume lactose products, but it would be helpful if the kitchen did not provide them. Staff interviews showed that the Dietary Manager, CNA, DON, and ADM were not consistently aware of the lactose allergy being communicated to dietary, and the DON stated the allergy should have been on the meal tray ticket. Record review showed the first resident’s care plan included providing and serving the diet as ordered, and the second resident’s care plan identified lactose allergy. The facility’s policies stated that food preferences, dislikes, and allergies should be obtained and that tray cards should be updated to reflect appropriate information. The Dietary Manager and other staff stated that meal tray tickets should be followed to ensure the right diet, texture, and resident, but the tray ticket for one resident did not match the ordered beverage and the tray ticket for the other resident did not reflect the documented lactose allergy.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Deficient Medication Storage and Labeling Practices
Penalty
Summary
Surveyors observed multiple failures in the storage and labeling of drugs and biologicals. On the west medication cart, two loose white pills and two loose pink pills were found in the top drawer, and an insulin vial for a resident did not have an open date. The LVN present was unable to identify the loose pills and confirmed that such pills should be discarded, not administered. The DON confirmed that loose pills should not be present in medication carts and that both insulin vials and their boxes should be labeled with the open date to prevent confusion if separated. In the west hall medication storage room, the refrigerator used for resident medications contained a plastic narcotic lock box that was not permanently affixed, as the padlock was not fully closed and the screws securing the bracket were loose and easily removed. The box contained vials of liquid lorazepam, a controlled substance. The DON demonstrated that the lock was not fully engaged and acknowledged the box was not securely attached. Additionally, the nurse treatment cart was found to have its keys stored in an unlocked container attached to the cart, which an LVN accessed openly. The DON stated that it was acceptable for the keys to be stored in this manner, as they were not in the line of sight and residents were not aware of their location.
Deficiencies in Kitchen Sanitation and Food Storage Practices
Penalty
Summary
Surveyors observed multiple failures in the facility's food service operations, including unclean conditions and improper food storage practices. Specifically, a ceiling vent and a side wall air vent in the kitchen were found covered with dirt and dust particles. Additionally, an opened jar of mayonnaise in the refrigerator and two bags of cookie pieces in the storage room were not dated, contrary to facility policy. The dish machine was also found to be malfunctioning, as it did not record the sanitizer concentrate level after a wash cycle, raising concerns about the effectiveness of dishware sanitation. Interviews with the Food Service Director confirmed that the vents had not been cleaned and that food items were not properly labeled with dates as required. The Food Service Director was unaware of the dish machine sanitizer issue, which was not functioning at the time of observation. The Maintenance Director stated he had not received a work order to clean the vents. Review of facility policies indicated that regular cleaning schedules and proper labeling and dating of food items were required, but these procedures were not followed, resulting in the cited deficiencies.
Failure to Maintain Catheter Bag Off Floor as Required by Infection Control Policy
Penalty
Summary
A deficiency was identified when a resident with a history of sepsis due to streptococcus pneumoniae, recurrent urinary tract infections, vesicoureteral reflux, dementia, and Parkinson's disease was observed with an indwelling urinary catheter bag that was not properly maintained according to facility policy and physician orders. The resident's care plan and physician orders specified that the catheter bag should be kept in a privacy (dignity) bag and off the floor at all times. However, during observation, the catheter bag was found visible from the doorway, not in a dignity bag, and touching the floor while the resident was in bed. Interviews with staff confirmed that the catheter bag should have been inside a dignity bag and placed in a basin to prevent contamination from the floor. The CNA interviewed was unsure who had corrected the issue after it was observed, and the DON acknowledged that the catheter bag should not be on the floor due to infection risk. Review of the facility's catheter care policy also confirmed the requirement to keep catheter tubing and drainage bags off the floor. These findings demonstrate a failure to follow established infection prevention and control protocols for catheter care.
Failure to Meet Minimum Room Size Requirements for Residents
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple occupancy rooms, as determined by interviews and record review. Specifically, 45 out of 46 resident rooms reviewed did not meet the required space, with measurements for each room showing less than 80 square feet per resident. The rooms in question were all measured by a Life Safety Inspector, and the findings were based on these direct measurements. The deficiency was further substantiated by the review of facility records, which confirmed the room sizes and the number of beds in each room. Additionally, the facility's Provider History Profile indicated that there was an existing room size waiver, which had expired prior to the current survey. The Administrator confirmed that a new waiver request had been submitted, but there had been no changes to the number or size of the affected rooms since the previous waiver. The deficiency was identified through both interviews and documentation, with no evidence of compliance with the required room size standards at the time of the survey.
Resident Elopement Due to Inadequate Supervision and Elopement Risk Assessment
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a history of dementia, mood disturbance, and wandering behaviors was able to leave the facility's front porch without staff knowledge. The resident, who required supervision or touch assistance with mobility and had a BIMS score indicating moderate cognitive impairment, was not identified on the care plan as being at risk for wandering or elopement prior to the incident. Despite staff concerns about the resident's safety on the front porch, the resident was allowed to sit outside unsupervised, leading to the resident leaving the premises, traveling to a grocery store 1.7 miles away, and ultimately being found at a homeless shelter where he had previously lived. Interviews with staff revealed inconsistent understanding and implementation of elopement risk assessments and supervision protocols. Some staff relied on a list at the nurses' station to identify residents at risk for elopement, while others based decisions on their own judgment or the resident's cognitive status at the time. Several staff members indicated that they would ask a nurse before allowing a resident outside, but there was no clear, consistently applied process for assessing and supervising residents with cognitive impairment or wandering behaviors. The resident's care plan did not address wandering or elopement risk until after the incident occurred. The facility's failure to ensure the environment was free from accident hazards and to provide adequate supervision resulted in the resident's unsupervised departure. The lack of a comprehensive and consistently implemented elopement risk assessment and supervision protocol contributed to the incident, as staff did not have clear guidance or documentation regarding which residents required supervision when outside. This deficiency was identified through observation, interviews, and record review, and was determined to have placed residents at risk for accidents that could result in serious harm.
Removal Plan
- Assess all residents in facility for any active exit seeking behaviors or any active wandering behaviors by DON or designee.
- Complete elopement assessments for all residents in facility by DON or Designee; ensure any resident at risk for elopement has interventions in place to include risk for elopement on residents Kardex and care plan.
- Review all resident current BIMS assessments to determine cognitive status by MDS nurse.
- Notify Medical Director of Immediate Jeopardy Situation.
- Complete ADHOC QA with IDT team regarding Immediate Jeopardy Situation.
- Initiate in-services for all staff on elopement policy, elopement prevention, how to identify a resident at risk for elopement in PCC via POC task (non-licensed nursing staff), how to identify a resident BIMS score in PCC via POC task, and instruct all other non-licensed staff to inquire with licensed nurses for questions regarding resident BIMS score.
- Provide in-service for licensed nurses on how to identify a resident at risk for elopement in PCC via elopement assessment, POC task and care plan, and how to identify resident BIMS assessment score located in special instructions tab in residents' chart in PCC.
- Require all non-licensed staff to notify licensed nurses prior to letting any resident go outside of facility.
- Ensure residents identified as cognitively impaired via BIMS assessment score (0-7 severe or 8-12 moderate cognitive impairment) utilize the back courtyard to sit outside upon their request or staff supervision.
- Complete in-service with DON/ADON and MDS nurse regarding entering BIMS score in special instruction tab in PCC by RCN.
- Ensure BIMS assessment score is located in the special instructions tab in each patient's chart (licensed nurses).
- Ensure facility patio/back courtyard is located on facility premises within a secure gate not considered leaving facility property.
- Review all elopement assessments to ensure any residents at risk for elopement have proper interventions in place (includes new admissions).
- Review all residents BIMS assessments to ensure residents identified with cognitive impairment have interventions in place (special instructions in place in PCC) (includes new admissions).
- Update special instructions tab in PCC if a change in BIMS score is identified.
- Notify staff if any BIMS score change is noted upon review of assessments and on an as needed basis via communication board in PCC.
- Ask 4 non-licensed nursing staff situational questions related to elopement (how to identify a resident at risk for elopement in PCC, what to do if a resident elopes).
- Ask 4 licensed nurses situational questions regarding elopement and cognition (how to identify a resident at risk for elopement in PCC, how to identify a resident with a cognitive deficit in PCC).
- Monitor to ensure there is no evidence of facility staff or visitors allowing residents to go outside without notifying nurse.
- Review all findings in monthly QA and make changes to the plan if needed.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations revealed that food items in the walk-in fridge/freezer were not properly labeled or dated, including strawberries, leafy greens, mixed frozen vegetables, and croissant dough. Additionally, expired food products such as hummus were not discarded, and food with freezer burn was not removed. In the dry food storage area, a bag of spaghetti was found open and spilled on the shelf, and a container of sugar was left open. These lapses in food storage and labeling were acknowledged by the Dietary Manager (DM) and other staff members during interviews, who admitted that the items should have been properly labeled, dated, and discarded if expired or compromised in quality. Further observations indicated that staff did not adhere to sanitary practices. Personal drinks were found on food prep tables, and a dietary aide was seen licking her fingers while placing dietary preference sheets on resident food trays. This unsanitary behavior was confirmed by the dietary aide, who acknowledged that it was not appropriate and could potentially make residents sick. The Activity Director also admitted to not following proper procedures for labeling and dating food items used for residents. The facility's policy on sanitation and food handling, which mandates proper handwashing, clean work surfaces, and securely covered and labeled food items, was not followed, leading to these deficiencies.
Failure to Respect Resident Dignity and Privacy
Penalty
Summary
The facility failed to treat residents with respect and dignity, as evidenced by multiple observations and interviews. LVN A entered Resident #22's room without knocking, despite the resident expressing that staff frequently entered without knocking, which he disliked. LVN A admitted to not knocking because she had been in the room several times that day and assumed the resident was expecting her. CNA R was observed standing while feeding Resident #40 during dinner, citing the lack of available chairs as the reason. CNA R acknowledged that she should have been at the resident's eye level for comfort. Similarly, LVN A was seen standing while feeding two unidentified residents, also due to the unavailability of chairs, and admitted that sitting down would have been more comfortable for the residents. RN F entered Resident #39's room without knocking during a medication pass. Although RN F announced herself, she recognized the importance of knocking to respect the resident's space. The Director of Nursing (DON) confirmed that staff are expected to knock and announce themselves before entering a resident's room and to sit while feeding residents to maintain their dignity.
Failure to Implement Enhanced Barrier Precautions in Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet the medical and nursing needs of eight residents. Specifically, the facility did not update the care plans to address the need for enhanced barrier precautions for residents with indwelling urinary catheters, feeding tubes, and other conditions requiring such precautions. This deficiency was observed in multiple residents, including those with acute kidney failure, chronic kidney disease, dementia, and neuromuscular dysfunction of the bladder, among other diagnoses. For instance, Resident #14, who had an indwelling urinary catheter due to neuromuscular dysfunction of the bladder, did not have enhanced barrier precautions included in her care plan. Observations revealed that there were no signs or indications of enhanced barrier precautions in her room, and no PPE storage with gowns was noted. Similar deficiencies were noted for Resident #19, who had a supra pubic catheter, and Resident #21, who had an indwelling urinary catheter and a wound, both of whom also lacked updated care plans and appropriate precautionary measures. Additionally, Resident #23, who had a feeding tube, and Resident #31, who had an indwelling urinary catheter, were also found to be without enhanced barrier precaution signs or PPE storage in their rooms. The facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the oversight, indicating that the nurse managers were responsible for updating the care plans but had not done so. The lack of adherence to enhanced barrier precautions was further confirmed through staff interviews and observations, highlighting a systemic issue in the facility's infection control practices.
Failure to Administer Methadone as Ordered
Penalty
Summary
The facility failed to ensure that a resident was administered Methadone as ordered by the physician. The resident, who had diagnoses including Parkinson's disease, blindness in one eye, and anxiety disorder, was admitted to the facility and required medication for pain management. The resident's comprehensive care plan included interventions to monitor and respond to pain, and the Methadone was to be administered twice a day. However, the Methadone narcotic log revealed that the resident received the last dose on the morning of 4/30/24, and subsequent doses were not administered as scheduled due to the facility running out of the medication. Interviews with the resident and Med Aide Q confirmed that the resident did not receive the scheduled doses of Methadone on 5/1/24. The resident reported being informed by an unidentified nurse that the medication needed to be refilled for three days. Med Aide Q indicated that the DON and ADON were notified about the shortage, and the DON confirmed that the NP had been informed and was waiting for the MD to sign the prescription. The DON acknowledged that the resident could suffer withdrawals if the Methadone was not administered as scheduled. The facility's policy and procedure for medication administration required that any deviation from the scheduled medication be documented in the nursing notes. However, there were discrepancies between the narcotic log and the nursing progress notes. The DON stated that the documentation on the narcotic log should match the MAR, indicating a failure in the facility's medication administration process and documentation practices.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to multiple deficiencies in infection control practices. Specifically, the facility did not utilize enhanced barrier precautions for several residents with indwelling urinary catheters and feeding tubes. Observations revealed that there were no enhanced barrier precaution signs or PPE storage in or around the rooms of these residents. Staff members, including CNAs and LVNs, were observed not wearing gowns as required by enhanced barrier precautions while providing care to these residents. Interviews with staff indicated a lack of understanding and training regarding enhanced barrier precautions, with some staff members unaware of the requirements and others incorrectly believing that enhanced barrier precautions were related only to the use of barrier cream or isolation for infections. Additionally, the facility failed to ensure proper hand hygiene and infection control principles were followed by staff. LVN A did not perform hand hygiene between glove changes and did not sanitize the site before obtaining a blood sample for an accu check on a resident. LVN C and Med Aide D were observed using the same paper towel to dry their hands and turn off the water faucet, which is considered cross-contamination. Interviews with the staff confirmed their awareness of the correct procedures but revealed lapses in following them. The deficiencies in infection control practices were further highlighted by the lack of proper training and implementation of enhanced barrier precautions. The DON and ADON acknowledged the issues and stated that training was provided through the facility's computer training program. However, the observations and interviews indicated that the training was not effectively implemented, putting residents at risk for infection. The facility's failure to adhere to infection control protocols and adequately train staff on enhanced barrier precautions contributed to the identified deficiencies.
Failure to Ensure Valid Out-of-Hospital Do Not Resuscitate (OOH DNR) Order
Penalty
Summary
The facility failed to ensure that a resident's Out-of-Hospital Do Not Resuscitate (OOH DNR) order was properly completed and valid. Specifically, the OOH DNR for a resident with severe cognitive impairment and multiple serious health conditions, including acute respiratory failure, acute kidney failure, and cardiomyopathy, was not signed by a witness, a second physician, or a notary public, rendering the document invalid. Despite the resident being identified as DNR status in their face sheet, comprehensive care plan, and order summary report, the incomplete OOH DNR form could lead to the resident's end-of-life wishes not being honored. During an interview, the Director of Nursing (DON) confirmed that the DNR document had been deleted from the electronic medical record to be corrected and that they were waiting for hospice to fix the DNR. The DON acknowledged that while the facility considered the DNR valid, external medical personnel would not honor it, potentially resulting in CPR being performed against the resident's wishes. The facility's policy on DNR orders was reviewed, which outlined the requirements for a valid OOH DNR, but the resident's document did not meet these requirements.
Failure to Ensure Accurate PASRR Screening for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure that individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening. Specifically, a resident with a diagnosis of bipolar disorder did not have this condition accurately reflected in their PASRR Level 1 Screening. The resident's face sheet and quarterly MDS assessment indicated a diagnosis of bipolar disorder, and the resident was taking Depakote daily for this condition. However, the PASRR Level 1 Screening completed earlier did not indicate any evidence of mental illness. The Director of Nursing (DON) acknowledged that the bipolar diagnosis was added after the initial PASRR Level 1 was completed and admitted that a new Level 1 should have been resubmitted to reflect the updated diagnosis. This oversight could result in the resident missing out on necessary PASRR services.
Failure to Maintain Proper Catheter Care
Penalty
Summary
The facility failed to ensure that two residents with indwelling urinary catheters received appropriate care to prevent urinary tract infections. Resident #21, a severely cognitively impaired female with chronic kidney disease and dementia, was observed with her catheter drainage bag touching the floor despite care plan interventions to keep it off the floor and in a dignity bag. Similarly, Resident #35, a male with diabetes and asthma, was seen in his wheelchair with his catheter bag touching the floor, contrary to his care plan instructions. Both residents had orders for catheter care every shift and to ensure the catheter bags were in privacy bags and off the floor, but these orders were not followed. Interviews with staff revealed that the catheter bags should not be touching the floor due to the risk of contamination and potential damage. The Director of Nursing (DON) confirmed that the facility had basins available to prevent catheter bags from touching the floor, but these were not utilized. The facility's policy on catheter care also emphasized keeping tubing and drainage bags off the floor, which was not adhered to in these cases.
Failure to Elevate Head of Bed During Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications. Specifically, RN F did not elevate the head of the bed to at least 30 degrees while administering medications via the feeding tube to a resident with severe cognitive impairment and multiple diagnoses, including dysphagia, gastro-esophageal reflux disease, and protein-calorie malnutrition. The resident's care plan and physician orders explicitly required the head of the bed to be elevated during feedings and medication administration to prevent complications such as regurgitation and aspiration. During an observation, RN F was seen administering medications to the resident while the resident was lying flat on the bed, with two pillows on either side of the resident's head. RN F acknowledged that the head of the bed might not have been elevated to the required 30 degrees, which could lead to regurgitation. The Director of Nursing (DON) confirmed that it was the facility's expectation for nursing staff to ensure the head of the bed was elevated during feedings and medication administration for residents with feeding tubes to prevent aspiration.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required oxygen therapy. Resident #15, who had chronic obstructive pulmonary disease, heart disease, and age-related cognitive decline, was observed with an oxygen concentrator set at 3 liters per minute, contrary to the physician's order of 4 liters per minute. Additionally, the oxygen concentrator's filter was covered in a thick white substance, indicating it had not been cleaned as required by the physician's orders. The Licensed Vocational Nurse (LVN) admitted to not knowing the location of the filters and stated that she had never checked them, believing it was the responsibility of the hospice service providing the equipment. The Director of Nursing (DON) confirmed that the facility's nursing staff were responsible for maintaining the oxygen concentrator filters and acknowledged the discrepancy in the oxygen setting. The observations and interviews revealed that the facility staff were not adhering to the physician's orders for oxygen therapy and were not maintaining the oxygen concentrator equipment properly. This failure to follow professional standards of practice and the resident's care plan could lead to inadequate oxygen delivery, potentially causing labored breathing and confusion in the resident. The DON confirmed that the oxygen concentrator should have been set at 4 liters per minute and that the nursing staff were responsible for ensuring the cleanliness of the oxygen filters, which were visibly dirty and covered in a white substance.
Failure to Ensure Proper Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure that residents who required dialysis received services consistent with professional standards of practice. Specifically, the facility did not maintain proper communication, coordination, and collaboration with the dialysis facility for a resident with end-stage renal disease. The resident's comprehensive care plan included interventions to monitor and report signs of infection, renal insufficiency, and other complications, but these were not consistently followed. The resident's dialysis communication record showed no pre-assessment vitals were taken by the nursing facility nurse from early March to late April, despite the resident's statement that staff used to take his blood pressure before dialysis. During an interview, the Director of Nursing (DON) confirmed that the resident refused his vitals before dialysis and acknowledged that staff should document such refusals. The DON also noted that without pre-dialysis vitals, staff would not be able to notice any changes in the resident's condition from the time he left the facility to when he arrived at the dialysis center. Additionally, the facility was unable to provide a dialysis policy when requested, further indicating a lack of proper protocol and documentation.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure that it was free of a medication error rate of 5 percent or greater, resulting in a medication error rate of 7.14%. This involved two residents who did not receive the correct dosage of Vitamin D. Specifically, Med Aide D administered 20 mcg (800 Unit) of Vitamin D to Resident #18 instead of the prescribed 50 mcg (2000 Unit), and 10 mcg (400 Unit) to Resident #28 instead of the prescribed 1000 Unit. The errors were due to Med Aide D using a Vitamin D bottle labeled 10 mcg (400 Unit) and following the incorrect dosage written on the cap rather than the label on the bottle or the residents' medication orders. Resident #18, a [AGE] year-old female with diagnoses including type 2 diabetes, personal history of infectious and parasitic diseases, and morbid obesity, and Resident #28, a [AGE] year-old female with diagnoses including protein-calorie malnutrition, type 2 diabetes, and dementia, were both affected by this error. During an interview, Med Aide D acknowledged the mistake and the DON confirmed that the expectation was for staff to check the medication order and label for accuracy. The facility's policy on medication administration procedures emphasizes adherence to the 10 rights of medication, including the right dose.
Failure to Properly Store and Administer Medications
Penalty
Summary
The facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles. During a medication pass, an LVN left the West Wing medication cart unlocked and unattended in the main hall between the units and the dining room area. The LVN admitted to leaving the cart unlocked because she was nervous, acknowledging that the cart should never be left unlocked and unattended due to the risk of theft and overdose by residents known to wander the unit. This incident was observed and confirmed during an interview with the LVN, who further stated that there were true addicts in the facility who could potentially misuse the medications if accessed improperly. Additionally, the facility failed to ensure medications were not left at the bedside for a resident diagnosed with Parkinson's disease, blindness in one eye, and anxiety disorder. The resident was found with a medication cup containing two pink oval tablets identified as Benadryl on the bedside table. The resident admitted to receiving the medications from a Med Aide earlier that morning but had forgotten to take them. The Med Aide confirmed that medications should not be left in the resident's room and that she was taught to watch residents take their medications. The DON also confirmed that no residents in the facility were allowed to self-medicate and that medications should not be left at the bedside to prevent adverse reactions or overdoses.
Failure to Maintain Accurate Medical Records for Pain Management
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for one resident reviewed for accuracy of medical records. Specifically, Med Aide Q documented that she administered Resident #11's afternoon dose of Methadone on two occasions after the resident had already received his last dose of Methadone during the scheduled morning dose. This discrepancy was identified through record reviews and interviews, revealing that the resident did not receive the scheduled morning dose of Methadone on one of the days in question and that the facility had run out of the medication. Resident #11, a male with diagnoses including Parkinson's disease, blindness in one eye, and anxiety disorder, was admitted to the facility and required Methadone for pain management. Despite the resident's comprehensive care plan indicating the need for pain medication therapy, the Methadone narcotic log and Medication Administration Record (MAR) showed inconsistencies. Interviews with the resident and Med Aide Q confirmed that the resident did not receive the scheduled doses as documented, and the Director of Nursing acknowledged the discrepancies between the narcotic log and the MAR.
Failure to Provide Behavioral Health Training to DON
Penalty
Summary
The facility failed to provide mandatory effective behavioral health training for the Director of Nursing (DON). The DON's personnel record, with a hire date of 10/19/23, showed no evidence of behavioral health training. During a record review and interview on 5/3/24, the BOM/HR Personnel confirmed that the DON did not have the required training. In an interview on the same day, the DON stated she had completed the training assigned to her but was unsure why she had not done the behavioral health training. She mentioned having received similar training at other workplaces but was uncertain about how the lack of this training could affect the residents. A policy for training was requested but not provided.
Facility Fails to Provide Minimum Required Square Footage in Resident Rooms
Penalty
Summary
The facility failed to ensure that 46 out of 49 multiple occupancy resident rooms provided a minimum of 80 square feet per resident. This deficiency was identified through observation, interview, and record review. The measurements of the rooms were found to be below the required square footage, with most rooms providing only around 73 square feet per resident. This issue was acknowledged by the Administrator during an interview, where he expressed a desire to continue with the room waiver for all resident rooms that did not meet the required square footage. The specific measurements of the rooms were detailed in the report, showing that none of the rooms met the 80 square feet requirement. The facility had a census of 42 residents at the time of the survey. This deficiency could affect all residents in need of at least 80 square feet of living space and could pose problems in their activities of daily living. The report did not mention any corrective actions or follow-up actions taken to address the deficiency after the incident.
Inaccurate Care Plan Documentation
Penalty
Summary
The facility failed to ensure the care plan accurately reflected the resident's status for one of the residents reviewed. Specifically, the care plan for a resident admitted with diagnoses including pulmonary embolism, stage 3 chronic kidney disease, dementia, and protein-calorie malnutrition, was not updated to reflect her current condition. The resident, who had stopped walking in December 2022, was documented in the care plan as needing appropriate footwear for ambulation and being able to propel her wheelchair, despite being totally dependent on staff for mobility and other activities of daily living (ADLs). This discrepancy was noted during an interview with the resident's Power of Attorney (POA) and the Director of Nursing (DON), who confirmed the resident's total dependence on staff for repositioning, feeding, ADLs, and transfers. Observations and interviews revealed that the resident was in a contracted fetal position in bed and was not ambulatory or able to propel her wheelchair. The facility's policy on comprehensive care planning mandates that care plans be developed and implemented based on the resident's clinical condition, cognitive and functional status, and use of services as identified in the comprehensive assessment. The failure to update the care plan accurately could place residents at risk of inadequate care, as the care plan provides essential information for staff to deliver appropriate care.
Failure to Lock Treatment Cart
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the treatment cart. During an observation and interview, it was noted that the nurse treatment cart was left unlocked and unattended. The Administrator had to lock the cart upon noticing it was left unsecured. This incident could result in harm due to unauthorized access to medications, misappropriation, and drug diversion. Nurse A admitted to not locking the treatment cart after completing wound care for a resident. She acknowledged the importance of locking the cart to prevent harm from medications and scissors stored in it. The Director of Nursing (DON) also emphasized the necessity of keeping the cart locked for safety reasons. The facility's policy mandates that medication carts must be locked when not in use or under direct supervision.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 903 citations issued within 25 miles in the last 12 months — including the 19 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| San Antonio North Nursing And Rehabilitation | 1.7 mi | ★★★★★ | 15 | 0 |
| Memorial Medical Nursing Center | 1.9 mi | ★★★★★ | 9 | 0 |
| San Pedro Manor | 2.2 mi | ★★★★★ | 1 | 0 |
| Meridian Care Monte Vista | 2.4 mi | ★★★★★ | 16 | 1 |
| St. Francis Nursing Home | 2.6 mi | ★★★★★ | 5 | 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 July 2026) and official state health department websites.