Above average — CMS composite of the measures below.
A standard survey is most likely before 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 San Pedro Manor during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and multiple chronic conditions sustained a skin tear to the lower shin that was documented by an LVN, who attempted but failed to reach the resident’s POA and did not leave a voicemail, assuming the treatment nurse would notify the family. The treatment nurse documented the wound, obtained MD orders, and provided treatment but did not contact the family, citing a facility practice that charge nurses handle family notification. The resident’s representative reported learning of the injury only upon visiting and seeing the wound, and leadership acknowledged that both the physician and the representative were not notified as required by the facility’s significant change in condition policy.
Surveyors found that a resident did not receive appropriate care for continence or incontinence, including improper catheter care and insufficient measures to prevent UTIs. These lapses resulted in a deficiency related to the standard of care for residents with bowel or bladder needs.
Several residents with intact cognition and ADL deficits reported that their meals, often served in their rooms, were frequently cold. Direct interviews, family input, and resident council records confirmed ongoing issues with food temperature. Observations and temperature checks showed that food items were served well below required temperatures, and staff practices during tray delivery contributed to the problem.
Surveyors observed that kitchen and dish room ceiling vents were dirty, stained, and in some cases rusty, with one vent not fully attached to the ceiling. Both the Food Service Director and Maintenance Director acknowledged the unclean conditions, which did not meet professional standards for food service safety.
A CNA did not follow infection control protocols while providing incontinent care to a resident with multiple health conditions, including failing to sanitize hands before donning gloves, not sanitizing between glove changes, and handling clean briefs after touching soiled items without proper hand hygiene. The DON confirmed these actions were not in line with facility policy, which requires hand hygiene and appropriate PPE use.
CNAs did not fully close a broken privacy curtain while providing incontinent care to a resident who was cognitively impaired and dependent for ADLs, resulting in a lack of privacy during care. Both staff confirmed the curtain was not completely closed and were unaware of how long it had been broken, despite facility policy requiring privacy during care.
The facility did not distribute mail to residents on Saturdays, instead holding weekend mail until Monday, despite policy requiring same-day delivery. Staff interviews and resident council feedback confirmed this practice, resulting in delayed access to mail and a failure to uphold residents' rights to timely and private communication.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
The facility did not maintain a clean and sanitary environment in a shared shower room, as observed by clogged drains with hair, dirty floors, and brown substances present. Staff interviews revealed inconsistent cleaning practices, lack of disinfectant supplies, and unclear division of cleaning responsibilities between CNAs and housekeeping. Policy documents lacked specific guidance for CNAs on cleaning and disinfecting the shower area.
A resident with multiple health conditions, including osteoporosis, was injured during a transfer to a transportation van for dialysis. The transportation driver pushed the resident too quickly, causing the resident's foot to get caught in the ramp gap, resulting in a sprained ankle. The facility failed to ensure a safe environment and adequate supervision, as outlined in the resident's care plan and facility policy.
The facility failed to maintain kitchen sanitation standards, as air vents over the food preparation area were found with dust and fuzz, risking food contamination. Interviews revealed confusion over cleaning responsibilities between kitchen and maintenance staff, contrary to the facility's sanitation policy and Federal Food Code requirements.
A facility failed to report three incidents to the State Survey Agency, violating its policies. One resident sprained an ankle during transport, another had ant bites from ants in her bed, and a third was given incorrect medications. Despite these events, the facility did not report them, citing a lack of perceived severity.
The facility failed to maintain an effective infection prevention and control program, as staff did not wear appropriate PPE while caring for two residents on Enhanced Barrier Precautions. Despite recent training and clear signage, staff only wore gloves instead of both gown and gloves, as required by facility policy. This oversight was acknowledged by the Infection Preventionist and DON, who noted the risk of spreading infections.
The facility failed to report incidents involving a resident's sprained ankle during transport, ant bites on another resident, and a medication error affecting a third resident to the State Survey Agency. These incidents were not reported despite the potential for harm and the facility's responsibility to do so.
A resident's bed was not maintained in proper working condition, potentially risking skin tears, injury, and discomfort. Despite the resident's need to elevate her legs due to edema, the bed's end was not functioning. The resident reported the issue, but staff and maintenance failed to resolve it. Interviews revealed a lack of communication and follow-up, and no work orders were found for the bed, contrary to the facility's policy requiring maintenance issues to be resolved within 72 hours.
The facility failed to maintain an effective pest control program, resulting in a resident experiencing ant bites and a kitchen infested with gnats. The resident, with moderate cognitive impairment, reported ants in her bed, leading to bites on her arms and legs. The kitchen had multiple gnats in food prep areas, despite regular pest control treatments. Staff interviews confirmed ongoing pest issues, posing a risk of food contamination.
A resident with schizoaffective disorder, schizophrenia, and depression was admitted without the proper PASRR Level II evaluation due to an oversight by the Social Worker, who failed to review the resident's clinical records. The PASRR Level 1 screening inaccurately indicated no mental illness, contrary to the resident's documented diagnoses.
A resident with severe cognitive impairment and a history of dysphagia did not receive proper g-tube care as per physician orders, leading to potential infection risks. The nurse responsible admitted to not providing the care, despite documenting it as completed, due to the resident's ability to eat orally. Facility leadership was unaware of the oversight, despite having a system for weekly checks.
A resident with severe cognitive impairment and multiple diagnoses was mistakenly given another resident's medications due to a distraction during medication preparation by an LVN. The resident was supposed to receive Pantoprazole and Tramadol but was given Alprazolam and Hydrocodone-Acetaminophen instead. The error was promptly reported, and the resident was monitored without adverse effects.
A resident's room in the facility was not maintained at a comfortable temperature, with readings reaching 82 degrees Fahrenheit. Despite the resident's complaints to the Maintenance Assistant, the issue persisted, and the Maintenance Director was only informed on the day of the survey. The resident, who has hypertension, anxiety disorder, and COPD, experienced discomfort due to the high room temperature.
A resident with severe cognitive impairment and a g-tube for nutrition did not receive proper g-tube care as per physician orders. The LVN responsible failed to provide the care and falsely documented it as completed. The ADON and DON were unaware of this issue until it was discovered during an observation. This failure to document accurately is considered falsification of records.
A resident with severe cognitive impairment and identified as an elopement risk managed to leave the facility undetected. The resident exited the building after walking past the nurses' station and taking the elevator to the first floor. Although the alarm system was functional, it was not heard by staff, allowing the resident to leave. The resident was found unharmed at a nearby gas station by the police. The incident highlighted inadequate supervision and alarm failure, placing residents at risk.
A CNA in an LTC facility failed to follow proper infection control procedures while providing incontinent care to a resident. The CNA did not change gloves or wash hands after touching a privacy curtain and between glove changes, despite having received infection control training. The DON confirmed these lapses, highlighting a deficiency in maintaining a safe and sanitary environment.
A resident did not receive scheduled doses of Alprazolam due to a delay in delivery from the hospice provider and lack of proper follow-up by facility staff. The resident, who had a history of anxiety and other conditions, missed several doses, which was against the physician's orders and facility policy.
Failure to Notify Physician and Representative of Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and representative of a significant change in condition following a skin tear. The resident was an older male with anxiety disorder, hypertension, and benign prostatic hyperplasia, admitted with a care plan that included treatment for a skin tear to the left lateral shin. An admission MDS showed a BIMS score of 12, indicating moderate cognitive impairment. Facility incident and accident reports identified a skin tear event for this resident, and physician telephone orders were obtained to cleanse the affected area and apply dressings daily. A progress note documented that an LVN observed a skin tear/abrasion to the left lower shin and attempted to call the resident’s daughter/POA, but there was no answer and no voicemail left. The treatment nurse’s subsequent progress note documented that she was notified of the skin tear and that the wound measured 8x6 cm, and she obtained and implemented MD orders, but did not contact the family, stating that per facility culture the charge nurse was responsible for family notification. The resident’s representative reported she was never contacted by nursing staff and only learned of the skin tear when she visited and saw the injury. Interviews with LVN A confirmed she attempted to call but did not leave a voicemail and believed the treatment nurse would call the family, while the treatment nurse confirmed she did not contact the family. The DON acknowledged that the resident’s representative should have been notified per the facility’s significant change in condition policy, which states that the resident representative will be notified of a change in condition. The Administrator stated that the physician should have been notified but was not, while staff prioritized providing care to the resident at that time.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These deficiencies were observed through direct surveyor findings, indicating lapses in the standard of care required for residents with these needs.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for three residents. Multiple residents with intact cognition and deficits in activities of daily living reported that their meals, often served in their rooms, were frequently cold. Direct interviews with these residents confirmed that both breakfast and lunch meals were served at temperatures below recommended standards, leading to dissatisfaction and refusal to eat. Family members also corroborated that meals were often cold when served. Observations and temperature checks revealed that food items such as eggs and sausage were served significantly below the required temperatures, with eggs at 94.82°F (required: 135°F) and sausage at 90.32°F (required: 140°F). Staff interviews indicated that food trays were transported in open tray rack carts after the plastic cover was removed, which contributed to the temperature drop. Resident council meeting records further documented multiple complaints about cold food. Facility dietary policy referenced the Texas Food Establishment Rules, which require adherence to established temperature guidelines, but these were not followed.
Failure to Maintain Clean and Safe Kitchen Ventilation Surfaces
Penalty
Summary
The facility failed to maintain cleanliness and proper condition of overhead ceiling vents in the main kitchen and dish room areas, as observed during a survey. Specifically, seven ceiling vents in the main kitchen were found to have visible dirt, dust particles, and stains, with one vent over the standing floor freezer not fully attached to the ceiling. Additionally, a vent cover over the dish machine in the dish room had several spots of rust accumulation on both the inside and outside surfaces. These conditions were directly observed during a walkthrough of the kitchen with the Food Service Director. Interviews with the Food Service Director and Maintenance Director confirmed awareness of the issues, with both acknowledging the presence of dirty and rusty vents and the need for cleanliness in the food service environment. Review of facility policy and relevant food safety codes indicated that non-food contact surfaces, such as ceiling vents, are required to be kept clean and free of dust, dirt, and debris. The failure to maintain these standards was documented through direct observation and staff interviews.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow proper infection control procedures while providing incontinent care to a resident with multiple medical conditions, including Wernicke's encephalopathy, dysphagia, hypothyroidism, hyperlipidemia, hypertension, and asthma. The resident was moderately cognitively impaired, always incontinent of bladder and bowel, and required total assistance with activities of daily living. During the observed care, the CNA washed her hands but then touched the room door with bare hands, did not sanitize her hands before donning gloves, and began care. Throughout the process, the CNA changed gloves multiple times without sanitizing her hands between glove changes. After cleaning the resident's buttocks and removing soiled briefs, the CNA failed to change gloves or sanitize hands before handling clean briefs. Interviews with the CNA and the Director of Nursing (DON) confirmed that the CNA did not follow established infection control protocols, including hand hygiene before gloving and between glove changes, as well as when transitioning from soiled to clean tasks. The DON acknowledged that the room door is considered a contaminated surface and that staff are required to sanitize hands before putting on gloves and between glove changes. Facility policy reviewed indicated that standard precautions, including proper hand hygiene and use of personal protective equipment (PPE), are required for all resident care activities.
Failure to Ensure Resident Privacy During Incontinent Care Due to Broken Curtain
Penalty
Summary
Certified Nursing Assistants (CNAs) E and F failed to ensure complete privacy for a resident while providing incontinent care. During the care, the privacy curtain in the resident's room was not fully closed, leaving the resident potentially exposed to anyone entering the room. The curtain was found to be broken and could only be closed halfway, which was confirmed by both CNAs during an interview. Both staff members acknowledged that the curtain should have been fully closed to protect the resident's privacy, but they were unaware of how long the curtain had been in disrepair. The resident involved had multiple medical diagnoses, including Wernicke's encephalopathy, dysphagia, hypothyroidism, hyperlipidemia, hypertension, and asthma. She was moderately cognitively impaired, always incontinent of bladder and bowel, and required total assistance with activities of daily living (ADLs). The resident's care plan indicated a need for dependent toileting hygiene due to her self-care deficits. The facility's policy stated that residents have the right to privacy, including the use of privacy curtains during care, but this was not upheld during the observed incident.
Failure to Distribute Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents had timely access to their mail and privacy in their communications, as required by resident rights. Specifically, mail delivered to the facility on Saturdays was not distributed to residents until the following Monday. This practice was confirmed during a confidential resident council meeting, where all residents present stated they did not receive mail on Saturdays, even if it arrived. Multiple staff interviews corroborated that weekend mail was placed in a drawer and held until Monday for distribution by the social worker or activities department, rather than being delivered to residents on the day of arrival. A review of the facility's Resident Mail Policy indicated that mail delivered for residents should be given to the Activities Department and hand-delivered to resident rooms on the day of delivery. However, staff interviews revealed a lack of clarity and adherence to this policy, with some staff unaware of the requirement to distribute mail on Saturdays. This resulted in a failure to provide residents with their mail in a timely manner and did not uphold their right to privacy and access to communication.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential resident information or proper record-keeping were not followed as expected. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Maintain Sanitary Conditions in Shared Shower Room
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program in the 3rd floor community shower room, which is used by up to 30 residents. Observations revealed that both shower stalls had drains clogged with large amounts of hair, a brown substance was present under one shower chair, and the floors were dirty with darkened areas and brown substance droppings in one of the stalls. Staff interviews confirmed that Certified Nursing Assistants (CNAs) were responsible for cleaning shower chairs between resident use, but one CNA reported only using shampoo to clean the chair due to a lack of disinfectant products. Housekeeping (Hsk) staff were responsible for cleaning the shower stalls and floors, but they left for the day by 4:00 PM, leaving cleaning duties to CNAs after that time. Further interviews with nursing and maintenance staff indicated confusion and inconsistency regarding cleaning responsibilities and procedures. The Assistant Director of Nursing (ADON) and Maintenance/Housekeeping Supervisor both described overlapping and unclear duties between CNAs and Hsk staff, particularly regarding the cleaning of feces and hair from drains. Policy documents reviewed stated that floors should be cleaned according to a schedule and that approved cleaning agents should be used in contaminated areas, but no specific policy for CNA responsibilities in cleaning and disinfecting shower rooms was provided. This lack of clear procedures and inadequate cleaning led to unsanitary conditions in the shared shower area.
Inadequate Supervision During Resident Transfer Leads to Injury
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision during the transportation of a resident, leading to an incident where the resident sustained an injury. The incident involved a male resident with end-stage renal disease, diabetes, osteoporosis, stroke, and seizure disorder, who used a manual wheelchair. On the day of the incident, the transportation driver did not safely transfer the resident onto the transportation van, resulting in the resident's foot getting caught in the gap where the ramp met the van, causing a sprain. The resident, who had intact cognition, reported immediate pain and swelling in his right ankle. The facility's records indicated that the resident's care plan included interventions to protect him from injury during transfers. Despite this, the transportation driver pushed the resident too quickly onto the van, leading to the injury. The facility's policy on transportation to and from off-site dialysis facilities was not effectively implemented, as evidenced by the lack of adequate supervision and safe transfer practices during the incident.
Failure to Maintain Kitchen Sanitation Standards
Penalty
Summary
The facility failed to maintain proper kitchen sanitation standards, specifically in the area of air vent cleanliness, which could lead to food contamination. During an observation, it was noted that five air conditioning vents over the food preparation area had accumulated fuzz and dust. This issue was identified as a potential risk for food contamination and food-borne illness due to the possibility of dust falling into the food. Interviews with various staff members revealed a lack of clarity and communication regarding the responsibility for cleaning the air vents. The kitchen staff and maintenance staff each believed the other was responsible for this task. The facility's policy on kitchen sanitation, which includes a comprehensive cleaning schedule, was not being followed, as evidenced by the lack of recorded cleaning tasks and unclear assignment of responsibilities. The Federal Food Code requires that non-food-contact surfaces, such as air vents, be kept free of dust and debris, a standard that was not met in this instance.
Failure to Report Incidents and Implement Policies
Penalty
Summary
The facility failed to implement its policies and procedures to prevent abuse, neglect, and exploitation of residents, as evidenced by three separate incidents involving residents. In the first incident, a resident with intact cognition and multiple medical conditions, including end-stage renal disease and osteoporosis, sprained his ankle when his foot got caught in the van ramp while being pushed by a transportation driver. Despite the resident experiencing significant pain and requiring an x-ray, the facility did not report the incident to the State Survey Agency as required by their policy. In the second incident, a resident with moderate cognitive impairment and a history of diabetes and stroke was found with ant bites on her body after ants were discovered in her bed. Although the facility treated the room and the resident reported no further issues, the incident was not reported to the State Survey Agency. The Director of Nursing (DON) did not consider the incident significant enough to warrant reporting, despite the facility's policy requiring such actions. The third incident involved a resident with severe cognitive impairment who was mistakenly given the wrong medications, including a narcotic pain pill and Xanax, instead of their prescribed medications. The error was recognized by the administering LVN, who notified the doctor and the DON. The resident was monitored for 72 hours and experienced no adverse effects. However, the incident was not reported to the State Survey Agency, as the DON and Operations Manager did not believe it met the criteria for reporting, despite the facility's policy indicating otherwise.
Inadequate Use of PPE in Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not donning appropriate Personal Protective Equipment (PPE) while providing care to two residents on Enhanced Barrier Precautions (EBP). Resident #57, a cognitively intact female with a colostomy due to spinal bifida and paraplegia, was observed receiving care from a CNA who only wore gloves, despite signage indicating the need for both gown and gloves. Similarly, Resident #185, a male with severe cognitive impairment and an indwelling catheter, received care from an LVN and a CNA who also failed to wear gowns, contrary to facility policy. Interviews with the involved staff revealed a lack of awareness regarding the necessity of wearing gowns, despite recent in-service training on infection control and clear signage. The Infection Preventionist and the Director of Nursing acknowledged the oversight, noting that PPE was readily available and emphasizing the risk of spreading infections due to improper PPE use. The facility's policy on Enhanced Barrier Precautions, which mandates gown and glove use during high-contact care activities, was not adhered to, leading to this deficiency.
Failure to Report Incidents to State Survey Agency
Penalty
Summary
The facility failed to report several incidents to the State Survey Agency as required by state law. One incident involved a resident who sprained his ankle when his foot got caught in the van ramp while being pushed by a transportation driver. Despite the resident experiencing significant pain and requiring an x-ray to rule out fractures, the incident was not reported to the State Survey Agency. The resident's care plan included interventions to protect him from injury due to his osteoporosis, yet the incident occurred during a routine transport to dialysis. Another incident involved a resident who was found with ant bites on her body. The resident, who had moderate cognitive impairment and required total assistance with most activities of daily living, was discovered with sugar ants all over her bed. Although the facility treated her room and the resident reported no further issues, the incident was not reported to the State Survey Agency. The facility's pest control logs indicated regular treatments for ants, but the incident was deemed not significant enough to report by the Director of Nursing. A third incident involved a resident who was given the wrong medications. The resident, who had severe cognitive impairment and multiple health conditions, was mistakenly administered a narcotic pain pill and Xanax instead of his prescribed medications. The error was recognized, and the resident was monitored for any adverse reactions, but the incident was not reported to the State Survey Agency. The Director of Nursing and the Operations Manager, who were responsible for reporting such incidents, did not report it as they believed there was no harm to the resident.
Failure to Maintain Resident's Bed in Working Condition
Penalty
Summary
The facility failed to maintain Resident #8's bed in proper working condition, which could potentially place residents at risk for skin tears, injury, falls, and discomfort during transfers. Resident #8, a [AGE] year-old female with intact cognition and active diagnoses including biliary cirrhosis, chronic pain syndrome, and fibromyalgia, required assistance with bed mobility and transfers. Despite her need to elevate her legs due to edema, the bed's end was not functioning, and the resident had reported this issue to staff and maintenance without resolution. Interviews with staff, including a CNA, RN, DON, Operations Manager, and Maintenance Director, revealed a lack of communication and follow-up regarding the bed's malfunction. The CNA had informed the Maintenance Director, who checked the bed but was unaware of the specific issue with the end of the bed. The facility had an online system for logging maintenance concerns, but no work orders were found for Resident #8's bed. The facility's policy required maintenance issues to be reported and resolved within 72 hours, but this was not adhered to in this case.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a deficiency related to pest infestation. A resident reported that her bed was infested with ants, leading to numerous bites on her arms and legs. The resident, who had moderate cognitive impairment and required total assistance with most activities of daily living, experienced this issue, which was documented in nursing notes. The Director of Nursing (DON) did not report the incident, as they did not consider it significant enough, despite the resident's visible symptoms and the need for medical intervention. Additionally, the facility's kitchen was observed to have multiple gnats in the food preparation, storage, and dishwasher areas. Staff were seen waving their hands to move the gnats while preparing food, indicating an ongoing issue. Interviews with staff revealed that pest control services were conducted once or twice a month, but the problem persisted. The facility's pest control logs and invoices confirmed regular treatments, yet the presence of pests in the kitchen continued, posing a risk of cross-contamination of food.
Failure in PASRR Screening for Mental Illness
Penalty
Summary
The facility failed to ensure that a new resident was not admitted with a mental disorder without the appropriate evaluation by the state mental health authority. Specifically, the Social Worker did not accurately complete the Preadmission Screening and Resident Review (PASRR) Level 1 screening for a resident who had been diagnosed with schizoaffective disorder, schizophrenia, and depression. The resident's Minimum Data Set (MDS) and care plan indicated these diagnoses, yet the PASRR Level 1 screening incorrectly marked 'NO' for the presence of a mental illness. The Social Worker admitted to not reviewing the resident's clinical records prior to admission, which led to the oversight of the resident's schizophrenia diagnosis. This oversight meant that the resident was not referred for a PASRR Level II evaluation, which could have identified the need for specialized services. The facility's policy requires that all residents with a positive PASRR Level 1 screening must have a PASRR Level II evaluation or documented attempts to obtain one, which was not followed in this case.
Neglect in G-Tube Care for Resident
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 associated with enteral feeding. Specifically, the facility did not provide the necessary g-tube care for a resident, as per physician orders. The resident, an elderly female with severe cognitive impairment and a history of dysphagia following a stroke, was observed without a dressing on her g-tube stoma, which had yellow exudate present. Despite the presence of a g-tube, the resident was able to eat and take medications orally, leading to the neglect of g-tube care. The nurse assigned to the resident admitted to not providing the required g-tube care, despite documenting that the care was completed. The nurse, who had been employed for four weeks and was working independently for only the second day, was unaware of the specific orders for g-tube care. This oversight was attributed to the resident's ability to eat by mouth, which led to the g-tube care not being prioritized. The nurse acknowledged the risk of infection due to the lack of g-tube care. Interviews with the ADON and DON revealed that they were unaware of the lapse in g-tube care for the resident. The facility had a system in place for weekly checks of residents' g-tubes, but the ADON could not recall if the resident's g-tube was checked during the last round. Both the ADON and DON emphasized the importance of following physician orders to prevent infections, highlighting a gap in the facility's adherence to its own policies and procedures regarding g-tube care.
Medication Error Due to Distraction
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving a resident who was administered incorrect medications. The resident, a male with severe cognitive impairment and multiple active diagnoses including chronic obstructive pulmonary disease, dysphagia, gastro-esophageal reflux disease, type 2 diabetes mellitus with diabetic neuropathy, and essential hypertension, was supposed to receive Pantoprazole Sodium Delayed Release 40 mg and Tramadol HCl 50 mg. Instead, he was given Alprazolam 0.5 mg and Hydrocodone-Acetaminophen 10-325 mg, which were intended for another resident. The error occurred when LVN A, who was responsible for administering the medications, became distracted by a staff member's question while preparing another resident's medication. This distraction led to the administration of the wrong medications to the resident. The resident was monitored for any adverse reactions, but fortunately, he did not exhibit any side effects or allergic reactions to the medications administered in error. Interviews with the involved staff, including LVN A, the ADON, and the DON, confirmed the occurrence of the medication error. LVN A acknowledged the mistake and reported it immediately to the physician and the DON. The facility's policy on medication administration emphasizes the importance of identifying residents prior to medication administration and documenting each medication order accurately, which was not adhered to in this instance.
Failure to Maintain Comfortable Room Temperature
Penalty
Summary
The facility failed to maintain a comfortable and safe temperature level in a resident's room, which is a violation of the resident's right to a safe, clean, comfortable, and homelike environment. The resident, a male with a history of hypertension, anxiety disorder, and chronic obstructive pulmonary disease, reported that his room had been uncomfortably hot for some time. Despite having a fan, the room temperature remained high, reaching 80 degrees Fahrenheit during an observation. Subsequent checks showed the temperature increased to 82 degrees Fahrenheit. The Maintenance Assistant was informed multiple times by the resident about the malfunctioning air conditioning unit, but the issue persisted. The Maintenance Assistant claimed that the air conditioning unit was functioning properly, as the temperature from the vent was 66 degrees Fahrenheit. However, the room temperature remained high. The Maintenance Director was only made aware of the issue on the day of the survey, and an AC repairman was called to address the problem. The Operations Manager was not informed of the issue until the survey, highlighting a communication breakdown within the facility.
Failure to Document G-Tube Care Accurately
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the documentation of g-tube care. The resident, an elderly female with severe cognitive impairment and a history of dysphagia following a stroke, was observed to have a g-tube for nutritional support. However, the Licensed Vocational Nurse (LVN) assigned to her care did not accurately document the g-tube care as required by the physician's orders. The LVN admitted to not providing the necessary care and falsely documenting that the care was completed. The LVN, who had been employed for four weeks and was working independently for only the second day, was unaware of the specific orders for g-tube care. Despite this, she documented on the Medication Administration Record (MAR) and Treatment Administration Record (TAR) that the care was provided. This discrepancy was discovered during an observation and interview, where it was noted that the g-tube site had yellow exudate and no dressing, although the resident did not report pain or discomfort. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that they were unaware of the lapse in care until it was brought to their attention. Both acknowledged that the failure to accurately document care constitutes falsification of records. The facility's policy requires that medications and treatments be administered only upon clear and complete orders, and that documentation must be accurate, which was not adhered to in this case.
Resident Elopement Due to Inadequate Supervision and Alarm Failure
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision to prevent accidents, resulting in an elopement incident involving a resident. The resident, who had severe cognitive impairment and was identified as an elopement risk, managed to leave the facility undetected. The incident occurred when the resident walked past the nurses' station, took the elevator from the third floor to the first floor, and exited the building. Although the alarm system was functional, it was not heard by the staff, allowing the resident to leave the premises. The resident was found at a gas station approximately a quarter of a mile from the facility by the police and returned unharmed. The resident was unable to verbalize the reason for leaving the facility. Prior to the incident, the resident had not shown any inclination to leave the facility and was able to verbalize his needs and be easily redirected by staff. The resident's care plan had identified him as an elopement risk, but the measures in place were insufficient to prevent the incident. Interviews with staff revealed that the charge nurse was the last to see the resident before the elopement, and the maintenance director confirmed that the alarm system was working but not heard. The facility's failure to prevent the elopement placed residents at risk of harm, serious injury, or death, and the incident was identified as a past non-compliance Immediate Jeopardy situation.
Infection Control Lapse During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a CNA during the care of a resident. The CNA did not change gloves or wash hands after touching the privacy curtain and before providing incontinent care to the resident. Additionally, the CNA failed to sanitize hands between glove changes after cleaning the resident's genitals and buttocks, which is a breach of standard infection control practices. These actions were observed during a specific incident involving a resident with a history of urinary tract infections and other medical conditions, who required extensive assistance with daily living activities. Interviews with the CNA and the Director of Nursing (DON) confirmed the lapses in infection control practices. The CNA acknowledged not changing gloves or washing hands as required, despite having received infection control training within the year. The DON confirmed that staff should change gloves and sanitize hands to prevent contamination and infection. The facility's nurse aide competency checklist indicated the need for hand hygiene and glove changes during perineal care, but there was no specific policy regarding these practices during incontinent care.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate administration of medications for a resident reviewed for medication administration. Specifically, the facility did not administer the prescribed Alprazolam Oral Tablet 0.5 MG to the resident as ordered by the physician. The resident missed several doses of the medication on multiple occasions due to a delay in delivery from the hospice provider and a lack of proper follow-up by the facility staff to ensure the medication was available and administered on time. The resident, who was cognitively intact with a BIMS score of 14, had a history of quadriplegia, muscle weakness, myocardial infarction, schizoaffective disorder, psychotic disorder, major depression, pain, and anxiety. The resident's care plan included administering medications as ordered. However, the resident did not receive his scheduled doses of Alprazolam on 3/21/2024 at 2:00 PM, and on 3/22/2024 at 6:00 AM and 2:00 PM. The facility staff documented that they were in contact with the hospice provider to obtain the medication, but there was a failure in ensuring the medication was delivered and administered in a timely manner. Interviews with facility staff and the hospice nurse revealed that there was a miscommunication and lack of proper coordination between the facility and the hospice provider. The hospice nurse confirmed that their agency had no record of being notified to fill the prescription before the resident ran out of medication. The facility's policy stated that medications should be administered as prescribed by the attending physician, but this was not adhered to in this case, leading to the resident missing critical doses of his anti-anxiety medication.
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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) |
|---|---|---|---|---|
| Meridian Care Monte Vista | 0.2 mi | ★★★★★ | 16 | 1 |
| St. Francis Nursing Home | 0.4 mi | ★★★★★ | 5 | 0 |
| San Antonio North Nursing And Rehabilitation | 0.5 mi | ★★★★★ | 15 | 0 |
| Memorial Medical Nursing Center | 0.6 mi | ★★★★★ | 9 | 0 |
| The Sarah Roberts French Home | 2.2 mi | ★★★★★ | 8 | 0 |
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