Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Schleicher County Medical Center during CMS and state inspections, most recent first.
Improperly Completed OOH-DNR Forms: Three residents had DNR/OOH-DNR paperwork that was not completed correctly. One resident with moderate cognitive impairment, one with severe cognitive impairment, and one hospice resident with severely impaired decision-making all had forms missing required witness information and/or proper physician completion, including NP signatures in place of a physician, missing dates, missing license numbers, and absent witness signatures.
Inaccurate discharge documentation for two residents. Two residents who died in the facility had records that conflicted: the Exit MDS and physician discharge summaries documented death in the facility, but the Transfer/Discharge Reports listed transfer/discharge to a nursing home with the destination unknown/TBD. Interviews with the administrator, ADON, and NC confirmed both residents died in the facility, and the ADON stated nursing staff completed the discharge paperwork and it was scanned into the EMR.
Oxygen cannula not stored in bag and touched with bare hands. A resident with dementia and COPD who required continuous O2 via nasal cannula had her cannula wrapped around the O2 tank on her wheelchair instead of being stored in a plastic bag when not in use. A CNA handled the part that goes into the resident's nose with bare hands and then placed it on the resident's nose. Staff stated the cannula was supposed to be kept in a bag to prevent contamination, and the facility policy required hand hygiene, gloves when in contact with O2 equipment, and keeping delivery devices covered in a plastic bag when not in use.
The facility's kitchen failed to store food items in accordance with professional standards, as observed in the dry storage area where several food items were not sealed properly. The Dietary Manager was unaware of the issue and admitted that opened food should be dated and stored in resealable containers to prevent cross-contamination.
A facility failed to include oxygen therapy in a resident's care plan, despite medical orders indicating its necessity. The resident, with severe cognitive impairment and multiple medical conditions, required maximum assistance for ADLs. The DON acknowledged the oversight, as she had been updating care plans since June.
A facility failed to label and date a vial of Tuberculin medication in the medication room, as observed during an inspection. The vial was found opened and undated, contrary to the facility's policy requiring medications to be labeled with an open date and discarded within 28 days unless specified otherwise. RN A was unaware of the undated vial, and the DON acknowledged the oversight, highlighting the shared responsibility among staff to monitor medication dates.
A resident with a history of stroke and chronic respiratory failure received care from two CNAs who failed to adhere to infection control protocols. CNA B did not change gloves after cleaning the resident's rectal area, and CNA C did not wash her hands before donning gloves. Both CNAs acknowledged their errors, which were against the facility's infection control policies. The facility's infection prevention program aims to prevent infection spread, but these lapses indicate a failure in its execution.
Improperly Completed OOH-DNR Forms
Penalty
Summary
The facility failed to ensure that three residents had properly completed Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) forms. Resident #1 was admitted with diagnoses including Alzheimer's disease, fractures of both legs, diabetes, COPD, seizures, heart problems, and UTIs. Her assessment showed a BIMS score of 8, indicating moderate cognitive impairment. Her care plan and orders reflected DNR status, but the DNR form showed the resident and her legal agent signed, while the notary signed without any witnesses present. The physician's statement was signed by a NP rather than a physician licensed by the Texas Medical Board, and it did not include the date, printed name, or license number. Resident #8 was admitted with dementia and CHF, and her quarterly assessment showed a BIMS score of 3, indicating severe cognitive impairment. Her care plan and medical orders reflected DNR status, but the OOH-DNR form was signed in the physician's statement section by a NP instead of a physician licensed by the Texas Medical Board. That signature also lacked the date and license number, and there was no physician signature in the section acknowledging that the document had been properly completed. Resident #33 was admitted with Alzheimer's disease, high cholesterol, and heart problems, and later had a significant change assessment showing severely impaired decision-making abilities and a life expectancy of less than 6 months. His care plan and physician orders reflected DNR status. The facility DNR form showed the authorized representative signed but did not date the form, the NP signed and dated the physician's statement but did not include a license number, and there were not two qualified witnesses. A nurse's note documented that hospice stated the DNR was not witnessed for the family member's signature and was therefore not valid, so the resident was placed on full code status until a new DNR could be obtained. The hospice OOH-DNR later showed the family member, hospice physician, and notary signatures, but there were no witnesses to the signing.
Inaccurate discharge documentation for two deceased residents
Penalty
Summary
The facility failed to ensure that medical records were accurately documented for 2 residents reviewed for record accuracy. Resident #33 was admitted with diagnoses including Alzheimer's disease, high cholesterol, and heart problems, and later died in the facility. Although the nurse's note documented that the resident was found unresponsive, without respirations or pulse, with dilated and fixed pupils, cold skin, and generalized cyanosis, the Exit MDS documented a death in facility while the Transfer/Discharge Report stated the resident was transferred/discharged to a nursing home, with the destination listed as unknown/TBD. The physician's discharge summary also documented that the resident died in the facility. Resident #34 was admitted with diagnoses including cerebral infarction, chronic kidney disease, and vascular dementia, and later died in the facility. The Exit MDS documented a death in facility, the Record of Death listed the time of death as 10:32 AM, and the physician's discharge summary documented that the resident died in the facility. However, the Transfer/Discharge Report completed for the resident stated the resident was transferred/discharged to a nursing home, with the destination listed as unknown/TBD. Interviews with the administrator, ADON, and NC confirmed both residents died in the facility, and the ADON stated the discharge summary and transfer/discharge documentation were completed by nursing staff and scanned into the electronic medical record.
Oxygen Cannula Not Stored in Bag and Touched With Bare Hands
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 1 of 4 residents reviewed for infection control. Resident #21 was admitted with diagnoses including dementia and COPD, had a BIMS score of 3 indicating severe impairment, and required continuous oxygen at 1-2 LPM via nasal cannula. Her care plan identified her as at risk for impaired gas exchange related to COPD, hypoxemia, and cough, and her MDS indicated she was dependent for upper extremity range of motion and received oxygen therapy. During an observation and interview, CNA A assisted Resident #21 to her wheelchair and the resident's oxygen nasal cannula tube was seen wrapped around the oxygen tank attached to the wheelchair. CNA A took the nasal cannula with her bare hands, touched the part that goes into the resident's nasal area, and then placed it on the resident's nose. CNA A stated the resident was not able to remove the oxygen nasal cannula and tube by herself and that another staff member must have removed it and placed it on the oxygen tank. CNA A also stated she had not noticed a storage bag on the tank for the oxygen nasal cannula tube. Resident #21 stated she did not remove the nasal cannula from her nose because she was unable to do so and that staff were the ones who would do that and store it in the storage bag. CNA A later stated that not having a bag to store the oxygen nasal cannula tube could lead to contamination and possibly introduce bacteria into the resident's nose. RN B and the ADON stated the oxygen nasal cannula tube was supposed to be stored in a plastic bag when not in use to prevent contamination, and the Administrator stated staff were expected to store it in a bag when not in use. The facility's oxygen administration policy stated staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment, and that delivery devices should be kept covered in a plastic bag when not in use.
Improper Food Storage in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety in its only kitchen, specifically in the dry storage area. During observations on two consecutive days, it was noted that several food items, including a bag of southern yellow cornbread, Tostitos original tortilla chips, cereal, and spaghetti pasta, were not sealed properly. The Dietary Manager (DM) was unaware of the improperly stored food and admitted that these items had been recently used, but he did not know how long they had been open. The DM acknowledged that all opened food items should be dated and stored in resealable containers to prevent cross-contamination, as per the facility's undated policy on food safety requirements.
Failure to Include Oxygen Therapy in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, specifically regarding the use of oxygen therapy. The resident, an elderly male with severe cognitive impairment and multiple medical diagnoses including palliative care and cerebral infarction, was admitted to the facility and required maximum assistance for activities of daily living. Despite the resident's need for oxygen therapy as indicated in his medical orders, the care plan did not include any provisions for oxygen use. The deficiency was identified during a review of the resident's records, which showed an absence of a care plan addressing oxygen therapy, despite the resident's medical orders specifying its use. The Director of Nursing (DON) acknowledged the oversight, noting that she had been working on care plans since taking over in June, as the MDS nurse was no longer handling them. The care plan was subsequently updated after the surveyor's intervention.
Failure to Label and Date Medication Vials
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles, as observed in the medication room. During an inspection, a vial of Tuberculin (TB) medication was found opened and undated in the refrigerator. The vial's label indicated that it should be discarded 30 days after being opened. RN A, who was present during the inspection, stated that it was each nurse's responsibility to date the vials when they are opened. However, RN A was unaware that the vial was undated. The Director of Nursing (DON) was informed of the undated TB vial and expressed uncertainty as to why it was not dated. The DON emphasized that it was the responsibility of all staff to monitor medications requiring an open date and ensure they are discarded when expired. The facility's policy on medication storage mandates that all medications, including multi-dose vials, should be labeled with an open date and discarded within 28 days unless specified otherwise by the manufacturer. The failure to date the TB vial could potentially lead to the use of expired medication, resulting in false TB test results.
Infection Control Deficiency During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during the care of a resident. The resident, who was admitted with diagnoses of stroke and chronic respiratory failure, was observed receiving incontinent care from the CNAs. During this care, CNA B did not change her gloves after cleaning the resident's rectal area and before applying ointment and handling a new brief, which could lead to cross-contamination. CNA C also failed to wash her hands before putting on gloves and assisting with personal care. The CNAs' actions were contrary to the facility's policies on hand hygiene and infection control, which require changing gloves when moving from dirty to clean tasks and washing hands for at least 20 seconds with soap and water. Both CNAs acknowledged their mistakes during interviews, attributing their lapses to nervousness and forgetting the proper steps. The Director of Nursing and LVN D confirmed that the CNAs had been trained on these procedures and reiterated the importance of following them to prevent the spread of infections. The facility's policies emphasize the importance of hand hygiene and proper glove use as part of standard precautions to prevent infection transmission. Despite this, the CNAs did not adhere to these protocols during the observed care, potentially placing residents at risk for cross-contamination and infection spread. The facility's infection prevention and control program is designed to provide a safe and sanitary environment, but the observed deficiencies indicate a failure in its implementation during this incident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Eldorado
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At San Angelo | 37.3 mi | ★★★★★ | 19 | 0 |
| Crockett County Care Center | 38.4 mi | ★★★★★ | 0 | 0 |
| St. Juanita Retirement And Rehab | 38.5 mi | — | 6 | 0 |
| Avir At Meadow Creek | 38.6 mi | ★★★★★ | 8 | 0 |
| Regency House | 38.7 mi | ★★★★★ | 6 | 0 |
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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 October 2026) and official state health department websites.