Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
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 Sonterra Health Center during CMS and state inspections, most recent first.
Care plans for three residents were not kept current with their assessed needs. One resident’s plan still listed Cephalexin even though the medication had been stopped, another resident’s ADL assistance levels were not updated to match the MDS and staff-confirmed maximal assistance needs, and a third resident’s plan did not include leg contractures that staff said affected turning, repositioning, and pain management.
Kitchen staff failed to follow food safety standards during food storage and preparation. An ice scoop was stored inside the ice machine, a reach-in refrigerator temperature log showed an out-of-range reading, cabbage with a black substance was stored in the kitchen, a personal beverage was placed in front of disposable plates, and a dietary aide prepared food while wearing a necklace and hoop earrings.
The facility failed to maintain current hospice POCs for two residents receiving hospice services. One resident had terminal bronchiectasis with severe cognitive impairment, and the other had Parkinson’s disease with moderate cognitive impairment. Although hospice orders, visit notes, and other hospice paperwork were present, the current hospice POC was missing from both the hospice binder and the EMR, and staff and hospice nurses were unsure who was responsible for providing or maintaining the document.
A resident admitted with neurogenic bladder and an indwelling urinary catheter did not have a physician order for catheter care at admission, even though the care plan called for catheter care every shift and as needed. The DON said the order should have been entered on admission but was missed, and the MDS C nurse said the daily interdisciplinary review should have caught it. Staff reported they had been providing catheter care, but no active order was in place.
MDS Nutritional Coding Errors: Two residents had inaccurate MDS nutrition coding. One resident with COPD and dysphagia had a discharge MDS that omitted tube feeding despite active PEG tube feeding orders, and another resident with dementia, DM2, and dysphagia had a quarterly MDS that omitted an active LCS therapeutic diet. Staff later stated the nutritional approaches appeared to have been missed and that the diet should have been coded as therapeutic.
A resident admitted with urinary retention had an indwelling urinary catheter ordered and present, but the initial baseline care plan did not include the catheter. The DON and MDS C nurse acknowledged the catheter should have been in the care plan, and the facility policy required a baseline care plan within 48 hours of admission with instructions for effective, person-centered care.
A resident with type 2 DM, generalized weakness, chronic pain syndrome, and a stage 2 coccyx pressure wound did not have an active EBP order in the chart, and no EBP signage was posted outside or inside the room. During wound care, the nurse used PPE, and interviews with the LVN, DON, wound care LVN, and Infection Preventionist ADON confirmed the missing order and signage for the resident’s open wound.
Medications Left at Bedside Without Direct Observation: A resident with multiple chronic conditions, including dementia, was found with a cup of pills and a cup of powder on the bedside table instead of having the meds directly observed as swallowed. The resident said the med aide left the meds after he said he wanted to sleep and would take them later. An LPN and the DON stated meds were not to be left at the bedside and that no residents were approved for self-administration; the med aide said she left them because she thought he would take them when ready.
Unlocked Medication Cart Left Unattended: The 300 hall med cart was observed unlocked and unattended by the workstation, with the drawers facing the hallway and no nurse in sight. Two residents were nearby, and a CNA walked past the cart. RN A later stated she had removed a med, went to a resident room, and forgot to lock the cart. The DON and ED stated med carts must be locked when unattended, and the facility policy required meds to be stored in locked compartments.
The facility did not consistently conduct timely and comprehensive care plan reviews for two residents, missing several required quarterly reviews and failing to ensure the participation of residents and their representatives. The Director of Social Services acknowledged missed meetings due to lack of a formal schedule, and staff interviews confirmed that care plan meetings were not held regularly, despite the facility's policy assigning responsibility for scheduling to the MDS Coordinator.
A resident with cognitive impairment and risk factors for skin breakdown did not have weekly skin assessments documented as required by facility policy. Although the MAR indicated assessments were completed, actual documentation was missing for most weeks, and staff interviews confirmed the assessments were not consistently performed or recorded.
A resident with diabetes was not administered prescribed insulin for two days, leading to hospitalization for Diabetic Ketoacidosis. The facility failed to transcribe hospital discharge orders into the electronic medical record, resulting in a significant medication error. Staff interviews revealed that the admitting nurse may have missed a page of the orders, and the oversight was discovered when the resident felt unwell.
A resident with diabetes and other health conditions experienced a medication error when insulin orders were not transcribed, leading to hyperglycemia and hospitalization. The facility failed to report this neglect to the State Survey Agency as required by policy.
A medication security lapse occurred when a blister package of Tamulosin HCL was left unattended on a medication cart in the 400 hall. The medication, prescribed for a resident with Benign Prostatic Hypertrophy, was accessible to anyone passing by, as the cart was left at the end of the hall without a nurse in sight. RN A admitted the oversight, and both the DON and Administrator confirmed that medications should be stored securely inside the cart or medication room, as per facility policy.
Two residents with cognitive impairments and dysphagia were not provided with the necessary assistance during meals as outlined in their care plans. One resident was left unsupervised and choked, resulting in death, while another was observed eating unassisted despite requiring substantial help. Staff interviews revealed a lack of familiarity with care plans, leading to inconsistent care and placing residents at risk.
A resident with a history of dementia and dysphagia was left unsupervised during a meal, leading to choking and subsequent death. Despite requiring assistance with eating, the resident was found in distress with a piece of broccoli obstructing his airway. Staff interviews revealed confusion about supervision protocols, contributing to the incident.
The facility did not post daily nurse staffing information as required, with observations revealing outdated postings. The responsibility for updating this information was not delegated during the scheduling coordinator's absence, leading to a lack of accessible staffing data for residents and visitors.
The facility failed to secure medication carts, leaving them unlocked and unsupervised, with approximately 450 pills exposed. An LVN admitted to leaving the carts unattended due to workload. The ADON and Administrator acknowledged the risk of potential harm to residents from unsecured medications, which violated the facility's policy.
The facility failed to label sandwiches with preparation and expiration dates, as observed during a survey. A sandwich was found unmarked on a snack cart, and a CNA confirmed it was unsafe to serve without labeling. The Food Service Manager stated that all snacks should be labeled, aligning with the facility's policy and FDA guidelines.
The facility failed to ensure accurate MDS assessments for five residents, leading to deficiencies in their care plans. Errors included not reflecting hospice services, incorrect documentation of pressure sores, and inaccurate bowel and bladder incontinence status. Both MDS staff and the DON acknowledged the importance of accurate assessments for proper care.
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in their care. One resident's fall prevention measures were not properly implemented, another resident's incontinence was not accurately reflected in the care plan, and a third resident's hospice status was not included in the care plan.
The facility failed to ensure RN coverage for at least 8 consecutive hours a day, 7 days a week, as required. Interviews and record reviews revealed multiple days without RN coverage between November and December 2023. The DON and scheduler could not provide evidence of RN coverage on the specified dates, leading to the deficiency report.
The facility failed to store, prepare, distribute, and serve food safely. Insulated plate lids and bases were not air-dried, leading to potential cross-contamination. Additionally, a cook tasted food with a bare finger and continued using the same equipment, risking contamination.
A resident's care plan was not updated to reflect his NAS regular texture diet, despite active orders and meal tickets indicating this diet. The discrepancy between the care plan and the resident's actual dietary needs was confirmed by staff, potentially affecting the resident's quality of life.
The facility failed to provide proper incontinent care for a resident, as CNA C did not return the foreskin to its original position after cleaning. Both CNAs involved acknowledged their mistake despite being trained to reposition the foreskin. The resident's care plan did not reflect his incontinence, and the DON confirmed the importance of proper care to prevent complications.
Care Plans Not Updated to Reflect Current Resident Needs
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans that reflected the residents’ current needs for 3 of 8 residents reviewed. The report states that the facility did not ensure care plans included measurable objectives and timeframes consistent with the comprehensive assessment for Resident #3, Resident #4, and Resident #14. The facility’s policy required the interdisciplinary team to develop a comprehensive person-centered care plan for each resident based on identified medical, nursing, mental, and psychosocial needs. Resident #4’s care plan included a focus for risk for infection related to recurring UTI and listed Cephalexin Oral Tablet 250 mg as an intervention, but the order summary report did not show an active order for Cephalexin. During interview, staff stated the resident was no longer taking Cephalexin and that it should have been removed from the care plan because it no longer reflected the resident’s current orders. Resident #4 had a diagnosis of UTI and a BIMS score of 6, indicating severe cognitive impairment. Resident #3’s care plan listed ADL interventions for toileting hygiene, upper body dressing, and putting on/taking off footwear as supervision, but the MDS showed the resident required substantial/maximal assistance for those tasks. Staff confirmed the resident needed maximal assistance with toileting, dressing, and shoes, and stated the care plan was not updated to reflect the current level of assistance. Resident #14’s care plan did not reflect that she had contractures of the legs, although staff confirmed the condition and stated it affected how she needed to be turned, repositioned, and assisted with pain management. Resident #14 had a UTI diagnosis and a BIMS score of 15, indicating intact cognition.
Kitchen Food Storage and Food Handling Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During observation and interview on 07/07/2026, an ice scoop was hanging on a hook on the right-hand side of the interior of the ice machine. Record review of the July 2026 refrigerator temperature log for the reach-in refrigerator next to a food preparation area showed an evening temperature of 42 degrees Fahrenheit on 07/01/2026, signed by the CDM. The CDM stated she documented that temperature because 42 degrees was not safe, and said the plug had been out for an unknown length of time, while the morning temperature that same day was 34 degrees Fahrenheit. The kitchen also had a cabbage with a black substance on it stored in a cardboard box on a shelf beneath a food preparation tabletop and about 6 inches above the floor. A personal beverage was observed in front of a stack of disposable plates. During observation on 07/08/2026, Dietary Aide F was preparing food while wearing a chained necklace laying on top of her shirt and small hoop earrings. The CDM stated the necklace was acceptable as long as it was not long, and later stated she did not know what the black substance on the cabbage was but threw it out so no resident could get sick. Staff interviews also reflected that personal beverages should not be stored in the kitchen or storage area because they could cause contamination.
Missing Current Hospice Care Plans for Two Residents
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for two residents receiving hospice services, because the current hospice plan of care was not maintained in the facility records for either resident. For one resident, the record showed diagnoses including acute and chronic respiratory failure with hypoxia and bronchiectasis, severe cognitive impairment on MDS, and hospice enrollment for terminal bronchiectasis. The resident’s hospice binder contained prior hospice plans of care and related forms, but the binder did not include a plan of care for the current certification period. The electronic record also contained hospice visit notes and hospice orders, but no current hospice plan of care was present until the hospice nurse later provided one during the survey. For the second resident, the record showed diagnoses including encephalopathy, acute bronchitis, and Parkinson’s disease, with moderate cognitive impairment on MDS and hospice enrollment for Parkinson’s disease. The resident’s hospice folder contained a delineation of duties document, a palliative care form, DNR paperwork, and other hospice-related documents, but it did not include a plan of care for the current certification period. The electronic record likewise contained hospice orders and admission orders, but no hospice plan of care was present in the chart during the survey review. Interviews with hospice nurses and facility staff showed uncertainty about who was responsible for providing or maintaining the current hospice care plan documentation. One hospice nurse stated she was unsure who was responsible for bringing the current hospice care plan and later provided a current document during the survey. Another hospice nurse stated she was unsure whether the facility had a copy of the hospice care plan and did not know if it had been requested. Facility leadership stated staff checked hospice documentation regularly and believed frequent communication with hospice staff kept them updated on orders and treatment, but the current hospice plan of care was not maintained in the records for either resident.
Missing Physician Order for Catheter Care
Penalty
Summary
The facility failed to ensure that Resident #29 had physician orders in place for immediate care at the time of admission. Resident #29 was a male admitted with a diagnosis of reflex neuropathic bladder, and the MDS assessment documented that he had an indwelling catheter. The physician orders included an order for a 16Fr catheter connected to a closed urinary drainage system for neurogenic bladder, but no order was present for catheter care. The resident’s baseline care plan identified that he had an indwelling catheter related to neurogenic bladder and included an intervention to provide catheter care every shift and as needed. During interview, the resident stated staff had been providing care for the catheter, and observation confirmed he had an indwelling urinary catheter. The DON stated catheter care should have been ordered upon admission and that the order was missed for unknown reasons. The MDS C nurse stated the interdisciplinary team reviews orders daily and should have caught the missing order, while an LVN and CNA stated they had been providing catheter care and were not aware there was no active order for it.
MDS Nutritional Coding Errors
Penalty
Summary
The facility failed to ensure Resident #126’s Discharge Return Anticipated MDS assessment accurately reflected her nutritional status. Resident #126 was a female admitted to the facility and later discharged on 04/13/2026. Her diagnoses included COPD, acute respiratory failure with hypoxia, and dysphagia. On the discharge MDS, Section K showed she received a mechanically altered diet while a resident, but she was not coded as having received tube feeding while a resident, even though the order summary showed active orders for continuous tube feeding via PEG and a PEG feeding tube related to dysphagia during the assessment period. The facility also failed to accurately code Resident #64’s Quarterly MDS assessment for nutritional approaches. Resident #64 was a female with diagnoses including dementia, type 2 diabetes mellitus, and dysphagia. Her Quarterly MDS showed she had a BIMS score of 14 and indicated she received none of the listed nutritional approaches while a resident, with therapeutic diet not selected. However, the order summary showed an active LCS diet with regular texture, thin liquids, and scoop dish with meals during the assessment period, which staff stated should have been considered a therapeutic diet. During interviews, staff stated the nutritional approaches appeared to have been missed on both assessments. LPN C stated she would review the resident order listing when completing Section K and later acknowledged that Resident #126’s feeding tube should have been checked and that Resident #64’s LCS diet should have been coded as a therapeutic diet. LPN K stated the missed coding could affect reimbursement and might impact the care plan when updated. The DON and ADM stated they did not believe the coding errors impacted either resident’s care, but acknowledged the errors might affect reimbursement and future care plan triggers.
Baseline Care Plan Missing Indwelling Urinary Catheter
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care for Resident #133. Resident #133 was a 73-year-old male admitted with a diagnosis of urinary retention, and physician orders dated 07/03/2026 included a 16Fr catheter to a closed urinary drainage system. The resident’s 5-day MDS assessment was still in progress because he had recently been admitted, and observation on 07/08/2026 confirmed that he had an indwelling urinary catheter. Record review of the baseline care plan dated 07/04/2026 showed that the indwelling urinary catheter was not included. During interview, the resident stated he had a urinary catheter and staff had been providing care for it. The DON stated the catheter was not identified in the initial care plan and that accurate care plans are important so staff know what care the patient requires. The MDS C nurse also stated the catheter should have been included in the initial care plan and did not know why it was not. The facility policy stated that within 48 hours of admission, the facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care.
Missing EBP Order and Room Signage for Resident with Pressure Wound
Penalty
Summary
The facility failed to maintain an infection prevention and control program for Resident #21, who was admitted with diagnoses including type 2 diabetes mellitus, generalized muscle weakness, and chronic pain syndrome and had a BIMS score of 8 indicating moderately impaired cognition. Record review showed the resident had a new stage II pressure wound to the coccyx, and the physician orders included wound treatment for the coccyx wound, but there was no order for Enhanced Barrier Precautions (EBP). The care plan, dated 06/09/2026, identified the resident’s stage 2 pressure ulcer to the coccyx related to immobility and included the intervention to use EBP. During observation of wound care, the wound care nurse donned PPE when entering the room, but there was no signage outside or inside the resident’s room indicating the need for PPE. Interviews with the LVN, DON, wound care LVN, and Infection Preventionist ADON confirmed that the resident had an open pressure wound and should have had an EBP order and signage posted, and the DON stated she was aware that both were missing. The facility policy described EBP as the use of gown and gloves during high-contact resident care activities for residents with wounds and indwelling medical devices.
Medications Left at Bedside Without Direct Observation
Penalty
Summary
The facility failed to ensure medications were not left at the bedside and were administered under proper supervision for one resident who was cognitively intact and had diagnoses including diabetes, dementia, hypertension, depression, benign prostatic hyperplasia, and pain. The resident’s medication orders included multiple daily oral medications such as Aricept, aspirin, docusate calcium, Flomax, losartan, Metamucil, a multivitamin, Myrbetriq, venlafaxine, and Lyrica, with several scheduled for 7:00 a.m. administration. During observation, the resident was found sitting in his room with one medication cup containing several pills and another medication cup containing tan powder on the bedside table in front of him. During interview, the resident stated nursing staff provided his medications and that he was not allowed to keep medications at the bedside because he might misuse them. He stated the powder was for constipation and the pills were his morning medications, and that the medication aide had left them there after he said he wanted to sleep and would take them later. LVN A observed the medication cups on the bedside table and stated she would discard them and dispense a new set of medications. She also stated residents were not allowed to keep medications at the bedside and that residents who self-administered medications required a physician order and care plan. The DON stated medications could not be left at the resident’s bedside and that nursing staff were supposed to stay and watch the resident consume the medications. The DON further stated there were no residents in the facility who could self-administer medications, and that self-administration would require assessment, physician notification, an order, and care planning. Medication Aide B stated she left the medications on the bedside table because she thought the resident would take them when ready, but she did not stay to observe ingestion and did not report the resident’s refusal to LVN A at the time. Facility policy stated the person administering medication must remain with the resident until all medication has been swallowed, and medications must be stored in locked compartments accessible only to authorized personnel.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with State and Federal laws for 1 of 4 medication carts reviewed, specifically the 300 hall medication cart. During an observation on 06/07/2026 from 8:58 a.m. to 9:01 a.m., the 300 hall medication cart was found unlocked and unattended by the workstation, with the lock sticking out in the fullest position. The drawers faced the hallway, anyone walking by could open them, and there was no nurse within sight of the cart. Two residents were sitting in wheelchairs about 6 feet away, and a CNA walked by the cart while pushing a meal cart down the hallway. During the observation and interview at 9:02 a.m., RN A approached the cart after the surveyor opened the top drawer and asked if it was locked; RN A stated it was not. RN A later stated she had removed a medication from the cart, went to a resident's room, and forgot to lock it before walking away, adding that she knew better and had been doing this long enough to know it needed to be locked. The DON stated that if the cart was out of sight, it needed to be locked, that anyone could get into it if it was unlocked and unattended, and that it needed to always be locked. The Executive Director stated the carts should be locked when unattended and that staff received training on ensuring the cart was locked when unattended. The facility policy stated drugs were to be stored in locked compartments and that medication carts were to be locked or attended by authorized persons.
Failure to Conduct Timely and Comprehensive Care Plan Reviews
Penalty
Summary
The facility failed to prepare and maintain comprehensive care plans for two residents, as required. Specifically, the care plans were not reviewed and revised quarterly following each assessment, and the participation of the residents and their representatives was not consistently included to the extent practicable. For one resident with severe cognitive impairment and a history of muscle wasting, urinary tract infections, and mild cognitive impairment, quarterly care plan reviews were missed in two out of five required periods. For another resident with epilepsy, a history of falls, and hypertensive heart disease, three out of six quarterly care plan reviews were missed. Interviews revealed that the residents' representatives were not regularly involved in care plan meetings, with one stating she could not recall recent participation and another having to request a meeting. The Director of Social Services acknowledged that care plan review meetings were missed and attributed this to a lack of a formal schedule, stating that she was attempting to catch up on overdue assessments. The facility's policy indicated that the MDS Coordinator was responsible for scheduling and preparing the care plan meeting calendar, but no updated policy on regular care plan meetings was provided upon request. The DON and Administrator confirmed that issues with the regularity of care plan meetings had been identified previously. Documentation showed that the facility had discussed care plan meeting processes in a QAPI meeting, but gaps in care plan reviews persisted for the residents involved.
Failure to Document Weekly Skin Assessments per Facility Policy
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with professional standards for one resident reviewed for record accuracy. Specifically, the facility did not ensure that weekly skin evaluations were documented as required by facility policy for six out of seven weeks during a specified period. Although the Medication Administration Record (MAR) indicated that weekly skin evaluations were marked as completed, a review of the actual assessment documentation revealed that these evaluations were not performed or recorded for the majority of the required dates. Interviews with nursing staff and the Director of Nursing (DON) confirmed that weekly skin assessments were not conducted or documented during the months in question. The resident involved was an elderly female with a history of muscle wasting, urinary tract infections, and mild cognitive impairment, and was identified as being at risk for pressure ulcer development. The resident's care plan included interventions for monitoring skin integrity, and facility policy required weekly skin and wound assessments by a licensed nurse. Despite these requirements, the necessary documentation was missing, and staff interviews indicated a lack of consistent practice and understanding regarding the completion and documentation of weekly skin assessments.
Failure to Administer Insulin Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of insulin. The resident, a male with a history of diabetes type 1, renal dialysis dependence, and hypertension, was not administered his prescribed insulin medications, Touch U-200 and Novo Log, for two days. This lapse occurred from March 12 to March 14, 2025, leading to the resident being sent to the hospital and diagnosed with Diabetic Ketoacidosis, a serious complication of diabetes. The deficiency was identified through a review of the resident's medical records and interviews with facility staff. The resident's hospital discharge instructions included orders for insulin administration, which were not transcribed into the facility's electronic medical record system. This oversight was discovered when the resident expressed feeling unwell, prompting a family member to inquire about the insulin administration. The Licensed Vocational Nurse (LVN) on duty confirmed the omission and reported it to the Assistant Director of Nursing (ADON). Interviews with the facility's nursing staff revealed that the admitting nurse may have missed a page of the admission orders, leading to the medication error. The ADON and Director of Nursing (DON) acknowledged the failure to transcribe the insulin orders and emphasized the importance of following policy and procedure regarding medication administration. The Medical Director was informed of the missed insulin orders but was not initially concerned due to the long-acting nature of the insulin. However, the failure to administer the insulin as prescribed placed the resident at risk for severe health complications.
Failure to Report Medication Error and Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the State Survey Agency as required by their policy. This incident involved a medication error where a resident's insulin orders were not transcribed, leading to the resident experiencing hyperglycemia and being sent to the emergency room for evaluation. The resident, who was dependent on renal dialysis and had diabetes and hypertension, was admitted to the hospital with diabetic ketoacidosis, a serious complication of diabetes. Interviews and record reviews revealed that the Licensed Vocational Nurse (LVN) discovered the error after the resident expressed feeling unwell and a family member inquired about the insulin administration. The Assistant Director of Nursing (ADON) was informed but did not report the incident to the State Survey Agency. The Director of Nursing (DON) and the Administrator were also aware of the incident but did not report it, believing the issue was corrected. However, upon reviewing the neglect guidelines, the Administrator acknowledged the need to report the incident.
Medication Security Lapse on 400 Hall
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, as observed with the 400 hall medication cart. A blister package of Tamulosin HCL, prescribed for a resident with Benign Prostatic Hypertrophy, was found on top of the medication cart, unattended. The cart was located at the end of the hall with no nurse in sight, allowing anyone passing by to potentially access the medication. This oversight was acknowledged by RN A, who admitted the medication should have been secured in the cart but was left out due to a hectic night. Interviews with the Director of Nursing (DON) and the Administrator confirmed that medications should be stored inside the medication cart or in the medication room, not left on top of the cart. Both emphasized the responsibility of the nursing staff, particularly the nurse with the keys, to ensure medications are secured. The facility's Medication Access and Storage Policy mandates that all drugs and biologicals be stored in locked compartments, accessible only to authorized personnel. The failure to adhere to this policy was evident in the incident involving the 400 hall medication cart.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for two residents, leading to significant deficiencies in their care. Resident #1, who had a history of dementia, dysphagia, and other cognitive impairments, required assistance with eating as per his care plan. However, on the evening of the incident, he was left unsupervised in his room during a meal, resulting in a choking incident. Despite efforts by staff to assist him, including performing the Heimlich maneuver and calling emergency services, Resident #1 was pronounced deceased at the facility. Resident #2, who had severe cognitive impairment and dysphagia, also required assistance with eating according to her care plan. Observations revealed that she was left to eat unassisted on multiple occasions, despite her care plan indicating she needed substantial assistance. Staff interviews indicated a lack of awareness and understanding of the care plans, with some staff members not knowing how to access or interpret the care plans and Kardex, leading to inconsistent care. The deficiencies in care for both residents were compounded by a lack of communication and training among staff regarding the residents' care plans. Interviews with staff revealed that many were not familiar with the care plans or the requirement to review them, resulting in inadequate supervision and assistance during meals. This failure to adhere to the care plans placed residents at risk for weight loss, malnutrition, and dehydration.
Inadequate Supervision During Meal Leads to Resident's Death
Penalty
Summary
The facility failed to ensure adequate supervision for a resident during the evening meal, leading to a tragic incident. The resident, who had a history of dementia, dysphagia, and other conditions affecting swallowing and coordination, was left unsupervised in his room. Despite requiring assistance with eating, the resident was found choking and later pronounced deceased. Staff interviews revealed confusion and inconsistency regarding the supervision requirements for residents needing assistance with meals. The resident's care plan and assessments indicated a need for staff assistance with eating due to risks of aspiration and difficulty swallowing. However, during the incident, the resident was left alone, and staff were not immediately available to provide the necessary assistance. The resident was found in distress, with secretions and a piece of broccoli obstructing his airway. Despite efforts to clear the obstruction and provide emergency care, the resident did not survive. Interviews with staff highlighted a lack of clear communication and understanding of the facility's protocols for supervising residents during meals. Some staff believed they could leave the resident unattended if they only required assistance, while others understood that constant supervision was necessary. This inconsistency contributed to the failure to provide the required supervision, ultimately leading to the resident's death.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information, which is a requirement to ensure transparency and accessibility of staffing data to residents and visitors. During an observation, it was noted that the facility's Daily Nursing Care Hours posting was outdated, displaying information from two days prior. This deficiency was confirmed through interviews with the Assistant Director of Nursing (ADON) and the Administrator, who acknowledged that the posting should be updated daily. The Administrator further explained that the responsibility for generating and posting this information fell to CNA D, the scheduling coordinator, who did not delegate the task during their scheduled time off. The facility's policy, dated May 2007, mandates that nurse staffing data be posted daily in a clear and readable format in a prominent location accessible to residents and visitors. The failure to adhere to this policy was attributed to a lack of coordination in the staffing process, particularly when the designated staff member was unavailable. This oversight could potentially deny residents and visitors access to important staffing information, as the data was not updated as required.
Unsecured Medication Carts in Facility
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by their policy. During an observation, it was noted that the 100-hall medication aide cart, the nurse medication cart, and the treatment cart were left unlocked and unsupervised. These carts were positioned at the end of the 100-hall, out of the line of sight of the nurse, LVN A, who was seated at the nurses' station documenting at the computer. One of the medication carts had approximately 15 medication cards on top, each containing about 30 pills, totaling an estimated 450 pills, which were unsecured. Interviews with LVN A, the Assistant Director of Nursing (ADON), and the Administrator confirmed that the medication carts should have been locked whenever unattended. LVN A admitted to the bad habit of leaving the carts unlocked due to having responsibilities for two halls. The ADON and the Administrator both acknowledged the risk of potential harm to residents due to unsecured and uncontrolled medications. A review of the facility's Medication Access and Storage policy from May 2007 reiterated that all drugs and biologicals should be stored in locked compartments, accessible only to authorized personnel.
Failure to Label Prepared Food Items
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not labeling sandwiches with preparation and expiration dates. During an observation, a sandwich was found wrapped in clear plastic cling wrap and stored at room temperature on a snack cart without any labeling. This lack of labeling was confirmed by a CNA, who stated that the sandwich was not safe to serve due to the absence of information regarding its preparation date and expiration. The Food Service Manager acknowledged that all snacks prepared by the kitchen should have been labeled with the date of preparation and the date by which they should no longer be served. A review of the facility's Food Preparation and Storage policy indicated that food items should be properly dated and labeled, and any unmarked or unlabeled foods should be discarded after three days. The United States Food and Drug Administration's 2022 Food Code also requires that ready-to-eat, time/temperature control for safety food prepared and held for more than 24 hours be clearly marked with a date to ensure safety.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate assessments for five residents, leading to deficiencies in their care plans. Resident #6's quarterly MDS assessment did not reflect that the resident was receiving hospice services, despite physician orders and a comprehensive care plan indicating hospice care. Similarly, Resident #17's significant change MDS assessment failed to document hospice services, even though the resident had been receiving hospice care since early March. Both MDS A and MDS B acknowledged the errors and emphasized the importance of accurate coding to trigger appropriate care plans. Resident #19's quarterly MDS assessment inaccurately reflected her pressure sore status, interventions, and treatments, despite having a Stage 3 pressure sore with documented interventions and treatments. The MDS assessment failed to capture these critical details, which are essential for guiding and communicating care needs to staff. MDS A admitted to not knowing how these details were missed, and the DON highlighted the importance of accurate MDS assessments for ensuring proper care. Resident #53's quarterly MDS assessment inaccurately documented bowel and bladder incontinence, stating the resident was frequently incontinent when he was always incontinent. Observations and interviews confirmed the resident's total dependence on bowel and bladder care. Similarly, Resident #67's admission MDS assessment incorrectly marked him as always incontinent of bladder instead of not rated due to an indwelling urinary catheter. Both MDS A and the DON acknowledged the inaccuracies and stressed the need for accurate MDS assessments to reflect the residents' conditions and guide their care plans effectively.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents, leading to deficiencies in their care. Resident #19, who had a history of falls and was severely cognitively impaired, required a floor mat beside her bed as a fall prevention measure. However, observations revealed that the floor mat was not properly placed, and staff were unaware of its incorrect placement, potentially putting the resident at risk of falls. Interviews with the CNA and DON confirmed the oversight and the importance of the intervention for the resident's safety. Resident #53, who was cognitively intact but frequently incontinent of bowel and bladder, did not have his incontinence accurately reflected in his comprehensive care plan. Despite being dependent on bowel and bladder care, his care plan only mentioned the need for assistance with toilet use. Observations and interviews with the resident and staff confirmed that he was always incontinent and did not use the toilet, urinal, or bedpan, highlighting a significant gap in his care plan. Resident #127, who was moderately cognitively impaired and dependent on staff for ADLs, was admitted to hospice services with a terminal diagnosis of cardiovascular accident. However, his comprehensive care plan did not reflect his hospice status. Interviews with the MDS coordinator and DON confirmed that the care plan should have been updated to include hospice services, emphasizing the importance of accurate care plans for effective communication and care delivery.
Failure to Ensure RN Coverage for 8 Hours Daily
Penalty
Summary
The facility failed to ensure the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified through interviews and record reviews, which revealed that there was no RN coverage for 8 hours on multiple days between November 4, 2023, and December 15, 2023. Specifically, the facility lacked RN coverage on 11/04/23, 11/05/23, 11/18/23, 11/19/23, 11/25/23, 11/26/23, 12/07/23, and 12/15/23. The Director of Nursing (DON) confirmed the absence of RN coverage on these dates and stated that the facility had a scheduler responsible for ensuring RN coverage. However, the scheduler did not provide evidence of RN coverage on the specified dates. Interviews with the DON and the scheduler revealed that the DON worked Monday to Friday for 8 hours a day and covered weekends if RN hours were not covered. The DON was also on-call when there was no RN on duty. The scheduler, a Certified Nursing Assistant (CNA), stated that she scheduled RN coverage for at least 8 hours per day but could not recall any day without RN coverage in November or December 2023. The facility administrator confirmed that there was no policy regarding RN coverage but stated that the facility followed the State Operations Manual (SOM) and Texas Administrative Code (TAC) regarding RN hour regulation. Despite these assertions, there was no evidence provided to confirm RN coverage on the specified dates, leading to the deficiency report.
Food Service Safety Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility did not ensure that insulated plate lids and bases were air-dried before being stacked, leading to water droplets remaining on them. This was observed when DA J took the washed insulated plate lids and bases from the dishwashing machine and stacked them on a cart without allowing them to air dry. Later, during lunch meal service, DA J placed these wet lids and bases over and under plates, which could potentially cause cross-contamination. Both DA J and the DS acknowledged that this practice could lead to foodborne illness due to cross-contamination from the water droplets. Additionally, the facility failed to ensure that Cook I prepared pureed pasta salad in a sanitary manner. Cook I was observed tasting the pasta salad with his bare finger and then continuing to use the same equipment without washing it, which he admitted could contaminate the food. The DS confirmed that this action constituted cross-contamination and could make residents sick. The facility's policies on cleaning dishes and employee sanitary practices were not followed, as dishes were not allowed to air dry, and clean spoons were not used for tasting food.
Failure to Update Resident Care Plan for Dietary Needs
Penalty
Summary
The facility failed to review and revise the comprehensive person-centered care plan for a resident diagnosed with dementia, syncope, dysphagia, and weakness. The resident's care plan was not updated to reflect that he was on a no added salt (NAS) regular texture diet, despite his active orders and meal tickets indicating this diet. The resident's quarterly MDS assessment indicated he was severely cognitively impaired and required setup assistance for eating, but his care plan still listed a mechanical soft texture diet. Observations and interviews revealed that the resident consistently received a regular texture diet, and staff were aware of this requirement. However, the care plan was not updated accordingly, which was confirmed by the MDS coordinator and the Director of Nursing (DON). The failure to update the care plan after the quarterly MDS assessment in January led to a discrepancy between the care plan and the resident's actual dietary needs, potentially affecting the resident's quality of life.
Failure to Provide Proper Incontinent Care for Resident
Penalty
Summary
The facility failed to ensure a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. During an observation, CNA C did not return the foreskin of Resident #53 to its original position after cleaning his penis during incontinent care. This action was contrary to the facility's policy and procedure for perineal care, which requires the foreskin of an uncircumcised male to be repositioned after cleaning. Both CNA C and CNA D, who assisted in the care, acknowledged their mistake and confirmed they were trained to reposition the foreskin but failed to do so during the incident. Resident #53, who is cognitively intact with a BIMS score of 15/15, has diagnoses including epilepsy, unsteadiness on feet, repeated falls, weakness, and other malaise. His comprehensive care plan did not reflect his incontinence of bowel and bladder, only noting his need for assistance with ADLs due to epilepsy. The Director of Nursing (DON) confirmed the importance of repositioning the foreskin to prevent complications such as infection and impaired blood circulation. Competency checklists for both CNAs indicated they had satisfactorily completed training for incontinent care, including repositioning the foreskin.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 937 citations issued within 25 miles in the last 12 months — including the 11 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.
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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.
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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) |
|---|---|---|---|---|
| Stone Oak Care Center | 0.5 mi | ★★★★★ | 10 | 0 |
| The Enclave | 1.2 mi | ★★★★★ | 3 | 0 |
| Coronado At Stone Oak | 1.3 mi | ★★★★★ | 15 | 0 |
| Estates At Shavano Park | 4.9 mi | ★★★★★ | 18 | 0 |
| Castle Hills Rehabilitation And Care Center | 5.4 mi | ★★★★★ | 20 | 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 October 2026) and official state health department websites.