Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Southeast Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a known elopement risk was allowed onto a secure unit patio where an LPN lost sight of him while distracted by another resident. The resident used a chair to climb over a 6-foot fence and was later found outside the facility near a busy road, with staff confirming there was no direct supervision on the patio at the time.
Food Storage and Kitchen Sanitation Deficiencies: Staff failed to maintain basic food safety and sanitation practices in the kitchen. Observations showed a trash can next to the hand sink with a lid that was not foot-pedal operated, a freezer with ice buildup, loose parts, and dripping water onto food, and frozen garlic bread and meat patties stored in open bags and boxes so they could be touched directly. A scoop was stored in a bin with oatmeal, one refrigerator lacked a thermometer and contained unlabeled, undated items, another refrigerator had unlabeled, undated cornbread, and the drinks table, kitchen floor, and walls were soiled.
Unsecured Storage Areas Contained Hazardous Materials: Multiple storage areas on B Hall, E Hall, and in the Dining Room were left unlocked or without a locking door and were accessible to residents, staff, and visitors. An unlocked biohazard room, housekeeping closet, dietary storage closet, and activities closet contained biohazard material, chemical cleaning supplies, portable food warming cans labeled harmful or fatal if swallowed, and items such as paint, nail polish, a hot glue gun, a hammer, power tools, and insect spray.
Lack of Toilet Paper in Secure Unit Bathrooms: Surveyors observed that two resident rooms in the secure unit had no toilet paper in the bathroom, and the Housekeeping Supervisor confirmed that toilet paper had been removed from all 8 rooms in the unit to prevent residents from stuffing toilets. Toilet paper was kept at the nurse station and residents had to ask staff for it, creating a delay for ambulatory residents needing immediate access. The Administrator stated toilet paper should be installed in rooms where residents could use the toilet.
Soiled towels were observed on the floor in the resident shower room at the front of B Hall. An MA confirmed the condition during the observation, and the facility policy stated that a homelike environment is essential for resident comfort, dignity, and quality of life.
An LVN left a computer screen open and unattended on a locked med cart, exposing a resident’s morning medication list. The resident had dementia, osteoarthritis, and mononeuropathy, and a BIMS score of 4 indicating severe cognitive impairment. The LVN said he stepped away for about five minutes to assist another resident and did not minimize the screen. The DON stated staff were expected to uphold HIPAA and lock computer screens when away from them.
A resident with a history of stroke, major depressive disorder, and hemiplegia, and a BIMS score indicating no cognitive impairment, reported that staff held her ID, Social Security card, and debit card after she had provided them at admission. She stated she requested her debit card the prior week to make a payment but did not receive it back. The BOM admitted retaining the debit card in a safe and not returning it due to being busy and concerns it might be lost, without offering a locked box option. The ADON acknowledged keeping the resident’s keys and wallet with ID and Social Security card locked in an office cabinet and not consulting the resident about their disposition. The DON confirmed that staff should have provided the personal items upon request and that withholding them violated resident rights to dignity and self-determination.
A resident with a history of stroke, major depressive disorder, and left-sided hemiplegia, cognitively intact per BIMS, reported having diarrhea, delayed staff response, difficulty accessing the call light, and verbally aggressive CNAs who allegedly manhandled her during a 3:00 AM shower, pressured her to use briefs, and resisted providing bed baths and a bedpan as she preferred. She stated she had voiced these concerns to multiple nursing staff. A CNA confirmed the resident had previously reported rough care and resistance to her toileting and bathing preferences and said she told a charge nurse. Later, the resident repeated these concerns to an LVN, who acknowledged understanding the complaints but did not complete a grievance form or document the concerns in a progress note, and the grievance officer (ADM) was unaware of the issues. The DON confirmed there was no documentation by the LVN of the resident’s grievances, demonstrating a failure to follow the facility’s grievance policy.
A resident with diabetes, stroke, and hypertensive heart disease had a care plan calling for weekly skin checks and podiatry referral as needed, and a physician order allowing evaluation and treatment for mycotic nail care. Despite this, staff documentation of a foot evaluation did not address toenail condition, and the resident’s fingernails and toenails became long, with discoloration noted on the right great toenail. An LVN initially did not recognize the resident as diabetic and did not identify the long nails during earlier rounds, and the DON confirmed there was no documentation of long toenails or discoloration and that a podiatry referral had not been made until after the LVN’s later assessment.
Surveyors found that the facility did not follow the posted and planned lunch menu on one observed day, when some residents received mashed potatoes with gravy, others without, and some were served egg noodles even though these items were not on the menu. Two residents reported they did not always receive all items listed on the menu and had previously complained without resolution. The Dietary Manager confirmed that gravy and egg noodles were not part of the planned meal and acknowledged that any substitutions should have been discussed and documented per facility policy requiring menu changes to be recorded and reviewed by the Dietician.
A resident with diabetes and a physician-ordered CCHO renal diet was not served meals consistent with her therapeutic menu. For one observed lunch, the posted and served meal included mashed potatoes and egg noodles instead of the ordered CCHO-renal items, and the resident reported she was often given foods she should not have despite prior complaints. The DON confirmed the resident should not have received mashed potatoes, and the Dietary Manager acknowledged that required menu items and substitutions were not followed or documented in accordance with facility policy.
The facility failed to employ a qualified Director of Food and Nutrition Services, as the DM lacked necessary certifications and experience. The consultant RD provided limited hours, and the administrator was unaware of the certification requirements. This deficiency could risk residents' nutrition and safety.
The facility failed to meet food service safety standards, with issues including improper air-drying of plastic bowls, incorrect logging of dish machine sanitizer concentrations, and inadequate food storage practices. Observations revealed unsealed food items, expired hard-boiled eggs, a grimy can opener, and a dented can of beans, all posing potential risks for foodborne illness. The Dietary Manager acknowledged these deficiencies and was working to resolve them.
Two residents experienced deficiencies in their living environment. One resident had a broken bedside dresser with drawers that wouldn't stay closed, and the issue was not promptly addressed by maintenance. Another resident's bathroom lacked toilet paper for four days, forcing her to use rough paper towels. Staff acknowledged the oversight, and the facility's policies on maintenance and resident rights were not followed, impacting the residents' quality of life.
The facility failed to maintain a safe and sanitary environment in two resident hallways. In Hallway A, rooms lacked toilet back lid covers and had unattached baseboard molding. In Hallway F, a bathroom door and wall were damaged, with the resident's wheelchair use contributing to the damage. The Maintenance Director was unaware of these issues due to a lack of reporting in the Maintenance Book.
A resident's Out-of-Hospital Do Not Resuscitate (OOH DNR) order was improperly witnessed, with the resident's signature dated differently from the witnesses' signatures, potentially invalidating the document. The resident, with chronic kidney disease and other health issues, was identified as DNR status, but the facility failed to ensure the OOH DNR was properly executed, risking the resident's end-of-life wishes being dishonored.
A facility failed to include oxygen therapy in a resident's care plan, despite an order for supplemental oxygen due to shortness of breath. The resident, with a history of colon cancer and dementia, had an oxygen concentrator in the room that was not in use, and the oxygen tubing was improperly stored. Interviews revealed a lack of awareness and documentation of the resident's oxygen needs, contrary to the facility's policy on comprehensive care plans.
A resident requiring supplemental oxygen did not receive proper respiratory care due to the facility's failure to store oxygen tubing and nasal cannula correctly and to date the equipment. The tubing was found hanging loosely and almost touching the floor, and the humidifier bottle was not consistently dated, contrary to facility policy. This oversight was confirmed by the DON, who acknowledged the risk of cross-contamination and infection.
A facility failed to provide adequate pharmaceutical services when two expired vials of Lorazepam were found in the medication storage room intended for a resident with severe cognitive impairment and anxiety disorder. The DON confirmed the oversight, despite a recent audit by the consultant pharmacist. The facility's policy requires regular inspections to prevent such occurrences.
A facility failed to secure medications properly when an LVN left a FIASP insulin pen unattended on a medication cart while performing an accu-check in a resident's room. The cart was out of the LVN's line of sight, posing a risk for drug diversion. Both the LVN and DON acknowledged the error, and the facility's policy requires medications to be locked or under direct observation.
The facility failed to ensure the sliding doors on the dumpster were closed, exposing refuse and potentially risking exposure to germs and diseases. A resident frequently opened the doors, believing it helped staff. The facility's policy required proper disposal of garbage, and the Food Code mandated covered receptacles.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a G-tube, as an LVN did not wear a gown during enteral feeding, despite EBP signage and available PPE. The resident, with severe cognitive impairment, required EBP due to the feeding tube. The LVN, a new hire, admitted forgetting the gown, although trained in EBP. The facility's policy requires gown and gloves for high-contact care with indwelling devices.
A resident's call light system was not functioning properly, with the light inside the room activating but not the hallway light, which was also missing a cover. The resident, with a history of dementia and anxiety, reported the issue had persisted for several days. The Maintenance Director confirmed the malfunction and noted no work orders had been placed, highlighting a lapse in routine checks and communication.
Failure to Supervise Resident on Secure Patio Led to Elopement
Penalty
Summary
The facility failed to ensure adequate supervision to prevent elopement for a resident with dementia, wandering, alcohol abuse, heart failure, and a history of falls. The resident’s BIMS score was 03, indicating severe cognitive impairment, and his elopement/wandering risk assessment identified him as at risk for elopement or unsafe wandering. His care plan identified him as a risk for elopement secondary to dementia and included more frequent rounding. On the evening of the incident, the resident was given access to the secure unit patio by an LPN. The LPN then lost visible contact with him because she was distracted by another resident at the nurse station. The nurse station did not have direct eye contact with the patio; visibility was only through an adjacent window, and the window shade was closed. A chair was present in the patio area, and the resident used it to lean against the 6-foot fence and climb over it. The report states the resident eloped from the patio between 6:45 p.m. and 7:10 p.m. The resident was later found outside the facility near a busy two-lane road, approximately ninety-six feet beyond the facility boundary. He was ambulatory and later stated he did not remember eloping. Another resident who had been on the patio stated there was no staff present with them. Staff interviews confirmed that the resident was not physically supervised on the patio and that the elopement was discovered only after he had already left the secure area.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During observation, the trash can next to the hand-washing sink had a lid that was closed and was not operated by a foot pedal. Freezer #1 contained approximately 1/4 inch of ice at the bottom and on the sides, a loose lower section hanging about 1 inch from the freezer, and water dripping from the top inside of the freezer onto food items below. The Dietary Manager confirmed these conditions during the observation. Freezer #1 also contained frozen garlic bread and frozen meat patties stored in open plastic bags inside open cardboard boxes, allowing the surveyor to reach in and touch the exposed food items without moving either container. A scoop was located in the same plastic bin as oatmeal. Refrigerator #1 contained milk but did not have a thermometer, and later contained a tray with approximately eight individual cups of liquid and a ramekin of food that were unlabeled and undated. Refrigerator #2 contained cornbread that was unlabeled and undated. The Dietary Manager and Dietary Corporate Representative confirmed these observations. Additional observations showed the table on which the drinks machine was placed was soiled, and the floor and walls of the kitchen were soiled. The Dietary Corporate Representative confirmed these conditions and later stated the noted deficiencies had been corrected. The facility policy, Food Safety and Sanitation Plan, stated that the facility follows an effective food safety program focused on preventing food safety hazards before they occur.
Unsecured Storage Areas Contained Hazardous Materials
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment in B Hall, E Hall, and the Dining Room because multiple storage areas were left unsecured and accessible to residents, staff, and visitors. On B Hall, the biohazard storage room was unlocked and contained biohazard material, and the activities closet was also unlocked and contained paint, nail polish, and a hot glue gun. On E Hall, the housekeeping closet was unlocked and contained potentially hazardous chemical cleaning materials, and the maintenance closet was not fitted with a locking door and contained a hammer, power tools, and insect spray. In the Dining Room, a dietary storage closet was unlocked and contained approximately 25 individual cans of portable food warming mechanisms, each labeled as harmful or fatal if swallowed. During observations, LVN H, the Head of Housekeeping and Laundry, Maintenance Assistant J, the DON, and the Activities Director each confirmed the unsecured closets and the items stored inside them. Record review of the facility policy, Homelike Environment, dated 04/24/2025, stated that a homelike environment is essential for promoting the comfort, dignity, and quality of life of residents.
Lack of Toilet Paper in Secure Unit Bathrooms
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity in the secure unit when toilet paper was removed from resident bathrooms. During an initial tour, surveyors observed that rooms 107 and 108 had no toilet paper available in the bathrooms. Room 107 housed one resident, and room 108 housed two residents. Later observation showed housekeeping staff placing toilet paper in the secure unit residents’ bathrooms. During interview, the Housekeeping Supervisor confirmed that the secure unit’s rooms had no toilet paper and stated that all 8 rooms in the unit, housing 14 residents, had toilet paper removed as a way to prevent residents from stuffing the toilets. The Housekeeping Supervisor stated toilet paper was stored at the nurse station and residents had to ask nursing staff for it, and acknowledged there would be a delay for a continent, ambulatory resident needing to use the bathroom quickly. The Administrator stated toilet paper should be installed in rooms where residents were ambulatory and could use the toilet. The facility’s Resident Rights policy stated residents have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.
Soiled Towels Found in Shower Room
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment in the resident shower room at the front of B Hall. During observation on 03/31/2026 at 10:57 a.m., the shower room was found to contain soiled towels on the floor. Medication Aide I was interviewed at that time and confirmed the soiled towels were on the floor in the shower room. Record review of the facility policy, Homelike Environment, dated 04/24/2025, stated that a homelike environment is essential for promoting the comfort, dignity, and quality of life of residents.
Unattended Computer Screen Exposed Resident Medication Information
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident’s personal and medical records when an LVN left a computer screen open and unattended on a locked medication cart. Resident #18, a [AGE]-year-old female admitted to the facility with diagnoses including dementia, osteoarthritis, and mononeuropathy, had a Quarterly MDS dated 3/13/26 showing a BIMS score of 4, indicating severe cognitive impairment. On 4/1/26 at 9:08 AM, observation showed the locked medication cart with a computer unattended in the Fiesta hallway, exposing Resident #18’s morning medication list. At 9:10 AM, the LVN stated the medication aide had called in sick, so he was expected to pass his own medications. He said he prepared and administered medications for Resident #18 and then walked away for about five minutes to assist another resident, leaving the computer screen visible and not minimized. He acknowledged he should have minimized the screen when he stepped away. The DON later stated she was not aware the records had been left open and unattended, and she stated it was her expectation that nursing staff uphold HIPAA regulations and lock computer screens when away from them.
Failure to Return Resident’s Personal Identification and Financial Cards Upon Request
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s rights to dignity, self-determination, and access to personal property by not returning requested identification and financial cards. The resident was admitted with diagnoses including cerebral infarction, major depressive disorder, and hemiplegia affecting the left non-dominant side. Her admission MDS showed a BIMS score of 15/15, indicating no cognitive impairment, and she required substantial to maximum assistance with ADLs in bed and was dependent for toileting. Her care plan noted impaired cognition with risk of further decline, with goals that her needs be met timely and dignity maintained. During an interview, the resident reported that upon admission she gave her identification and Social Security card to front office staff, and that staff also had her bank card. She stated she had requested her bank card the prior week so she could make a payment on belongings in storage, but staff had not returned it despite saying they would. The BOM acknowledged having the resident’s debit card, explaining that it was initially locked in the medication cart and then placed in the safe with the resident’s agreement. The BOM stated the resident requested the debit card the previous week, but it was not returned because the BOM was busy with end-of-month tasks and was concerned it might be lost or taken; the BOM had not offered the resident a locked box option and did not know the resident’s specific financial needs. Separately, the ADON reported she had the resident’s keys and wallet containing her ID, Social Security, and VA cards locked in a filing cabinet in her office, and stated she had not thought about them until discussing the situation with the BOM. The ADON acknowledged she should have asked the resident what she wanted done with these items and recognized the resident’s right to receive her personal belongings upon request. The DON confirmed learning that the resident had asked staff for her debit card, ID, and Social Security card and stated staff should have provided these personal items upon request rather than delaying for a week, and that withholding them violated the facility’s resident rights policy, which affirms residents’ rights to a dignified existence, self-determination, and freedom from interference in exercising their rights.
Failure to Initiate and Document Grievance for Resident Care Concerns
Penalty
Summary
The deficiency involves the facility’s failure to promptly and properly process and document a resident grievance in accordance with its grievance policy. A resident admitted with cerebral infarction, major depressive disorder, and left-sided hemiplegia had an admission MDS showing a BIMS score of 15/15, indicating no cognitive impairment, and care plan needs including incontinence of bowel and bladder, frequent checks for wetness and soiling, and extensive assistance with toileting. During observation and interview, the resident reported having diarrhea for a week, difficulty obtaining timely assistance, needing to bang on the wall for help, and sometimes not having the call light within reach due to her paralysis and staff placing it on her left side. The resident also reported that a male and a female CNA were verbally aggressive, that they woke her at 3:00 AM insisting on showering her, and that she was manhandled during the shower. She stated she preferred bed baths and use of a bedpan, and that the female CNA spoke to her in a loud, demeaning tone, gave her a hard time about using the bedpan and receiving bed baths, and wanted her to use briefs despite her objections. The resident stated she had expressed these concerns to different nursing staff. A CNA reported that a few weeks earlier the resident had told her some staff were rough and gave her a hard time about using the bedpan or receiving a bed bath instead of a shower; the CNA stated she reported these concerns to a charge nurse but could not recall which nurse. Later, in the presence of LVN B, the resident repeated the same concerns she had shared with the surveyor, including that a Black CNA talked loudly to her, gave her a hard time about using the bedpan, did not want to provide bed baths, and that staff took a long time to respond when she asked for help, as well as mentioning being manhandled during a shower. LVN B acknowledged being aware of these concerns and stated he was required to write a progress note and follow the grievance process, but he did not complete a grievance form or enter a progress note regarding the resident’s complaints. The Administrator, identified as the grievance officer per facility policy, reported not knowing about the resident’s concerns, and the DON confirmed that there was no progress note from LVN B documenting his conversation with the resident and that he was new to LTC and may not have been familiar with the grievance process. This failure to initiate and document the grievance process for the resident’s reported concerns constitutes the cited deficiency.
Failure to Provide Timely Foot Care and Podiatry Referral for Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate foot care and timely podiatry referral for a resident with diabetes and multiple comorbidities. The resident was admitted with diagnoses including cerebral infarction, hypertensive heart disease, and enterocolitis due to C. difficile, and had a care plan identifying diabetes with a goal to reduce complications, including weekly skin checks and referral to a podiatrist as needed. A physician order dated 12/25/25 authorized evaluation and treatment for mycotic nail care, and a skin assessment on 1/6/26 documented a foot evaluation but did not include any information about the condition of the resident’s toenails. On observation, the resident was noted to have long fingernails and reported that both her fingernails and toenails were long and needed cutting, describing them as “like claws.” During an interview, an LVN initially stated the resident was not diabetic and that CNAs could provide nail and foot care on shower days, but upon reviewing the electronic health record, he acknowledged the resident had Type 2 diabetes and was receiving daily insulin. He also stated that nursing staff should provide nail care and reported that he had rounded on the resident twice on the date of observation without noticing or being informed about the long nails. Later observation and assessment with the same LVN confirmed that the resident’s toenails were long and needed cutting, and the LVN identified discoloration of the right great toenail, stating that if it was fungus, a podiatrist would need to assess it and that a podiatry referral would be required. The DON stated that the resident was known to sometimes refuse care and that refusals should be documented in progress notes, but there was no documentation on the weekly skin assessment reflecting long toenails or discoloration. The DON further stated that foot assessments should be captured on weekly skin assessments and that nursing staff should refer the resident to podiatry as needed, acknowledging that, to her knowledge, the resident had not been referred to podiatry until after the LVN’s assessment on 1/6/26, despite the existing policy on managing special needs such as podiatry and the physician order for mycotic nail care.
Failure to Follow Posted Lunch Menu and Document Substitutions
Penalty
Summary
The deficiency involves the facility’s failure to follow the posted and planned lunch menu for one of two days of observation. The written and calendar menus for the lunch meal on 1/6/26 listed fried chicken, spinach, mashed potatoes, sugar cookies, and a buttered dinner roll. During observation of the lunch meal service, some residents were served gravy with their mashed potatoes while others were not, and some residents received egg noodles even though noodles were not listed on the menu. One resident was served mashed potatoes without gravy and also received egg noodles, while another resident received mashed potatoes with gravy. The Dietary Manager later confirmed that gravy and egg noodles were not part of the planned menu for that meal. Two residents reported in interviews that they did not always receive all items as reflected on the menu and stated they had previously complained about this issue without seeing improvement. They expressed that they did not like when they did not receive what was listed on the menu but felt they could not do anything about it. The Dietary Manager stated that the cook should have followed the menu and that any substitutions should have been discussed with her and documented on the substitution log for Dietician review. Facility policy titled “Menu Changes and Substitutions” dated 10/2010 stated that any variations from the planned menu must be properly documented by the Dietary Services Manager and reviewed and signed by the Dietician, and that menu changes and substitutions, when necessary, must be made with foods of equivalent nutritive value.
Failure to Follow Physician-Ordered Therapeutic Diet
Penalty
Summary
Surveyors identified that the facility failed to provide a physician-ordered therapeutic CCHO renal diet to a resident. The resident had diabetes and minimal cognitive impairment, and her care plan and physician orders specified a CCHO renal diet with regular texture and thin liquids. The resident’s individualized CCHO-renal menu for a specific lunch called for baked chicken breast with chicken gravy, orange twist, buttered chopped spinach, rice, buttered dinner roll, sugar cookies, and appropriate beverages. However, the facility’s weekly menu calendar and the posted daily menu listed fried chicken, spinach, mashed potatoes, sugar cookies, and a buttered dinner roll for that meal, which did not match the resident’s therapeutic menu. During observation and interview at the lunch meal, the resident was actually served baked chicken, mashed potatoes, egg noodles, a sugar cookie, and a buttered dinner roll, and had eaten about half of the meal, including the mashed potatoes and noodles. The resident stated she was diabetic, understood she should limit carbohydrate intake, and reported she was often served items not on her menu or that she should not have, and that prior complaints had not helped. The DON confirmed the resident was on a CCHO diet and should not have received mashed potatoes. The Dietary Manager confirmed the resident should have received rice instead of mashed potatoes, that egg noodles were not on the menu, and that the cook had substituted egg noodles for rice without following the menu or documenting the substitution per policy. Facility policies required meals to be provided according to physician orders, the facility diet manual, and menu spreadsheet, and required any menu variations to be documented and reviewed by the dietitian, which did not occur in this case.
Inadequate Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to employ staff with the necessary competencies and skills to manage the food and nutrition services effectively. The Director of Food and Nutrition Services (DM) did not possess the required certification, education, or qualifications for the role. Specifically, the DM was not a certified dietary manager or certified food service manager, did not hold an associate's or higher degree in food service management or hospitality, and lacked experience as a dietary manager in a long-term care facility for over two years. This was the DM's first position in a nursing facility, and although enrolled in a certified dietary manager program, he had not completed any classes at the time of the survey. Additionally, the facility's consultant registered dietitian (RD) was not employed full-time, providing only 12 to 16 hours of consultative services per month. The facility administrator was unaware of the DM's lack of certification and the updated requirement for certification upon hire. The facility had contracted with a foodservice company, and all dietary staff, including the DM, were employed by the contractor. The administrator acknowledged the importance of the DM being proficient in food sanitation, safety, and meeting the dietary needs of residents. The job description for the DM position required the individual to be a registered dietitian or certified dietary manager, as per federal and state regulations.
Food Safety Deficiencies in Facility's Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies in the storage, preparation, distribution, and serving of food. Observations revealed that plastic bowls were not allowed to air-dry properly in the dish room, as they were placed face-down on a wet tray without an air-drying net, potentially leading to bacterial accumulation. Additionally, the facility used an incorrect log to record dish machine wash cycle temperatures and chlorine sanitizer concentrations, resulting in no recorded measurements of the chemical sanitizer concentration, which could lead to inadequate sanitization of dishes and flatware. Further deficiencies were noted in the storage of food items. An opened package of cream cheese and pre-packaged hard-boiled eggs were found in the reach-in cooler without being properly sealed, and hard-boiled eggs past their use-by date were not discarded. The tabletop can opener was observed to be covered with grime, which could contaminate food. In the dry storage room, an opened bag of powdered sugar was not properly sealed, and a dented #10 can of beans was not removed from the rack, posing a risk of contamination from bacteria. Interviews with the Dietary Manager (DM) confirmed awareness of these issues, acknowledging that staff were trained on proper procedures but failed to adhere to them. The DM, who had been in the position for approximately one month, was in the process of addressing these kitchen issues. The facility's policies and the U.S. FDA Food Code were reviewed, highlighting the importance of proper food storage, labeling, and equipment cleanliness to prevent foodborne illness.
Failure to Maintain Safe and Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents. For one resident, the bedside dresser was broken, with drawers that would not stay closed, posing a risk of belongings falling out. The resident expressed concern about the dresser and stated that maintenance was aware of the issue. The maintenance log confirmed the dresser was noted as unsteady, and the Maintenance Director acknowledged awareness of the problem for about a week. However, the issue was not addressed promptly, and the Administrator admitted to not reviewing the resident council notes that highlighted the problem earlier. Another resident's bathroom lacked toilet paper, forcing her to use rough paper towels for personal hygiene. The resident reported being without toilet paper for about four days despite requesting it from the nursing staff. The CNA and housekeeper acknowledged the unacceptable condition of the bathroom, with the housekeeper admitting to not remembering if extra toilet paper was left for the resident. The EVS Manager stated that housekeepers should make more frequent rounds to restock supplies, especially for residents with diarrhea, but this protocol was not followed. The facility's policies on maintenance inspections and resident rights were not adhered to, leading to these deficiencies. The maintenance policy required routine inspections and prompt corrections, while the resident rights policy emphasized the facility's responsibility to care for residents properly. These lapses in following established procedures resulted in a diminished quality of life for the affected residents.
Environmental Deficiencies in Resident Hallways
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in two of the six resident hallways reviewed. Specifically, in Hallway A, resident rooms #104 and #107 lacked back lid covers for the toilet bowls, and a 2-foot strip of floor baseboard molding was not attached to the wall in another room. These deficiencies were observed during a survey, and the Maintenance Director was not previously aware of these issues as they had not been reported in the Maintenance Book. In Hallway F, the bathroom door in a resident's room had numerous horizontal scrapes and a jagged opening near the hinge, exposing the hollow inside of the door. Additionally, the wall opposite the toilet had scrapes and small holes. The Maintenance Director was informed of these issues only after a State Surveyor's observation and noted that the resident, who uses a wheelchair and has impaired vision, frequently caused damage to the door and wall. The facility's maintenance request log did not show any logged requests for these repairs, indicating a lapse in the reporting and maintenance process.
Improper Witnessing of Resident's DNR Order
Penalty
Summary
The facility failed to ensure a resident's right to formulate an advance directive was properly executed. Specifically, the Out-of-Hospital Do Not Resuscitate (OOH DNR) order for a resident was not properly witnessed. The resident's signature on the OOH DNR was dated differently from the signatures of the two witnesses, which were required to be on the same date to validate the witnessing process. This discrepancy was identified during a review of the resident's records, which included a focus on the resident's DNR status as part of their care plan. The resident, an elderly man with chronic kidney disease, hemiplegia, and chronic ischemic heart disease, was identified as having intact cognition with a BIMS score of 15. Despite being identified as DNR status in his care plan and physician's orders, the improper witnessing of his OOH DNR order could have led to his end-of-life wishes being dishonored. The facility's social worker acknowledged the issue, noting that the OOH DNR was completed by the hospice provider but emphasized that it was still the facility's responsibility to ensure the validity of the document.
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, which included the omission of oxygen treatment in the care plan. The resident, a man with a history of colon cancer and dementia, was admitted to the facility and had an order for supplemental oxygen due to shortness of breath. However, the care plan initiated did not include a focus area for oxygen therapy, which is a critical component of the resident's medical needs. Observations revealed that the oxygen concentrator in the resident's room was not in use, and the oxygen tubing was improperly stored and not dated correctly. Interviews with the Director of Nursing and an LVN indicated a lack of awareness and documentation regarding the resident's oxygen needs. The facility's policy on comprehensive care plans mandates that services necessary to maintain the resident's well-being should be described, but this was not adhered to in this case.
Improper Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide proper respiratory care for a resident, identified as Resident #42, who required supplemental oxygen. Observations revealed that the oxygen tubing and nasal cannula were not stored properly, as they were hanging loosely over the oxygen concentrator and almost touching the floor, rather than being stored in a bag. Additionally, the oxygen tubing and humidifier bottle were not consistently dated, which is necessary to ensure they are changed weekly as per facility policy. This oversight was confirmed by the Director of Nursing (DON) during an interview, who acknowledged that improper storage and lack of dating could lead to cross-contamination and infection. Resident #42, a man with a history of colon cancer and moderate cognitive impairment, was admitted to the facility with an order for supplemental oxygen to manage shortness of breath. Despite this need, the facility did not adhere to its own policy for oxygen administration, which requires labeling and regular changing of disposable parts. The failure to follow these protocols placed the resident at risk for respiratory compromise and infection, as the facility did not maintain the necessary standards of care for respiratory therapy.
Expired Medications Found in Facility's Medication Storage
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, as evidenced by the presence of expired medications in the medication storage room. During an inspection, two expired vials of Lorazepam 2mg/ml were found among the medications intended for a resident with severe cognitive impairment and anxiety disorder. The resident, who had been re-admitted to the facility with diagnoses including dementia, epilepsy, and anxiety disorder, had an active order for Lorazepam oral tablets to manage his condition. The presence of expired medications could potentially compromise the therapeutic effects intended for the resident. The Director of Nursing (DON) confirmed the presence of the expired medications during an interview and noted that the facility's consultant pharmacist had recently audited the medication room without identifying any expired drugs. The facility's policy mandates that all medications be stored, dated, and labeled according to the manufacturer's recommendations, and that the consultant pharmacist routinely inspects the medication rooms for expired or deteriorated medications. Despite these procedures, the expired vials were not identified and removed, indicating a lapse in the facility's pharmaceutical service processes.
Failure to Secure Medications on Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored securely and labeled according to professional principles, as observed with one of the medication carts. On the specified date, an LVN left a FIASP insulin pen unsecured on top of a medication cart while attending to a resident's accu-check inside the resident's room. The medication cart was left outside the room and out of the LVN's line of sight, which could lead to potential drug diversion or misuse. During an interview, the LVN acknowledged the mistake, stating that she had intended to take the insulin pen into the room but forgot. She confirmed that medications should always be locked when not directly supervised. The DON also confirmed that the insulin should not have been left unsecured and acknowledged the risk of medication theft. The facility's policy mandates that medications must be under direct observation or locked during administration.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse by not ensuring that the sliding doors on both sides of the dumpster were completely closed. During an observation, it was noted that the doors were open, exposing bags of refuse inside the dumpster. This practice was identified as a potential risk for exposing residents to germs and diseases carried by vermin and rodents. The Regional DM confirmed that the doors should have been closed to prevent pests from entering the dumpsters and potentially spreading foodborne illness. Interviews with the Administrator and DON revealed that a resident frequently opened the dumpster doors, believing it made the staff's job easier. The facility's policy, dated October 2019, stated that all garbage and refuse should be collected and disposed of safely and efficiently, with the Dining Services Director responsible for ensuring proper handling. Additionally, the Food Code from the U.S. Public Health Service and FDA required that receptacles for refuse be kept covered with tight-fitting lids or doors if kept outside the food establishment.
Failure to Implement Enhanced Barrier Precautions for G-tube Feeding
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically in the implementation of Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube (G-tube). During an observation, a Licensed Vocational Nurse (LVN) did not wear a gown while administering enteral feeding via the G-tube to a resident, despite the presence of an EBP sign and available personal protective equipment (PPE) at the resident's door. The LVN acknowledged forgetting to don a gown, which is a requirement under EBP for residents with indwelling medical devices to prevent the spread of infection. The resident involved was a man with severe cognitive impairment, receiving more than half of his nutrition and fluid intake through tube feeding. His care plan indicated the need for EBP due to the presence of the feeding tube. The Director of Nursing (DON) confirmed that the LVN, who was a new hire, had received training in infection control, including EBP, but failed to adhere to the protocol during the feeding procedure. The facility's policy mandates the use of gown and gloves during high-contact care activities for residents with devices like feeding tubes, regardless of their colonization status with multidrug-resistant organisms (MDROs).
Deficiency in Resident Call Light System
Penalty
Summary
The facility failed to ensure that the call light system in a resident's room was functioning properly, which could lead to delays in assistance and affect the resident's quality of life. The resident, a woman with a history of conversion disorder with seizures, dementia, generalized anxiety disorder, and repeated falls, reported that her call light had been broken for 3-4 days. When she pressed the call light next to her bed, the red light inside her room activated, but the light outside her door did not, and the hall call light was missing a cover, exposing the bulb and wires. This issue was confirmed by a CNA who was unaware of the malfunction and by the Maintenance Director, who found that the emergency light button in the bathroom was partially pressed down, blocking the signal. The Maintenance Director stated that he had not been informed of the call light issue, and there were no work orders in the maintenance log regarding the malfunction. The facility's policy required routine inspections of the physical plant, but the Maintenance Director did not perform routine checks of the call lights, relying instead on staff to report issues in the maintenance log. The lack of a functioning call light system in the resident's room was a significant oversight, as it is crucial for residents to be able to call for help when needed.
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 944 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Buena Vida Nursing And Rehab-san Antonio | 0.5 mi | ★★★★★ | 26 | 5 |
| Pecan Valley Rehabilitation And Healthcare | 0.6 mi | ★★★★★ | 9 | 0 |
| Highland Nursing Center | 1.6 mi | ★★★★★ | 20 | 0 |
| Normandy Terrace Nursing & Rehabilitation Center | 2.4 mi | ★★★★★ | 18 | 1 |
| The Rio At Mission Trails | 2.9 mi | ★★★★★ | 19 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.