Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Spanish Meadows during CMS and state inspections, most recent first.
A facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for two residents who needed help with transfers. One resident had severe cognitive impairment, Parkinson's disease, and muscle weakness; the other had dementia, Parkinson's disease, and muscle weakness with intact cognition. Both care plans only stated to assist with transfers as needed, and staff interviews confirmed the transfer needs were not resident centered or specific.
A resident with severe cognitive impairment, osteoporosis, prior spinal fracture, and significant assistance needs for transfers and ADLs experienced an unwitnessed fall in the bathroom, after which an LVN documented pain to the right heel, hip, and lower back, visible redness and a scrape, and inability to ambulate. A later note documented multiple rib fractures, a T5 vertebral fracture, and a lumbar transverse fracture. Although the DON and Administrator were informed of the unwitnessed fall and facility procedures and policy required reporting unwitnessed falls with injury, injuries of unknown origin, and suspected abuse/neglect to the state within a two-hour timeframe when serious bodily injury is suspected, no self-report was submitted to the state incident system for this event.
A resident with severe cognitive impairment, significant mobility limitations, and a history of falls experienced an unwitnessed fall and was found on the floor in the bathroom doorway with pain to the right heel, hip, and lower back, along with redness and a back scrape. An LVN assessed the resident, notified the NP, and the resident was sent to the hospital. On readmission, another LVN documented that the resident had multiple rib fractures, a T5 vertebral fracture, and a lumbar transverse process fracture based on hospital report, but did not recall notifying administration. The DON and administrator, who served as the abuse coordinator, acknowledged that the event met criteria for reporting an injury of unknown source with serious bodily injury within a 2-hour timeframe, yet no report was submitted to the state incident system despite facility policy requiring prompt external reporting of such incidents.
Food Items Not Properly Labeled and Dated in Kitchen Storage. Surveyors observed 4 cans of evaporated milk in dry storage without an out-of-the-box date and 7 4 oz. sherbert cups in the freezer without an expiration date or out-of-the-box label. Staff stated the box for the evaporated milk had been discarded and the cans were not labeled when removed, and the sherbert box with the dates had also been thrown out. The facility policy required dry, refrigerated, and frozen foods to be labeled and dated.
A resident receiving IV Vancomycin had an IV bag hanging in his room that was labeled with another resident's name, and an LPN said he accidentally grabbed the wrong bag because both residents had the same medication ordered. Another resident with sepsis and moderate cognitive impairment had a peripheral IV dressing that was not dated or initialed when observed, despite orders to assess the site each shift and change the Hep-Lock every 72 hours.
A resident with COPD, chronic respiratory failure, and OSA was ordered continuous O2 at 2 LPM via NC, but surveyors observed the oxygen concentrator set at 1 LPM instead. The resident said he did not change the setting, and an LPN confirmed the flow rate was incorrect before adjusting it to the ordered level.
Discontinued IV Vancomycin for a resident with sepsis and pneumonia was still hanging in the med room alongside another resident’s same medication and dose. The DON observed the current and discontinued IV meds, while an LVN said she had discontinued the MAR entry and placed the medication in the box for discontinued meds but did not complete a discontinuation form or notify the DON. The facility policy required the nurse receiving the stop order to document the discontinuation and notify the dispensing pharmacy.
Unpackaged prefilled NS syringes were observed on the bedside tables of two residents instead of being stored in locked compartments. One resident had a PICC line order for saline flushes, and the other had an IV flush order. An LVN said she was unsure why the syringe was left at the bedside, and the DON said nursing administration checked rooms for items not supposed to be at bedside.
Expired food was found in a resident's personal refrigerator after staff failed to ensure the refrigerator was properly maintained and checked for expired items. The resident had Alzheimer's disease, severe cognitive impairment, HF, and HTN, and could not recall when the orange juice and gelatin were placed in the refrigerator. Staff said managers were responsible for daily checks, but the assigned manager said he did not see the expired items when he checked the room. The facility policy stated perishable foods brought by visitors or family should be discarded on or before the use-by date.
A CNA performed perineal care on a severely cognitively impaired resident without changing gloves after touching the bed remote, despite knowing the remote could be contaminated. The facility also did not consistently post the correct contact precaution signage for two residents on transmission-based precautions; one room had an EBP sign instead of a contact precaution sign, and another room had only a generic "see nurse before entering" sign. Staff interviews confirmed the signage and glove-use lapses.
The facility did not maintain effective pest control, as a live roach was observed in the kitchen and staff interviews confirmed ongoing sightings of roaches despite regular monthly pest control services and sanitation efforts. Staff described previous infestations and ongoing measures to reduce attractants, but pests continued to be present in the facility.
A resident with multiple risk factors for skin breakdown did not have required weekly skin assessments documented for ten consecutive weeks, despite physician orders and facility policy. Although the TAR was signed as if assessments were completed, no detailed records or body diagrams were found for the period. Interviews with the DON, an LVN, and the previous wound care nurse confirmed the assessments were either not documented or not completed, and routine monitoring failed to identify the missing documentation.
A resident with severe intellectual disabilities and dementia did not receive timely PASRR-recommended specialized services due to the facility's failure to initiate the NFSS request within the required timeframe. Confusion among staff regarding responsibility for submitting the NFSS and an incorrectly submitted request led to the resident not receiving PASRR-authorized services as outlined in the care plan, despite therapy being provided through other means.
The facility failed to maintain a safe, clean, and homelike environment for two residents due to unaddressed water damage in their rooms. One resident was moved after a hole in the roof and wet ceiling were discovered, while another expressed concerns about potential leaks in her new room. Observations and interviews revealed delayed recognition and response to the water damage, contributing to an unpleasant and unsafe environment.
A resident with cognitive impairment and a history of wandering eloped from the facility through a fire door with a malfunctioning alarm, resulting in an unwitnessed fall and multiple fractures. The resident's care plan indicated a risk of wandering, but interventions lacked specific initiation dates, and the resident was not adequately monitored. Staff were unaware of the resident's exit until after the incident, and the door alarm was found to be deactivated, contributing to the resident's unsupervised exit and injuries.
The facility failed to ensure that five dietary staff members had current food handler's certificates, potentially risking residents' health. The Dietary Manager did not verify certificates, relying on verbal confirmation, and the HR Manager was unaware of the requirement. The facility lacked a policy mandating these certificates, violating the Texas Administrative Code.
The facility failed to maintain sanitary conditions in the kitchen and dish room, with broken floor tiles, stained walls, and unclean equipment. The juice dispenser nozzles had slimy substances, and the ice machine had a black spot that could contaminate ice. The Dietary Manager and Maintenance Director were unaware of these issues, and cleaning logs were missing or incomplete. The Director of Nursing and Dietician were unclear about their responsibilities, and the Administrator was unaware of the problems.
A facility failed to report an alleged abuse incident involving a resident with dementia to the state agency within the required timeframe. The incident was reported to the facility but not communicated to the state agency until days later. Staff interviews revealed inconsistencies in reporting and documentation, and no physical evidence of abuse was found.
A facility failed to provide written discharge notices to a resident, their representative, or the Ombudsman, as required by regulations. The deficiency was identified when a resident was discharged home twice without proper documentation. Interviews with staff revealed confusion about responsibility for discharge notices, and the DON admitted that no written notice existed for the most recent discharge.
A resident with multiple health issues experienced severe weight loss due to the facility's failure to initiate timely interventions. Despite being on a special diet and prescribed an appetite stimulant, the resident lost 8.2% of their body weight in a month. The LVN noticed poor eating habits but did not notify the ADON, and the DM was unaware of any interventions. The ADON did not review the weight loss until the following month, missing the opportunity for timely intervention, and the facility's protocol for weight loss was not followed.
A facility failed to supervise a resident during a nebulizer treatment, leaving him unattended with a misaligned mask. The resident, with severe cognitive impairment and dependent on staff for all ADLs, was at risk of respiratory distress. Interviews revealed RTs left the resident alone to attend to others, unaware of protocol requirements. The DON later clarified that staff should remain with residents during treatments, highlighting a communication gap and protocol adherence issue.
A Med-Aide in an LTC facility was observed feeding two residents without sanitizing her hands or wearing gloves, contrary to the facility's infection control policy. Despite regular training, the Med-Aide admitted to not following proper protocol, citing the residents' demanding nature. The DON acknowledged the lapse, and the Administrator was informed but could not confirm any negative effects on the residents.
The facility failed to maintain a safe and comfortable environment, as observed in a resident's room with peeling sheet rock and a separated vinyl strip caused by a bed's metal rod. The Maintenance Director noted this was a recurring issue, while the Administrator was unaware of the damage. The facility's policy requires maintenance to keep the building in good repair.
The facility failed to post complete nurse staffing information for four consecutive days, as required by policy. Observations showed that dry erase boards used for posting lacked necessary details, such as census information and night shift data. Interviews with staff, including the ADON and DON, confirmed the absence of required information, particularly in the south wing due to repairs. The Administrator was unaware of the updated posting requirements, leading to the deficiency.
The facility failed to maintain a safe and sanitary environment, with moisture damage and black discoloration observed in various areas, including resident rooms and common areas. Despite ongoing roof repairs and cleaning efforts, extensive water damage and discoloration persisted, raising concerns about the facility's ability to provide a comfortable living environment.
The facility failed to maintain a safe and homelike environment for four residents due to water damage in their rooms, leading to black discoloration and potential mold issues. Observations showed damage around vents and windows, with residents reporting leaks during rain. Staff acknowledged the problem, and the administrator stated roof repairs were ongoing, but the facility had not tested for mold. This compromised the residents' right to a safe living environment.
Incomplete Person-Centered Care Plans for Transfer Assistance
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for two residents whose assessments identified a need for assistance with transfers. Resident #1 was a male with diagnoses including unspecified dementia, Parkinson's disease without dyskinesia, and muscle weakness. His quarterly MDS showed a BIMS score of 4, indicating severely impaired cognition, and his chair/bed-to-chair transfer status was coded as partial/moderate assistance. His care plan, initiated on 11/28/25, identified him as at risk for falls and needing staff assistance with transfers due to decreased physical mobility, weakness, unsteady gait, and cognitive impairment, with the intervention listed as assist with transfers as needed. Resident #2 was a male with diagnoses including dementia, Parkinson's disease without dyskinesia, and muscle weakness. His quarterly MDS showed a BIMS score of 13, indicating intact cognition, and his chair/bed-to-chair transfer status was also coded as partial/moderate assistance. His care plan, initiated on 7/26/25, identified him as at risk for falls and needing staff assistance with transfers and ADLs, with the intervention listed as assist with transfers as needed. During interviews, CNA A stated Resident #1 needed assistance with transfers because he could not transfer independently due to Parkinson's disease, and LVN B stated Resident #1 needed assistance because of an unsteady gait. LVN B also stated the assistance needed for both residents was not resident centered. The DON stated the care plans had to be accurate and resident specific.
Failure to Report Unwitnessed Fall With Serious Injuries per Abuse/Neglect Policy
Penalty
Summary
The deficiency involves the facility’s failure to implement its written abuse, neglect, and exploitation policy regarding reporting of serious injuries and injuries of unknown origin. An elderly female resident with severe cognitive impairment (BIMS score of 3) and multiple diagnoses including osteoarthritis, osteoporosis, Alzheimer’s disease, hypertension, prior thoracic vertebral burst fracture, and spinal stenosis was admitted with significant mobility and safety needs. Her care plan documented the need for assistance with ADLs and transfers due to decreased mobility, weakness, unsteady gait and balance, poor safety awareness, and a history of falls and multiple fractures related to a prior fall and spinal surgery. Progress notes showed that on a night in early March, an LVN documented that the resident was found sitting on the floor in the restroom doorway after an unwitnessed fall. The resident reported she had been walking back to bed after using the restroom, fell onto her bottom and back, and complained of pain in the right heel, right hip, and lower back. The LVN documented redness to the right heel, a red scrape on the lower back, guarding to the right hip, and that the resident was unable to ambulate but could bear weight. A head-to-toe assessment was completed, PRN acetaminophen was given, and the nurse practitioner was notified. A later progress note by another LVN documented that the resident had multiple rib fractures, a T5 vertebral fracture, and a lumbar transverse fracture. Despite the unwitnessed fall and subsequent identification of multiple fractures, record review of the state’s TULIP incident reporting system showed the facility did not submit a self-reported incident for this event. In interviews, the DON and Administrator both acknowledged awareness of the unwitnessed fall on the date it occurred and stated that facility procedures required reporting unwitnessed falls with injury, injuries of unknown origin, and suspected abuse or neglect to the state within a two-hour timeframe when serious bodily injury is suspected. They confirmed that no report was made to any state agency regarding this resident’s unwitnessed fall, and that the injuries became known to the facility upon the resident’s later readmission from the hospital, when they received information about chronic and acute fractures. The facility’s written policy on Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property requires reporting suspicions of serious bodily injury within two hours and making an initial report to the state agency if an incident is considered reportable, which was not followed in this case.
Failure to Timely Report Unwitnessed Fall With Serious Injuries
Penalty
Summary
The deficiency involves the facility’s failure to timely report an alleged violation involving an unwitnessed fall and subsequent serious bodily injuries for one resident. The resident was an elderly female with osteoarthritis, osteoporosis, Alzheimer’s disease, hypertension, a history of a stable burst thoracic vertebral fracture, and spinal stenosis. Her MDS showed a BIMS score of 3, indicating severe cognitive impairment, and she required substantial/maximal assistance for toilet and bed/chair transfers. Her care plan documented decreased mobility, weakness, unsteady gait and balance, poor safety awareness, a history of falls, and status post spinal surgery with multiple fractures due to a prior fall. On the night of the incident, an LVN documented that the resident was found sitting on the floor in the restroom doorway after an unwitnessed fall. The resident stated she had been walking back to bed after using the restroom and fell back onto her bottom and back, denied hitting her head, and complained of pain to the right heel, right hip, and lower back. The LVN noted redness to the right heel, a red scrape to the lower back, no visible discoloration to the hips, and that the resident guarded her right hip but could bear weight, though she was unable to ambulate. A head-to-toe assessment was completed, PRN acetaminophen was given, the NP was notified, and the resident was transferred to the hospital. The LVN reported the fall to the DON and ADON. The DON later confirmed the fall was unwitnessed, that the cognitively impaired resident reported losing her balance while returning to bed, and that the resident was sent to the emergency room. When the resident was readmitted from the hospital, another LVN documented that the resident had multiple rib fractures, a T5 vertebral fracture, and a lumbar transverse process fracture. This LVN stated she received this information in report from the hospital nurse but did not recall whether she notified the administrator or DON. The DON and administrator both acknowledged that the administrator was the abuse coordinator and responsible for reporting allegations of abuse, neglect, exploitation, and injuries of unknown source, and that the required reporting timeframe for such allegations, including those resulting in serious bodily injury, was two hours. The DON stated the incident was not reported to the state agency because the fractures were not confirmed at the facility, and the administrator acknowledged the incident was not reported within the two-hour timeframe. Review of the state incident reporting system (TULIP) confirmed there was no self-reported incident for this resident, despite the facility’s policy requiring immediate or within-24-hour external reporting of reportable incidents and a two-hour limit for reporting suspicions involving serious bodily injury.
Food Items Not Labeled and Dated in Storage
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for storage, preparation, and sanitation. During an initial kitchen tour on 1/27/2026 at 10:30 AM, surveyors observed 4 cans of evaporated milk in the dry storage pantry without an out-of-the-box date, although the expiration date on the cans was 1/7/27. The same observation found 7 4 oz. sherbert cups in the freezer that did not have an expiration date and had no out-of-the-box label. In interviews, kitchen staff and the Dietary Manager stated that labeling and dating food items was important and that a designated staff member was responsible for receiving, storing, and labeling merchandise. One staff member said she had thrown out the box that contained the evaporated milk to make room for new merchandise and did not label the cans when removing them from the box. She also said the box containing the sherbert ice cream had been discarded, which removed the expiration and open dates. The facility policy titled Food Receiving and Storage required dry foods removed from original packaging to be labeled and dated and refrigerated or frozen foods to be covered, labeled, and dated.
IV Medication Labeling and IV Dressing Documentation Deficiencies
Penalty
Summary
The facility failed to ensure parenteral fluids were administered consistent with professional standards of practice for Resident #54 and failed to ensure the dressing on Resident #70's peripheral IV line was dated and initialed. Resident #54 was admitted with diagnoses including chronic respiratory failure, heart failure, COPD, pneumonia, and sepsis, and his record showed an order for Vancomycin HCl IV 1000 mg/200 mL at bedtime. During observation, an empty Vancomycin bag was hanging on an IV pole in Resident #54's room, and the label on the bag showed another resident's name. In an interview, the LVN stated he had given Resident #54 the medication and that there were three bags of the same Vancomycin IV medication. He said he accidentally grabbed the medication that belonged to another resident because both residents had the exact same medication ordered and he only saw the first name on the bag. The DON stated medication administration in-services were ongoing and that the LVN was suspended pending investigation. The LNFA stated nursing in-services and a plan of correction were started immediately, and spot checks were being done. Resident #70 was admitted with diagnoses including sepsis and anogenital warts, and his MDS showed moderate cognitive impairment. His orders included assessment of the IV site each shift and changing the Hep-Lock every 72 hours and as needed. During observation, Resident #70 had an IV access to the left forearm covered with a dressing that was not labeled or dated. An LVN stated that not knowing how long the IV had been inserted could cause possible infection or infiltration, and another LVN later stated he had replaced the IV access and dated it for 1/23/2026. The DON stated nurses were to check the IV flush order, secure the site, and check for signs and symptoms of infection, and that the facility policy states to label the IV site.
Oxygen Flow Rate Set Incorrectly for Resident on Continuous O2
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for Resident #23, a male admitted on 9/13/2025 with diagnoses including COPD, chronic respiratory failure, and obstructive sleep apnea. His quarterly MDS dated 12/21/25 showed a BIMS score of 6 and indicated oxygen therapy under special treatments, procedures, and programs. His active orders as of 1/26/2026 directed oxygen at 2 L/min via nasal cannula continuously via oxygen concentrator, and his care plan stated he had a BIPAP and continuous oxygen per nasal cannula, which he often refused to keep on, with an intervention to give oxygen as ordered at 2 LPM continuously. During observation on 1/27/2026 at 11:37 AM, the oxygen concentrator was set at 1 LPM instead of the ordered 2 LPM. The resident was sitting in his wheelchair and had no signs of respiratory distress at that time. The resident stated he did not move the setting and only knew he was supposed to be on 2 liters. The nurse assigned to the resident observed the setting at 1 LPM, stated it should have been 2 LPM per the physician order, and adjusted it to 2 liters before assessing the resident. The DON stated oxygen settings are checked every shift and documented, and the facility policy on oxygen administration directed staff to review physician orders or facility protocol before administration.
Discontinued IV Vancomycin Left in Medication Room
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of each resident when discontinued medication was not removed from the medication storage room. Resident #78, a male with diagnoses including sepsis and pneumonia, had an order for Vancomycin HCl IV solution 1000 mg/200 mL starting on 1/15/2026 and discontinued on 1/16/2026. The MAR showed the medication was administered on 1/15/2026 and again on 1/16/2026. During an observation on 1/27/2026, Vancomycin IV medication for Resident #78 was still hanging in a clear plastic bag in the medication room, next to Resident #54's Vancomycin IV medication at the same dose. The DON observed both the current and discontinued IV medications in the room. The DON stated discontinued medications were supposed to be placed in a designated bin in the medication room, but later said the IV Vancomycin had not been inventoried and remained in storage. An LVN stated she discontinued the medication on the MAR, removed it from the med cart, and placed it in the medication room in a box designated for discontinued medication, but she did not complete any form indicating it was discontinued and did not notify the DON. The facility policy stated the nurse receiving the discontinuation order is responsible for documenting the discontinuation and notifying the dispensing pharmacy.
Unsecured Normal Saline Syringes Left at Bedside
Penalty
Summary
The facility failed to ensure biologicals were stored in locked compartments and accessed by authorized personnel for 2 residents reviewed for medication storage. On 1/27/2026, surveyors observed an unpackaged prefilled 10 cc syringe of Normal Saline on top of Resident #61's bedside table at 12:27 PM and an unpackaged, prefilled 10 cc syringe of Normal Saline on top of Resident #54's bedside table at 4:35 PM. The report stated that the syringes were left at the bedside rather than stored in a locked compartment. Resident #61 was a [AGE]-year-old female admitted on 1/16/2026 with diagnoses including sepsis, incisional hernia with obstruction, and perforation of the intestine. Her physician orders included flushing a PICC line in the right upper extremity with 10 cc of saline every shift and with antibiotic therapy. Resident #54 was a [AGE]-year-old male admitted on 7/18/2025 with diagnoses including sepsis and pneumonia. His physician orders included flushing the IV line with 10 cc of NS before and after medication administration every shift. During interview, an LVN said she was not sure why the syringe was left on Resident #61's bedside table and stated she disposed of syringes in the medication cart sharps container or trash can; she also said she made rounds every 1 to 2 hours and did not see the syringe on the bedside table. The DON stated nursing administration performed rounds and checked resident rooms for items not supposed to be at bedside, and that in-services were given to staff regarding IV supplies at bedside including NS.
Expired Food Found in Resident Refrigerator
Penalty
Summary
The facility failed to have and follow a policy for the use and storage of foods brought to residents by family and other visitors, and failed to maintain a resident's personal refrigerator. During observation, Resident #90's personal refrigerator contained 4 small individual cartons of orange juice and an individual container of gelatin that were all expired, with an expiration date of 01/21/26. A resident refrigerator temperature log was taped to the top of the refrigerator and showed the refrigerator had last been checked on 01/27/26 in the morning. Resident #90's record showed she was an [AGE]-year-old female with diagnoses including Alzheimer's Disease, unspecified heart failure, and essential hypertension. Her MDS showed a BIMS score of 06, indicating severe cognitive impairment. In interview, Resident #90 said she drank orange juice and ate gelatin but could not recall when the items were brought in or who placed them in the refrigerator. Staff interviews showed managers were responsible for checking resident room refrigerators daily for proper temperature and expired food, and Manager E was assigned to Resident #90's room, but he said he had not seen any juices or gelatin in the refrigerator when he checked it that morning. The facility policy stated that nursing staff would discard perishable foods on or before the use-by date.
Infection Control Failures With Glove Use and Precaution Signage
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During an observation of perineal care for a resident with severe cognitive impairment, a CNA donned gloves, touched the bed remote to raise the bed, and then continued perineal care with the same gloves without changing them. The CNA later stated she knew she was supposed to change gloves after touching the bed remote but forgot, and other staff confirmed that gloves were to be removed and replaced after touching the remote because it could be contaminated. The resident involved in the glove-contamination observation was an older male admitted to the facility with diagnoses including acute ischemic heart disease, hypertension, unspecified dementia, and benign prostatic hyperplasia. His quarterly MDS assessment showed a BIMS score of 4, indicating severe cognitive impairment. The facility’s competency evaluation for perineal care included raising the bed to a comfortable height and washing hands, and the facility’s infection control policy stated that infection control practices were intended to prevent and manage transmission of diseases and infections and that personnel were to be trained on infection control policies and practices upon hire and periodically thereafter. The facility also failed to implement the required contact precautions signage for two residents under transmission-based precautions. One resident had an order for contact precautions due to MRSA to the blood, and observation showed a yellow bag with gloves and gowns and an EBP sign affixed to it, along with a separate sign on the door frame that said, PLEASE SEE NURSE BEFORE ENTERING. Another resident had an order for contact precautions due to HPV/anogenital warts, and observation showed a yellow bag with gloves and gowns but no sign on the bag indicating the type of precautions, only a door-frame sign that said, PLEASE SEE NURSE BEFORE ENTERING. Staff interviews confirmed that the correct precaution sign was not consistently posted and that the yellow bag system was being used to hold precaution supplies and signs.
Failure to Maintain Effective Pest Control for Roaches
Penalty
Summary
The facility failed to maintain effective pest control, as evidenced by the presence of a live roach observed on the floor behind a freezer in the kitchen. Interviews with the Dietary Manager revealed that there had been a significant infestation about six months prior, and although the situation had improved, roaches were still occasionally seen, particularly in the kitchen. The Dietary Manager described efforts to reduce attractants, such as removing boxes from shipments, and noted that food trays were inspected by multiple staff members to ensure they were free of pests. The cook also acknowledged that roaches were sometimes seen and described cleaning procedures when pests were found. The Maintenance Supervisor confirmed that both dead and live roaches were still occasionally observed and outlined the process for notifying pest control services, which included a monthly contract with a commercial vendor. Record reviews showed consistent monthly pest control services targeting cockroaches, rodents, flies, and ants, with documentation of pest activity found during recent services. Facility policies required ongoing pest control and sanitation to keep the building free from insects and rodents, but observations and staff interviews indicated that the measures in place had not fully eliminated the presence of roaches in the facility.
Failure to Document Weekly Skin Assessments as Ordered
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, specifically by not documenting physician-ordered weekly skin assessments over a period of approximately two months. The resident in question was an elderly female with multiple diagnoses, including dementia, psoriasis, and incontinence, and was identified as being at risk for skin breakdown. Her care plan and physician orders required weekly skin assessments by a licensed nurse, and the Treatment Administration Record (TAR) indicated that these assessments were signed off as completed. However, a review of the actual skin assessment documentation revealed that no detailed skin assessment records were completed for ten consecutive weeks. Interviews with facility staff, including the DON, LVN A, and the previous wound care nurse, confirmed that the required skin assessments were not documented as per facility policy, which mandates completion of a body diagram and detailed findings regardless of changes in skin integrity. The DON acknowledged the gap in documentation and stated that he had not previously noticed the missing assessments. LVN A, who was responsible for the assessments during the period in question, stated she had performed the assessments but did not document them and was unsure of the reason, suggesting she may have been hurried or lacked time. Both LVN A and the previous wound care nurse confirmed their understanding of the documentation requirements and the importance of completing the body diagram each week. The facility's policy on pressure ulcer and injury risk assessment requires that findings be documented on an approved skin assessment tool, including the type of assessment and the condition of the resident's skin. Despite staff training and annual competencies covering skin assessment documentation, the required records were not completed for the resident during the specified period. The lack of documentation was not identified or addressed by the wound care nurse or DON during routine monitoring, resulting in incomplete clinical records for the resident.
Failure to Timely Initiate PASRR-Recommended Services
Penalty
Summary
The facility failed to incorporate the recommendations from the PASRR Level II determination and evaluation report for a resident with severe intellectual disabilities and dementia. The resident, who had significant cognitive and physical impairments, was identified as PASRR positive and required specialized services, including occupational and physical therapy. The care plan indicated the need for service coordination with behavioral health and the involvement of relevant parties in care planning meetings, as well as the submission of necessary forms to request habilitative services. Despite these documented needs and agreements made during the annual interdisciplinary team (IDT) meeting, the facility did not initiate the Nursing Facility Specialized Services (NFSS) request within the required 20 business days following the IDT meeting. Interviews with facility staff revealed confusion and lack of clarity regarding responsibilities for submitting the NFSS in the LTC Online Portal. The DON, who had recently assumed responsibility for this task, acknowledged that the NFSS for the resident was submitted incorrectly and subsequently denied, resulting in the resident not receiving PASRR-authorized services through the appropriate process, although therapy services were provided outside of PASRR. Record reviews and staff interviews further indicated that the facility's process for coordinating PASRR-related services was inconsistent, with unclear delegation of duties between the MDS nurse, DON, and other staff. The facility's admission policy required coordination with the PASRR program for residents with mental disorders or intellectual disabilities, but the failure to timely and correctly submit the NFSS resulted in noncompliance with these requirements for the resident in question.
Failure to Maintain Safe and Homelike Environment Due to Water Damage
Penalty
Summary
The facility failed to ensure a safe, clean, and comfortable environment for two residents, leading to a deficiency in maintaining a homelike setting. Resident #1, a female with dementia and moderate cognitive impairment, was moved from her room due to inclement weather and roof renovations. Observations revealed slight bubbling on the ceiling seams in her previous room, indicating water damage. The Director of Nursing (DON) was unaware of the wet ceiling until notified by Life Safety, who discovered a hole in the roof and wet ceiling from the attic side. This lack of awareness and delayed response contributed to the deficiency. Resident #2, also with dementia and moderate cognitive impairment, along with other health conditions, was similarly moved due to weather and renovations. A maintenance worker was observed patching the walls and ceiling in her previous room. Resident #2 expressed concerns about potential leaks in her new room, which were addressed after she reported them. A CNA and an LVN noted water dripping issues in Resident #2's previous room, but the LVN did not observe any additional leaks during his checks. The facility's failure to promptly recognize and address the water damage in both residents' rooms resulted in an environment that was unpleasant, unsanitary, and unsafe.
Resident Elopement Due to Inadequate Supervision and Malfunctioning Door Alarm
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident who eloped from the facility without staff knowledge. The resident, who had a history of cognitive impairment and was at risk for wandering, exited the facility through a fire door that had a malfunctioning alarm. The resident was found outside the facility by a respiratory therapist after sustaining an unwitnessed fall, resulting in multiple fractures and abrasions. The resident's care plan indicated a risk of wandering, but the interventions lacked specific initiation dates, and the resident was not adequately monitored. The facility's staff, including the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs), were unaware of the resident's exit until after the incident occurred. The door alarm, which should have alerted staff to the resident's exit, was found to be deactivated, and there was a lack of communication regarding the alarm's status, particularly due to ongoing construction at the facility. Interviews with staff revealed that the resident had been wandering the halls but was not considered exit-seeking. The staff did not hear any alarms during the time of the incident, and it was later discovered that the door alarm was not functioning. The facility's failure to ensure the door alarms were activated and to monitor residents at risk for elopement contributed to the resident's unsupervised exit and subsequent injuries.
Failure to Ensure Dietary Staff Have Food Handler's Certificates
Penalty
Summary
The facility failed to ensure that five of its dietary staff members possessed the necessary food handler's certificates, which are required to safely and effectively carry out the functions of the food and nutrition service. Specifically, Dietary Staff M, N, P, Q, and R did not have current food handler's certificates, which could place residents at risk of food-borne illness. The deficiency was identified through interviews and record reviews, revealing that these staff members were working in the facility's kitchen without the appropriate certification. The Dietary Manager (DM) admitted to not verifying the certificates upon hiring, relying instead on verbal confirmation from the staff. The Human Resources (HR) Manager, responsible for ensuring staff credentials, was unaware of the requirement for kitchen staff to have food handler's certificates within 30 days of employment. The facility lacked a policy mandating these certificates, and the Administrator was unable to provide documentation or articulate the potential negative effects on residents. This oversight contravenes the Texas Administrative Code, which mandates that all food employees complete an accredited food handler training course within 30 days of employment.
Facility Fails to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain the kitchen and dish room in a clean and sanitary condition, as observed during a survey. The kitchen had multiple broken floor tiles with black substances adhered to the grout, cracked tiles with black substances collected in the corners, and walls with yellowish stains and black spots on the ceiling. The vinyl backsplash strip was also noted to have black spots and was separating from the wall. The Dietary Manager (DM) acknowledged the issues, attributing the yellowish stains to water leaks from recent rains and mentioned that the roof was being repaired. However, she was unaware of the nature of the black spots on the ceiling. The facility also failed to ensure the cleanliness of the juice dispenser nozzles and the ice machine. During a follow-up observation, one juicer had nozzles with reddish and white slimy substances adhered to them. The DM and dietary staff were unable to locate the daily cleaning schedule log for the juicer, and it was revealed that the juicer was not included in the cleaning schedule prior to October 21, 2024. The ice machine had a black spot on the plastic backsplash, which could potentially contaminate the ice. The Maintenance Director, responsible for cleaning the ice machine, admitted to missing the spot during the last cleaning and did not maintain cleaning logs. Interviews with the Director of Nursing (DON) and the Dietician revealed a lack of clarity regarding responsibilities for ensuring the cleanliness of the kitchen equipment. The DON stated that improper cleaning of the ice machine could cause respiratory issues for residents, while the Dietician, who visited the facility twice a month, claimed the kitchen was kept in a sanitary condition. The Administrator was unaware of the issues and could not comment on any negative effects on residents. The facility's sanitation policy emphasized maintaining a clean and sanitary food service area, but the observed conditions did not align with these standards.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of physical abuse involving a resident to the State Survey Agency within the required timeframe. The incident, which involved a resident with unspecified dementia and other medical conditions, was reported to the facility on a later date but was not communicated to the state agency until several days after the alleged occurrence. The resident was unable to recall the staff member involved, and the facility's investigation did not find any physical evidence of abuse, such as bruising or changes in behavior. Interviews with staff and other residents revealed inconsistencies in the reporting and documentation of the incident. The social worker acknowledged that a grievance should have been documented but was not, and the Director of Nursing and Administrator admitted to errors in the dates recorded in the investigation report. Staff members interviewed did not observe any signs of abuse or mistreatment, and the resident's roommate did not witness any abusive behavior. The facility's policy requires immediate reporting of such incidents, but this protocol was not followed in this case.
Failure to Provide Written Discharge Notices
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to a resident, their representative, or the Office of the State Long-Term Care Ombudsman at least 30 days prior to the discharge, or as soon as practicable, as required by regulations. This deficiency was identified for a resident who was discharged home on two separate occasions. The facility did not have any written discharge notices for these events, and the only documentation found was a verbal discharge notification via telephone noted on a Notice of Medicare Non-Coverage form. Interviews with various staff members, including the ADON, DON, Admissions Coordinator, Assistant Business Office Manager, Administrator, and Social Worker, revealed a lack of clarity and responsibility regarding the handling and documentation of discharge notices. The DON admitted that there was no written discharge notification for the resident's most recent discharge, and efforts to locate such documentation were unsuccessful. This lack of proper documentation and communication could potentially affect residents by limiting their access to advocacy services, discharge options, and appeal processes.
Failure to Address Severe Weight Loss in Resident
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, resulting in severe weight loss. The resident, who had multiple diagnoses including sepsis, pressure ulcer, acute kidney failure, anorexia, and dementia, experienced a significant weight loss of 8.2% over a month. Despite being on a mechanical soft diet with added shakes and prescribed an appetite stimulant, the resident's weight continued to decline. The facility's staff did not initiate timely interventions to address the resident's weight loss. The Licensed Vocational Nurse (LVN) noticed the resident was not eating well in bed and suggested dining room meals for encouragement, but there was no evidence of further action or notification to the Assistant Director of Nursing (ADON) about the weight loss. The Dietary Manager (DM) was unaware of any interventions for the resident's weight loss and had not been informed by the Dietician, who had not assessed the resident since January. The ADON, responsible for tracking residents' weights, did not review the resident's weight loss until the first of the following month, missing the opportunity for timely intervention. The facility's protocol for weight loss, which includes notifying the Dietician and conducting weekly weight checks, was not followed. The Director of Nursing (DON) acknowledged the failure to adhere to proper protocol, which could have resulted in continued weight loss and risk to the resident's health.
Failure to Supervise Resident During Nebulizer Treatment
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident #38, who required nebulizer treatments. The resident, a 72-year-old male with severe cognitive impairment and dependent on staff for all activities of daily living, was observed receiving a nebulizer treatment without staff supervision. The mask was not properly positioned, and the resident began coughing, prompting the State Surveyor to notify the floor nurse. The nurse indicated that respiratory therapists (RTs) were responsible for nebulizer treatments, but they were not informed when the treatment started or that the resident was left alone. Interviews with the RTs revealed that they initiated nebulizer treatments and then attended to other residents, leaving the resident unattended for short periods. The RTs were unsure if the facility's protocol allowed leaving a resident alone during treatment, and one RT admitted to not having recent training or skills check-off. The Director of Nursing (DON) later clarified that staff should remain with the resident during nebulizer treatments, contradicting the RTs' actions. The facility's policy on administering nebulizer treatments required staff to stay with the resident throughout the procedure. The lack of supervision during the nebulizer treatment posed a risk of respiratory distress for Resident #38, who could not adjust the mask or cough up phlegm independently. The facility's failure to ensure staff remained with the resident during treatment was a deviation from professional standards and the resident's care plan, which included monitoring breathing and lung sounds before and after treatment. The incident highlighted a gap in communication and adherence to protocols among the facility's staff.
Infection Control Lapse During Resident Feeding
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of Med-Aide T during a lunch dining observation. Med-Aide T was observed feeding Resident #69 a barbeque sandwich with her bare hands and then proceeded to feed Resident #14 a pureed diet without sanitizing her hands or wearing gloves. This practice was repeated multiple times, and at one point, Med-Aide T was feeding both residents simultaneously with bare hands. These actions were contrary to the facility's hand hygiene policy, which emphasizes hand hygiene as the primary means to prevent the spread of healthcare-associated infections. The Director of Nursing (DON) acknowledged the lapse in infection control practices, noting that staff were expected to sanitize their hands or wear gloves when feeding residents. Despite regular in-service training on infection control, Med-Aide T admitted to not following proper protocol, citing the residents' demanding nature as a reason for her actions. The Administrator was informed of the incident but was unable to confirm any negative effects on the residents. The facility's hand hygiene policy, revised in October 2023, mandates that all personnel adhere to hand hygiene practices to prevent the transmission of infections.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in one of the halls reviewed. Specifically, Resident #37's room was found to have peeling sheet rock and a separated vinyl strip on the wall behind the bed. The Maintenance Director explained that the damage was caused by a metal rod extending from the bed's headboard, which was a recurring issue in multiple rooms. The Administrator was not aware of the wall damage in some resident rooms and could not confirm any negative effects on residents. The facility's Maintenance Service policy, last revised in 2009, states that maintenance is responsible for keeping the building in good repair and free from hazards.
Failure to Post Complete Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted and readily accessible to residents and visitors with all required information for four consecutive days. Observations by the State Surveyor revealed that the facility used dry erase boards to display staffing information, but these boards did not contain all the necessary details. On one occasion, the board only displayed the current date and the total number of CNAs, LVNs, and RNs, without additional required information. During a walkthrough, it was noted that the north wing had a board with some staffing details, but it lacked information for the night shift and was not present in the south wing due to ongoing repairs. Interviews with staff, including an LVN, the ADON, and the DON, confirmed that the staffing information was not consistently posted as required. The ADON and DON acknowledged the absence of a board in the south wing and the lack of census information. The Administrator admitted to being unaware of the updated requirements for posting staffing information in a specific format. The facility's policy, revised in August 2022, mandates that staffing data, including the number of nursing personnel and resident census, be posted in a clear and readable format within two hours of each shift's start. However, this policy was not adhered to, leading to the deficiency.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as evidenced by moisture damage and black discoloration observed in various areas. The issues were noted in multiple rooms, restrooms, and hallways, with specific instances of water damage and black discoloration around vents, ceilings, and walls. These conditions were observed during a survey, and interviews with staff and the administrator confirmed ongoing issues related to water damage and discoloration, which began after a hurricane earlier in the year. Interviews with staff, including an LVN and the administrator, revealed that while no acute respiratory problems were reported among residents, the facility had been addressing the roof replacement in sections and cleaning discoloration as it was identified. The administrator mentioned that the worst parts of the roof had been replaced, and efforts were ongoing to address the remaining issues. Despite these efforts, the survey found extensive areas of concern, including black discoloration and water damage in resident rooms, restrooms, and common areas. Observations and record reviews indicated that the facility had been actively working to address the issues, with maintenance crews cleaning and replacing air vents. However, the presence of black discoloration and water damage persisted in many areas, raising concerns about the facility's ability to provide a safe and sanitary environment. The facility's policies emphasize treating residents with dignity and respect, which includes maintaining a clean and comfortable living environment, yet the observed conditions fell short of these standards.
Water Damage and Mold Concerns in Resident Rooms
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for four residents due to water damage in their rooms. Observations revealed water damage to the walls and ceilings in two rooms, with black discoloration indicating possible mold presence. The damage was noted around vents, window sills, and restroom areas, creating an unpleasant and potentially unsafe environment for the residents. Interviews with residents and staff highlighted the ongoing issue of leaking ceilings, particularly during rain, which had resulted in residents' belongings and beds getting wet. One resident reported being moved to a different room due to leaks, only to experience similar issues in the new room. Staff members acknowledged the leaks, with some indicating that repairs were underway but not yet completed. The administrator confirmed that the roof replacement was being conducted in sections, with the most severely affected areas addressed first. However, the facility had not tested the vents for mold, and the black discoloration was only superficially treated with Clorox. Despite these efforts, the facility's failure to promptly and effectively address the water damage compromised the residents' right to a safe and comfortable living environment.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 100 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Brownsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ebony Lake Nursing And Rehabilitation Center | 1.6 mi | ★★★★★ | 14 | 0 |
| Alta Vista Rehabilitation And Healthcare | 2.2 mi | ★★★★★ | 16 | 0 |
| Mesa Hills Post Acute | 2.8 mi | ★★★★★ | 6 | 0 |
| Las Alturas Nursing & Transitional Care Brownsvill | 3.3 mi | ★★★★★ | 2 | 0 |
| Fox Hollow Post Acute | 3.9 mi | ★★★★★ | 12 | 3 |
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 August 2026) and official state health department websites.