Above 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 St. Francis Nursing Home during CMS and state inspections, most recent first.
Unsecured cleaning materials were observed in Hall 200 when a can of disinfectant spray and later a container of disinfecting wipes were left on top of carts in the hallway. Both items carried caution labels, and an LPN confirmed they were potentially within reach of residents; the LPN also stated that at least one resident in the hall had a history of wandering. The DON stated that potentially harmful cleaning materials were expected to remain secured when not in use.
Incomplete OOH-DNR Witness Signature: A resident with dementia and memory impairment had an OOH-DNR form that was not fully executed because Witness #1 signed only a first name and did not provide a last name, date, or full printed name. The SW confirmed the advance directive was witnessed incorrectly, and the DON stated all OOH-DNR forms were expected to be completed fully and correctly.
Infection control lapses were observed for two residents. A CNA provided incontinent care to a resident with quadriplegia, dementia, and total dependence, then placed soiled gloved hands into clean rinse water and used the washcloth on the resident. An MA also touched a pill with bare fingers while administering meds to a resident with heart failure, cellulitis, diabetes, HTN, and osteoporosis. The DON confirmed both practices were improper.
Open dumpster doors were observed on two recyclable refuse containers on the loading dock, and both dumpsters contained food-related waste. The Maintenance Director stated staff sometimes placed regular waste in the dumpsters and that the doors should be kept closed to keep pests out. Facility policy and the Food Code required outside refuse receptacles to be pest-proof and kept covered with tight-fitting lids or doors.
A resident with severe cognitive impairment and a history of falls sustained a head injury, scalp laceration, and cervical fracture after a fall. The assigned LVN moved the resident using a mechanical lift and delayed calling 911, despite clear signs of head trauma and altered vital signs. The LVN did not follow established protocols for head injuries, resulting in delayed emergency care and further risk to the resident.
A resident with severe cognitive impairment, legal blindness, and a history of falls was left unsupervised on the edge of her bed by a CNA who left to retrieve supplies. During this time, the resident fell, sustaining a head injury, scalp laceration, subarachnoid hemorrhage, and a C-1 vertebral fracture. The incident occurred despite the resident's care plan requiring staff assistance and supervision for all ADLs and transfers.
The facility failed to properly store, label, and date food items in the kitchen, including an opened milk container and a bag of biscuits without labels, and a bin of brown sugar with an ajar lid. A dented can of Mandarin oranges was also improperly stored with undented cans. Staff acknowledged these lapses, citing time constraints and oversight.
The facility lacked a policy for the use and storage of foods brought by family and visitors, leading to unlabeled and undated food items in personal refrigerators in resident rooms. Observations showed that refrigerators contained items like melted ice cream shakes and hard-boiled eggs without proper labeling. Additionally, a refrigerator's temperature exceeded the acceptable range, with no corrective action taken despite consistent high readings. Interviews with staff confirmed the lack of monitoring and adherence to the facility's policies.
A rat was observed in the kitchen of a facility, despite having a pest control program in place. The facility had a contract with a pest control company for bi-monthly services, but a rat was seen running from the dry storage room into the kitchen. Staff reported this was the first sighting, and no food packages were found tampered with. A small opening was found in the mechanical room, but it did not lead outside, leaving the entry point of the rat unknown.
The facility failed to ensure call lights were within reach for two residents, compromising their ability to request assistance. One resident with severe cognitive impairment and another with moderate impairment were both found with call lights out of reach, despite care plans indicating the need for accessibility. Interviews with staff confirmed the importance of this requirement.
A resident's medical information was exposed when a medical assistant left a computer screen unlocked and unattended during a medication pass. The resident, an 86-year-old female with severe cognitive impairment, had her morning medication list visible. The DON was unaware of the incident and emphasized the importance of adhering to HIPAA regulations by locking computer screens.
The facility failed to ensure proper respiratory care for two residents requiring oxygen therapy, as their oxygen tubing was found undated. Both residents had physician orders for weekly tubing changes, but observations revealed undated tubing, and the residents were unsure if changes occurred. The LVN and DON acknowledged the oversight, which posed a risk of respiratory infection.
A facility failed to limit a PRN order for Xanax to 14 days for a resident with anxiety, dementia, and hypertension. The order lacked a stop date, and staff interviews revealed a lack of awareness of the 14-day limitation policy. This oversight could lead to unnecessary medication use.
A resident with moderate cognitive impairment and medical conditions required wound care, during which an LVN failed to change gloves and sanitize hands between tasks, breaching infection control protocols. Despite recent training, the LVN did not adhere to the facility's policy, potentially risking infection spread. The DON acknowledged the lapse in hand hygiene as a deficiency in infection control practices.
The facility failed to post accurate daily nurse staffing information, as the actual hours worked by licensed and unlicensed nursing staff often exceeded the posted hours. Observations and interviews revealed discrepancies between posted and actual hours, with the HR Director providing documentation of the issue. The Administrator acknowledged the discrepancy but believed the posted hours demonstrated adequate staffing levels.
Unsecured Cleaning Materials in Hall 200
Penalty
Summary
Potentially harmful cleaning materials were left unsecured in Hall 200, where a can of disinfectant spray was observed on top of a cart at the far end of the hall on 01/20/2026 at 12:18 p.m. The spray was labeled, "Caution, keep out of reach of children." No residents were present in the hallway at the time of the observation. During an interview at 12:20 p.m., LVN C confirmed the disinfectant spray was potentially within reach of residents and stated that at least one resident from Hall 200 had a history of wandering. On 01/23/2026 at 11:05 a.m., a container of disinfecting wipes was observed on top of a cart at the near end of Hall 200. The container was labeled, "Caution, keep out of reach of children, hazardous to humans and domestic animals, caution causes moderate eye irritation." No residents were present in the hallway at the time. During an interview at 11:05 a.m., LVN C again confirmed the disinfecting wipes were potentially within reach of residents and stated that at least one resident from Hall 200 had a history of wandering. During an interview with the DON at 12:05 p.m., the DON stated she expected potentially harmful cleaning materials to remain secured when not in use so residents would not come into contact with them.
Incomplete OOH-DNR Witness Signature
Penalty
Summary
The facility failed to ensure one resident’s right to formulate an advance directive when Resident 40’s Texas Out-of-Hospital Do Not Resuscitate (OOH-DNR) form was not fully signed by Witness #1 and was therefore invalid. Resident 40 was admitted with diagnoses including unspecified dementia, hyperlipidemia, and vitamin deficiency. The annual MDS indicated the resident was rarely or never understood, and a staff assessment for mental status showed both short- and long-term memory problems. The care plan, revised 12/10/2025, included a request for DNR measures related to resident/family choice. Record review of the OOH-DNR form dated 12/03/2025 showed Witness #1 signed only her first name and did not sign her last name, include the date of signing, or provide her full printed name. During interview, the Social Worker stated she was responsible for advance directives and confirmed the OOH-DNR was witnessed incorrectly, describing the error as an oversight. The DON stated her expectation was that all OOH-DNR forms be completed fully and correctly. The Texas Health and Human Services guidance reviewed by surveyors stated an OOH-DNR order must be properly executed and signed and dated by two competent adult witnesses, and that health professionals can refuse to honor a DNR if the form is not signed twice by all who need to sign it or is filled out incorrectly.
Infection Control Lapses During Incontinent Care and Medication Administration
Penalty
Summary
The facility failed to maintain an infection prevention and control program for two residents during observed care. Resident #14 had diagnoses including quadriplegia, chronic pain, dementia, anxiety disorder, and Huntington's disease, and was documented as severely cognitively impaired, totally dependent for care, and always incontinent of bowel and bladder. During incontinent care, CNA A used two basins, one with soapy water and one with clear water, and after cleaning the resident following a bowel movement, she did not change her gloves before placing her gloved hands into the clear water to retrieve a washcloth. Her gloves were soiled from cleaning the resident, and she then used the washcloth to rinse the resident's skin. The CNA stated she did not change her gloves because she did not realize she could contaminate the water with the gloves she was using. Resident #78 had diagnoses including heart failure, cellulitis, type 2 diabetes mellitus, hypertension, and osteoporosis, and required moderate assistance with care. During medication administration, Medication Aide B touched a pill with her bare fingers to separate it from other pills in the cup while administering medications to the resident. The medication aide stated she had sanitized her hands but was not wearing gloves and understood the risk of contaminating the medication before giving it to the resident. The DON stated the medication aide should have worn gloves to touch the pills or used a utensil to pick up the pill from the cup, and confirmed the risk of infection for the resident.
Open Dumpster Doors and Improper Refuse Disposal
Penalty
Summary
The facility failed to dispose of garbage and refuse properly for two of three refuse containers on the loading dock, specifically Dumpster #1 and Dumpster #2 used for recyclable refuse. An observation on 01/23/2026 at 10:19 AM showed both dumpsters with V-shaped pull-down doors in the open position. Dumpster #1 was approximately halfway full and Dumpster #2 was approximately one-third full, and both contained food-related waste. During an interview on 01/23/2026 at 10:40 AM, the Maintenance Director stated the dumpsters were intended for recyclable waste only, but staff occasionally placed regular waste inside them. He stated the dumpsters could be closed by lifting the top lid, lifting the V-shaped door, then closing the top lid over the door and securing it with a latch. Record review of the facility policy and the Food Code showed that garbage containers should be pest-proof, have tightly fitting lids, and outside receptacles should be kept covered with tight-fitting lids or doors.
Failure to Provide Timely and Appropriate Care After Resident Fall with Head Injury
Penalty
Summary
A deficiency occurred when a resident with a history of falls, severe cognitive impairment, legal blindness, and dependence on staff for all activities of daily living experienced a fall resulting in a head injury, scalp laceration, hematoma, and a fractured cervical vertebra. The resident was found on the floor by a CNA, and the assigned LVN responded by applying pressure to the bleeding wound and then moving the resident from the floor to the bed using a mechanical lift before notifying medical personnel or emergency services. The LVN did not immediately call 911, instead prioritizing stopping the bleeding and transferring the resident, despite the presence of significant head trauma and altered vital signs. The LVN delayed contacting the physician and the DON, waiting approximately 30 minutes after the fall to notify the physician and about an hour to notify the DON, who then instructed the LVN to call 911. Emergency services were not summoned until over an hour after the incident, during which time the resident exhibited elevated blood pressure, a large hematoma, and was uncooperative with assessment. The LVN acknowledged in interviews that she was aware of the importance of not moving a resident with a suspected head or neck injury and that she should have called for assistance and emergency services immediately, but failed to do so at the time. The facility's care plan and fall prevention protocols required staff to assess for injuries and avoid moving residents with suspected head or neck trauma, as well as to notify emergency services promptly in the event of significant injury. Despite these protocols, the LVN moved the resident and delayed emergency notification, actions which were confirmed by documentation, staff interviews, and review of the resident's medical records. The resident was subsequently diagnosed at the hospital with multiple traumatic injuries, including a subarachnoid hemorrhage and cervical fracture.
Resident Left Unattended During Care Results in Serious Fall Injury
Penalty
Summary
A deficiency occurred when a resident with a history of falls, severe cognitive impairment, legal blindness, and dependence on staff for all activities of daily living (ADLs) was left unattended during care. The resident's care plan identified her as high risk for falls and required staff assistance with mobility, transfers, and ADLs. Despite these documented needs, a CNA left the resident sitting on the edge of her bed while the CNA went to retrieve a towel from the bathroom, leaving the resident unsupervised. During this period of being left alone, the resident fell from the bed, resulting in a head injury, scalp laceration, hematoma/contusion to the forehead/scalp, traumatic subarachnoid hemorrhage, and a fracture to the C-1 vertebrae of her neck. The incident was discovered when the CNA heard a loud thump and returned to find the resident on the floor, bleeding from the head. The resident was subsequently assessed by nursing staff, who noted significant injuries and vital sign abnormalities, and was later transferred to the hospital for further evaluation and treatment. Interviews and record reviews confirmed that the CNA was aware of the resident's fall risk and the need for supervision but failed to ensure the resident's safety by leaving her unattended. The resident's care plan and fall risk assessments were not followed, and the CNA did not secure all necessary supplies before beginning care, resulting in the resident being left in a vulnerable position. The facility's investigation determined that the fall could have been prevented if the resident had not been left alone during care.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. Specifically, the facility did not properly store, label, and date food items in the walk-in cooler, freezer, and dry storage room. An opened container of lactose-free whole milk in the walk-in cooler was not labeled with the date it was opened or a use-by date. In the walk-in freezer, a plastic bag containing six biscuits was found without any labeling or date marking. Additionally, a plastic storage bin containing brown sugar in the dry storage room was left with its lid ajar, exposing the sugar to potential contamination. Furthermore, a dented can of Mandarin oranges was stored alongside undented cans in the dry storage room, which is against food safety standards. During an interview, the kitchen staff acknowledged that the milk, biscuits, and sugar were used for breakfast and were not labeled immediately due to time constraints. They also admitted that the dented can had not been separated from the others. The facility's policy requires that all opened food containers be labeled and dated, and that dented cans be segregated to prevent potential foodborne illness. The U.S. FDA Food Code mandates that ready-to-eat foods be clearly marked with a date when opened and that food be stored in a manner that protects it from contamination.
Deficiency in Food Storage and Labeling in Resident Rooms
Penalty
Summary
The facility failed to have a policy regarding the use and storage of foods brought to residents by family and other visitors, which led to unsafe and unsanitary conditions in personal refrigerators in resident rooms. Observations revealed that personal refrigerators in rooms 115, 208, and 215 contained food items that were unlabeled and undated, such as melted ice cream shakes, sliced apples, and hard-boiled eggs. Interviews with CNAs confirmed the presence of these unlabeled and undated food items. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that perishable food and drinks in residents' personal refrigerators should be labeled and dated to prevent consumption of spoiled foods, but this was not being monitored as housekeeping was responsible for overseeing it. Additionally, the internal temperature of the refrigerator in one resident's room exceeded the acceptable range of 41 degrees Fahrenheit, with a recorded temperature of 53 degrees Fahrenheit. An interview with an LVN revealed that the temperature had been consistently recorded at 50 degrees Fahrenheit from October 1 to October 14, 2024, without any corrective action taken. The facility's undated policy on foods brought by family/visitors and the in-room refrigerator policy were not effectively implemented, as evidenced by the lack of monitoring and maintenance of proper food storage conditions.
Rodent Sighting in Kitchen Despite Pest Control Measures
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live rodents within the premises. During an observation in the dry storage room of the kitchen, a rat was seen running into the kitchen, indicating a breach in pest control measures. Interviews with the kitchen staff revealed that this was the first sighting of a rat in the kitchen, and there was no evidence of food packages being tampered with by rodents. However, the presence of rodents poses a risk of disease transmission and food contamination. The Maintenance Director confirmed that the facility had a contract with a pest control company, which serviced the facility twice a month, including the kitchen and exterior areas. Despite these measures, a small opening was found in the mechanical room, although it did not lead outside, and the Maintenance Director was unsure how the rat entered the facility. The facility's pest control policy outlined responsibilities for management, staff, and the pest control contractor, but the occurrence of a rat sighting suggests a lapse in the effectiveness of the pest control program.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that residents had the right to reside and receive services with reasonable accommodation of their needs and preferences. Specifically, the facility did not ensure that the call lights for two residents were within reach, which is a critical aspect of maintaining their independence, dignity, and well-being. Resident #3, an 86-year-old female with severe cognitive impairment due to dementia, was observed with her call light out of reach on the nightstand. Despite her severe cognitive impairment, she expressed that staff would check on her if the call light was out of reach. Her care plan specifically included the intervention to keep the call light within reach due to her impaired mobility. Similarly, Resident #49, a female with moderate cognitive impairment and impaired physical mobility, was also found with her call light out of reach. She humorously remarked that she would have to send smoke signals if she needed help, indicating her awareness of the situation. Her care plan also required that essential items, including the call light, be kept within reach. Interviews with the CNA and the DON highlighted the importance of call light accessibility and acknowledged the potential negative outcomes if residents could not access their call lights when needed.
Failure to Lock Computer Screen Exposes Resident's Medical Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical records, specifically for an 86-year-old female resident with severe cognitive impairment, chronic obstructive pulmonary disease, depressive disorder, and dementia. During a medication pass, a medical assistant (MA D) left the computer screen unlocked and unattended, exposing the resident's morning medication list. This incident was observed on October 17, 2024, at 9:12 AM. MA D admitted during an interview that she was unaware of the need to lock the computer screen and believed minimizing the screen was sufficient. The Director of Nursing (DON) was not aware of the incident until informed and stated that it was the facility's expectation for nursing staff to adhere to HIPAA regulations by locking computer screens when unattended. The facility's policy, dated March 2014, requires that all patient information accessed during medication pass be positioned to minimize visibility.
Failure to Date Oxygen Tubing for Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents who required oxygen therapy. Resident #6, a female with hypertension, heart failure, and hearing loss, was observed with undated oxygen tubing. Her care plan indicated the need for oxygen therapy, and physician orders required weekly changes of the oxygen tubing. However, during an observation, the resident's oxygen tubing was found undated, and she could not recall if it had ever been dated. Similarly, Resident #23, a female with general anxiety, congestive heart failure, and a dependency on oxygen, was also found with undated oxygen tubing. Her care plan required continuous oxygen due to shortness of breath, and physician orders also mandated weekly changes of the tubing. During an interview, the resident was unsure if her tubing was changed. The assigned LVN confirmed the lack of dating on the tubing and acknowledged that the night shift was responsible for this task. The DON confirmed the oversight and recognized the risk of respiratory infection due to the undated tubing.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic drugs were limited to 14 days, as required, for a resident who was prescribed Xanax 0.25 mg for anxiety. The resident, an 84-year-old female with diagnoses including anxiety, dementia, and hypertension, had a PRN order for Xanax without a specified stop date. The medication order was initiated on 10/11/24, but there was no documentation of a stop date or physician reassessment after 14 days, as mandated by facility policy. Interviews with facility staff revealed a lack of awareness and adherence to the policy regarding the 14-day limitation on PRN psychotropic medications. An LVN expressed uncertainty about why the Xanax order was written for an indefinite period and acknowledged the risk of falls associated with prolonged use. The DON confirmed the absence of a stop date on the order and admitted to being unaware of the 14-day limitation requirement. This oversight could potentially lead to the resident receiving unnecessary psychotropic medication.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a Licensed Vocational Nurse (LVN) who did not adhere to proper hand hygiene protocols during wound care for a resident. The resident, a female with moderate cognitive impairment and medical conditions including hypertension and heart failure, required daily wound care for a sacral/coccyx wound. During an observation, the LVN did not change gloves or sanitize her hands after removing the resident's soiled dressing and before applying a clean dressing, which is a breach of infection control practices. The LVN acknowledged the lapse in protocol, attributing it to nervousness due to being observed by a State Surveyor. Despite having recently completed competency training on infection control, the LVN failed to follow the facility's policy on infection prevention, which mandates changing gloves and sanitizing hands between tasks. The Director of Nursing (DON) confirmed that improper hand hygiene between glove changes could lead to the spread of infection, highlighting a deficiency in the facility's infection control practices.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to post accurate daily nurse staffing information, specifically the actual hours worked by licensed and unlicensed nursing staff responsible for resident care. Observations on 10/16/24 revealed that the facility's daily nursing staffing posting was visible and included details such as the hours of each nursing shift, the staff working on each shift, and the total hours worked by each group of staff. However, the posted hours did not reflect the actual hours worked by the nursing staff, as confirmed by interviews and record reviews. Interviews with the HR Director and the Administrator revealed that the actual hours worked by the nursing staff often exceeded the posted hours. The HR Director provided documentation showing that on several dates, the actual hours worked were greater than those posted. The Administrator acknowledged that the posted hours were usually less than the actual hours worked but believed they demonstrated adequate staffing levels. A review of the facility's policy on staffing indicated that the facility was supposed to maintain adequate staffing and provide accurate information from payroll records, which was not reflected in the daily postings.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meridian Care Monte Vista | 0.2 mi | ★★★★★ | 16 | 1 |
| San Pedro Manor | 0.4 mi | ★★★★★ | 1 | 0 |
| San Antonio North Nursing And Rehabilitation | 0.9 mi | ★★★★★ | 15 | 0 |
| Memorial Medical Nursing Center | 0.9 mi | ★★★★★ | 9 | 0 |
| The Sarah Roberts French Home | 1.9 mi | ★★★★★ | 8 | 0 |
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