Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St. Juanita Retirement And Rehab during CMS and state inspections, most recent first.
The facility failed to ensure CNA C had current NAR verification before working resident care shifts. Records showed CNA C’s NAR had expired, yet she worked multiple overnight shifts after expiration. CNA C said she knew it was expired and had asked the HR Coordinator for help renewing it through TULIP, while the HR Coordinator and HR Manager acknowledged the lapse. Facility policy required current credentials before work and ongoing verification of employee credentials.
Failure to Post Daily Nurse Staffing Information: The facility did not post the daily nurse staffing information at the nurse's station, and only an assignment sheet was present. The DON and Corporate QA Nurse gave differing accounts of who completed the staffing posting, and the facility had not updated the required staffing information for an extended period. The facility policy required daily posting of the number of nursing personnel responsible for direct resident care.
A resident with a history of cerebral infarction, Alzheimer’s disease, and hypertensive heart/chronic kidney disease was admitted with an expectation of dual certification and hospice plus PT services, but after assessment the facility determined the resident did not qualify for those services and arranged transfer by ambulance to another facility with hospice. The administrator acknowledged there was no physician order or family approval documentation for the transfer and stated he believed the hospice liaison was responsible for handling all documentation. The resident’s family member reported she did not sign any documents or agree to the move and learned of the transfer only from the hospice company, not from the facility. This conflicted with facility policy requiring safe and orderly transfer or discharge and proper notice of bed-hold and readmission requirements, and resulted in the resident and representative not receiving written notice of the transfer and its reasons in a language and manner they understood.
Kitchen Food Storage and Utensil Protection Deficiency: Surveyors observed uncovered plates in the plate warmer, uncovered cooking and serving utensils hanging above a prep table, uncovered silverware in bins, and an uncovered food grater on a shelf. A container of red potatoes with sprouting potatoes was also found in dry storage. The DM said she was unaware utensils needed to be covered, and the Administrator said he assumed the utensil racks met requirements.
Opened Tuberculosis solution in a medication room refrigerator was found without an open date label. The DON stated the vial should be dated when opened and is good for 28 days, and the facility policy required opened multi-dose vials to be dated and discarded within 28 days unless the manufacturer specifies otherwise.
Expired CNA Registry Verification
Penalty
Summary
The facility failed to ensure registry verification showed that CNA C met competency requirements before providing care to residents. Record review showed CNA C had a date of hire listed in the personnel file, and the last Employability Status Check Search showed CNA C’s NAR status had expired. Employee time clock records showed CNA C worked multiple overnight shifts after the expiration date, including several 6:00 p.m. to 6:00 a.m. shifts. During interviews, CNA C stated she knew her NAR status had expired and that she had told the HR Coordinator she needed help renewing it through TULIP. The HR Coordinator stated he was not aware the status was expired, though he knew it was close to expiring and had missed helping her on prior occasions. The HR Manager confirmed CNA C’s NAR was expired and stated she had been instructed to renew it herself, with his help. The HR Coordinator, DON, and Corporate Quality Assurance Nurse all stated that EMR/NAR checks were supposed to be completed upon hire and annually, and the facility policy required current credentials before beginning work and throughout employment.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing information with the current date, resident census, and the total number of staff and actual hours worked at the beginning of each shift. During an observation and interview on 05/26/2026 at 11:32 A.M., the daily staffing posting was not hanging at the nurse's station, and only an assignment sheet for staffing was present. The Corporate Quality Assurance Nurse stated the daily staffing was completed by the DON, and the DON stated the night shift nurses completed the daily staffing posting. The DON also stated she would be responsible for ensuring the daily staffing was posted. The facility did not update and post the daily nurse staffing information from 5/10/2026 through 5/26/2026. During interviews, the Corporate Quality Assurance Nurse said the facility had changed the person responsible for staffing and that the nurse taking over the staffing position would be responsible for completing the daily staffing. She stated she would start in-services and education regarding the changes. Record review of the facility policy titled, Direct Care Daily Staffing Numbers, dated July 2016, indicated the facility would post on a daily basis for each shift the number of nursing personnel responsible for providing direct care to residents.
Failure to Provide Required Written Transfer/Discharge Notice to Resident Representative
Penalty
Summary
The facility failed to provide written notice of transfer or discharge, including the reasons for the move, to a resident and the resident’s representative in a language and manner they understood prior to the transfer. A male resident with diagnoses including cerebral infarction, Alzheimer’s disease, and hypertensive heart/chronic kidney disease was admitted with an anticipated dual certification status and placement on the skilled side, with hospice and physical therapy services expected. After admission, the facility’s assessment determined the resident did not meet qualifications for hospice and physical therapy services, which changed the services to be provided. The resident’s record showed a discharge after a one-day stay, with transfer by ambulance to another facility with hospice services, but there was no documentation of a physician order for the transfer or any written notice to the resident or representative explaining the reason for the move. During interviews, the resident’s family member stated she did not sign any documents or agree to the transfer and that she was informed of the move only by the hospice company, not by the facility. The administrator reported that, after determining the resident did not qualify for hospice and physical therapy, he spoke with the hospice company and concluded the resident could not remain, and he acknowledged having no physician order or family approval documentation for the transfer. He stated he believed the hospice liaison should have handled all aspects of the transfer, including documentation. The hospice liaison reported that the administrator repeatedly called insisting the resident be removed, stating it was the hospice company’s responsibility, and that the process for transfer was not followed. Facility policy titled “Your Rights and Protections as a nursing home resident” stated the nursing home must safely and orderly transfer or discharge residents and provide proper notice of bed-hold and/or readmission requirements, which was not reflected in the documentation for this resident’s transfer.
Kitchen Food Storage and Utensil Protection Deficiency
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. During the initial kitchen tour, surveyors observed that the top plate in the plate warmer was facing up and was not covered, cooking and serving utensils hanging above a food preparation table were not covered, silverware in bins was not covered, and a food grater on a shelf was not covered. These observations showed that cleaned equipment and utensils were being stored in a manner exposed to air contamination. Surveyors also observed a plastic container of red potatoes with sprouting potatoes in dry storage. In interview, the Dietary Manager stated a cover for the plate warmer had been ordered, said she was not aware utensils needed to be covered, and said she would remove the red potatoes with sprouts. The Administrator stated the utensil racks had been installed by the builder and that he assumed they met government requirements and followed facility policy. Review of the facility's Food Storage policy and the Food Code showed that equipment and utensils should be stored in a clean, dry location and protected from splash, dust, or other contamination.
Opened Tuberculosis Solution Was Not Dated in Medication Room
Penalty
Summary
The facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, including the appropriate accessory and cautionary instructions and the expiration date when applicable, for 1 of 1 medication rooms. During observation on 12/23/2025 at 10:30 AM, the refrigerator in Medication room [ROOM NUMBER] contained an opened Aplisol Tuberculin solution that did not have an open date labeled. During interview on 12/23/25 at 10:31 AM and again at 12:36 PM, the DON stated that once Tuberculosis solution was opened, it needed to be dated with the open date and was good for 28 days after opening. She stated the risk of not having an open date was that staff would not be able to know when it expired and that it would not be effective. Record review of the Recommended Medication Storage policy, undated, reflected that multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Angelo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At San Angelo | 1.5 mi | ★★★★★ | 19 | 0 |
| Avir At Meadow Creek | 2.4 mi | ★★★★★ | 3 | 0 |
| Regency House | 3.6 mi | ★★★★★ | 6 | 0 |
| Avir At Arbor Terrace | 3.9 mi | ★★★★★ | 16 | 0 |
| Cedar Manor Nursing And Rehabilitation Center | 4 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.