Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Stone Oak Care Center during CMS and state inspections, most recent first.
An LVN completed an initial admission assessment, baseline care plan, and comprehensive care plan for a resident with multiple complex diagnoses without required RN review or oversight. Despite RNs being present in the facility, the necessary RN signature and review were missing, and interviews revealed a lack of understanding among staff regarding the requirement for RN involvement in these processes, resulting in a deficiency related to nursing staff competencies and adherence to scope of practice regulations.
A resident with diabetes did not receive a prescribed dose of Lantus insulin on the first night of admission because an LVN assumed the medication was not available and failed to access the emergency medication kit, despite a physician order and the drug's availability. The LVN also incorrectly documented the administration of the insulin on the MAR, intending only to record blood glucose monitoring.
A resident with diabetes did not receive a prescribed dose of Lantus insulin on their first night in the facility, although an LVN documented that the medication was administered. The LVN later admitted the insulin was not given, mistakenly recording its administration while only intending to document a blood glucose check. The facility did not have a policy addressing documentation accuracy, and the interim DON confirmed the error.
A resident admitted for hospice respite care did not receive prescribed glaucoma eye drops for several days due to a lack of coordination and communication between facility staff and hospice representatives. Although the resident's medication list was available in the electronic record and the medications were brought to the facility, neither the admitting nurse nor the hospice RN reviewed the reconciliation list, resulting in the omission of the medications from initial orders and delayed administration.
A resident with multiple diagnoses, including cancer and muscle wasting, experienced a fall that was documented in risk management and progress notes, with interventions added to the care plan. However, the quarterly MDS assessment was incorrectly coded as having no falls, despite the incident being reported and discussed among staff. The RNAC acknowledged the error, and facility policy requires accurate MDS assessments as the basis for care planning.
The facility did not thoroughly investigate two separate allegations of abuse and neglect, as required by policy. In both cases, the investigations failed to include interviews or assessments of other residents in the same units as the alleged victims, relying instead on interviews from other units and routine staff rounds. Some resident questionnaires were submitted late and lacked identifying information, preventing verification by surveyors.
A resident with dementia and muscle weakness had two PRN Tramadol orders—one for 1 tablet and one for 2 tablets—without clear pain scale parameters to guide administration. Nursing staff were uncertain about when to use each dose, and the orders did not specify indications for administration, leading to inconsistent practices and confusion among staff.
A resident's clinical record contained inaccurate documentation, including notes about conjunctivitis and erythromycin treatment that were not supported by diagnoses, physician orders, or medication administration records. Both the DON and NP confirmed the documentation was entered in error, resulting in incomplete and inaccurate medical records.
A resident with dementia and a forehead wound requiring sutures did not have Enhanced Barrier Precautions (EBP) properly implemented, despite orders and care plans indicating the need. Observations showed no EBP signage or PPE cart, and staff interviews revealed confusion about the resident's EBP status and infection control protocols. Documentation indicated EBP was completed, but actual practices did not align with facility policy.
Three residents had inaccurate MDS assessments, including failure to document hypoglycemic medication use for a diabetic resident, incorrect coding of urinary continence for a resident with a suprapubic catheter, and failure to indicate antidepressant use for a resident with depression. These errors were acknowledged by the MDS coordinator and clinical leadership, and were inconsistent with facility policy and CMS requirements.
Surveyors found expired intravenous antibiotics, a germicidal wipe, and a bottle of Senna-Plus in the medication room and a nursing cart. A resident with multiple diagnoses and severe cognitive impairment had discontinued use of the antibiotics, but the expired medications remained accessible. Staff confirmed the expired items were not used but could not explain their presence, and there was no specific policy for removing expired medications or supplies.
The facility did not obtain food from approved or satisfactory sources and failed to ensure that food was stored, prepared, distributed, and served according to professional standards.
A resident with Alzheimer's disease, heart failure, and other chronic conditions was found to be living in a room where the air conditioning vent was visibly soiled with a black substance, rust, and dust. Facility staff confirmed the vents were dirty, and records showed the room was scheduled for deep cleaning, but the vents had not been cleaned at the time of observation. The resident's care plan identified a risk for infection, and facility policy required a clean environment, which was not maintained.
The facility did not complete or transmit required MDS discharge assessments for two residents after their discharge, despite both having documented discharge plans and care needs. Interviews with the DOCR, DON, and ADM confirmed the assessments were not done, and the responsible staff member was no longer available, resulting in the deficiency.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs. These deficiencies were observed during the survey and directly impacted residents requiring assistance with bowel and bladder management.
Nurses and nurse aides lacked the appropriate competencies to provide care that maximizes each resident's well-being, resulting in care that did not meet regulatory standards for individualized resident needs.
A CNA provided peri care to a male resident with severe cognitive impairment and incontinence, changing gloves multiple times without performing hand hygiene between glove changes. This action was observed and confirmed by both the CNA and the DON, and was not in accordance with the facility's hand hygiene policy.
A resident with severe cognitive impairment and a history of wandering was able to leave the facility unsupervised for several hours after staff failed to apply a wander guard and did not communicate her supervision needs. The resident exited the building when an RN, unaware of her status, opened the door for her. The incident revealed lapses in staff communication, assessment, and adherence to elopement prevention protocols.
Staff failed to immediately report an incident in which a visitor was observed pounding on a resident's bed and yelling, as required by policy and regulation. The incident was reported up the internal chain of command but not to the administrator or state agency within the required timeframe, and the administrator only learned of the event after surveyor intervention. The resident involved had severe cognitive impairment and was highly dependent on staff for care.
A resident with severe cognitive impairment was subjected to alleged verbal abuse and physical intimidation by a visitor, as documented in progress notes. The facility did not investigate or report the incident as required, due to the administrator's lack of awareness of the documented allegation.
The facility did not maintain complete and accurate medical records for two residents, including a missing and incomplete discharge summary for one resident and inconsistent documentation of bathing for another. Staff interviews confirmed that required documentation was either not completed or updated after the fact, contrary to professional standards.
A resident was inaccurately documented as having a feeding tube in their MDS assessment, despite observations and interviews confirming they were eating by mouth. The error was acknowledged by the MDS Coordinator, who stated it was an accidental entry, potentially risking inadequate care.
The facility failed to maintain accurate care plans for two residents, leading to potential care discrepancies. One resident's care plan did not reflect their daily anticonvulsant medication, while another's inaccurately included oxygen therapy. These inaccuracies were confirmed through interviews and record reviews, posing risks of inappropriate or missed care.
A resident with a gastrostomy tube did not receive the prescribed enteral feeding rate, and medication flushes were not administered as ordered. The feeding pump was set at 60cc per hour instead of the prescribed 65cc per hour, and an LVN failed to perform necessary water flushes before and between medications. The DON confirmed the importance of adhering to these protocols to prevent malnutrition and tube blockage.
A resident with moderate cognitive impairment and multiple diagnoses was prescribed continuous oxygen at 2L/min but was observed receiving 3L/min. An agency nurse did not verify the oxygen setting, assuming it was correct. The DON acknowledged the risk of respiratory distress if the prescribed rate is not maintained, and the facility lacked a policy for oxygen therapy management.
A nurse failed to perform required water flushes before and between medication administrations via G-tube for a resident with dysphagia and gastrostomy status. Despite having passed a competency checklist, the nurse did not adhere to the prescribed procedure, as confirmed by another nurse and the DON. This failure was observed during medication preparation and contradicted the facility's policy on enteral tube medication administration.
A CNA in an LTC facility was observed picking up a roll that fell from a resident's tray with her bare hands and placing it back on the plate, contrary to the facility's food safety policy. The CNA acknowledged the unsanitary action but did not immediately replace the roll. The DON confirmed that staff are trained to avoid direct hand contact with food to prevent contamination.
Two residents were affected by infection control lapses in a facility. A CNA failed to change gloves and sanitize hands during incontinent care, while an LVN did not wear gloves when handling medication for a resident with a gastrostomy tube. Both staff members had received infection control training, but did not adhere to protocols, as confirmed by the DON.
Failure to Ensure RN Oversight of LVN Admission Assessments and Care Planning
Penalty
Summary
The facility failed to ensure that nursing staff, specifically an LVN, had and demonstrated the appropriate competencies and skill sets to provide nursing and related services in accordance with regulatory requirements. An LVN conducted an initial admission assessment, initiated a baseline care plan, and started the comprehensive care plan for a newly admitted resident with complex medical diagnoses, including acute on chronic combined systolic and diastolic heart failure, type 2 diabetes mellitus, and bilateral primary open-angle glaucoma. The LVN completed a head-to-toe assessment and care planning without the required review or oversight by an RN, as indicated by the absence of an RN signature on the assessment documentation. Interviews revealed that the LVN believed she was permitted to complete both the initial and baseline assessments and care plans independently, based on her training and facility practice, and was unaware that RN review was required. The Director of Nursing Services (DNS) and the new DON both confirmed that facility practice involved LVNs completing these assessments, with the expectation that an RN would review and sign off within 48-72 hours. However, in this instance, the RN review did not occur as required, and the baseline care plan and initial assessment were not signed by an RN. Record review and interviews further established that the facility had RNs on staff during the time of the admission, but the process for ensuring RN oversight was not followed. The Texas Board of Nursing LVN Scope of Practice specifies that LVNs must work under the supervision of an RN and are not permitted to perform independent comprehensive assessments or initiate care plans without RN involvement. The failure to ensure RN review and oversight of the LVN's assessments and care planning resulted in a deficiency related to nursing staff competencies and scope of practice.
Failure to Administer Ordered Insulin Due to Medication Access and Documentation Errors
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administration of medications for a resident with multiple diagnoses, including type 2 diabetes mellitus. Upon admission, the resident had a physician's order for Lantus (insulin glargine) to be administered subcutaneously at bedtime. Although the medication was documented as given on the Medication Administration Record (MAR), the assigned LVN did not actually administer the insulin on the first night of admission. The LVN stated she assumed the medication had not arrived from the pharmacy and inadvertently documented its administration when she only intended to record the completion of blood glucose monitoring (accuchecks). The resident later reported not receiving her insulin on the first night but had no noticeable effects and continued to receive her medication on subsequent nights. The facility's Director of Nursing Services confirmed that Lantus was available in the emergency medication kit and should have been administered as ordered. The LVN did not access the e-kit to obtain the medication, despite its availability and the presence of a physician order. Facility policy required medications to be administered accurately and timely as ordered by the physician.
Inaccurate Documentation of Insulin Administration by LVN
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) documented in the medical record that she administered Lantus (insulin glargine) to a newly admitted resident with type 2 diabetes, when in fact the medication was not given. The resident's medical record, including the Medication Administration Record (MAR), indicated that the insulin was administered as ordered by the physician. However, during interviews, the LVN admitted she did not administer the insulin because she assumed it had not yet arrived from the pharmacy, and she inadvertently documented its administration while intending only to record the completion of blood glucose monitoring (accuchecks). The LVN also acknowledged that the insulin was available in the facility's emergency medication kit but did not access it or administer the medication. The resident, who had recently been admitted with diagnoses including acute on chronic combined systolic and diastolic heart failure, type 2 diabetes mellitus, and primary open-angle glaucoma, reported not receiving her insulin on her first night in the facility but had no adverse effects and had informed staff. The facility lacked a specific policy addressing documentation accuracy, and the existing medication administration policy did not cover documentation procedures. The interim Director of Nursing Services (DNS) confirmed the documentation error and emphasized the importance of accurate record-keeping and following physician orders.
Failure to Coordinate Hospice Medication Orders on Admission
Penalty
Summary
The facility failed to effectively collaborate and communicate with hospice representatives to ensure a resident received prescribed glaucoma medications upon admission. The resident, admitted for hospice respite care, had a documented history of primary open-angle glaucoma and was taking three specific eye drop medications at home, as detailed in her preadmission home health paperwork. Despite this information being uploaded into the facility's medical record prior to admission, the medications were not included in the initial hospice orders written at the facility, and the resident did not receive these medications for several days after admission. Interviews revealed that the admitting nurse did not review the medication reconciliation list available in the resident's electronic medical record, relying instead on verbal instructions from the Admissions Coordinator and the hospice nurse. The hospice nurse, in turn, based her medication orders on the medications physically provided by the resident and did not consult the preadmission medication list. The resident and her family reported that the eye drops were brought to the facility and given to staff, but the medications were not administered until several days later, after the issue was discovered by facility leadership. Facility leadership, including the DON and DNS, stated that their process was to follow the orders written by the hospice nurse and not to reference the preadmission medication reconciliation list unless questions arose. The contract between the facility and hospice required joint development and agreement on the plan of care, but in practice, the facility deferred to hospice for medication orders. This lack of coordination and communication resulted in the resident missing several doses of her prescribed glaucoma medications immediately following admission.
Inaccurate MDS Coding of Resident Fall
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status regarding falls. Specifically, a male resident on hospice care with diagnoses including malignant neoplasm of the kidney, muscle wasting, and anxiety experienced a fall in his room while reaching for a blanket. The incident was documented in the facility's risk management system and in progress notes, with no injuries observed and appropriate notifications made to the physician, DON, and responsible party. Interventions, such as adding bed bolsters, were implemented and documented in the care plan. Despite the fall being documented in multiple records and discussed among staff, the resident's subsequent quarterly MDS assessment was coded as having had no falls since the prior assessment. The RNAC responsible for completing the MDS stated that her process for identifying falls included attending interdisciplinary meetings and reviewing risk management reports. However, she acknowledged that she coded the MDS incorrectly, indicating no falls, despite the existence of a risk management report documenting the incident. Interviews with the RNAC, DON, and administrator revealed a belief that the miscoding on the MDS would not impact the resident's care as long as the care plan was accurate and interventions were in place. The facility's policy requires that each resident receives an accurate assessment and that the MDS serves as the clinical basis for care planning and delivery. In this case, the MDS assessment did not accurately reflect the resident's fall history, constituting a deficiency in assessment accuracy.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to provide evidence that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for two residents reviewed for abuse and neglect. In the first case, a family member alleged neglect after observing a resident in a soiled brief. The facility's investigation did not include a physical assessment of the resident due to her discharge status and only included resident and staff interviews from other units, not the unit where the resident resided. The administrator confirmed that residents on the relevant unit were not surveyed during the investigation, and the determination of safety was based on routine staff rounds rather than direct investigation of the specific unit involved. In the second case, a family member alleged that a resident had been physically assaulted, resulting in a facial injury. The investigation included a physical assessment of the resident, interviews with the resident and family, and review of video footage. However, the investigation did not include abuse or neglect surveys of residents in the memory care unit where the resident lived, as the administrator believed those residents could not participate due to cognitive decline. No physical assessments were performed in place of verbal surveys for these residents, and the administrator relied on staff interviews and routine rounds to determine safety. Facility policy required investigations to include observations of the alleged victim, monitoring of at-risk residents, and assessment of interactions between staff and residents. Despite this, the investigations for both residents did not include direct interviews or assessments of other residents in the same units as the alleged victims. Additionally, some resident interview questionnaires were provided after the survey exit, without documentation of room numbers, making it impossible for surveyors to verify their relevance to the cases.
Lack of Clear Parameters for PRN Pain Medication Orders
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications for a resident with dementia and muscle weakness. Specifically, the resident had two PRN orders for Tramadol 50mg—one for 1 tablet and one for 2 tablets every 6 hours as needed for pain—without clear parameters or indications for when each dose should be administered. The medication administration record showed that the 1-tablet dose was given multiple times for varying pain levels, but the 2-tablet dose was never administered. Nursing staff reported uncertainty about when to use each order, and the orders lacked specific pain scale parameters to guide administration. The facility's pain management policy required monitoring and following physician orders, but the orders themselves were not sufficiently detailed to ensure proper administration. Interviews with staff revealed that nurses were unsure about the correct circumstances for administering the different PRN doses, and the pharmacist acknowledged that including pain scale parameters would be best practice. The physician clarified that the orders should have specified 1 tablet for pain levels 1-4 and 2 tablets for pain levels 5-10, but this was not reflected in the orders as written or transcribed. The lack of clear parameters in the PRN orders led to inconsistent administration practices and potential confusion among staff.
Inaccurate Clinical Documentation in Resident Medical Record
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for one resident, as required by accepted professional health information management standards. Specifically, the resident's clinical record included provider notes documenting symptoms of eye redness, a diagnosis of conjunctivitis, and treatment with erythromycin ointment. However, a review of the resident's list of medical diagnoses did not include conjunctivitis, and there were no corresponding physician orders or medication administration records indicating that erythromycin was ever ordered or administered. During interviews, both the Director of Nursing (DON) and the Nurse Practitioner (NP) stated they did not recall the resident experiencing eye redness, and the NP confirmed that the documentation regarding conjunctivitis was entered in error. The facility's policy requires that a medical record be maintained for every person admitted, in accordance with accepted professional standards and practices. The inaccurate documentation in the resident's clinical record represents a failure to meet these standards.
Failure to Implement Enhanced Barrier Precautions for Resident with Wound
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident with dementia and muscle weakness who had a forehead wound with sutures. Despite physician orders and care plans indicating the need for Enhanced Barrier Precautions (EBP) every shift, there was no signage or PPE cart present outside the resident's room on multiple observations. The resident's Treatment Administration Record (TAR) was signed as if EBP had been implemented, but staff interviews revealed confusion and lack of awareness regarding the resident's EBP status. The CNA was unaware of any isolation precautions for the resident, and the LVN did not recall signing the TAR or understand why EBP was ordered. The Director of Nursing (DON), acting as interim infection preventionist, also expressed uncertainty about the necessity of EBP for the resident and was unsure why the order was present or why staff had documented its implementation. The facility's infection control policy required EBP for residents with open wounds requiring a dressing, but the resident's wound was observed without a dressing. The lack of proper implementation and documentation of EBP, as well as staff confusion regarding infection control protocols, led to the deficiency.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the clinical status of three residents. For one resident with diabetes mellitus, the admission MDS did not indicate the use of hypoglycemic medication, despite active orders and administration of insulin (Lantus) for diabetes management. Both the Director of Clinical Records (DOCR) and the Director of Nursing (DON) acknowledged that the omission was an error and that the MDS should have accurately documented the use of insulin as a high-risk medication. Another resident with a flaccid neuropathic bladder and a suprapubic catheter had their Quarterly MDS assessment incorrectly coded. Although the resident had an indwelling catheter, the assessment was marked as "Always incontinent" instead of "Not rated" as required by the CMS RAI Manual for residents with catheters during the look-back period. The MDS coordinator and DOCR confirmed the miscoding, and the DON stated that MDS accuracy was the responsibility of the MDS coordinator. A third resident, diagnosed with depression and prescribed mirtazapine, had their quarterly MDS assessment coded as not receiving antidepressants, despite physician orders and medication administration records confirming ongoing antidepressant therapy. The MDS coordinator acknowledged the error, stating the resident should have been coded as receiving an antidepressant. Facility policy and CMS regulations require accurate and comprehensive assessments to ensure proper care planning and service delivery.
Expired Medications and Supplies Not Removed from Medication Room and Carts
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the timely removal of expired medications and supplies from the medication room and nursing carts. During observations, three expired intravenous antibiotic solutions intended for a resident with a history of sepsis, muscle weakness, type 2 diabetes, urinary tract infection, and hypertension were found in the medication room after the medication had been discontinued. Additionally, an expired germicidal wipe and an expired bottle of Senna-Plus were found in the medication room and a nursing cart, respectively. Staff interviews confirmed that these expired items were not in use, but there was no clear explanation for why they remained accessible. Record reviews indicated that the resident had severe cognitive impairment and had received the antibiotic as ordered, with the medication discontinued prior to the survey. The Director of Nursing and nursing staff acknowledged that expired medications and supplies should have been removed but were not, and also noted the absence of a specific facility policy regarding the handling of expired medications and wipes. The facility's existing medication administration policy did not address the removal of expired items.
Noncompliance with Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating noncompliance with established food safety and handling protocols. No additional details regarding specific residents, staff, or events are provided in the report.
Soiled Air Conditioning Vents in Resident Room
Penalty
Summary
A deficiency was identified when a resident's room was found to have an air conditioning vent in the ceiling that was visibly soiled with a black substance and rust, and the return vent was covered with dust. This was observed during a facility survey, and both the Director of Nursing (DON) and the District Manager for environment confirmed the presence of dust, rust, and dirt on the vent. The facility's deep clean schedule indicated that the room was scheduled for cleaning, but at the time of observation, the vents remained unclean. The resident involved was an elderly male with a history of Alzheimer's disease, heart failure, muscle weakness, muscle wasting and atrophy, and dementia. His quarterly MDS assessment indicated a BIMS score of 00, showing he was unable to complete the interview. The resident's care plan noted a risk for infection due to his compromised medical condition. The facility's policy required the environment to be maintained to protect the health and safety of residents, personnel, and the public, but the observed condition of the air conditioning vents did not meet these standards.
Failure to Complete and Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to encode and transmit required Minimum Data Set (MDS) discharge assessments within 14 days after discharge for two residents. For one resident, who had diagnoses including congestive heart failure, peripheral vascular disease, and acute respiratory failure with hypoxia, there was no discharge MDS assessment completed or transmitted as of several months after discharge. This resident's care plan included discharge planning interventions, and records indicated he was to be discharged home with family and provider services. For the second resident, who had diagnoses of muscle weakness, depression, and hypertension, and was cognitively intact, there was also no discharge MDS assessment completed or transmitted after discharge to a private home or apartment. This resident's care plan included a focus on returning home with supportive care and services. Interviews with facility staff, including the Director of Clinical Reimbursement (DOCR), Director of Nursing (DON), and Administrator (ADM), confirmed that the discharge MDS assessments were not completed for these two residents. The DOCR acknowledged the missing assessments and was unsure why they were not completed, noting that the responsible staff member was no longer available. The DON and ADM were unaware of the missing assessments until the time of the interview and recognized that the assessments had not been completed or submitted as required.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with incontinence, improper catheter care practices, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly related to the care provided to residents requiring assistance with bowel and bladder management.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified due to a lack of evidence that staff possessed or applied the required skills and knowledge to meet the individualized needs of all residents. This failure resulted in care that did not fully support the highest possible level of well-being for each resident, as required by regulatory standards.
Failure to Perform Hand Hygiene Between Glove Changes During Peri Care
Penalty
Summary
A certified nursing assistant (CNA) failed to follow proper infection control procedures while providing peri care to a male resident with severe cognitive impairment, hemiplegia, and incontinence. During the care, the CNA changed gloves multiple times without sanitizing or washing hands between glove changes, despite the facility's policy requiring hand hygiene between glove changes. This was observed while the CNA cleaned the resident's groin, buttock, and rectal areas and replaced the resident's brief. Interviews with the CNA and the Director of Nursing (DON) confirmed that hand hygiene should have been performed before donning new gloves to prevent infection. The facility's hand hygiene policy, revised in January 2023, specifically required the use of alcohol-based hand rub or soap and water between glove changes. The failure to adhere to this policy was directly observed and acknowledged by both the CNA and the DON.
Resident Elopement Due to Failure in Supervision and Safety Protocols
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, including vascular dementia and Alzheimer's disease, was able to elope from the facility without staff knowledge for nearly seven hours. The resident had a history of wandering, as indicated by her previous facility and her Minimum Data Set (MDS) assessment, which showed a BIMS score of 1 out of 15 and recent wandering behavior. Despite this, the resident was not provided with a wander guard upon admission, and staff failed to implement appropriate supervision or monitoring measures. The sequence of events leading to the deficiency began with the resident's admission, during which the need for a wander guard was communicated to staff and documented in the electronic medical record (EMR) dashboard. However, the assigned nurse did not apply the wander guard, and there was a lack of communication between staff regarding the resident's supervision needs. Video surveillance showed that the wander guard was handled but not applied, and the nurse going on break did not relay any special supervision instructions. Later, a registered nurse opened the facility door and allowed the resident to exit, not recognizing her as a resident. The resident was able to leave the facility and was later found at a nearby hospital, which contacted the facility. Staff interviews revealed gaps in training and procedures for identifying residents versus visitors, as well as failures in following established protocols for new admissions at risk for elopement. The facility's policy required assessment and intervention for elopement risk, but these were not properly executed, resulting in the resident's unsupervised exit.
Failure to Timely Report Alleged Abuse by Visitor
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than two hours after the allegation was made, as required by regulation and facility policy. Specifically, a visitor was observed by a CNA pounding hard on a resident's bed and yelling, "Wake up!" The resident's roommate questioned the visitor's behavior, asking why they were always so mean. The CNA reported the incident to an LVN, who then reported it to the ADON, but neither the administrator nor the state agency was notified within the required timeframe. The administrator only became aware of the incident after being informed by the surveyor and confirmed that she had not seen the relevant nursing note prior to this intervention. The resident involved was an elderly female with Alzheimer's disease, severe cognitive impairment (BIMS score of 01), and significant functional dependencies, making her particularly vulnerable. Record review confirmed that no self-reported incidents regarding allegations of neglect or abuse were submitted to the state system. Interviews with staff revealed a misunderstanding of the reporting chain of command, with both the CNA and LVN believing that their actions fulfilled reporting requirements, while the ADON did not recall receiving a report. Facility policy required prompt reporting of suspected abuse, including by visitors, but this was not followed in this case.
Failure to Investigate and Document Alleged Abuse by Visitor
Penalty
Summary
The facility failed to provide evidence that all allegations of abuse, neglect, or mistreatment were thoroughly investigated and documented for one resident. Specifically, a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and anxiety, was the subject of an incident in which a visitor was observed angrily pounding on her bed and yelling at her to wake up. The resident was also heard asking the visitor why they were always so mean to her. This incident was documented in the resident's progress notes. Despite the documentation of this event, the facility administrator confirmed that no investigation was conducted because she was unaware of the incident and had not reviewed the progress note prior to the surveyor's inquiry. The facility's policy requires prompt reporting and investigation of all suspected abuse, including verbal abuse by visitors, and mandates reporting to the appropriate authorities within specified time frames. However, in this case, the required investigation and reporting did not occur.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, the electronic medical record did not contain a completed discharge summary at the time of discharge. The discharge summary was found to have errors and was not marked as complete or locked in the system, with missing answers to required prompts. Interviews with staff confirmed that the summary was not finalized according to facility expectations, which require a completed, signed, and dated document without errors. For another resident, documentation of showers or baths was inconsistent and not appropriately recorded in the electronic medical record. Initially, only one shower was documented for a specific week, but later, an additional entry was added after staff were prompted to update their documentation. The CNA responsible stated that the shower had been provided but was not documented at the time, and the entry was made later to keep records up to date. The facility's policy requires that a medical record be maintained for every resident in accordance with accepted professional standards, including accurate records of care and services provided.
Inaccurate MDS Assessment for Resident Without Feeding Tube
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, identified as Resident #55, who was incorrectly documented as having a feeding tube. This error was discovered during a review of the resident's quarterly MDS assessment dated May 1, 2024, which inaccurately indicated the presence of a feeding tube. However, observations and interviews confirmed that Resident #55 was eating meals by mouth and did not have a feeding tube. The resident's care plan, dated June 5, 2024, also did not identify the presence of a feeding tube. Interviews with the Assistant Director of Nursing (ADON) and the MDS Coordinator further confirmed that Resident #55 did not have a feeding tube. The ADON stated that the resident had been eating meals and snacks by mouth and had never had a feeding tube during the ADON's tenure at the facility. The MDS Coordinator acknowledged that the feeding tube was checked accidentally during the last assessment and recognized the risk of the resident not receiving appropriate care due to this error. The facility's failure to accurately assess the resident's status could potentially lead to inadequate care.
Inaccurate Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which led to deficiencies in their care. For one resident, the care plan did not reflect the daily administration of an anticonvulsant medication, Keppra, which was prescribed for seizure management. Despite the resident's medical records and medication administration records indicating the use of Keppra, the care plan was not updated to include this critical information. Interviews with the resident and facility staff confirmed the oversight, highlighting the risk of missing important care information due to inaccuracies in the care plan. For another resident, the care plan inaccurately included oxygen therapy as part of the resident's care, despite the absence of any physician orders or observations of the resident receiving such therapy. The resident confirmed not being on oxygen therapy recently, and staff interviews corroborated that the care plan should not have included this treatment. The inaccuracies in the care plans could lead to residents receiving inappropriate or missed care, as the care plans serve as essential communication tools for staff to understand and provide the necessary care.
Deficiency in Enteral Feeding and Medication Administration
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube received the appropriate treatment and services as ordered by the physician. Specifically, the enteral feeding tube rate for the resident was set at 60cc per hour instead of the prescribed 65cc per hour. This discrepancy was observed during a survey, and the responsible nurse admitted to not checking the feeding pump's settings, assuming it was correct. The Director of Nursing (DON) confirmed the importance of maintaining the prescribed feeding rate to prevent malnutrition and ensure the resident receives the necessary nutrients. Additionally, the facility did not adhere to the prescribed medication administration protocol for the resident with the gastrostomy tube. An LVN failed to administer the required water flushes before and between medications, as confirmed by another LVN present during the administration. The DON acknowledged the necessity of these flushes to prevent clogging or blockage of the tubing. The facility lacked a specific policy or procedure on G-tube management, which was confirmed by the Administrator when requested by the surveyor.
Failure to Provide Prescribed Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring oxygen therapy, as observed by surveyors. Resident #16, who was moderately cognitively impaired and had diagnoses including cerebral atherosclerosis, refractory anemia, and unspecified convulsions, was prescribed continuous oxygen at 2 liters per minute. However, during multiple observations on the same day, the resident's oxygen concentrator was found to be set at 3 liters per minute, contrary to the prescribed rate. An interview with RN A, an agency nurse assigned to the resident, revealed that she did not verify the oxygen concentrator's setting and assumed it was correct. The Director of Nursing confirmed the importance of maintaining the prescribed oxygen rate to prevent respiratory distress. Additionally, the facility lacked a policy or procedure for oxygen therapy management, as confirmed by the Administrator when requested by the surveyor.
Failure in G-Tube Medication Administration
Penalty
Summary
The facility failed to ensure that a nurse, identified as LVN C, demonstrated competency in administering medications via a G-tube for a resident with dysphagia, atherosclerotic heart disease, and gastrostomy status. The resident, who was moderately cognitively impaired and dependent on staff for activities of daily living, had active orders requiring specific water flushes before and between medication administrations through the G-tube. However, during an observation, LVN C did not perform the required premedication water flush of 30 CC and did not flush with water between medications, as confirmed by another nurse, LVN D, who was present during the administration. Interviews with LVN C and the Director of Nursing (DON) confirmed the necessity of the flushes to prevent clogging or blockage of the tubing. Despite LVN C having passed a competency checklist for tubing and medication administration just two days prior, the failure to adhere to the prescribed procedure was evident. The facility's policy on medication administration via enteral tube also outlined the importance of flushing to maintain tube patency, which was not followed in this instance.
Food Safety Protocol Breach
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a dining session. A Certified Nursing Assistant (CNA) was seen picking up a roll that had fallen from a resident's tray onto the table with her bare hands and placing it back onto the resident's plate. This action was contrary to the facility's policy, which prohibits direct contact with food using bare hands. The CNA acknowledged that she should have replaced the roll instead of handling it with her hands, recognizing the unsanitary nature of her action. Despite this acknowledgment, the resident continued to eat the roll before the CNA returned with a replacement. The Director of Nursing (DON) confirmed that staff are trained not to touch residents' food with bare hands to prevent contamination and potential illness. The facility's policy on food preparation and handling, revised in June 2019, explicitly states that bare hands should not come into direct contact with food. This incident highlights a lapse in following established food safety protocols, which could affect residents dining in the facility's dining room.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two separate incidents involving improper care practices. In the first incident, a Certified Nursing Assistant (CNA) did not change gloves or sanitize her hands before touching a clean brief after providing incontinent care to a resident. This resident had multiple diagnoses, including anemia, hypertension, and chronic kidney disease, and required extensive assistance with daily activities. The CNA confirmed during an interview that she did not follow proper hand hygiene protocols, despite having received training in infection control. In the second incident, a Licensed Vocational Nurse (LVN) failed to wear gloves while handling medication for a resident who received nutrition and medication via a gastrostomy tube. The resident had a history of dysphagia and atherosclerotic heart disease and was dependent on staff for assistance with activities of daily living. The LVN acknowledged the lapse in protocol during an interview, confirming that she should have worn gloves to prevent cross-contamination. The Director of Nursing (DON) confirmed that both staff members had received infection control training within the year, and the facility's policies required sanitary practices during medication administration.
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.
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What surveyors actually found near you
We read the 985 citations issued within 25 miles in the last 12 months — including the 20 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 San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sonterra Health Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Coronado At Stone Oak | 0.8 mi | ★★★★★ | 2 | 0 |
| The Enclave | 1.1 mi | ★★★★★ | 20 | 0 |
| Estates At Shavano Park | 5.2 mi | ★★★★★ | 20 | 0 |
| Castle Hills Rehabilitation And Care Center | 5.9 mi | ★★★★★ | 52 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.