Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Sarah Roberts French Home during CMS and state inspections, most recent first.
Missing Admission Physician Orders: A resident admitted with multiple diagnoses, including DM II, HTN, acute respiratory failure with hypoxia, cognitive communication deficit, altered mental status, and UTI, did not have a physician order specifically authorizing admission to the facility. The chart showed only an order stating the resident required nursing facility care, with no documented physician visit, while the resident had significant care needs including impaired vision, severe cognitive impairment, wandering, incontinence, insulin administration, and therapy services.
A resident admitted with multiple medical and cognitive diagnoses was not seen face-to-face by a physician after admission, despite charted NP and psychiatry visits. The record showed severe cognitive impairment, wandering, incontinence, insulin use, and therapy needs, while the resident stated she had not been visited by a physician since admission. Facility policy required physician visits within the first 30 days and at regular intervals thereafter, with specific requirements during the initial 90 days.
Improper Administration of Delayed-Release Pantoprazole: An LVN gave a resident a whole pantoprazole tablet even though the resident had orders for meds to be crushed or given in liquid form due to a swallowing problem and choking risk. The resident had severe cognitive impairment, a mechanically altered diet, and an MBSS summary that recommended crushing meds or using liquid form. The pharmacy label said the delayed-release pantoprazole was not to be crushed, and the pharmacist stated it would be ineffective if crushed.
Staff did not follow Enhanced Barrier Precautions during the transfer of a resident with skin impairment and incontinence, as two CNAs failed to wear gowns and gloves despite facility policy and posted signage requiring PPE for high-contact care activities.
The facility did not report several incidents of alleged abuse, neglect, or injury—including a fracture, a head laceration requiring staples, and a resident-to-resident altercation—within the required two-hour timeframe. In each case, the events were reported to authorities later than policy and regulation require, despite clear facility guidelines mandating immediate reporting.
The facility failed to maintain an effective training program for 17 staff members, including CNAs, Med Aides, and RNs, lacking annual training in essential areas like Communication, QAPI, and Behavioral Health. The HR Manager cited a challenging year as the reason for the oversight, which was confirmed through interviews and record reviews.
The facility failed to provide mandatory annual training for 17 staff members, including CNAs, Med Aides, LVNs, RNs, and administrative staff. Essential training topics such as Communication, Residents Rights, QAPI, Infection Control, Ethics, Behavioral Health, HIV, Falls, and Restraints were not documented. The HR Manager attributed the oversight to a challenging year, and the lack of training was confirmed through personnel record reviews and interviews.
The facility failed to provide mandatory behavioral health training for 16 out of 17 staff members, including CNAs, med aides, and administrative staff. Interviews and record reviews revealed that these employees did not receive annual training on essential topics such as communication, resident rights, QAPI, infection control, ethics, behavioral health, HIV, falls, and restraints. The HR manager and administrator acknowledged the oversight, citing a challenging year as a contributing factor, and recognized the increased risk of poor treatment, abuse, and neglect of residents.
The facility failed to provide mandatory annual training on communication and other essential topics for 8 out of 17 staff members reviewed, including CNAs, LVNs, and maintenance personnel. This oversight was confirmed through personnel records and training logs, with the HR Manager citing a challenging year as a contributing factor. The Administrator acknowledged the increased risk to residents due to this deficiency.
The facility failed to provide mandatory annual training on residents' rights and other essential topics for three staff members, including a cook, admissions staff, and the DON. Personnel records showed no evidence of required training, and the HR Manager acknowledged the oversight, citing a challenging year. This deficiency could affect residents' care due to uninformed staff.
The facility did not provide mandatory training on abuse, neglect, exploitation, and misappropriation for five employees, including Admissions, CNA, Med Aide, LVN, and ADON. Training logs showed no evidence of annual training on essential topics, confirmed by interviews with HR and Admin. The lack of training could affect resident care.
The facility failed to provide mandatory infection prevention and control training for four staff members, including a cook, maintenance staff, a CNA, and a medication aide. Personnel records showed no evidence of required annual training on topics such as communication, resident rights, and infection control. Interviews revealed that the HR manager and administrator were responsible for ensuring training through an online system, but challenges during the year led to this oversight.
The facility failed to provide mandatory ethics training for four staff members, including a cook, a CNA, a Med Aide, and the DON. Personnel records showed these employees did not receive annual training on essential topics like communication, resident rights, QAPI, infection control, ethics, and more. The HR Manager, responsible for assigning these trainings, cited a challenging year as the reason for the oversight. The facility's policy requires annual training and documentation, which was not adhered to, potentially placing residents at risk.
A resident with severe cognitive impairment and chronic health conditions was admitted to a facility with an incomplete DNR order. The facility failed to ensure the DNR was properly documented and communicated, resulting in the resident being classified as a full code. The resident's responsible party was not informed about the process or the facility's ability to assist with completing the DNR form.
A resident with Alzheimer's disease suffered a nose fracture from an unwitnessed fall, but the LTC facility failed to report the injury to HHSC as required. The resident was unable to explain the incident, and the facility's staff misunderstood the reporting requirements, leading to a deficiency in reporting suspected abuse or neglect.
A resident's care plan in an LTC facility failed to include her code status, despite her being admitted with a full code status. The resident, with dementia and other chronic conditions, had a DNR order from a previous facility, but the documentation was incomplete. Interviews revealed communication gaps and procedural oversights, with the DON acknowledging the omission and the MDS nurse typically discussing code status without it being documented.
The facility failed to discard expired supplies in a medication storage room and a crash cart, including gastrostomy tubes, iodoform packing strips, a CPR barrier mask, and a capnography mask. The DON stated that night shift nurses were responsible for checking for expired supplies, but these were not removed as required by the facility's policy.
The facility failed to prepare mechanical soft porkchops to the correct consistency, as observed during a meal. Cook A, who was trained on mechanical soft textures, left large pieces in the dish, posing a choking risk. The Dietary Manager confirmed the importance of proper texture for resident safety. The facility's policy on therapeutic diets was reviewed, but the specific process for mechanical soft diets was not provided.
A facility failed to coordinate hospice care and ensure proper documentation for a resident receiving hospice services. The resident, with severe cognitive impairment and multiple diagnoses, lacked a completed Physician Certification of Terminal Illness in their records. Staff interviews revealed lapses in document review and coordination responsibilities, contrary to facility policy.
Missing Admission Physician Orders
Penalty
Summary
The facility failed to have physician orders for the immediate care of Resident #2 at the time of admission. Record review showed Resident #2 was admitted with diagnoses including diabetes II, anxiety disorder, hypertension, acute respiratory failure with hypoxia, cognitive communication deficit, altered mental status, and urinary tract infection. The physician order dated 11/1/2025 at 2:27 PM stated that the resident required or continued to require nursing facility care for 180 days, but it did not specifically document that the resident was to be admitted to the facility. Further record review showed no physician visit documented in the chart, although there was a nurse practitioner visit on 11/18/2025 and a psychiatry initial evaluation on 11/12/2025. The resident’s record also reflected significant care needs, including impaired vision, a BIMS score of 7/13, behaviors and wandering, wheelchair use, supervision for ADLs, frequent bowel and bladder incontinence, insulin and injection administration, and therapy services. The LVN stated the resident was admitted from the hospital and did not have an order to admit to the facility, and the DON stated that after reviewing the orders, she did not see orders for this resident.
Failure to Ensure Required Physician Face-to-Face Visits After Admission
Penalty
Summary
The facility failed to ensure Resident #2 was seen face-to-face by a physician within the required time frame after admission. Record review showed the resident was admitted on 11/1/2025 with diagnoses including diabetes type II, anxiety disorder, hypertension, acute respiratory failure with hypoxia, cognitive communication deficit, altered mental status, and urinary tract infection. The chart contained a nurse practitioner visit on 11/18/2025 and a psychiatry initial evaluation on 11/12/2025, but no record of a physician visit. The resident’s quarterly MDS reflected severe cognitive impairment, behaviors, wandering, wheelchair use, supervision needs for ADLs, frequent bowel and bladder incontinence, insulin/injection administration, and therapy services. The resident’s care plan identified diabetes, prior head surgery from a fall, ADL self-care needs, risk for wandering and falls, weakness, memory impairment, inability to manage medications, and difficulty falling asleep. During interview, Resident #2 stated she had not been visited by a physician since admission. An LVN stated the resident had been admitted from the hospital. The facility policy stated residents must be seen by a physician within the first 30 days after admission and every 30 days thereafter for the first 90 days, then every 60 days after that, with the physician able to delegate visits to a PA or NP, but the attending physician must alternate visits with the PA or NP during the Medicare admission period.
Improper Administration of Delayed-Release Pantoprazole
Penalty
Summary
The facility failed to ensure pharmaceutical services were provided to meet the needs of each resident when an LVN administered a whole pantoprazole tablet to a resident whose orders required medications to be crushed or given in liquid form because of a choking risk. The resident had diagnoses including Alzheimer's disease, anxiety, and hypertension, and had a BIMS score of 6, indicating severe cognitive impairment. Her care plan identified a swallowing problem related to GERD and a mechanically altered diet, with staff to be informed of her special dietary and safety needs. The resident's MBSS consult summary documented strategies for pills, including crushing medications or using liquid form due to choking risk. The physician's orders also directed that pills be crushed and/or given in liquid form. However, the resident's pantoprazole 20 mg delayed-release medication was supplied by the pharmacy as a whole pill with a label stating do not crush. The MAR showed the pantoprazole was administered as a whole pill on multiple days, and during interview the LVN stated she had given the medication whole without crushing because the resident could tolerate the small pill. The pharmacist stated the pantoprazole was delayed release and should not be crushed, and that if crushed it would be ineffective; he also stated a sprinkle formulation could be used in applesauce. The DON and Administrator stated the expectation was for nursing staff to administer medications as prescribed. The report also states the resident was assessed without negative outcomes and the physician was notified with no new orders.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to follow the facility's Enhanced Barrier Precautions (EBP) protocol while providing care to a resident with a history of type 2 diabetes mellitus and a foot ulcer. During an observed transfer using a mechanical lift, two CNAs did not wear gowns as required by the facility's EBP policy, despite signage and PPE supplies being present outside the resident's room. The resident's care plan indicated the need for EBP due to actual skin impairment and incontinence, and the facility's policy specified that gowns and gloves must be worn during high-contact activities such as transfers. Interviews with the CNAs and facility leadership confirmed that staff were aware of the EBP requirements, but the CNAs believed gowns were only necessary for certain types of care, not transfers. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) both stated that the expectation was for staff to don gowns and gloves during transfers for residents on EBP. The facility's policy, dated 4/1/2024, clearly outlined the need for PPE during such activities, but this was not followed during the observed incident.
Failure to Timely Report Alleged Abuse, Neglect, and Injuries
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation was made, as required by regulation and facility policy. In four separate cases, the facility did not report incidents involving major injuries or allegations of abuse within the required timeframe to the administrator and the State Survey Agency. These incidents included a resident with a coccyx fracture, a resident with a head laceration requiring staples after a fall, and a resident-to-resident altercation involving an allegation of being hit. In the first case, a resident with Alzheimer's disease and a history of falls was found to have a coccyx fracture after an X-ray ordered by hospice. The facility received the X-ray results indicating a likely acute fracture but did not report the incident to the appropriate authorities until two days later. In the second case, a resident with severe cognitive impairment and a history of unassisted transfers fell in the bathroom, resulting in a head injury that required five staples. The incident was not reported until the following day, outside the required reporting window. In the third case, a resident with minimal cognitive impairment alleged that her roommate hit her on the side of the face. The allegation was made to staff, but the facility did not report the incident to the authorities until two days later. Interviews with current administrative staff revealed that they were not employed at the time of the incidents and were unsure why the required reporting timelines were not met. Facility policy clearly states that all allegations of abuse, neglect, or injuries of unknown source must be reported immediately, but not later than two hours after the incident occurs or is suspected.
Failure to Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff members, affecting 17 employees reviewed for training requirements. The deficiency was identified through interviews and record reviews, revealing that required trainings were not provided annually to various staff members, including Cooks, Maintenance, Admissions, CNAs, Med Aides, LVNs, RNs, Admin, DON, and ADON. The lack of training covered essential topics such as Communication, Residents Rights, QAPI, Infection Control, Ethics, Behavioral Health, HIV, Falls, Restraints, and Emergency Preparedness. Personnel records showed that employees hired as far back as 1996 and as recently as 2023 did not receive the necessary annual training. For instance, a CNA hired in 2010 lacked training in Communication, QAPI, Behavioral Health, HIV, and Restraints. Similarly, a Med Aide hired in 2022 did not receive training in Dementia, QAPI, Behavioral Health, and Falls. The HR Manager, responsible for assigning these trainings through an online system, acknowledged the oversight, attributing it to a challenging year. Interviews with HR and the Admin highlighted the importance of these trainings in ensuring residents' well-being and preventing poor treatment, abuse, and neglect. The facility's policy on in-service training, dated August 2022, outlined the required training topics and emphasized the need for training prior to staff providing services to residents, annually, and as necessary based on facility assessment. However, the documentation of completed training was found lacking, contributing to the deficiency.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff, affecting 17 employees reviewed for training requirements. The deficiency was identified through interviews and record reviews, revealing that the facility did not provide mandatory annual training on various essential topics such as Communication, Residents Rights, Quality Assurance and Performance Improvement (QAPI), Infection Control, Ethics, Behavioral Health, HIV, Falls, and Restraints. This lack of training was evident across multiple staff roles, including Cooks, Maintenance, Admissions, Certified Nursing Assistants (CNAs), Medication Aides, Licensed Vocational Nurses (LVNs), Registered Nurses (RNs), and administrative staff. Personnel records showed that employees hired as far back as 1996 and as recently as 2023 had not received the required annual training. For instance, a CNA hired in 2010 had no evidence of training in Communication, QAPI, Behavioral Health, HIV, and Restraints. Similarly, a Med Aide hired in 2022 lacked training in Dementia, QAPI, Behavioral Health, and Falls. The HR Manager, responsible for assigning these trainings through an online system, acknowledged the oversight, attributing it to a challenging year. Interviews with the HR Manager and the Administrator highlighted the importance of these trainings in ensuring residents receive proper care and are protected from poor treatment, abuse, and neglect. The facility's policy on in-service training, dated August 2022, outlined the required training topics and emphasized the necessity of completing these trainings before staff provide services to residents and annually thereafter. However, the facility failed to adhere to these policies, as evidenced by the lack of documented training across the reviewed personnel records.
Failure to Provide Mandatory Behavioral Health Training
Penalty
Summary
The facility failed to provide mandatory and effective behavioral health training for 16 out of 17 employees reviewed, including various staff members such as cooks, maintenance personnel, admissions staff, CNAs, med aides, LVNs, RNs, and administrative staff. The deficiency was identified through interviews and record reviews, which revealed that these employees did not receive annual training on essential topics such as communication, resident rights, QAPI, infection control, ethics, behavioral health, HIV, falls, and restraints. The lack of training was documented in personnel records, which showed no evidence of the required training being provided annually. Interviews with the HR manager and the administrator highlighted that the facility used an online system, RELIAS, for initial and annual staff training. However, the HR manager admitted to not ensuring that staff received their annual training, citing a challenging year as a contributing factor. The administrator acknowledged the shared responsibility with HR to ensure staff training and recognized that the lack of training increased the risk of poor treatment, abuse, and neglect of residents. The facility's policy on in-service training, dated August 2022, outlined the required training topics and emphasized the importance of completing training before staff provide services to residents, annually, and as necessary based on the facility assessment. Despite this policy, the facility failed to document completed training for the staff, as evidenced by the absence of records showing the date, time, topic, method, competency assessment, and hours of training completed.
Failure to Provide Mandatory Staff Training
Penalty
Summary
The facility failed to provide mandatory effective communication training for 8 out of 17 employees reviewed, including various staff members such as a cook, maintenance personnel, CNAs, a med aide, and LVNs. The personnel records revealed that these employees did not receive annual training on essential topics such as communication, resident rights, QAPI, infection control, ethics, behavioral health, HIV, falls, and restraints. The lack of documented training was confirmed through a review of training logs provided by the HR Manager, indicating a systemic issue in ensuring staff compliance with required training protocols. Interviews with the HR Manager and the Administrator highlighted that the responsibility for ensuring staff received their initial and annual training fell on both HR and the Administrator. The HR Manager admitted to challenges in the past year that contributed to the oversight in training. The Administrator acknowledged that the absence of annual training increased the risk of poor treatment, abuse, and neglect of residents. The facility's policy on in-service training outlined the required topics and the necessity for training to be completed before staff provided services to residents, annually, and as needed based on facility assessments.
Deficiency in Staff Training on Residents' Rights
Penalty
Summary
The facility failed to provide mandatory and effective training on residents' rights for three of the seventeen employees reviewed, including a cook, an admissions staff member, and the Director of Nursing (DON). The personnel records for these employees showed no evidence of annual training on critical topics such as residents' rights, abuse prevention, dementia care, and other essential areas. The HR Manager, responsible for assigning these trainings through an online system called RELIAS, acknowledged the oversight and attributed it to a challenging year. The lack of training was confirmed through interviews with both the HR Manager and the facility administrator, who recognized the importance of these trainings in ensuring residents' well-being. The facility's policy on in-service training, dated August 2022, outlines the required training topics and the necessity for these to be completed annually. However, the records reviewed indicated a failure to adhere to these requirements, as evidenced by the absence of documented training for the specified employees. The policy also mandates that training be documented by the staff development coordinator, including details such as the date, topic, method, and hours of training completed. This deficiency in training could potentially place residents at risk due to staff being uninformed about essential care practices and resident rights.
Failure to Provide Mandatory Staff Training
Penalty
Summary
The facility failed to provide mandatory and effective training on abuse, neglect, exploitation, and misappropriation for five out of seventeen employees reviewed. These employees included Admissions, CNA E, Med Aide D, LVN G, and ADON. The training logs, as provided by the HR Manager, showed no evidence of annual training on critical topics such as Residents Rights, Abuse, Dementia, QAPI, Behavioral Health, and others. The lack of training was confirmed through interviews with the HR Manager and the Administrator, who acknowledged the oversight and its potential impact on resident care. The HR Manager admitted to using an online system, RELIAS, for staff training but failed to ensure that staff received their annual training. The facility's policy on in-service training, dated August 2022, outlines the required training topics and the necessity for annual training. However, the records reviewed indicated that these requirements were not met for the specified employees, potentially placing residents at risk due to the staff's lack of training.
Failure to Provide Mandatory Infection Control Training
Penalty
Summary
The facility failed to provide mandatory effective training on standards, policies, and procedures for an infection prevention and control program for four employees, including a cook, maintenance staff, a CNA, and a medication aide. The personnel records for these employees showed no evidence of receiving required annual training on various topics such as communication, resident rights, QAPI, infection control, ethics, behavioral health, HIV, falls, and restraints. This lack of training was identified through interviews and record reviews conducted by surveyors. Interviews with the HR manager and the administrator revealed that the facility uses an online system, RELIAS, for staff training. The HR manager is responsible for ensuring staff receive their annual training by assigning them through the system. However, the HR manager admitted that it had been a challenging year, which contributed to the oversight. The administrator acknowledged that the lack of training could increase the risk of poor treatment, abuse, and neglect of residents. The facility's policy on in-service training outlines the required topics and the documentation process, but these were not adhered to in this instance.
Failure to Provide Mandatory Ethics Training
Penalty
Summary
The facility failed to provide mandatory effective ethics training for four out of seventeen employees reviewed, including a cook, a CNA, a Med Aide, and the Director of Nursing (DON). The personnel records revealed that these staff members did not receive annual training on essential topics such as communication, resident rights, QAPI, infection control, ethics, behavioral health, HIV, falls, and restraints. The HR Manager, responsible for assigning these trainings through an online system, acknowledged the oversight, attributing it to a challenging year. The lack of training was confirmed through interviews with both the HR Manager and the Administrator, who emphasized the importance of these trainings in ensuring residents' well-being. The facility's policy on in-service training, dated August 2022, outlines the required training topics and the necessity for these to be completed annually. However, the records showed no evidence of compliance with these requirements for the specified employees. The policy also mandates documentation of completed training, including details such as the date, time, topic, method, and competency assessment. The failure to adhere to these training protocols could potentially place residents at risk due to staff being uninformed and inadequately prepared to handle various aspects of resident care.
Failure to Ensure Resident's Advance Directive
Penalty
Summary
The facility failed to ensure that a resident's right to formulate an advance directive was honored, specifically for a resident who was admitted with a Do Not Resuscitate (DNR) order from a previous facility. The resident, who was severely cognitively impaired and had multiple chronic health conditions, did not have a completed Out-of-Hospital (OOH) DNR form in her medical record. The form lacked necessary signatures, including those of a witness and a doctor, and was not notarized, which led to the resident being classified as a full code in the facility. Interviews with the resident's responsible party (RP) revealed that they were not informed by the facility staff about the process of completing the DNR form or that the facility could assist with it. The RP believed that all family members agreed on the DNR status due to the resident's condition. The social worker, who was a contracted vendor, documented the RP's desire for a DNR but stated that other facility staff were responsible for following up on the code status changes. The Director of Nursing (DON) and the Administrator acknowledged the oversight, with the DON stating that the resident's wishes would not be honored if the code status was not properly documented. The facility's policy on advance directives required that such documents be maintained in the resident's medical record and communicated to care staff, but this was not followed in this case, leading to the deficiency.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin involving a resident who suffered a nose fracture. The incident was unwitnessed, and the resident, who had moderately impaired cognition due to Alzheimer's disease and white matter disease, was unable to explain how the injury occurred. The facility's policy requires that such incidents be reported immediately, but the staff did not report the injury to the state reporting agency (HHSC) within the required timeframe. The resident, an elderly female with a history of Alzheimer's disease, was found on the floor with a nose fracture and was unable to recall the events leading to her fall. The facility's records indicated that the resident had a history of poor balance and safety awareness, which contributed to the fall. Despite the severity of the injury, which required medical intervention, the facility did not classify it as a reportable incident because they believed they understood the circumstances of the fall. Interviews with the facility's Administrator and DON revealed a misunderstanding of the reporting requirements for injuries of unknown origin. The Administrator believed the resident had communicated the cause of the fall, and the DON did not document the resident's account of the incident. The facility's policy clearly outlines the need to report such injuries, but the staff failed to adhere to these guidelines, resulting in a deficiency in reporting suspected abuse, neglect, or injuries of unknown origin.
Failure to Document Code Status in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically omitting the resident's code status. The resident, an elderly female with dementia, type 2 diabetes mellitus, and chronic obstructive pulmonary disease, was admitted with a full code status according to her face sheet. However, her comprehensive care plan and order summary report did not reflect this code status. Additionally, there was a discrepancy in the resident's transfer admission records, which indicated a Do Not Resuscitate (DNR) order from a previous facility, but the necessary documentation was incomplete, lacking witness and doctor signatures. Interviews with the resident's responsible party (RP) and facility staff revealed communication gaps and procedural oversights. The RP was unaware that the facility could assist with completing the DNR paperwork and was informed that the OOH DNR form needed notarization. The social worker, who was contracted to assist with care plan meetings, documented the resident's or RP's code status preferences but did not follow up on changes. The Director of Nursing (DON) acknowledged the oversight and mentioned that the MDS nurse typically discusses code status during meetings, yet it was not documented in the care plan. This deficiency could potentially place residents at risk of not receiving necessary care aligned with their preferences.
Expired Supplies Found in Medication Storage and Crash Cart
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not discarding and replacing expired supplies in one of the three medication storage rooms and one of the two crash carts reviewed. During an observation, it was found that the central supply storage room contained expired gastrostomy tubes and iodoform packing strips. Additionally, the north hallway crash cart contained a CPR barrier mask and a capnography mask with expired use-by dates. These expired supplies were not removed, which could potentially affect the therapeutic benefits of medications administered to residents. Interviews with facility staff revealed that the night shift nurses were responsible for checking the crash carts for expired supplies. However, the Director of Nursing (DON) acknowledged that expired supplies should not be present and should be removed. The facility's policy on medication storage emphasized the importance of maintaining medication storage areas in a clean, safe, and sanitary manner, and required that expired or deteriorated drugs be returned to the pharmacy or destroyed. Despite these policies, the facility did not adhere to the procedures, leading to the presence of expired supplies in the storage areas.
Improper Preparation of Mechanical Soft Diet
Penalty
Summary
The facility failed to ensure that food prepared for residents on a mechanical soft diet was in the proper consistency, as observed during one of the three meals. Specifically, Cook A did not prepare the mechanical soft porkchops to the appropriate texture, resulting in four quarter-sized pieces being present in the tray. This inconsistency was identified during an observation by a surveyor, who noted the improper preparation of the porkchops intended for residents requiring a mechanical soft diet. Interviews with Cook A and the Dietary Manager (DM) revealed that Cook A had been trained on preparing mechanical soft textures and understood the importance of achieving the correct consistency to prevent choking. Both Cook A and the DM acknowledged that the large pieces of porkchop could pose a choking hazard to residents. A review of the facility's policy on therapeutic diets confirmed the requirement for altered consistency diets, but the specific process for preparing mechanical soft diets was not provided by the Administrator upon request.
Failure to Coordinate Hospice Care and Documentation
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. Specifically, the facility did not ensure that the most recent Physician Certification of Terminal Illness was completed and included in the hospice documents for a resident. This oversight could potentially place residents receiving hospice services at risk of inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. The resident in question was admitted with diagnoses including atherosclerotic heart disease, acute kidney disease, and dementia, and was receiving hospice care. The facility's records showed that the Certification of Terminal Illness form was not signed by the necessary hospice staff, attending physician, and hospice physician. Interviews with facility staff revealed that the medical records department had recently taken responsibility for hospice documents and acknowledged that the wrong document might have been sent and not reviewed. The facility's policy required designated staff to coordinate care and ensure the necessary hospice documentation was obtained, which was not adhered to in this case.
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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 Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. Francis Nursing Home | 1.9 mi | ★★★★★ | 5 | 0 |
| Meridian Care Monte Vista | 2 mi | ★★★★★ | 16 | 1 |
| Morningside Manor | 2.1 mi | ★★★★★ | 9 | 1 |
| San Pedro Manor | 2.2 mi | ★★★★★ | 1 | 0 |
| Memorial Medical Nursing Center | 2.3 mi | ★★★★★ | 9 | 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 July 2026) and official state health department websites.