Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Frank M. Tejeda Texas State Veterans Home during CMS and state inspections, most recent first.
Two residents reported financial concerns that were not timely reported as alleged violations to the administrator and State Survey Agency as required. One resident with intact cognition and dementia-related diagnoses filed a grievance after learning from her daughter that her credit card had been charged for a grocery curbside order she did not make; a staff member later admitted using the resident’s stored card information on a personal phone for a personal purchase while the resident was hospitalized. Another cognitively intact resident reported $57 missing from a locked drawer, stating the key had been kept in a visible, unlocked drawer. In both cases, the concerns were documented as grievances, but the social worker and administrator did not treat them as reportable allegations of misappropriation or theft under facility policy and regulatory requirements, and they were not reported to state authorities within mandated timeframes.
Two residents reported financial and property concerns that were not treated as reportable abuse-related allegations. One resident with DM2 and dementia, but intact BIMS, filed a grievance after learning her credit card had been charged for a grocery curbside order she did not make; a staff member later documented that the resident’s saved card was used in error for the staff member’s personal order. Another cognitively intact resident reported $57 missing from a locked drawer, with the key kept visibly in an unlocked drawer; a SW documented that the drawer was intact and no money was found. The DON and Administrator acknowledged that these grievances were not reported to the State Survey Agency and were not investigated as alleged violations, despite facility policies requiring prompt reporting and investigation of suspected misappropriation and theft of resident property.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, as the facility did not ensure adequate safeguards against physical, mental, sexual abuse, physical punishment, or neglect by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility failed to maintain effective infection control practices for three residents. A resident was not placed under contact precautions as ordered, and improper glove use was observed during wound care. Another resident's medication administration involved cross-contamination risks due to improper handling of a water cup. Additionally, a resident self-administering eye drops was not instructed to sanitize hands, leading to potential infection spread.
A resident's annual MDS assessment failed to accurately reflect their tobacco use, despite their care plan indicating smokeless tobacco use and observations by staff. The responsible RN acknowledged the oversight, attributing it to the resident's past use of a vape cigarette. The facility uses the RAI manual for MDS updates, which was not followed correctly in this case.
A facility failed to update a resident's care plan to accurately reflect their current tobacco use, which stated the resident smoked and used a vapor cigarette, while they had quit smoking and only used dip tobacco. The resident was cognitively intact, and the oversight was acknowledged by the DON and RN responsible for care plan updates.
A resident with multiple health conditions, including diabetes and chronic kidney disease, did not receive proper incontinent care, leading to a deficiency in preventing urinary tract infections. CNAs failed to clean the resident's urinary meatus and did not re-clean after the resident urinated, contrary to facility policy. The DON confirmed the oversight, highlighting a lapse in following infection control protocols.
A facility failed to label a bottle of Ciprofloxacin 0.3% ophthalmological solution with an open date, as required by professional principles. This medication, prescribed for a resident with chronic allergic conjunctivitis, was observed without the necessary labeling, which was confirmed by a Medication Aide. The DON stated that medications should be labeled with open dates to ensure they are not used beyond their effective period.
Failure to Timely Report Alleged Misappropriation and Theft of Resident Property
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, misappropriation, or mistreatment, including injuries of unknown source, were reported within required timeframes to the administrator and appropriate state officials. For one resident, an unauthorized use of a credit card by a staff member for a personal purchase was not identified or treated by the administrator as an alleged violation of misappropriation of funds, despite being brought forward through the grievance process. For a second resident, an allegation of missing money from a locked drawer was not reported by the social worker to the administrator as an alleged theft or misappropriation, and the administrator did not report the allegation to the State Survey Agency within 24 hours as required. Resident #1 was an older female with type 2 diabetes mellitus, unspecified dementia, and a cognitive communication deficit, but with a BIMS score of 14 indicating intact cognition and no documented memory concerns. She was dependent on staff for toileting hygiene but independent in other ADLs. She was sent to the ER on 02/28/2026 and admitted with Flu A, returning to the facility on 03/02/2026. On 03/06/2026, she submitted a grievance stating that her daughter had informed her that her credit card had been charged for $152 at a grocery store curbside service, and that she had not made a purchase that day. The grievance was received by the Social Services Director. Subsequent documentation showed that the Health Information Manager admitted using the resident’s credit card "in error" for a personal curbside order because the resident’s card information had been stored in the staff member’s personal phone wallet from prior food orders placed for the resident. The Health Information Manager’s written statement confirmed that the resident’s credit card had been used on 02/28/2026 for a personal grocery order while the resident was in the hospital, and that the staff member contacted the responsible party and arranged reimbursement. The DON acknowledged being notified of the grievance and that the staff member had used the resident’s credit card without authorization, and also acknowledged that the incident was not reported to the State, though she stated it perhaps should have been. The administrator stated she was aware of the grievance, reviewed it, and knew that the staff member had used the resident’s credit card stored on a personal cell phone for a personal purchase, but she did not consider it an alleged violation requiring reporting because she believed it was unintentional and did not rise to that level. No employee coaching record related to this incident was provided upon request. Resident #2 was an older male with atherosclerotic heart disease, a history of transient ischemic attack, and seizures, with a BIMS score of 13 indicating intact cognition and no documented memory concerns, and was independent in self-care and mobility. He submitted a grievance reporting that $57 was missing from a locked drawer in his room, stating that he remembered the drawer being locked and that the key was kept in another, unlocked drawer with his socks where it was visible. The social worker documented examining the drawer, finding it intact and not openable without a key, and confirmed that no money was found. The resident was educated on key use, his right to keep the key on his person, to maintain a spending log, and his right to file a police report, which he declined at that time. The administrator later acknowledged being aware of this grievance of missing money but stated that it was not brought to her as an allegation of theft and that she did not view it as a specific allegation requiring reporting to the State Agency. She described that many male residents loan money to others and was unsure whether the missing money grievance was confirmed. The DON reported she had not been notified of this grievance and would need to follow up with the social worker. Facility policies on abuse, misappropriation, and grievances stated that all alleged or suspected violations, including theft or misappropriation of resident property, must be promptly reported to community management and appropriate state agencies, and that residents have the right to be free from abuse and exploitation and to keep personal property secure from theft or loss. Despite these policies, the allegations involving unauthorized use of a resident’s credit card and missing resident funds were not treated and reported as required alleged violations. The facility’s written guidance defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent, and defined an alleged violation as any observed or reported situation that, if verified, could be noncompliance with federal requirements related to mistreatment, exploitation, neglect, abuse, or misappropriation. The same guidance required that all alleged or suspected violations and all substantiated incidents of abuse be promptly reported to appropriate state agencies. Nonetheless, the administrator and social worker did not report the two residents’ allegations of unauthorized credit card use and missing money to the State Survey Agency within the required timeframes, resulting in the cited deficiency for failure to timely report suspected abuse, neglect, exploitation, or misappropriation.
Failure to Investigate and Report Alleged Misappropriation and Theft of Resident Property
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and report alleged violations of abuse, neglect, and exploitation, specifically misappropriation of funds and theft of property, for two residents. For the first resident, an older female with type 2 diabetes mellitus, unspecified dementia, and a cognitive communication deficit, the quarterly MDS showed a BIMS score of 14, indicating intact cognition without noted memory concerns. Her care plan documented impaired cognitive function/dementia or impaired thought process, and she was dependent on staff for toileting hygiene but independent in eating, showering, and mobility. A grievance form dated 03/06/2026 documented that this resident reported her daughter had informed her that the resident’s credit card was charged $152.00 at a grocery store curbside service, and the resident stated she had not made a purchase on that date. The grievance noted that the resident still had the credit card in her wallet and that her daughter was canceling the card. Further documentation for this resident included a written statement dated 03/10/2026 from the Health Information Manager, who reported that on 02/28/2026 she placed a curbside grocery order and, in error, used the resident’s credit card that had been previously saved in her phone wallet after prior authorized purchases for the resident. She acknowledged that this error resulted in a $152.42 charge to the resident’s card, described contacting the responsible party, and described arrangements to reimburse the funds. The Director of Nursing later stated in interview that she recalled the grievance about unauthorized use of the credit card but did not report it to the State Survey Agency or conduct an investigation because she viewed it as an unintentional occurrence. The Administrator, who served as the Abuse and Neglect Coordinator, similarly stated that she did not consider the incident to rise to the level of an alleged violation, did not report it to the State Survey Agency, and did not investigate further. For the second resident, an older male with atherosclerotic heart disease, a history of transient ischemic attack, and seizures, the quarterly MDS showed a BIMS score of 13, indicating intact cognition and organized thinking, and he was documented as independent in self-care and mobility. His care plan indicated he was able to participate in activities of his choice within his physical and cognitive abilities. A grievance form dated 03/13/2026 documented that this resident reported $57 missing from a locked drawer in his room, stating he remembered the drawer being locked and that the key was kept in another, unlocked drawer with his socks where it was visible. The social worker documented examining the drawer, noting it was not broken and could not be opened without a key, and that the key was visible in the other drawer; no money was found. The grievance response included education to the resident about key use, his right to keep the key on his person, to maintain a spending log, and his right to file a police report, which he declined at that time. The DON stated she was not notified of this grievance and was unaware whether the incident was investigated further by the Administrator. The Administrator stated that the grievance was handled by the social worker, that she was not familiar with the details, and that she did not view all grievances involving money as reportable allegations, so she did not report or investigate this matter as an official allegation. Facility documents, including the Code of Conduct, Grievances policy, Statement of Resident Rights, and Abuse Guidance, described expectations that staff respect resident rights, not take resident property, and immediately report any suspected abuse, neglect, or theft of resident property to supervisors and community management. The Abuse Guidance defined misappropriation of resident property as wrongful use of a resident’s belongings or money without consent and defined an alleged violation as any reported situation that, if verified, could be noncompliance with federal requirements related to mistreatment, exploitation, neglect, abuse, or misappropriation of resident property. The same guidance stated that all alleged or suspected violations and all substantiated incidents of abuse would be promptly reported to appropriate state agencies per state and federal requirements. Despite these written policies, the facility did not treat the unauthorized use of the first resident’s credit card or the second resident’s report of missing funds from a locked drawer as alleged violations requiring investigation and reporting to the State Survey Agency, resulting in the cited deficiency.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. For Resident #23, the facility did not implement contact precautions as ordered by the physician. Despite the presence of a contact isolation sign, Resident #23 was observed in the day room with other residents, indicating a failure in communication and implementation of isolation protocols. Additionally, during wound care, LVN D did not change gloves or sanitize hands after cleansing the wound, which could lead to the spread of infection. For Resident #90, improper infection control practices were observed during medication administration. MA G was seen handling a cup of water with her fingers inside the cup, which could result in cross-contamination. Despite being trained in infection control, MA G admitted to forgetting the proper procedure while managing multiple tasks simultaneously. Resident #135's supervised self-medication administration of eye drops also demonstrated lapses in infection control. MA C did not instruct the resident to sanitize hands before applying the eye drops and failed to observe the resident's technique, which included wiping excess medication with soiled hands. This oversight could lead to cross-contamination and further infection, as the resident's hands were not cleaned before or after the procedure.
Inaccurate Tobacco Use Assessment for Resident
Penalty
Summary
The facility failed to ensure that the assessment accurately reflected the resident's status for one resident whose assessments were reviewed. Specifically, the resident's use of tobacco was not identified on the resident's annual Minimum Data Set (MDS) assessment. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, had a comprehensive care plan indicating the use of smokeless tobacco. However, the MDS assessment incorrectly coded the resident as not using tobacco, which was an oversight by the responsible RN. This error occurred despite the resident's care plan clearly stating the use of smokeless tobacco and the resident being observed using it in the facility's smoking area. The RN responsible for completing the MDS acknowledged the error, attributing it to the resident's previous use of a vape cigarette, which had been discontinued two years prior. The Director of Nursing (DON) was unaware of the discrepancy in the annual assessment, although she had observed the resident using smokeless tobacco. The facility utilized the Resident Assessment Instrument (RAI) manual for MDS and care plan updates, which was available to staff digitally. The coding instructions in the RAI manual specify that any form of tobacco use during the look-back period should be coded as 'yes,' indicating a failure to adhere to these guidelines in this instance.
Failure to Update Resident's Care Plan for Tobacco Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and time frames to meet the resident's mental, nursing, and psychosocial needs. Specifically, the facility did not update the care plan to accurately reflect the resident's current tobacco use. The resident, who was cognitively intact with a BIMS score of 15, had a care plan that incorrectly stated they smoked tobacco and used a vapor cigarette, while in reality, they had quit smoking and only used dip tobacco. The Director of Nursing (DON) acknowledged that the care plan should have been updated to reflect the resident's current use of smokeless tobacco. The MDS LVN, responsible for updating care plans, missed this change. The facility's RN stated that care plans were updated every three months or as needed, but the smoking section was overlooked. The facility used the RAI manual as their policy for MDS and care plan updating, which was available to staff digitally.
Inadequate Incontinent Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident, leading to a deficiency in preventing urinary tract infections. The resident, who had a history of Type 2 diabetes mellitus, hypothyroidism, hypertension, chronic kidney disease, and Guillain-Barre syndrome, was frequently incontinent of bladder and bowel and required extensive assistance with activities of daily living. During an observation, it was noted that CNA A did not clean between the labia or the urinary meatus while providing incontinent care. Additionally, after the resident urinated while being turned on her side, CNA A and CNA B did not clean the genital area again before placing a clean brief on the resident. Interviews with CNA A and CNA B revealed that they did not clean the resident thoroughly due to concerns about being too invasive and acknowledged the oversight of not cleaning the urinary opening. The Director of Nursing confirmed that the urinary meatus area should have been cleaned and that the resident should have been cleaned again after urination. The facility's policy on perineal care, which includes cleaning from front to back, was not followed, contributing to the risk of infection and skin breakdown for the resident.
Medication Labeling Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles, specifically regarding the labeling of an ophthalmological solution for a resident. During an observation, it was noted that a bottle of Ciprofloxacin 0.3% ophthalmological solution, prescribed for a resident with chronic allergic conjunctivitis, was not labeled with an open date. This oversight was confirmed by a Medication Aide, who acknowledged that the medication had been previously opened and should have been marked with an open date to track its expiration. The Director of Nursing (DON) confirmed that the facility's expectation was for all medications to be labeled with their open dates, as medications like eye drops are only effective for 30 days after opening. The facility's policy, revised in January 2023, also required medications to be labeled with expiration dates in accordance with professional standards and regulations. The lack of an open date on the medication bottle could prevent staff from determining the expiration date, potentially leading to the administration of expired medications.
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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 Floresville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harmony Care At Floresville | 0.5 mi | — | 1 | 0 |
| Prairie Meadows Rehabilitation And Healthcare Cent | 0.8 mi | — | 8 | 3 |
| Country Care Manor | 15.2 mi | — | 6 | 0 |
| Bluebonnet Nursing And Rehabilitation | 21.9 mi | — | 7 | 0 |
| Southeast Nursing & Rehabilitation Center | 23.4 mi | — | 16 | 1 |
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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.