Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
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 Juniper Village At Lincoln Heights during CMS and state inspections, most recent first.
The facility failed to ensure accurate MDS assessments for several residents, leading to discrepancies between documented and actual conditions. A resident's falls, another's oxygen therapy, hospice care for a resident, and a deep tissue injury were not accurately reflected in the MDS, despite being noted in care plans. Staff acknowledged these errors, highlighting the need for alignment between MDS and care plans.
The facility's kitchen was found to have several deficiencies in food storage and safety practices. Observations revealed open food packages, unlabeled and undated turkey slices, and personal items stored near food, which could lead to contamination and foodborne illnesses. Interviews with staff confirmed these practices were against facility policies, which require proper sealing, labeling, and storage of food items.
A facility failed to develop a baseline care plan for a resident admitted with a colostomy, despite having physician orders for colostomy care. The resident, with multiple health conditions, did not receive a care plan within 48 hours of admission, as required. Interviews with staff revealed a misunderstanding that physician orders were sufficient, leading to potential inappropriate care due to the lack of a baseline care plan.
A resident's care plan was not updated after a quarterly MDS assessment showed a change in bowel incontinence status. Despite the resident's inability to use the toilet, the care plan still required one staff member's assistance for toilet use. Observations and interviews confirmed the oversight, and the facility's policy mandates care plan updates based on MDS assessments.
A facility failed to provide a safe environment and adequate supervision when a used disposable razor was found in a resident's bathroom. The resident, who had moderate cognitive impairment and required assistance with personal hygiene, was unable to use the razor independently. Staff interviews confirmed the razor should have been discarded in a sharps container to prevent infection and injury, as per facility policy.
A facility failed to ensure proper pharmaceutical services when an expired medication, Benadryl itching stopping gel, was found in a medication cart. The gel had expired in May 2021 and was discovered during an observation. The ADON confirmed the expired medication's presence and acknowledged that nurses should discard expired medications per facility policy.
A resident's ear wax removal kit was found unattended and unsecured on a nightstand in their room, contrary to the facility's policy requiring all medications to be stored in locked compartments. The resident, who had severe cognitive impairment and required assistance with daily activities, was not present in the room at the time. Interviews with staff confirmed that medications should not be left unattended in residents' rooms.
A facility failed to maintain accurate clinical records for a resident, documenting a deep tissue injury on the wrong heel. The resident, with multiple medical conditions, had a care plan and physician orders indicating a left heel injury, but the initial evaluation incorrectly noted it on the right heel. This error, acknowledged by the wound care nurse, posed a risk of improper wound care due to misinformation.
A resident with multiple health conditions, including moderate cognitive impairment, was found with a dirty Yankauer suction tube on her nightstand, which was not discarded after use as required by the facility's infection control policy. This oversight was confirmed by both an LVN and the DON, indicating a failure in maintaining proper infection control procedures.
A resident with a history of respiratory failure was not monitored to ensure continuous oxygen supply, leading to a significant drop in oxygen saturation levels. The facility failed to document the resident's condition accurately and did not connect her to a functioning oxygen concentrator after a transfer. Interviews revealed communication lapses and oversight in ensuring the resident's oxygen needs were met, resulting in an Immediate Jeopardy finding.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate assessments for five residents, leading to discrepancies between the residents' actual conditions and their documented status on the Minimum Data Set (MDS). Resident #15 experienced falls on two occasions, which were not recorded in the Quarterly MDS, despite being documented in the care plan. Similarly, Resident #5 had a fall that was not reflected in the MDS, although it was noted in the care plan. These omissions indicate a lack of accurate documentation of falls, which are critical for assessing the residents' needs and planning appropriate interventions. Resident #18 had been using oxygen therapy since admission, but this was not coded in the Admission MDS, even though it was included in the care plan. This oversight suggests a disconnect between the care provided and the documentation, potentially affecting the resident's care plan and the facility's financial reimbursement. Additionally, Resident #1 was receiving hospice care, but the MDS inaccurately indicated that the resident was not receiving such care, despite the care plan and hospice consent form confirming otherwise. Resident #20 had a deep tissue injury on the left heel, which was not documented in the admission MDS, although it was noted in the care plan and observed during wound care. This inaccuracy could lead to inadequate wound care due to the lack of proper documentation. Interviews with facility staff, including the MDS nurse, Administrator, and DON, revealed acknowledgment of these errors and the importance of ensuring that the MDS and care plans align to accurately reflect residents' needs and conditions.
Food Storage and Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. Several issues were identified, including an open bag of kernel corn in the walk-in freezer, a container of turkey slices in the walk-in cooler that was not labeled or dated, and an open bag with two rolls in the dry storage room. Additionally, a box of oatmeal was found with the top off, and six containers of seasoning were left open in the dry storage room. These lapses in food storage practices could potentially expose residents to foodborne illnesses. Further observations revealed that two employee backpacks were stored on a shelf next to food items in the dry storage room, which is not an appropriate location for personal belongings. Interviews with the Dietary Manager (DM) and Dietary Aide (DA) confirmed that these practices could lead to contamination and foodborne infections. The facility's policies on food storage were reviewed, highlighting that food storage areas should be used exclusively for food and paper products, and opened packages should be resealed to prevent contamination. The refrigerated food storage policy also mandates that all foods should be covered, labeled, and dated.
Failure to Develop Baseline Care Plan for Colostomy Care
Penalty
Summary
The facility failed to ensure that a baseline care plan was completed and provided to a resident and/or their representative within 48 hours of admission. Specifically, the facility did not develop a baseline care plan for a resident who was admitted with a colostomy. The resident, a female with multiple diagnoses including a laceration of the sigmoid colon, type 2 diabetes, anemia, hypertension, and dysphagia, was admitted to the facility with a physician's order for colostomy care. However, the baseline care plan did not include instructions for colostomy care, which is essential for providing effective and person-centered care. Interviews with facility staff, including an LVN and the MDS nurse, revealed that the baseline care plan was not developed as required. The MDS nurse acknowledged the oversight, mistakenly believing that the presence of physician orders for colostomy care was sufficient. The Director of Nursing confirmed that the absence of a baseline care plan could lead to inappropriate care, as it affects the Kardex used by CNAs to provide care. The facility's policy on care planning emphasizes the need to write activity goals and approaches based on MDS triggers and the current needs of the resident, which was not adhered to in this case.
Failure to Update Care Plan After MDS Assessment
Penalty
Summary
The facility failed to update and revise the care plan for a resident after a quarterly Minimum Data Set (MDS) assessment indicated a change in the resident's condition. The resident, who had a history of atherosclerotic heart disease, cerebral infarction, epilepsy, major depressive disorder, and hypertension, was found to have moderate cognitive impairment with a BIMS score of 9 out of 15. The quarterly MDS assessment revealed that the resident was always incontinent to bowel and could not be transferred to the toilet due to medical or safety concerns. Despite this, the resident's care plan, last revised in August 2022, still indicated that the resident required one staff member's assistance to use the toilet. Observations and interviews confirmed that the resident was provided incontinence care by CNAs, and the MDS nurse acknowledged the failure to update the care plan to reflect the resident's current needs. The Director of Nursing (DON) also confirmed that the care plan should have been updated following the quarterly MDS assessment. The facility's policy on care planning assessment requires that care plans be revised based on comprehensive MDS assessments and triggered areas, which was not adhered to in this case.
Failure to Ensure Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents for a resident. During an observation, a used disposable razor was found on the sink faucet in the bathroom of a resident who had moderate cognitive impairment and required assistance with personal hygiene. The resident was unable to use the razor independently due to his condition, which included a left-sided hand contracture and weakness. The presence of the razor posed a risk of infection or physical injury to the resident and others. Interviews with staff, including an LVN and the DON, confirmed that the razor should have been discarded in a sharps container after use to prevent infection and injury. The facility's policy on handling infectious waste required contaminated disposable items to be placed in red plastic bags and stored in biohazard storage until removal. The failure to follow this policy resulted in the deficiency noted by the surveyors.
Expired Medication Found in Nursing Cart
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals. During an observation, a medication cart in the A and B hall was found to contain an expired medication, Benadryl itching stopping gel, which had expired in May 2021. This was discovered on October 9, 2024. An interview with the Assistant Director of Nursing (ADON) confirmed the presence of the expired medication in the cart, and the ADON acknowledged that nurses are responsible for discarding expired medications according to facility policy. The facility's policy on medication storage requires that expired, discontinued, and/or contaminated medications be removed from storage and disposed of properly.
Unsecured Medication Found in Resident's Room
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and allowed unauthorized access to medications, as observed in the case of a resident. The resident's ear wax removal kit was found unattended and unsecured on the nightstand at the bedside. This incident was noted during an observation when the resident was not present in the room. Interviews with the LVN and the DON confirmed that medications should not be left unattended in residents' rooms according to the facility's policy. The resident involved had a severe cognitive impairment with a BIMS score of 3 out of 15 and required assistance with daily activities. The resident's medical history included pneumonia, hypomagnesemia, cerebral vascular disease, heart failure, dementia, and hypertension. The LVN speculated that the medication might have been brought by the resident's family, but acknowledged the potential harm if the medication was used incorrectly by the resident or others. The facility's policy mandates that all medications, including over-the-counter and complementary and alternative medicine, be stored in a locked cabinet, cart, or medication room accessible only to authorized personnel.
Inaccurate Documentation of Wound Care
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, which is a violation of accepted professional standards. Specifically, the wound care nurse documented a deep tissue injury on the resident's right heel, when in fact, the injury was on the left heel. This discrepancy was identified during an observation and interview with the wound care nurse, who acknowledged the error and admitted that the incorrect documentation could lead to a lack of proper wound care or incorrect treatment. The resident involved was an elderly male with multiple medical conditions, including acute respiratory failure, anemia, type 2 diabetes mellitus, a stage 3 pressure ulcer in the sacral region, hypertension, and spinal stenosis. The resident's care plan and physician orders indicated the presence of a pressure injury on the left heel, which required specific wound care treatment. However, the initial skin evaluation incorrectly noted the injury on the right heel, leading to potential risks due to misinformation in the medical records. The Director of Nursing confirmed that the facility lacked a policy regarding medical record accuracy, although it was acknowledged that records should accurately reflect the residents' medical status.
Infection Control Deficiency Due to Improper Disposal of Medical Device
Penalty
Summary
The facility failed to establish and maintain an effective infection control program, as evidenced by the improper handling of a medical device used by a resident. During an observation, a suction tube Yankauer, which is an oral suction tool, was found on a resident's nightstand. The Yankauer was opened, covered in a plastic bag, connected to a suction machine, and appeared dirty with brown-colored residue. This device should have been discarded after use to prevent infection, as per the facility's policy on handling infectious waste. The resident involved was an elderly female with a history of atherosclerotic heart disease, cerebral infarction, epilepsy, major depressive disorder, and hypertension. She had moderate cognitive impairment and required partial assistance with oral hygiene. The facility's care plan indicated a potential for aspiration, necessitating suction as needed. Interviews with the LVN and DON confirmed that the Yankauer should have been discarded after each use, highlighting a lapse in following infection control protocols.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident, leading to a significant deficiency. The resident, who had a history of altered mental status, muscle weakness, depression, post-COVID-19 condition, and acute respiratory failure with hypoxia, was not monitored to ensure she was connected to continuous oxygen as per her physician's order. This oversight resulted in the resident being connected to an empty oxygen e-cylinder, causing her oxygen saturation levels to drop to the 60s, which was not accurately documented by the facility staff. The deficiency was further compounded by the facility's failure to document the resident's change of condition in her progress notes upon discovering she was not connected to continuous oxygen. Additionally, when the resident was transferred to a different location within the facility, she was not connected to an oxygen concentrator with a functioning humidifier. These lapses in care and documentation contributed to the resident's deteriorating condition, as observed by various staff and caretakers who noted her lethargy and inability to wake up or respond. Interviews with facility staff and caretakers revealed a lack of communication and oversight in ensuring the resident's oxygen needs were met. Despite being informed by caretakers and hospice staff about the resident's condition, the facility staff failed to take timely action to reconnect her to a functioning oxygen source. The Director of Nursing acknowledged the oversight and the facility's responsibility to provide adequate medical care, even with the presence of unlicensed caretakers. The deficiency was identified as an Immediate Jeopardy, indicating a severe lapse in care that required immediate attention.
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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) |
|---|---|---|---|---|
| Broadway Nursing & Rehabilitation | 1.1 mi | — | 13 | 0 |
| The Village At Incarnate Word | 2 mi | — | 8 | 0 |
| Northeast Rehabilitation And Healthcare Center | 2.8 mi | — | 6 | 1 |
| Parklane West Healthcare Center | 2.9 mi | — | 13 | 0 |
| Castle Hills Rehabilitation And Care Center | 3.3 mi | — | 44 | 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.