Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 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 Meridian Care Monte Vista during CMS and state inspections, most recent first.
A resident with ALS, a tracheostomy, and a documented OOH DNR and DNR physician orders was found unresponsive by a CNA, who notified an LVN. After assessment by two LVNs revealed loss of pulse and respirations, a Code Blue was called, and RT staff initiated suctioning and ambu-bag ventilation while an LVN performed chest compressions. Staff were unsure of the resident’s code status, relied on an outdated crash cart binder that contained incorrect DNR information, and continued resuscitation while the LVN searched the EMR for verification. EMS arrived, continued CPR, and obtained a pulse before being informed by the LVN that the resident was actually a DNR, despite existing documentation and the responsible party’s prior completion of DNR forms. The facility lacked a specific policy for Out-of-Hospital DNRs, relying only on a general resident rights policy regarding refusal of treatment.
The facility did not update its Emergency Preparedness Plan annually, failed to correct a persistent fire alarm system trouble signal, and allowed overgrown vegetation and dead branches to accumulate near the building, including the smoking area. The Administrator was unaware of the annual review requirement for the emergency plan, and the Maintenance Director acknowledged ongoing issues with the fire alarm and grounds maintenance.
The facility did not report multiple allegations of abuse, neglect, or mistreatment involving four residents, including emotional distress, neglect of a G-tube dressing, rough incontinent care, and verbal abuse. These incidents were documented in grievance reports but were not reported to the state agency as required, despite residents having significant cognitive and physical impairments.
The facility did not thoroughly investigate or report multiple allegations of abuse, neglect, or mistreatment involving four residents, including incidents of poor treatment, neglect of care, rough handling, and verbal abuse. Despite documentation of grievances and internal discussions among leadership, required reporting to the state agency was not completed, and there was no evidence that further potential harm was prevented during the investigation process.
Medication carts containing drugs, including narcotics, were left unattended and unlocked in two separate hallways for several minutes, with staff unable to account for the responsible personnel. Facility policy requires carts to be locked when not attended, but in both instances, the carts were accessible to unauthorized individuals while residents and CNAs were present in the area.
A resident with complex medical needs, including a sacral pressure injury, did not have daily wound care consistently documented in the treatment administration record as required by physician orders and facility policy. Several dates lacked evidence of wound care being provided, and staff interviews confirmed the expectation for timely documentation. The resident's representative also reported inconsistent care and had to provide dressings personally.
A resident with intact cognition and multiple chronic conditions was repeatedly told by staff that his family member would be called if he refused to change clothes, a practice used to gain compliance with care. This approach, which was included in the care plan at the family member's request, made the resident feel threatened and sad, and was acknowledged by the DON and administrator as a violation of the resident's rights to self-determination and choice.
Two residents' rights were not protected when an LVN diverted Norco pain medication by being the sole staff member to call in refills and receive pharmacy deliveries, bypassing required verification procedures. Audits later revealed missing medication cards, and staff interviews confirmed that established protocols for receiving and securing narcotics were not consistently followed.
A resident with complex medical needs was discharged to a hospital without the facility sending the required discharge notice to the state LTC ombudsman. Interviews with the ombudsman, SW, DON, and administrator confirmed that no notification was made, and the facility's records did not contain evidence of such notice.
A facility exceeded the acceptable medication error rate with a 7.69% error rate due to late administration of medications to a resident with GERD and constipation. A new RN administered carafate and enulose over an hour late, citing unfamiliarity with the residents and procedures. The facility's policy mandates timely medication administration to ensure therapeutic effectiveness.
The facility's kitchen failed to meet food service safety standards by improperly storing plastic containers without air-drying, inadequately labeling and dating chopped beef brisket in the cooler, and failing to properly label and seal French fries in the freezer. These actions could lead to foodborne illness due to bacterial growth and deterioration in food quality.
A resident with severe cognitive impairment and multiple medical conditions was left exposed during catheter care when two CNAs failed to fully close the privacy curtain. The incident was observed by surveyors, and the CNAs admitted the oversight. The facility's DON confirmed that privacy should have been maintained, and staff had received training on resident rights.
A resident with a cognitive communication deficit did not have their needs fully addressed in their care plan, as required by facility policy. Despite having a history of hemiplegia, hemiparesis, major depressive disorder, and aphasia, the care plan lacked a focus on communication needs. Staff interviews confirmed the omission, and the resident used a communication card not documented in the care plan.
A resident with severe cognitive impairment and legal blindness was found to have hazardous cleaning supplies in their bathroom, posing a risk of contact with dangerous substances. Facility staff confirmed the presence of these materials, which were not supposed to be in resident rooms, as per facility policy.
A resident with a history of cancer, diabetes, and dementia displayed signs of depression and isolation but was not referred to mental health services, despite multiple documented reports of these symptoms. The facility's policy required providing behavioral health services to maintain residents' well-being, which was not followed.
A medication cart was left unlocked by an RN during medication administration, contrary to facility policy and training. The cart, containing various medications, was out of the RN's sight, posing a risk of misappropriation or accidental ingestion. The DON confirmed the breach of protocol, despite the RN having passed a proficiency checklist.
The facility failed to maintain an effective infection prevention and control program. An RN did not sanitize a blood pressure cuff between two residents, risking cross-contamination. Additionally, two CNAs did not wear gowns while caring for a resident on enhanced barrier precautions, despite signage. Both incidents occurred despite staff having received infection control training.
The facility failed to properly dispose of garbage in Dumpster #1, which was overflowing and missing a drainage plug, with trash scattered around the area. Interviews revealed that trash was picked up twice a week, and the dumpster had been recently replaced. The facility's waste disposal policy and the U.S. Public Health Service Food Code require sealed and covered waste containers with drain plugs, which were not followed.
A resident with severe cognitive impairment suffered a fracture to her left tibia, which was not reported to the state agency as required. The injury was discovered after the resident returned from an Adult Day Care program, and despite the presence of a significant bruise and swelling, the facility did not classify it as an injury of unknown origin. The facility's staff relied on the resident's limited communication about the bus, leading to a failure to report the incident within the required timeframe.
A resident with intellectual disabilities and diabetes did not have a comprehensive care plan, missing crucial details like LIDDA contact information, Adult Day Care specifics, and transportation arrangements. Interviews revealed a lack of communication and coordination among staff, with the MDS Coordinator unavailable and the DON acknowledging the oversight. The facility's policy required comprehensive care plans, but the necessary updates were not made.
Failure to Honor Resident’s Documented DNR Status During Code Blue Event
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s Out-of-Hospital Do Not Resuscitate (OOH DNR) order and documented DNR status when the resident was found unresponsive and staff initiated resuscitation. The resident was an older female with diagnoses including depression, anxiety disorder, ALS, and a tracheostomy, and had a BIMS score of 15, indicating she was cognitively intact. Her care plan, physician orders, and an OOH DNR form signed by the physician and two witnesses all documented that her code status was DNR. Despite this, when she was found unresponsive in her room, staff proceeded with CPR and other resuscitative measures after determining she had no pulse and had stopped breathing. According to interviews and record review, an agency CNA discovered the resident unresponsive and notified an LVN, who assessed the resident and noted she was pale but breathing, with a weak pulse. Another LVN entered, performed a sternal rub and other stimuli without response, while the first LVN rechecked pulses at multiple sites and then reported finding no pulse and that the resident had stopped breathing. At that point, a Code Blue was called. Respiratory therapy staff removed the breathing circuit from the tracheostomy, suctioned the airway, and began manual ventilation with an ambu bag. Another LVN began chest compressions. During this period, staff questioned whether the resident was a DNR or full code, and there was hesitation because the LVN leading the response was unsure of the resident’s code status. Staff reported that the crash cart binder, which they relied on to verify code status, was not up to date and contained DNR information for residents who were no longer in the facility. The LVN in charge stated she attempted to verify the resident’s status by checking the crash cart binder and then the electronic medical record, but resuscitation had already been initiated and continued while this verification was pending. EMS arrived and continued compressions, and a pulse was recovered before the LVN informed EMS that the resident was actually a DNR based on the documentation she eventually located. The resident’s responsible party later confirmed that a DNR had been completed at the hospital and again at the facility, and stated that the resident did not want CPR, including having her ribs cracked, and that the facility did not abide by the resident’s wishes. The facility did not have a specific policy for Out-of-Hospital DNRs, only a general resident rights policy stating that residents have the right to refuse treatment.
Removal Plan
- Provided in-service training to staff on resident rights, including: Timely Emergency Services & Professional Standards for CPR; How to Identify the Resident Code Status; and Abuse & Neglect.
- Required all new hires to complete the in-service trainings on resident rights, code status, and CPR-related standards.
- Implemented a process for night shift nurses to print the daily resident census, highlight residents with DNR status, and place the dated census sheet in each crash cart binder along with a copy of each resident’s DNR.
- Implemented a process for morning-shift ADONs to check crash cart binders for accuracy and needed DNR code status updates.
- Implemented DON review of resident code status and crash cart binder accuracy.
- Implemented use of a Standard of Care (SOC) spreadsheet that includes a DNR column and records the date of any code status change; tracked by the corporate nurse.
- Implemented audits of printed reports for new admissions to verify code status and ensure crash cart binders are updated accordingly.
- Implemented a process for the Social Worker to deliver newly executed DNR documentation to the DON for updating the electronic medical record and adding the DNR to the crash cart binder and SOC tracking.
- Implemented a DON audit of resident charts for DNR documentation.
- Implemented corporate nurse audits of SOCs.
Deficiencies in Fire Safety Systems, Emergency Preparedness, and Grounds Maintenance
Penalty
Summary
The facility failed to maintain a safe environment by not correcting impairments related to the fire alarm system, not maintaining outside areas free of fire hazards, and not ensuring the Emergency Preparedness Plan was evaluated and updated annually. During inspection, the Emergency Preparedness Plan was found to have last been reviewed and signed in 2005, with no documentation of a more recent review. The Administrator, newly employed for one week, was unaware of the requirement for annual review and update of the Emergency Preparedness Plan and had not yet reviewed it. The facility housed 52 residents, including 17 who were dependent on ventilators for maintaining oxygen levels. Observations revealed the fire alarm annunciator near the Nurse Station displayed a trouble signal indicating a low battery, and the Maintenance Director confirmed ongoing issues with the fire alarm control panel, including a DC battery charge failure. Service tags on the panel indicated recent attempts to address the issue, but the trouble signal persisted. Additionally, the outside inspection showed overgrown vegetation, dead tree branches, dead brush, and leaves along the rear of the building, particularly near the smoking area, with multiple trees leaning against the roof. The Maintenance Director acknowledged responsibility for grounds maintenance and awareness of the overgrown vegetation but cited workload as a reason for the delay in addressing these hazards.
Failure to Timely Report Allegations of Abuse, Neglect, or Mistreatment
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the appropriate authorities within the required timeframes. Specifically, the facility did not report four separate allegations of abuse, neglect, or mistreatment involving four different residents. These allegations included a nurse allegedly treating a resident poorly and causing emotional distress, a nurse neglecting to change a gastric tube stoma dressing and instructing the resident to do it herself, rough incontinent care resulting in discomfort to an amputated leg, and verbal abuse where a staff member insulted a resident. Record reviews and interviews revealed that these allegations were documented in grievance reports but were not reported to the state agency as required by facility policy and state regulations. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that the grievances were reviewed by the interdisciplinary team, including the previous administrator, but the allegations were not recognized or reported as abuse, neglect, or exploitation (ANE) to the state agency. The current administrator also confirmed that the grievances should have been reported but were not, either due to lack of recognition or assumption that another staff member had reported them. The residents involved had varying degrees of cognitive and physical impairment, including diagnoses such as cerebral vascular accident, seizures, end-stage renal disease, severe obesity, amputation, adjustment disorder with depressed mood, and Parkinson's disease. Their care plans indicated significant needs for assistance with activities of daily living and communication. Despite these vulnerabilities, the facility did not follow established procedures to report the allegations, as confirmed by the absence of corresponding reports in the state’s incident database.
Failure to Investigate and Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated and reported as required. For four out of ten residents reviewed, there was no evidence that allegations of abuse, neglect, or mistreatment were properly investigated or that further potential harm was prevented during the investigation process. The facility also did not report the results of these investigations to the state agency, as required by policy and regulation. One resident with severe cognitive impairment and a history of stroke and seizures was alleged by her representative to have been treated poorly by a nurse, resulting in the resident crying, which was noted as rare for her. Another resident, who was cognitively intact and dependent on a gastrostomy tube for nutrition, alleged that a nurse neglected to change her tube dressing and instructed her to do it herself, contrary to her care plan requiring staff assistance. In both cases, grievance reports were documented, but the DON stated she did not recall the reports and had not reported the investigation results to the state agency. A third resident, with end-stage renal disease, severe obesity, and an above-knee amputation, alleged rough incontinent care by a staff member, resulting in soreness to her amputated leg. The ADON recalled discussing the allegation but did not report the results to the state agency. A fourth resident, with severe cognitive impairment and a history of depression and Parkinson's disease, alleged verbal abuse by a CNA. The ADON and administrator discussed the allegation but did not recognize it as reportable. A review of the state incident database confirmed that none of these allegations were reported as required. The facility's policy mandates immediate reporting of such allegations, but this was not followed.
Unattended and Unlocked Medication Carts
Penalty
Summary
Facility staff failed to ensure that medication carts containing drugs and biologicals, including narcotics, were securely locked and attended as required by facility policy and professional standards. On two separate occasions, a medication cart on the 100-hall and a respiratory therapy medication cart on the 200-hall were observed left unattended, unsupervised, and unlocked in the hallways. The 100-hall cart was left unlocked for 10 minutes while residents and CNAs walked by, and the 200-hall cart was left unlocked for 5 minutes with similar hallway traffic. In both cases, the responsible staff members were not present, and the carts were accessible to unauthorized individuals. Interviews with facility staff, including the ADON, LVN, and RT, confirmed that the carts were left unlocked due to human error and lack of awareness of the assigned nurse's whereabouts. The facility's policy requires medication carts to be locked when not in use or out of the nurse's view, and to be parked securely when unattended. The DON acknowledged that the expectation is for all medication carts to be locked when not attended by nursing staff.
Incomplete Documentation of Wound Care in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was admitted with multiple complex diagnoses, including Guillain-Barre disease, respiratory failure, and a tracheostomy. Specifically, the resident was prescribed daily wound care for a sacral pressure injury, but the November treatment administration record (TAR) lacked documentation of wound care on several specified dates. The care plan and physician's orders indicated the need for daily and PRN wound care, yet the TAR showed blanks for the prescribed treatment on multiple days. Interviews with facility staff confirmed the expectation that all care should be documented as soon as it is provided, and the Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the missing documentation in the resident's record. The resident's representative reported that the facility neglected general care and wound care, stating that the resident did not consistently receive the prescribed wound care and that the representative had to provide dressings personally. The DON stated that the wound was improving according to the wound care physician's documentation but was unaware of the missing entries in the TAR. The facility's policy requires accurate maintenance of medical records, but the lack of documentation for wound care on the specified dates resulted in incomplete and unorganized records for the resident.
Failure to Support Resident's Right to Refuse Care Without Coercion
Penalty
Summary
Staff failed to promote and facilitate a resident's right to self-determination and choice, specifically regarding the right to refuse care. The resident, an adult male with diagnoses including hypertension, chronic kidney disease, and coronary artery disease, and with intact cognition as evidenced by a BIMS score of 15, was subjected to staff telling him that his family member would be called if he refused to change his clothes. This approach was used as a means to gain compliance with care, as confirmed by both the DON and a CNA, and was described as a threat by the resident himself. The care plan included a directive to call the family member upon refusal of care, per the family member's request. The resident reported feeling sad and infantilized by this practice, expressing concern that his family member would be angry and stop visiting if called. The DON acknowledged that staff had become accustomed to using the threat of calling the family member to compel the resident to comply with care, and recognized this as a violation of the resident's rights. The administrator also confirmed that such actions were not permitted, even if requested by the family, as they infringed upon the resident's right to refuse care and could cause psychosocial harm.
Failure to Prevent Diversion of Pain Medication
Penalty
Summary
The facility failed to protect the rights of two residents to be free from misappropriation of property, specifically regarding the diversion of pain medications. Both residents had orders for Norco, with one resident rarely taking the medication and the other receiving it on a scheduled basis for pain management. The medications were administered and refilled exclusively by one LVN, who was also the only person to receive the medications from the pharmacy. This allowed the LVN to divert medications when they were delivered, as she was responsible for calling in refills and receiving the deliveries without adequate oversight. The deficiency was identified after an audit revealed several cards of Norco were unaccounted for, prompting further investigation. The audit involved both the in-house and hospice pharmacies, and it was discovered that the LVN had diverted the medications upon delivery. The process in place at the time did not ensure that medications were properly secured or that there was a reliable verification system involving multiple staff members when narcotics were received from the pharmacy. Interviews with staff indicated that the standard procedure required two nurses to verify and sign for narcotics upon delivery, but this process was not consistently followed in the cases involving the two residents. The lack of adherence to established protocols for receiving and securing medications enabled the LVN to divert the narcotics without detection for an extended period.
Failure to Notify State Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to send a copy of a resident's discharge notice to the Office of the State Long-Term Care (LTC) Ombudsman prior to the resident's discharge, as required. Record review and interviews confirmed that a resident with diagnoses including Guillain-Barre disease, respiratory failure, and a tracheostomy was admitted for LTC and later discharged to a hospital for elevated care, with no expectation of return. There was no evidence in the medical record that a discharge notice was sent to the state ombudsman. Interviews with the state ombudsman, social worker (SW), director of nursing (DON), and administrator revealed that none were aware of a notification being made to the ombudsman regarding the resident's discharge. The SW stated she had been directed not to coordinate with the ombudsman and had no evidence of a report for the discharge. The facility's policy indicated that for resident-initiated discharges, notification to the ombudsman was not required, but the discharge in question was not clearly documented as resident-initiated.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.69% due to two errors out of 26 opportunities. These errors involved a resident who was administered medications late. Specifically, RN A administered a 10 gram carafate tablet and 30 milliliters of 10 gm/15mL enulose solution to the resident at 5:29 p.m., which was one hour and twenty-nine minutes past the scheduled time of 4:00 p.m. The resident involved had a medical history of biliary cirrhosis, fibromyalgia, and gastro-esophageal reflux disease (GERD) with esophagitis. The resident's care plan included interventions to manage GERD and constipation, with specific medication orders for carafate and enulose to be administered at designated times to optimize therapeutic effects. The late administration of these medications could potentially affect their effectiveness, particularly the carafate, which was intended to be given before meals. RN A, who was new to the facility and unfamiliar with the residents and their medications, attributed the delay to his lack of familiarity with the medication administration procedures. The Director of Nursing (DON) confirmed that RN A was a new staff member and suggested that the late administration was due to his inexperience. The facility's policy requires medications to be administered within one hour of their prescribed time, emphasizing the importance of timely administration for optimal therapeutic effect.
Food Storage and Labeling Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. The first issue identified was the improper storage of plastic storage containers in the dish room. Three opaque plastic containers were stacked on top of each other without any separation to allow for air circulation, resulting in visible moisture between the containers. This practice contradicts the facility's policy and the U.S. FDA Food Code, which require equipment and utensils to be air-dried before being stacked or stored to prevent bacterial growth. The second deficiency involved the improper labeling and dating of a container of chopped beef brisket in the walk-in cooler. The container, which was partially full, was labeled with the date it was received, but not with the date it was opened or a use-by date. This oversight could lead to the proliferation of bacteria, as the facility's policy mandates that all opened food items be labeled with both the date opened and the use-by date to ensure food safety. The third issue was the improper storage and labeling of French fries in the reach-in freezer. A package of food wrapped in brown paper and loosely covered with plastic wrap was found without a label indicating its contents. The package was dated but not properly sealed, which could result in freezer burn and deterioration of food quality. The facility's policy requires all frozen foods to be covered, labeled, and dated to ensure they are consumed by their use-by dates or discarded if necessary.
Failure to Ensure Resident Privacy During Catheter Care
Penalty
Summary
The facility failed to ensure personal privacy for a resident during catheter care, as observed by surveyors. Two CNAs did not completely close the privacy curtain while providing catheter care, leaving the resident exposed and visible from the room's door. This incident occurred while other staff members were present in the room providing care for the resident's roommate. The CNAs acknowledged during an interview that the privacy curtain was not fully closed, although it should have been. The resident involved had a history of severe cognitive impairment and was dependent on staff for activities of daily living. The resident's medical conditions included dysphagia, type 2 diabetes mellitus, cerebral palsy, and spina bifida, and they had an indwelling catheter due to a neurogenic bladder. The facility's Director of Nursing confirmed that privacy should have been maintained during care and that staff had received training on resident rights within the year. The facility's policy on dignity emphasized the importance of maintaining resident privacy during personal care and treatment procedures.
Incomplete Care Plan for Resident with Communication Deficit
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which is a requirement to ensure that all residents' needs are met. Specifically, the care plan for a resident with a cognitive communication deficit was incomplete, as it did not address the resident's communication needs. This oversight was identified during a review of the resident's records, which showed that the resident had a history of hemiplegia, hemiparesis, major depressive disorder, and aphasia following a cerebral infarction. Despite these conditions being documented, the care plan lacked a focus section on the resident's communication deficit, which is crucial for staff to provide appropriate care. Observations and interviews with staff revealed that the resident used a communication card to express needs, but this method was not included in the care plan. The MDS LVN responsible for care plans acknowledged the omission and could not explain why the communication deficit was not included. The Director of Nursing also confirmed that the communication impairment should have been reflected in the care plan to ensure the resident's needs were met. The facility's policy requires that care plans include measurable objectives and timeframes to address residents' physical, psychosocial, and functional needs, which was not adhered to in this case.
Hazardous Materials Found in Resident's Bathroom
Penalty
Summary
The facility failed to maintain a safe environment for a resident with severe cognitive impairment and legal blindness. During an observation, it was found that the resident's bathroom contained several cleaning supplies with hazardous warnings, such as disinfecting sprays, isopropyl alcohol, bleach, multipurpose cleaner, and germicidal alcohol wipes. These items were stored behind a shower curtain, making them accessible to the resident, who was diagnosed with unspecified dementia with psychotic symptoms, legal blindness, and anxiety disorder. The presence of these hazardous materials in the resident's bathroom posed a risk of contact with potentially dangerous substances. Interviews with facility staff, including an RN and the DON, confirmed the presence of these cleaning supplies in the resident's bathroom. The RN acknowledged that the supplies should not have been there, given the resident's legal blindness and dementia diagnosis. The DON stated that cleaning supplies should not be present in resident rooms to prevent contact with hazardous materials. It was noted that a family member of the resident might have brought the supplies into the room, which was against the facility's policy of providing a safe and homelike environment.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, leading to a deficiency in maintaining the resident's highest practicable physical, mental, and psychosocial well-being. The resident, who was admitted with diagnoses including malignant neoplasm of the lung, type 2 diabetes mellitus, and unspecified dementia, displayed signs and symptoms of depression. Despite these symptoms being documented in multiple progress notes over several months, the resident was not offered mental health services. The resident's quarterly MDS indicated moderate cognitive impairment, and the resident consistently reported feelings of depression, isolation, and loneliness. Interviews and record reviews revealed that the resident expressed feelings of being a prisoner and not understanding why they were residing at the facility. The Director of Nursing (DON) acknowledged being unaware of the lack of referral to mental health services and confirmed that the resident had expressed feelings of depression and isolation. The facility's policy on Behavioral Health Services, revised in February 2019, stated that the facility would provide necessary behavioral health services to maintain residents' well-being, which was not adhered to in this case.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by professional principles. During a medication administration round, RN C left the Hall 200 Medication Cart unlocked while entering a resident's room and closing the door, leaving the cart out of sight. The unlocked cart contained blister packs, bottles, and vials of medications intended for residents, which could lead to misappropriation or accidental ingestion. In an interview, RN C acknowledged leaving the cart unlocked and admitted to forgetting the requirement to keep it locked. The Director of Nursing (DON) confirmed that the medication cart should have been locked and that nursing staff had been trained on drug diversion prevention, including keeping carts locked when not in use. The facility's policy on medication cart security also mandates that carts be securely locked when out of the nurse's view. Despite RN C having passed a proficiency checklist for medication administration, this oversight occurred.
Infection Control Deficiencies in Equipment Sanitization and Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving improper care practices. In the first incident, a registered nurse (RN) did not sanitize a blood pressure cuff between using it on two different residents. The RN acknowledged the oversight and recognized the potential risk for cross-contamination. The Director of Nursing (DON) confirmed that the RN should have sanitized the equipment between uses, as per the facility's policy on cleaning and disinfection of resident-care equipment. In the second incident, two certified nursing assistants (CNAs) failed to wear gowns while providing care to a resident who was on enhanced barrier precautions. Despite signage indicating the need for such precautions, the CNAs were unaware of the requirement. The DON confirmed that gowns should have been worn to prevent cross-contamination, in accordance with the facility's policy on enhanced barrier precautions. Both the RN and the CNAs had received infection control training within the year, and the facility conducted regular skills checks.
Improper Garbage Disposal Practices
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, specifically with Dumpster #1. Observations revealed that the dumpster was overflowing with trash, preventing the lid from closing completely, which left an 18-inch gap. Additionally, the dumpster was missing a drainage plug on the right side, and there was trash and debris scattered around the area, including plastic bags, an empty cardboard case of soda, a plastic glove, an empty water bottle, and a cigarette butt. Interviews with the Food Service Director (FSD) and the Maintenance Director confirmed that trash was typically picked up twice a week, and the dumpster had been recently replaced. The Maintenance Director acknowledged the missing drain plug and its importance in preventing animals from accessing the dumpster. The facility's waste disposal policy and the U.S. Public Health Service Food Code require that waste containers be emptied regularly, sealed, and covered with tight-fitting lids, and that drain plugs be in place, which were not adhered to in this instance.
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 fracture to her left tibia. The resident, who had moderate intellectual disabilities, autistic disorder, and severe cognitive impairment, was unable to communicate how the injury occurred. Despite the presence of a significant bruise and swelling on her leg, the facility did not report the incident to the state reporting agency (HHSC) within the required two-hour timeframe. The resident was wheelchair and bedbound, requiring maximum assistance for activities of daily living and was dependent on staff for transfers. The injury was discovered after the resident returned from an Adult Day Care program, where she traveled via a public bus service without staff supervision. The facility's Director of Nursing (DON) and other staff members were aware of the injury but did not classify it as an injury of unknown origin, as the resident reportedly mentioned the bus in relation to the injury, despite her severe cognitive impairment. Interviews with facility staff revealed that there was confusion and a lack of clarity regarding the origin of the injury. The DON and Administrator did not report the injury to the state agency, as they did not suspect abuse or neglect, relying instead on the resident's limited communication about the bus. The facility's policy required reporting injuries of unknown origin, but the staff did not adhere to this policy, resulting in a failure to report the incident as required.
Deficient Care Plan for Resident with Intellectual Disabilities
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with moderate intellectual disabilities, autistic disorder, and type 2 diabetes mellitus with diabetic polyneuropathy. The care plan did not include essential details such as the name and contact information of the LIDDA representative, the next scheduled IDT meeting, or specifics about the Adult Day Care services the resident attended three times a week. Additionally, the care plan lacked information on the community bus service used for transportation to the Adult Day Care, including the schedule, interventions for transport, and contact information. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's care plan. RN B described the process of preparing the resident for Adult Day Care but noted that there was no daily or written communication with the Adult Day Care facility. The receptionist and LVN A confirmed that the care plan did not include necessary transportation and contact information. The MDS Coordinator, who was responsible for care plans, was unavailable for interviews, and the DON acknowledged that the care plan should have included the missing information. The facility's policy on comprehensive person-centered care plans emphasized the need for measurable objectives and timetables to meet residents' needs. However, the DON admitted that the care plan for the resident's Adult Day Care and transportation was not updated when the activity was initiated. The Administrator and LIDDA also provided insights into the lack of communication and coordination between the facility and the Adult Day Care, highlighting the deficiency in ensuring continuity of care for the resident.
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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) |
|---|---|---|---|---|
| San Pedro Manor | 0.2 mi | — | 1 | 0 |
| St. Francis Nursing Home | 0.2 mi | — | 5 | 0 |
| San Antonio North Nursing And Rehabilitation | 0.7 mi | — | 13 | 0 |
| Memorial Medical Nursing Center | 0.7 mi | — | 9 | 0 |
| The Sarah Roberts French Home | 2 mi | — | 8 | 0 |
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