Hacienda Oaks at Beeville

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan for each resident, consistent with the resident's rights, that includes measurable short-term and long-term objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #2 and Resident #41) of 8 residents reviewed for care plans. 1. The facility failed to ensure Resident #2's comprehensive care plan reflected the use of a soft touch call light. 2. The facility failed to ensure Resident #41's comprehensive care plan reflected what his PTSD triggers were. This failure could place residents at risk of not receiving individualized care and services to attain or maintain the residents' highest practicable physical, mental, and psychosocial wellbeing. 1. [...]

Inspectors wroteBased on observations, interview, and record reviews, the facility failed to provide the required 80 square feet per resident in 48 of 48 resident rooms (1-2-3-4-5-6-7-8-9-10-11-12-13-14-15-16-17-18-19-20-21-22-23-24-25-27-28-29-30-31-33-34-35-36-37-38-39-41-42-43-44-45-46-48-49-50-51 and 52) in that: The facility failed to provide the required 80 square feet per resident for all 48 rooms. This failure could restrict the amount of resident care equipment and resident's personal effects that could be accommodated in these resident rooms and limit the residents' ability to move about the room.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from any significant medication errors for one of five residents (Resident #1) reviewed for medication errors. The facility failed to hold Resident #1's valsartan (blood pressure medication) when Resident #1's blood pressure was outside of physician's parameters on May 8th, 2026. This failure could place residents at risk for complications such as low blood pressure, exacerbation of symptoms, and potential hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan, which included the instructions for resident care needed to provide effective and person-centered care, was completed for 1 of 5 residents (Resident #1) reviewed for baseline care plans. The facility did not complete the baseline care plan within 48 hours of admission to include the minimum healthcare information necessary to properly care for Resident #1. This failure could place residents at risk of not receiving person-centered care and/or services to meet their physical and/or psychosocial needs.

Inspectors wroteBased on interview and record review the facility failed to ensure the comprehensive care plan was developed and implemented for each resident consistent with resident rights to include measurable objectives and timeframes to meet residents medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 1 of 5 residents (Resident #3) reviewed for care plans. The facility failed to add the diagnosis, or anything related to the diagnosis, of Dementia to Resident #3's care plan. This failure could place residents at risk for receiving inadequate care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments to reflect the current condition for 1 of 5 residents (Resident #2) whose care plans were reviewed for timing and revision. The facility failed to ensure Resident #2's care plan was revised to accurately reflect current blood pressure medication status. This deficient practice could place residents at risk of receiving inadequate, individualized care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident's right to privacy for 1 (Resident #22) of 8 residents reviewed for privacy and dignity. The facility failed to ensure LVN-A provided privacy to Resident #22 while administering his medications in the middle of the dining room without permission. This failure could cause residents to feel uncomfortable, disrespected, and possibly a loss of dignity due to a lack of privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, transportation of linens designed, to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 linen carts and one (Resident #12) of 8 residents reviewed for infection control practices, in that: 1. The facility failed to ensure LA D covered the linen cart on Hall A. 2. The facility failed to ensure LVN C washed/sanitized hands between glove changes while performing wound care on Resident #12. 3. The facility failed to ensure Resident #12's wound did not come in contact with a contaminated, soiled surface. These failures could place residents that require wound care at risk for cross-contamination and infections.

Inspectors wroteBased on observations, interview, and record reviews, the facility failed to provide the required 80 square feet per resident in 48 of 48 resident rooms (1-2-3-4-5-6-7-8-9-10-11-12-13-14-15-16-17-18-19-20-21-22-23-24-25-27-28-29-30-31-33-34-35-36-37-38-39-41-42-43-44-45-46-48-49-50-51 and 52) in that: All 48 rooms did not account for 80 square feet per resident. This failure could restrict the amount of resident care equipment and resident ' s personal effects that could be accommodated in these resident rooms and limit the residents ' ability to move about the room.

Inspectors wroteBased on observation, interview, and record review the facility failed to care for each resident in a manner that promotes maintenance and enhancement of their quality of life for two (Resident #1 and Resident #2) of 4 residents reviewed for privacy and dignity. The facility failed to ensure Resident #1 and Resident #2's urinary catheter bags were covered. This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen and 2 of 2 resident refrigerators reviewed for sanitation. 1. The facility failed to implement an approved cleaning schedule. 2. The facility failed to ensure equipment was clean and sanitized. 3. The facility failed to ensure food thermometers were calibrated prior to use. 4. The facility failed to ensure holding food was at the correct temperature for service. 5. The facility failed to ensure thermometers were wiped clean between foods. 6. The facility failed to ensure items in the unit refrigerators were not expired. 7. The facility failed to ensure items in the unit refrigerators were labeled and dated. 8. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure a PASRR evaluation was completed on newly admitted residents prior to admission and after admission for 5 of 8 residents reviewed for PASRR screenings (Residents #6, #16, #33, #42, and #60. 1. The facility failed to ensure Resident #6 received a Level 1 Screening. 2. The facility failed to ensure Residents #16, #33, #42, and #60's PASRR Level 1 screening indicated the residents were positive for mental illness. This failure placed residents at risk of not receiving or benefiting from specialized therapy and equipment services they may require.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that respiratory care was provided, consistent with professional standards of practice, for four residents (R #6, R #53, R #63, and R #46) of eight residents reviewed for respiratory care and services. 1.) R #46's suction machine canister had mucus secretions left in the canister for an unknown amount of time. 2.) R #46's suction tubing (connects to aspirators and other medical instruments used for extracting or evacuating body fluids and debris) for the suction machine was not dated or disposed after being used. 3) R # 6, R #53, and R #63 did not have a complete set of supplies that were needed to be able to perform suctioning treatment if needed. This failure could place residents who received respiratory care and services at risk for respiratory complications.

Inspectors wroteBased on observations and interviews, the facility failed to ensure all controlled drugs and biologicals were stored in separately locked and permanently affixed compartments for 1 of 1 expired/discontinued medication storage room (storage closet of the DON/ADON office) reviewed for labeling/storage of drugs and biologicals. The facility failed to ensure discontinued controlled medications for disposal were stored and separately locked in a permanently affixed compartment. This failure could place the facility at risk of drug diversion and access to medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for four residents (Resident #60, Resident #36, Resident #48, and Resident #10) of five residents observed for infection control practices during wound care and medication pass. 1.) CNA A and LPN A did not perform hand hygiene for at least 20 seconds during and after wound care for Resident #60. 2.) LPN A did not sanitize hands between a glove change while performing wound care on Resident #60. 3.) LPN A contaminated the Calcium Alginate Rope (a sterile dressing, advanced fiber-structured alginate with a highly absorbent capacity) with Resident #60's brief while performing wound care. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents were treated with respect and dignity and failed to care for each resident in a manner and environment that promoted maintenance or enhancement of his or her quality of life for one (Resident #270) of eight residents reviewed for dignity. The facility failed to provide Resident #270 with choices concerning her toileting. This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure care plans were updated for 1 of 8 residents (Resident #59) reviewed for care plans. Resident #59's care plan had no references to whether she was continent. This failure could place residents at risk for unmet care needs and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one resident (Resident #63) of nineteen residents reviewed for quality of care. The facility did not reposition or otherwise provide pressure relieving interventions for resident #63 per facility protocol and left her laying on her back in bed with the head of bed elevated and a pillow under her head. This deficient practice could affect residents receiving preventative skin care at risk for pressure ulcer development or a deterioration of a current pressure ulcer.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers and residents having pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and further development of skin breakdown or pressure ulcers for 1 (Resident #63) of 3 residents reviewed for pressure ulcers. -The facility failed to prevent the development of Resident #63's facility acquired sacral pressure ulcer. -The facility failed to ensure Resident #63 was repositioned This failure placed residents at risk of developing new pressure injuries/ulcers, worsening of existing pressure injuries/ulcers, infection, experiencing pain, decreased quality of life, and death.

Inspectors wroteBased on Interviews and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 4 of 109 days reviewed for RN coverage. 1. The facility failed to ensure that an RN was present in the facility on two occasions, and 2. The facility failed to ensure that an RN was present in the facility for at least 8 consecutive hours per day on two separate occasions. This failure could place residents at risk of missed nursing assessments, interventions, and treatments.

Inspectors wroteBased on Observations, interviews, and record review, the facility failed to provide the required 80 square feet per resident in 48 of 48 resident rooms (1-2-3-4-5-6-7-8-9-10-11-12-13-14-15-16-17-18-19-20-21-22-23-24-25-27-28-29-30-31-33-34-35-36-37-38-39-41-42-43-44-45-46-48-49-50-51 and 52). All 48 rooms did not account for 80 square feet per room. This failure could restrict the amount of resident care equipment and resident's personal effects that could be accommodated in these resident rooms and limit the residents' ability to move about the room.