616 W Russell Pl, San Antonio, TX 78212 · Bexar County · (210) 735-9233
106 certified beds, about 57 residents a day · For profit - Individual · Medicare and Medicaid since 1978
CMS Care Compare ratings, data as of September 1, 2026 · CCN 455450 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on February 13, 2026, inspectors cited 9 health deficiencies (the Texas average is 9.4, the national average 9.2).
Of 49 health citations since September 2023, 2 were rated as actual harm or immediate jeopardy to residents (2 immediate jeopardy).
CMS lists 2 fines totaling $23,438 in the last three years; the largest was $14,325, and the latest is dated March 20, 2026.
Nurses and nurse aides worked 4.74 hours per resident per day, against 3.39 across Texas and 3.86 nationally. Registered nurses accounted for 0.39 of those hours.
68.4% of nursing staff left within the year CMS measured (Texas average 55.3%).
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 49 health citations on file.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure assessments accurately reflected thestatus of the residents for 1 of 9 residents (Resident #1) reviewed for resident assessments. The facility failed to ensure Resident #1s shortness of breath, mechanical ventilation and active diagnosis of pneumonia (lung infection) was reflected on the discharge MDS dated [DATE]. This deficient practice could place residents at risk of inadequate care.
Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensiveperson-centered care plan for each resident, consistent with the resident rights, which includes measurable objective andtimes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 Residents (Resident #2) of 9 residents reviewed for comprehensive care plans. The facility failed to accurately reflect Resident #2's skin and preventive interventions in the care plan. This deficient practice placed residents at risk of missed or miscommunicated care. Record review of Resident #2's electronic face sheet dated 07/16/2026 reflected a [AGE] year-old female admitted on [DATE]/2025. Her diagnoses included: [...]
Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure that a resident who receives necessary respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for 1 resident (Resident #2) of 3 residents who received tracheostomy care. The facility failed to secure Resident #2's suctioning tubing to the lid and place the suction catheter tip into the package sleeve after being used. These deficient practices could place residents at risk and could result in the introduction of foreign substances to the airway.
Inspectors wroteBased on interview and record review the facility failed to immediately consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there is a significant change in the resident's physical, mental, or psychosocial status for 1 of 1 resident (Resident #1) reviewed for medication administration, in that: The facility failed to ensure the physician and RP were notified of missed doses of Rifaximin 550mg for hepatic encephalopathy between 04/27/2026 and 05/16/2026 due to medication not being available. This failure puts the resident at risk for not receiving therapeutic effects from their medications.
Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals) for 1 of 1 resident (Resident #1) to meet the needs of the resident, in that: The facility failed to ensure Resident #1 received ordered medication Rifaximin 550mg for hepatic encephalopathy between 04/27/2026 - 05/16/2026 due to medication being unavailable. This failure could place residents at risk for not receiving therapeutic effects from their medications.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 1 of 10 (Resident #1) reviewed for advance directives. The facility failed to honor Resident #1's Out-of-Hospital Do Not Resuscitate (OOH DNR) when on [DATE] the resident was found unresponsive and was resuscitated after respirations and pulse ceased. The non-compliance was identified as PNC. The Immediate Jeopardy (IJ) began on [DATE] and ended on [DATE]. The facility corrected the non-compliance before the survey began on [DATE]. This failure could place residents at risk of pain associated with resuscitation and mental anguish.
Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident's responsible party was informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose alternative options is he or she preferred for 2 of 5 (Residents #52 and #4) residents reviewed for resident rights. The facility failed to notify and obtain consent from Resident #52 or her RP to administer buspirone (used to treat anxiety) and failed to adequately disclose potential side effects or complete all portions of the consents including physician diagnostic criteria and signature for diazepam (a benzodiazepine used to treat anxiety) and Lexapro (antidepressant). 2. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biological were stored in a manner that permitted only authorized personnel to have access to the keys for 1of 2 Medication Rooms (100 hall medication room) reviewed for pharmacy services. The facility failed to ensure 1 of 2 doors remained locked on the hallway medication room. This failure could place residents receiving medication at risk for access by unauthorized personal, visitors and residents.
Inspectors wroteBased on observation, interview, 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 disease and infection for 3 of 6 residents (Residents #3, #5 and#43) reviewed for infection control, in that: 1. On 02/12/2026, the Facility failed to ensure LVN A changed gloved and sanitize her hands after touching Resident #3's environment. 2. On 02/12/2026, the Facility failed to ensure RT C wore a gown while providing care for Resident #5 who was on Enhanced Barrier Precaution. 3. On 02/12/2026, the Facility failed to ensure LVN A used a disposable cloth under Resident #43's wound, during wound care, to prevent cross contamination. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 2 units (unit 200) reviewed for physical environment, in that: The Facility failed to ensure that hazardous products, such as disinfecting wipes, were kept out of reach of the residents. These deficient practices could place residents and staff at-risk for injury.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care with 48 hours of the resident's admission for 1 (Resident #68) of 1 residents reviewed for baseline care plans, in that: Resident #68 did not have a baseline care plan. This deficient practice could result in improper treatment.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 5 residents (Residents #5) reviewed for care plans: The facility failed to ensure Resident #5 comprehensive care plan included a plan for anemia with goals and interventions to address her low hemoglobin and hematocrit (which could be symptoms of anemia). This deficient practice could cause incomplete information to be given to staff responsible for care to the residents and place residents at risk of receiving improper care and services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure incontinent care was provided in accordance with appropriate treatment and service practices to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Residents #3) reviewed for for quality of care, in that: The facility failed to ensure, while providing incontinent care for Resident #3, CNA B did not make multiple passes with the same wipe to clean Resident #3, she spread the resident's labia and cleaned Resident #3's anal area. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispending, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 8 residents (Resident #5) reviewed for pharmacy services. The facility failed to ensure Resident #5 received the correct dose of ferrous sulfate (iron supplement) on 3/11/2026 of 5 ml of 300 mg/5 ml (60 Fe) as prescribed by the physician. This failure could place residents at risk of receiving the correct dosage of medication and put them at risk for medication errors.
Inspectors wroteBased on interview and record review, the facility failed to ensure the resident was not given a psychotropic drug unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #4) reviewed for unnecessary medications, in that: The facility failed to ensure Resident #4 psychotropic medication, Atarax was prescribed no longer than 14 days PRN. Resident #4 was ordered PRN Atarax (an antihistamine medication with sedative and hypnotic effects used to treat anxiety disorders) on 1/15/2026 without a stop date. This failure could place residents at risk of receiving unnecessary psychotropic medications.
Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to correct impairments during the inspection for 1 of 1 Fire Alarm System, inspected for regulatory requirements, failed to ensure outside areas, were maintained in good condition and kept free of conditions which constituted a fire or health hazard and failed to ensure the Emergency Preparedness Plan had been evaluated and updated annually. The Emergency Preparedness Plan was not updated at least annually. The Fire Alarm Control Panel was impaired indicating a low battery trouble signal. There were multiple trees on the back side of the facility leaning up against the roof which could constitute a fire hazard. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 7 of 10 residents (Residents #2, #3, #5, #6, #7, #8 and # 9) reviewed for infection control, in that: 1. RT A was observed providing tracheotomy care to Resident #2 on 08/18/2025 at 10:05 a.m. without wearing a gown while Resident #2 was on enhanced barrier precautions. 2. RT D was observed providing a nebulizer treatment for Resident #3's tracheotomy on 08/18/2025 at 10:45 a.m. Resident #3 was on enhanced barrier precautions and RT D wore a face mask below her mouth and did not wear a gown. 3. [...]
Inspectors wroteBased on interview and record review the facility personnel failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 6 residents (Resident #1) whose records were reviewed for code status. Facility staff failed to follow emergency protocol, did not obtain an AED, did not obtain the crash cart, or continue CPR until EMS arrived after Resident #1, and who had a Full Code in place, was found unresponsive with no pulse or respirations. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 9:11 p.m. [...]
Inspectors wroteBased on record reviews and interviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 4 of 10 residents (Residents #1, #2, #3, #4) reviewed for the allegation of abuse, neglect, exploitation and or mistreatment. 1. [...]
Inspectors wroteBased on record reviews and interviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, had evidence that all alleged violations were thoroughly investigated, prevented further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress. for 4 of 10 residents (Resident #1, #2, #3, #4) reviewed for the allegations of abuse, neglect, exploitation and or mistreatment. 1. On 12/3/2024 the facility failed to investigate an allegation of abuse and or mistreatment when Resident #1's Representative alleged a nurse treated Resident #1 poorly and made Resident #1 cry. 2. On 12/23/2024 the facility failed to investigate an allegation of neglect and or mistreatment when Resident #2 alleged a nurse neglected to change a gastric tube stoma dressing. [...]
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 of 4 medication carts reviewed for security and control, in that: 1. LVN E left the 100-hall medication cart unattended, unsupervised, and unlocked. 2. RT K left the 200-hall respiratory therapy medication cart unattended, unsupervised, and unlocked. These failures could place residents at risk of misappropriation of property, not receiving the therapeutic effects of medications, and or adverse effects of medications.
Inspectors wroteBased on interviews and record reviews the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and were systematically organized, for 1 of 8 residents (Resident #8) reviewed for consents for accurate medical records. Resident #8's November 2024 treatment administration report had no documentation for his prescribed daily wound care for the wound on his sacrum (a single bone comprised of five separate vertebrae. It is shaped like an upside-down triangle and sits at the bottom of the spinal column, connecting it to the pelvis) on the following dates: o 11/10/2024 , o 11/15/2024, o 11/20/2024, o 11/21/2024, and, o 11/24/2024. The failure could place residents at risk for inaccurate and unorganized medical records.
Inspectors wroteBased on interviews and record reviews, the facility failed to promote and facilitate resident's self determination with support of resident choice and the right to refuse care for 1 of 4 (Resident #7) reviewed for resident rights. Resident #7 was unable to refuse care without the threat of calling his family member. This failure could affect the resident's psychosocial well-being and the ability to maintain highest level of independence.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to protect the rights of residents to be free from misappropriation of property for 2 of 8 residents (Resident #5, Resident #6) reviewed for misappropriation of medication. The facility failed to ensure Resident #5's and Resident #6's medications were secured and not diverted when delivered to the facility. The noncompliance was identified as past noncompliance. The noncompliance began on [DATE] and ended on [DATE]. This failure could place residents who receive pain medications at risk of diminished quality of life and distress.
Inspectors wroteBased on record reviews and interviews the facility failed to send a copy of the residents' discharge notice, prior to discharge, to the representative of the Office of the State Long-Term Care (LTC) Ombudsman of the residents' transfer or discharge and the reasons for the move, for 1 of 8 residents (Resident #8) reviewed for notifying the LTC Ombudsman of the residents' discharge. Resident #8 was discharged on 12/2/2024 without a notice to the LTC state ombudsman. This failure could place residents at risk of not knowing their rights or receiving the services of the state LTC Ombudsman.
Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure its medication error rate was not 5% or greater. The facility had a medication error rate of 7.69%, based on 2 errors out of 26 opportunities, which involved 1 of 6 residents (Resident #1) reviewed for medication administration and medication errors. RN A administered Resident #1's medications: a 10 gram of carafate tablet (an anti-ulcer medication) and 30 milliliters of 10 gm/15mL enulose solution (a laxative used to treat constipation), scheduled at 04:00 p.m., at 05:29 p.m., one hour and twenty-nine minutes late. These deficient practices could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.
Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The facility failed to store plastic storage containers to allow for air-drying in the dish room. 2. The facility failed to store, label and date a container of chopped beef brisket in the walk-in cooler. 3. The facility failed to store and label French fries in the reach-in freezer. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 5 residents (Resident #46) reviewed for privacy, in that: CNA A and CNA B did not close completely Resident #46's privacy curtain while providing catheter care. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 1 of 8 residents (Resident #56) reviewed for care plans. Resident #56's cognitive communication deficit was not addressed in his comprehensive care plan. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 (Resident #8) of 18 reviewed for environment, in that: Resident #8's bathroom contained potentially hazardous materials. This deficient practice could result in residents, staff, and/or the public coming into contact with potentially hazardous materials.
Inspectors wroteBased on interview and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (Resident #48) of 18 residents reviewed, in that: Resident #48 displayed signs and symptoms of depression and was not offered mental health services. This deficient practice could place residents with mental health concerns at risk of diminished psychosocial well-being.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 of 3 medication carts (Hall 200 Medication Cart) reviewed for storage, in that: During medications administration, RN C left Hall 200 Medication cart unlocked on 1 occasion. This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed medications.
Inspectors wroteBased on observation, interview, 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 disease and infection for 3 of 9 residents (Residents #162, #4, and #46) reviewed for infection control, in that: 1. RN D did not sanitize the blood pressure cuff between Resident #162 and Resident #4. 2. CNA A and CNA B did not wear a gown while providing care to Resident #46 who had been place on enhanced barrier precautions. These deficient practices could place residents at-risk for infection due to improper care practices.
Inspectors wroteBased on observation, interview and record review, the facility failed a to dispose of garbage and refuse properly for 1 of 2 Dumpsters (Dumpster #1) reviewed for disposal of garbage. The facility failed to ensure the waste in Dumpster #1 was removed to allow the top lid to close, the dumpster had a drainage plug, and the area around the dumpster was free of trash and debris. These deficient practices could place residents at risk for exposure to germs and diseases carried by vermin and rodents.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse or neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation result in serious bodily injury for 1 of 4 Residents (Resident #3) whose records were reviewed for abuse and neglect., in that; The facility failed to report to the state reporting agency (HHSC) an injury of unknown origin when Resident #3 suffered a fracture to her left tibia (lower leg). This deficient practice could affect any resident and could contribute to further abuse and neglect.
Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #3) reviewed for care plans, in that The facility failed to ensure Resident #3's comprehensive care plan included: -LIDDA representative name/office and contact information and next scheduled IDT meeting -Adult Day Care Services three days a week including the name of the facility and the name and phone number of their contact person at the ADC and interventions for continuity of care between the two facilities. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for each that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of 16 resident (Resident #25, Resident #33, Resident #35, and Resident #44) reviewed for care plans. 1. The facility failed to ensure smoking was included on Resident #25's care plan. 2. The facility failed to ensure smoking was included on Resident #33's care plan. 3. The facility failed to ensure smoking was included on Resident #35's care plan. 4. The facility failed to ensure Resident #44's side rail use was care planned. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who need respiratory care were provided such care, consistent with professional standards of practice for 4 of 17 residents (Resident #40, Resident #44, Resident # 47, and Resident #49) reviewed for respiratory care. 1. The facility failed to replace the oxygen concentrator humidification reservoirs in a timely manner. 2. Facility failed to ensure Resident #44 and Resident #49 nebulizer supplies were bagged and dated to prevent cross contamination. These deficient practices could affect residents who receive oxygen therapy and nebulizer treatments which could contribute to respiratory infections.
Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for three residents (Residents #31, #36, and #54) out of 5 residents reviewed for medication administration in that: 1. Resident #31 had metoprolol (a medication for high blood pressure) administered outside the parameters as ordered by the physician. 2. Resident #36 had ibrutinib (a medication for cancer) administered without a pharmacy label. 3. Resident #54 had midodrine (a medication low blood pressure) administered outside of the parameters as ordered by the physician and Resident #54 missed administration of hydralazine (a medication for elevated blood pressure). [...]
Inspectors wroteBased on observation, interviews and record reviews, the facility failed ensure residents are free of any significant medication errors for three residents (Residents #31, #36, and #54) out of 5 residents reviewed for medication administration in that: 1. Resident #31 had metoprolol (a medication for high blood pressure) administered outside the parameters as ordered by the physician. 2. Resident #36 had ibrutinib (a medication for cancer) administered without an appropriate label. 3. Resident #54 had midodrine (a medication low blood pressure) administered outside of the parameters as ordered by the physician. Resident #54 missed administration of hydralazine (a medication for elevated blood pressure). This failure could place residents at risk for not receiving the intended therapeutic effects of their medications and possible adverse reactions.
Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: The facility failed to ensure all foods in the refrigerator were labeled and dated with use by dates. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of resident needs 2 of 8 resident rooms (Resident #42 and Resident #44) reviewed for call lights. The facility failed to ensure Resident #42 and Resident 44's call lights were within reach and placed for easy access. The deficient practice could place residents at risk of not receiving care or attention needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 8 residents (Residents #10 and #25) whose assessments were reviewed, in that: The facility failed to ensure Resident #10 and #25's Quarterly MDS Assessments were coded correctly for bed rails. This failure could place residents at-risk for inadequate care due to inaccurate assessments.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 8 residents (Resident #25) for care plan revisions, in that: The facility failed to ensure bed rails were removed from Resident #25's care plan. This failure could place residents at risk of receiving inappropriate care.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure an incontinent resident who had a urinary catheter received appropriate treatment and services to prevent urinary tract infections for 1 of 1 resident (Resident #29) reviewed for catheter care in that; The facility failed to ensure Resident #29 was provided catheter care to professional standards to prevent infections. This deficient practice could place residents at-risk for exposure to pathogens causing infection resulting in diminished quality of life.
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure a medication error rate below 5% for 2 of 3 residents (Residents #31 and #36), in that; During medication administration observations, LVN A administered medications erroneously resulting in a 7.59% (2 errors out of 26 opportunities) medication administration error rate: 1. LVN A administered metoprolol (a medication for high blood pressure) to Resident #31 outside the parameters as ordered by the physician. 2. LVN A administered ibrutinib (a medication for cancer) to Resident #36 without a pharmacy label. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys in 1 medication carts of 6 medication carts (First Floor Treatment Cart) reviewed for medication storage, in that; The facility failed to ensure the First Floor Treatment Cart was locked when left unattended in the hallway. This deficient practice could place residents at risk of medication misuse or drug diversion.
Inspectors wroteBased on interview and record review the facility failed to implement establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, and smoking safety for 3 (Residents #25, #33 and #35) of 3 residents reviewed did not have their smoking assessment. 1. The facility failed to ensure a smoking assessment was completed for Resident #25 quarterly. 2. The facility failed to ensure a smoking assessment was completed for Resident #33 upon admission. 3. The facility failed to ensure a smoking assessment was completed for Resident #35 quarterly. This failure could affect smoking residents and could result in harm if policies were not followed.
Inspectors wroteBased on interviews, and record reviews, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 1 of 4 residents (Resident #1), reviewed for resident records, in that: The facility failed to ensure Resident #1's physician orders reflected the resident's Advance Directive code status after Resident #1's Out of Hospital Do Not Resuscitate form was provided to the facility. This deficient practice could affect all residents whose records are maintained by the facility and could place them at risk for errors in care and treatment.
16 fire safety citations on file: 2 on February 13, 2026, 10 on November 6, 2024, 4 on September 22, 2023.
| Date | Penalty | Amount or length |
|---|---|---|
| March 20, 2026 | Fine | $9,113 |
| August 3, 2025 | Fine | $14,325 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Texas | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 4.74 | 3.39 | 3.86 |
| Registered nurses | 0.39 | 0.43 | 0.69 |
| All nursing staff on weekends | 4.04 | 2.98 | 3.42 |
| Nurse aides | 2.49 | ||
| Licensed practical nurses | 1.87 | ||
| Nursing staff turnover (share who left in a year) | 68.4% | 55.3% | 45.8% |
| Registered nurse turnover | 75.0% | 54.6% | 42.9% |
| Administrators who left | 2 |
CMS expects 7.05 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 5.03 on weekdays and 4.04 on weekends, 20% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 1.9% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.40 in April to June 2025 to 4.74 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 4.74 | 0.39 | 5.03 | 4.04 | 1.9% | 0 of 90 | 57 |
| Oct to Dec 2025 | 4.84 | 0.38 | 5.17 | 4.02 | 7.6% | 0 of 92 | 56 |
| Jul to Sep 2025 | 4.66 | 0.35 | 4.88 | 4.09 | 12.6% | 1 of 92 | 60 |
| Apr to Jun 2025 | 4.40 | 0.35 | 4.69 | 3.66 | 7.1% | 3 of 91 | 55 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Texas, Jan to Mar 2026 | 3.33 | 0.40 | 3.50 | 2.93 | 2.2% | 0.7% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Texas, all employers | |||
| CNAs (nursing assistants) | $18.03 | $16.97 to $20.71 | 88,680 |
| LPNs and LVNs | $29.92 | $27.46 to $32.89 | 57,560 |
| Registered nurses | $46.14 | $38.06 to $50.53 | 271,380 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Texas | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 20.8 | 15.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 2.1 | 0.3 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.5 | 0.8 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 5.7 | 3.3 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 3.9 | 1.5 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 14.3 | 14.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 14.4 | 3.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 10.2 | 9.6 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 36.0 | 25.7 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 9.7 | 12.3 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.6 | 2.2 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.5 | 2.1 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Meridian Care Monte Vista's Medicare short-stay residents. How to read these, and what Medicare pays for.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
US median of homes 51.5% · Texas: 116 better, 50 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 24 eligible stays.
11.4% this home
No different from the national rate
US median of homes 10.7% · Texas: 0 better, 9 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 29 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
US median of homes 7.1% · Texas: 4 better, 11 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 13 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Texas57.3% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 16 residents counted.
0.0% this home
Median of homes: Texas0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 23 residents counted.
0.0% this home
Median of homes: Texas1.3% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 23 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Texas98.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 4 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: RJ MERIDIAN CARE ALTA VISTA LLC.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Balentine, Jay | Direct ownership interest | Individual | 01/08/2010 | |
| Lozano, Ramiro | Direct ownership interest | Individual | 01/08/2010 | |
| Balentine, Jay | Corporate officer | Individual | 01/08/2010 | |
| Lozano, Ramiro | Corporate officer | Individual | 11/30/2009 | |
| Aziz, Wesam | Operational/managerial control | Individual | 06/01/2023 | |
| Glisczinski, Kimberly | Operational/managerial control | Individual | 05/19/2022 | |
| Nienaber, Pamela | Operational/managerial control | Individual | 02/10/2023 | |
| Aziz, Wesam | Adp of the SNF | Individual | 01/30/2025 | |
| Balentine, Jay | Adp of the SNF | Individual | 01/08/2010 | |
| Glisczinski, Kimberly | Adp of the SNF | Individual | 01/30/2025 | |
| Lozano, Ramiro | Adp of the SNF | Individual | 01/08/2010 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Texas. NursingHomeClear cannot take or act on complaints.