Cycle 1
Health 2025-02-12 · Fire 2025-02-12
17 health deficiencies
Top issue: Nutrition and Dietary (5 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
San Antonio, TX
Southeast Nursing & Rehabilitation Center
2-star overall rating with 1-star inspections with $188,383 in total fines with 17 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
4302 E Southcross Blvd, San Antonio, TX
(210) 333-1223
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
116
Certified beds
Average residents
78
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Ruby Healthcare
Operator or chain grouping
Approved since
2001-09-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 3 overall / 2 health / 3 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.14
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.36
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.60
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.25
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.17
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.15
CMS adjusted RN staffing hours
Adjusted total hours
3.77
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
83%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,690
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.02
Composite VBP score used to determine payment impact.
Payment multiplier
0.9853
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.11
Baseline 97.33% · Performance 63.95% · Measure score 4.11 · Achievement 0 · Improvement 4.11
Adjusted total nurse staffing
1.70
Baseline 4.03 hours · Performance 3.56 hours · Measure score 1.70 · Achievement 1.70 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.54% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 10.81% · Lower 95% interval 6.78% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 9 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.27 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 11 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 6.25% |
8.2%
1.9 pts worse
|
Numerator 5 · Denominator 80 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
2.1
0.8 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.1 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 79.8% |
97.1%
17.3 pts worse
|
93.4%
13.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 82.1% · Q2 78.7% · Q3 77.1% · Q4 81.0% · 4Q avg 79.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
97.9%
0.9 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.3%
2 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 1.4% · Q4 1.3% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
3.3%
1.4 pts worse
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 10.9% · Q3 3.3% · Q4 0.0% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.5% |
18.9%
5.4 pts better
|
19.6%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 15.2% · Q3 14.3% · Q4 10.1% · 4Q avg 13.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.3% |
10.8%
6.5 pts better
|
16.7%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 5.6% · Q3 2.9% · Q4 2.8% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 3.9% |
15.4%
11.5 pts better
|
16.3%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 8.5% · Q3 0.0% · Q4 3.2% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.3% |
16.1%
6.8 pts better
|
14.9%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 12.3% · Q3 6.6% · Q4 9.1% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.7% |
15.0%
3.3 pts better
|
19.8%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 11.9% · Q3 11.0% · Q4 7.3% · 4Q avg 11.7% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
4.2%
1.8 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.9% · Q3 0.9% · Q4 2.5% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 39.7% |
89.7%
50 pts worse
|
81.7%
42 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 48.3% · Q4 20.0% · 4Q avg 39.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.0% |
12.0%
About the same
|
12.0%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 12.5% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.2% |
1.5%
2.7 pts worse
|
1.6%
2.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.7% |
25.9%
9.2 pts better
|
23.9%
7.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.7% · Observed 12.5% · Expected 17.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-13 · Fire 2024-01-13
16 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-11-18 · Fire 2022-11-18
25 health deficiencies
Top issue: Resident Assessment and Care Planning (10 deficiencies)
7 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-12
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-02-21
F · Potential for more than minimal harm
2025-02-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-27
F · Potential for more than minimal harm
2025-02-12
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-02-21
E · Potential for more than minimal harm
2025-02-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-03-27
F · Potential for more than minimal harm
2024-01-13
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-02-10
E · Potential for more than minimal harm
2024-01-13
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-01-15
E · Potential for more than minimal harm
2024-01-13
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-01-15
E · Potential for more than minimal harm
2024-01-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-02-01
F · Potential for more than minimal harm
2022-11-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-28
F · Potential for more than minimal harm
2022-11-18
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-12-28
F · Potential for more than minimal harm
2022-11-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-28
E · Potential for more than minimal harm
2022-11-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-28
E · Potential for more than minimal harm
2022-11-18
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-12-28
D · Potential for more than minimal harm
2022-11-18
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-12-28
D · Potential for more than minimal harm
2022-11-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2026-01-12
D · Potential for more than minimal harm
2026-01-09
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2026-01-23
D · Potential for more than minimal harm
2026-01-09
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2026-01-28
D · Potential for more than minimal harm
2026-01-09
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2026-01-28
D · Potential for more than minimal harm
2026-01-09
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2026-01-28
F · Potential for more than minimal harm
2025-02-12
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2025-02-13
F · Potential for more than minimal harm
2025-02-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-13
E · Potential for more than minimal harm
2025-02-12
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-02-13
E · Potential for more than minimal harm
2025-02-12
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-02-12
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-02-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-02-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-02-12
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-02-12
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-02-12
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-02-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-02-12
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-02-13
E · Potential for more than minimal harm
2024-01-13
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-01-26
E · Potential for more than minimal harm
2024-01-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-15
E · Potential for more than minimal harm
2024-01-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-15
E · Potential for more than minimal harm
2024-01-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-14
D · Potential for more than minimal harm
2024-01-13
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-15
D · Potential for more than minimal harm
2024-01-13
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-01-19
D · Potential for more than minimal harm
2024-01-13
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-01-15
D · Potential for more than minimal harm
2024-01-13
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-01-26
D · Potential for more than minimal harm
2024-01-13
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-01-15
D · Potential for more than minimal harm
2024-01-13
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-01-15
D · Potential for more than minimal harm
2024-01-13
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-01-15
D · Potential for more than minimal harm
2024-01-13
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-01-15
D · Potential for more than minimal harm
2024-01-13
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-01-15
D · Potential for more than minimal harm
2024-01-13
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-01-15
D · Potential for more than minimal harm
2024-01-13
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-01-15
D · Potential for more than minimal harm
2024-01-13
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-01-15
F · Potential for more than minimal harm
2023-12-01
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-12-02
E · Potential for more than minimal harm
2023-10-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-10-14
D · Potential for more than minimal harm
2023-10-13
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-14
D · Potential for more than minimal harm
2023-08-25
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-09-19
K · Immediate jeopardy
2023-08-19
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-09-22
K · Immediate jeopardy
2023-08-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-22
K · Immediate jeopardy
2023-08-19
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-09-22
J · Immediate jeopardy
2023-08-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-08-19
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-08-19
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-08-19
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-08-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-08-19
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-09-22
E · Potential for more than minimal harm
2023-07-31
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-05-18
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-06-23
F · Potential for more than minimal harm
2023-05-18
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2023-06-23
F · Potential for more than minimal harm
2023-05-18
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-05-18
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-05-18
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-06-23
E · Potential for more than minimal harm
2022-11-18
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-12-23
E · Potential for more than minimal harm
2022-11-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-12-23
D · Potential for more than minimal harm
2022-11-18
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2022-12-23
D · Potential for more than minimal harm
2022-11-18
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-12-23
D · Potential for more than minimal harm
2022-11-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-12-23
D · Potential for more than minimal harm
2022-11-18
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-12-23
Penalties and ownership
What sits behind the stars
$188,383
2023-07-31
Fine
Fine · fine $188,383
Fine
Ownership
Beasley, Genetta
Operational/Managerial Control · Individual
Hooper, Grady
Corporate Officer · Individual
Mesquite Hc SNF LLC
Operational/Managerial Control · Organization
Scheiner, Eliezer
Operational/Managerial Control · Individual
Silberstein, Ari
Operational/Managerial Control · Individual
Southeast Hc LLC
Operational/Managerial Control · Organization
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#3
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2-star overall rating with 2-star inspections with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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