Las Alturas de Penitas: DNR Order Failures - TX]
That exchange, documented during a May 2026 inspection, sits at the center of what federal surveyors found at this nursing home on Liberty Boulevard in Penitas, a small city in the Rio Grande Valley near the Texas-Mexico border. The deficiency involved the facility's handling of Out-of-Hospital Do Not Resuscitate orders, the legal documents that direct emergency responders and health care professionals to allow a person to die naturally rather than attempt resuscitation.
These are not bureaucratic forms. They are the written expression of a person's decision about how they want to die.
Texas law governing these orders is specific about witnessing. The Out-of-Hospital DNR form must be signed and dated by two competent adult witnesses who have watched the person make their signature. Both witnesses must be present for the same act. The date on a witness signature is meant to reflect exactly that: the moment the witness saw the resident sign.
At Las Alturas de Penitas, inspectors found something different. In at least one case, the date on a witness signature did not match the date on the resident's signature. Rather than treating that as a problem requiring correction, the facility went with the date of the witness signature and moved on. The Director of Nursing, when confronted with the discrepancy during the inspection, told surveyors the order was valid.
It was not a position supported by the facility's own paperwork. Record review of the OOH-DNR Order instructions, revised by the facility as recently as October 2023, spelled out the requirement plainly: the order must be signed and dated by two competent adult witnesses who have witnessed either the competent adult person making their signature, or an authorized declarant making theirs. The instructions exist in the facility's own files. The Director of Nursing had access to them.
The facility's Advance Directives policy, also reviewed during the inspection and dated 2023, described the process in similar terms. The interdisciplinary team is supposed to honor the care decisions a resident has expressed, initiate the appropriate DNR form, and obtain the physician's signature according to the OOH-DNR instructions. The medical record and the resident's plan of care should reflect the resident's wishes and the physician's orders together.
That chain, from the resident's expressed wish to the legally executed document to the physician's order to the care plan, depends on each link holding. A witness signature dated differently from the resident's signature breaks the chain at the beginning.
The purpose of the OOH-DNR form, as stated in the facility's own instructions, is to direct health care professionals to forgo resuscitation attempts and to permit the person to have a natural death with peace and dignity. The form is designed to travel with a person. It applies in physicians' offices, hospital clinics, and emergency departments. When emergency responders arrive, they look at the form. If the form is not properly executed, they may not honor it.
That is the practical consequence of what inspectors found. A resident who had made the decision not to be resuscitated, who had gone through the process of signing the form and having it placed in their medical record, may have ended up with a document that would not withstand scrutiny in an emergency.
The Director of Nursing's response to inspectors did not acknowledge that risk. The position was that the form was valid. The inspection record does not indicate that the facility, at the time of the survey, had moved to correct the flawed documents or re-execute them properly.
Inspectors classified the deficiency as causing minimal harm or the potential for actual harm, and noted that few residents were affected. The lower harm classification reflects the fact that no documented resuscitation had yet been attempted on a resident with a flawed order. It does not mean nothing was at stake. In elder care inspections, the gap between "minimal harm" and catastrophic harm is often the gap between the moment of inspection and the moment of crisis.
The requirement that witnesses be present and contemporaneous exists for a reason that goes beyond formality. Advance directives, and DNR orders specifically, are vulnerable to pressure, confusion, and error precisely because the person making them is often ill, elderly, and dependent on the institution around them. The witnessing requirement is a check. It ensures that someone outside the medical staff, someone with no stake in the outcome, saw the resident make their choice freely and in the moment. A witness who signs days later, or whose date doesn't match the resident's, cannot honestly attest to having seen that.
Las Alturas de Penitas is a licensed nursing facility serving residents in Hidalgo County, one of the poorest counties in the United States. The population it serves is predominantly elderly and Spanish-speaking. Many residents in facilities like this one rely entirely on the institution to navigate the paperwork that governs their care. They sign what staff bring them. They trust that the forms will be handled correctly.
The inspection report does not name the residents whose DNR orders were at issue. It does not describe their conditions, their ages, or how long they had been at the facility. It does not say whether any of them understood that the documents meant to carry their final wishes might not hold up when it mattered.
What the report does say is that when inspectors found the problem and asked the person responsible for nursing oversight to account for it, the answer was that everything was fine.
The resident whose form had the mismatched witness date had made a decision. They had put their name on a document that said, when the time comes, let me go. Whether that document would have done what they intended, in an emergency room or in the back of an ambulance, was a question the facility had not asked itself before inspectors arrived, and had not answered honestly once they did.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Las Alturas De Penitas from 2026-05-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 8, 2026 · Our methodology
LAS ALTURAS DE PENITAS in PENITAS, TX was cited for violations during a health inspection on May 28, 2026.
These are not bureaucratic forms.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.