Latest reports, citations, and penalties from CMS data
The inspection, completed November 24, 2025, revealed gaps in care delivery despite what appeared to be adequate staffing levels....
Staff immediately intervened and helped the resident back to their room, according to nursing notes....
The director of nursing told inspectors he wasn't aware the residents weren't receiving showers or bed baths....
Resident #105 lived with severe cognitive impairment, epilepsy, heart failure, intellectual disability, and muscle weakness....
She told inspectors she never took the ring off and was very upset when she discovered it missing....
Instead, Licensed Nurse 1 administered a 20-milligram tablet that belonged to a different resident....
"She forgot to sanitize the glucometer, and it should have been done after using the glucometer," the nurse told inspectors when confronted about the lapse....
Moderate pain registers 4-6, while severe pain spans 7-10....
The facility's own dietary manager acknowledged the violation could lead to cross-contamination and pest control problems....
Patient 1 had been admitted in September with Type 2 diabetes and was identified as an elopement risk from day one....
The woman, identified in the inspection report as a family friend of the resident, discovered the confused man around 8:30 a.m....
Federal inspectors found Estates at Shavano Park operating without a policy for assessing nurse competencies during a complaint investigation in November....
The Social Worker acknowledged during an October 28 interview that she had addressed the family's previous concern about the call light placement....
The staffing shortage created a cascade of care failures....
Resident 1 had been admitted to the facility after experiencing falls....
The falsified documentation at Lutheran Home came to light when an outside infusion clinic contacted facility administrators....
The missed 6 AM dose was never mentioned during shift report, the nurse told inspectors....
But staff were following incomplete orders anyway....
The resident had intact cognition with a score of 15 on cognitive testing....
The facility's director of nursing pulled the complete staff list and found no employee assigned those initials....