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🔎 Retama Manor Nursing Center-victoria South

Inspection Results


Inspection Overview

Retama Manor Nursing Center-victoria South has been cited for a total of 43 deficiencies since we began saving each survey.

In Texas, the average facility has **34.42 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2025-04-27
Correction Date: 2025-05-19
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

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.

Survey Date: 2024-07-12
Correction Date: 2024-08-05
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Survey Date: 2024-07-12
Correction Date: 2024-08-05
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2024-07-12
Correction Date: 2024-08-05
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-05-19
Correction Date: 2023-06-16
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: B

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Survey Date: 2023-05-19
Correction Date: 2023-06-16
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Survey Date: 2023-05-19
Correction Date: 2023-06-16
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2022-11-04
Correction Date: 2022-11-25
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2022-07-03
Correction Date: 2022-07-05
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Report COVID19 data to residents and families.

Survey Date: 2022-07-03
Correction Date: 2022-07-05
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Survey Date: 2022-03-18
Correction Date: 2022-04-29
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Assure the security of all personal funds of residents deposited with the facility.

Survey Date: 2022-03-18
Correction Date: 2022-04-29
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2022-03-18
Correction Date: 2022-04-29
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: B

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Survey Date: 2022-03-18
Correction Date: 2022-04-29
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2022-03-18
Correction Date: 2022-04-29
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2022-03-18
Correction Date: 2022-04-29
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2022-03-18
Correction Date: 2022-04-29
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2022-03-18
Correction Date: 2022-04-29
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2022-03-18
Correction Date: 2022-04-29
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2022-03-18
Correction Date: 2022-04-29
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2022-03-18
Correction Date: 2022-04-29
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Keep all essential equipment working safely.

Survey Date: 2022-03-18
Correction Date: 2022-04-29
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: C

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Survey Date: 2022-03-18
Correction Date: 2022-04-29
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Survey Date: 2022-03-18
Correction Date: 2022-04-29
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2020-12-11
Correction Date: 2021-01-08
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2020-12-11
Correction Date: 2021-01-08
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2020-12-11
Correction Date: 2021-01-08
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: E

Dispose of garbage and refuse properly.

Survey Date: 2020-12-11
Correction Date: 2021-01-08
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2020-12-11
Correction Date: 2021-01-08
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: B

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Survey Date: 2020-12-11
Correction Date: 2021-01-08
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Survey Date: 2020-12-11
Correction Date: 2021-01-08
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Survey Date: 2020-12-02
Correction Date: 2020-12-18
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2020-09-11
Correction Date: 2020-10-02
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2020-09-11
Correction Date: 2020-10-02
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Respond appropriately to all alleged violations.

Survey Date: 2020-09-11
Correction Date: 2020-10-02
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2020-09-11
Correction Date: 2020-10-02
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2020-09-11
Correction Date: 2020-10-02
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-08-19
Correction Date: 2020-09-11
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Provide care by qualified persons according to each resident's written plan of care.

Survey Date: 2019-05-31
Correction Date: 2019-06-07
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Survey Date: 2019-05-31
Correction Date: 2019-06-07
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2019-05-31
Correction Date: 2019-06-07
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2019-05-31
Correction Date: 2019-06-07
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: B

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Survey Date: 2019-05-31
Correction Date:
Category: Environmental Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**