Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ignite Medical Resort San Antonio, Llc during CMS and state inspections, most recent first.
Surveyors found a treatment cart left unlocked and unattended in a public hallway, out of view of the nurses' station, with wound cleanser, iodine, and wound care supplies accessible in its drawers. An RN reported he had stepped into a resident’s room briefly and acknowledged he was not supposed to leave the cart unlocked because it contained treatments and medications. Staff in black uniforms, later confirmed by a PTA to be therapists, were present in the hallway but were not attending the cart. The ADON stated that treatment carts are expected to be locked like med carts due to the presence of scissors and medications and that the assigned staff member is responsible for locking the cart when unattended, consistent with the facility’s written medication storage policy requiring medication supplies to remain locked when not in use or not attended by authorized personnel.
Two residents with complex wounds and orders for Enhanced Barrier Precautions (EBP) received wound care from an RN who did not follow required infection control practices. The RN entered each resident’s room and performed coccyx and groin wound treatments without donning a gown, and there was no EBP signage or PPE available outside the rooms despite EBP orders and care plans. During wound care, the RN failed to change gloves or perform hand hygiene after cleaning wounds and before applying treatments and dressings, and moved from one wound site to another while wearing the same gloves. In interviews, the RN and ADON acknowledged that EBP, glove changes, and hand hygiene were required by facility policy for wound care and when moving from contaminated to clean body sites.
Failure to Complete Annual CNA Performance Reviews: The facility failed to complete annual performance reviews for CNAs and did not provide regular in-service education based on those reviews. Record review showed all eligible CNAs were due for a review, but the HR Dir, DON, and a CNA all confirmed there was no formal annual review process and that informal performance discussions and notes were not documented in employment records.
Laundry department staff failed to clean lint from the interiors of 2 gas commercial dryers for about a year. Surveyors observed the dryers operating with visible burner flames, while lint and dust lined the interior and exterior of the machines and covered the drive motors. The Laundry Aide said she only cleaned the front side daily, and the Maintenance Director said the rear of the dryers had not been cleaned in the past year and that the machines were covered with lint and dust throughout.
Inadequate staff competency for PleurX catheter care: A resident with lung cancer and malignant pleural effusion had an active order for PleurX drainage, but the care plan did not include the procedure and nursing documentation did not show the catheter was drained after return from the hospital. The resident said multiple nurses told her they could not drain it because they did not know how. Interviews showed an ADON, an LVN, and another LVN lacked consistent knowledge of the order and training; one LVN said she had no facility training and did not use sterile technique, and the DON said PleurX training and skills validation were not part of new hire or annual competency review.
A resident with type 2 DM, anxiety, and HTN was ordered Potassium & Sodium Phosphates Oral Packet with meals, but the MAR showed 18 missed doses documented as medication unavailable. The resident said she had not received the medication since admission, while the MA and LVN were unaware of the missed doses until surveyor intervention. The DON stated the pharmacy did not send the medication because it was treated as OTC and required her authorization, which she had not received.
Failure to Implement Transmission-Based Precautions: The facility did not ensure EBP were initiated for several residents with orders for EBP, and rooms lacked isolation signage and PPE carts. A resident admitted after heart surgery had wounds and an EBP order, another resident with sepsis and UTI had an EBP order but no EBP care plan, and other residents with dialysis or other qualifying conditions also lacked visible precautions. The facility also failed to place a resident with VRE on contact isolation when admitted on antibiotics for positive blood cultures.
Two residents were admitted without physician orders supporting immediate care needs. One resident with lung cancer and a PleurX catheter returned to the facility without a clear, implemented drainage order being followed by nursing, and staff were unsure of the correct drainage frequency. Another resident with a T11-T12 fracture was observed wearing a TSLO brace, but the chart had no TSLO order or care plan, even though staff documented and trained on brace use.
A resident admitted with a T11-T12 fracture and a TSLO back brace had no order or care plan for the brace, even though nursing notes documented the brace was needed when out of bed. The resident was observed wearing the brace and said it helped with movement and pain. Interviews showed an LVN was unaware of the brace need, a CNA had been trained by therapy to apply it but did not report that training, and the DOR, Administrator, and DON acknowledged the resident needed the brace despite the missing order and care plan.
Failure to provide scheduled bathing assistance for a resident with ADL deficits and limited mobility. The resident, admitted with surgical aftercare and dialysis dependence, was care planned for substantial maximal assistance with bathing, but CNA documentation showed multiple missed bathing tasks and the resident stated she had not been offered a bath since arrival. CNAs reported the resident preferred daytime showers, yet the primary nurse and DON were unaware the resident had not bathed.
Missing Physician Order for Indwelling Urinary Catheter: A resident with urinary retention had an indwelling urinary catheter documented on the MDS and observed in place, but the physician's orders did not include a catheter order even though hospital discharge orders did. An LVN confirmed the catheter was present without an order, and the DON stated the order had been entered as part of an admission order set by the admission nurse.
A resident with malignant pleural effusion and lung cancer had a PleurX drain that was not managed per MD order. Nursing staff were unsure of the drainage schedule, some said they had not been trained on PleurX care, and one nurse reported using non-sterile technique. The care plan did not include the drain procedure, and the DON said PleurX competency validation was not part of new hire or annual training.
Medication administration errors resulted in an 8% error rate, with two residents receiving insulin aspart after breakfast instead of before meals as ordered. One resident with DM and a prosthetic knee infection and another resident with DM, cerebral palsy, and CKD were observed after breakfast with blood sugars checked late; an LVN and the ADON both stated they delayed insulin because they were concerned about hypoglycemia and waited until meal trays were on the floor before giving injections.
Unlocked Medication Cart Left Unattended: An LVN left the 200-hall west medication cart unattended and unlocked in the hallway while assessing a resident's blood sugar in a closed room. The ADON, administrator, and DON stated medication carts were expected to be locked when not attended, and the facility policy required medication supplies to remain locked when not in use or attended by authorized personnel.
Both facility elevators were repeatedly observed to bounce and make unusual noises during operation, with staff and maintenance confirming ongoing issues over several months. Service records showed multiple calls for similar problems, but documentation of repairs was incomplete and the facility's policy did not address the specific issue of elevator bouncing. No injuries were reported, but the elevators remained in use by residents and staff despite the deficiencies.
A capsule of Lyrica, a Schedule V controlled substance, was found improperly stored in an unmarked cup in a medication cart drawer rather than in the required double-locked compartment. A CNA had removed the medication from its original packaging and left it unsecured instead of discarding it, contrary to facility policy and federal regulations.
A facility failed to protect the confidentiality of resident records when an LPN left a Vital Signs Flow Sheet Report visible on a medication cart, exposing personal information of 14 residents. Staff interviews confirmed the expectation for confidentiality, but the incident still occurred, affecting residents, including one severely cognitively impaired and another cognitively intact.
The facility failed to implement baseline care plans within 48 hours of admission for three residents, leading to potential risks due to unmet immediate care needs. The care plans lacked necessary information on ADLs and mobility, despite residents having significant impairments. Staff interviews revealed confusion over responsibility for care plan completion and inconsistent communication of residents' needs.
The facility failed to secure medication carts on multiple occasions, leaving them unlocked and unattended in various halls. This included carts containing medications such as insulin, thyroid medications, and prescription creams. Although narcotics were double locked, the accessible medications posed a risk of unauthorized access. Nursing staff admitted to leaving the carts unlocked while attending to residents, contrary to facility policy requiring carts to be locked when not in use.
A resident with a history of surgical aftercare, pneumonia, and schizophrenia did not have his weight monitored as per physician orders, which required weekly checks during the night shift. The facility failed to document any refusal or attempts to obtain the weight on the scheduled date, leading to a lapse in care. The resident was eventually weighed days later, revealing significant weight loss, prompting dietary intervention.
A resident with a pressure ulcer on the left heel did not receive consistent care as ordered, with Prevelon boots not applied while in bed or sitting in a chair. Observations showed the resident without boots on multiple occasions, and documentation was inconsistent. Despite the facility having the boots in stock, there was a delay in providing them, and staff were unaware of the issue. The resident's ulcer showed improvement, but the lack of adherence to care orders could have affected healing.
The facility failed to maintain food safety standards, with expired Osmolite found in a fridge and staff not wearing proper facial hair restraints. Observations showed improper hand hygiene and cross-contamination during meal prep, with trays dried using a hand towel instead of air drying. These practices contradict the facility's policy and could risk foodborne illness.
The facility failed to develop and implement baseline care plans within 48 hours of admission for eight residents, as required by their policy. This deficiency was identified through interviews and record reviews, which revealed that the baseline care plans for these residents were not completed in the specified timeframe. The residents involved had various medical conditions, necessitating timely and effective care planning. The DON admitted to being unable to complete the care plans on time due to other job duties, which resulted in missed or inadequate care planning for the residents.
The facility failed to maintain an effective infection prevention and control program, with staff not sanitizing equipment or performing hand hygiene between resident interactions. An RN did not sanitize a glucometer between uses for two residents, one on droplet precautions, and failed to wash hands between glove changes. Additionally, a server did not sanitize hands between handling meal trays, despite wearing gloves. These practices were contrary to the facility's infection control policies.
The facility failed to respond promptly to call lights for three residents, leading to distress and unmet care needs. One resident experienced a two-hour delay after vomiting, another faced delays for toileting needs, and a third reported multiple 45-minute waits. Despite these issues, the Administrator believed responses were timely.
A facility failed to accurately assess a resident's functional capacity by omitting a documented anxiety disorder from the Initial MDS Assessment and care plan. The resident, admitted with orthopedic aftercare and diabetes, had a physician-documented anxiety diagnosis and was prescribed hydroxyzine. The DON acknowledged the omission and the potential risk of inadequate anxiety care.
A resident with acute kidney failure, diabetes, and hypertension was unable to use the bathroom call light due to a malfunction, which was not reported to maintenance. The resident, who had decreased vision and was at fall risk, expressed concern after a recent fall. The maintenance director confirmed the issue was due to disconnected wiring, and the facility's policy on call light outages was not followed.
A resident in an LTC facility did not receive scheduled doses of Dexamethasone due to the medication's unavailability. The resident, who was cognitively impaired and had multiple health conditions, missed eight doses over two days. The facility's process for medication ordering failed to ensure timely availability, and the pharmacy did not have the medication in stock during a holiday weekend. The resident was later given IV Dexamethasone and returned to baseline.
Unlocked, Unattended Treatment Cart with Medications and Supplies in Public Hallway
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper controls and that only authorized personnel had access to the keys for a treatment cart. During an observation on 3/25/26 at 1:38 p.m., a state investigator found Treatment Cart #1 unlocked and unattended in the 100 hall, in front of a resident room with the door closed and out of view of the nurses' station. The drawers of the cart contained wound cleanser, iodine, and wound care supplies. Three staff members in black uniforms were assisting residents in the hallway, but none were attending the cart. The facility’s written policy titled “Medication Storage” dated 2007 stated that medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access. In an interview at 1:40 p.m. on 3/25/26, an RN stated he had gone into a resident’s room for only two minutes and acknowledged he was not supposed to leave Treatment Cart #1 unlocked because it contained treatments and medications. He further stated that unattended carts should be locked to prevent residents from accessing the contents. On 3/26/26 at 1:04 p.m., a PTA reported that facility therapists wore black uniforms, confirming the identity of the staff observed in the hallway. In a separate interview on 4/2/26 at 4:12 p.m., the ADON stated that treatment carts were supposed to be locked because they contained scissors and medications that could be dangerous to guests, staff, and residents, and that the cart should be treated like a medication cart. The ADON also stated that the person assigned to the cart was responsible for ensuring it was locked when unattended, and that any staff member could lock a medication cart if it was seen unlocked and unattended. The DON was not available during the investigation.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to failure to follow Enhanced Barrier Precautions (EBP) and basic infection control practices during wound care for two residents. One resident was admitted with osteomyelitis, muscle weakness, and a need for assistance with personal care, and had an actual impairment to skin integrity with a care plan intervention to follow facility protocols for treatment of injury. This resident had physician orders for daily and PRN coccyx wound care and an order for EBP. During observed wound care to this resident’s coccyx, the RN entered the room without donning a gown, despite the EBP order, and there was no EBP signage or PPE outside the room. A second resident was admitted with surgical aftercare following circulatory system surgery, sepsis, muscle weakness, and a need for assistance with personal care, and was care planned for EBP related to wounds. This resident had orders for wound care to the coccyx and to bilateral groin surgical incisions, including cleansing, application of betadine, Santyl, nystatin powder, calcium alginate, and dressings. During observed wound care to this resident’s coccyx and groin areas, the same RN entered the room without donning a gown, and there was no EBP signage or PPE outside the room, despite the resident being on EBP for wounds. Additional infection control failures were observed in the RN’s wound care technique. For the first resident, the RN cleaned the coccyx wound, applied treatment, packed the wound, and applied a foam dressing without performing hand hygiene or changing gloves after cleaning the wound and before applying treatments and dressing. For the second resident, the RN cleaned the right groin wound and then the left groin wound without removing gloves, performing hand hygiene, or donning clean gloves between areas, and then applied treatments and dressings to both groin wounds while still wearing the same gloves and without hand hygiene. In interviews, the RN acknowledged that EBP were required for wound care and that she was expected to change gloves and perform hand hygiene when moving from dirty to clean tasks and from one wound to another, and the ADON confirmed that EBP and hand hygiene practices were required per facility policy. Facility policies on hand hygiene, wound care, EBP, and infection control all required appropriate PPE use, glove changes, and hand hygiene, which were not followed in these observed instances.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete a performance review of every nurse aide at least once every 12 months and failed to provide regular in-service education based on the outcome of those reviews for 1 of 1 facility reviewed for competent staffing. Record review of the staff roster provided by the HR Dir on 9/23/2025 showed 35 CNA staff members, and 25 of the 25 CNAs who were eligible for an annual performance review had been employed long enough to require one during the review period from 1/1/2025 through 9/1/2025. During interview, the HR Dir stated the facility did not have a formal process for annual reviews and that informal, periodic performance evaluations were completed by nursing managers, but those evaluations were not documented. A CNA stated she had worked at the facility for 6 years and had not participated in an annual performance review with nursing leadership. The DON stated there was not a formal annual performance review process, that ADONs met with staff and took notes on concerns, and that the notes were used to determine training needs, but the notes were not documented in employment records. The facility policy titled Performance Evaluation stated employees would be evaluated on their anniversary date and that informal performance discussions may occur between scheduled evaluations.
Laundry Dryers Not Cleaned of Lint Buildup
Penalty
Summary
The facility failed to ensure the laundry department remained free from accident hazards when it did not clean lint from the interiors of 2 commercial dryers for about a year. During an observation, the laundry department was found to have 2 natural gas fueled commercial dryers with their mechanical backs housed in an enclosed room accessed by a wood frame door. The dryers were operating, the burner flames were visible inside the machines, and a layer of dust and lint was observed lining the interior and exterior of the dryers and covering the electrical motors that drove the clothing tumblers. During interview, the Laundry Aide stated she cleaned lint from the front side of the dryers every day but had not been assigned to clean the back of the machines. The Maintenance Director, who also supervised the laundry department, stated the dryers had not been cleaned out from the rear in the past year and that the machines were covered with lint and dust throughout the interior and exterior. He stated the dryers needed to be cleaned immediately and suspended from use, and later stated he had dismantled and cleaned them and placed them back in service. The manufacturer’s maintenance manual reviewed by surveyors included instructions for quarterly, bi-annual, and annual cleaning and maintenance tasks, including vacuuming air vents on drive motors, removing front panels to vacuum, and cleaning burner tubes and orifice areas of lint buildup.
Inadequate staff competency for PleurX catheter care
Penalty
Summary
The facility failed to ensure that licensed nurses had the specific competencies and skill sets needed to care for a resident with a PleurX catheter. Resident #108 was a cognitively intact female with diagnoses including malignant pleural effusion and lung cancer, and she had an active order for PleurX drainage of the right chest every other day. Her care plan did not reflect the PleurX draining procedure, and the record did not show nursing documentation of the catheter being accessed and drained after she returned from the hospital on 9/18/2025 through 9/22/2025, despite the physician’s note stating nursing staff should manage the drain as ordered. During interview, the resident stated multiple nursing staff told her they could not drain the catheter because they did not know how, and she said she had been told the drain would be done but it was not performed on the expected schedule. She also stated the catheter had not been accessed since she returned from the hospital. The resident denied shortness of breath, chest pain, or difficulty breathing at the time of interview, and her documented vital signs during that period did not show abnormalities in oxygen saturation or respiratory rate. Staff interviews showed inconsistent knowledge and training. LVN G said he was unaware of the physician’s every-other-day order, believed the drain was scheduled every five days, and stated he had not received facility training on PleurX catheters. ADON A said she had previously received training but acknowledged the facility did not document it, and she did not verify the resident’s statement that the catheter had been drained or contact the provider when the resident requested a different frequency. LVN F stated she had performed the procedure several times without facility training and without sterile technique. The DON stated PleurX training and skills validation were not included in new hire or annual curriculum, and the facility competency checklist did not include PleurX or chest tubes. The facility policy required aseptic technique, review of the care plan, and initial and annual competency validation.
Missed phosphate medication doses
Penalty
Summary
The facility failed to ensure that Resident #87 was free from significant medication errors when the prescribed Potassium & Sodium Phosphates Oral Packet 280-160-250 MG was not administered as ordered. The resident was admitted with diagnoses including type 2 diabetes, anxiety disorder, and hypertension, and the quarterly MDS showed a BIMS score of 15, indicating intact cognition. The physician ordered one packet by mouth with meals at 7:30 a.m., 11:30 a.m., and 1:30 p.m., but the MAR from 9/16/25 to 9/23/25 showed 18 missed doses documented as medication unavailable. The record review showed no physician order to hold the medication during the period the doses were missed, and the order was discontinued only after surveyor intervention. The resident stated she had not received the medication since admission but felt she did not need it. The MA stated she did not know the medication was unavailable until the surveyor’s intervention, and the LVN stated he was unaware of the missed doses until the MA informed him that day. The DON stated the pharmacy did not send the medication because it was considered over-the-counter and required her authorization, and she had not been informed that the resident was missing doses until notified by the LVN.
Failure to Implement Transmission-Based Precautions
Penalty
Summary
The facility failed to maintain an infection prevention and control program for 5 of 5 residents reviewed for infection control. Residents #52, #53, #87, and #121 had orders for enhanced barrier precautions, but the report states the facility did not ensure those precautions were initiated. For Resident #52, the record showed an order for enhanced barrier precautions related to chronic wounds, MDRO colonization or infection, ostomy, IV therapy, dialysis, or indwelling devices, and the care plan reflected enhanced barrier precautions had been initiated; however, during observation the room had no posted signage indicating enhanced barrier precautions and no PPE cart was present in the hallway. Resident #52 was admitted after heart surgery and had a surgical wound on the chest and a wound on the right thigh. Resident #53 had diagnoses including sepsis and UTI, with an order for enhanced barrier precautions, but the care plan did not reflect enhanced barrier precautions and the room also lacked signage and a PPE cart. Resident #87 had diagnoses including surgical aftercare following circulatory system surgery and dependence on renal dialysis, with an order and care plan for enhanced barrier precautions, but the room likewise had no signage and no PPE cart. Resident #121 had an order for enhanced barrier precautions, and the room was observed without signage and without a PPE cart. The facility also failed to ensure contact isolation precautions were initiated for Resident #108 when she was admitted on antibiotic therapy for blood culture results positive for VRE. The DON stated she was unaware of Resident #108's VRE diagnosis and said Resident #108 should have been on contact isolation precautions based on that diagnosis. The DON also stated she was unaware of the missing transmission-based precaution signage and PPE carts for Residents #52, #53, #87, and #121, and said the signage and PPE carts should have been implemented as soon as staff became aware of the need for transmission-based precautions. The facility policy titled Infection Control Policy stated the resident's clinical record and door will display the appropriate isolation notification and that PPE should be readily available near the entrance to the resident's room.
Missing Admission Orders for PleurX Drain and TSLO Brace
Penalty
Summary
The facility failed to ensure that physician orders for immediate care were in place at the time of admission for 2 residents. For one resident with a history of lung cancer, malignant pleural effusion, and a PleurX catheter, the record showed a readmission to the facility without a clear, implemented order for nursing staff to drain the catheter immediately upon return. The resident’s admission record, care plan, and nursing documentation did not reflect care planning for the PleurX draining procedure during the period reviewed. The resident’s hospital discharge paperwork showed the PleurX catheter had been accessed and drained by hospital staff before return to the facility, and a physician progress note later documented that nursing staff were to manage the PleurX drain as ordered and as needed. However, nursing staff did not document accessing or draining the PleurX during the days reviewed after readmission. During interview, the primary nurse stated he had been told the catheter was to be drained every five days, was unaware the order directed drainage every other day, and was unsure when it had last been drained. The ADON stated she had not verified the resident’s report that the catheter had already been drained and had forgotten to contact the provider when the resident requested a different frequency. For the second resident, the admission record showed a T11-T12 fracture and nursing documentation noted that the resident had a TSLO brace when out of bed. The resident was observed wearing the brace and stated it helped with movement and pain. However, the physician order record contained no TSLO order, and the care plan also lacked interventions or supports for the brace. Nursing staff stated they were unaware of the brace need because it had not been included in report, and the DOR stated therapy staff had trained CNA staff on applying the brace while out of bed. The Administrator and DON acknowledged the resident needed the brace but had no order or care plan for it.
Failure to Include TSLO Brace in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was admitted with a thoracolumbar spine orthosis (TSLO) back brace need. The resident was admitted with diagnoses that included a fracture of the T11-T12 vertebra and was documented in the nursing progress notes as needing a TSLO brace when out of bed. However, the resident’s physicians orders did not include an order for the TSLO brace, and the care plan did not include interventions or supports for the brace. A review of the resident’s record showed the admission occurred on 9/18/2025, and the first nursing note on that date documented the resident’s need for the TSLO brace. During observation, the resident was seated in her room wearing the TSLO back brace and stated she had a broken back, that the brace helped her with movement and minimized pain, and that she had been admitted from the hospital with the brace. The resident could not recall whether she wore the brace daily but did recall that a CNA applied it that morning. Interviews and record review showed staff awareness was inconsistent. An LVN stated she was unaware the resident had a need for a back brace because the report she received did not include it, and she found no order or care plan for the TSLO brace. A CNA stated therapy staff trained him to apply the brace daily, but he had not reported that training to anyone and was unaware whether other CNAs knew about the brace. The DOR stated therapy staff reviewed the hospital documents and recognized the TSLO brace order, and the Administrator and DON stated the resident had a need for the brace even though there was no order or care plan for it.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to ensure a resident who was unable to perform activities of daily living received the necessary bathing assistance to maintain good grooming and personal hygiene. Resident #87, an [AGE]-year-old female admitted in September 2025 with diagnoses including encounter for surgical aftercare following surgery on the circulatory system and dependence on renal dialysis, had no BIMS score submitted as of 9/21/2025. Her care plan, initiated 9/16/2025, identified ADL self-care performance deficits and limitations in physical mobility and directed that she required substantial maximal assistance to shower and bathe herself. Record review of the scheduled bathing tasks showed the resident was assigned bathing assistance on night shifts on Mondays, Wednesdays, and Fridays, but staff marked the task as not completed on 9/16/2025, 9/17/2025, and 9/20/2025, and 9/22/2025 was marked not applicable. During observation on 9/22/2025, the resident was seen resting in bed wearing a hospital gown and stated she had not been offered bathing assistance since arrival, had not declined a bath, and had not asked for one. On 9/23/2025, she again stated she had not been offered bathing assistance by overnight staff. CNA B stated the resident consistently refused night bathing because she preferred to shower during the day, but she had not notified the primary nurse that the resident had not bathed since admission. The primary nurse and DON were unaware the resident had not received bathing assistance since arrival, and the DON stated the facility assigns bathing times by room number and that staff should communicate resident requests or refusals to the primary nurse or ADON.
Missing Physician Order for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure that a resident who had an indwelling urinary catheter had a clinical condition demonstrating that catheterization was necessary. Resident #50 was admitted with diagnoses including urinary retention, congestive heart failure, and hypertension. The quarterly MDS showed a BIMS score of 14 and indicated the resident had an indwelling catheter. Record review of the physician's orders for September 2025 showed there was no order for the resident's indwelling urinary catheter, even though the hospital discharge orders dated 9/15/2025 included an order for a 16 Fr indwelling urinary catheter. Observation showed the catheter was present in the peri area and the urinary bag was covered and hanging on the movable part of the bed frame. The resident stated she had had a urinary catheter since admission. An LVN confirmed the resident had an indwelling urinary catheter and verified there was no physician's order for it, while also stating staff emptied the catheter each shift and checked for signs and symptoms of infection. The DON stated the physician's orders did not include an indwelling urinary catheter order because the orders were entered as an order set by the admission nurse, and stated the resident risked possible improper care to the catheter site if nurses did not know she had a urinary catheter. Facility policy stated transcribing and verifying orders are the responsibility of a licensed nurse.
PleurX Drain Not Performed as Ordered
Penalty
Summary
The facility failed to ensure Resident #108’s PleurX catheter was drained according to the physician’s order and by competent staff. The resident was admitted with diagnoses including malignant pleural effusion and secondary malignant neoplasm of the lung, and her MDS reflected intact cognition with a BIMS score of 14. The physician’s order directed nursing staff to drain the PleurX to the right front chest every other day, and the physician’s progress note also directed nursing staff to manage the drain as ordered and as needed. After the resident returned from the hospital, the record did not show nursing documentation that the PleurX was accessed and drained from the time of return through the survey review period. The resident stated the catheter had not been accessed since she returned to the facility and said multiple nursing staff told her they could not drain it because they did not know how. She also said she had been told it would be drained, but the schedule was not being followed. Observation showed a coiled catheter with an intact dressing on the resident’s right lower chest area. Interviews showed staff confusion about the order and lack of training. One LVN said he was told the drain was scheduled every five days and did not know the physician ordered every other day; he also said he had not received facility training on PleurX catheters. Another nurse said she had accessed and drained the catheter several times but had not received facility training and had not used sterile technique. The DON stated PleurX training and skills validation were not included in new hire or annual competency validation, and the care plan did not include the PleurX draining procedure. The facility policy required aseptic technique, review of the care plan, and initial and annual competency validation.
Medication administration error rate exceeded threshold
Penalty
Summary
The facility failed to keep its medication error rate below 5%, with 2 medication administration errors identified in 25 opportunities for an 8% error rate. The errors involved insulin aspart administration for 2 residents reviewed for medication administration. Both residents had physician orders for blood glucose checks before meals and insulin as needed based on sliding-scale results, with insulin aspart ordered to be given subcutaneously before meals and at bedtime. Resident #126 was admitted with diagnoses including type II diabetes with hyperglycemia and infection of the right knee prosthetic. During observation, the resident was in bed with his breakfast tray on his bedside table and stated he had eaten breakfast about 20 minutes earlier and had not yet had his blood sugar checked. LVN K then checked the blood sugar at 155 and administered 2 units of insulin aspart after breakfast. LVN K stated she gave the insulin after breakfast because she did not want to administer it too far ahead of the meal and was concerned the resident could "crash" because the insulin was fast acting. Resident #25 was admitted with diagnoses including type II diabetes, cerebral palsy, and chronic kidney disease. During observation, ADON LVN A prepared to administer insulin by checking the resident's blood sugar, which was 138, and stated he would not receive insulin based on the order. She then stated she waited to administer the insulin until after breakfast because she was concerned he might drop in blood sugar, and she would wait until the breakfast trays were out on the floor before giving insulin injections. At the time of observation, the resident had already eaten breakfast and stated his blood sugar had been checked after breakfast. The administrator and DON stated the expectation was for nursing staff to follow physician orders, check blood sugar before breakfast, and administer insulin as needed before meals.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in locked compartments under proper temperature controls and accessible only to authorized personnel for 1 of 6 medication carts reviewed, the 200-hall medication cart. During an observation and interview on 9/23/2025 at 10:43 AM, the 200-hall west medication cart was seen parked in the 200-hall west hallway, unattended and unlocked, while staff and residents were observed nearby in the hallway. During an interview on 9/23/2025 at 10:45 AM, the ADON stated the cart was assigned to LVN G and that medication carts were expected to be locked when not attended. At 10:49 AM, LVN G stated he was in a resident's room assessing blood sugar, could not see the cart because the room door was closed for privacy, and left the cart unlocked because of human error. A later interview with the administrator and DON on 9/24/2025 confirmed the expectation that medication carts be secured and locked when staff were not directly using them. The facility policy dated January 2023 stated medication supplies should remain locked when not in use or attended by authorized persons.
Failure to Maintain Elevators in Safe Operating Condition
Penalty
Summary
The facility failed to maintain both of its elevators in safe operating condition, as evidenced by repeated issues with bouncing, slow travel, and unusual noises during operation. Surveyors observed both elevators exhibiting multiple bounces when moving between floors, with elevator #2 displaying more severe and frequent bouncing, as well as creaking, groaning, and popping sounds. No current inspection certificates were posted in either elevator at the time of observation, although records indicated that both had passed their last annual inspection. Review of service records revealed a pattern of recurring problems with the elevators, including multiple service calls for issues such as bouncing, being stuck, and slow operation. The facility's Maintenance Director acknowledged that one of the elevator shocks was not working and that the issue had been ongoing for an unknown period. He also stated that repairs required corporate approval and that documentation of service calls and repairs was lacking, with no invoices or detailed records available for parts ordered or work completed. Interviews with staff confirmed that the elevators had been bouncing for several months and that residents regularly used them. The Maintenance Director and DON both recognized the potential for falls due to the elevator issues, although no injuries had been reported. The facility's elevator maintenance policy did not address the specific issue of car movement or bouncing, only stating that inoperable elevators should be shut down and serviced.
Improper Storage of Controlled Substance in Medication Cart
Penalty
Summary
A deficiency was identified when a medication cart on the 100 hallway was found to have a capsule of Lyrica (pregabalin), a Schedule V controlled substance, stored improperly. The capsule, intended for a specific resident, was discovered in an unmarked medication cup in the upper right drawer of the cart, outside of the required double-locked controlled substance compartment. The medication had been removed from its original blister pack and was not labeled. This was observed during a review of the medication cart and confirmed through staff interviews. Further investigation revealed that a CNA had accidentally removed the Lyrica capsule from its packaging earlier and, instead of discarding it, placed it in a cup to the side in the cart. The CNA admitted to this practice and stated that the medication was not labeled. The DON clarified that the facility's expectation was for any unused or accidentally removed controlled substances to be wasted with a witness and co-signed, and that all controlled substances should be stored in a locked narcotic drawer, as per facility policy and federal regulations.
Confidentiality Breach of Resident Records
Penalty
Summary
The facility failed to protect the confidentiality of personal and medical records for 14 residents, as observed during a survey. An unattended Vital Signs Flow Sheet Report was found on a locked medication cart in the 200-East Hall, displaying personal information such as names, room numbers, vital signs, and dialysis appointment times. This document was left visible and unattended, potentially exposing sensitive information to anyone passing by. The staff member identified in relation to this incident was an LPN, who acknowledged that the vital signs document should not be visible to everyone. Interviews with facility staff, including the ACNO and CNO, revealed that the expectation was for personal protected information to remain confidential and not be visible in public areas. The facility's policy on medical records, last revised in May 2023, emphasized the importance of maintaining the confidentiality of patient records. Despite these policies, the incident occurred, affecting residents, including one who was severely cognitively impaired and another who was cognitively intact, both of whom expressed concerns about their information being exposed.
Failure to Implement Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement a baseline care plan for each resident within 48 hours of admission, as required by their policy. This deficiency was identified for three residents who were reviewed for baseline care plans. The absence of a timely baseline care plan meant that the residents' immediate needs, such as activities of daily living (ADLs), mobility, and other care requirements, were not adequately addressed, potentially placing them at risk for inconsistent care. For Resident #1, the baseline care plan lacked selections for functional abilities related to self-care, mobility, and activities of daily living. The resident had multiple diagnoses, including syncope, hemiplegia, and hemiparesis, and required assistance with various ADLs. Despite these needs, the care plan was not initiated until several days after admission. Similarly, Resident #2's baseline care plan did not include necessary information about self-care and mobility needs, despite the resident being bedbound and requiring extensive assistance. Resident #3's care plan also lacked interventions for ADL transfer and mobility needs, even though the resident had significant mobility impairments and required assistance. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for completing baseline care plans. The admissions nurse was believed to be responsible for initiating the care plan, but this was not consistently executed. Direct care staff often did not receive adequate information about new residents' needs, relying instead on verbal reports or their own observations. This inconsistency in communication and documentation contributed to the failure to meet the residents' immediate care needs within the required timeframe.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as observed in three medication carts located in different halls of the facility. On multiple occasions, medication carts on the 200-East Hall, 200-West Hall, and 300-West Hall were found unlocked and unattended. This was confirmed through observations and interviews with the nursing staff responsible for these carts. The staff members admitted to leaving the carts unlocked while attending to residents, which included administering medications or assisting with personal care tasks. During the observations, it was noted that the unlocked carts contained various medications and supplies, such as over-the-counter medications, insulin, thyroid medications, and prescription creams. Although the narcotics drawers were double locked, the accessible medications posed a risk of unauthorized access. The nursing staff acknowledged the potential risks associated with leaving the carts unlocked, including the possibility of residents accessing medications they should not have. Interviews with the facility's nursing leadership, including the Assistant Chief Nursing Officers and the Chief Nursing Officer, revealed a clear expectation that medication carts should always be locked when not in use or attended by authorized personnel. The facility's policy on medication storage emphasized the importance of securing medication supplies to prevent unauthorized access. Despite these policies, the failure to lock the medication carts when unattended was a recurring issue, as observed during the survey.
Failure to Monitor Resident's Weight as Per Physician Orders
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding the monitoring of the resident's weight as per physician orders. The resident, a male with a history of surgical aftercare, pneumonia, and schizophrenia, was supposed to have his weight taken every Tuesday night shift. However, the facility did not obtain his weight on the scheduled date, and there was no documentation of any refusal or attempts to take the weight at a different time. Interviews with staff revealed that the resident had a history of refusing various interventions, and it was likely that he refused to have his weight taken on the scheduled date. Despite this, the staff did not document any refusal or make further attempts to obtain the weight on that day. The lack of documentation and follow-up meant that the resident's weight was not monitored, which could have implications for his health, especially given his potential for nutritional and hydration alterations. The facility's policy required residents to be weighed weekly, especially with a significant change in condition or as per physician orders. The failure to adhere to this policy and the lack of documentation of the resident's refusal or any subsequent attempts to obtain the weight led to a deficiency in care. The resident was eventually weighed three days later, revealing a significant weight loss, which prompted a dietary intervention. However, the initial failure to follow the physician's order and document the process was a clear lapse in the facility's care standards.
Failure to Apply Prevelon Boots as Ordered for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, leading to a deficiency in treatment and care according to professional standards. The resident, a male with a history of surgical aftercare, pneumonia, and schizophrenia, was admitted with a pressure ulcer on his left heel. Despite physician orders for Prevelon boots to be worn while in bed or sitting in a chair, the resident was observed multiple times without the boots, indicating non-compliance with the prescribed treatment. Observations over several days revealed that the resident was not wearing the Prevelon boots as ordered, both while in bed and sitting in a wheelchair. The Treatment Administration Record showed inconsistencies in the documentation of the boots being applied, with some days marked as refused and others left blank. Interviews with staff indicated a delay in providing the boots, despite the facility having them in stock, and a lack of awareness from the Chief Nursing Officer about the resident not having the boots. The resident's pressure ulcer showed signs of improvement over time, with a decrease in surface area, but the failure to consistently apply the Prevelon boots as ordered could have impacted the healing process. The facility's policy on foot care emphasizes the importance of maintaining mobility and good foot health, which was not adhered to in this case, potentially putting the resident at risk for further skin breakdown.
Food Safety and Hygiene Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations and interviews. Expired Osmolite, a tube feeding formula, was found in the third-floor nutrition fridge, with a best-by date of February 1, 2024. The Director of Nursing confirmed that expired Osmolite should not be present in any nutrition fridge. Additionally, staff members were observed not wearing appropriate facial hair restraints, which could lead to hair contamination in food. One staff member was seen without a beard guard after returning from a break, and another staff member's mustache was not covered while handling dishes and food. Further observations revealed improper hand hygiene and cross-contamination practices during meal preparation. A staff member was seen preparing meals without changing gloves or washing hands after handling various food items and equipment, which could lead to cross-contamination. The use of a hand towel to dry trays, lids, and bases instead of allowing them to air dry was also noted, which could result in contamination. Interviews with staff, including the Executive Chef and Dietician, confirmed that these practices were not in line with the facility's policy on preventing foodborne illness and maintaining hygiene standards. The facility's policy on employee hygiene and sanitary practices was reviewed, highlighting the need for proper handwashing, use of utensils, and wearing of hair restraints to prevent foodborne illness. The U.S. Public Health Service Food Code was also referenced, emphasizing the requirement for food employees to wear hair restraints to prevent hair from contacting food and clean equipment. These deficiencies in food safety practices could place residents at risk for foodborne illness, as noted in the report.
Failure to Implement Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for eight residents, as required by their policy. This deficiency was identified through interviews and record reviews, which revealed that the baseline care plans for these residents were not completed in the specified timeframe. The residents involved had various medical conditions, including acute and chronic respiratory failure, sepsis, fractures, and other complex health issues, necessitating timely and effective care planning. The report highlights that the baseline care plans for residents were either initiated late or not completed within the required 48-hour period. For instance, Resident #77's care plan was completed several days after admission, and similar delays were noted for other residents. Interviews with the MDS Coordinator and the Director of Nursing (DON) confirmed these lapses, with the DON acknowledging the importance of timely care plans to ensure residents' needs are met. The facility's policy mandates that a baseline care plan be developed for each resident within 48 hours of admission, yet this was not adhered to for the residents reviewed. The DON admitted to being unable to complete the care plans on time due to other job duties, which resulted in missed or inadequate care planning for the residents. This failure to meet the policy requirements could potentially affect the quality of care provided to the residents.
Infection Control Deficiencies in Staff Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies involving staff practices. RN-E did not sanitize the glucometer between uses for two residents, one of whom was on droplet precautions, potentially risking cross-contamination. Despite acknowledging the oversight, RN-E admitted to not having disinfecting wipes available on the medication cart, which contributed to the failure to sanitize the equipment properly. Additionally, RN-E did not perform hand hygiene between glove changes and when entering or exiting resident rooms, including a room with droplet precautions. This lapse in hand hygiene was confirmed by both RN-E and the Director of Nursing (DON), who acknowledged the risk of spreading germs due to these practices. The facility's policy requires handwashing or sanitizing before and after resident contact and glove removal, which was not adhered to in these instances. Furthermore, Server B, responsible for meal tray distribution, did not sanitize hands between handling trays and entering or exiting resident rooms, despite wearing gloves. The gloves were worn due to having acrylic nails, but Server B admitted that hand sanitization should have been performed regardless. The General Manager (GM) confirmed that hand sanitization is part of infection control, as outlined in the facility's policy, which was not followed during the meal service.
Delayed Call Light Response for Residents
Penalty
Summary
The facility failed to provide timely responses to call lights for three residents, which could affect the care they receive. Resident #201, who was admitted with conditions including spine fusion, type 2 diabetes, and adult T-cell lymphoma, experienced a delay of two hours in response to his call light after feeling nauseous and vomiting. This delay caused significant distress to the resident, who considered self-discharge due to the incident. Resident #67, with diagnoses such as pulmonary embolism and acute respiratory failure, reported a delay in call light response for a toileting need, which was not addressed until after lunch. A family member corroborated this by stating that they observed over an hour delay on several occasions. Resident #203, diagnosed with anemia, UTI, and malignant neoplasm of the endocervix, also reported multiple instances where it took 45 minutes for staff to respond to her call light. The facility's resident council meeting notes and grievance log further indicated concerns about call light response times. Despite these reports, the facility's Administrator believed that staff responded to call lights in a timely manner. The facility's Admission Agreement emphasizes the right of residents to live in an environment that promotes dignity and respect, which was not upheld in these instances.
Failure to Accurately Assess Resident's Anxiety Disorder
Penalty
Summary
The facility failed to conduct an accurate comprehensive assessment of a resident's functional capacity, specifically omitting a diagnosis of anxiety disorder. The resident, a male admitted with orthopedic aftercare, infection due to joint prosthesis, and type 2 diabetes, had a documented diagnosis of anxiety disorder and was prescribed hydroxyzine for anxiety management. However, this diagnosis was not reflected in the resident's Initial MDS Assessment under the psychiatric/mood disorder section, nor was it included in the resident's care plan. The Director of Nursing acknowledged the omission and recognized the potential risk of not providing appropriate care related to anxiety.
Inoperable Call Light System in Resident's Bathroom
Penalty
Summary
The facility failed to ensure that a working call system was available in each resident's bathroom and bathing area, specifically affecting one resident. On a specified date, the resident attempted to use the call light, which did not illuminate the nurse call light outside and above the room door. This malfunction could potentially place residents at risk by not receiving timely care and attention. The resident, who had a history of acute kidney failure, type 2 diabetes mellitus, and primary hypertension, expressed concern about the inoperable bathroom call light, especially after a recent fall in the room. The resident's care plan noted decreased vision, hearing difficulties, and a fall risk, highlighting the importance of a functional call system. During an observation and interview, the resident reported the bathroom call light was not working, and the maintenance director confirmed the issue was due to disconnected wiring. The maintenance director was unaware of the problem as no work order had been submitted. The facility's policy on preventative maintenance and call light outages requires immediate notification to maintenance for repairs, which was not followed in this instance. The lack of awareness and communication among staff contributed to the deficiency, as the LVN assigned to the resident's hallway was also unaware of the malfunction.
Failure to Administer Scheduled Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in acquiring and administering the scheduled doses of Dexamethasone, a corticosteroid, on two consecutive days. The resident, a cognitively impaired elderly female with a history of cerebral meningioma, hyperlipidemia, dementia, anxiety disorder, hypertension, and muscle weakness, missed eight doses of the medication due to its unavailability. The medication was not in the facility's emergency supply box, and the pharmacy, which was new to the facility, did not have it in stock during a holiday weekend. Interviews with the Director of Nursing (DON) and medical assistants revealed that the facility's process for ordering medications involved checking for a seven-day supply and reordering as needed. However, the Dexamethasone was not reordered in time, and the facility's stock did not include this medication. The DON acknowledged the issue and mentioned working with the pharmacy to prevent future delays. Despite the missed doses, the resident was later started on IV Dexamethasone and returned to baseline, but the initial failure to administer the medication as prescribed was noted as a deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Huebner Creek Health & Rehabilitation Center | 0.2 mi | ★★★★★ | 26 | 0 |
| Mesa Vista Inn Health Center | 0.4 mi | ★★★★★ | 24 | 0 |
| Northgate Health And Rehabilitation Center | 0.4 mi | ★★★★★ | 29 | 0 |
| Remington Transitional Care Of San Antonio | 0.6 mi | ★★★★★ | 3 | 0 |
| Sorrento | 0.8 mi | ★★★★★ | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.