Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Lakeside Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in kitchen food storage and sanitation, including improperly stored and labeled food items such as open juice containers, undated tart shells, spilled ice cream cups, exposed strawberries, and an unlabeled juice bag. Additionally, cleaning equipment like mops was not stored according to professional standards, as required by facility policy and the FDA Food Code.
A resident with cognitive impairment and incontinence was provided care by two staff members who did not fully close the privacy curtain, leaving the resident exposed while a roommate was present. The curtain was found to be too short to provide complete privacy, and staff acknowledged the oversight during interviews.
The facility did not ensure that each resident received an accurate assessment, resulting in incomplete or incorrect information used to determine care and services.
A nurse failed to properly sanitize between her fingers while providing ostomy care to a resident with multiple health conditions, despite facility policy and recent infection control training. This lapse in hand hygiene occurred during a procedure that required total assistance and was confirmed by both the nurse and the DON.
A resident with Guillain-Barre syndrome and paraplegia had his call light placed inside a nightstand drawer, making it inaccessible. This was against the facility's policy and expectations, as confirmed by interviews with the LVN and DON. The resident expressed reluctance to bother CNAs, highlighting a potential barrier to requesting assistance.
Two residents were moved to a different room without receiving the required written notice. One resident, with severe cognitive impairment, was not informed, and her responsible party was not notified. The other resident initially declined the move but later agreed verbally. Staff confirmed that verbal notifications were given, and no written records were maintained, as the facility's protocol required written notice only if a resident disagreed with the change.
The facility did not adequately address grievances from the resident council or provide a private space for their meetings. Residents felt their grievances were not followed up on and feared staff reprimand. Meetings were held with staff present, and the grievance system was deemed ineffective by the ombudsman. The facility's grievance log showed limited resolution, and there was no specific policy for the resident council.
A facility failed to create a baseline care plan for a resident with a history of falls and a recent femur fracture, omitting necessary fall risk interventions. Despite some measures being in place, the care plan lacked documentation of these interventions. The facility's policies did not address baseline care plans, and the DON did not confirm the absence of fall interventions in the care plan.
A resident with GERD was prescribed Prilosec to be administered at 0630, but it was given at 810 a.m. due to the resident's preference to take medication after breakfast. The facility's policy requires medications to be administered as ordered and any deviations to be reported, which was not followed in this case.
A medication cart in the 300 hall was found with eleven loose pills, violating storage protocols. Nurse E confirmed the issue, and the DON stated that nurses are responsible for ensuring carts are free of loose medications. The facility policy mandates bi-weekly checks by ADONs to prevent such occurrences.
The facility failed to prepare pureed food according to the recipe, using chicken broth and water instead of margarine and milk, resulting in an inadequate consistency. The CDM confirmed the prepared food was not served, and the RD approved broth for residents with milk allergies. No policy for following recipes was available.
A resident's room in the facility was found to have two significant floor cracks, posing a tripping hazard and potential infection control issue. Despite the resident's reports to nursing staff, no maintenance was conducted, and staff interviews revealed a lack of awareness or action regarding the cracks. The maintenance supervisor and administrator acknowledged the issue upon observation, but no work order had been submitted, and the facility's policy on building upkeep was not provided.
The facility failed to maintain an effective pest control program, as gnats were observed around the beverage station in the dining room. Despite the pest control company's visit, the issue persisted, and residents received beverages from the affected area without proper cleaning of mugs and glasses. Staff and residents reported ongoing problems with gnats.
Deficient Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the storage, preparation, and handling of food items. Specific findings included a partially opened orange juice container sitting on top of a box of orange juice with leakage present, an open and undated box of graham cracker tart shells exposed to air, and a box of vanilla ice cream cups in the freezer that was open, undated, and contained cups that had spilled and melted contents. Additionally, a box of strawberries in the freezer was found open with torn plastic wrap, exposing the fruit to air. An individually wrapped glazed donut was stored in a baggie with illegible labeling, and an undated, unlabeled bag of red juice was found under the juice dispenser, not connected to the machine. A kitchen employee removed this juice bag upon noticing the surveyor's attention. Further, the facility failed to properly store cleaning equipment, as a mop was found stored head-side down in the drain compartment of a mop bucket and later leaning against the wall with the mop head up, both of which do not comply with professional standards for air-drying and preventing contamination. The Dietary Manager confirmed that the mop was not stored correctly and attempted to address the issue during the survey. These observations were made during kitchen inspections and were supported by a review of facility policy and the FDA Food Code, which require proper storage of food and cleaning equipment.
Failure to Ensure Resident Privacy During Incontinent Care
Penalty
Summary
On 07/30/2025, two staff members, CNA A and RA B, provided incontinent care to a resident who was moderately cognitively impaired, always incontinent of bladder, and frequently incontinent of bowel. During this care, the privacy curtain in the resident's shared room was not completely closed, leaving the resident exposed to view if someone entered the room. The curtain was observed to be folded on one end and too short to fully close, and the resident's roommate was present in the room at the time. Both staff members acknowledged during interviews that the privacy curtain was not fully closed and stated they had not noticed the curtain's inadequate length prior to the incident. The facility's policy requires maintaining privacy curtains for dressing and care, and staff had received training on resident rights within the past year. The Director of Nursing confirmed that privacy should have been provided during care and that the curtain should have been completely closed.
Failure to Ensure Accurate Resident Assessments
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure that each resident received an accurate assessment. The report notes that assessments were not completed accurately, which is required to determine the appropriate care and services for residents. Specific details about the residents involved, their medical history, or their condition at the time of the deficiency are not provided in the report. The deficiency centers on the inaccuracy of resident assessments, which are essential for planning and delivering individualized care.
Failure to Follow Proper Hand Hygiene During Ostomy Care
Penalty
Summary
During an observation of colostomy care for a resident with multiple diagnoses including dementia, diabetes, dysphagia, depression, hypothyroidism, hypertension, and ileostomy status, a Licensed Vocational Nurse (LVN) failed to follow proper infection control procedures. Specifically, while providing ileostomy care, the LVN used hand sanitizer between glove changes after removing the collection bag and after cleaning the stoma, but did not sanitize between her fingers as required by facility policy. This lapse was confirmed during an interview with the LVN, who acknowledged not sanitizing between her fingers and recognized the importance of this step in preventing cross contamination. The resident involved required total assistance with activities of daily living, was always incontinent of bladder, and had an ostomy. The facility's hand hygiene policy, dated 10/2022, specifies that all surfaces of the hands and fingers must be covered with sanitizer until dry. The Director of Nursing (DON) confirmed that staff are trained at least annually on infection control practices, including proper hand sanitization techniques, and that skills are checked at least annually. Despite this, the observed failure to sanitize between fingers during care represented a breach of the facility's infection prevention and control program.
Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for residents to maintain their independence and safety. The resident in question, a male with Guillain-Barre syndrome, paraplegia, and pulmonary hypertension, was observed to have his call light placed inside a nightstand drawer, making it inaccessible. This oversight was noted during an observation and confirmed through interviews with the resident and staff. The resident expressed reluctance to bother the CNAs, indicating a potential barrier to requesting assistance. Interviews with the facility's staff, including the LVN and the DON, revealed that the call light's inaccessibility was not in line with the facility's expectations and policies. The DON emphasized the importance of having call lights within arm's reach to prevent falls and ensure timely assistance. However, she was unaware of the specific situation with this resident, indicating a lapse in monitoring and adherence to the facility's policy, which mandates that call lights be placed within residents' reach.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to provide written notice of a room change to two residents, which is a violation of their rights. Resident #41, a female with severe cognitive impairment, and Resident #80, a female without cognitive impairment, were moved to a different room without receiving the required written notification. The facility did not provide evidence that either resident was given written notice before the room change occurred. Interviews revealed that Resident #41's responsible party was not informed of the room change and only discovered it upon visiting the facility. The responsible party stated that the notification was mistakenly given to another family member not listed as the primary contact. Resident #80 initially declined the room change when informed verbally by the DON, but later agreed when assured that Resident #41 would also be moved. However, Resident #80 confirmed that no written notification was provided. Staff interviews indicated that the facility's protocol was to issue written notifications only if a resident disagreed with a room change. The ADON and DON confirmed that verbal notifications were given, and no written records were maintained. The facility's policy on room changes was not provided, and the ADM did not see a concern with the lack of written notification, as he believed there was no potential for abuse in this scenario.
Failure to Address Resident Council Grievances and Provide Meeting Privacy
Penalty
Summary
The facility failed to adequately address and respond to grievances raised by the resident council, as well as provide a private space for their meetings. Residents expressed concerns during interviews that their grievances were not being followed up on and feared reprimand from staff for raising issues. The Activities Director (AD) revealed that meetings were held with staff present, despite it being the president's preference, and that meetings took place in the dining room or conference room, which did not ensure privacy. The ombudsman confirmed that staff were always present at meetings and suggested that the facility's grievance system was ineffective, with complaints from residents about unresolved grievances. The facility's grievance log showed that only grievances from April 2024 were noted as resolved, with the resident council president being the only person notified of the resolutions. The facility's grievance policy stated that grievances should be acknowledged within three working days, but there was no specific policy regarding the resident council. The AD admitted that resolved grievances were not always discussed with residents, assuming they would speak up if they wanted to hear about the solutions, which may have contributed to the residents' perception that their grievances were not being addressed.
Failure to Develop Baseline Care Plan for Fall Risk
Penalty
Summary
The facility failed to develop a baseline care plan for a resident that included necessary interventions for fall risk, which is a professional standard of quality care. The resident, a cognitively intact male with a history of falls and a recent left femur fracture, was admitted to the facility without a care plan addressing his medium risk for falls. Despite having some fall interventions in place, such as a call light within reach and a bed in the lowest position, the care plan did not document these interventions or any specific strategies to mitigate the risk of falls. The facility's policies on fall management and care planning did not provide guidance on creating baseline care plans, and no specific policy for baseline care plans was available upon request. The Director of Nursing (DON) acknowledged that new admissions should have fall interventions in place but did not confirm the absence of such interventions in the resident's care plan. This oversight could lead to inadequate care for residents at risk of falls, as evidenced by the lack of documented interventions for the resident in question.
Medication Administration Timing Error
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in the administration of medication. A resident with a history of acute pancreatitis, cirrhosis of the liver, and hepatic failure was prescribed Prilosec 20 mg daily at 0630 for GERD. However, the medication was administered at 810 a.m., outside the ordered time range. This discrepancy was observed on the electronic medication administration record, which indicated the medication was not given as ordered. Interviews revealed that the resident preferred not to take medication before breakfast, which was known to the nursing staff. Despite this preference, the facility's policy required medications to be administered per physician orders, and any deviations should be reported to the charge nurse. The Director of Nursing (DON) confirmed that medication errors, such as administering medications outside the one-hour window, should be reported to the DON, physician, and responsible party. The facility's policy also required any irregularities in medication administration to be reported to the physician.
Improper Storage of Medications in Nurse Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored according to currently accepted professional principles, as observed in one of the four medication carts. Specifically, the Nurse Medication Cart in the 300 hall was found to contain eleven loose medication pills inside one of its drawers. This was confirmed during an interview with Nurse E, who acknowledged the presence of the loose pills. The Director of Nursing (DON) stated that medication carts should not have loose medications and that it was the responsibility of the nurse in charge of the cart. Additionally, the Assistant Directors of Nursing (ADONs) were supposed to check the medication carts bi-weekly to identify and dispose of any loose medications according to facility policy. The facility's policy on Medication Access and Storage requires that medication storage areas be kept clean, well-lit, and free of clutter.
Failure to Follow Puree Diet Recipe
Penalty
Summary
The facility failed to prepare pureed food according to the prescribed methods that conserve nutritive value, flavor, and appearance. Specifically, during the preparation of Pureed Buttered Bread, the staff member did not follow the recipe, which required the use of white sliced bread, melted margarine, and milk to achieve a smooth, pudding or soft mashed potato consistency. Instead, the staff member used chicken broth and water, resulting in a product that did not meet the required consistency and hardened on the steam table due to liquid evaporation. The Certified Dietary Manager (CDM) confirmed that the prepared pureed bread observed by the surveyor was not used for the lunch service. The CDM also mentioned consulting with the Registered Dietitian (RD) about using broth instead of milk, which was deemed acceptable for residents with milk allergies. However, the facility did not have a policy available for following recipes, as requested by the Director of Nursing (DON). This deficiency could potentially affect residents on a pureed diet by providing them with an inadequate diet that could impact their health.
Facility Fails to Address Floor Cracks in Resident's Room
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, specifically for one resident who was found to have two significant cracks in the floor of her room. These cracks, measuring approximately 1.5 millimeters in width and extending 12 feet and 8 feet in length, respectively, were observed during a survey. The resident, who has severe cognitive impairment due to unspecified dementia, reported that the cracks had been present since she moved into the room and had expressed her concerns to the nursing staff, although she could not recall specific individuals. Despite her reports, no maintenance had been conducted, and the cracks remained unaddressed. Interviews with various staff members, including LVNs, the ADON, the social worker, and the maintenance supervisor, revealed that none had observed the cracks or received any work orders related to floor repairs in the resident's room. The maintenance supervisor acknowledged the significance of the cracks upon observation and noted that they required an outside vendor for repair. The administrator, upon observing the cracks for the first time, recognized the potential tripping hazard and infection control concern they posed. Despite the facility's protocol for reporting such issues, no work order had been submitted, and the facility's policy on physical environment and building upkeep was not provided during the survey.
Deficient Pest Control in Dining Room
Penalty
Summary
The facility failed to maintain an effective pest control program in the dining room, as evidenced by the presence of an unknown number of gnats surrounding the beverage station during lunch service. Observations revealed that these flying insects were around mugs and glasses that were being used by residents. The Activities Director acknowledged the presence of bugs and indicated that either the maintenance director or the dietary department would address the issue. Despite this, eight residents received beverages from the station without the mugs and glasses being sent back to the kitchen for cleaning. Interviews with staff and residents highlighted ongoing issues with gnats in the dining room. The Housekeeping Supervisor noted that the pest control company had visited earlier in the day to address the problem, but the issue persisted. The Maintenance Director confirmed that the pest control company targeted the dining room and other areas of the facility. A review of the pest control service log corroborated the service date for the dining area. The facility's policy on maintaining an effective pest control program was undated and defined measures to eradicate and contain common household pests.
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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) |
|---|---|---|---|---|
| Westover Hills Rehabilitation And Healthcare | 1.7 mi | ★★★★★ | 6 | 0 |
| Windemere At Westover Hills | 2 mi | ★★★★★ | 6 | 0 |
| Legend Oaks Healthcare And Rehabilitation - West S | 2.3 mi | ★★★★★ | 11 | 0 |
| Las Colinas Of Westover | 2.8 mi | ★★★★★ | 18 | 0 |
| The Mission At Blue Skies Of Texas East | 3.5 mi | ★★★★★ | 0 | 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.