Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Patriot Heights Health Care Center during CMS and state inspections, most recent first.
Fall Mat Not Utilized as Care Planned: A resident with dementia, severe cognitive impairment, a history of falls, and high fall risk had a fall mat listed in the care plan, but staff observed the mat folded up against the wall instead of being in use while the resident was in bed. CNA stated she forgot to replace the mat after breakfast, and the BOM did not notice it was not in place. The resident was also observed attempting to get up from bed without help.
A resident with cellulitis, morbid obesity, and fungal moisture-associated skin damage was observed with a 3-oz bottle of antifungal powder at the bedside. The bottle lacked a pharmacy label and was identified as stock medication used by CNAs. The resident stated she was not allowed to self-administer meds and that staff had left the powder at the bedside, while the ADON and RN confirmed she should not have had access to it.
Two residents with severe cognitive impairment were involved in an incident where a male resident with a history of sexually inappropriate behavior placed his mouth on a female resident's breast in a common area. Despite care plan interventions and known behavioral risks, the facility did not prevent the incident, which was witnessed by staff and reported to administration and law enforcement. Both residents were evaluated and found to have no new injuries.
A shower room in the West Hall was found to have a missing tile, which was not promptly repaired despite facility policies requiring staff to report such maintenance issues and conduct regular inspections. The Maintenance Director and Administrator confirmed the deficiency, noting that the missing tile could lead to structural damage if left unaddressed.
A resident with severe cognitive impairment and multiple health conditions was found to be missing a gold wedding ring after returning from a hospital stay. Although staff searched for the ring and a replacement was provided, the facility did not report the alleged misappropriation to the State Survey Agency within the required 24-hour period, as staff believed the ring was only misplaced and not stolen. This failure to report constituted a deficiency in compliance with reporting requirements.
The facility failed to secure medication carts and properly store medications, leading to potential risks. A treatment cart was left unlocked, a resident's wound cream was unattended in their room, and an expired insulin pen was found in a nursing cart. Staff acknowledged these oversights, confirming that medications should be secured and disposed of according to policy.
A resident with severe cognitive impairment and multiple health issues experienced significant weight loss, which was not accurately reflected in their MDS assessment. The MDS nurse, new to the role, mistakenly marked the weight loss section incorrectly, potentially impacting the resident's care.
A resident with multiple health conditions, including asthma, was found to have outdated nebulizer equipment, with the tubing and mask not changed since May, contrary to the facility's policy of weekly updates. This oversight was confirmed by both an RN and the DON, highlighting a lapse in providing appropriate respiratory care.
A medication aide in an LTC facility held a resident's Metoprolol Tartrate 25 mg due to low diastolic blood pressure, contrary to the physician's order, which specified holding the medication only if the systolic blood pressure was below 110 or pulse below 60. The aide did not notify the charge nurse, leading to a medication error as confirmed by the DON.
A facility failed to implement a policy for the use and storage of foods brought by visitors, leading to a deficiency. A resident with cognitive impairment had undated olives in their personal refrigerator, posing a risk of foodborne illness. Staff interviews revealed that nursing staff were responsible for monitoring personal refrigerators, but this was not done, violating the facility's policy on safe food handling and storage.
A resident with multiple medical conditions, including a state 3 pressure ulcer, refused wound care, but the LVN did not document this refusal in the treatment administration record, only in the 24-hour nursing report. The DON confirmed the need for accurate documentation as per facility policy, highlighting a risk of incorrect or duplicate wound care.
Fall Mat Not Utilized as Care Planned
Penalty
Summary
The facility failed to ensure that a resident's environment remained free of accident hazards and that the resident received adequate supervision to prevent accidents when the resident's fall mat was not in place as care planned. Resident #1 had diagnoses including dementia with behavioral disturbance, anxiety disorder, and a history of falling. The resident's MDS reflected severe cognitive impairment, substantial to maximal assistance needs for mobility, and reports of falls without injury. The care plan identified the resident as dependent on staff for bed mobility and transfers and included interventions such as a low bed, scoop mattress, room placement closer to the nurse's station, and fall mats. The resident's fall risk evaluation documented a history of falls, three or more falls in the past three months, disorientation at all times, chairbound status, incontinence, and the need for assistive devices. During observation, the resident was sitting in a low bed while the fall mat was observed folded up against the wall at the foot of the bed rather than being in use. The resident stated he had never had any falls and denied needing help to get out of bed, and he attempted to get up before being told not to. Further observation showed the call light activated, and the BOM entered the room and then exited after speaking with the resident. Later, CNA A was observed entering the room to change the resident, with the fall mat still folded against the wall, and then exiting with the resident in a wheelchair. CNA A stated she had forgotten to put the fall mat back in place after breakfast and acknowledged the resident could be injured if he fell without it. The BOM stated she did not notice the folded mat, and ADONs stated fall mats for residents at risk for falls were expected to be utilized and checked by staff. The facility's fall management policy stated residents with high risk factors would have individualized care plans with interventions to prevent falls and minimize complications if a fall occurred.
Unsecured antifungal powder left at resident bedside
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 when Resident #2 was observed with a 3-ounce bottle of antifungal powder at the bedside. Resident #2 was admitted with diagnoses including cellulitis of the right lower limb, morbid obesity due to excess calories, bacterial infection, and age-related physical debility. Her care plan identified fungal moisture-associated skin damage under both breasts and abdominal folds, with interventions to administer treatments as ordered. Her order summary included Nystatin External Powder 100,000 Unit/GM applied topically twice a day for fungal infection. During observation and interview, Resident #2 stated she was not allowed to administer medications to herself and said the antifungal powder had been left at the bedside by unknown staff, although staff applied it to her. The bottle at the bedside did not have a pharmacy label and was identified by the resident as being used for a fungus under her belly. The ADON observed the bottle at the bedside and stated it was a stock bottle used by nurse aides, that the resident was not supposed to have it at the bedside, and that the resident required a physician's order and assessment to safely treat herself. Staff interviews reflected that CNA staff did not have access to antifungal powder and were not allowed to administer topical medications unless directed by a nurse.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from abuse and neglect, specifically failing to ensure a safe environment free from sexual abuse. One male resident with a history of traumatic brain injury, vascular dementia, and severe cognitive impairment was known to engage in sexually inappropriate remarks and uninvited physical contact with female staff. Despite these documented behaviors and care plan interventions, the resident was able to place his mouth on the breast of a female resident in a common area. The incident was witnessed by a staff member, who immediately separated the residents. The male resident's care plan included interventions such as redirection, staff accompaniment for female employees, and analysis of behavioral triggers. However, these measures did not prevent the incident from occurring. The female resident involved had a history of trauma, including past sexual abuse, and also had severe cognitive impairment. Her care plan noted her risk for re-traumatization and included interventions for trauma processing and psychosocial support. At the time of the incident, both residents were in the dining room, and the female resident was found with her shirt lifted and the male resident's mouth on her breast. Following the incident, both residents were evaluated and found to have no new injuries, though the female resident had a pre-existing bruise on her breast. The event was reported to facility administration, the attending physician, and the residents' contacts. The incident was also reported to law enforcement. The deficiency centers on the facility's failure to prevent the male resident, who had a known history of sexually inappropriate behavior, from having unsupervised access to other residents, resulting in sexual abuse of another cognitively impaired resident.
Failure to Maintain Safe and Sanitary Shower Room Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in one of eight shower rooms observed, specifically in the West Hall. Observations on multiple dates revealed a missing shower tile in the resident shower room, which was not promptly addressed. Interviews with the Maintenance Director and Administrator confirmed that staff are expected to report maintenance issues through work orders and that daily inspections of resident rooms should occur. The missing tile was acknowledged as a problem that could lead to structural damage if not repaired. Review of the facility's Preventive Maintenance Program policy indicated that all staff are responsible for inputting work orders to notify the plant manager of any non-working systems, with weekly and monthly inspections scheduled.
Failure to Timely Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure that an allegation of misappropriation of a resident's property was reported to the State Survey Agency within the required 24-hour timeframe. Specifically, a resident with severe cognitive impairment and multiple medical conditions, including COPD, respiratory failure, and type 2 diabetes, was reported by a family member to be missing a gold wedding ring. The ring was noticed missing after the resident returned from a hospital stay, and staff were unable to determine its whereabouts despite searching the resident's room, belongings, and laundry, and questioning CNAs and hospice aides. The incident was documented in the facility's grievance resolution form, and a replacement ring was purchased for the resident. Despite the facility's policy requiring immediate reporting of misappropriation of resident property, the missing ring was not reported to the State Survey Agency within 24 hours. Interviews with staff, including the LSW, DON, and Administrator, revealed that the incident was not reported because the family member did not explicitly state the ring was stolen and was satisfied with the replacement. However, the Administrator did report the missing ring to the local police department within 24 hours. The failure to report the incident to the State Survey Agency as required constituted a deficiency in the facility's handling of alleged misappropriation.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely and under proper temperature controls, as well as to restrict access to authorized personnel only. During an observation, a treatment cart was found unattended and unlocked in the North-hall, containing various wound care supplies. RN B acknowledged the oversight, stating that the cart should have been locked at all times, and was unsure why it was left open. The Director of Nursing (DON) confirmed that all medication and treatment carts should be locked when unattended. In another instance, a resident's Triad Hydrophilic wound dressing cream was found unattended on the nightstand in the resident's room. The resident, who had moderately cognitive impairment, was not present in the room at the time. Both the Assistant Director of Nursing (ADON) and RN B confirmed that medications should not be left in residents' rooms unattended, as per facility policy. They speculated that the medication might have been left out by mistake after use. Additionally, a Novolog insulin pen belonging to another resident was found in the South-hall nursing cart with an open date that exceeded the 28-day usage period. The ADON acknowledged that the insulin pen should have been discarded after 28 days, as per the facility's policy and pharmacy standards. The DON reiterated that the insulin pen should have been disposed of after the specified period.
Inaccurate MDS Assessment of Resident's Weight Loss
Penalty
Summary
The facility failed to ensure that a resident's quarterly Minimum Data Set (MDS) assessment accurately reflected a significant weight loss. The resident, who had severe cognitive impairment and multiple diagnoses including protein-calorie malnutrition and kidney failure, experienced an 11% weight loss over six months. However, the MDS assessment incorrectly marked the weight loss section as 'No or unknown,' despite the resident's care plan and weight log indicating significant weight loss. The MDS nurse, who was relatively new to the role, acknowledged the error and attributed it to a lack of experience. The facility's policy requires comprehensive assessments to develop individualized care plans, but the inaccurate MDS assessment could lead to inadequate care. The Centers for Medicare & Medicaid Services (CMS) MDS 3.0 Manual mandates accurate assessments, which were not met in this case.
Failure to Update Nebulizer Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, as evidenced by the observation of outdated nebulizer equipment. Resident #11, who has a medical history including cerebral infarction, dementia, atherosclerotic heart disease, asthma, and sleep apnea, was found to have a nebulizing mask and tubing that were last dated on 05/12/2024, despite being observed on 07/28/2024. The resident's physician orders indicated the need for nebulizer treatment as needed for shortness of breath or wheezing, yet the equipment had not been changed in accordance with the facility's policy. Interviews with RN B and the Director of Nursing (DON) confirmed that the nebulizer tubing and mask should have been changed weekly, as per the facility's policy. However, the equipment had not been updated since May, potentially exposing the resident to the risk of respiratory infections. The failure to adhere to the policy was acknowledged by RN B, who was unaware of the reason for the oversight, and by the DON, who reiterated the requirement for weekly changes.
Medication Error Due to Failure to Follow Physician's Orders
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors during medication administration. On the specified date, a medication aide (MA) held a resident's Metoprolol Tartrate 25 mg due to the resident's low diastolic blood pressure of 50, despite the physician's order only requiring the medication to be held if the systolic blood pressure was less than 110 or the pulse was less than 60. The MA did not notify the charge nurse about holding the medication, which was against the facility's policy and the physician's orders. The resident involved had multiple diagnoses, including hypertension, chronic atrial fibrillation, and chronic kidney disease, and was moderately cognitively impaired. The Director of Nursing (DON) confirmed that the resident should have received the medication since the systolic blood pressure and pulse were within the acceptable range. The facility's policy mandates that medications be administered as prescribed by the attending physician, and any deviations should be communicated to the charge nurse immediately. The failure to notify the charge nurse and follow the physician's orders constituted a medication error.
Failure to Implement Food Storage Policy
Penalty
Summary
The facility failed to implement a policy regarding the use and storage of foods brought to residents by family and other visitors, which resulted in a deficiency. This was observed in the case of a resident who had a personal refrigerator in their room containing a small plastic container of olives without a date. The resident, who had moderately cognitive impairment and required assistance for eating and hygiene, could not recall when the olives were brought in by their son. Interviews with facility staff revealed that the nursing staff was responsible for monitoring residents' personal refrigerators and discarding undated food items. However, this was not done in the case of the resident's olives, which posed a risk of foodborne illness. The facility's policy required that residents and individuals bringing in food be educated on safe food handling and storage, but this was not effectively enacted, leading to the deficiency.
Failure to Document Wound Care Refusal
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, specifically regarding the documentation of wound care refusal. The resident, who had multiple medical conditions including a state 3 pressure ulcer, refused wound care on a specific date. However, the Licensed Vocational Nurse (LVN) responsible for the resident's care did not document this refusal in the treatment administration record, which is considered an official medical record. Instead, the refusal was only noted in the 24-hour nursing report. The LVN admitted to forgetting to document the refusal due to being busy on a holiday when the wound care nurse was not available. The Director of Nursing (DON) confirmed that the LVN should have documented the refusal in the treatment administration record to ensure accuracy. The facility's policy requires an explanatory note on the medication/treatment administration record when treatments are withheld or refused. This oversight placed residents at risk for incorrect or duplicate wound care due to incomplete and inaccurate medical records.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Heights On Huebner | 0.6 mi | ★★★★★ | 17 | 0 |
| Remington Transitional Care Of San Antonio | 0.9 mi | ★★★★★ | 3 | 0 |
| Wurzbach Nursing And Rehabilitation | 1 mi | ★★★★★ | 0 | 0 |
| Ignite Medical Resort San Antonio, Llc | 1.3 mi | ★★★★★ | 18 | 0 |
| Sorrento | 1.3 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.