Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Remington Transitional Care Of San Antonio during CMS and state inspections, most recent first.
A resident with a history of hypertension and heart failure received Metoprolol Succinate despite a recorded diastolic blood pressure below the physician-ordered threshold. The nurse responsible could not recall the event but stated she would typically re-check blood pressure if values were outside the administration range, though no repeat value was documented. The facility's policy required complete and timely documentation, and this omission resulted in an incomplete medical record.
A resident's MDS re-entry assessment did not document a recent fall that resulted in a fracture and hospitalization, despite the incident being recorded in the care plan, incident report, and confirmed by staff and hospital records. The LVN responsible for the MDS was unaware of the omission, and both the DON and Administrator acknowledged the error, noting that the assessment should have accurately reflected the resident's fall history.
A resident with a history of falls and multiple medical conditions did not have fall mats placed on both sides of the bed as specified in the care plan. Staff interviews and observations confirmed that only one mat was present, despite documentation and facility policy requiring mats on both sides for fall prevention.
A resident with moderate cognitive impairment experienced an unsafe and uncomfortable environment due to a window that could not be fully closed, resulting in water damage, and a non-functional refrigerator that prevented safe food storage. Staff were unaware of the window issue, and the refrigerator problem was not promptly addressed, leading to unsanitary and unpleasant living conditions.
Surveyors found that staff failed to observe two residents taking their prescribed medications, resulting in a medication error rate of 17.24%, well above the acceptable threshold. In both cases, nursing staff left medications at the bedside or did not confirm ingestion, contrary to facility policy and competency requirements. The residents involved had significant medical needs and required varying levels of assistance, but staff did not ensure medications were taken as ordered.
Surveyors found that two medication carts had drugs with labeling discrepancies and improper storage. One resident's furosemide label did not match the physician's blood pressure parameters, and another resident's allopurinol package lacked an updated label for a dosage change. Additionally, a medication cart was left unlocked and unattended while a nurse was in a resident's room, contrary to facility policy. The DON confirmed that proper labeling and cart security procedures were not followed.
The facility did not ensure menu variety or accommodate resident food preferences, as two residents reported dissatisfaction with the frequent serving of beans, which appeared in up to 10 out of 21 meals per week. One resident's care plan addressed nutritional concerns, while another's did not mention diet. Staff interviews confirmed the repetitive menu and lack of prior adjustments despite complaints.
Surveyors found that kitchen staff did not label refrigerated food products with discard dates, as required by facility policy and the FDA Food Code. Instead, staff relied on memory to discard food after 72 hours, and the facility's policies had not been updated to reflect current regulations. This failure to properly label food products was confirmed through observation and staff interviews.
Nursing staff failed to follow infection control protocols, including not sanitizing a blood glucose monitor between residents, handling medication with bare hands after touching contaminated surfaces, not cleaning an insulin pen's rubber stopper before use, and not using a clean paper towel to turn off the faucet after handwashing. Additionally, Enhanced Barrier Precautions were not implemented for a resident with a surgical wound, contrary to facility policy.
Two residents did not have their discharge MDS assessments transmitted to CMS within the required 14-day period. One resident's discharge assessment was overdue by 83 days and another's by 9 days, with the latter still marked as 'In Progress.' The DON indicated that MDS review was managed by corporate staff, and MDS Coordinators confirmed the assessments were missed, contrary to facility policy and RAI Manual requirements.
Two residents with moderate cognitive impairment and ADL deficits did not have their care plans updated to reflect their need for eating assistance, despite assessments and staff observations confirming these needs. Staff relied on informal communication rather than documented care plans or the Kardex, leading to gaps in the provision of necessary care.
The facility failed to develop and implement baseline care plans for three residents, missing critical information such as antibiotic therapy, antipsychotic medication, and oxygen therapy. This oversight was acknowledged by multiple staff members, including the DON and ADON, highlighting the importance of accurate care plans for effective and person-centered care.
The facility failed to employ appropriately certified and skilled staff in the food and nutrition service. The Food Service Supervisor (FSS) did not have the necessary national certification and demonstrated knowledge deficits. The Administrator acknowledged the certification error and noted the need for additional training and mentoring for the FSS.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards. Open cases of food were found in the walk-in freezer, and a tabletop can opener was covered in grime, both of which were acknowledged by the Food Service Supervisor as needing proper sealing and cleaning to prevent contamination.
A resident admitted with pneumonia, acute respiratory failure, and emphysema did not have physician orders for oxygen therapy documented upon admission. Despite being on oxygen therapy, the oversight was not identified by the nursing staff or the DON, and no policy on oxygen administration was in place.
The facility failed to include a resident's Heparin therapy in her care plan, despite her serious medical conditions and the ongoing administration of the medication. Both the ADON and DON acknowledged the oversight, which could lead to serious complications.
The facility failed to obtain physician's orders for a resident requiring oxygen therapy, despite the resident being on oxygen since admission. This oversight was not identified by the nursing staff or the DON, and no policy or procedure on oxygen administration was in place.
The facility failed to follow the scheduled menu for a lunch meal, substituting cauliflower with cooked carrots without proper review or notification. Frequent menu substitutions were made without the required involvement of the consultant RD, contrary to facility policy.
Failure to Document Repeat Blood Pressure Prior to Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, specifically regarding the administration of Metoprolol Succinate, a blood pressure medication. The physician's order required the medication to be held if the resident's systolic blood pressure (SBP) was less than 100 mmHg, diastolic blood pressure (DBP) was less than 60 mmHg, or heart rate (HR) was less than 60. On the date in question, the resident's DBP was recorded as 57 mmHg, which was below the threshold for medication administration. The medication administration record indicated that the medication was given, but the blood pressure and pulse values were documented as 'NA,' with no definition provided for this notation. Further review of the electronic medical record revealed two blood pressure readings for that day: one at 127/57 mmHg and another at 150/69 mmHg. There was no documentation of a repeat blood pressure check or a progress note regarding the administration of Metoprolol Succinate or reassessment of the resident's blood pressure. During interviews, the nurse responsible for administering the medication could not recall the specific event but stated she would typically re-check blood pressure if initial values were outside the administration range. She acknowledged that if she had re-checked the blood pressure, she likely did not document the new values, which would result in a medication administration error. The Director of Nursing confirmed that the facility's policy required accurate and timely documentation of all assessments and care provided, including repeat vital signs when indicated by medication orders. The lack of documentation for the repeat blood pressure value was identified as a failure to maintain a complete and accurate medical record, as required by professional standards and facility policy.
MDS Assessment Failed to Reflect Resident's Fall History After Hospital Re-entry
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status following a hospital re-entry. Specifically, the re-entry MDS assessment did not document a fall that resulted in a fracture, which was the reason for the resident's hospitalization and subsequent return to the facility. The resident, an elderly female with diagnoses including a right humerus fracture, metabolic encephalopathy, and chronic kidney disease, had a documented fall at the facility. This fall was recorded in the care plan and incident report, and was confirmed by both the resident and staff interviews, as well as hospital records. However, the MDS section J1700, which addresses fall history, was inaccurately coded to indicate no falls in the month prior to re-entry. Interviews with facility staff revealed that the LVN responsible for completing the MDS was unaware of the omission, despite having updated the care plan to reflect the fall. The Director of Nursing and the Administrator both acknowledged that the fall should have been documented in the MDS, and that such inaccuracies could lead to missed care. The CMS RAI User's Manual requires that the assessment accurately reflect the resident's status, including any falls in the month preceding entry or re-entry, which was not met in this case.
Failure to Implement Fall Prevention Interventions as Outlined in Care Plan
Penalty
Summary
The facility failed to fully implement a comprehensive, person-centered care plan for a resident identified as being at high risk for falls. The resident, a male with a history of a displaced femur fracture, atherosclerotic heart disease, bipolar disorder, dementia, and anxiety, required extensive assistance with activities of daily living and had experienced multiple falls both prior to and during his stay. His care plan and Kardex specifically required that fall mats be placed on both sides of his bed as a fall prevention measure. However, during observations, only one fall mat was present on the right side of the bed, with none on the left side as required by his care plan. Interviews with the resident, his family member, the DON, an RN, and a CNA confirmed that the care plan intervention was not fully implemented. Staff members acknowledged the importance of having mats on both sides of the bed and indicated that they referenced the care plan and Kardex for guidance, but failed to notice or address the missing mat. The facility's own policies required comprehensive care plans with measurable objectives and the implementation of fall prevention interventions based on individual risk factors, but these were not followed in this instance.
Failure to Maintain Safe and Functional Resident Environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for a resident, as evidenced by two main deficiencies observed during the survey. One of the resident's windows could not be fully closed, remaining open by approximately one inch for at least a week. This allowed rainwater to enter the room, resulting in warping and water damage to the interior windowsill. The resident and their representative reported the issue to a staff member after the rain incident, but the Maintenance Director was not made aware of the problem until the survey. The Maintenance Director confirmed the damage and acknowledged that he was responsible for maintaining the building's condition but had not been notified of the window issue or the resulting water damage. Additionally, the resident's room refrigerator was found to be non-functional for an undetermined period, with temperatures recorded at 58 and 60 degrees Fahrenheit on separate occasions. The resident's representative stated she was unable to bring in outside food due to the refrigerator not working and had not reported the issue to staff. The facility's ambassador, responsible for morning rounds and identifying room concerns, noted the refrigerator temperature was high and reported it to the Maintenance Director, but was unaware of the window issue. The facility's administrator and staff discussed unreliable thermometers and the need to monitor new refrigerators to ensure proper function, but there was no clear policy for ensuring a homelike environment or functioning equipment. The resident involved had a history of repeated falls, weakness, and dementia, with moderate cognitive impairment as indicated by a BIMS score of 9 out of 15. The facility's failure to maintain the resident's environment, including the inability to close the window and the lack of a functioning refrigerator, resulted in an unpleasant, unsanitary, and potentially unsafe living space. These deficiencies were identified through observations, interviews, and record reviews, and were not addressed in a timely manner due to lapses in communication and monitoring.
Failure to Maintain Acceptable Medication Error Rate Due to Lack of Observation During Administration
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5 percent, as evidenced by a calculated error rate of 17.24% based on 5 errors out of 29 observed opportunities. This deficiency was identified through observation, interview, and record review involving two residents who were being administered medications by nursing staff. The facility's own policy and competency assessments require staff to observe residents taking their medications to ensure they are swallowed and not left at the bedside, but this protocol was not followed. For one resident with multiple complex diagnoses, including diabetes, end stage renal disease, and pancreatic cancer, the assigned RN provided the resident with metoclopramide and pantoprazole in a medicine cup and placed a cup of liquid sucralfate on the bedside table. The RN then left the room without observing whether the resident took the medications, despite the resident expressing discomfort and holding the medication cup in her hands. The resident's care plan indicated a need for limited assistance with self-care, and her cognitive assessment showed moderate impairment in daily decision making. In another instance, an LVN administered medications to a resident with a history of sepsis, cellulitis, and gout. The resident, who was cognitively intact but required assistance with personal hygiene, took some pills but removed the docusate and placed it on her bedside table, expressing uncertainty about taking it. The LVN also left a cup of mixed protein liquid at the bedside without confirming ingestion. It was not determined if the resident ever took the docusate or the protein supplement. The DON confirmed that staff are required to observe residents taking their medications and that no residents were authorized for self-administration.
Medication Labeling and Storage Deficiencies on Medication Carts
Penalty
Summary
Surveyors observed that the facility failed to ensure drugs and biologicals were labeled and stored according to professional standards on two of three medication carts reviewed. On the 200-hall east cart, a resident's furosemide package had a pharmacy label with blood pressure parameters that did not match the physician's order, potentially leading to confusion during administration. The nurse interviewed was unsure about the correct parameters and stated he would contact the pharmacy or provider if uncertain. Additionally, on the 200-hall west cart, a resident's allopurinol package did not have an updated label or change direction sticker to reflect a new dosage order, and the nurse was unsure if such stickers were available, though the DON confirmed they were. Further, the 200-hall west medication cart was found unlocked and unattended while the nurse was in a resident's room, contrary to facility policy and medication pass competency requirements. The DON confirmed that medication carts should be locked when unattended to prevent unauthorized access. Facility policy also requires that medication carts not be left unlocked or unattended in resident care areas. These lapses in labeling and storage practices were directly observed and confirmed through staff interviews and record reviews.
Failure to Provide Menu Variety and Meet Resident Food Preferences
Penalty
Summary
The facility failed to ensure that menus met the nutritional needs and preferences of residents, as well as to provide adequate variety in food options. Record reviews and interviews revealed that two residents expressed dissatisfaction with the repetitive inclusion of beans in their meals, with one resident specifically noting issues with constipation and diarrhea and requesting no beans on their tray. The facility's menu for a five-week period showed that beans were served in up to 10 out of 21 meals per week, including being served twice in a single day on multiple occasions. The facility's own policy emphasized the importance of providing a well-balanced and nutritious menu that meets resident preferences, but this was not reflected in practice. Additionally, the comprehensive care plan for one resident with a history of meal refusal addressed nutritional concerns, while another resident's care plan did not mention food intake or diet at all. Interviews with the Registered Dietitian (RD) and Certified Dietary Manager (CDM) confirmed awareness of the repetitive menu and acknowledged resident complaints, but also indicated that the menu had not been adjusted prior to the survey. The Administrator was unaware of the frequency of beans on the menu and stated that the menu had been reviewed before implementation. No other relevant menu policies were provided by the facility.
Failure to Label Food Products with Discard Dates in Kitchen Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to label food products in the kitchen refrigerator with discard dates, as required by professional food service standards. During observations, all packaged foods in the fridge were found to have only preparation dates and lacked discard dates. Interviews with the Certified Dietary Manager (CDM) and Registered Dietitian (RD) revealed that they did not believe it was necessary to include discard dates on food labels, relying instead on staff knowledge to discard food after three days. However, the facility's policy required all refrigerated foods to be dated, labeled, and used within 72 hours, and the FDA Food Code 2022 mandates clear marking of ready-to-eat, time/temperature control for safety foods with the date by which the food should be consumed, sold, or discarded. Further interviews confirmed that kitchen staff did not routinely write discard dates on food products, as they were accustomed to discarding items after 72 hours based on training. The RD acknowledged that their policies had not been updated to reflect the 2022 FDA Food Code changes and agreed that including discard dates would help staff quickly identify when to discard food. The lack of discard dates on food products in the refrigerator constituted a failure to store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Multiple Lapses in Infection Control Practices by Nursing Staff
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices by staff and lack of adherence to established protocols. Specifically, a registered nurse (RN) did not sanitize a blood glucose monitor between uses for two residents, despite using the same device consecutively. The RN acknowledged during an interview that the monitor should be sanitized between residents to prevent the spread of pathogens. Additionally, the RN handled a medication pill with bare hands after touching various surfaces, including keys and a computer keyboard, before administering the medication to a resident. The RN stated he believed it was acceptable to touch pills with bare hands but later recognized the potential for contamination. Further deficiencies were observed in the administration of insulin, where the RN failed to clean the rubber stopper of an insulin pen with an alcohol swab prior to attaching the needle and administering the medication. The Director of Nursing (DON) indicated that while the facility's policy did not specify cleaning the pen, it would be important to prevent cross-contamination. Manufacturer guidelines for the insulin pen recommend wiping the pen tip with an alcohol swab before use, which was not followed in this instance. Additional infection control lapses included a licensed vocational nurse (LVN) not using a clean paper towel to turn off the faucet after handwashing, instead using bare hands, which could lead to recontamination. The LVN stated that paper towels were not easily accessible and acknowledged the correct procedure. The facility also failed to implement Enhanced Barrier Precautions (EBP) for a resident with a surgical wound and a wound vacuum device, as required by facility policy. The resident's room lacked appropriate EBP signage, and the DON confirmed that EBP should have been in place for this resident due to the risk of infection associated with her wound.
Failure to Timely Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the CMS system within 14 days of discharge for two residents. For one resident, a male with diagnoses including pneumonia, acute respiratory failure with hypoxia, sepsis, dysphagia, and gastrostomy status, the discharge MDS assessment was 83 days overdue following his discharge. His medical record showed completed entry and admission MDS assessments, but the required discharge assessment was not submitted in the required timeframe. For the second resident, a female with a history of skin transplant, the discharge MDS assessment was 9 days overdue, and the assessment was still marked as 'In Progress' after her discharge with home health services. Her record also showed a completed MDS assessment prior to discharge, but the discharge assessment was not finalized or transmitted as required. Interviews with the Director of Nursing (DON) and two MDS Coordinators revealed that the discharge MDS assessments for these residents were simply missed. The DON stated that review of MDS assessments was handled by corporate staff, not by himself. The MDS Coordinators acknowledged the oversight and indicated the importance of completing discharge MDS assessments for CMS and insurance notification. Facility policy and the RAI Manual both require that OBRA discharge assessments be completed and submitted within 14 days of discharge, which was not followed in these cases.
Failure to Update and Implement Comprehensive Care Plans for Eating Assistance
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with identified deficits in activities of daily living (ADLs), specifically related to eating. For one resident with type 2 diabetes and moderate cognitive impairment, the care plan did not include interventions for eating assistance, despite the resident requiring set up or clean-up help as documented in the admission MDS assessment. Observations confirmed the resident struggled to remove plastic coverings from food items, and staff interviews indicated that assistance was needed but not formally documented in the care plan. For another resident with hemiplegia following a stroke and moderate cognitive impairment, the care plan also lacked interventions for eating, even though the resident required substantial or maximal assistance and needed to be fed, as indicated in the MDS assessment. Staff interviews revealed that knowledge of these needs was communicated informally rather than through updated care plans or the Kardex, which is used by CNAs to guide care. The facility's policy required care plan revisions upon status change, but this was not followed, resulting in incomplete documentation of the residents' care needs.
Failure to Implement Baseline Care Plans for New Residents
Penalty
Summary
The facility failed to develop and implement a baseline care plan for three residents, which included necessary instructions for effective and person-centered care. Resident #25's baseline care plan did not reflect that he received antibiotic therapy at dialysis, despite having diagnoses such as septicemia, metabolic encephalopathy, and ESRD. The care plan also failed to include instructions for removing the pressure dressing from the shunt site after dialysis. The DON acknowledged the importance of accurate care plans to ensure proper care by staff. Resident #104's baseline care plan did not indicate that she was receiving an antipsychotic medication, despite her diagnoses of pneumonia, major depressive disorder, and anxiety disorder. The Order Summary Report showed an active order for Sertraline HCL, but this was not reflected in the care plan. Both the DON and ADON admitted that the psychotropic medication was missed in the care plan, emphasizing the need for accurate documentation to monitor for side effects. Resident #253's baseline care plan did not reflect her need for oxygen therapy, despite her diagnoses of pneumonia, acute respiratory failure with hypoxia, and emphysema. The hospital discharge summary and daily skilled notes indicated that she required oxygen via nasal cannula, but this was not included in the care plan or active orders. Multiple staff members, including the LVN and ADON, acknowledged the oversight and the potential risk of respiratory distress due to the missing oxygen orders. The DON confirmed that the oxygen orders were missed and stressed the importance of including such critical information in the baseline care plan.
Inadequate Certification and Training for Food Service Supervisor
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. The Food Service Supervisor (FSS) did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. The FSS was hired as a cook in 2019 and assumed the position of FSS in September 2023. Upon assuming the FSS position, the FSS completed a Texas Food Manager's Certification program, believing it met the requirements for the position. However, this certification was not a national certification and did not meet the necessary qualifications for the role. The facility's Registered Dietitian (RD) was also contracted and not a full-time employee, further complicating the situation. During interviews, the FSS and the Administrator acknowledged the certification error. The Administrator admitted to knowing that the Texas Food Manager's Certification was not appropriate for the FSS position and had paid for the FSS to take the National Food Manager Certification exam, which the FSS did not complete. The Administrator also noted that the FSS demonstrated knowledge deficits and would benefit from additional training and mentoring. This deficiency could place residents at risk of foodborne illness and inadequate nutrition due to the lack of appropriately certified and skilled staff in the food and nutrition service.
Failure to Maintain Food Safety Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation in the walk-in freezer, three open cases of food were found: a 30-lb. case of mixed vegetables, a 30-lb. case of cut green beans, and a 10-lb. case of beef fritters. The interior plastic bags of these cases were also open, exposing the food to potential contaminants, freezer burn, and a decrease in quality. The Food Service Supervisor (FSS) acknowledged that the food should have been properly sealed to maintain freshness and that the cooks were responsible for ensuring this. Additionally, the tabletop can opener in the kitchen was observed to be covered with sticky grime that was black and brown in color. The grime covered the blade, the plastic insert inside the base, and the part of the base affixed to the table with screws. The FSS confirmed that the can opener was in need of cleaning and sanitizing and stated that the cooks were responsible for keeping it clean to prevent cross-contamination and foodborne illness. The facility's policies on food storage and can opener maintenance were reviewed and found to be in line with the U.S. Public Health Service Food Code, but were not being followed by the staff.
Failure to Obtain Physician Orders for Oxygen Therapy Upon Admission
Penalty
Summary
The facility failed to ensure that at the time of admission, there were physician orders for the immediate care of a resident who required oxygen therapy. Specifically, Resident #253, who was admitted with diagnoses including pneumonia, acute respiratory failure with hypoxia, and emphysema, did not have physician orders for oxygen therapy upon admission. Despite the hospital discharge summary indicating the need for oxygen supplementation, and the resident being observed on oxygen therapy via nasal cannula, no formal orders were documented until several days after admission. Interviews with the resident, nursing staff, and the Director of Nursing (DON) revealed that the oversight was not identified by any of the four nurses who attended to the resident since her admission. The resident's nurse acknowledged that oxygen therapy requires a physician's order and that the wrong rate could lead to respiratory compromise. The DON admitted that the oxygen orders were missed and that there was no existing policy or procedure on oxygen administration in the facility. This deficiency could have resulted in respiratory distress for the resident due to improper oxygen administration.
Failure to Include Anticoagulant Therapy in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #3, who was on anticoagulant therapy. Despite being admitted with multiple serious medical conditions, including metabolic encephalopathy, diabetes mellitus, rhabdomyolysis, and atherosclerotic heart disease, the resident's care plan did not address her Heparin therapy. This omission was identified during a review of the resident's records, which showed active orders for Heparin Sodium Solution and confirmed administration of the medication every 12 hours. Interviews with the resident and staff corroborated that the Heparin therapy had been ongoing since shortly after admission, yet it was not included in the care plan. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both acknowledged that the Heparin therapy should have been included in the care plan due to its critical nature and the need for careful monitoring to prevent serious complications such as bleeding. The facility's policy on comprehensive care plans, dated 10/24/2022, mandates the inclusion of measurable objectives and timeframes to meet residents' medical needs, which was not adhered to in this case. This deficiency could potentially affect other residents requiring specific care and interventions, leading to missed care or harm.
Failure to Obtain Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident requiring respiratory care, including tracheostomy care and tracheal suctioning, received such care consistent with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not obtain oxygen orders from the physician for a resident who was admitted with diagnoses including pneumonia, acute respiratory failure with hypoxia, and emphysema. Despite the resident being on oxygen therapy since admission, this was not reflected in the baseline care plan or active orders, and the oversight was not identified by the nursing staff or the Director of Nursing (DON) until several days later. Observations and interviews revealed that the resident was on oxygen therapy via nasal cannula at a rate of 2.5 l/min, but no physician's order was in place to authorize this treatment. The resident's hospital discharge summary indicated a plan for oxygen supplementation, but this was not followed up with a formal order in the facility. The DON acknowledged the oversight and the lack of a policy or procedure on oxygen administration, which could have led to respiratory distress due to incorrect oxygen administration.
Failure to Follow Scheduled Menu and Review Substitutions
Penalty
Summary
The facility failed to follow the scheduled menu for residents on regular and modified diets for the lunch meal on 04/25/2024. The posted menu indicated that the lunch meal should include baked pork chop, buttered corn, and cauliflower with red potatoes. However, during an observation, it was noted that cauliflower was missing from the steam table and had been substituted with cooked carrots. The Food Service Supervisor (FSS) acknowledged the substitution and stated that the cauliflower did not arrive with the food shipment. He logged the substitution but did not post it for the residents or discuss it with the consultant registered dietitian (RD). Additionally, there was no weekly menu posted in the facility, and the substitution was not reviewed with the RD as required by the facility's policy. The Dietetic Technician Registered (DTR) also confirmed that she had not discussed any substitutions with the consultant RD, despite the facility's policy requiring such reviews. Further record review revealed a history of frequent menu substitutions dating back to October 2023, with minimal involvement from the consultant RD. Of 58 food items substituted, the RD's initials were present next to only a few items replaced in January, February, and April of 2024. The facility Administrator was unaware of the frequent substitutions and stated that substitutions should only be made in emergencies and reviewed with the consultant RD. The facility's policy emphasized the importance of serving menus as planned and required the RD to review and approve any substitutions to ensure nutritional adequacy. The failure to follow the menu and properly review substitutions could place residents at risk of not having their nutritional needs met.
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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) |
|---|---|---|---|---|
| Sorrento | 0.4 mi | ★★★★★ | 17 | 0 |
| Mesa Vista Inn Health Center | 0.6 mi | ★★★★★ | 24 | 0 |
| Northgate Health And Rehabilitation Center | 0.6 mi | ★★★★★ | 29 | 0 |
| Ignite Medical Resort San Antonio, Llc | 0.6 mi | ★★★★★ | 18 | 0 |
| Huebner Creek Health & Rehabilitation Center | 0.8 mi | ★★★★★ | 26 | 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.