Average — CMS composite of the measures below.
The next survey window likely opens 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 Sage Park San Antonio during CMS and state inspections, most recent first.
Incomplete Food Handler Training for Kitchen Staff: The facility’s kitchen failed to store, prepare, distribute, and serve food in accordance with professional standards when four dietary staff members did not have completed Food Handler Certificates. The Exec Chef stated this was an oversight, and record review confirmed that Cook-I, DA-J, DA-K, and DA-L had not completed the required training.
Kitchen sanitation and food service safety standards were not maintained. Surveyors observed dusty wall and ceiling vents, dirt on the top of the dish machine, brown ceiling stains around a sprinkler head, and two kitchen staff members without beard restraints. The dish machine was tested through three cycles and only reached 110 degrees Fahrenheit instead of the required 120 degrees Fahrenheit, and the Executive Chef stated no work order had been placed for the vents to be cleaned.
An infection control deficiency occurred when an LPN used a BP cuff on two residents without sanitizing it between uses, and a CNA handled a soiled brief and then continued with clean care without removing gloves or sanitizing hands. During incontinent care for another resident, the CNA did not retract the foreskin on an uncircumcised male and left feces on the skin after care. The residents involved had significant medical needs, including incontinence, catheter use, and dependence on staff for hygiene.
Environmental Maintenance and Cleanliness Deficiencies: The facility failed to maintain a safe, functional, sanitary, and comfortable environment in 2 resident rooms, the beauty salon, and the laundry room. Surveyors observed missing bathroom sink light covers in 2 rooms and stained, dirty ceiling vents in the salon and laundry room. The EVS Director stated no work order had been received for the observed areas, and review of maintenance work orders showed the repairs were not noted for completion.
Inaccurate MDS Fall History: A resident with significant cognitive impairment, ADL dependence, an indwelling catheter, and bowel incontinence had a quarterly MDS that stated she had no falls since the prior assessment. Records showed she was at risk for falls and had multiple falls with a forehead laceration and later incidents before the MDS. The DON confirmed the MDS was inaccurate and should have reflected the resident’s fall history.
Failure to Include Fall Risk and Interventions in Care Plan: A resident with HF, anxiety, pain, severe cognitive impairment, ADL dependence, and an indwelling catheter was identified as a fall risk and had multiple falls with a forehead laceration, but the comprehensive care plan did not document her fall risk or related interventions. Staff interviews confirmed the care plan should have reflected the resident’s fall risk and measures such as a low bed and floor mats, yet this information was not included.
Failure to provide proper perineal care for an incontinent male resident: A resident who was always incontinent of bowel and bladder and dependent on staff for perineal hygiene was observed receiving incontinent care when a CNA wiped around his penis and genital area without pulling back the foreskin to clean the penis. The CNA stated she was trained to do so, the DON confirmed it should have been done, and the facility policy required pulling back the foreskin to clean the area and then returning it to place.
A facility failed to maintain respiratory equipment for two residents receiving oxygen therapy and nebulizer treatment. One resident had a dirty, worn oxygen filter, an unchanged humidifier bottle, and nasal cannula tubing left unbagged when not in use. Another resident had a dirty, dusty oxygen filter and a nebulizer mask left unbagged after treatment. The DON and nursing staff acknowledged the equipment should have been checked, cleaned, changed, and stored as ordered.
An expired bottle of Atropine 1% drops was found on the Medication Cart for B and C Halls during a surveyor observation. An LVN said she usually checks carts for expired meds but did not know why the bottle was not removed sooner, and the DON stated the medication should have been removed earlier because it had been expired for 6 months. The RNC stated expired meds must be removed from carts, and the DON said there was no facility policy or procedure addressing expired meds on the medication cart.
Unlocked Treatment Cart Left Unattended: An RN and the ADON performed wound care for a resident and left the treatment cart unlocked in the hall and out of view while taking supplies into the room. The cart contained medicated ointments and solutions used for wound care. The RN stated the cart should have been secured, and the DON and RNC stated medication and treatment carts must be locked when not in view of the nurse.
Improper garbage disposal was observed for 2 of 2 dumpsters reviewed. Both Dumpster #1 and Dumpster #2 had lids that were not secured because the bins were overflowing with garbage, and two bags of garbage plus a pile of cooked noodles were found on the ground beside Dumpster #2. An LCS stated he knew the lids needed to be secure to help prevent rodent infestation and said garbage pickup was scheduled later in the day.
The facility failed to ensure accurate MDS assessments for several residents, leading to discrepancies between documented and actual conditions. A resident's falls, another's oxygen therapy, hospice care for a resident, and a deep tissue injury were not accurately reflected in the MDS, despite being noted in care plans. Staff acknowledged these errors, highlighting the need for alignment between MDS and care plans.
The facility's kitchen was found to have several deficiencies in food storage and safety practices. Observations revealed open food packages, unlabeled and undated turkey slices, and personal items stored near food, which could lead to contamination and foodborne illnesses. Interviews with staff confirmed these practices were against facility policies, which require proper sealing, labeling, and storage of food items.
A facility failed to develop a baseline care plan for a resident admitted with a colostomy, despite having physician orders for colostomy care. The resident, with multiple health conditions, did not receive a care plan within 48 hours of admission, as required. Interviews with staff revealed a misunderstanding that physician orders were sufficient, leading to potential inappropriate care due to the lack of a baseline care plan.
A resident's care plan was not updated after a quarterly MDS assessment showed a change in bowel incontinence status. Despite the resident's inability to use the toilet, the care plan still required one staff member's assistance for toilet use. Observations and interviews confirmed the oversight, and the facility's policy mandates care plan updates based on MDS assessments.
A facility failed to provide a safe environment and adequate supervision when a used disposable razor was found in a resident's bathroom. The resident, who had moderate cognitive impairment and required assistance with personal hygiene, was unable to use the razor independently. Staff interviews confirmed the razor should have been discarded in a sharps container to prevent infection and injury, as per facility policy.
A facility failed to ensure proper pharmaceutical services when an expired medication, Benadryl itching stopping gel, was found in a medication cart. The gel had expired in May 2021 and was discovered during an observation. The ADON confirmed the expired medication's presence and acknowledged that nurses should discard expired medications per facility policy.
A resident's ear wax removal kit was found unattended and unsecured on a nightstand in their room, contrary to the facility's policy requiring all medications to be stored in locked compartments. The resident, who had severe cognitive impairment and required assistance with daily activities, was not present in the room at the time. Interviews with staff confirmed that medications should not be left unattended in residents' rooms.
A facility failed to maintain accurate clinical records for a resident, documenting a deep tissue injury on the wrong heel. The resident, with multiple medical conditions, had a care plan and physician orders indicating a left heel injury, but the initial evaluation incorrectly noted it on the right heel. This error, acknowledged by the wound care nurse, posed a risk of improper wound care due to misinformation.
A resident with multiple health conditions, including moderate cognitive impairment, was found with a dirty Yankauer suction tube on her nightstand, which was not discarded after use as required by the facility's infection control policy. This oversight was confirmed by both an LVN and the DON, indicating a failure in maintaining proper infection control procedures.
A resident with a history of respiratory failure was not monitored to ensure continuous oxygen supply, leading to a significant drop in oxygen saturation levels. The facility failed to document the resident's condition accurately and did not connect her to a functioning oxygen concentrator after a transfer. Interviews revealed communication lapses and oversight in ensuring the resident's oxygen needs were met, resulting in an Immediate Jeopardy finding.
Incomplete Food Handler Training for Kitchen Staff
Penalty
Summary
The kitchen failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility’s only kitchen. During interview, the Executive Chef stated that the absence of completed Food Handler Certificates for four kitchen staff members, identified as Cook-I, DA-J, DA-K, and DA-L, was an oversight. Record review of the Dietary Staff's Food Handler Certificates showed that these four staff members had not completed their Food Handler Certificates. The Texas Food Code was also reviewed and stated that all food employees must successfully complete an accredited food handler training course within 60 days of employment, with training covering food safety, good hygiene practices, and how to avoid cross-contamination.
Kitchen sanitation and dish machine temperature deficiencies
Penalty
Summary
The kitchen failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During observation on 1/6/26, surveyors found two wall vents across from the freezer with dust and dirt, a 3x3 ft ceiling vent in the dry storage room with dust and dirt on its outer surface, and a 3x3 ft ceiling vent at the entrance to the dish machine room with dust and dirt on its outer surface. In the kitchen pantry room, the top surface of the dish machine had dirt particles on it, and there were numerous brown stain markings on the ceiling around the sprinkler head. The facility also failed to clean the kitchen vents, and the Executive Chef stated on 1/8/26 that no work order had been placed for the vents to be cleaned. Surveyors also observed two kitchen staff members, Cook-G and Dietary Aide-H, not wearing beard restraints. The dish machine was run through three cycles and did not reach the required rinse temperature for a cold rinse machine; it only reached 110 degrees Fahrenheit instead of 120 degrees Fahrenheit. During interview, staff stated that clean ceiling vents and beard restraints help prevent dust and hair particles from falling onto the kitchen floor or prepared food, and that the proper dish machine rinse temperature ensures plates and silverware are properly cleaned. Record review showed the facility policy required the food service area to be maintained in a clean and sanitary manner and that floors, walls, and ceilings must be free of dirt, litter, and moisture.
Infection Control Failures During Shared Equipment Use and Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for residents receiving incontinent care and for shared equipment use. During observation on 01/08/2026 at 08:40 am, LVN C took blood pressure for Resident #38, who received blood pressure medication, and then went to Resident #39, who also received blood pressure medication, without sanitizing the blood pressure cuff between residents. During interview, LVN C stated she forgot to sanitize the cuff and acknowledged that not sanitizing it could cause cross contamination and spread infection. Resident #8 was documented as having hypertensive heart disease with heart failure, anxiety disorders, pain, an indwelling urinary catheter, and bowel incontinence, and she was dependent on staff for ADLs. During incontinent care on 01/08/2026 at 10:20 am, CNA E cleaned the resident and then changed gloves and sanitized hands. CNA D then removed the soiled brief, placed it in the trash can near the bed, and continued placing the clean brief on the resident without discarding her soiled gloves or sanitizing her hands. CNA D stated she had been trained on infection control and knew she should have discarded the soiled gloves and sanitized her hands before handling clean items. Resident #3 was documented as having acute respiratory failure with hypoxia, muscle weakness, anemia, atrial fibrillation, and heart failure, and he was dependent on staff for perineal hygiene and always incontinent of bowel and bladder. During incontinent care on 01/08/2026 at 11:20 am, CNA D wiped around the resident’s penis and genital area without retracting his foreskin to clean the penis and left dried feces on his buttock area near his thighs after cleaning the anal area. CNA D stated she had been trained to retract the foreskin on uncircumcised males during incontinent care and to clean the penis, and that not cleaning under the foreskin could cause infection. The DON later stated CNA D should have pulled back the foreskin and completely cleaned the feces off the skin, and that LVN C should have sanitized the blood pressure cuff between residents.
Environmental Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 2 of 27 resident rooms and in the beauty salon and laundry room reviewed for environmental concerns. During observations with the Administrator and Environmental Services Director, one resident room had a missing light cover on 1 of 4 bathroom sink overhead lights, and another resident room also had a missing light cover on 1 of 4 bathroom sink overhead lights. The beauty salon had an 18 x 18 overhead ceiling vent that was stained and had dirt particles, and the laundry room had an 18 x 18 overhead ceiling vent that was stained and had dirt particles. During interview, the Environmental Services Director stated he had not received a work order request for repair of the observed areas. He also stated that building repairs had to be completed for facility upkeep and resident safety. The Administrator stated that building repairs were necessary to be done on a timely basis for facility operations. Record review of maintenance work orders from 12/1/25 through 12/31/25 showed the observed areas for repair were not noted for completion. Record review of the facility policy titled Preventative Maintenance Program dated 7/10/20 stated that a preventative maintenance program promotes cost-effectiveness throughout the community, enhances the quality of life for residents, and improves the working conditions for associates.
Inaccurate MDS Fall History
Penalty
Summary
The facility failed to ensure Resident #8’s quarterly MDS assessment accurately reflected her fall status. Resident #8 was a [AGE]-year-old female admitted to the facility with diagnoses including hypertensive heart disease with heart failure, anxiety disorders, and pain. Her quarterly MDS dated 11/14/2025 indicated she was rarely understood, sometimes able to understand, not a candidate for BIMS, dependent on staff for ADLs, had an indwelling urinary catheter, was always incontinent of bowel, and had no falls since admission/entry or reentry or the prior assessment, whichever was more recent. Record review showed Resident #8 was identified as at risk for falls on her FRA dated 08/04/2025. The facility incident report dated 10/06/2025 documented that she was found responsive on the floor with a laceration to her forehead, and the facility incidents and accidents reflected additional falls on 10/08/2025 and 11/08/2025 before the quarterly MDS assessment. Her care plan addressed bowel incontinence and later noted a urinary tract infection and a forehead laceration related to a fall, but it did not note a history of falls or fall-risk interventions. During interview, the DON stated Resident #8 was at risk for falls and had 2 recent falls with interventions in place, and confirmed the quarterly MDS was inaccurate and needed to reflect her fall history.
Failure to Include Fall Risk and Interventions in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one resident that included measurable objectives and timeframes to meet her medical, nursing, mental, and psychosocial needs. Resident #8 was a [AGE]-year-old female admitted with diagnoses including hypertensive heart disease with heart failure, anxiety disorders, and pain. Her quarterly MDS reflected that she rarely understood and sometimes was able to understand, was not a candidate for a BIMS, was dependent on staff for ADLs, had an indwelling urinary catheter, and was always incontinent of bowel. Her fall risk assessment dated 08/04/2025 identified her as at risk for falls. Record review showed Resident #8 had an incident on 10/06/2025 when she was found responsive on the floor with a laceration to her forehead, and the facility incident records reflected additional falls on 10/08/2025 and 11/08/2025 before the quarterly MDS assessment. However, the comprehensive person-centered care plan dated 09/04/2025 only reflected a focus related to a forehead laceration from a fall that was later resolved and did not note a history of falls, fall risk, or interventions. Observations on 01/06/2026, 01/07/2026, 01/08/2026, and 01/09/2026 showed the resident lying in bed with the bed in a low position and floor mats on both sides. During interviews, the DON and RNC stated the resident was at risk for falls, had recent falls, and the care plan needed to reflect the fall risk and interventions such as the low bed and floor mats.
Failure to Provide Proper Perineal Care for an Incontinent Male Resident
Penalty
Summary
The facility failed to ensure appropriate care for a resident who was incontinent of bladder and dependent on staff for perineal hygiene. Resident #3 was a male resident with diagnoses including acute respiratory failure with hypoxia, muscle weakness, anemia, atrial fibrillation, and heart failure. His admission MDS reflected that he could understand and be understood, had a BIMS score of 15 out of 15, was always incontinent of bowel and bladder, and required staff assistance to maintain perineal hygiene. His care plan identified risk for impaired skin integrity and risk for infection, with interventions related to evaluating bladder and bowel incontinence and educating the resident/representative on techniques to prevent infection. During observed incontinent care, CNA D wiped around the resident’s penis and genital area without pulling back his foreskin to clean the penis. CNA D stated she had been trained to pull back the foreskin on uncircumcised males during incontinent care and clean the penis, and acknowledged that not cleaning under the foreskin could cause infection. The DON stated CNA D should have pulled back the resident’s foreskin during incontinent care to ensure he was clean and to prevent infection. The facility policy for incontinent care also directed staff to pull back the foreskin of an uncircumcised male to clean the area and then return the foreskin to place after drying well.
Respiratory Equipment Not Maintained as Ordered
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who were receiving oxygen therapy and related respiratory treatments. Resident #14, a female with diagnoses including fracture of the right femur, muscle weakness, dysphagia, and Parkinsonism, was ordered oxygen at 2 LPM via nasal cannula at night, with oxygen tubing changes, oxygen filter cleaning, and humidifier cannister changes every Wednesday and as needed. Observations showed her oxygen concentrator had a dirty, worn, and crumbling filter, the humidifier bottle was not changed as ordered, and the nasal cannula tubing was not bagged when not in use. Resident #15, a female with diagnoses including acute respiratory failure with hypoxia, metabolic encephalopathy, COPD, and acute pulmonary edema, was receiving continuous oxygen therapy at 5-7 L/min via nasal cannula with a humidified cannister and also received respiratory therapy. Her care plan directed that the oxygen filter be cleaned every Wednesday and as needed. Observations showed her oxygen concentrator filter was dirty and dusty, and her nebulizer mask was not bagged when not in use. The resident stated staff were the ones who checked her equipment, and the charge nurse stated she had not noticed the equipment was not bagged or the filter was dirty. Interviews with the DON and nursing staff confirmed that the oxygen filters, tubing, humidifier bottles, and nebulizer equipment should have been checked and changed as ordered. The DON stated the dirty filter could disrupt airflow and result in respiratory distress or URI, and staff stated not changing or bagging the equipment as ordered could result in URI or shortness of breath. The facility policy titled Oxygen Administration required regular checks and cleaning of oxygen equipment, masks, tubing, and cannulas, and changing masks and tubing every 7 days and as needed.
Expired Atropine Found on Medication Cart
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when surveyors observed the Medication Cart for B and C Halls containing a plastic bottle of Atropine 1% drops with an expiration date of 08/29/2025. The expired medication was found during observation on 01/08/2026 at 08:20 am while the cart was being checked with an LVN. During interviews, the LVN stated she usually checks the medication cart for expired medications when she works but did not know how the expired Atropine was not removed sooner, and she stated the medication could decrease in effectiveness after expiration and harm a resident. The DON stated the medication carts were checked routinely and the Atropine should have been removed earlier because it had been expired for 6 months. The RNC stated expired medications needed to be removed from carts and that nurses must ensure medication carts and the treatment cart were either within view or locked. The DON also stated there was no facility policy and procedure addressing expired medications on the medication cart.
Unlocked Treatment Cart Left Unattended
Penalty
Summary
The facility failed to ensure drugs and biologicals used in the facility were labeled and stored in accordance with accepted professional principles, including being kept in locked compartments with proper access control. During observation on 01/07/2026 at 3:20 pm, RN A and the ADON performed wound care for Resident #3. RN A took the wound care treatment and supplies into the resident’s room without securing the treatment cart, and the ADON closed the room door, leaving the treatment cart in the hall unlocked and out of view. The cart contained medicated ointments and solutions used for wound care. During interview, RN A stated she should have secured the treatment cart because a drug diversion could occur or someone without need could access the cart and cause harm, and she stated it was her responsibility to secure the cart because she had the keys. The DON stated medications and treatment solutions or ointments must be secured in the medication and treatment cart when out of sight of the nurse. The RNC stated expired medications needed to be removed from carts and that medication carts or the treatment cart left unlocked and unattended could result in harm of others or misappropriation of supplies or drugs. The facility policy titled Storage of Medication stated medications are to be stored in a safe, secure, and orderly manner and compartments containing medications are locked when not in use.
Improper Dumpster Garbage Disposal
Penalty
Summary
The facility failed to dispose of garbage and refuse properly for 2 of 2 dumpsters reviewed, Dumpster #1 and Dumpster #2. On observation, both dumpsters had lids measuring approximately 3x5 ft that were not secured to the dumpster basin because the bins were overflowing with garbage. In addition, two bags of garbage and a pile of cooked noodles were observed on the ground beside Dumpster #2. During interview, the Clinical Specialist stated he was aware that the garbage lids needed to be secure to the garbage bins to prevent rodent infestation and said the facility's garbage was to be picked up later in the day, although he was unsure of the exact pickup time. Record review of the facility policy titled Cleaning-Trash Collection Areas dated 7/20/10 stated that trash containers must have a lid and be closed at all times when not in use.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate assessments for five residents, leading to discrepancies between the residents' actual conditions and their documented status on the Minimum Data Set (MDS). Resident #15 experienced falls on two occasions, which were not recorded in the Quarterly MDS, despite being documented in the care plan. Similarly, Resident #5 had a fall that was not reflected in the MDS, although it was noted in the care plan. These omissions indicate a lack of accurate documentation of falls, which are critical for assessing the residents' needs and planning appropriate interventions. Resident #18 had been using oxygen therapy since admission, but this was not coded in the Admission MDS, even though it was included in the care plan. This oversight suggests a disconnect between the care provided and the documentation, potentially affecting the resident's care plan and the facility's financial reimbursement. Additionally, Resident #1 was receiving hospice care, but the MDS inaccurately indicated that the resident was not receiving such care, despite the care plan and hospice consent form confirming otherwise. Resident #20 had a deep tissue injury on the left heel, which was not documented in the admission MDS, although it was noted in the care plan and observed during wound care. This inaccuracy could lead to inadequate wound care due to the lack of proper documentation. Interviews with facility staff, including the MDS nurse, Administrator, and DON, revealed acknowledgment of these errors and the importance of ensuring that the MDS and care plans align to accurately reflect residents' needs and conditions.
Food Storage and Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. Several issues were identified, including an open bag of kernel corn in the walk-in freezer, a container of turkey slices in the walk-in cooler that was not labeled or dated, and an open bag with two rolls in the dry storage room. Additionally, a box of oatmeal was found with the top off, and six containers of seasoning were left open in the dry storage room. These lapses in food storage practices could potentially expose residents to foodborne illnesses. Further observations revealed that two employee backpacks were stored on a shelf next to food items in the dry storage room, which is not an appropriate location for personal belongings. Interviews with the Dietary Manager (DM) and Dietary Aide (DA) confirmed that these practices could lead to contamination and foodborne infections. The facility's policies on food storage were reviewed, highlighting that food storage areas should be used exclusively for food and paper products, and opened packages should be resealed to prevent contamination. The refrigerated food storage policy also mandates that all foods should be covered, labeled, and dated.
Failure to Develop Baseline Care Plan for Colostomy Care
Penalty
Summary
The facility failed to ensure that a baseline care plan was completed and provided to a resident and/or their representative within 48 hours of admission. Specifically, the facility did not develop a baseline care plan for a resident who was admitted with a colostomy. The resident, a female with multiple diagnoses including a laceration of the sigmoid colon, type 2 diabetes, anemia, hypertension, and dysphagia, was admitted to the facility with a physician's order for colostomy care. However, the baseline care plan did not include instructions for colostomy care, which is essential for providing effective and person-centered care. Interviews with facility staff, including an LVN and the MDS nurse, revealed that the baseline care plan was not developed as required. The MDS nurse acknowledged the oversight, mistakenly believing that the presence of physician orders for colostomy care was sufficient. The Director of Nursing confirmed that the absence of a baseline care plan could lead to inappropriate care, as it affects the Kardex used by CNAs to provide care. The facility's policy on care planning emphasizes the need to write activity goals and approaches based on MDS triggers and the current needs of the resident, which was not adhered to in this case.
Failure to Update Care Plan After MDS Assessment
Penalty
Summary
The facility failed to update and revise the care plan for a resident after a quarterly Minimum Data Set (MDS) assessment indicated a change in the resident's condition. The resident, who had a history of atherosclerotic heart disease, cerebral infarction, epilepsy, major depressive disorder, and hypertension, was found to have moderate cognitive impairment with a BIMS score of 9 out of 15. The quarterly MDS assessment revealed that the resident was always incontinent to bowel and could not be transferred to the toilet due to medical or safety concerns. Despite this, the resident's care plan, last revised in August 2022, still indicated that the resident required one staff member's assistance to use the toilet. Observations and interviews confirmed that the resident was provided incontinence care by CNAs, and the MDS nurse acknowledged the failure to update the care plan to reflect the resident's current needs. The Director of Nursing (DON) also confirmed that the care plan should have been updated following the quarterly MDS assessment. The facility's policy on care planning assessment requires that care plans be revised based on comprehensive MDS assessments and triggered areas, which was not adhered to in this case.
Failure to Ensure Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents for a resident. During an observation, a used disposable razor was found on the sink faucet in the bathroom of a resident who had moderate cognitive impairment and required assistance with personal hygiene. The resident was unable to use the razor independently due to his condition, which included a left-sided hand contracture and weakness. The presence of the razor posed a risk of infection or physical injury to the resident and others. Interviews with staff, including an LVN and the DON, confirmed that the razor should have been discarded in a sharps container after use to prevent infection and injury. The facility's policy on handling infectious waste required contaminated disposable items to be placed in red plastic bags and stored in biohazard storage until removal. The failure to follow this policy resulted in the deficiency noted by the surveyors.
Expired Medication Found in Nursing Cart
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals. During an observation, a medication cart in the A and B hall was found to contain an expired medication, Benadryl itching stopping gel, which had expired in May 2021. This was discovered on October 9, 2024. An interview with the Assistant Director of Nursing (ADON) confirmed the presence of the expired medication in the cart, and the ADON acknowledged that nurses are responsible for discarding expired medications according to facility policy. The facility's policy on medication storage requires that expired, discontinued, and/or contaminated medications be removed from storage and disposed of properly.
Unsecured Medication Found in Resident's Room
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and allowed unauthorized access to medications, as observed in the case of a resident. The resident's ear wax removal kit was found unattended and unsecured on the nightstand at the bedside. This incident was noted during an observation when the resident was not present in the room. Interviews with the LVN and the DON confirmed that medications should not be left unattended in residents' rooms according to the facility's policy. The resident involved had a severe cognitive impairment with a BIMS score of 3 out of 15 and required assistance with daily activities. The resident's medical history included pneumonia, hypomagnesemia, cerebral vascular disease, heart failure, dementia, and hypertension. The LVN speculated that the medication might have been brought by the resident's family, but acknowledged the potential harm if the medication was used incorrectly by the resident or others. The facility's policy mandates that all medications, including over-the-counter and complementary and alternative medicine, be stored in a locked cabinet, cart, or medication room accessible only to authorized personnel.
Inaccurate Documentation of Wound Care
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, which is a violation of accepted professional standards. Specifically, the wound care nurse documented a deep tissue injury on the resident's right heel, when in fact, the injury was on the left heel. This discrepancy was identified during an observation and interview with the wound care nurse, who acknowledged the error and admitted that the incorrect documentation could lead to a lack of proper wound care or incorrect treatment. The resident involved was an elderly male with multiple medical conditions, including acute respiratory failure, anemia, type 2 diabetes mellitus, a stage 3 pressure ulcer in the sacral region, hypertension, and spinal stenosis. The resident's care plan and physician orders indicated the presence of a pressure injury on the left heel, which required specific wound care treatment. However, the initial skin evaluation incorrectly noted the injury on the right heel, leading to potential risks due to misinformation in the medical records. The Director of Nursing confirmed that the facility lacked a policy regarding medical record accuracy, although it was acknowledged that records should accurately reflect the residents' medical status.
Infection Control Deficiency Due to Improper Disposal of Medical Device
Penalty
Summary
The facility failed to establish and maintain an effective infection control program, as evidenced by the improper handling of a medical device used by a resident. During an observation, a suction tube Yankauer, which is an oral suction tool, was found on a resident's nightstand. The Yankauer was opened, covered in a plastic bag, connected to a suction machine, and appeared dirty with brown-colored residue. This device should have been discarded after use to prevent infection, as per the facility's policy on handling infectious waste. The resident involved was an elderly female with a history of atherosclerotic heart disease, cerebral infarction, epilepsy, major depressive disorder, and hypertension. She had moderate cognitive impairment and required partial assistance with oral hygiene. The facility's care plan indicated a potential for aspiration, necessitating suction as needed. Interviews with the LVN and DON confirmed that the Yankauer should have been discarded after each use, highlighting a lapse in following infection control protocols.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident, leading to a significant deficiency. The resident, who had a history of altered mental status, muscle weakness, depression, post-COVID-19 condition, and acute respiratory failure with hypoxia, was not monitored to ensure she was connected to continuous oxygen as per her physician's order. This oversight resulted in the resident being connected to an empty oxygen e-cylinder, causing her oxygen saturation levels to drop to the 60s, which was not accurately documented by the facility staff. The deficiency was further compounded by the facility's failure to document the resident's change of condition in her progress notes upon discovering she was not connected to continuous oxygen. Additionally, when the resident was transferred to a different location within the facility, she was not connected to an oxygen concentrator with a functioning humidifier. These lapses in care and documentation contributed to the resident's deteriorating condition, as observed by various staff and caretakers who noted her lethargy and inability to wake up or respond. Interviews with facility staff and caretakers revealed a lack of communication and oversight in ensuring the resident's oxygen needs were met. Despite being informed by caretakers and hospice staff about the resident's condition, the facility staff failed to take timely action to reconnect her to a functioning oxygen source. The Director of Nursing acknowledged the oversight and the facility's responsibility to provide adequate medical care, even with the presence of unlicensed caretakers. The deficiency was identified as an Immediate Jeopardy, indicating a severe lapse in care that required immediate attention.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 940 citations issued within 25 miles in the last 12 months — including the 20 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Broadway Nursing & Rehabilitation | 1.1 mi | ★★★★★ | 33 | 1 |
| The Village At Incarnate Word | 2 mi | ★★★★★ | 8 | 0 |
| Northeast Rehabilitation And Healthcare Center | 2.8 mi | ★★★★★ | 10 | 1 |
| Parklane West Healthcare Center | 2.9 mi | ★★★★★ | 13 | 0 |
| Castle Hills Rehabilitation And Care Center | 3.3 mi | ★★★★★ | 52 | 1 |
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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.