Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at San Antonio Wellness & Rehabilitation during CMS and state inspections, most recent first.
Food service staff failed to follow basic hygiene and sanitation practices during kitchen and dining room operations. The DNS and another staff member were observed without proper hair restraints and beard guards, and the soda/juice gun dispenser had dried juice and dark slime buildup. An LVN passed out silverware and ice to residents without washing or sanitizing hands, touched a resident, and wiped his nose with bare hands before continuing service. A Dietary Aide was also observed reusing gloves, wearing improper hair and beard coverings, and handling silverware and kitchen equipment without hand hygiene, while the DNS reentered the kitchen multiple times without washing hands.
A facility failed to label insulin pens with open dates and failed to keep a medication cart locked. Two residents with diabetes had insulin pens found in nursing carts without open dates, including one Lantus pen and one NovoLOG Mix 70/30 pen, and staff stated they would not know when to discard them without that information. In addition, an unlocked med cart was observed in a hallway near the nurse’s station during shift change with residents nearby, and staff confirmed carts should remain locked unless under direct and continuous supervision.
Incomplete Incontinence Care During Perineal Cleaning: A resident with severe cognitive impairment, an indwelling catheter, and total bowel incontinence did not receive complete perineal care when an LPN cleaned the penis, groin, scrotum, rectum, and right buttock but missed the left buttock area before applying a clean brief. The LPN said she forgot to clean that area, and the DON confirmed it should have been cleaned per facility policy.
Improper IV Line Flush Volume During Antibiotic Administration: An LVN administered IV Meropenem through a resident’s central line and flushed the medication port with 10 ml NS instead of the ordered 5 ml before and after medication administration. The resident had a central line for IV therapy related to osteomyelitis, along with severe cognitive impairment and dependence for transfers. The LVN stated she believed the order was for 10 ml, while the DON confirmed the ordered flush volume was 5 ml.
A resident with sleep apnea and an order for CPAP at night had her CPAP mask left uncovered on the nightstand when not in use. The LVN and DON stated the mask should have been stored in a plastic bag, and the facility policy required oxygen items to be kept in a plastic bag at the bedside when not in use.
Expired medication was found in a medication cart, and an insulin pen for a resident with DM2 was still being used past the labeled discard date. The medication aide confirmed using the expired product, and an LVN confirmed the insulin pen remained in use beyond 28 days after opening; the DON acknowledged both issues.
Infection control practices were not followed for two residents. A medication aide used a blood pressure cuff and machine on one resident after coming from another resident’s room without cleaning the equipment first, and a CNA changed gloves multiple times during peri care for another resident without washing or sanitizing hands between glove changes. The DON confirmed both staff actions were improper.
A resident with dementia and two Stage III pressure injuries to the left medial foot had physician-ordered wound care scheduled three times weekly, with treatments documented on the MAR throughout the month except for one treatment date. On that date, the MAR entries for both wound care orders were left blank. The treatment nurse reported being off that day, and an LVN who served as staffing coordinator stated she performed the wound care per the orders but forgot to document it and did not correct the omission later. Facility leadership and staff interviews confirmed that nurses are required to sign the MAR when treatments are completed and that documentation must be finished by the end of the shift, in accordance with the facility’s documentation policy.
A resident with severe cognitive impairment and dementia was moved from a rehabilitation unit to a secure unit without receiving written notice or explanation, and without notification or consent from her emergency contact. Facility leadership confirmed there was no signed consent or clear documentation of family notification, despite policy requiring resident and representative involvement in such decisions.
A resident with severe cognitive impairment and no documented exit-seeking behaviors was transferred to a secure unit without proper assessment, documentation, or physician order. Staff interviews indicated the resident was easily redirected and not at risk for elopement, while the family was not informed of the reason for the move. The care plan and risk assessments were updated only after the investigation began, resulting in a deficiency for involuntary seclusion.
Two residents with dementia and elopement risk were placed in a secure unit without complete or accurate physician orders reflecting their admission or secure unit placement. Medical records lacked timely documentation, and orders were either missing, discontinued without reason, or entered only after investigation began, contrary to facility policy requiring accurate and complete physician orders.
The facility did not report incidents of alleged abuse and misappropriation involving two residents within the required timeframes, failing to notify the administrator and state authorities as mandated by regulations.
A resident with multiple chronic conditions reported to the LSW that a CNA was rough during perineal care, did not stop when requested, and mocked her. The LSW documented and reported the grievance to the Administrator, but there was no evidence of a thorough investigation or state reporting, despite facility policy requiring such action for allegations of abuse or neglect.
A resident with severe cognitive impairment was involved in a physical altercation with another resident, but the care plan was not updated by the IDT to reflect this incident or address changes in behavior, despite facility policy requiring such updates after behavioral events.
The facility failed to maintain a safe environment by having patio doors that locked behind individuals, preventing re-entry without a code. This posed an entrapment risk for residents and staff, as observed in two patios. Interviews confirmed that not all residents knew the re-entry code, and the doors lacked signage for assistance.
A dietary aide in an LTC facility failed to follow proper hand hygiene protocols during meal preparation, handling food and utensils without changing gloves or washing hands between tasks. This non-compliance with the facility's Dining Services Standards posed a risk of cross-contamination and potential foodborne illness to residents.
A resident with minimal cognitive impairment and a history of diabetes and depression experienced a breach of privacy when a CNA entered his room without knocking during a discussion with a surveyor. The resident expressed feelings of insignificance, highlighting the importance of respecting residents' dignity and privacy. The facility's policy requires staff to treat residents with respect and dignity.
A resident with moderate cognitive impairment and complex medical conditions reported not receiving medications to several staff members, but no grievance was documented. The CNA and BOM involved were unaware of grievance procedures, and the LVN did not report the complaint, believing the medication was administered. The facility's grievance log lacked entries for the complaint, indicating a failure to follow grievance policy.
A resident with dysphagia was served potato chips, inconsistent with their mechanical soft diet, during lunch and dinner. Despite physician orders and SLP recommendations, facility staff, including the dietician and nursing directors, showed uncertainty about the dietary requirements. The facility's policy excludes such foods, highlighting a failure to meet the resident's dietary needs.
A resident with severe cognitive impairment and incontinence issues received care from an LVN who failed to follow proper infection control protocols. The LVN did not wash or sanitize her hands between glove changes and used her bare hand to turn off the faucet after washing. Despite regular training, these actions posed a risk for infection transmission, as confirmed by the DON.
Food Service Hygiene and Sanitation Lapses
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen and dining areas. During an initial kitchen observation on 02/17/2026, the DNS and another staff member were not wearing hair nets, and neither had beard guards covering facial hair. The commercial bar soda/juice gun dispenser handle also had dried juice buildup and dark slime on the inside of the handle. During the initial lunch service in one dining room on 02/17/2026, LVN-L was observed passing out silverware without sanitizing or washing hands first. LVN-L touched a resident while patting her on the back, then continued distributing silverware without washing or sanitizing hands. LVN-L was later observed pulling down his mask, wiping his nose with bare hands, and then putting ice into water cups and passing them to residents without washing or sanitizing his hands. On 02/19/2026, a Dietary Aide was observed going into and out of the kitchen wearing the same plastic gloves without sanitizing or washing hands or changing gloves. The Dietary Aide wore a baseball cap with hair visibly showing on the sides and back, did not wear a hair net, and had a face mask pulled down past his beard around his neck without covering the beard. The DNS was also observed exiting and reentering the kitchen on three separate occasions without washing his hands after reentering. During another observation, the Dietary Aide was seen rolling silverware in the dining room, entering the kitchen to demonstrate the dishwasher, and returning to the dining room without washing or sanitizing his hands. The DNS stated the juice dispenser was sanitized nightly and deep cleaned two times per month, but there was no cleaning log and he could not confirm who had cleaned it last.
Unlabeled insulin pens and unsecured medication cart
Penalty
Summary
The facility failed to ensure insulin and other biologicals were labeled in accordance with accepted professional principles and stored securely. Resident #36, a male with type 2 diabetes, influenza, and hypertension, had an order for Insulin Glargine 10 units subcutaneously each morning. On 02/18/2026, his Insulin Glargine pen was found in the 500 and 600-hall nursing cart with no open date. The pen label stated to discard after 28 days, and the DON stated the open date should have been written on the pen because staff would not know when to discard it without that date. Resident #21, a male with Alzheimer’s disease, type 2 diabetes, and hypertension, had an order for NovoLOG Mix 70/30 FlexPen 36 units subcutaneously daily with a hold parameter for blood sugar less than 100. On 02/18/2026, his insulin pen was found in the 200-hall nursing cart with no open date. The pen label stated to open and store at room temperature for 14 days. The DON stated the pen should have been discarded 14 days after opening and that without an open date staff would not know when to discard it. The DON also stated the facility did not have a specific insulin policy and was following professional guidelines. The facility also failed to keep a medication cart locked or under direct observation of authorized staff. On 02/19/2026, an unlocked medication cart was observed in the 300 hallway in front of the nurse’s station while charge nurses were in shift change and four residents were sitting about 6 feet away. The cart remained unsecured for more than 20 minutes until the ADON was notified and secured it. Interviews with nursing staff and the ADON confirmed that medication carts should always be locked unless directly and continuously supervised, and that the cart had been left unlocked during the shift change process.
Incomplete Incontinence Care During Perineal Cleaning
Penalty
Summary
The facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Resident #4 was a male with diagnoses including epilepsy, obstructive and reflux uropathy, benign prostatic hyperplasia, and Down syndrome. His MDS showed a BIMS score of 0 out of 15, indicating severe cognitive impairment, and he was dependent for transfers. The MDS also indicated he had an indwelling urinary catheter and was always bowel incontinent. The resident’s care plan directed staff to check him frequently and as required for incontinence, wash, rinse, and dry the perineum, change clothing as needed after incontinence episodes, and maintain catheter tubing and drainage bag. During observation, LVN-A provided incontinent care by cleaning the penis, groin, scrotum, rectum, and right buttock, but did not clean the resident’s left buttock area before placing a clean brief under him. LVN-A stated she forgot to clean the left buttock area and acknowledged it should have been cleaned to prevent possible infection even though it appeared visually clean. The DON stated the left buttock area should have been cleaned per facility policy.
Improper IV Line Flush Volume During Antibiotic Administration
Penalty
Summary
Resident #6 received intravenous antibiotic therapy through a central line for osteomyelitis and had diagnoses that included sepsis, peripheral vascular disease, and dysphagia. The resident’s significant change MDS assessment showed a BIMS score of 0 out of 15, indicating severe cognitive impairment, and the resident was dependent for chair-to-bed transfer. The care plan identified that the resident was on IV antibiotic therapy related to osteomyelitis and directed staff to administer medications as ordered. The physician order dated 01/21/2026 directed staff to flush the IV line with 5 ml normal saline before and after medication administration. During observation, LVN-B hung Meropenem 500 mg IV and flushed the medication port of the resident’s central line with 10 ml normal saline before connecting the medication. In interview, LVN-B stated she had flushed with 10 ml because she thought the order said 10 ml before and after medication, but acknowledged the order was for 5 ml. The DON stated LVN-B should have flushed with 5 ml normal saline as ordered and that following the physician order was the nurse’s responsibility.
Uncovered CPAP Mask Left at Bedside
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for Resident #77. The resident was a female with diagnoses including cellulitis of the left lower limbs, chronic pulmonary embolism, anemia, and sleep apnea. Her MDS assessment showed a BIMS score of 15 out of 15, indicating intact cognition, and she had an order to apply CPAP at night and as needed at bedtime for sleep apnea. On observation, Resident #77 was in bed watching television while her CPAP mask connected to the machine sat uncovered on the nightstand. The resident stated she used her CPAP every night when sleeping. The LVN and DON both stated the CPAP mask should have been covered in a plastic bag when not in use to prevent possible infection, and the facility policy for oxygen administration stated oxygen items are to be stored in a plastic bag at the resident's bedside when not in use.
Expired Medications and Overused Insulin Pen
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by allowing expired medications to remain in medication carts and by using an insulin pen beyond its labeled discard date. During observation, one bottle of Nutricia Pro-Stat was found inside the 400-500-600-hall medication aide cart even though it had expired on 01/02/2026. The medication aide confirmed she had opened it on 02/16/2026 and used it, and the DON stated expired medications should have been discarded. For Resident #73, who had diagnoses including muscle wasting and atrophy, anemia, and type 2 diabetes mellitus, the record showed an order for insulin glargine (Lantus) 10 units subcutaneously at bedtime and a BIMS score of 10 out of 15, indicating moderate cognitive impairment. Observation revealed the resident’s Lantus pen in the 200-hall nursing cart with an open date of 01/07/2026 and a label stating to discard after 28 days once opened. The LVN confirmed the pen was still being used nightly past the 28-day discard date, and the DON stated it should have been discarded on 02/04/2026 per the label.
Infection Control Lapses During Blood Pressure Check and Peri Care
Penalty
Summary
The facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 2 of 24 residents reviewed. Resident #106 was a male admitted with diagnoses including aftercare following amputation, heart failure, and type 2 diabetes mellitus. His admission MDS showed a BIMS score of 15 out of 15 and dependence for chair-to-bed and toilet transfers. A physician order directed blood pressure monitoring with parameters for holding metoprolol. During observation, Medication Aide-C came out of another resident’s room with a blood pressure cuff and machine and then entered Resident #106’s room and measured his blood pressure without cleaning the cuff and machine first. In interview, the medication aide stated she had used the equipment on another resident and should have cleaned it before using it on Resident #106. Resident #132 was a female admitted with diagnoses including cerebral infarction, type 2 diabetes mellitus, and hypertension. Her baseline care plan directed staff to monitor and document ADL abilities and assist as needed. During observation, CNA-F provided peri care, cleaned the resident’s groin and genital area, turned the resident to the side, and changed her gloves without washing or sanitizing her hands before continuing care. The CNA repeated the glove change without hand hygiene before cleaning the buttock and rectum area and again before placing a new brief. In interview, CNA-F stated she should have washed or sanitized her hands whenever she changed her gloves to prevent infection. The DON stated the medication aide should have cleaned the blood pressure cuff and machine before use and the CNA should have washed or sanitized her hands whenever she changed her gloves.
Failure to Document Wound Care Treatment on MAR
Penalty
Summary
The facility failed to maintain complete and accurate clinical records when a nurse did not document wound care treatment on a resident’s medication administration record (MAR) for a scheduled treatment date. The resident was an elderly female with encephalopathy, dementia, short- and long-term memory deficits, and severely impaired cognitive skills, and had two Stage III pressure injuries to the left medial foot (inferior and superior). Her care plan, initiated in 2023 and revised in 2025, included interventions for pressure ulcer prevention and treatment, including administering wound treatments as ordered and monitoring for effectiveness. The December 2025 MAR contained physician orders for wound care to both left medial foot pressure injuries three times weekly and PRN on the day shift, with documented initials on multiple dates throughout the month. Record review showed that for both wound care orders, the MAR entries were blank on 12/26/2025, indicating no documentation of treatment on that date. LVN A explained that when wound care is completed, the nurse signs the MAR, and a blank entry could indicate the treatment was not completed; she confirmed she provided wound care on an earlier date but was unsure if she was assigned to the resident on 12/26/2025. The treatment nurse stated she completed the resident’s wound care on 12/24/2025 and was off on 12/26/2025, and that charge or administrative nurses were responsible for wound care when she was off. LVN N, the staffing coordinator, stated she provided wound care to the resident on 12/26/2025 following the MAR orders but forgot to document the treatment, realized this after going home, was unable to access the record remotely, and then forgot to update the MAR the following day. The DON stated that when the treatment nurse is not scheduled, the charge nurse is responsible for wound care and that the nurse who completes the treatment must sign the MAR by the end of the shift, consistent with the facility’s documentation policy requiring completion of MAR/TAR entries with each medication or treatment.
Failure to Provide Written Notice Before Resident Room Change
Penalty
Summary
The facility failed to provide a resident with written notice, including the reason for a room or roommate change, prior to moving the resident from a rehabilitation unit to a secure unit. Record review showed that the resident, who had severe cognitive impairment and was an elopement risk due to dementia, was transferred without documentation of notification or consent from either the resident or her emergency contact. The care plan was updated to reflect the new placement, but there was no evidence of written or verbal communication regarding the change. Interviews with the resident's family member and emergency contact revealed that they were not informed about the room change and did not provide authorization. The family member only learned of the move after visiting the facility and did not receive any explanation or notification from staff. Facility leadership, including the DON and Administrator, confirmed that there was no signed consent for the room change and were unsure if the family was notified. The facility's policy requires residents to be informed of their rights and involved in care planning, but this was not followed in this instance.
Failure to Prevent Involuntary Seclusion Due to Improper Secure Unit Placement
Penalty
Summary
The facility failed to ensure that a resident was free from involuntary seclusion and physical restraint not required to treat medical symptoms. A female resident with severe cognitive impairment, dementia, and heart failure was admitted and later placed on a secure unit. Documentation showed that initial elopement risk assessments indicated no risk, and there was no evidence of behavioral symptoms such as wandering or exit-seeking prior to her transfer. The resident's care plan and medical record did not contain orders or clear documentation justifying her placement on the secure unit at the time of transfer. Interviews with staff, including CNAs and LPNs, revealed that the resident had not exhibited exit-seeking behaviors or attempts to elope. Staff described her as forgetful and easily redirected, with occasional wandering only when searching for misplaced items. The resident herself did not express distress about her placement and participated in activities, but her family was not informed about the reason for her move to the secure unit and requested her return to the general population. The care plan was updated to reflect elopement risk only after the investigation began, and the elopement risk evaluation with a moderate risk score was not completed or available in the electronic medical record until after the surveyor's inquiry. Facility leadership, including the ADON and DON, could not provide consistent or documented reasons for the resident's placement on the secure unit, and there was no physician order for the move. The facility's policy on wandering and elopement did not specify criteria or procedures for secure unit placement. The lack of proper assessment, documentation, and communication regarding the resident's transfer to the secure unit constituted a failure to protect the resident from involuntary seclusion.
Incomplete and Inaccurate Medical Records for Secure Unit Placement
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for two residents regarding their admission orders and secure unit placement. For the first resident, there were no active orders reflecting admission to the facility or to the secure unit at the time of review. The resident's elopement risk evaluation was not completed or available in the electronic medical record until after the investigation began, and the order for secure unit placement was only entered after the investigation was underway. Interviews with facility staff, including the DON and ADON, confirmed that there was no active admission order and that the move to the secure unit was not properly documented in the resident's orders, despite being care planned. For the second resident, a similar deficiency was identified. The resident's order summary and recap reports showed no active orders for facility admission or secure unit placement at the time of review. Previous orders for admission and secure unit placement had been discontinued without documented reasons, and late entries were made for prior skilled services. The care plan indicated that the resident was to reside in the memory care unit due to dementia and elopement risk, but this was not supported by current, active physician orders in the medical record. Both residents had significant medical histories, including dementia, heart failure, and psychiatric diagnoses, and were assessed as having varying levels of elopement risk. Despite these risks and the need for secure unit placement, the facility did not maintain complete and accurate physician orders in accordance with accepted professional standards. The facility's own policy required that physician orders be complete, accurate, and maintained in the resident's medical record, but this was not followed for these two residents.
Failure to Timely Report Alleged Abuse and Misappropriation
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or misappropriation were reported within the required timeframes. Specifically, for two of six residents reviewed, the facility did not report an incident of misappropriation involving a missing gold diamond necklace for one resident, nor did it report an incident of alleged abuse for another resident, both within the mandated reporting periods. These incidents were identified through interviews and record reviews, which showed that the facility did not notify the administrator and appropriate state authorities immediately, or within the required two-hour or 24-hour windows, as specified by regulations. The deficiency centers on the facility's failure to follow established procedures for timely reporting of suspected abuse and misappropriation events.
Failure to Investigate Allegation of Rough Care and Mistreatment
Penalty
Summary
The facility failed to provide evidence that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one resident. A resident with a history of chronic medical conditions, including COPD, depression, and morbid obesity, reported to the Licensed Social Worker (LSW) that a CNA was rough during perineal care, did not stop when asked, and made fun of her. The resident described specific actions by the CNA, such as improper placement of a brief, rough handling, and mocking gestures. The LSW documented the grievance and reported it to the Administrator, as per facility protocol. However, there was no evidence that the facility conducted a thorough investigation into the resident's allegations. The Administrator acknowledged receiving the grievance but did not report the incident to the state or conduct further investigation, citing the resident's history of false reporting and satisfaction with the resolution of not having the CNA assigned to her care. The facility's records and interviews confirmed that no self-reported incidents were filed, and the facility's policy on abuse and neglect investigation was not followed in this case.
Care Plan Not Updated After Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team following both comprehensive and quarterly assessments, as required. Specifically, after a resident with severe cognitive impairment and a history of dementia and anxiety disorder was involved in a physical altercation with another resident, the care plan was not updated to reflect this incident of resident-to-resident aggression. The care plan did not include any interventions or documentation related to aggression or altercations, despite the occurrence of a significant behavioral event. Interviews with facility staff revealed that although the incident was discussed in morning meetings and the care plan for the other resident involved was updated, the care plan for this resident was not revised. The MDS Coordinator responsible stated that because the resident did not experience psychological trauma or significant physical injury, the care plan was left unchanged. Facility policy required the care plan to be revised to address changes in behavior and care, but this was not followed in this case.
Entrapment Risk Due to Locked Patio Doors
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and that residents received adequate supervision to prevent accidents. This deficiency was observed in two of the three patios reviewed for entrapment and lack of supervision. Specifically, the secured enclosed patios by the 100-300 and 400-600 hall dining rooms had doors that allowed exit but locked behind anyone who exited, preventing re-entry without a code. This posed a risk of entrapment for residents, staff, and the public, as the doors lacked signage with a phone number or access code for re-entry. During observations, it was noted that residents, including one who used a rollator walker, could access these patios without knowing the re-entry code. Interviews with staff, including the ADON and Maintenance Director, confirmed that the doors were designed to lock behind individuals, and not all residents were aware of the code to re-enter. The Maintenance Director acknowledged the risk and stated that the facility leadership had decided to remove the locks to allow free movement in and out of the patios.
Failure in Hand Hygiene During Meal Preparation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the area of hand hygiene during meal preparation. During an observation, a dietary aide (DA) was seen handling food items and kitchen utensils without changing gloves or washing hands between tasks. The DA carried a bag of hamburger buns from the pantry, placed them on the counter, and then handled a sandwich and a knife without removing gloves or washing hands. This sequence of actions was repeated when the DA retrieved a loaf of bread and cheese from the pantry, prepared a sandwich, and placed it on the griddle, again without changing gloves or washing hands. Interviews with the DA and the Director of Nursing Services (DNS) confirmed that the DA was aware of the proper hand hygiene protocols but failed to follow them, acknowledging the risk of cross-contamination and potential illness to residents. The facility's policy on Dining Services Standards, revised in December 2022, clearly outlines the requirement for hand hygiene and glove use, emphasizing the need to remove gloves and wash hands when leaving and returning to the work area. Despite this training, the DA's actions did not align with the established procedures, posing a risk of foodborne illness to residents.
Failure to Respect Resident's Privacy and Dignity
Penalty
Summary
The facility failed to uphold the dignity and privacy of a resident, identified as Resident #48, during an interaction with a surveyor. While the resident was discussing medical concerns with the surveyor, a CNA entered the room without knocking, interrupting the conversation. This action led the resident to express feelings of insignificance and a lack of privacy, stating that it felt as though he did not matter in his own room. Resident #48, who has a history of Diabetes Mellitus with Diabetic Neuropathy and Major Depressive Disorder, was noted to have minimal cognitive impairment and valued his autonomy in choosing daily activities. The CNA admitted to not knocking before entering, believing the resident was aware of his return with water. The Director of Nursing acknowledged the incident as a dignity and privacy issue, emphasizing the expectation for staff to knock before entering residents' rooms. The facility's policy on resident rights, revised in 2020, mandates respect and dignity for all residents, ensuring they can exercise their rights without interference.
Failure to Document and Address Resident Grievance
Penalty
Summary
The facility failed to ensure that residents could voice grievances without fear of discrimination or reprisal, as evidenced by the case of a resident who alleged she did not receive her medications on a specific date. The resident, who was assessed with moderate cognitive impairment and had complex medical conditions, reported her grievance to multiple staff members, including a Licensed Vocational Nurse (LVN), a Certified Nursing Assistant (CNA), and the Business Office Manager (BOM). Despite these reports, no grievance was documented, and the resident did not receive assistance in filing a grievance report. Interviews with staff revealed a lack of awareness and adherence to the facility's grievance policy. The CNA who received the complaint was unaware of the grievance procedures and did not assist the resident in filing a report. The BOM, who was informed of the complaint, did not document it as a grievance, believing it was unnecessary since the medication administration record indicated the medications were given. The LVN, who was directly involved, also failed to document the complaint or report it to a superior, as he believed the medication had been administered and the resident's allegation did not constitute neglect. The facility's grievance logbook did not contain any entries for the resident's complaint, indicating a systemic failure to document and address grievances as per the facility's policy. The Director of Nursing (DON) expressed surprise at the staff's failure to follow procedures, despite previous in-service training on grievances. The administrator, who serves as the grievance officer, confirmed that he had not received any grievance report regarding the resident's complaint, highlighting a breakdown in the facility's grievance handling process.
Failure to Provide Appropriate Mechanical Soft Diet
Penalty
Summary
The facility failed to ensure that a resident with specific dietary needs received food prepared in a form designed to meet those needs. The resident, who was on a mechanical soft diet due to dysphagia and other medical conditions, was served potato chips during both lunch and dinner. This was contrary to the physician's orders and the Speech Language Pathologist's (SLP) recommendations, which specified a mechanical soft diet. Observations confirmed that the resident consumed meals that included potato chips, which are not consistent with the mechanical soft diet requirements. Interviews with facility staff revealed discrepancies in understanding the dietary needs of the resident. The SLP expressed that potato chips were not suitable for a mechanical soft diet, while the dietician believed they were acceptable. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) also expressed uncertainty about the appropriateness of potato chips for the resident's diet. The facility's policy on mechanical soft diets explicitly excludes hard, crunchy foods like potato chips, indicating a failure to adhere to established dietary guidelines for residents with swallowing difficulties.
Infection Control Lapse During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A during the provision of incontinent care to a resident. The resident, a male with severe cognitive impairment and incontinence issues, was observed receiving care from LVN A, who did not adhere to proper hand hygiene protocols. Specifically, LVN A did not wash or sanitize her hands between glove changes after removing the resident's soiled brief and before handling a clean brief. Additionally, she used her bare hand to turn off the faucet after washing her hands, which is against infection control practices. During interviews, LVN A acknowledged her lapses in hand hygiene and glove changes, recognizing the potential for infection transmission. The Director of Nursing (DON) confirmed that these actions posed a risk for spreading infections. Despite having received regular training and competency validation in hand hygiene, LVN A did not follow the facility's infection control policies, which emphasize the importance of handwashing and avoiding contact with clean items after handling soiled materials.
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 824 citations issued within 25 miles in the last 12 months — including the 14 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) |
|---|---|---|---|---|
| Trucare Living Centers - Selma | 3.2 mi | ★★★★★ | 11 | 0 |
| Advanced Rehabilitation & Healthcare Of Live Oak | 4 mi | ★★★★★ | 4 | 0 |
| Avir At Converse | 4.5 mi | ★★★★★ | 12 | 0 |
| Windcrest Nursing And Rehabilitation | 4.7 mi | ★★★★★ | 0 | 0 |
| Crestway Nursing & Rehabilitation | 4.9 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for San Antonio Wellness & Rehabilitation.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.