Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 San Antonio Wellness & Rehabilitation during CMS and state inspections, most recent first.
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.
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.
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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.
Illustrative
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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) |
|---|---|---|---|---|
| Trucare Living Centers - Selma | 4.6 mi | ★★★★★ | 11 | 0 |
| Windcrest Nursing And Rehabilitation | 4.8 mi | ★★★★★ | 12 | 0 |
| The Enclave | 4.9 mi | ★★★★★ | 20 | 0 |
| Advanced Rehabilitation & Healthcare Of Live Oak | 5.2 mi | ★★★★★ | 3 | 0 |
| Avir At Converse | 5.4 mi | ★★★★★ | 13 | 0 |
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