Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Lev At San Antonio during CMS and state inspections, most recent first.
Surveyors found one of four medication carts, the MA Med Cart for 500 Hall, unlocked while a medication aide was putting items away and preparing for shift change, despite facility policy requiring all drugs and biologicals to be stored in locked compartments accessible only to authorized personnel. The MA acknowledged the cart should not have been left unlocked due to resident safety concerns, and the ADON confirmed the cart should have been locked to prevent unauthorized access.
Surveyors found that medication and treatment carts containing drugs and biologicals were left unlocked and unattended by nursing staff, contrary to facility policy and professional standards. Interviews with LVNs and the DON confirmed that carts should have been locked when not in use, but this protocol was not followed, resulting in unsecured access to medications.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Two residents experienced a lack of dignified care and communication when staff failed to communicate in a language understood by a quadriplegic resident during personal care, and nursing staff did not document or respond to another resident's reports of numbness and chest pain. Both residents felt ignored and disrespected, with one questioning her importance after her health concerns were not addressed.
A resident with intact cognition and multiple psychiatric and neurological diagnoses was not informed about the care plan for a facial laceration sustained during surgery. Despite expressing concern about scarring and a preference for ointment, the resident was not told by the Wound Care Nurse that no new treatment orders were in place. Facility policy requires residents to be informed and involved in their care, but this did not occur in this case.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve complaints.
A resident with a new diagnosis of Bipolar II Disorder did not receive a required PASARR Level I screening after admission. The initial PASARR did not reflect the mental health diagnosis, and staff interviews revealed uncertainty about the need for a new screening when new diagnoses are identified. Facility policy requires prompt referral for further review when a serious mental disorder is newly evident.
A resident with moderate cognitive impairment and multiple diagnoses experienced uncontrollable nausea and vomiting during her menstrual cycles, but this was not reflected in her comprehensive care plan. Despite staff awareness and a standing order for Zofran, the care plan was not updated by the interdisciplinary team after assessments, and the facility could not provide a policy on care plan updates when requested.
Two residents did not receive care in accordance with professional standards and their preferences: one resident's facial laceration was not treated or communicated about despite her concerns, and another resident's reports of numbness and chest pain were not properly assessed, documented, or reported by LVNs, resulting in missed physician notification and lack of follow-up.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A medication aide administered prescribed medications to a resident 51 minutes past the scheduled time without notifying the charge nurse, resulting in a medication error rate of 7.14%, which exceeds the required threshold. The resident had diabetes with neuropathy and GERD, and the late administration was due to the resident receiving a bath at the scheduled time.
A nurse failed to disinfect a glucometer between uses on two residents, both with diabetes and sepsis, despite facility policy requiring disinfection after each use. The nurse performed hand hygiene but did not clean the device before attempting to use it on a second resident, and the DON confirmed that staff are expected to use approved chemical wipes for bloodborne pathogens between each use.
The facility did not post the most recent survey results in a location accessible to residents, family members, and legal representatives. The survey results binder available in the public area contained outdated information, omitting the latest recertification survey findings, despite facility policy requiring the most current results to be posted.
A facility failed to maintain a clean and comfortable environment due to persistent adhesive glue seeping from under the flooring, resulting in dirty, sticky floors and matted debris on medication cart wheels. Despite repeated cleaning efforts and contractor interventions, the issue persisted, affecting a resident who used a wheelchair and leading to ongoing unsanitary conditions.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with multiple complex diagnoses was discharged without a physician's order or a completed discharge summary. Staff confirmed that required documentation was missing, and facility policy requiring a discharge summary to the receiving provider was not followed.
A resident with multiple diagnoses, including autistic disorder and diabetes, was discharged to another facility without the required notification being sent to the State Long-Term Care Ombudsman. The social worker responsible for this task was unaware of the notification requirement, and the administrator confirmed that the Ombudsman had not been informed, contrary to facility policy.
The facility failed to ensure timely follow-up medical care for two residents, leading to significant health complications. One resident experienced a delay in esophageal stent removal, resulting in the stent migrating into the stomach, while another resident missed a cardiology follow-up, leading to hospitalization for heart issues. The deficiencies were due to inadequate processes for managing medical appointments.
The facility failed to store, prepare, and serve food according to professional standards, with deficiencies noted in the storage of cookies, shortening, and coffee filters on the floor, uncovered condiment cups in the cooler, and improperly sealed and labeled food items in the walk-in cooler and freezer. These lapses could risk foodborne illnesses.
The facility failed to provide education and offer influenza vaccinations to three residents during the designated period, despite having a policy to do so. This oversight was confirmed through interviews and record reviews, revealing a lack of documentation in the residents' immunization records. The residents had various medical conditions, increasing their vulnerability to influenza.
A facility failed to support a resident's transportation needs for non-medical appointments, impacting his ability to explore benefits related to his blindness. Despite having intact cognition and being dependent on staff, the resident missed several important appointments due to the facility's policy of only arranging transportation for medical appointments. Staff interviews revealed concerns about the lack of support, and the facility's actions were inconsistent with the resident's rights as outlined in the admission agreement.
A resident with COPD, anxiety, and mood disorder expressed concerns about not receiving information on an oncology appointment. Despite communicating this to staff, including an LVN and a medication aide, no grievance report was initiated. The facility's grievance policy was not followed, leading to the resident's grievance being unaddressed.
A resident's drug regimen was not properly monitored for side effects and behaviors associated with their prescribed medications, including olanzapine, busPIRone, and sertraline. Despite the care plan's requirement for monitoring every shift, the medication administration record lacked sections for such monitoring. Interviews confirmed no observed side effects, but the facility's failure to adhere to its policy placed the resident at risk.
A facility failed to maintain accurate clinical records for a resident when an LVN did not document the administration of hydrocodone-acetaminophen on the medication administration record, despite recording it on the narcotic counting sheet. The LVN attributed this oversight to her inexperience and workload. The resident, who was cognitively intact, had a history of multiple health conditions. This documentation failure posed a risk of incorrect medication administration.
A facility failed to accurately reflect a resident's behavioral symptoms in the MDS assessment. Despite a documented incident of aggression, the MDS was coded as if no such behavior occurred. The resident, with a history of schizoaffective and anxiety disorders, was cognitively intact. The social worker admitted to the coding error, and the MDS nurse acknowledged the potential for inadequate care due to this inaccuracy.
A facility failed to properly secure a narcotic box containing Lorazepam in the medication room's refrigerator, as it was not permanently affixed. This oversight was confirmed by the DON and violated the facility's policy for storing Schedule II controlled medications. The resident involved had a prescription for Lorazepam to manage anxiety and agitation.
Unlocked Medication Cart on 500 Hall
Penalty
Summary
Surveyors identified a deficiency related to medication storage when, during observation of one of four medication carts (the MA Med Cart for 500 Hall) on 3/16/2026 at 1:54 p.m., the cart was found unlocked. In an interview at 1:56 p.m., the medication aide assigned to that cart confirmed it was unlocked and explained it was left that way because she was putting items away and preparing for a shift change to another hall. She acknowledged that the cart should not be unlocked because it would be unsafe for residents to have access to the medications. In a subsequent interview on 3/19/2026 at 10:04 a.m., the ADON stated the medication cart should have been locked to prevent unauthorized access and for resident safety. Review of the facility’s “Medication Storage” policy showed that all drugs and biologicals are required to be stored in locked compartments, with access to keys limited to authorized personnel, indicating the unlocked cart was not in compliance with facility policy. No specific residents, medical histories, or clinical conditions were mentioned in relation to this incident in the report.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
Surveyors observed that the facility failed to ensure all drugs and biologicals were stored securely in accordance with professional standards. Specifically, the nurse treatment cart was found unlocked, unattended, and unsupervised, containing various wound care medications such as miconazole antifungal powder, collagenase enzyme paste, hypochlorous acid solution, and other wound care products. Interviews with two LVNs confirmed that the cart was left unlocked, with one stating the keys were left by the nurse’s station and acknowledging that the cart should have been locked. The facility’s own policy requires all medications to be stored in locked compartments, but this was not followed in these instances. Additionally, a medication cart on the 400 hall was observed unlocked and unattended while a nurse was administering medications in a resident’s room. The nurse admitted the cart should have been locked when unattended. The Director of Nursing confirmed the expectation that medication carts be locked when not in use and acknowledged the risk if this protocol is not followed. These observations and staff interviews demonstrate a failure to adhere to the facility’s medication storage policy.
Failure to Follow Professional Standards for Food Procurement and Service
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Ensure Dignified Care and Communication for Residents
Penalty
Summary
The facility failed to ensure that residents' rights to a dignified existence, self-determination, and effective communication were upheld for two residents. One resident, who was completely dependent on staff due to quadriplegia and had no cognitive impairment, reported feeling disrespected and demoralized when staff providing incontinent care communicated only in Spanish, a language she did not understand. Despite her care plan specifying that staff should converse with her during care, bilingual and Spanish-only speaking CNAs conversed with each other in Spanish and did not translate their communication for the resident. The resident expressed frustration and a sense of isolation, as she was unable to communicate her needs or preferences effectively, particularly regarding the quality of her care. Another resident, with a history of cardiomyopathy, diabetes, and moderate cognitive impairment, reported experiencing numbness in her left arm and leg, as well as chest pain, to both day and night nursing staff. Despite these reports, there was no documentation in the resident's progress notes regarding these symptoms, nor evidence that nursing staff assessed her, notified a physician, or took further action. The resident expressed feelings of sadness and questioned whether she mattered, as she had not received feedback or follow-up from the nursing staff regarding her health concerns. Interviews with facility leadership confirmed that staff did not follow established policies requiring communication in a language residents understand and prompt reporting and documentation of changes in condition. The Director of Nursing acknowledged that the lack of action in response to the resident's reported symptoms was inappropriate and could have jeopardized the resident's health. The facility's own policies emphasized the importance of respect, dignity, and communication, but these were not followed in the care of the two residents involved.
Failure to Inform Resident of Care Plan for Facial Laceration
Penalty
Summary
The facility failed to ensure that a resident was informed and involved in decisions regarding care for a facial laceration sustained during a surgical procedure. The resident, who had diagnoses including schizoaffective disorder, bipolar disorder, and Parkinson's disease but demonstrated intact cognition with a BIMS score of 14, reported not being told about the care plan for the cut on her face. She expressed concern about potential scarring and a preference for ointment, but stated that the nurse had not communicated any plan of care. The Wound Care Nurse confirmed that while the resident's physician was notified and no new orders were given, she did not inform the resident about the absence of new treatment orders for the laceration. The Director of Nursing (DON) indicated that the facility's process should include completing a risk management form and notifying relevant parties, but acknowledged that she was not informed about the laceration because it was considered a scab. Facility policy requires that residents be informed of and participate in their treatment, including being told about risks, benefits, and alternatives. In this instance, the resident was not provided with information or choices regarding the treatment of her facial laceration, resulting in a failure to honor her right to self-determination and informed participation in her care.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address and resolve resident complaints in a timely and non-retaliatory manner.
Failure to Complete PASARR Screening After New Mental Health Diagnosis
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program for a resident who was newly diagnosed with a serious mental disorder. Specifically, a resident was admitted with diagnoses including Bipolar II Disorder, end stage renal disease, and type 2 diabetes mellitus. The resident's diagnosis of Bipolar II Disorder was documented after the initial PASARR screening, which did not reflect this mental health diagnosis. Despite the new diagnosis, there was no evidence that a subsequent PASARR Level I screening was completed as required by facility policy. Interviews with facility staff revealed uncertainty regarding the need for a new PASARR screening when a new mental health diagnosis is identified after admission. The social worker, who recently assumed responsibility for PASARR oversight, was unsure if a new screening was necessary in such cases. The DON stated that it was expected for PASARR screenings to be completed upon receipt of a new diagnosis and acknowledged that failure to do so could result in residents not receiving appropriate services. Review of the facility's policy confirmed that residents with newly evident or possible serious mental disorders should be promptly referred for a Level II review.
Care Plan Not Updated for Resident's Menstrual-Related Nausea and Vomiting
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a female resident with a history of hypoglycemia, bipolar disorder, and type 2 diabetes mellitus was reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly reviews. Specifically, the care plan did not include information regarding the resident's uncontrollable nausea and vomiting during her menstrual cycles, despite this being a recurring issue noted by both nursing and medical staff. The resident had a moderate cognitive impairment, as indicated by a BIMS score of 11, and there was a standing order for Zofran to address her symptoms. Interviews with facility staff, including an LVN, a nurse practitioner, and the DON, confirmed that the resident experienced frequent uncontrollable nausea and vomiting during her menstrual cycle, and that this should have been documented in her care plan. The absence of this information in the care plan meant that other staff might not be aware of the resident's symptoms, potentially leading to misdiagnosis. Additionally, when requested, the facility was unable to provide a policy on updating care plans prior to the survey team's exit.
Failure to Provide Timely Care and Notification for Change of Condition and Wound Management
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards and residents' preferences for two residents. One resident with a history of schizoaffective disorder, bipolar disorder, and Parkinson’s disease developed a facial laceration after surgery. Although the wound care nurse assessed the injury and was aware of the resident’s concern about potential scarring, no wound care orders were documented or implemented, and the resident was not informed of the care plan. The resident expressed a preference for ointment to prevent scarring, but her concerns were not addressed, and the physician was not properly notified until after surveyor intervention. Another resident with diagnoses including cardiomyopathy and type 2 diabetes with diabetic polyneuropathy reported episodes of numbness in her left arm and leg, as well as chest pain, to multiple nurses. Despite these symptoms representing a significant change in condition, the nursing staff did not document the events, notify the physician or responsible party, or complete a change of condition evaluation. Interviews revealed that the nurses believed the concerns had been addressed by other staff or by lab orders, but there was no communication or documentation to confirm this. The nurse practitioner stated she was not informed of the numbness or chest pain and would have taken further action if she had been notified. The facility’s policy requires prompt notification of the physician and responsible party in the event of significant changes in a resident’s condition, including life-threatening symptoms or clinical complications. In both cases, the required notifications, assessments, and documentation were not completed, resulting in a lack of appropriate care and communication regarding the residents’ conditions and preferences.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Medication Error Rate Exceeds 5% Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, during medication administration observations. Out of 28 medication administration opportunities, there were 2 errors, resulting in a 7.14% medication error rate. Specifically, a medication aide administered metoclopramide and gabapentin to a resident 51 minutes past the prescribed administration window. The aide did not notify the charge nurse about the late administration, which was outside the facility's policy of administering medications within one hour before or after the scheduled time. The resident involved had diagnoses including diabetes mellitus with diabetic neuropathy and gastro-esophageal reflux, and was assessed as having intact cognition. The resident's care plan and physician orders specified the timing and dosage for the medications. The delay occurred because the resident was receiving a bath at the scheduled time, and the aide chose to return later without informing supervisory staff. Facility policy and interviews confirmed that this timing exceeded the acceptable administration window and constituted a medication error.
Failure to Disinfect Glucometer Between Residents
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, specifically regarding the disinfection of glucometers between resident uses. During an observation, an LVN used a glucometer to assess the blood sugar level of one resident and, without disinfecting the device, proceeded to use the same glucometer on another resident. The LVN performed hand hygiene but did not disinfect the glucometer before attempting to assess the second resident. The state surveyor intervened before the second resident's blood was drawn. During interviews, the LVN acknowledged the failure to disinfect the glucometer and recognized the risk of cross contamination. The DON confirmed that the facility's expectation was for staff to disinfect glucometers between each resident use with an approved chemical wipe for bloodborne pathogens. Record reviews showed that both residents involved had diagnoses including diabetes and sepsis, and both were receiving insulin injections per physician orders. The facility's policy on glucometer disinfection required cleaning and disinfecting the devices after each use and according to the manufacturer's instructions for multi-resident use. The deficiency was identified through observations, interviews, and record reviews, which confirmed that the facility did not follow its own written standards, policies, and procedures for infection control regarding glucometer disinfection.
Failure to Post Most Recent Survey Results in Accessible Location
Penalty
Summary
The facility failed to post the results of its most recent recertification survey in a location that was readily accessible to residents, family members, and legal representatives. During an observation and record review, it was found that the survey results binder, located by the receptionist desk in the public common area, only contained survey results up to February 2024. However, a review of the Texas Unified Licensure Information Portal (TULIP) indicated that the most recent recertification survey was conducted in August 2024, and these results were not included in the binder. During an interview, the Administrator confirmed that it was facility policy to keep the most recent survey results in the binder and accessible to the public. The Administrator acknowledged responsibility for ensuring the binder was up to date and stated she was unaware that the most recent survey results were missing. The facility's policy was reported to follow HHSC guidelines, but the omission of the latest survey results was confirmed through both observation and record review.
Failure to Maintain Clean and Sanitary Environment Due to Flooring Adhesive Issues
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment due to ongoing issues with flooring adhesive seeping from under the tiles, resulting in dirty and sticky floors. Observations over several days revealed that the glue was oozing out, causing the floors to collect hair and debris, which also accumulated on the wheels of medication carts. The Housekeeping Director confirmed that cleaning and mopping efforts were ineffective in containing the glue, and that the problem had persisted since the flooring was installed about a year prior. The issue was further corroborated by a resident who reported that the sticky floors caused debris to stick to his wheelchair and hands as he propelled himself. A review of the facility's correspondence with the flooring contractor documented multiple unsuccessful attempts to address the adhesive problem, including cleaning, buffing, and re-gluing the floors. The contractor acknowledged that the glue provided by the manufacturer was faulty and that the issue had not been resolved despite repeated interventions. The Administrator confirmed awareness of the problem and ongoing coordination with the contractor to find a solution. The deficiency was identified through observations, interviews, and record reviews, and was found to affect the cleanliness and safety of the facility's environment.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details regarding specific residents, staff actions, or the circumstances leading to the deficiency are provided in the report.
Failure to Document Physician Discharge Order and Summary
Penalty
Summary
The facility failed to properly document the discharge of a resident, as required by policy and regulatory standards. Specifically, there was no physician's order for the resident's discharge, nor was there a completed discharge summary by either the physician or nursing staff. The resident, who had diagnoses including autistic disorder, trisomy 21-mosaicism, and type 2 diabetes with hyperglycemia, was discharged with only a brief progress note indicating the resident left in good spirits via gurney with EMT and that all belongings were taken. However, the electronic medical record lacked both the required discharge order and summary. Interviews with facility staff, including the ADON and MDS Nurse, confirmed that the necessary documentation for the discharge was not completed. The ADON acknowledged awareness of the requirements for a physician's discharge order and a discharge summary, but these were not present in the resident's record. Review of facility policy indicated that a discharge summary should be provided to the receiving care provider, including an overview of the resident's stay and a final summary of their status at discharge, but this was not done in this case.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to provide required notification to the Office of the State Long-Term Care Ombudsman regarding the discharge of a resident. Record review showed that the resident, who had diagnoses including autistic disorder, trisomy 21-mosaicism, and type 2 diabetes with hyperglycemia, was cognitively intact and had requested alternate nursing facility placement. The resident was discharged to another nursing facility, but the Ombudsman did not receive written notification of this discharge. Interviews with facility staff revealed that the social worker, who was responsible for sending discharge notifications to the Ombudsman, was unaware of the notification requirement at the time of the resident's discharge. The administrator confirmed that the Ombudsman had not been notified, and acknowledged the importance of this notification for proper discharge procedures. Facility policy required that discharge summaries be available for release to authorized persons and agencies, with the resident's consent, but this process was not followed in this instance.
Failure to Schedule Timely Medical Follow-Ups
Penalty
Summary
The facility failed to ensure that two residents received timely follow-up medical care as recommended by their healthcare providers, leading to significant health complications. Resident #22, a male with a history of esophageal obstruction and other related conditions, was discharged with instructions to have an esophageal stent removed within 4-6 weeks. However, the facility did not schedule the follow-up appointment until 10 weeks later, by which time the stent had migrated into the stomach, necessitating an unplanned removal procedure that caused traumatic dilation of the esophagus. Similarly, Resident #5, a female with a history of hypertension, atrial fibrillation, and myocardial infarction, was discharged with instructions to follow up with a cardiologist within 1-2 weeks. The facility failed to schedule this appointment, and the resident did not see a cardiologist until a hospitalization several months later for heart health issues. The delay in follow-up care was attributed to a failure in the facility's process for managing medical appointments, as the necessary paperwork was not uploaded correctly, and the appointment was not rescheduled after being canceled. Interviews with facility staff, including the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs), revealed a lack of clarity and responsibility in scheduling follow-up appointments. The DON acknowledged that the facility should have intervened to ensure timely appointments and that the nursing staff should have been responsible for making these appointments. The failure to adhere to professional standards of practice in scheduling necessary medical follow-ups placed residents at risk for delayed treatment and diminished quality of care.
Removal Plan
- Resident #22 was assessed by licensed nurse, no adverse reactions noted.
- Resident #5 was assessed by licensed nurse, no adverse reactions noted.
- Licensed nurses physically present were educated in person regarding the community process for scheduling consults and medical appointments. Training conducted by DON and/or ADON.
- Licensed nursing staff not physically present, to include those that are PRN and on leave, were contacted by the Administrator, ADON and/or DON via phone and provided education regarding the communities process on scheduling consults and medical appointments.
- All licensed staff will be required to have training on community process of resident appointments before assuming resident care responsibilities.
- Licensed nurse, ADON and/or DON will review documentation from the hospital to confirm appointments are scheduled in the timeframe requested for new residents.
- Upon return from appointments, Licensed nurse, ADON and/or DON will review documentation from resident appointments to confirm appointments are scheduled in the timeframe requested if follow up is documented for current residents.
- Once documentation is reviewed, the Licensed Nurse, ADON or DON will enter an order into Point Click Care that will include the appointment details per the documentation received from the hospital and/or the appointment.
- DON and/or ADON will review orders the following business day and ensure that appointments are made per the recommendations of the physician.
- DON, ADON or Licensed Nurse will enter progress note after appointment is confirmed to ensure staff have the details for the appointment.
- If doctor/clinic is unable to coordinate in the specified timeframe, DON, ADON or Licensed Nurse will work with the resident/family and physician to locate a different provider that can accommodate their needs if physician deems necessary.
- If an appointment is made outside of the timeframe requested by the physician, the DON, ADON or Licensed Nurse will enter a progress note explaining the reason for the delay and confirm attending physician.
- The DON, ADON, MDS Coordinator or other designee will review re-admission paperwork as a secondary review from admitting nurse to ensure that residents care is followed up.
- When the community is notified of a cancelled appointment, they will follow the process and enter a new order into PCC, stating that appointment was cancelled and needs to be rescheduled.
- Appointments will be maintained in a calendar book to be located at nurses' station for appointment tracking.
- DON, ADON or other designee will be responsible for ensuring calendar is up to date and will be reviewed no less than three times a week.
- The process outlined above was reviewed by the Director of Nursing, Nursing Home Administrator and Medical Director during an Ad Hoc QAPI meeting.
- The Administrator will be responsible for monitoring the above actions for compliance which will be an ongoing process.
- The Administrator will complete an audit no less than one time per month and a report of findings will be reported to the facility's QAPI committee no less than one time per month for six months.
Deficiencies in Food Storage and Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. Several deficiencies were noted, including improper storage of food items in the dry storage room, where cases of cookies, shortening, and coffee filters were found on the floor. This was contrary to the facility's policy, which requires items to be stored at least six inches above the floor to prevent contamination. Interviews with staff revealed that the items were not on the floor when the dietary manager last checked, indicating a lapse in maintaining proper storage practices. In the reach-in cooler, disposable condiment cups of salsa and butter were found uncovered, lacking lids or plastic wrap. This oversight could lead to potential cross-contamination, as confirmed by the dietary manager during an interview. Additionally, in the walk-in cooler, several food items, including a pan of cake, a bag of sliced turkey breast, a container of whipped topping, and a bag of boiled eggs, were not covered or labeled with a use-by date. The facility's policy mandates that all refrigerated foods be tightly sealed and labeled to ensure freshness and prevent contamination. Further inspection of the walk-in freezer revealed two bags of food, identified as biscuits and chocolate chip cookies, that were not properly sealed or labeled. The facility's policy requires that all frozen foods be stored in moisture-proof wrap or containers with appropriate labeling. The dietary manager acknowledged that the responsibility for labeling and sealing these items lay with the dietary aide or cook who returned them to the freezer. These lapses in food storage and labeling practices could place residents at risk for foodborne illnesses.
Failure to Offer Influenza Vaccination and Education
Penalty
Summary
The facility failed to develop and implement policies and procedures to ensure that residents or their representatives received education regarding the benefits and potential side effects of the influenza immunization. This deficiency was identified for three residents who were reviewed for the influenza vaccine offering. The facility did not provide the necessary education to these residents, which is a critical step before offering the vaccine. The report highlights that the facility did not offer the influenza immunization to the three residents during the designated period from October 1 through March 31. This oversight was confirmed through interviews and record reviews, which showed that the residents' immunization records lacked documentation of the vaccine being offered or declined. Additionally, the facility's policy, which mandates offering the influenza vaccine annually, was not followed for these residents. The residents involved had various medical conditions, including dementia, chronic kidney disease, and type II diabetes, which could increase their vulnerability to influenza. Despite the facility's policy to minimize the risk of influenza by offering annual immunizations, the failure to adhere to this policy placed the residents at potential risk of exposure to the influenza virus.
Failure to Support Resident's Transportation Needs for Non-Medical Appointments
Penalty
Summary
The facility failed to support and accommodate a resident's needs and choices regarding transportation for non-medical appointments, which led to a deficiency in honoring the resident's right to self-determination. The resident, who has diagnoses including blindness and glaucoma, requested assistance with transportation to explore benefits related to his condition. Despite having intact cognition and being dependent on staff for various needs, the facility did not arrange transportation for the resident's non-medical appointments, which were necessary for exploring potential benefits and improving his quality of life. Interviews with facility staff revealed that transportation arrangements were only made for medical or health-related appointments, and the facility's transportation van was not in use due to registration issues. The resident missed several appointments with an organization that could assist with benefits due to the facility's refusal to arrange transportation. Staff members expressed concerns about the lack of support for the resident's transportation needs, noting that the appointments were important for the resident's health and quality of life. The facility's actions were inconsistent with the resident's rights as outlined in the admission agreement, which emphasized the importance of supporting residents in exercising their rights and achieving the highest possible level of health.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to honor a resident's right to voice grievances without discrimination or reprisal, as evidenced by the case of Resident #16. Resident #16, a female with diagnoses including Chronic Obstructive Pulmonary Disease, anxiety, and mood disorder, expressed concerns about not receiving information regarding an oncology appointment ordered by her physician. Despite her attempts to communicate this issue to various staff members, including LVN A and MA O, no grievance report was initiated on her behalf. On two separate occasions, Resident #16 communicated her grievance to staff members. On the first occasion, she informed LVN A during the night shift about her concern regarding the lack of information on her oncology appointment. LVN A did not generate a grievance report, believing the resident's expression was a concern rather than a complaint. On the second occasion, Resident #16 expressed her grievance to MA O, who then reported it to the ADON. However, the ADON stated that MA O did not report it as a complaint, and thus no grievance report was generated. The facility's grievance policy requires staff to report grievances on a designated form and forward it to a grievance official. However, in this case, the staff failed to adhere to this policy, resulting in Resident #16's grievance not being documented or addressed. This failure could potentially lead to unresolved issues and feelings of not being heard among residents.
Failure to Monitor Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not monitoring the side effects and behaviors associated with the resident's prescribed medications. The resident, who was cognitively intact, was taking olanzapine for schizoaffective disorder, busPIRone for anxiety disorder, and sertraline for depression related to schizoaffective disorder. Despite the comprehensive care plan requiring monitoring of side effects and behaviors every shift, the medication administration record lacked sections for such monitoring. Interviews with the resident, an LVN, and the DON confirmed that there were no observed side effects or adverse behaviors related to the medications. However, the facility's failure to monitor these aspects as per the care plan and facility policy placed the resident at risk of side effects and adverse reactions. The facility's policy on the use of psychotropic medications emphasized ongoing evaluation of the effects on a resident's well-being, which was not adhered to in this case.
Incomplete Documentation of Narcotic Administration
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, specifically regarding the administration of hydrocodone-acetaminophen. The Licensed Vocational Nurse (LVN) administered the medication on several occasions as ordered and documented these administrations on the narcotic counting sheet. However, the LVN did not document these administrations on the resident's medication administration record, which is a requirement according to professional standards and the facility's policy. This oversight was attributed to the LVN's inexperience and workload, as she had been working as a floor nurse for only three weeks and was very busy during the dates in question. The resident involved had a history of type 2 diabetes mellitus, atherosclerotic heart disease, hypertension, pain in the left arm, and anxiety disorder. The resident was cognitively intact, as indicated by a recent assessment. The failure to document the administration of the narcotic medication on the medication administration record posed a risk of incorrect medication administration due to incomplete and inaccurate medical records. The facility's Director of Nursing confirmed the documentation failure and noted the potential harm of incorrect dosing due to this inaccuracy.
Inaccurate MDS Assessment of Resident's Behavioral Symptoms
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of a resident, leading to a deficiency. Specifically, a resident's quarterly MDS assessment indicated no physical behavioral symptoms directed toward others, despite a nursing note documenting an incident where the resident hit another resident. The MDS assessment, dated 05/08/2024, inaccurately coded the resident's behavior as not exhibited, even though there was a documented incident of aggression on 05/03/2024. This discrepancy was acknowledged by the social worker responsible for coding the MDS, who admitted to mistakenly coding the behavior as not exhibited, believing the incident to be isolated. The resident involved had a history of end-stage renal disease, type 2 diabetes mellitus, schizoaffective disorder, and anxiety disorder. The resident was cognitively intact, as indicated by a BIMS score of 13/15. The MDS nurse confirmed that the assessment was inaccurate and expressed concern that such inaccuracies could lead to the facility missing patterns of aggressive behavior, potentially resulting in inadequate care. The facility's policy and the CMS MDS 3.0 Manual require accurate and standardized assessments, which were not adhered to in this case.
Improper Storage of Controlled Substances
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by their policy. During an observation, it was noted that the narcotic box inside the medication room's refrigerator was not permanently affixed to the compartment. This box contained a bottle of Lorazepam 2mg/ml prescribed to a resident. The Director of Nursing (DON) confirmed that the narcotic box was not secured as per the facility's policy, which mandates that Schedule II controlled medications be stored within a separately locked, permanently affixed compartment when other medications are stored in the same area. The resident involved had been admitted with diagnoses including Alzheimer's disease, muscle wasting and atrophy, and anorexia. The resident had a physician's order for Lorazepam Oral Concentrate 2 mg/ml to be administered as needed for anxiety, agitation, or restlessness. The failure to secure the narcotic box could potentially result in the resident not receiving their medication as prescribed, due to the risk of the medication being removed from the refrigerator.
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 922 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) |
|---|---|---|---|---|
| The Heights At Medical Center | 1 mi | ★★★★★ | 13 | 0 |
| The Atrium Rehabilitation Center | 1.2 mi | ★★★★★ | 1 | 0 |
| Oak Park Nursing And Rehabilitation Center | 1.5 mi | ★★★★★ | 25 | 0 |
| Wurzbach Nursing And Rehabilitation | 1.6 mi | ★★★★★ | 0 | 0 |
| Golden Estates Rehabilitation Center | 1.8 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Lev At San Antonio.
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 July 2026) and official state health department websites.