Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Village At Incarnate Word during CMS and state inspections, most recent first.
Unsafe handling of food brought in by a visitor: A volunteer prepared food in her apartment and brought it to the facility for a birthday celebration for several residents. Surveyors observed three trays of hot food on a table with no portable heat source, temperature measuring device, or temp log visible. The consultant RD, staff RD, Administrator, and DON stated the facility was unaware of the event and that safe food handling practices were not ensured when food was brought in from outside the facility.
A facility failed to have and communicate a policy for the use and storage of food brought in by family and visitors. Three trays of hot food were observed on a table without a heat source, temperature monitoring, or a log. A volunteer Sister said she regularly brought food from her apartment for special events, but she had not been given the policy or educated on safe food handling. The RD, DON, and Administrator stated they were unaware of the regular outside food brought in and had not ensured safe food handling practices were used.
A resident with dementia, severe cognitive impairment, incontinence, total care needs, and a stage 3 sacral pressure ulcer was not placed on Enhanced Barrier Precaution despite having a wound order for sacral care. Surveyors observed no EBP sign or PPE outside the room, and two CNAs entered for a mechanical lift transfer without gowns. Staff interviews showed the CNA relied on the missing sign, the LVN said there was no EBP order, and the ADON stated she forgot to place the resident on EBP even though residents with wounds must be on it.
Improper Disposal and Maintenance of Waste Containers: The recycling bin on the back dock was left propped open by cardboard tubes that prevented the lid from closing, and the RD was unable to move them. An outdoor grease container nearby was coated with grease, grime, and food particles, with a puddle of grease on the ground in front of it. The RD stated the grease container was serviced by a contractor every three months, while facility policy required outside receptacles to remain covered and grease containers to be cleaned on a monthly basis or as needed.
A resident who was fully dependent on staff for transfers and bathing sustained a significant eye bruise when a CNA performed a mechanical lift transfer alone, contrary to facility policy and training that required two staff for such procedures. The incident occurred when the CNA, unable to find assistance, proceeded with the transfer, resulting in the resident's face being struck by the lift. Staff interviews confirmed knowledge of the two-person requirement for mechanical lift use.
The facility's kitchen failed to meet food service safety standards. A fire extinguisher inspector was in the kitchen without proper hair restraints, and food items such as pudding cups and chili were not labeled or dated. Additionally, pie crusts were found unsealed and exposed to freezer burn, violating the facility's storage policy.
A facility failed to update a resident's care plan to reflect a change in diet texture from thin to nectar thick liquids, as ordered by a physician. The resident, with a history of atrial fibrillation, cardiac pacemaker, major depressive disorder, and Parkinson's disease, was at risk due to this oversight. The MDS nurse admitted the care plan was not revised, contrary to facility policy requiring updates with changes in resident conditions.
The facility failed to ensure safe storage of food in residents' personal refrigerators, with unlabeled and undated items found in two rooms. An LVN and the DON confirmed the issue, acknowledging the risk of foodborne illness due to improper monitoring by night shift Charge Nurses.
The facility failed to ensure a safe environment in the Red Hall, with water temperatures in rooms 18, 20, 21, and 27 exceeding 110 degrees Fahrenheit. Observations showed temperatures between 112 and 113 degrees, confirmed by the Maintenance director, who noted ongoing issues since May 2024. The facility's policy emphasizes a safe and comfortable environment, which was not maintained.
A newly admitted resident's baseline care plan failed to include necessary instructions for oxygen therapy, despite the resident's acute and chronic respiratory failure. The omission was confirmed by the MDS Nurse and DON, who acknowledged that the oversight could lead to improper care.
A resident was prescribed PRN Lorazepam for anxiety without a stop date, contrary to the facility's policy requiring reassessment after 14 days. The resident, with diagnoses of anxiety, dementia, and Alzheimer's, did not receive the medication in September. Staff interviews revealed uncertainty and oversight regarding the indefinite prescription, highlighting a lapse in following the updated policy on psychotropic medication use.
A resident's medical record contained an incorrect prescription for Tylenol, allowing for an excessive dosage of acetaminophen. The order permitted up to 45 grams in 24 hours, far exceeding the safe limit of 4000 mg. Interviews with the DON and Consultant Pharmacist confirmed the error, with the DON suggesting it was a typo. The facility's documentation policy was not followed, risking potential harm to the resident.
A facility failed to maintain an effective infection control program when an LVN did not sanitize her hands between glove changes during wound care for a resident with a stage 4 pressure ulcer. The LVN also touched the bedside table with her gloved hand without changing gloves or sanitizing her hands before continuing the procedure, risking cross-contamination and infection. The resident had a history of osteomyelitis and was at high risk for infection.
Unsafe handling of food brought in by a visitor
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety during a potluck event hosted by Volunteer D. Observation on 12/09/2025 at 11:50 PM revealed a table at the end of A Hall with three trays of hot food: white and wild rice with pieces of chicken covered with cheese, small pieces of cooked ham, and a vegetable medley of broccoli, carrots, and cauliflower. There was no portable heat source or other means of maintaining food temperature present, and no temperature measuring devices or temperature log visible. During interview, Volunteer D stated she was a Sister (nun) and that she prepared food in her apartment and brought it to the facility for several of the Sisters who were residents to celebrate Resident #58's birthday. She stated she brought food in on a monthly basis for special events and, when asked about temperature, said her oven was at 350 degrees. The consultant RD stated the facility failed to ensure safe food handling practices were used when food was brought from outside the facility for residents by a visitor and should have been aware of the event. The staff RD stated she was unaware Volunteer D had brought in food that day. The Administrator stated she was unaware Volunteer D fed residents food from outside the facility and understood the risk involved if food safety was not maintained. The DON stated it was the facility's responsibility to ensure safe food practices were implemented when food was provided by family members or visitors and said, 'This one slipped by us.'
Failure to Manage Outside Food Brought for Residents
Penalty
Summary
The facility failed to have a policy regarding the use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. During observation, three trays of hot food were found on a table at the end of A Hall, including white and wild rice with pieces of chicken covered with cheese, small pieces of cooked ham, and a vegetable medley of broccoli, carrots, and cauliflower. There was no portable heat source or other means of maintaining food temperature present, and no temperature measuring devices or temperature log visible. During interview, Volunteer D stated she was a Sister who prepared food in her apartment and brought it to the facility for several Sisters who were residents to celebrate Resident #58's birthday, and that she brought food in on a monthly basis for special events. She stated she had not been provided with a policy regarding use and storage of food brought to residents from outside the facility and had not been educated on safe food handling practices. Facility staff, including the consultant RD, staff RD, DON, and Administrator, stated they were unaware she brought food in regularly or on special occasions and had not provided her a copy of the policy or ensured safe food handling practices were used.
Failure to Use Enhanced Barrier Precautions for Resident With Wound
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for one resident reviewed for infection control. Resident #4 had diagnoses including dementia, major depressive disorder, hypertension, schizophrenia, and malignant neoplasm, and the resident’s MDS showed a BIMS score of 02, indicating severe cognitive impairment. The resident was always incontinent of bowel and bladder and required total care for activities of daily living. The care plan identified a stage 3 pressure ulcer of the sacrum related to immobility, and the physician ordered wound care to the sacrum with cleansing, pat dry, and hydrocolloid dressing every evening shift on Monday, Wednesday, and Friday. Observation showed there was no sign outside the resident’s room indicating Enhanced Barrier Precaution, and no PPE was seen inside or outside the room. Two CNAs entered the room to perform a mechanical lift transfer without wearing protective gowns. During interview, a CNA stated the resident should have been on Enhanced Barrier Precaution because of the wound and said she entered without a gown because there was no sign on the door. The LVN stated there was no order for Enhanced Barrier Precaution, while the ADON stated residents with wounds must be on Enhanced Barrier Precaution and that she was responsible for starting the order and placing the signage and PPE in place, but she forgot to place the resident on Enhanced Barrier Precaution. The DON stated that a resident with a wound should be on Enhanced Barrier Precaution to protect the resident and staff from MDRO organisms.
Improper Disposal and Maintenance of Waste Containers
Penalty
Summary
The facility failed to dispose of garbage and refuse properly for one recycling bin and one grease container on the loading dock. On observation, the recycling bin was propped open by two cardboard tubes encased in plastic, and the lid could not be closed because the tubes extended above the bin. The RD attempted to kick the tubes so they would fit inside the bin and allow the lid to close, but was unable to move them. During interview, the RD stated the recycling bin lid should have been closed to prevent pests and other undesirable contaminants from entering the container. Observation also revealed an outdoor grease container to the right of the recycling bin that had a thick layer of grease and grime, with food particles stuck on the grease extending the length of the container. There was also a puddle of grease on the ground in front of the container, approximately 12 inches long and 6 inches wide, covered with dried leaves and debris. The RD stated the outdoor grease container was maintained by the contracted company every three months. Record review showed the facility policy required grease to be removed according to procedures established with Environmental Services, grease containers to be cleaned monthly or as needed by the contractor, and outside trash receptacles to have lids kept closed.
Failure to Provide Adequate Supervision During Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all activities of daily living due to diagnoses including dementia, Alzheimer's disease, diabetes, and a left hand contracture, was transferred using a mechanical lift by a single CNA, despite the care plan and facility policy requiring two staff for such transfers. The resident was non-ambulatory, used a wheelchair, and required total assistance for bathing and transfers. During a shower transfer, the CNA performed the mechanical lift transfer alone because other staff were unavailable to assist. Following the transfer, the resident was observed to have redness, clear discharge, and discoloration around the left eye, which was initially treated as an eye infection due to the resident's history of similar symptoms. However, further assessment revealed a bruise measuring 4.4 cm by 3.2 cm, and it was determined that the injury was caused when the resident's face was struck by the bar of the mechanical lift during the transfer. The CNA involved acknowledged being alone during the transfer and stated that she could not find another staff member to assist, as required by facility policy and training. Interviews with multiple staff members confirmed that all were trained to use two staff for mechanical lift transfers and were instructed not to perform such transfers alone. The incident was reported to administration and the state, and the facility's policy clearly stated that at least two nursing assistants are needed for safe mechanical lift transfers. The failure to follow this policy resulted in the resident sustaining a significant injury during the transfer.
Food Safety and Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in the kitchen, as observed during a survey. A fire extinguisher inspector was present in the kitchen during food preparation without wearing a beard guard or a full hair net, leaving approximately four inches of hair and facial hair uncovered. This was confirmed by the Chef, who acknowledged that the inspector should have been wearing appropriate hair restraints as per the facility's uniform dress code policy. Additionally, several food storage issues were identified. Pudding cups in Refrigerator #1 and a container of chili in Refrigerator #2 were found to be neither labeled nor dated, which was confirmed by the Chef. Furthermore, pie crusts in Freezer #1 were observed to be unsealed and exposed to freezer burn. These practices were in violation of the facility's policy on food and supply storage, which mandates that all food items be stored in a manner that prevents contamination and maintains their safety and wholesomeness.
Failure to Update Resident's Care Plan with Current Diet Order
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team after each assessment. Specifically, the care plan for a resident did not reflect the current diet texture order, which had been updated from thin to nectar thick liquids. This discrepancy was identified during a record review and interviews with facility staff. The resident, who had a history of paroxysmal atrial fibrillation, cardiac pacemaker presence, major depressive disorder, and Parkinson's disease, was at risk due to this oversight. The resident's care plan, dated August 20, 2024, indicated a regular, mechanically soft, thin diet, while the physician's order dated August 30, 2024, specified a regular diet with mechanical soft texture and nectar consistency. The speech therapy evaluation noted a swallowing disorder and recommended nectar thick liquids to prevent aspiration. The MDS nurse acknowledged the care plan had not been updated to reflect the new diet order, which could result in unmet care needs. The facility's policy requires care plans to be revised as residents' conditions change, but this was not adhered to in this case.
Deficient Food Storage Practices in Residents' Personal Refrigerators
Penalty
Summary
The facility failed to maintain safe and sanitary storage of food items in residents' personal refrigerators, as observed in two rooms. In Room #13, chicken tenders were found unlabeled and undated during two separate observations. Similarly, in another room, an opened container of strawberry jam was also found unlabeled and undated. These observations indicate a lack of adherence to the facility's policy requiring food brought from outside sources to be labeled and dated for safety. Interviews with staff, including an LVN and the DON, confirmed the presence of unlabeled and undated food items in the residents' personal refrigerators. The DON acknowledged that perishable food and drinks should be labeled and dated to prevent residents from consuming spoiled foods. It was noted that the night shift Charge Nurses were responsible for overseeing this process, but it was not being monitored effectively, leading to the potential risk of foodborne illness for the residents.
Unsafe Water Temperatures in Resident Hallway
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in the Red Hall, as evidenced by water temperatures exceeding the safe limit of 110 degrees Fahrenheit. Observations conducted on September 26, 2024, revealed that the water temperature in rooms 18, 20, 21, and 27 measured between 112 and 113 degrees Fahrenheit. These temperatures were recorded using a probe-type thermometer, indicating a consistent issue with water temperature regulation in this area of the facility. The Maintenance director confirmed the elevated temperature readings and acknowledged ongoing difficulties in maintaining water temperatures below 110 degrees Fahrenheit. The director also noted that there had been complaints from residents about water temperatures being too cold, which led to adjustments in the mixing valve for temperature stabilization. The facility's Water Temperature Log indicated that issues with controlling water temperatures had been present since May 10, 2024. The facility's policy, revised in February 2021, emphasizes providing a safe, clean, comfortable, and homelike environment, which was not upheld in this instance.
Failure to Include Oxygen Therapy in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a newly admitted resident that included necessary instructions for effective and person-centered care. Specifically, the baseline care plan for a resident with acute and chronic respiratory failure, among other conditions, did not include the use of oxygen therapy as needed for shortness of breath. This oversight was identified during a review of the resident's records, which showed an order for oxygen therapy that was not reflected in the baseline care plan. Interviews with the resident, the MDS Nurse, and the DON confirmed the omission. The resident reported using oxygen when experiencing shortness of breath, particularly at night. The MDS Nurse acknowledged the oversight, stating that the omission could lead to nursing staff not having all necessary information to provide optimal care. The DON confirmed that the MDS Nurse was responsible for completing the baseline care plans and agreed that the use of oxygen therapy should have been included.
Failure to Limit PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner documented their rationale for extending the order in the resident's medical record. This deficiency was identified for a resident who was prescribed Lorazepam 0.5 mg as needed for anxiety, with no stop date indicated on the order. The resident, a 95-year-old female with diagnoses including anxiety, dementia, and Alzheimer's disease, was moderately cognitively impaired and treated with anti-anxiety medications. Despite the prescription, the medication was not administered throughout September 2024. Interviews with facility staff revealed a lack of adherence to the policy requiring reassessment of the need for psychotropic medications after 14 days. An LVN expressed uncertainty about why the order for Lorazepam was written for an indefinite period and raised concerns about the risk of falls associated with prolonged use. The DON acknowledged the oversight in the order and confirmed the absence of a stop date for the PRN Lorazepam, attributing it to a possible oversight. The facility's policy, updated in July 2022, mandates that PRN orders for antipsychotic medications should not be renewed beyond 14 days without a healthcare practitioner's evaluation, which was not followed in this case.
Excessive Acetaminophen Dosage Error in Resident's Medical Record
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding the prescription of Tylenol. The resident, who was admitted with diagnoses including unspecified pain, a fracture of the right femur, and atrial fibrillation, had a prescription that incorrectly allowed for an excessive dosage of acetaminophen. The order stated to give two tablets every four hours as needed, with a maximum daily dosage of 45 grams, which far exceeds the safe limit of 4000 milligrams as noted by the National Center for Biotechnology Information. Interviews with the Director of Nursing (DON) and the Consultant Pharmacist confirmed the error, with the DON suggesting it was a typographical mistake. The Consultant Pharmacist acknowledged that exceeding 4000 milligrams of acetaminophen in a 24-hour period could lead to liver failure. The facility's policy on charting and documentation requires that all services and changes in a resident's condition be accurately documented to facilitate communication among the interdisciplinary team, which was not adhered to in this case.
Infection Control Lapse During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of LVN-A during wound care for a resident. LVN-A did not sanitize her hands between glove changes while performing wound care on a resident with a stage 4 pressure ulcer on the left buttock. Additionally, LVN-A touched the bedside table with her gloved hand and did not change gloves or sanitize her hands before continuing the wound care procedure. This lapse in protocol could lead to cross-contamination and potential infection. The resident involved had a history of osteomyelitis and a stage 4 pressure ulcer, indicating a high risk for infection. The facility's policy on standard precautions requires hand hygiene after contact with items in the resident's room and after removing gloves. Despite being trained in infection control, LVN-A acknowledged the risk of cross-contamination due to her actions. The Director of Nursing confirmed that the nurse should have followed proper hand hygiene protocols to prevent infection.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parklane West Healthcare Center | 1.1 mi | ★★★★★ | 13 | 0 |
| Sage Park San Antonio | 2 mi | ★★★★★ | 15 | 0 |
| San Pedro Manor | 2.5 mi | ★★★★★ | 1 | 0 |
| Meridian Care Monte Vista | 2.5 mi | ★★★★★ | 16 | 1 |
| San Antonio North Nursing And Rehabilitation | 2.5 mi | ★★★★★ | 15 | 0 |
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