Deficiencies (last 3 years)
Deficiencies (over 3 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
120% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 15, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to maintain complete, accurate, and accessible medical records for residents, specifically focusing on medication administration and documentation practices.
Findings
The facility failed to ensure proper documentation and monitoring of a resident's blood pressure prior to administering Metoprolol Succinate, resulting in incomplete clinical records and potential risk to resident care. The administering nurse did not document a repeat blood pressure check despite the initial reading being below the medication's hold parameters.
Complaint Details
The investigation was complaint-related focusing on Resident #1's clinical records and medication administration. The complaint involved failure to document a repeat blood pressure check before administering Metoprolol Succinate when the initial blood pressure was below the hold range. The complaint was substantiated with findings of incomplete documentation and potential medication error.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 5
Residents affected: 1
Medication dosage: 50
Blood pressure values: 127
Blood pressure values: 57
Blood pressure values: 150
Blood pressure values: 69
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Administered Metoprolol Succinate on 12/02/2025 and failed to document repeat blood pressure check |
| MD C | Physician | Provided care to Resident #1 and commented on medication administration and blood pressure concerns |
| LPN B | Licensed Practical Nurse | Recorded blood pressure values for Resident #1 on 12/02/2025 at 09:26 p.m. |
| DON | Director of Nursing | Provided explanation of medication administration times and expectations for documentation |
Inspection Report
Complaint Investigation
Deficiencies: 2
Nov 18, 2025
Visit Reason
The inspection was conducted due to complaints regarding the accuracy of resident assessments and the implementation of care plans, specifically focusing on ensuring accurate Minimum Data Set (MDS) assessments and comprehensive care plans for residents.
Findings
The facility failed to ensure the MDS assessment accurately reflected a resident's fall history, which could lead to missed care. Additionally, the facility failed to develop and implement a comprehensive care plan for another resident, specifically failing to provide fall mats on both sides of the bed as required, increasing the risk of injury.
Complaint Details
The complaint investigation found substantiated deficiencies related to inaccurate MDS assessments and incomplete care plan implementation, affecting residents at risk for falls and potential injury.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure the MDS assessment accurately reflected Resident #1's fall which resulted in a fracture and hospital admission. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement a comprehensive care plan for Resident #2, specifically not providing fall mats on each side of the bed as specified. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for MDS accuracy: 5
Residents reviewed for care plan implementation: 5
Resident #1 BIMS score: 12
Resident #2 BIMS score: 12
Resident #2 witnessed falls: 1
Resident #2 unwitnessed falls: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Completed Resident #1's re-entry MDS and missed coding the fall |
| DON | Director of Nursing | Confirmed Resident #1's fall and Resident #2's missing floor mat; provided statements on care plan importance |
| ADM | Administrator | Accountable for MDS assessments and care plan implementation; provided statements on deficiencies |
| RN B | Charge Nurse | Responsible for rounds on Resident #2's hall; did not notice missing floor mat |
| CNA C | Certified Nursing Assistant | Provided care to Resident #2; did not notice missing floor mat |
Inspection Report
Routine
Deficiencies: 8
Jun 3, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident safety, care planning, medication administration, infection control, food service, and MDS data transmission.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe and comfortable environment (e.g., broken window and refrigerator), failure to timely transmit MDS discharge assessments, incomplete care plans for residents, medication administration errors including failure to observe medication ingestion and improper handling, unlocked medication carts, unlabeled medication changes, repetitive menus with excessive beans, improper food labeling and storage, and lapses in infection prevention and control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to provide a safe, functional, sanitary, and comfortable environment due to a window that would not close and a non-functioning refrigerator in Resident #28's room. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to electronically transmit encoded, accurate, and complete MDS discharge assessments within 14 days for Residents #22 and #272. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement comprehensive person-centered care plans including measurable objectives for Residents #23 and #52, specifically related to eating assistance needs. | Level of Harm - Minimal harm or potential for actual harm |
| Medication error rate of 17.24% due to failure to observe medication ingestion and improper medication handling by staff for Residents #161 and #171. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure all drugs and biologicals were labeled correctly and medication carts were locked and secured, including mismatched medication label for Resident #31 and unlabeled medication change for Resident #161. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure menus met nutritional needs and provided variety, resulting in repetitive menus with excessive beans for Residents #24 and #172. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to label food products with discard dates in the kitchen, risking foodborne illness. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain infection prevention and control practices including improper sanitization of blood glucose monitors, improper medication handling, failure to clean insulin pen stoppers, improper hand hygiene, and failure to place Resident #217 on enhanced barrier precautions for surgical wound care. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 17.24
MDS discharge assessment overdue days: 83
MDS discharge assessment overdue days: 9
Meals including beans: 10
Meals including beans: 8
Meals including beans: 10
Meals including beans: 9
Meals including beans: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN F | Named in medication error findings, infection control lapses, and medication cart observations. | |
| LVN G | Named in medication error findings, medication cart observations, and infection control lapses. | |
| SW I | Social Worker | Reported monitoring refrigerator temperature and was unaware of window issue. |
| ADM | Administrator | Provided information about refrigerator replacement and menu review. |
| DON | Director of Nursing | Interviewed regarding MDS assessments, medication administration, infection control, and medication labeling. |
| MDS Coordinator B | LVN | Interviewed about MDS assessments and care plan updates. |
| MDS Coordinator C | LVN | Interviewed about MDS assessments and care plan updates. |
| RD | Registered Dietitian | Interviewed about menu planning and food service. |
| CDM | Certified Dietary Manager | Interviewed about menu planning and food service. |
Inspection Report
Complaint Investigation
Deficiencies: 7
Apr 26, 2024
Visit Reason
The inspection was conducted based on observations, interviews, and record reviews to investigate complaints related to the facility's failure to ensure proper physician orders at admission, baseline care plans, respiratory care, food and nutrition service competencies, menu adherence, and food safety practices.
Findings
The facility failed to obtain physician orders for oxygen therapy at admission for Resident #253, did not develop accurate baseline care plans for multiple residents, failed to provide comprehensive care plans including anticoagulant therapy for Resident #3, and did not ensure safe respiratory care. Additionally, the Food Service Supervisor lacked appropriate certification, the facility failed to follow posted menus with frequent unapproved substitutions, and food safety issues were noted including improperly stored frozen foods and unsanitary can opener conditions.
Complaint Details
The complaint investigation revealed multiple deficiencies including failure to obtain physician orders for oxygen therapy at admission, incomplete baseline and comprehensive care plans, inadequate respiratory care, insufficient food service staff qualifications, failure to follow menus, and food safety violations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Level of Harm - Potential for minimal harm: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to provide physician orders for resident's immediate care at admission, specifically oxygen therapy for Resident #253. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement baseline care plans reflecting residents' immediate needs for Residents #25, #104, and #253. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement a comprehensive care plan including measurable objectives and timeframes for Resident #3's anticoagulant therapy. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe and appropriate respiratory care including obtaining oxygen orders for Resident #253. | Level of Harm - Minimal harm or potential for actual harm |
| Food Service Supervisor lacked appropriate certification, education, or qualifications to serve as Director of Food and Nutrition Services. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow posted menus for residents on regular and modified diets; frequent unapproved menu substitutions occurred. | Level of Harm - Potential for minimal harm |
| Failed to store, prepare, distribute, and serve food in accordance with professional standards; open cases of frozen food with unsealed bags and unsanitary can opener observed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for admission physician orders: 24
Residents reviewed for baseline care plans: 24
Residents reviewed for comprehensive care plans: 24
Food items substituted: 58
Cases of open frozen food: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Nurse | Resident #253's nurse who revealed lack of oxygen order and discussed oxygen therapy risks. |
| DON | Director of Nursing | Discussed missed oxygen orders for Resident #253 and lack of policy on oxygen administration. |
| ADON A | Assistant Director of Nursing | Part of care planning team; acknowledged missed care planning for psychotropic medication and oxygen therapy. |
| Food Service Supervisor | FSS | Held position since 09/2023; lacked appropriate certification; responsible for menu substitutions and kitchen sanitation. |
| Administrator | Facility Administrator | Acknowledged FSS certification issues and unapproved menu substitutions. |
| Dietetic Technician Registered | DTR | Approved menu substitutions but did not discuss them with consultant RD. |
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 15, 2024
Visit Reason
The inspection was conducted as a routine annual survey of Remington Transitional Care of San Antonio to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating full compliance with applicable standards at the time of the survey.
Inspection Report
Routine
Deficiencies: 1
Feb 9, 2024
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically related to wound care practices for Resident #3.
Findings
The facility failed to maintain proper infection prevention and control during wound care for Resident #3, as Treatment Nurse B did not perform appropriate hand hygiene, glove changes, or sanitize surfaces during wound care procedures, potentially placing residents at risk of infection.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain an infection prevention and control program during wound care for Resident #3, including lack of hand hygiene, glove changes, and surface sanitization. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents Affected: 3
Residents Affected: Few
Date of wound care observation: Feb 8, 2024
Date of report: Feb 9, 2024
Date of Treatment Nurse B's wound care competencies: Nov 18, 2023
Date of facility hand hygiene policy: Oct 24, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Treatment Nurse B | Treatment Nurse | Named in infection control deficiency related to wound care |
| Infection Preventionist | Provided interview on proper wound care and infection prevention expectations | |
| Administrator | Provided interview regarding facility policies on wound care |
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 10, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction report for Remington Transitional Care of San Antonio following a survey completed on November 10, 2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Annual Inspection
Deficiencies: 4
Mar 10, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to pharmaceutical services, food safety, medical record accuracy, infection prevention and control, and other care standards at Remington Transitional Care of San Antonio.
Findings
The facility was found deficient in pharmaceutical services related to medication administration errors, food service sanitation issues with an unclean ice machine, incomplete and inaccurate medical record documentation regarding code status for a resident, and lapses in infection prevention practices including failure to sanitize equipment and improper glove handling.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide pharmaceutical services meeting residents' needs, including improper insulin administration and medication handling by licensed nurses. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure the nutritional room ice machine was clean, risking cross-contamination and foodborne illness. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain complete, accurate, and accessible medical records, specifically lacking a physician's order for code status for Resident #4. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain an infection prevention and control program, including failure to sanitize blood pressure cuff between residents and improper glove handling during wound care. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for medication administration: 8
Residents affected by pharmaceutical services deficiency: 3
Residents affected by food service sanitation deficiency: 1
Residents reviewed for medical record accuracy: 15
Residents affected by infection prevention deficiency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN D | Licensed Vocational Nurse | Administered insulin without priming the insulin pen |
| LVN E | Licensed Vocational Nurse | Dropped medications on medication cart counter and dispensed them to residents; failed to sanitize blood pressure cuff between residents |
| LVN Treatment Nurse F | Licensed Vocational Nurse | Placed disposable gloves in pant pocket and used them during wound care |
| DON | Director of Nursing | Provided statements on proper medication administration, infection control expectations, and facility policies |
| LVN Charge Nurse A | Licensed Vocational Nurse | Provided information on code status procedures and documentation |
| SW B | Social Worker | Discussed code status documentation and responsibilities |
| SW C | Social Worker | Clarified that Directive to Physicians and Family or Surrogates form does not constitute DNR status |
| Administrator | Facility Administrator | Discussed code status policies and responsibilities |
| MS | Maintenance Supervisor | Responsible for ice machine evaluation and cleaning |
| ADM | Administrator | Discussed ice machine cleaning and communication breakdown |
| LVN G | Licensed Vocational Nurse | Provided ice to residents and described reporting procedures for ice maker concerns |
| LVN Charge Nurse A | Licensed Vocational Nurse | Checked medical records for code status orders |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 17, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Remington Transitional Care of San Antonio, summarizing the findings from the survey completed on 02/17/2023.
Findings
No health deficiencies were found during the survey.
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