20 Reports
Inspection Report — Dec 9, 2025
Date: Dec 9, 2025
Visit Reason
The inspection was conducted to assess the competencies of nursing staff and nurse aides to ensure they provide care that maximizes each resident's well-being.
Findings
The facility failed to ensure that a staff member (Staff Member A) had the appropriate medication aide certification for 88 shifts while administering medications, posing potential risks to residents. Despite this, no medication errors or harm were reported, and the staff member worked under nurse supervision.
Citations (1)
Failure to ensure nurses and nurse aides have appropriate competencies to care for residents, specifically a staff member lacking a valid medication aide certificate while administering medications.
Report Facts
Shifts worked without valid MA certificate: 88
Residents on first-floor halls: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Medication Aide (MA) / GVN | Worked 88 shifts administering medications without a valid medication aide certificate; supervised by nurse RN C. |
| RN C | Registered Nurse | Supervised Staff Member A during shifts. |
| DON | Director of Nursing | Confirmed Staff Member A's certification status and supervised monitoring of license verification. |
| HRD | Human Resources Director | Verified Staff Member A's expired GVN and lack of MA certificate; informed DON. |
| Administrator | Facility Administrator | Unaware that Staff Member A did not possess a current MA certificate. |
Inspection Report — Nov 19, 2025
Annual Inspection
Date: Nov 19, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with pharmaceutical service regulations, specifically ensuring that a licensed pharmacist performs monthly drug regimen reviews and that attending physicians document review and actions taken regarding medication irregularities.
Findings
The facility failed to ensure the attending physician documented review and response to irregularities identified in Resident #1's medication regimen in August and September 2025, which could result in unintended medication effects or illness. Interviews and record reviews confirmed lack of provider response to pharmacist communications and incomplete documentation of medication regimen reviews.
Citations (1)
Failure to ensure the attending physician documented review and response to medication irregularities for Resident #1 in August and September 2025.
Report Facts
Residents reviewed for pharmaceutical services: 7
Dates of medication irregularities: 202508
Dates of medication irregularities: 202509
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Pharmacist (RPh) | Sent communications regarding Resident #1's medication irregularities in August and September 2025 | |
| Assistant Director of Nursing (ADON) | Responsible for medication regimen reviews and communication with providers | |
| Medical Doctor (MD) | Physician overseeing care, unaware of unanswered pharmacy recommendations for Resident #1 |
Inspection Report — Jul 31, 2025
Complaint Investigation
Date: Jul 31, 2025
Visit Reason
The inspection was conducted based on complaints regarding privacy violations, unsafe and unclean environment, food service safety, garbage disposal, and incomplete clinical record documentation at San Antonio North Nursing and Rehabilitation.
Complaint Details
The complaint investigation was substantiated with findings that the facility failed to protect resident privacy, maintain a safe and homelike environment, ensure food safety, properly dispose of garbage, and maintain accurate clinical documentation.
Findings
The facility was found deficient in maintaining resident privacy and confidentiality, ensuring a safe and homelike environment, food service safety standards, proper garbage disposal, and accurate clinical record documentation. Specific issues included unlocked computers exposing resident information, privacy curtains not closing fully during wound care, bathroom door and toilet repairs needed, dirty kitchen ceiling tiles and fixtures, open garbage dumpster doors, and blank spaces in medication administration records.
Citations (5)
Failed to keep residents' personal and medical records private and confidential, including leaving a computer unlocked exposing resident medication information and privacy curtains not closing completely during wound care.
Failed to honor residents' right to a safe, clean, comfortable, and homelike environment, including bathroom door damage and unsecured toilet.
Failed to procure food from approved sources and maintain food service safety, including dirty ceiling tiles, missing light bulb, rusted vent, and damaged bathroom floor molding in kitchen area.
Failed to properly dispose of garbage and refuse by not ensuring dumpster sliding doors were completely closed.
Failed to maintain complete and accurate clinical records, with blank spaces on medication administration record for Resident #11.
Report Facts
Residents reviewed for privacy: 7
Residents reviewed for safe environment: 30
Ceiling tiles needing replacement: 6
Garbage dumpsters: 2
Residents reviewed for clinical records: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA B | Named in privacy violation for leaving computer unlocked exposing resident medication information. | |
| LVN-C | Named in privacy violation for inability to fully close privacy curtains during wound care. | |
| DON | Director of Nursing | Interviewed regarding expectations for privacy, documentation, and corrective actions. |
| Food Service Director | Interviewed regarding kitchen cleanliness and garbage disposal issues. | |
| Maintenance Director | Interviewed regarding repairs needed in bathrooms and kitchen. | |
| Administrator | Interviewed regarding facility environment and garbage disposal. | |
| HR Director | Interviewed regarding medication administration documentation and staffing. | |
| RN A | Registered Nurse | Assigned to Resident #11 on 07/05/2025; unavailable for interview regarding missing documentation. |
Inspection Report — May 23, 2025
Complaint Investigation
Date: May 23, 2025
Visit Reason
The inspection was conducted following a complaint regarding inadequate care for a resident who was found sitting in urine in a chair, and concerns about incomplete medical record documentation and unsafe facility conditions.
Complaint Details
The complaint investigation was triggered by a family member's report that Resident #2 was found sitting in urine in a chair in the dining room on 05/18/2025. Interviews with staff and family confirmed the incident and inadequate response time. The complaint also included concerns about incomplete wound care documentation for Resident #1 and unsafe conditions in the Maintenance and Housekeeping Office.
Findings
The facility failed to provide appropriate care to a resident incontinent of bladder, resulting in the resident being left sitting in urine, which could lead to skin breakdown and infection. Additionally, the facility failed to maintain accurate and complete medical records for wound care treatments for another resident. The Maintenance and Housekeeping Office was found unsecured, posing a safety risk.
Citations (3)
Failure to provide appropriate care for a resident incontinent of bladder, resulting in the resident being left sitting in urine in a chair.
Failure to maintain complete and accurate medical records for wound care treatments, with missing documentation on multiple treatment days.
Failure to ensure the Maintenance and Housekeeping Office was secured, allowing potential unsafe access to tools and cleaning equipment.
Report Facts
Treatment days with missing documentation: 4
Number of residents reviewed for incontinent care: 6
Number of residents reviewed for clinical records: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-B | Registered Nurse | Named in the finding related to Resident #2 being left sitting in urine and was the charge nurse on duty |
| CNA-C | Certified Nursing Assistant | Assigned CNA to Resident #2 on the evening of 05/18/2025, involved in care after family arrival |
| LVN-D | Licensed Vocational Nurse | Admitting nurse for Resident #2, completed admission and baseline care plan |
| LVN-A | Licensed Vocational Nurse | Treatment nurse responsible for wound care documentation for Resident #1 |
| DON | Director of Nursing | Interviewed regarding expectations for care and documentation, and confirmed findings |
| Housekeeper E | Housekeeper | Confirmed Maintenance and Housekeeping Office door was ajar and usually kept locked |
| Maintenance Director | Maintenance Director | Confirmed leaving Maintenance and Housekeeping Office open and unattended |
Inspection Report — May 12, 2025
Routine
Date: May 12, 2025
Visit Reason
The inspection was conducted to assess compliance with medication storage regulations, specifically to ensure that all drugs and biologicals were stored in locked compartments as required.
Findings
The facility failed to ensure that one of four medication carts (Med Cart 1) was locked while unattended on 5/11/25, posing a risk of medication misuse and drug diversion. Interviews with staff confirmed that medication carts should be locked when unattended to prevent resident access.
Citations (1)
Failed to store all drugs and biologicals in locked compartments for 1 of 4 medication carts (Med Cart 1) reviewed for medication storage.
Report Facts
Medication carts reviewed: 4
Residents observed near medication cart: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Interviewed regarding residents walking around the nurses' station and medication cart security |
| LVN B | Licensed Vocational Nurse | Assigned to Med Cart 1 and interviewed about medication cart security |
| ADON | Assistant Director of Nursing | Interviewed about medication cart locking policies and resident safety |
| DON | Director of Nursing | Interviewed about expectations for medication cart security and resident safety |
Inspection Report — Feb 28, 2025
Annual Inspection
Date: Feb 28, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with dental care requirements, specifically regarding the failure to assist a resident in obtaining routine and emergency dental services.
Findings
The facility failed to assist Resident #1 in obtaining dental services after her top dentures were reported missing on 9/29/24, placing the resident at risk of choking and oral health complications. Interviews and record reviews confirmed the facility staff and administration were unaware of the missing dentures, and the resident expressed concern about choking while eating.
Citations (1)
Failure to assist Resident #1 with obtaining dental services when her top dentures were reported missing.
Report Facts
Residents Affected: 3
Residents Affected: 1
Resident weight gain: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed on 2/28/25, unaware of missing dentures | |
| Texas area president | Interviewed on 2/28/25, recalled email conversations but not contents | |
| Administrator | Interviewed on 2/28/25, unaware of missing dentures and noted choking risk | |
| CNA A | Interviewed on 2/28/25, stated Resident #1 had upper dentures at admission but missing later |
Inspection Report — Jan 10, 2025
Routine
Date: Jan 10, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding resident accommodations, privacy, and clinical record maintenance.
Findings
The facility failed to provide reasonable accommodation of resident needs and preferences related to call light accessibility for 3 residents, failed to maintain privacy during personal care for 1 resident due to missing privacy curtains, and failed to maintain accurate and timely documentation of wound care treatments for 1 resident.
Citations (3)
Failure to provide reasonable accommodation of resident needs and preferences for call light accessibility for 3 residents.
Failure to ensure residents had the right to personal privacy during personal care for 1 resident due to missing privacy curtain.
Failure to maintain clinical records in accordance with accepted professional standards for 1 resident, specifically missing documentation of wound care treatments on the TAR.
Report Facts
Residents reviewed for reasonable accommodations: 37
Residents affected by call light deficiency: 3
Residents affected by privacy deficiency: 1
Residents affected by clinical record deficiency: 1
Wound measurements: 45
Wound measurements: 35
Wound measurements: 0.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Completed Resident #1's wound care on 01/08/2025 but did not document on TAR |
| Wound Care LVN | Licensed Vocational Nurse | Responsible for wound care and documentation for Resident #1; provided reeducation on documentation |
| CNA A | Certified Nursing Assistant | Interviewed regarding call light placement and rounding |
| CNA D | Certified Nursing Assistant | Interviewed regarding call light placement and rounding |
| CNA E | Certified Nursing Assistant | Observed and interviewed regarding privacy curtain use during incontinent care for Resident #3 |
| CNA J | Certified Nursing Assistant | Observed and interviewed regarding privacy curtain use during incontinent care for Resident #3 |
| PTA | Physical Therapist Assistant | Interviewed regarding call light placement for Resident #3 |
| RN B | Registered Nurse | Worked overnight shift with Resident #1 and observed wound care completion |
| DON | Director of Nursing | Interviewed regarding call light placement, privacy curtain use, and wound care documentation monitoring |
| Administrator | Facility Administrator | Interviewed regarding call light placement and privacy curtain use |
| Housekeeping Director | Housekeeping Director | Interviewed regarding missing privacy curtains and maintenance |
| RN C | Charge Nurse | Interviewed regarding call light education for staff |
Inspection Report — Jun 29, 2024
Complaint Investigation
Date: Jun 29, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to properly prepare and orient Resident #1's legal guardian for the resident's transfer to a hospital.
Complaint Details
The complaint investigation revealed that Resident #1's legal guardian was not notified of the resident's transfer to a hospital or subsequent placement at another nursing facility. The guardian filed a missing person's report after being unable to locate the resident. The facility staff assumed the hospital would notify the guardian, but no documentation supported this. The resident was found at a different nursing home without a legal guardian listed.
Findings
The facility failed to provide and document sufficient preparation and orientation to Resident #1's legal guardian about the resident's transfer to the hospital, resulting in the guardian being unaware of the transfer and unable to follow up. There was no written discharge/transfer notice to the guardian, no efforts to ascertain the resident's condition in the hospital, and no documentation of communication regarding the resident's placement at another facility.
Citations (1)
Failed to ensure Resident #1's legal guardian was sufficiently prepared and oriented for Resident #1's transfer to hospital.
Report Facts
Residents affected: 3
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON A | Nursing progress note author and staff who communicated with hospital and legal guardian | |
| Administrator | Facility Administrator who provided information about resident placement and communication |
Inspection Report — Jun 13, 2024
Routine
Date: Jun 13, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, medication management, environmental conditions, and overall facility operations.
Findings
The facility was found deficient in multiple areas including failure to keep call lights within residents' reach, unsafe and unsanitary resident environments, improper respiratory care, unnecessary psychotropic medication use, unsafe food storage, improper garbage disposal, and maintenance issues such as roof leaks and broken electrical outlets. These deficiencies posed risks to resident safety, dignity, and well-being.
Citations (8)
Failed to ensure call lights were within reach for Residents #46 and #55.
Barrels of soiled linens and trash stored in Resident #14's restroom; Resident #33's shower chair and floor soiled with dark brown substance.
Resident #55 had access to an electronic cigarette despite being a supervised smoker.
Residents #4 and #56 had empty oxygen humidifier bottles on oxygen concentrators while in use.
Resident #20 was prescribed a psychotropic drug for anxiety with an indefinite PRN order exceeding the 14-day limit.
Personal refrigerator in resident room contained unlabeled and undated food items.
Garbage bin lids were left open on two separate occasions, risking pest harborage.
Broken electrical outlet, roof leak causing water puddle, missing floor paneling, and damaged ceiling tile in resident areas.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Assigned nursing assistant for Residents #46 and #55, acknowledged call light placement issues | |
| DON | Director of Nursing | Provided expectations on call light accessibility and medication oversight |
| Director of Housekeeping | Confirmed presence of soiled linens and trash in Resident #14's restroom | |
| ADON | Assistant Director of Nursing | Confirmed unsanitary conditions in Resident #33's restroom and oversight of oxygen humidifier bottle changes |
| RN C | Registered Nurse | Assigned nurse for Resident #55 and involved in oxygen therapy care |
| Administrator | Provided statements on facility expectations and awareness of deficiencies | |
| CNA A | Confirmed unlabeled and undated food in resident's personal refrigerator | |
| Dietary Director | Observed garbage bin lids left open and acknowledged regulations | |
| Maintenance Director | Acknowledged maintenance issues including broken electrical outlet and roof leak |
Inspection Report — Jun 6, 2024
Date: Jun 6, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with providing appropriate foot care and access to podiatry services for residents, specifically focusing on Resident #1's foot care needs.
Findings
The facility failed to ensure Resident #1 received adequate foot care and access to podiatry services, resulting in overgrown toenails causing a scabbed sore and potential risk for discomfort, poor foot hygiene, or physical decline. Interviews and record reviews revealed missed podiatry visits and inconsistent nail care documentation.
Citations (1)
Failure to provide appropriate foot care and access to podiatry services for Resident #1, resulting in overgrown toenails and a scabbed sore.
Report Facts
Residents Affected: 1
Residents Affected: 6
Date of last skin assessment: May 29, 2024
Date podiatry order started: Jul 6, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hospital RN A | Removed heel protector boots and assessed Resident #1's foot condition | |
| DON | Stated nurses were responsible for nail care and last cleaned Resident #1's nails on 5/29/2024 | |
| Treatment Nurse | Responsible for spot checking assessments and recalled asking social worker to put Resident #1 on podiatry list | |
| ADON | Reported no documentation of Resident #1 being seen by podiatrist and discussed risks of missed nail care |
Inspection Report — May 28, 2024
Complaint Investigation
Date: May 28, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report and investigate an attempted suicide incident involving Resident #1, and failure to implement a comprehensive person-centered care plan and appropriate treatment for psychosocial concerns.
Complaint Details
The complaint investigation was triggered by allegations that the facility failed to timely report and investigate an attempted suicide incident involving Resident #1, and failed to provide appropriate psychosocial care and monitoring.
Findings
The facility failed to timely report an attempted suicide incident to the State Survey Agency, failed to thoroughly investigate the incident, and failed to implement a comprehensive care plan with measurable objectives for Resident #1. Additionally, the facility failed to monitor side effects and behaviors related to psychotropic medications for multiple residents and had a medication error rate of 44% for Resident #7.
Citations (6)
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities for Resident #1's suicide attempt.
Failed to thoroughly investigate allegations of abuse and neglect for Resident #1's suicide attempt.
Failed to implement a comprehensive person-centered care plan with measurable objectives and timeframes for Resident #1, resulting in Immediate Jeopardy.
Failed to provide appropriate treatment and services to Resident #1 who displayed mental disorder or psychosocial adjustment difficulty, resulting in Immediate Jeopardy.
Failed to monitor side effects and behaviors related to psychotropic medications for Residents #1, #2, #3, #4, #5, and #6.
Failed to ensure medication error rate was below 5%, with a 44% error rate involving Resident #7.
Report Facts
Medication error rate: 44
Number of residents reviewed for medication management: 12
Number of licensed nursing staff trained: 19
Number of residents with new psychosocial orders: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Failed to follow care plan and put interventions in place for Resident #1; unsuccessful interview attempts noted |
| RN F | Registered Nurse | Charge nurse on duty during Resident #1's suicide attempt; reported no physical signs of injury |
| ADMIN | Administrator | Made decision not to report Resident #1's suicide attempt; involved in plan of removal and IJ response |
| Psych NP | Psychiatric Nurse Practitioner | Provided psychiatric follow-up for Resident #1; involved in psychosocial assessments and audits |
| MD E | Medical Director | Attended QAPI meetings; provided medical oversight and input on medication monitoring |
| ADON C | Assistant Director of Nursing | Responsible for monitoring care plan adherence and staff education |
| ADON D | Assistant Director of Nursing | Provided training on behavioral monitoring and care planning; involved in audits and monitoring |
| RDCS | Regional Director of Clinical Services | Provided training to ADON D and participated in QAPI meetings |
| CMA H | Certified Medication Aide | Administered medications late to Resident #7; acknowledged late medication administration |
Inspection Report — Feb 2, 2024
Routine
Date: Feb 2, 2024
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program and compliance with infection control policies based on observations, interviews, and record reviews.
Findings
The facility failed to maintain proper infection prevention and control practices for 3 of 4 residents reviewed, including improper wound care, inadequate hand hygiene during incontinent care, and failure to change gloves during nephrostomy care, potentially placing residents at risk of infection.
Citations (3)
During wound care of Resident #3, LVN D used the same gauze and tongue depressor multiple times without discarding, violating infection control practices.
During incontinent care for Resident #2, CNAs failed to properly wash and sanitize hands and reused wipes multiple times on the resident.
During nephrostomy care for Resident #1, LVN E did not change gloves when moving from one nephrostomy site to the other and wore double gloves improperly.
Report Facts
Residents affected: 3
Date of survey completed: Feb 2, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN D | Named in wound care infection control deficiency for Resident #3 | |
| CNA C | Named in incontinent care infection control deficiency for Resident #2 | |
| CNA F | Named in incontinent care infection control deficiency for Resident #2 | |
| LVN E | Named in nephrostomy care infection control deficiency for Resident #1 | |
| DON A | Director of Nursing | Interviewed regarding infection control failures and staff training |
| ADON B | Assistant Director of Nursing | Interviewed during wound care observation and identified as Infection Control Preventionist |
Inspection Report — Sep 8, 2023
Routine
Date: Sep 8, 2023
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control program, specifically to determine if the facility maintained a safe, sanitary environment to prevent communicable diseases and infections.
Findings
The facility failed to ensure proper infection control practices when a CNA did not change gloves or sanitize hands after cleaning a resident's feces before placing a clean brief, posing a risk of urinary tract infection. Interviews and record reviews confirmed staff training on proper glove use and hand hygiene, but the deficient practice was observed and acknowledged by staff.
Citations (1)
Failure to provide and implement an infection prevention and control program, specifically not changing gloves or sanitizing hands after cleaning Resident #1's feces before placing a clean brief.
Report Facts
Residents reviewed for infection control: 4
Resident #1's BIMs score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CN A A | Certified Nursing Assistant | Named in infection control deficiency for not changing gloves or sanitizing hands |
| CN A B | Certified Nursing Assistant | Witnessed the deficient practice and acknowledged proper procedure |
| ADON C | Assistant Director of Nursing | Provided interview confirming staff training and proper infection control procedures |
Inspection Report — Aug 19, 2023
Complaint Investigation
Date: Aug 19, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to notify a resident's physician of discharge, improper discharge procedures, and failure to provide discharge notices and summaries for Resident #1.
Complaint Details
The complaint investigation focused on Resident #1's discharge without physician notification, lack of discharge orders, unsafe discharge to a homeless shelter, failure to provide discharge notices and summaries, and failure to notify the Ombudsman. The investigation found substantiated deficiencies related to these issues.
Findings
The facility failed to notify Resident #1's physician prior to discharge, discharged Resident #1 without a physician order, failed to provide a valid discharge reason, failed to provide written records to the discharge location, failed to issue a 30-day discharge notice or notify the Ombudsman, and failed to ensure a safe discharge. Resident #1 was discharged to a local homeless shelter without proper preparation or documentation, and was later found at a local park. The facility also failed to provide a discharge summary, medication reconciliation, and post-discharge plan of care to the receiving facility.
Citations (5)
Failed to immediately inform a resident's physician of significant change and discharge without physician notification or order.
Discharged Resident #1 without valid reason and failed to provide written records to the discharge location.
Failed to issue a 30-day discharge notice and failed to notify the Ombudsman prior to discharge.
Failed to prepare Resident #1 for a safe discharge; Resident #1's whereabouts were unknown until found at a local park.
Failed to provide discharge summary, medication reconciliation, permanent medical necessity status, and post-discharge plan of care to the receiving facility.
Report Facts
Length of stay: 20
BIMS score: 8
MoCA score: 6
Discharge date: Aug 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician F | Primary Physician | Not notified prior to Resident #1's discharge |
| Administrator | Made decision to discharge Resident #1; was aware of discharge to homeless shelter | |
| SW | Social Worker | Initiated discharge planning; expressed concerns about unsafe discharge |
| DON | Director of Nursing | Agreed discharge was unsafe; involved in discharge planning |
| Driver | Transported Resident #1 to homeless shelter | |
| LVN G | Licensed Vocational Nurse | Noted Resident #1 discharged to homeless shelter |
| CNA C | Certified Nursing Assistant | Assisted Resident #1 with belongings; unaware of discharge preparations |
| Representative E | Local Homeless Shelter Representative | Reported no record of Resident #1 admission or discharge paperwork |
| DOR | Director of Rehabilitation | Discussed discharge plans and concerns about unsafe discharge |
| PT A | Physical Therapist | Provided therapy to Resident #1; noted cognitive and physical impairments |
| COTA B | Certified Occupational Therapy Assistant | Provided therapy to Resident #1; noted goals and discharge status |
Inspection Report — Aug 1, 2023
Complaint Investigation
Date: Aug 1, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident elopement incident where Resident #1 left the facility unsupervised and required emergency medical treatment.
Complaint Details
The complaint investigation was triggered by Resident #1 eloping from the facility on 08/01/2023, traveling approximately 1.5 miles away, and requiring emergency medical treatment for hypokalemia and hypotension. The facility lacked a care plan or wander guard system for elopement risk at admission. Multiple staff interviews and record reviews confirmed the incident and deficiencies in supervision and safety measures.
Findings
The facility failed to ensure adequate supervision and accident hazard prevention, resulting in Resident #1 eloping approximately 1.5 miles from the facility and requiring emergency medical treatment. The facility was found to be out of compliance with an Immediate Jeopardy identified and later removed after corrective actions including reassessment, implementation of wander guards, staff education, and system improvements. Additionally, infection control deficiencies were noted with staff improperly wearing masks.
Citations (3)
Failed to ensure the resident environment remained free of accident hazards and provide adequate supervision to prevent Resident #1 from eloping.
Receptionist B wore a facemask inappropriately leaving nose uncovered.
Housekeeper D wore a facemask inappropriately down around her neck.
Report Facts
Residents affected: 6
Resident elopement distance: 1.5
Staff in-service signatures: 64
Total staff: 93
Audits completed by DON: 2
Audits completed by treatment nurse: 2
Audits completed by Administrator: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Receptionist B | Receptionist | Observed wearing facemask improperly and involved in resident sign-out process |
| Housekeeper D | Housekeeper | Observed wearing facemask improperly during cleaning duties |
| Administrator | Facility Administrator | Notified of Immediate Jeopardy, involved in corrective actions and audits |
| DON | Director of Nursing | Involved in resident reassessment, staff education, audits, and interviews |
| Corporate Registered Nurse | Corporate Registered Nurse | Provided information on staff training and facility policies |
| CNA C | Certified Nursing Assistant | Reported resident was not known to exit seek and notified charge nurse |
| LVN A | Licensed Vocational Nurse | Assigned nurse for Resident #1, unaware of elopement details |
| Maintenance Director | Maintenance Director | Demonstrated door alarms were in working order |
| Nursing Scheduler | Nursing Scheduler | Located Resident #1 at hospital and notified Administrator and DON |
| Local Police Officer | Police Officer | Responded to missing person report and search for Resident #1 |
Inspection Report — Jul 25, 2023
Complaint Investigation
Date: Jul 25, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to reasonably accommodate the needs and preferences of residents, specifically related to the call light system for Resident #7.
Complaint Details
The complaint investigation found that Resident #7 was unable to reach the call light for over one hour while calling for help due to the call light being misplaced under his blanket. Resident #8 confirmed the delay in staff response. The facility's staff acknowledged the expectation to check call light placement every shift and every two hours but could not verify compliance on the day of inspection.
Findings
The facility failed to ensure the call light was accessible to Resident #7, who could not reach or trigger it, resulting in delayed care and potential harm. Interviews and observations confirmed the call light was found under Resident #7's blanket near his feet, and staff did not check its placement as required.
Citations (1)
Failure to reasonably accommodate the needs and preferences of Resident #7 by not ensuring the call light was within reach, resulting in delayed response to calls for help.
Report Facts
Residents reviewed: 8
Residents affected: 1
BIMS score: 7
BIMS score range: 13
Temperature: 74
Temperature: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide A | Nurse Aide | Responded to call light, repositioned call light, raised room temperature |
| LVN B | Licensed Vocational Nurse (Charge Nurse) | Responsible for checking call light placement, could not verify last check on 07/25/23 |
Inspection Report — Jun 29, 2023
Annual Inspection
Date: Jun 29, 2023
Visit Reason
The inspection was conducted to assess the safety, functionality, sanitation, and comfort of the nursing home environment, including biohazard rooms, ceiling vents, and resident rooms, following a grievance about environmental conditions.
Findings
The facility failed to provide a safe and comfortable environment due to an unlocked biohazard room with full sharps containers, dusty and dirty ceiling vents, and a resident room with a malfunctioning air conditioning unit causing high temperatures. Maintenance and housekeeping issues were noted, including lack of work orders and delayed corrective actions.
Citations (3)
Second floor biohazard room did not lock and contained four full sharps containers.
Vent near the elevator on the second floor was covered with dust and a black substance.
Resident room on second floor was hot with an average temperature of 85 degrees F due to improperly mounted AC unit blowing warm air.
Report Facts
Temperature reading: 85
Number of full sharps containers: 4
Date of grievance: Jun 16, 2023
Date of inspection: Jun 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Stated biohazard room did not lock due to self-closer arm issue and described attempts to fix AC unit | |
| Administrator | Responsible for maintenance and environment; acknowledged dirty vents and AC issues | |
| DON | Director of Nursing | Reported on biohazard room locking issue and vent cleanliness responsibility |
Inspection Report — Jun 20, 2023
Complaint Investigation
Date: Jun 20, 2023
Visit Reason
The inspection was conducted due to complaints regarding the validity of advance directives and failure to provide CPR to a resident with Full Code status, as well as concerns about environmental conditions in resident rooms.
Complaint Details
The complaint investigation was substantiated with findings that included an invalid OOH-DNR for Resident #9 and failure to provide CPR to Resident #1 with Full Code status, resulting in an Immediate Jeopardy that was removed after corrective actions.
Findings
The facility failed to ensure a valid Out-of-Hospital Do Not Resuscitate (OOH-DNR) for one resident, and failed to provide CPR to a resident with Full Code status, resulting in an Immediate Jeopardy situation that was later removed. Additionally, unsafe and unsanitary environmental conditions were found in four resident rooms, including black substances in showers, missing shower heads, and plumbing issues.
Citations (3)
Resident #9's Out-of-Hospital Do Not Resuscitate (OOH-DNR) was invalid due to missing signatures and incomplete witness information.
Failure to provide basic life support, including CPR, to Resident #1 who had Full Code status, after being found unresponsive with no pulse or respirations.
Unsafe and unsanitary environmental conditions in 4 resident rooms, including black substance on shower walls and floors, missing shower heads, missing toilet tank lids, loose PVC piping under sinks, and missing closet bars.
Report Facts
Residents reviewed for advance directives: 13
Residents reviewed for Full code status: 14
Residents affected by deficiencies: 4
Staff signatures on emergency procedures in-service: 44
Staff interviewed for emergency procedures training: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Agency LVN A | Licensed Vocational Nurse | Named in failure to provide CPR to Resident #1. |
| ADON LVN B | Assistant Director of Nursing | Named in failure to provide CPR and emergency response oversight. |
| Corporate Registered Nurse | Involved in interviews and education regarding emergency procedures and OOH-DNR correction. | |
| CNA F | Certified Nursing Assistant | Witnessed Resident #1 found unresponsive and reported to Agency LVN A. |
| CNA G | Certified Nursing Assistant | Witnessed Resident #1 found unresponsive and reported to Agency LVN A. |
| Housekeeping Supervisor | Confirmed environmental deficiencies in resident rooms. | |
| Administrator | Facility Administrator | Provided statements on emergency procedures and environmental conditions. |
Inspection Report — Apr 14, 2023
Routine
Date: Apr 14, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident privacy, quality of life, activities of daily living, incontinence care, medication storage, food safety, equipment maintenance, and room size standards at San Antonio North Nursing and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to protect resident privacy, maintain a pleasant environment, provide adequate personal care and hygiene, ensure timely incontinent care, secure medication carts, properly label and store food, maintain kitchen equipment, and provide adequate room size per resident. These deficiencies posed risks of privacy violations, diminished quality of life, infection, injury, and potential harm to residents.
Citations (8)
Failed to ensure residents' personal and medical records were kept private and confidential; computer screen with resident information was left open and visible.
Failed to ensure environment was free of unpleasant odors and residents could spend time outside per preferences.
Failed to provide necessary care and services to maintain good nutrition, grooming, and personal and oral hygiene; residents' fingernails were long, jagged, and dirty.
Failed to provide appropriate care for residents incontinent of bladder; urinary catheter bag was full and backing up, and incontinent care was not timely leading to strong foul odor.
Failed to ensure all drugs and biologicals were stored in locked compartments; medication cart was left unlocked and unattended.
Failed to store, prepare, distribute and serve food in accordance with professional standards; food items were not properly labeled, dated, and expired items were present.
Failed to maintain all mechanical, electrical and patient care equipment in safe operating condition; oven grease can was welded and could not be removed or properly cleaned.
Failed to provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 5
Residents affected: 2
Residents affected: 1
Residents affected: Many
Residents affected: Many
Residents affected: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA D | Medication Aide | Left medication cart unlocked during medication administration |
| LVN A | Licensed Vocational Nurse | Stated staff were trained to lock medication carts |
| ADON | Assistant Director of Nursing | Stated medication carts should be locked to prevent unauthorized access |
| DON | Director of Nursing | Stated unlocked medication carts pose risk of overdose and allergic reaction |
| ADM | Administrator | Stated unlocked medication carts pose risk of overdose and theft |
| CNA G | Certified Nursing Assistant | Reported foul odor near Resident #8's room and issues with incontinent care |
| CNA F | Certified Nursing Assistant | Reported Resident #8's incontinent care issues and nail care procedures |
| LVN C | Licensed Vocational Nurse | Reported on Resident #8's incontinent care and nail care monitoring |
| MDSN | MDS Nurse | Observed full urinary catheter bag for Resident #10 |
| CNA E | Certified Nursing Assistant | Reported emptying catheter bags at end of shift |
| DC I | Cook | Reported grease can on oven #2 could not be removed and cleaned properly |
| MAINT | Maintenance Staff | Reported grease can on oven #2 was welded and could not be removed |
| DS | Dietary Supervisor | Reported food labeling and storage deficiencies |
| DA B | Dietary Aide | Reported lack of training on food labeling policy |
| DA A | Dietary Aide | Reported lack of recent training on food labeling policy |
Inspection Report — Mar 15, 2023
Routine
Date: Mar 15, 2023
Visit Reason
The inspection was conducted to assess compliance with food service safety standards, specifically regarding the storage, preparation, distribution, and serving of food at the facility.
Findings
The facility failed to store non-refrigerated food properly, as nine cases of food were found stored on the floor in a closet with cobwebs and numerous trapped insects, posing a risk of food contamination and potential foodborne illness to residents.
Citations (1)
Failed to store non-refrigerated food in a manner that protected it from contamination, with cases of food stored on the floor and presence of cobwebs and insects in the storage area.
Report Facts
Cases of food stored on floor: 9
Date of observation: Mar 15, 2023
Date of interviews: Mar 16, 2023
Months Dietary Manager in position: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Confirmed presence of food cases on floor and lack of dating on cans; stated cobwebs and insects could lead to contamination. | |
| Administrator | Confirmed food was stored on floor for emergency purposes and acknowledged room was not climate controlled with presence of cobwebs and insects. | |
| Director of Nursing (DON) | Confirmed presence of food cases on floor during interview. |
23 CMS Surveys
CMS Survey — Mar 16, 2023
Mar 16, 2023
CMS Survey — Jun 20, 2023
Jun 20, 2023
CMS Survey — Jun 29, 2023
Jun 29, 2023
CMS Survey — Jul 26, 2023
Jul 26, 2023
CMS Survey — Aug 5, 2023
Aug 5, 2023
CMS Survey — Aug 19, 2023
Aug 19, 2023
CMS Survey — Sep 8, 2023
Sep 8, 2023
CMS Survey — Feb 2, 2024
Feb 2, 2024
CMS Survey — May 28, 2024
May 28, 2024
CMS Survey — Jun 6, 2024
Jun 6, 2024
CMS Survey — Jun 13, 2024
Jun 13, 2024
CMS Survey — Jun 29, 2024
Jun 29, 2024
CMS Survey — Jan 10, 2025
Jan 10, 2025
CMS Survey — Feb 28, 2025
Feb 28, 2025
CMS Survey — May 12, 2025
May 12, 2025
CMS Survey — May 23, 2025
May 23, 2025
CMS Survey — Nov 19, 2025
Nov 19, 2025
CMS Survey — Dec 9, 2025
Dec 9, 2025
CMS Survey — Apr 14, 2023
Apr 14, 2023
CMS Survey — Jun 13, 2024
Jun 13, 2024
CMS Survey — Jul 31, 2025
Jul 31, 2025
CMS Survey — Mar 16, 2023
Mar 16, 2023
CMS Survey — Sep 8, 2023
Sep 8, 2023
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