Inspection Reports for San Pedro Manor
515 W Ashby Pl, San Antonio, TX 78212, United States, TX, 78212
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
243% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 6
Date: Aug 8, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, privacy, incontinent care, food service, infection control, and facility cleanliness.
Findings
The facility was found deficient in multiple areas including failure to ensure timely mail distribution and privacy in communication, inadequate privacy during care, improper incontinent care practices risking infection, serving cold food not meeting temperature standards, failure to maintain clean kitchen vents, and lapses in infection prevention practices by staff.
Deficiencies (6)
Failed to ensure residents had the right to send and receive mail timely and with privacy; mail received on Saturdays was not distributed until Monday.
Failed to ensure residents' privacy during care; privacy curtain was broken and not fully closed during incontinent care for Resident #92.
Failed to provide appropriate incontinent care; CNA made multiple passes with the same wipe and did not separate labia during cleaning, risking infection for Residents #12 and #92.
Failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature; meals served cold to Residents #6, #43, and #93.
Failed to maintain clean kitchen environment; dirty and rusty overhead ceiling vents in kitchen and dish room.
Failed to maintain infection prevention and control program; CNA E did not sanitize hands properly before and between glove changes while providing incontinent care to Resident #92.
Report Facts
Residents affected: 5
Residents affected: 1
Residents affected: 2
Residents affected: 3
Ceiling vents: 7
Food temperature: 94.82
Food temperature: 90.32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Certified Nursing Assistant | Named in privacy curtain and infection control deficiencies; failed to close privacy curtain and sanitize hands properly during incontinent care. |
| CNA F | Certified Nursing Assistant | Named in privacy curtain deficiency; failed to close privacy curtain during incontinent care. |
| CNA G | Certified Nursing Assistant | Named in incontinent care deficiency; made multiple passes with the same wipe during care. |
| Receptionist D | Named in mail distribution deficiency; stated mail received on weekends is not distributed until Monday. | |
| Receptionist C | Named in mail distribution deficiency; stated weekend mail is put in drawer for Monday distribution. | |
| HR | Named in mail distribution deficiency; stated mail is supposed to be distributed on Saturdays. | |
| SS | Named in mail distribution deficiency; stated residents should get mail on Saturday. | |
| DON | Director of Nursing | Named in multiple deficiencies; confirmed training provided, staff skills checks, and commented on privacy and infection control failures. |
| Food Service Director | Named in kitchen cleanliness deficiency; responsible for work order to clean/replace vents. | |
| Maintenance Director | Named in kitchen cleanliness deficiency; received work order for vent cleaning/replacement. | |
| Activity Director | Named in food temperature deficiency; reported resident council complaints about cold food. |
Inspection Report
Deficiencies: 1
Date: Jul 30, 2025
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control program compliance, specifically related to the use of enhanced barrier precautions for residents with wounds.
Findings
The facility failed to maintain an infection prevention and control program by not ensuring staff used appropriate personal protective equipment (PPE) such as gowns when caring for a resident with a surgical chest incision requiring enhanced barrier precautions. PPE was not readily available near the resident's room, and no signage was posted to indicate the need for PPE, placing residents at risk of infection.
Deficiencies (1)
Failure to provide and implement an infection prevention and control program, including failure to use gowns and PPE for a resident with a surgical chest incision requiring enhanced barrier precautions.
Report Facts
Residents affected: 1
Date of incident: Jul 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Failed to wear gown while caring for Resident #8 and demonstrated knowledge of EBP but did not see signage |
| MDS RN | Minimum Data Set Registered Nurse | Stated residents with wounds and high-contact care should be on EBP and PPE was not readily available |
| ADON | Assistant Director of Nursing | Confirmed Resident #8 should have been on EBP and PPE was not available near resident's room |
Inspection Report
Deficiencies: 1
Date: Jul 17, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards regarding the maintenance and accuracy of resident medical records, specifically focusing on documentation related to resident falls.
Findings
The facility failed to maintain complete and accurate medical records for Resident #1, with conflicting documentation about whether two falls on 5/28/25 and 7/12/25 were witnessed or unwitnessed. This discrepancy could affect accurate monitoring and interventions for fall prevention.
Deficiencies (1)
Failure to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, specifically inaccurate documentation of witnessed versus unwitnessed falls for Resident #1.
Report Facts
Fall risk score: 11
BIMS score: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Authored nurse note and incident report related to Resident #1's fall on 5/28/25 |
| LVN B | Licensed Vocational Nurse | Authored nurse note related to Resident #1's fall on 7/12/25 |
| LVN C | MDS Nurse | Interviewed regarding documentation errors for Resident #1's falls |
| DON | Director of Nursing | Interviewed regarding awareness and correction of documentation inaccuracies |
| RN | Intensive Care Unit Registered Nurse | Interviewed about Resident #1's condition and hospital transfer |
| Administrator | Facility Administrator | Interviewed regarding documentation findings and staff in-service plans |
Inspection Report
Routine
Deficiencies: 1
Date: May 6, 2025
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control program, specifically focusing on the cleanliness and sanitation of the 3rd floor community shower rooms.
Findings
The facility failed to maintain a clean and sanitary environment in the 3rd floor shower room, with observations of hair clogs in drains, brown substances under shower chairs, dirty floors with feces, and inadequate cleaning and disinfecting practices by staff.
Deficiencies (1)
The 3rd floor shower room had drains clogged with hair, brown substance under a shower chair, dirty floors with darkened areas and feces, indicating failure to maintain a sanitary environment.
Report Facts
Residents potentially affected: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Provided information about shower chair cleaning practices and product availability | |
| RN B | Registered Nurse | Observed dirty conditions in the 3rd floor shower room and notified maintenance |
| Maintenance Assistant C | Described cleaning responsibilities and use of disinfectant wipes for shower chairs | |
| ADM | Administrator | Committed to ensuring staff education on cleaning/disinfecting shower rooms |
| DON | Director of Nursing | Committed to ensuring staff education on cleaning/disinfecting shower rooms |
| Maintenance/Hsk Supervisor | Described cleaning schedules, chemical use, and responsibilities for shower room sanitation |
Inspection Report
Routine
Deficiencies: 10
Date: Jun 27, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations related to resident safety, abuse prevention, medication administration, infection control, equipment maintenance, and pest control.
Findings
The facility was found deficient in maintaining comfortable room temperatures, timely reporting of abuse and neglect incidents, proper medication administration, infection control practices, equipment maintenance, and pest control. Specific failures included inadequate temperature control in a resident's room, failure to report incidents involving residents, medication errors, improper care and documentation of feeding tubes, failure to use appropriate PPE, malfunctioning resident bed, and presence of pests in the kitchen and resident rooms.
Deficiencies (10)
Failed to maintain comfortable and safe temperature levels in Resident #2's room, which was observed to be 80-82 degrees Fahrenheit.
Failed to implement written policies and procedures to prevent abuse, neglect, and theft, including failure to report incidents involving Residents #40, #36, and #9 to the State Survey Agency.
Failed to timely report suspected abuse, neglect, or theft involving Residents #40, #36, and #9 to the State Survey Agency.
Failed to ensure Resident #40 was safely transferred onto the transportation van, resulting in a sprained foot.
Failed to ensure accurate PASARR Level 1 screening for Resident #63, resulting in failure to identify mental illness and refer for appropriate evaluation.
Failed to provide appropriate gastrostomy tube care for Resident #19 per physician orders, including failure to clean the g-tube stoma and inaccurate documentation of care.
Failed to ensure Resident #9 was free from significant medication errors when LVN A administered the wrong medications on 04/22/24.
Failed to maintain infection prevention and control program, including failure of staff to don appropriate PPE when providing care to Residents #57 and #185 on Enhanced Barrier Precautions.
Failed to maintain Resident #8's bed in proper working condition, limiting the resident's ability to adjust the bed and potentially increasing risk of injury.
Failed to maintain an effective pest control program, resulting in ant infestation in Resident #36's bed and presence of gnats in the kitchen food preparation and storage areas.
Report Facts
Temperature readings: 80
Temperature readings: 82
Pain level: 10
BIMS score: 14
BIMS score: 11
BIMS score: 3
BIMS score: 12
BIMS score: 4
Medication error monitoring duration: 72
Feeding tube care dates: 2
Pest control treatment frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Administered wrong medications to Resident #9 and documented progress notes on 04/22/24 |
| LVN F | Licensed Vocational Nurse | Assigned nurse for Resident #19 who failed to provide and accurately document g-tube care |
| DON | Director of Nursing | Interviewed regarding medication error, g-tube care, and incident reporting |
| Operations Manager | Interviewed regarding incident reporting and medication error reporting responsibilities | |
| Maintenance Assistant | Interviewed about Resident #2's AC issues | |
| Maintenance Director | Interviewed about Resident #2's AC repair and Resident #8's bed maintenance | |
| LVN B | Licensed Vocational Nurse | Notified LVN A about Resident #40's foot injury |
| CNA C | Certified Nursing Assistant | Provided care to Resident #57 without wearing gown as required |
| LVN D | Licensed Vocational Nurse | Provided catheter care without wearing gown |
| CNA E | Certified Nursing Assistant | Provided catheter care without wearing gown |
| Infection Preventionist | Provided infection control in-service and interviewed about PPE compliance | |
| CNA G | Certified Nursing Assistant | Reported Resident #8's bed not working to Maintenance Director |
| RN H | Registered Nurse | Interviewed about Resident #8's bed and care |
Inspection Report
Routine
Deficiencies: 6
Date: Jun 27, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident safety, abuse reporting, food safety, medical record accuracy, equipment functionality, and pest control.
Findings
The facility was found deficient in maintaining comfortable room temperatures for residents, timely reporting of abuse and neglect incidents, food service sanitation, accurate medical record documentation, safe and functional resident equipment, and effective pest control measures.
Deficiencies (6)
Failed to provide comfortable and safe temperature levels between 71 to 81 degrees Fahrenheit for one resident's room.
Failed to timely report suspected abuse, neglect, or theft incidents involving three residents to the State Survey Agency.
Failed to store, prepare, distribute, and serve food in accordance with professional standards due to dust and fuzz on kitchen air vents.
Failed to maintain medical records accurately for one resident by documenting g-tube care that was not provided.
Failed to maintain mechanical, electrical, and patient care equipment in safe operating condition; resident's bed was not functioning properly.
Failed to maintain an effective pest control program; resident had ant infestation and multiple gnats were observed in the kitchen.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Pest control treatments: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Administered wrong medications to Resident #9 and reported the error |
| LVN F | Licensed Vocational Nurse | Failed to provide and inaccurately documented g-tube care for Resident #19 |
| Maintenance Assistant | Checked Resident #2's AC multiple times and reported to Maintenance Director | |
| Maintenance Director | Responded to Resident #2's AC issue and checked Resident #8's bed | |
| Operations Manager | Responsible for reporting abuse and unaware of Resident #9 medication error | |
| DON | Director of Nursing | Reviewed incidents, medication errors, and g-tube care documentation; responsible for compliance oversight |
| CNA G | Certified Nursing Assistant | Reported Resident #8's bed not working to Maintenance Director |
| RN H | Registered Nurse | Provided care to Resident #8 and reported no knowledge of bed malfunction |
| Dietary Supervisor | Reported kitchen air vents cleaning schedule and pest control efforts | |
| Maintenance Supervisor | Responsible for maintenance and pest control oversight |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 17, 2024
Visit Reason
Annual survey inspection of San Pedro Manor nursing home to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 17, 2024
Visit Reason
The inspection was conducted due to a complaint investigation related to a resident elopement incident and infection control concerns at the nursing home.
Complaint Details
The complaint investigation was substantiated with findings that Resident #1 eloped from the facility on 12/04/2023, placing residents at risk of harm. The immediate jeopardy began on 12/04/2023 and ended on 12/22/2023 after corrective actions were implemented. Infection control deficiencies were also identified related to improper glove use and hand hygiene by staff.
Findings
The facility failed to prevent Resident #1 from eloping on 12/04/2023, resulting in immediate jeopardy that was corrected before the survey. Additionally, the facility failed to maintain proper infection prevention and control practices for Resident #2, specifically related to hand hygiene and glove use during incontinent care.
Deficiencies (2)
Failed to ensure the resident environment remained free of accident hazards and provide adequate supervision to prevent Resident #1 from eloping on 12/04/2023.
Failed to maintain an infection prevention and control program; CNA did not change gloves or wash hands properly during incontinent care for Resident #2.
Report Facts
Resident elopement date: Dec 4, 2023
Immediate Jeopardy duration: 18
Staff training attendance: 103
Number of employees interviewed: 22
Resident #2 admission date: Jan 20, 2020
Resident #2 readmission date: Sep 30, 2023
Resident #2 Quarterly MDS assessment date: Feb 12, 2024
Resident #2 BIMS score: 15
In-service training dates: Training conducted on 01/04/2024, 03/27/2024, and 05/08/2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON | Director of Nursing | Interviewed regarding Resident #1 elopement and infection control practices |
| LVN C | Licensed Vocational Nurse | Interviewed about Resident #1's behavior and supervision |
| CNA A | Certified Nursing Assistant | Observed and interviewed regarding improper glove use and hand hygiene during care of Resident #2 |
| HR Director | Human Resources Director | Interviewed about changes to reception desk hours after elopement incident |
| Maintenance Director | Maintenance Director | Interviewed about elopement drills and alarm system changes |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 2, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide pharmaceutical services ensuring accurate medication administration for Resident #1.
Complaint Details
The complaint investigation found that Resident #1 missed several doses of prescribed Alprazolam on 3/21/2024 and 3/22/2024. Hospice was not notified timely to refill the medication, and the facility staff failed to administer the medication despite its delivery. Resident #1 expressed feeling 'crazy' due to missed doses and suspected facility staff error. The Director of Nursing and other staff confirmed the missed doses and acknowledged the failure.
Findings
The facility failed to ensure Resident #1 received his scheduled Alprazolam Oral Tablet 0.5 MG as ordered by the physician on multiple occasions, resulting in missed doses. The failure was linked to delays in medication delivery from hospice and lack of timely administration by facility staff.
Deficiencies (1)
Failure to provide pharmaceutical services to ensure accurate administration of medications for Resident #1, specifically missed doses of Alprazolam Oral Tablet 0.5 MG as ordered.
Report Facts
Missed medication doses: 3
Residents reviewed for medication administration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Treatment Nurse | Interviewed regarding Resident #1's medication administration and hospice communication |
| LVN B | Drafted progress note on 3/22/2024 regarding pending medication delivery | |
| RN C | Registered Nurse | Confirmed missed doses and Resident #1's reaction during telephone interview |
| Hospice Nurse D | Hospice Nurse | Confirmed no notification from facility to hospice for medication refill |
| DON | Director of Nursing | Agreed Resident #1 missed scheduled doses of Alprazolam |
Inspection Report
Routine
Census: 19
Deficiencies: 5
Date: May 12, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident rights, accurate resident assessments, food safety, waste disposal, and safeguarding of medical records.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during feeding, inaccurate resident assessments, improper food storage and preparation practices, inadequate waste disposal, and failure to secure resident medical records, all posing potential risks to residents' health, safety, and privacy.
Deficiencies (5)
Failure to promote care that maintained or enhanced dignity and respect for residents, specifically feeding a resident while standing above eye level.
Failure to ensure the assessment accurately reflected the resident's status, including incorrect PASRR coding.
Failure to store, prepare, distribute, and serve food in accordance with professional standards, including expired cheese, unlabeled opened milk containers, dish machine not reaching proper temperature, and employee wearing jewelry while preparing food.
Failure to properly dispose of garbage and refuse, including waste receptacles without tight-fitting lids and overfilled receptacles outside the facility.
Failure to safeguard resident-identifiable information and maintain medical records securely, with records scattered on the floor in an unlocked room accessible to construction workers.
Report Facts
Residents affected: 19
Residents affected: 6
Residents affected: 1
Residents affected: 3
Residents affected: 1
Dish machine temperature: 110.5
Dish machine temperature: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in dignity and feeding assistance deficiency for standing while feeding Resident #72 |
| ADON B | Assistant Director of Nursing | Observed and interviewed regarding feeding method and dignity concerns |
| MDS Coordinator | Responsible for completion of MDS, involved in inaccurate assessment deficiency | |
| DM | Dietary Manager | Interviewed regarding food safety deficiencies including expired food, labeling, dish machine temperature, and employee jewelry |
| [NAME] C | Kitchen Staff | Observed wearing jewelry while preparing food |
| Maintenance Director | Interviewed regarding waste disposal issues | |
| Administrator | Interviewed regarding feeding dignity, waste disposal, and medical records safeguarding | |
| Staff D | Provided information about medical records storage and security | |
| DON | Director of Nursing | Informed about unsecured medical records in conference room |
Inspection Report
Routine
Deficiencies: 3
Date: Mar 21, 2023
Visit Reason
The inspection was conducted to evaluate compliance with resident rights, medication administration, and staff licensure requirements at San Pedro Manor.
Findings
The facility failed to treat residents with dignity during feeding, failed to ensure medication was consumed by residents, and employed a nursing staff member without a valid license for 28 days. These deficiencies posed risks to resident safety and quality of care.
Deficiencies (3)
Failure to treat resident with respect and dignity during feeding; ADON B was on a personal phone call while feeding Resident #6.
Failure to provide pharmaceutical services ensuring medication was consumed; MA A left Resident #5's medication at bedside without ensuring consumption.
Employed Staff C, a Graduate Vocational Nurse, who worked 28 days without a valid nursing license.
Report Facts
Residents affected: 6
Residents affected: 6
Staff affected: 21
Days worked without license: 28
Hours worked without license: 221.63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON B | Assistant Director of Nursing | Engaged in personal phone call while feeding Resident #6; provided training to Staff C |
| MA A | Medication Aide | Left medication at bedside without ensuring Resident #5 consumed it |
| Staff C | Graduate Vocational Nurse (GVN) | Worked 28 days without a valid nursing license; failed LVN licensing exam; lacked proper supervision and training |
| DON | Director of Nursing | Provided statements on expectations for staff behavior and medication administration; unaware of Staff C's license expiration |
| Administrator | Facility Administrator | Unaware of Staff C's license expiration and exam failure |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 1, 2023
Visit Reason
The inspection was conducted as a routine annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
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