Inspection Reports for Silver Creek Nursing and Rehab
9014 Timber Path, San Antonio, TX 78250, TX, 78250
Back to Facility ProfileDeficiencies (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
Annual Inspection
Deficiencies: 6
Date: Jul 2, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, food and nutrition services, infection control, and the facility environment at Silver Creek Nursing and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate pressure ulcer care, inadequate monitoring of residents' fluid intake, unsafe food storage and kitchen maintenance issues, lack of policy enforcement on foods brought by visitors, inadequate infection prevention and control practices, and environmental maintenance deficiencies in resident areas and shower rooms.
Deficiencies (6)
Failed to ensure a resident with pressure ulcers received necessary treatment and services, including repositioning every 2 hours as per care plan.
Failed to provide nutritional and hydration care consistent with fluid restriction orders for a resident, including failure to assess and document fluid intake.
Failed to maintain kitchen cleanliness and repair damaged kitchen infrastructure including vents, lighting, tiles, and floor molding.
Failed to enact and enforce a policy regarding use and storage of foods brought to residents by family and visitors, resulting in unlabeled and undated food in resident's personal refrigerator.
Failed to maintain an infection prevention and control program, including improper storage of clean linen, lack of PPE availability, and staff not following transmission-based precautions.
Failed to provide a safe, functional, sanitary, and comfortable environment due to unclean vents, broken lighting, damaged floor molding, and rusted sprinkler heads in resident hallways and shower rooms.
Report Facts
Fluid restriction: 1500
Fluid intake nursing: 780
Fluid intake dietary: 720
Inspection date: Jul 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Named in failure to reposition Resident #13 and fluid intake monitoring for Resident #39 | |
| RN G | Named in repositioning oversight and fluid intake monitoring | |
| DON | Director of Nursing | Named in repositioning expectations and infection control program oversight |
| CNA F | Observed serving excess fluids to Resident #39 | |
| CNA H | Named in fluid intake monitoring for Resident #39 | |
| LVN I | Named in fluid intake monitoring for Resident #39 | |
| ADON J | Assistant Director of Nursing | Named in fluid intake monitoring and communication |
| Cook-A | Named in kitchen cleanliness deficiencies | |
| Food Service Director | Named in kitchen cleanliness deficiencies and repair responsibility | |
| Administrator | Named in kitchen and environmental maintenance deficiencies | |
| Maintenance Director | Named in kitchen and environmental maintenance deficiencies | |
| Laundry Aide C | Named in improper linen storage | |
| CNA D | Named in failure to use PPE for Resident #78 | |
| CNA K | Named in failure to use PPE for Resident #191 | |
| LVN L | Named in failure to use PPE for Resident #191 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 19, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of abuse involving Resident #1 who fell off the bed on 03/14/2025.
Complaint Details
The complaint investigation found that the facility did not report an allegation of abuse within 24 hours to the State Survey Agency when Resident #1 fell off the bed. The allegation was substantiated as the facility acknowledged the failure to report timely and inadequate supervision by CNA A during care.
Findings
The facility failed to report the abuse allegation within the required timeframe and failed to provide adequate supervision and assistance during incontinent care, resulting in Resident #1 falling off the bed. The facility identified this as past non-compliance and corrected the issue prior to the survey.
Deficiencies (2)
Failure to timely report suspected abuse, neglect, or theft to proper authorities for Resident #1.
Failure to ensure adequate supervision and use of assistive devices to prevent accidents for Resident #1, resulting in a fall.
Report Facts
Residents reviewed for abuse: 3
Residents affected: 1
Staff in-service completion: 40
PRN staff in-service completion: 2
Staff interviewed: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in findings for failing to provide adequate supervision and assistance during incontinent care leading to Resident #1's fall |
| LVN B | Licensed Vocational Nurse | Assessed Resident #1 for injuries and reported the incident to the administrator |
| DON | Director of Nursing | Provided information on reporting responsibilities and care plan adherence |
| Administrator | Facility Administrator | Responsible for reporting allegations of abuse; acknowledged failure to report within required timeframe |
Inspection Report
Deficiencies: 1
Date: Mar 12, 2025
Visit Reason
The inspection was conducted to assess the safety, functionality, sanitation, and comfort of the nursing home environment, focusing on resident hallways for environmental concerns.
Findings
The facility failed to replace dirty ceiling tiles and clean rusted air vents on four of five resident hallways (100, 200, 400, and 500), which could place residents at risk of diminished quality of life due to exposure to an unpleasant and unsafe environment. Maintenance staff acknowledged the issues and noted these had not been a work priority, while the administrator was previously unaware of the conditions.
Deficiencies (1)
Failure to replace dirty ceiling tiles and clean rusted air vents on resident hallways 100, 200, 400, and 500.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding the condition of ceiling tiles and air vents, responsible for cleaning and maintenance. | |
| Administrator | Interviewed about awareness of facility conditions and work order system. |
Inspection Report
Routine
Deficiencies: 3
Date: Aug 27, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, treatment administration, infection control, and documentation practices at Silver Creek Nursing and Rehabilitation.
Findings
The facility failed to ensure appropriate wound care treatment and documentation for multiple residents, including failure to label wound dressings, follow physician orders, and accurately document treatment administration. Additionally, the facility failed to maintain proper infection control signage for residents on enhanced barrier precautions.
Deficiencies (3)
Failure to label and date wound treatment dressing and follow physician orders for wound care for Resident #2.
Failure to maintain complete and accurate treatment administration records (TAR) for 7 residents (#1, #2, #3, #4, #5, #6, #8).
Failure to maintain an infection control program ensuring enhanced barrier precaution signs were posted on Resident #2's room door.
Report Facts
Residents reviewed for quality of care: 8
Residents affected by treatment administration deficiencies: 7
Residents affected by infection control deficiency: 1
Wound size: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Licensed Vocational Nurse | Named in wound care deficiencies for failing to label wound dressings and follow physician orders |
| RN A | Registered Nurse | Treatment nurse responsible for wound care Monday-Friday, observed wound care and interviewed regarding TAR documentation |
| CNA B | Certified Nursing Assistant | Observed wound care dressing issues and interviewed regarding infection control signage |
| RN B | Infection Preventionist | Interviewed regarding enhanced barrier precautions and signage responsibility |
| DON | Director of Nursing | Interviewed regarding wound care protocols, TAR documentation, and infection control signage |
| Administrator | Facility Administrator | Interviewed regarding wound care monitoring and TAR compliance |
Inspection Report
Routine
Deficiencies: 3
Date: Jun 6, 2024
Visit Reason
The inspection was conducted to evaluate compliance with medication storage and labeling standards, as well as food service safety and sanitation practices in the facility.
Findings
The facility failed to ensure proper medication storage, including the presence of expired medications and loose pills on medication carts, and failed to maintain sanitary conditions during food preparation, specifically not allowing puree processor parts to air dry before use, which could risk contamination.
Deficiencies (3)
Expired bottle of medication was stored in the drawer of the 400-hall medication cart.
Medication cart assigned to hall 100 had a loose pill.
Facility failed to store, prepare, distribute, and serve food in accordance with professional standards; puree processor parts were not allowed to air dry before use, causing liquid to drip onto floor and countertop.
Report Facts
Medication carts inspected: 6
Date of medication cart observation: Jun 5, 2024
Date of food preparation observation: Jun 4, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA A | Observed expired medication on cart and interviewed regarding medication storage responsibilities | |
| DON | Director of Nursing | Provided training information and expectations regarding medication storage and cart audits |
| RN A | Registered Nurse | Observed loose pill on medication cart and interviewed about medication storage responsibilities |
| ADM | Administrator | Interviewed regarding staff training and expectations on medication storage |
| [NAME] A | Cook | Observed during puree meal preparation and interviewed about sanitation practices |
| DM | Dietary Manager | Interviewed about training and sanitation practices in food preparation |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 22, 2023
Visit Reason
The inspection was conducted due to a complaint regarding failure to immediately consult the resident's physician and notify the responsible party prior to placing an indwelling urinary catheter in Resident #1.
Complaint Details
The complaint investigation revealed that Resident #1 had an indwelling urinary catheter inserted without a physician's order and without notification to the resident's physician or responsible party. The catheter was left in place after attempts to collect urine via in-and-out catheter failed. The resident developed a urinary tract infection and was hospitalized. Interviews with nursing staff, the resident's responsible party, and the physician confirmed lack of notification and absence of a physician's order.
Findings
The facility failed to notify Resident #1's primary physician and responsible party before placing an indwelling urinary catheter without a physician's order, which placed the resident at risk for untimely and inappropriate care, including infection. Interviews and record reviews confirmed the catheter was inserted without proper orders and notification.
Deficiencies (2)
Failure to immediately consult the resident's physician and notify the responsible party prior to placing an indwelling urinary catheter in Resident #1.
Failure to ensure incontinent care was provided in accordance with appropriate treatment and service practices to prevent urinary tract infections and to restore continence for Resident #1, including insertion of an indwelling urinary catheter without a physician's order.
Report Facts
Residents reviewed: 5
BIMS score: 2
Dates of catheter insertion and related notes: Catheter inserted on 11/16/2023; progress notes dated 11/15/23, 11/16/23, 11/17/23
Date of hospital record: Hospital record dated 11/18/23 noting UTI and catheter presence
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Attempted in-and-out catheterization and left indwelling catheter in place without order |
| RN J | Registered Nurse | Noted cooperation of Resident #1 with indwelling catheter |
| LVN G | Licensed Vocational Nurse | Inserted foley catheter and cared for Resident #1 |
| CNA C | Certified Nursing Assistant | First time caring for Resident #1 with indwelling catheter |
| RN D | Registered Nurse | Stated catheter was inserted on 11/16/23 and left in |
| CNA K | Certified Nursing Assistant | Worked with Resident #1 while indwelling catheter was in place |
| Physician I | Primary Physician | Notified about UTI and catheter after the fact; not informed prior to catheter placement |
| DON | Director of Nursing | Stated an order is needed for indwelling catheter and notification is required; acknowledged lack of order and notification |
| Hospital Nurse F | Hospital Nurse | Noted no clear reason for catheter placement based on resident condition |
| LVN B | Licensed Vocational Nurse | Assisted in placing indwelling catheter without knowledge of order |
Inspection Report
Deficiencies: 4
Date: May 12, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory standards related to dialysis care, menu and food service safety, infection control, and other aspects of resident care and facility operations.
Findings
The facility was found deficient in maintaining proper communication and coordination with the dialysis center for a resident requiring dialysis, failing to follow menus as prescribed including unauthorized recipe changes, improper food storage and sanitation practices, and inadequate infection control practices during resident care.
Deficiencies (4)
Failed to ensure residents who required dialysis received appropriate services due to lack of communication and coordination with dialysis facility.
Failed to ensure menus were followed; served Homestyle Macaroni & Cheese containing meat despite recipe indicating vegetarian option without dietician approval.
Failed to store, prepare, distribute and serve food in accordance with professional standards; multiple food items in dry storage were opened, unlabeled, undated, or contaminated with mold.
Failed to establish and maintain an infection control program; CNA did not change gloves or sanitize hands when performing incontinent care, risking cross contamination.
Report Facts
Dialysis treatments per week: 3
Date of dialysis communication records reviewed: Dialysis Communication Records dated 4/12/23, 4/26/23, and 5/8/23 were blank.
Date of menu observation: Observation of meal with Homestyle Macaroni & Cheese with meat on 05/10/2023.
Number of food storage violations: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Failed to follow infection control requirements during incontinent care for Resident #71. |
| RN A | Registered Nurse | Reported issues with dialysis communication records not being returned or completed. |
| LVN B | Licensed Vocational Nurse | Described procedures for handling dialysis communication records and importance of completed forms. |
| DON | Director of Nursing | Discussed importance of dialysis communication records and infection control practices. |
| DM | Dietary Manager | Admitted to adding meat to vegetarian recipe without dietician approval and improper food storage practices. |
| Administrator | Facility Administrator | Acknowledged that dietician should have been contacted before menu changes and residents have right to know meal contents. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 3, 2023
Visit Reason
The inspection was conducted as a routine annual survey of Silver Creek Nursing and Rehabilitation to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met all required standards at the time of the survey.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 30, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify a resident's physician of significant changes in condition, specifically related to bowel movements and resulting health decline.
Complaint Details
The complaint involved Resident #1 not having bowel movements for multiple days (4/10-4/12 and 4/15-4/18/23) without physician notification, leading to emergency surgery and colostomy. The facility failed to assess, document, and notify the physician as required. Immediate Jeopardy was identified on 4/27/2023 and removed on 4/30/2023 after corrective actions.
Findings
The facility failed to notify the physician of Resident #1's lack of bowel movements over multiple days, resulting in delayed medical intervention, emergency surgery, and a colostomy. Documentation and assessments were lacking, and staff failed to follow bowel management protocols. Immediate Jeopardy was identified but later removed after corrective actions.
Deficiencies (2)
Failure to immediately inform the resident's physician of significant change in condition related to bowel movements.
Failure to provide treatment and care according to orders and resident's preferences, resulting in emergency surgery and colostomy.
Report Facts
Days without bowel movement: 3
Days without bowel movement: 4
Date of Immediate Jeopardy identification: Apr 27, 2023
Date of Immediate Jeopardy removal: Apr 30, 2023
Number of nursing staff trained: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Stated facility had no explanation why physician was not notified after PCC alert for Resident #1's lack of bowel movement. |
| LVN B | Licensed Vocational Nurse | Unaware of Resident #1's no bowel movement from 4/15/23-4/18/23; stated floor nurse RN C should have contacted MD. |
| RN C | Registered Nurse | Charge nurse responsible for responding to PCC alerts; did not call MD after 72-hour alert for Resident #1. |
| DON | Director of Nursing | Acknowledged missed documentation and failure to notify MD; initiated training and corrective actions. |
| MD K | Medical Director and Resident #1's primary physician | Notified of Immediate Jeopardy; unaware of no bowel movement incidents until hospital admission. |
| Community Nurse U | Community Nurse | Informed facility of Resident #1's emergency surgery and concerns about neglect. |
| MD L | Physician | Not notified of no bowel movement incidents; stated nursing should have notified and ordered diagnostic tests. |
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