The Lev at San Antonio: Missing Hospital Records - TX
The Lev at San Antonio failed to secure hospital documentation when Resident #1 returned from an emergency visit on July 5, 2025, federal inspectors found during a complaint investigation completed August 14.
The resident was sent to the hospital at their family's request and returned "only a couple of hours" later, according to the facility's director of nursing. But no written orders, treatment notes, or discharge summaries came back with the patient.
Instead, LVN A documented in the facility's electronic system that there were "no new orders" based solely on a telephone conversation with hospital staff.
"We are only taking verbal information from the hospital," the director of nursing told inspectors during an August 14 interview.
The nursing director described this as an industry-wide problem. She said hospitals routinely send residents back to nursing facilities "without any paperwork or documentation."
But the facility wasn't requesting the records either.
When inspectors asked about the facility's process for obtaining hospital records, the director of nursing said she was "unsure what the facility policy was for obtaining and retaining hospital records."
She explained that the facility's approach was to have the resident's physician evaluate them within a few days of returning from the hospital. The director believed this provided "continuity of care" even without written hospital records.
The facility's own policy contradicts this practice.
A 2023 policy titled "Maintenance of Medical Records" requires the facility to maintain clinical records that are "complete" and "accurately documented" in accordance with "acceptable standards of practice."
The policy states that medical records must reflect "the current plan of care and services provided" and be maintained according to "accepted professional standards of practices."
Hospital records contain critical information about what happened during a resident's emergency visit - diagnostic tests, treatments administered, medication changes, and discharge instructions. Without this documentation, nursing staff cannot provide informed follow-up care.
The director of nursing acknowledged that hospital records were "important, so the facility knew how to tend and care for the residents."
Yet the facility had no system in place to obtain them.
When inspectors tried to interview LVN A, who handled the resident's return from the hospital, the director of nursing said the licensed vocational nurse "was not responding to her calls or requests for interview and was unavailable."
The director mentioned that "typically the medical records person was responsible for uploading any records into the computer" - but apparently not for requesting them from hospitals in the first place.
This gap in medical documentation creates risks for residents returning from hospital visits. Without written records of what occurred during their emergency treatment, nursing staff must guess at appropriate follow-up care based on incomplete verbal information.
The facility's reliance on physician follow-up visits within "a few days" doesn't address the immediate care needs that might arise from a resident's hospital treatment.
Federal regulations require nursing homes to maintain complete and accurate medical records for each resident. The failure to obtain hospital records when residents return from emergency visits violates these standards and potentially compromises resident safety.
The inspection was conducted in response to a complaint, though the specific nature of the complaint was not detailed in the available records.
Inspectors classified this as a violation causing "minimal harm or potential for actual harm" affecting "few" residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Lev At San Antonio from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
THE LEV AT SAN ANTONIO in SAN ANTONIO, TX was cited for violations during a health inspection on August 14, 2025.
The resident was sent to the hospital at their family's request and returned "only a couple of hours" later, according to the facility's director of nursing.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.