San Antonio Wellness: Elopement Risk Without Orders - TX
The resident, identified as Resident #2 in the inspection report, had an elopement risk evaluation score of 15.0, indicating imminent risk for elopement. She was described as wandering aimlessly and having "intentionally or unintentionally attempted to leave the community" in the past.
Despite this high-risk assessment, the facility's medical records showed no active physician orders for secure unit placement when inspectors reviewed them on September 10. The Order Summary Report from that date reflected no orders for admission to the facility or orders for secure unit placement.
The resident's care plan, accessed on July 11, stated she was admitted to and would reside in the facility's Memory Care Unit for ongoing care and supervision. The plan identified her as "an elopement risk/wanderer" due to being disoriented to place, having a history of attempts to leave the facility unattended, impaired safety awareness, wandering aimlessly, and significantly intruding on the privacy or activities of others.
A review of the resident's Order Recap Report revealed a complex history of discontinued and held orders. An order to "May admit to secure unit" for delusional disorders had been discontinued on July 10, with no reason documented for the discontinuation. Multiple admission orders had been placed on hold, discontinued, and reissued throughout the resident's stay.
The most recent active orders included admissions for skilled services related to hypertensive urgency and ataxia, but these had also been discontinued by late July and August. No current orders specifically authorized the resident's placement in the secure memory care unit where inspectors observed her on September 10 at 11:58 a.m.
The resident was not able to be interviewed due to her cognitive impairment. However, her guardian and resident representative told inspectors during a September 11 interview that the resident's care at the nursing facility had been "amazing." The guardian stated the resident was provided the care she required, was aware the resident was on the secure unit, and neither she nor the resident had experienced any issues with staff or other residents on the unit.
Inspectors attempted to interview the attending physician, identified as MD C, on September 11 at 3:22 p.m., but did not receive a call back.
The facility's own policy on physician orders, revised in June 2020, states that its purpose is to "ensure that all physician orders are complete and accurate." The policy assigns responsibility to the Medical Records Department to "verify that physician orders are complete, accurate and clarified as necessary."
The care plan for Resident #2 was initially created on January 21, 2025, and revised on March 20, 2025. It specifically addressed her diagnosis of unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, along with her risk for elopement.
The inspection records show the resident had multiple emergency room visits during her stay, with orders being placed on hold when she was sent for evaluation and resumed when she returned. One hold order from April 27 to May 4 was documented as being due to an ER evaluation, and another from July 9 to July 10 followed the same pattern.
Federal regulations require nursing homes to provide services under physician orders and maintain complete and accurate medical records. The gap between the facility's assessment of the resident as an imminent elopement risk and the absence of current physician orders for her secure placement represents a potential violation of these requirements.
The resident's guardian expressed satisfaction with the care provided, noting no problems with staff or other residents on the secure unit. However, the documentation issues identified by inspectors highlight the importance of maintaining proper physician orders to authorize the level of care and supervision residents receive.
The inspection was conducted as part of a complaint investigation on September 11, 2025. Federal inspectors classified the violation as 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 San Antonio Wellness & Rehabilitation from 2025-09-11 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
SAN ANTONIO WELLNESS & REHABILITATION in SAN ANTONIO, TX was cited for violations during a health inspection on September 11, 2025.
The resident, identified as Resident #2 in the inspection report, had an elopement risk evaluation score of 15.0, indicating imminent risk for elopement.
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.