San Antonio Wellness: Resident Locked Without Orders - TX
The resident's family member and emergency contact told inspectors at San Antonio Wellness & Rehabilitation she didn't understand why her relative had been transferred to the secure unit. She was eventually told the resident had gone to the front desk asking where the family member was, though she couldn't recall who provided this information or when.
The family member demanded the resident be moved back to the general population hall during a care planning meeting.
When inspectors interviewed the resident on September 10, she described the facility as "very nice" and said she got along with almost everyone. She mentioned wanting a roommate after her previous one was moved for taking her personal items to another room. The resident never expressed wanting to leave the secured unit and didn't explain why she was there. She praised the activities director for taking residents outside and called the staff "amazing."
The resident appeared calm and content during the conversation, showing no signs of distress about her placement.
Staff working on the secure unit painted a different picture than what administrators claimed. CNA A told inspectors the resident had not exhibited exit-seeking behaviors and was easily redirected if she appeared to wander aimlessly. The aide said the resident's wandering mostly happened when she had forgotten something and was looking for it.
LPN B, a nurse on the secure unit, said she had never seen the resident try to escape or act like she wanted to leave. She described the resident's behavior as simply being forgetful due to poor short-term memory, but easily redirected. The nurse said the resident would sometimes go to the exit door to look through the window and put her hands on the bar, but knew the door was locked and didn't try to exit.
The nurse said she wasn't aware of any elopement attempt and hadn't been told by other staff of such an incident.
When pressed by inspectors, facility leadership provided conflicting explanations. The Assistant Director of Nursing said residents didn't need physician orders for secure unit placement if there was an elopement attempt. She claimed the resident originally came for skilled services, not long-term care, but tried to escape from the rehabilitation unit.
The ADON couldn't explain why no elopement assessment was done before the placement, especially since the initial assessment showed no risk. She also couldn't explain why a second elopement assessment showing "moderate risk" with a creation date of June 16, 2025, was entered into the resident's record on September 10, 2025 — the day of the inspection.
The Director of Nursing told inspectors the resident didn't have orders for secure unit placement. She claimed the resident was moved due to being "exit seeking and combative," and said the transfer was planned from the time of admission.
The administrator acknowledged he couldn't provide details about why there were no orders for the move, but recalled the resident had exhibited behaviors right after admission.
Inspectors attempted to reach the facility's physician but received no callback.
The facility's own policy on wandering and elopement, revised in August 2020, states its purpose is "to enhance the safety of residents" and requires the facility to "identify residents at risk for elopement and minimize any possible injury as a result of elopement." However, the policy doesn't include a process or specific indications for evaluating residents for secure unit placement.
The case highlights a fundamental breakdown in the facility's assessment and placement procedures. While staff working directly with the resident described her as calm and easily redirected, administrators moved her to a locked unit without the required physician authorization or proper documentation.
The resident's family continues to seek her transfer back to the general population, where she could have the roommate she requested and participate in activities without the restrictions of a secure dementia unit.
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 family member demanded the resident be moved back to the general population hall during a care planning meeting.
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.