Federal inspectors cited Silver Tree Nursing and Rehabilitation Center on October 10 for not maintaining comprehensive care plans that reflected the actual care residents received.
The investigation centered on two residents whose behaviors weren't properly recorded in their individualized care documents.
Resident #2 repeatedly refused wound treatments, but administrators never documented these refusals in his care plan. During an October 10 interview at 4:37 PM, the Administrator and Director of Nursing acknowledged they should have included this information because care plans must be person-centered and reflect what care each resident actually receives.
The second case involved a resident with a documented history of making false allegations about her care.
Resident #3's responsible party told inspectors the woman could become manipulative when angry or when she didn't get her way. The family member explained she had a pattern of fabricating stories about her treatment to make it appear she needed to leave the facility and return home.
Mental health staff confirmed this behavioral pattern. A counselor from an outside mental health organization interviewed on October 13 at 3:54 PM said Resident #3 disliked being at the facility because she wanted to go home. The counselor revealed the resident had a history of making up accusations about her care, particularly when she was in a bad mood.
"If Resident #3 got into a bad mood, anything bothered her," the counselor told inspectors.
Both the facility and the mental health organization had been working with the resident on these behaviors through psychiatric and psychological services.
Despite this well-documented pattern, administrators failed to include any reference to the resident's history of making allegations in her care plan. The Administrator and Director of Nursing told inspectors they knew about Resident #3's tendency to make accusations against staff but hadn't documented it.
The Administrator noted these accusations and allegations were not reportable events, but acknowledged they should have been included in the care plan documentation.
Federal regulations require nursing homes to maintain comprehensive care plans that describe the services provided to help residents achieve their highest practicable physical, mental, and psychosocial well-being. The plans must also acknowledge a resident's right to refuse treatment.
The facility's own policy on comprehensive care planning, though undated, states that care plans must describe the services furnished to maintain residents' well-being and acknowledge treatment refusal rights.
Inspectors found the facility violated these requirements by failing to document significant aspects of both residents' care needs and behaviors.
For Resident #2, the omission meant his care plan didn't accurately reflect his actual treatment experience, since wound care refusals were a recurring issue that affected his medical management.
For Resident #3, the missing documentation left out crucial behavioral information that staff needed to understand her communication patterns and provide appropriate care. The counselor confirmed that both the facility and mental health professionals were actively addressing these behaviors, making their absence from the care plan even more significant.
The violation affected few residents and resulted in minimal harm or potential for actual harm, according to the inspection findings.
Care plan documentation serves multiple purposes in nursing home operations. It guides daily care decisions, helps staff understand individual resident needs, and ensures continuity when different employees provide care across shifts.
When behavioral patterns like treatment refusals or false allegations aren't documented, new staff members lack crucial context for interactions with residents. This can lead to confusion, inappropriate responses, or missed opportunities to provide person-centered care.
The inspection occurred as part of a complaint investigation, though the specific nature of the complaint wasn't detailed in the available documentation.
Silver Tree Nursing and Rehabilitation Center operates at 930 Roy Richard Drive in Schertz, about 20 miles northeast of San Antonio.
The facility must submit a plan of correction addressing how it will ensure care plans accurately reflect all aspects of resident care, including behavioral patterns and treatment refusals.
Both residents remain at the facility, where staff continue working with mental health professionals to address the behavioral issues that should have been documented in care plans from the beginning.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Silver Tree Nursing and Rehabilitation Center from 2025-10-10 including all violations, facility responses, and corrective action plans.
Additional Resources
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