The facility failed to complete or maintain the required nursing admission assessment for the woman, who was admitted with cerebral infarction, acute respiratory failure, diabetes, seizures, and chronic lung disease. Federal inspectors found the missing documentation during a November complaint investigation.
Resident #5, described as moderately cognitively impaired, was admitted on an unspecified date in late October. Her medical conditions included hematemesis — vomiting blood — along with mobility problems requiring assistance with personal care.
During a November 12 interview, the resident told inspectors she couldn't remember being examined by a doctor since her arrival. She said she believed she didn't receive her diabetes pills, insulin, or seizure medications during her first few days at the facility.
The facility's electronic records showed a physician completed an admission physical assessment on October 29. But nursing staff never documented their own admission assessment, which federal regulations require within 72 hours of arrival.
The Administrator, who is also a registered nurse, acknowledged the missing records during a November 14 interview. She explained that the admitting nurse had to leave the floor due to a family emergency on the day Resident #5 arrived. The Administrator and Assistant Director of Nursing took over the admission process.
"The Administrator stated she verified the physician orders and input the resident's medications into the electronic record," inspectors wrote. But the nursing admission assessment "was not in the electronic record and could not be found."
The Administrator told inspectors it was best practice to complete the nursing admission assessment at the time of admission, no later than 72 hours afterward. She acknowledged there was a problem with not having a complete nursing assessment because the assessment was used to develop the resident's care plan.
Federal regulations require nursing homes to maintain complete clinical records that follow accepted professional standards. The missing assessment for Resident #5 represents a failure that "could place the residents at risk for errors in care and treatment," according to the inspection report.
The resident's complex medical history made the missing assessment particularly concerning. Her diagnoses included cerebral infarction, a type of stroke that occurs when blood flow to part of the brain is blocked. She also suffered from acute respiratory failure with hypoxia, a condition where the lungs cannot provide enough oxygen to the blood.
Her other conditions included chronic obstructive pulmonary disease, which damages airways and makes breathing difficult, plus epilepsy requiring seizure medications. She had abnormalities of gait and mobility, hyperlipidemia, and needed help with personal care.
The facility's most recent comprehensive assessment, completed under the Minimum Data Set system, confirmed the resident was moderately cognitively impaired for daily decision-making skills.
Nursing admission assessments serve as the foundation for developing individualized care plans. Without this baseline documentation, staff lack critical information about a resident's condition, needs, and appropriate interventions.
The inspection occurred following a complaint and focused on record-keeping practices. Inspectors reviewed five residents' records for accuracy and completeness, finding the documentation failure affected Resident #5.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the missing assessment created ongoing risks for the stroke patient, whose multiple medical conditions required careful monitoring and coordinated care.
The Administrator's admission that the nursing assessment simply could not be found highlighted systemic problems with the facility's record-keeping. Electronic health records are designed to prevent such losses, but the facility failed to ensure proper documentation was completed and maintained.
Memorial Medical Nursing Center is located on West Cypress Street in San Antonio. The November 14 inspection was completed as part of the federal oversight system that monitors nursing home compliance with health and safety standards.
The missing assessment meant care planning proceeded without essential baseline information about the resident's nursing needs, functional status, and care preferences that should have been documented upon admission.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Memorial Medical Nursing Center from 2025-11-14 including all violations, facility responses, and corrective action plans.
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