Remington Transitional Care: Fall Mat Gap Puts Resident at Risk - TX
The violation was tagged under F0656, which covers the development and implementation of comprehensive care plans. Inspectors classified the harm as minimal or potential, with few residents affected. But the finding points to something specific and concrete: a written plan that staff knew about and didn't follow, for a resident whose fall risk had already been assessed and documented.
The facility's own fall prevention policy, dated August 2022, stated that each resident's risk factors and environmental hazards would be evaluated when developing the care plan, that interventions would be monitored for effectiveness, and that the plan would be revised as needed. The care plan for Resident 2 had already gone through that process. Someone had assessed this person, identified the risk, and written down what needed to happen. Mats on both sides of the bed. That was the answer the assessment produced.
The mats weren't there.
During an interview at 2:56 p.m. on the day of inspection, the facility's administrator said she did round on residents and that she expected staff to implement care plan interventions because those interventions were what had been assessed to meet each resident's needs. She didn't dispute the gap. She described, instead, what the expectation was supposed to be.
Remington's comprehensive care plan policy, in place since October 2022, requires the facility to develop and implement person-centered care plans with measurable objectives and timeframes covering each resident's medical, nursing, and psychological needs. The policy is explicit that plans must be consistent with resident rights and grounded in comprehensive assessment. For Resident 2, the assessment had been done. The plan had been written. The intervention, floor mats on both sides of the bed, had been identified as what this person needed.
Implementation is where it stopped.
Fall-related injuries are among the most serious and common harms in nursing home settings. For residents with documented fall risk, the gap between a written intervention and an absent one isn't administrative. It's physical. A fall from a bed without mats lands differently than a fall onto one.
The inspection was complaint-driven, meaning someone, a resident, a family member, or a staff member, raised a concern that prompted regulators to look. What they found when they looked was a resident whose care plan called for a specific protective measure that wasn't in place, and a facility whose own administrator confirmed the expectation that it should have been.
The violation carries a harm level of minimal or potential, which in regulatory terms means inspectors did not document that Resident 2 was actually injured as a result of the missing mats. That classification reflects what inspectors could confirm. It does not describe what could have happened on any night before they arrived.
Remington Transitional Care of San Antonio is a transitional care facility, meaning many of its residents are recovering from hospitalizations, surgeries, or acute medical events. These are people in the middle of recovery, often with reduced mobility, altered balance, or post-procedural weakness. Fall prevention plans exist precisely because this population is vulnerable in ways that are both predictable and preventable. The assessment process is designed to catch those risks before they become injuries.
For Resident 2, the system worked up to a point. The risk was identified. The intervention was named. The plan was written and on file. The administrator knew what staff were expected to do.
The mats were not on both sides of the bed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Remington Transitional Care of San Antonio from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 2, 2026 · Our methodology
REMINGTON TRANSITIONAL CARE OF SAN ANTONIO in SAN ANTONIO, TX was cited for violations during a health inspection on November 18, 2025.
The violation was tagged under F0656, which covers the development and implementation of comprehensive care plans.
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.