San Antonio North Nursing: Infection Control Failure - TX
That finding sits at the center of a complaint inspection completed May 29, 2026, at San Antonio North Nursing and Rehabilitation. Federal inspectors cited the facility for a single infection control violation involving one resident, a man identified in the report as Resident #3.
He had been living at the facility since January 2025, readmitted in March 2026. His medical history was substantial: paraplegia, Type 2 diabetes, a focal traumatic brain injury, a chronic ulcer on his right lower leg that had failed to progress through normal wound healing, difficulty swallowing, schizoaffective disorder, major depressive disorder, high blood pressure. He was deaf and non-speaking. His most recent cognitive assessment, from May 14, 2026, showed a perfect score — no cognitive impairment — but he needed limited to extensive help with daily activities and was frequently incontinent of both bladder and bowel.
His care plan, written in December 2025, was direct about what staff were supposed to do. Because of his chronic wound, he had been placed on enhanced barrier precautions, an infection control protocol specifically designed to reduce the spread of multidrug-resistant organisms. The plan required staff to put on a gown and gloves before any high-contact personal care. Wound care was explicitly listed as a high-contact activity requiring that protection.
The resident, according to the care plan, had refused to keep a sign or organizer on his door indicating his precaution status. He would remove them. That detail matters, because it means the only reliable safeguard was staff memory and training.
On the morning of May 28, 2026, at 11:27 a.m., an inspector watched the assistant director of nursing, identified in the report as ADON A, enter the room and provide wound care without a gown. No gown before entering. No gown during care.
Nineteen minutes after the observation ended, the inspector spoke with ADON A directly. Her explanation was brief. She stated she forgot Resident #3 was on enhanced barrier precautions. She said she had received training on the protocol.
The director of nursing, interviewed that afternoon, confirmed what the precautions required and why. Staff needed to wear a gown and gloves, the DON said, to protect both the resident and themselves from infection. The DON said infection control training was provided to staff and that skills were checked annually.
The person who forgot was not a new hire or a floor aide working a double shift. She was the assistant director of nursing — one of the facility's senior clinical leaders, someone whose role includes oversight of exactly this kind of care practice.
Enhanced barrier precautions exist because certain wounds and certain patients carry a higher risk of harboring or transmitting organisms that don't respond to standard antibiotics. The protocol the facility had written for itself, dated April 2025, listed wound care first among the high-contact activities that required gown and gloves. Not last. First.
Resident #3 is paraplegic, diabetic, and has a wound on his lower right leg that has already been classified as chronic, meaning it has not healed on its own timeline. He is also deaf and non-speaking. He could not call out to ask why no gown appeared. He could not flag down another nurse. He had already told the facility, in the only way available to him, that he did not want warning signs on his door.
The facility's own records show he understood his situation clearly. His cognitive score was a 15 out of 15. He knew where he was and what was happening to him.
What happened on the morning of May 28 was not a documentation gap or a paperwork error. A senior nurse stood at the bedside of a vulnerable man with an open wound and provided care without the protection his care plan required. Then she told an inspector she had simply forgotten.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for San Antonio North Nursing and Rehabilitation from 2026-05-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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 22, 2026 · Our methodology
San Antonio North Nursing and Rehabilitation in San Antonio, TX was cited for violations during a health inspection on May 29, 2026.
That finding sits at the center of a complaint inspection completed May 29, 2026, at San Antonio North Nursing and Rehabilitation.
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.