Northeast Rehab: Wound Care Records Missing 3 Days - TX
The resident, a man with moderate cognitive impairment recovering from surgery, had a stage 3 pressure ulcer on his coccyx. Stage 3 ulcers reach into the tissue beneath the skin. His physician had ordered the wound cleaned with normal saline and packed with Triad paste once a day. The care plan called for staff to monitor the wound for effectiveness. On August 15, 16, and 17, the treatment administration record showed nothing.
Federal inspectors flagged the gaps during a complaint inspection on August 21, 2025.
The nurse, identified in the inspection report as RN-J, told inspectors she had provided the wound care on all three days. She said she forgot to document it because she was very busy. "It was RN-J's mistake," she said, "and the resident might have improper wound care due to lack of documentations."
The director of nursing said the same thing in a separate interview. "If they did not document correctly, it might cause improper wound care to Resident #4 due to lack of communications." She called documentation a basic nursing responsibility.
The resident himself told inspectors on the morning of August 21 that he had no pain and that nurses had been giving him wound care. That account, offered by a man the facility's own records described as having moderate cognitive impairment, was the only evidence suggesting the wound had been treated during those three days. The treatment record, the document that exists precisely so care can be verified and tracked, showed nothing.
The man was admitted to the facility in the spring of 2025. His diagnoses included the pressure ulcer, muscle wasting and atrophy, an old heart attack, muscle weakness, and depression. He needed partial assistance to move from a chair to his bed and supervision to use the toilet. His cognitive score, recorded in a May assessment, put him at 11 out of 15 on a standard screening, the range associated with moderate impairment.
A stage 3 pressure ulcer on the coccyx, in a man who needs help transferring and whose muscle mass is already deteriorating, is not a wound that tolerates gaps in attention. Pressure ulcers at that stage can deepen rapidly, develop bacterial infections, and, in patients with limited mobility and poor tissue health, become far harder to close than to prevent. The inspection report noted that the documentation failures placed residents at risk for missed treatments, wound deterioration, and infection.
Whether the wound actually deteriorated during those three days is not something the inspection report resolves. Inspectors did not document the wound's condition on August 21 or compare it to earlier measurements. The finding was classified as minimal harm or potential for actual harm, the lower end of CMS's harm scale. RN-J maintained she had performed the care. The record offered no way to confirm or contradict that.
That is precisely the problem. A treatment administration record exists so that the next nurse who enters the room knows what was done and when. It exists so a physician can evaluate whether a wound is responding. It exists so that if a wound worsens, someone can trace back through the days and determine what happened. Three blank lines in a row on a wound care record do not just represent a paperwork failure. They represent three days during which no one reading that chart could know what had been done to a man who could not fully advocate for himself.
The facility's own nursing documentation policy, updated in October 2024, listed medication and treatment administration among the items that must be recorded in the resident's chart. RN-J acknowledged she knew that. She said she should have documented after each treatment. She said she did not.
The wound was still there when inspectors arrived.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Northeast Rehabilitation and Healthcare Center from 2025-08-21 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
Northeast Rehabilitation and Healthcare Center in San Antonio, TX was cited for violations during a health inspection on August 21, 2025.
The resident, a man with moderate cognitive impairment recovering from surgery, had a stage 3 pressure ulcer on his coccyx.
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.