Buena Vida Nursing And Rehab-san Antonio
Buena Vida Nursing and Rehab-San Antonio in SAN ANTONIO, TX — inspection on October 6, 2025.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an observation, 10/01/2025 at 1:17 p.m., Resident #5 was observed lying in bed with a foley catheter bag attached to the side of the bed, facing the open door.
The foley catheter bag did not have a privacy cover and the content of the bag was exposed.
During an interview with Resident #5, 10/01/2025 at 1:18 p.m., Resident #5 stated staff would often place the foley catheter bag on the opposite side of the bed for privacy and Resident #5 stated she was not bothered if people can see her bag.
During an interview with LVN D, 10/02/2025 at 10:07 a.m., LVN D stated she was assigned to Resident #5 on 10/01/2025 and LVN D stated she observed Resident #5 without a foley privacy bag before lunch time. LVN D stated she looked for a privacy bag and could not locate one, so she notified the interim DON. LVN D stated the nurses were responsible for ensuring privacy bags were covering foley catheter bags and stated she had received training on privacy covers. LVN D stated it was important for privacy covers to be in place for the residents' privacy.
During an interview with the Administrator, 10/03/2025 at 1:36 p.m., the Administrator stated all foley catheter bags should have a privacy cover and some of the foley catheter bags have a shaded side so the bag can be turned to expose the shaded side for privacy.
The Administrator stated nursing staff and anyone that identified a resident without a foley bag privacy cover would notify the charge nurse or nursing management and said facility staff had received training on privacy covers.
The Administrator stated that privacy covers were important to provide dignity and respect for the rights of each resident.
The Administrator stated the facility did not have a policy on privacy covers for foley bags and stated the facility follows the resident rights policy.
Record review of a facility document titled, Resident Rights, the document revealed, A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.
The facility must protect and promote the rights of the resident.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
455390 10/06/2025
Buena Vida Nursing and Rehab-San Antonio 5027 Pecan Grove San Antonio, TX 78222
Record review of an undated facility policy titled, Documentation, revealed, Special forms in the
jeopardy to resident health or notes, flow sheets, medication sheets, incident reports, and summary sheets (daily, weekly, monthly, safety discharge).
The procedure revealed, document completed assessments in a timely manner and per policy.
Record review of a facility policy, revised 05/05/2025, titles, Pressure Injury: Prevention,
a weekly basis completed in [EMR].
Record review of facility wound treatment management policy, revised 05/05/2025, revealed in the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders.
This may be the treatment nurse or the assigned licensed nurse in the absence of the treatment nurse and treatments will be documented on the Treatment Administration Record.
The effectiveness of treatments will be monitored through ongoing assessment of the wound.
Record review of the facility's undated abuse and neglect policy revealed, neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.
This was determined to be an Immediate Jeopardy (IJ) on 10/04/2025 at 12:26 p.m.
The Administrator and Interim DON were notified.
The Administrator and the DON were provided with the IJ Template on 10/04/2025 at 12:35 p.m.
The following Plan of Removal submitted by the facility was accepted on 10/04/2025 at 4:43 p.m.: Plan of Removal F-F600 Problem:
The facility failed to protect the residents' right to be free from neglect. Resident #1 was not provided wound care daily or skin assessments by facility nursing staff from 08/28/2025 - 09/24/2025. He was admitted to the hospital on [DATE] for osteomyelitis and had to have a left BKA.
Interventions:100% skin rounds completed by 5pm 10/2/2025 by Administrative Nurses and Corporate Compliance Nurses.
All findings will be communicated to MD and orders transcribed in [EMR].The following in-services were initiated by Regional Compliance Nurse on 10/02/2025: Any nurse not present or in-serviced on 10/02/2025 will not be allowed to assume their duties until in-serviced.
All new hires will receive education upon hire.Licensed NursesPressure ulcer prevention and treatment including providing treatment as ordered and Initialing/Dating dressing.Documentation and Accurate Assessment of Pressure UlcersInitiating wound orders per MD and upon admission/readmission.If a C.N.A reports to a charge nurse about a change in skin integrity/wound status, the charge nurse must assess and notify MD of changes immediately.Notification of Physician with change of condition immediately.Admin Personnel Wound care monitoring will be reviewed in stand up and stand down (morning and afternoon meetings) WARS and TARs will be reviewed for holes/omissions daily in stand up and stand down All staffo Abuse, Neglect, Exploitation Policy in-service was initiated on 10/2/25 by Administrator and completed on 10/3/2025.o Inservice all staff that complaints or concerns from outside care teams are to be director [sic] to the administrator for initiation of investigation on 10/4/2025 by Regional Staff/Administrator Administratoro Inservice for Ensuring that Nursing Manager(s) review any new wound orders and validate that the orders were transcribed and entered into [EMR] on 10/4/2025 by Area Director of Operations by auditing the order listing report each day in stand up. DON/DESIGNEE INSERVICED TO ROUND WITH WOUND MD/NP STARTING 10/7/25 UNTIL INDEFINATLEY [sic] AND ENTER ORDERS IN [EMR]AS SOON AS THE ORDER IS VERBALLY GIVEN BY MD. ALL [Wound Care physician] PROGRESS NOTES WILL BE PRINTED WITHIN 24 HRS OF RECIEPT AND ORDERS WILL BE REVIEWED BY DON/DESIGNEE IN STAND UP TO ENSURE OR
455390 10/06/2025
Buena Vida Nursing and Rehab-San Antonio 5027 Pecan Grove San Antonio, TX 78222
During an interview with DON, 10/05/2025 at 11:48 a.m., revealed the DON
rounding with the wound care physician weekly and validating daily in clinical review that resident treatment orders reflect the wound care physician progress notes, wound assessments are completed weekly and on admission and readmission, each resident has appropriate wound care orders, wound dressings are accurately dated and monitoring wound administration to ensure wound treatments are completed daily.
The DON stated she would track the monitoring on a monitoring log and document her findings, and the findings would be brought to the monthly QAPI to review for compliance.
During an interview with Medical Director, 10/5/2025 at 2:09pm, revealed the Medical Director and [physician] were notified of the immediate jeopardy for neglect and wound care by the Administrator on 10/04/2025 and the Medical Director reviewed the plan of removal, the protocols and steps being taken to ensure compliance.
Record review of a monitoring document revealed, The DON/designee will view each wound weekly to ensure the correct order is in place.
The document had 5 blocks with blanks for a date, resident name, and staff name.
Record review of a monitoring document revealed, The DON/designee will audit all skin assessments and weekly ulcer assessments weekly to ensure all assessments match the resident's current condition weekly.
The document had 5 blocks with blanks for the date, weekly skin assessments correct YES/No, staff name.
Record review of a monitoring document revealed, DON/Designee will review all admissions/readmissions within 24 hours of admission.
The document had 5 blocks with blanks for date, resident name, admission complete YES/NO if no describe on back of form and staff name.
Record review of a monitoring document revealed, DON/Designee will review WAR for completion of ordered wound treatments 5 x weekly.
The document had 5 blocks for date, resident name, WAR/TAR completed YES/No If no, describe on back of form and staff name.
Record review of a monitoring document revealed, DON/Designee will assess all dressing to ensure date reflects current date.
The document had 5 blocks for date, resident name, Dressing dated correctly YES/NO if no, describe on back of form and staff name.
Record review of a monitoring document revealed, DON/Designee will validate all wounds have treatment orders in place weekly x 4 weeks.
The document had 5 blocks for date, resident name, treatment orders in place YES/NO If no, describe on back of form and staff name.
Record review of an ADHOC QAPI meeting, dated 10/2/2025 revealed signatures including the Administrator, Interim DON, and ADON.
The Administrator was informed that the Immediate Jeopardy was removed on 10/06/2025 at 2:24 p.m.
The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.
455390 10/06/2025
Buena Vida Nursing and Rehab-San Antonio 5027 Pecan Grove San Antonio, TX 78222
During an observation, 10/05/2025 at 9:23 a.m. and 10:08 a.m., HHSC Investigator W completed a head-to-toe skin assessment for Resident #3 and #5.
The findings had been identified by facility nursing staff, listed on skin assessments completed on 10/02/2025 and orders were present for the observed skin findings.
Record review of EMR UDA log revealed 63 resident names.
The log revealed that each resident had a UDA, weekly skin assessment created on 10/02/2025 and the status of the assessments were completed.
Record review of 9 sample residents revealed skin assessments completed on 10/02/2025 and treatment orders were present.
Record review of a facility staff roster revealed 44 direct care employees that included 26 CNAs (4 PRN), 15 LVNs (6 PRN), 2 RNs (1PRN).
Record review of a facility in-service tracking spreadsheet revealed 16 CNAs received in person training and 6 CNAs had not worked on the schedule and had received a text message with training for reporting and identifying skin concerns. 4 CNAs had not worked on the floor and were unable to be contacted by phone or text.
Record review of an in-service, dated 10/4/2025 and 10/06/2025, titled CNA- Report all new skin issued to nurse asap and documenting the findings/alert in the kiosk. CNAs in serviced on s/sx of skin breakdown, common pressure areas and prevention.
The in-service had 16 signatures.
Record review of staffing schedule for 10/04/2025 revealed all CNAs scheduled for 6 a.m.-6 p.m. and 6 p.m.-6 a.m. signed the CNA in-service and on 10/05/2025 6 a.m.-6 p.m. all CNA's had been in-serviced on abuse and neglect and identifying and reporting skin concerns.
Record review of an employee roster revealed 73 total employees.
Record review of an in-service, dated 10/04/2025, revealed an in-service, complaints or concerns form outside care teams are to be directed to the administrator for initiation of investigation.
The in-service revealed 62 signatures.
Record review of an in-service, dated 10/4/2025, directed to Admin Personnel, read DON/Designee must round with MD/NP and enter orders in [EMR] as soon as the order is verbally given by MD.
All [Wound care physician] progress notes will be printed within 24 hrs and orders will be reviewed to ensure orders match.
The in-service had 4 signatures including the Administrator, Interim DON, RN, and ADON/LVN.
Record review of an in-service, dated 10/2/2025, directed to Admin/Personnel, revealed the DON/designee will review each wound weekly x 4 weeks.
The DON/designee will audit all skin assessments and weekly ulcer assessments weekly to ensure all assessments match the resident's current condition weekly x 4 weeks. DON/Designee will review WAR for completion of ordered wound treatments 5 x weekly.
455390 10/06/2025
Buena Vida Nursing and Rehab-San Antonio 5027 Pecan Grove San Antonio, TX 78222
During an observation, 10/02/2025 at 12:02 p.m., the daily staffing poster display was observed to be empty with no staffing poster observed.
During an observation, 10/02/2025 at 4:00 p.m., the daily staffing poster display was observed to be empty with no staffing poster observed.
Record review of a facility staff schedule, dated 10/01/2025, revealed the facility had 5 licensed nurses, 2 MAs and 11 CNAs scheduled throughout the day.
Record review of a facility staff schedule, dated 10/02/2025, revealed the facility had 5 licensed nurses, 2 MAs and 10 CNAs scheduled throughout the day.
During an interview with the Administrator, 10/03/2025 at 1:36 p.m., the Administrator stated the ADON was responsible for updating the daily staffing posters daily and the ADON had received a directive to complete the daily staffing form and post it daily at the reception desk.
The Administrator said it was important to post the daily staffing posters because it gives families and visitors the ability to know how many staff are present for the patients and gives us a visual number of staff available and it is part of our regulatory requirements.
The Administrator stated the facility did not have a policy on posting staffing information daily but followed the regulatory guidelines.
455390 10/06/2025
Buena Vida Nursing and Rehab-San Antonio 5027 Pecan Grove San Antonio, TX 78222
dated 09/05/2025, revealed Resident #8 had a BIMS score of 00, indicating a severe cognitive
feeding tube.
Record review of Resident #8's undated comprehensive care plan revealed a care plan,
to the gastric tube placement and the intervention, posting at the residents room entrance indicating the resident is on enhanced barrier precautions.During an observation, 10/01/2025 at 1:52 p.m., Resident #8's room had PPE supplies outside of the room door and no EBP sign posted to indicate that Resident #8 was on EBP.
During an interview with LVN C, 10/01/2025 at 1:58 p.m., LVN C stated Resident #8 had a peg tube and stated Resident #8 had a PPE cart outside of his room because he had a peg tube. LVN C stated she was not sure if there was a EBP sign indicating Resident #8 was on EBP. LVN C stated she had training on EBP precautions not too long ago but it was not recent and stated she did not know who was responsible for posting the EBP signs. LVN C stated it was important to post the signs, I guess so we know what to put on.
During an interview with the Administrator, 10/03/2025 at 1:36 p.m., the Administrator stated EBP was to be used for a list of reasons and for anything that can be contagious when contacting the patient.
The Administrator stated residents on EBP would have a PPE container outside of the resident room and would have a sign on the resident door indicating they were on EBP.
The Administrator stated staff had received training on EBP and it was important for residents on EBP to be identified with a sign because We have residents with suppressed immune systems and if they were in contact with someone who has something that is contagious, they could get infected and put them at greater risk.
The Administrator stated catheter tubing should not touch the floor Because there is debris on the floor and particles can get in the peri area and it is an infection control concern.
Floors are unsanitary and stated staff had received training on keeping foley tubing off of the floor.
Record review of a facility policy titled, Enhanced Barrier Precautions revealed, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities.
The policy revealed, Communication to Staff: The facility will utilize postings outside the room and [EMR] to communicate to staff is a resident requires EBP.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.