Castle Hills Rehabilitation And Care Center
Castle Hills Rehabilitation and Care Center in San Antonio, TX — inspection on February 22, 2026.
Found 3 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
Observation and interview on 02/21/2026 at 4:30 p.m. revealed Resident #1 was on the bed and sleeping in her room at the acute hospital. Resident #1's family member was at the bedside and said that the resident was sleeping, and he did not want to bother the resident to see the wounds.
Interview on 02/21/2026 at 5:00 p.m. the hospital nurse said Resident #1 had stage 2 pressure ulcers to her left and right buttock areas.
Interview on 02/22/2026 at 2:37 p.m. the facility wound care LVN-A stated when Resident #1 was admitted to the facility, the resident had an unhealed stage 2 pressure ulcers to her left and right buttock area, and the nurse provided wound care as ordered.
Interview on 02/22/2026 at 3:15 p.m. the DON stated Resident #1's admission MDS dated [DATE] was inaccurate regarding pressure ulcers because the resident had an unhealed stage 2 pressure ulcers to her left and right buttock area. In the Section M (Skin conditions), the question of Does this resident have one or more unhealed pressure ulcers/injuries? should have been coded as Yes. DON said the facility MDS nurse did not work on 02/22/2026 because it was Sunday, and DON had responsibility for overseeing MDS accuracy and did not know the reason for the inaccurate MDS assessment. DON said inaccurate MDS assessment might affect inappropriate care to the resident.
Record review of the facility policy, titled Documentation in Medical Record, revised 06/06/2025, revealed Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.
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
455510 02/22/2026
Castle Hills Rehabilitation and Care Center 8020 Blanco Rd San Antonio, TX 78216
The facility failed to ensure Resident #1's care plan reflected her unhealed stage pressure ulcer to her left and right buttock area.
This failure could place residents at risk for not receiving proper care and services.The findings included:
Record review of Resident #1's face sheet, dated 02/22/2026, revealed the resident was a 65-years-old female and admitted to the facility on [DATE] with diagnosis of pressure ulcer of sacral region (wound that from as a direct result of pressure over a bony prominence to the buttock area).
Record review of Resident #1's admission MDS, dated [DATE], revealed the resident's BIMS score was 11 out of 15, which indicated the resident had moderate cognitive impairment, and in Section M (Skin conditions), it was coded that Resident #1 did not have one or more unhealed pressure ulcers/injuries.
Record review of Resident #1's comprehensive care plan, dated 01/30/2026, revealed [Resident #1] had deep tissue injury to right and left heel.
For intervention - provide pressure reduction/relieving mattress, skin care, treatment, and turning and repositioning schedule per assessment.
Further record review of the care plan revealed there was no care plan regarding Resident #1's pressure ulcers to right and left buttock.
Record review of Resident #1's wound care assessment, visit dated 02/02/2026, revealed Resident #1 had stage 2 pressure ulcer of left and right buttock area.
Record review of Resident #1's physician order, dated 02/04/2026, revealed the resident had the order of Wound Care - Left and Right buttock State 2 - Apply triad with collagen particles daily one time a day for wound care treatment.
Observation and interview on 02/21/2026 at 4:30 p.m. revealed Resident #1 was on the bed and sleeping in her room at the acute hospital. Resident #1's family member was at the bedside and said that the resident was sleeping, and he did not want to bother the resident to see the wounds.
Interview on 02/21/2026 at 5:00 p.m. the hospital nurse said Resident #1 had stage 2 pressure ulcers to her left and right buttock areas.
Interview on 02/22/2026 at 2:37 p.m. the facility wound care LVN-A stated when Resident #1 was admitted to the facility, the resident had an unhealed stage 2 pressure ulcers to her left and right buttock area, and the nurse provided wound care as ordered.
Interview on 02/22/2026 at 3:15 p.m. with DON stated Resident #1 received wound care as ordered, but there was no care plan for specifically stage 2 pressure ulcer to the resident's left and right buttock area because of inaccurate MDS assessment.
The facility should have developed Resident #1's care plan regarding the resident's stage 2 pressure ulcer to her left and right buttock area, and no care plan might affect inappropriate care to the resident.
Record review of the facility policy, titled Comprehensive Care Plans, revised 06/02/2025, revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.6.
The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment.
The objectives will be utilized to monitor the resident's progress.
Alternative interventions will be documented, as needed.
455510 02/22/2026
Castle Hills Rehabilitation and Care Center 8020 Blanco Rd San Antonio, TX 78216
care.
She stated the nurses should have documented on Resident #1's treatment administration
communication among health care professionals.
Record review of the facility policy, titled
interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2.
Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. 3.
Documentation may be performed manually or as per the facility's specific electronic medical record software program.
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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.