Northeast Rehabilitation And Healthcare Center
Northeast Rehabilitation and Healthcare Center in San Antonio, TX — inspection on August 21, 2025.
Found 4 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 interviews from 08/19/2025 to 08/21/2025 with Resident #1,
of the facility policy, titled Resident Right - Abuse Prevention, undated, the facility had the policy of It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation and if the suspected perpetrator is an employee: remove employee immediately from the care of any resident and suspend employee during the investigation.
The noncompliance was identified as PNC (Past Non-Compliance).
The noncompliance began on 04/04/2025 and ended on 04/05/2025.
The facility had corrected the noncompliance before the survey began.
455754 08/21/2025
Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218
Review of the facility policy
each resident that includes measurable objectives and timeframes to meet a resident's medical,
455754 08/21/2025
Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218
Observation and interview on 8/20/25 at 4:30 PM revealed the MS, CNA A and the lead CNA standing in the hallway maneuvering the mechanical lift used to transfer Resident #1.
The wheels were turning and rolling without any problems.
The lead CNA stated she had experienced difficulties maneuvering the mechanical lift transferring a heavier resident.
She stated it was difficult to maneuver when a resident was heavier.
The MS stated he a local company had recently serviced the mechanical lift and did not find any problems with it.
Observation and interview at 4:45 PM on 8/20/25 with the ADM revealed he reviewed the footage of CNA A when she pulled it back stepping out into the hallway. He stated the wheels on the back of the mechanical lift were rolling. He presented the video and the wheels were rolling.
Further review of the footage showed CNA A using force and pushing the mechanical lift sideways when attempting to position the legs under the bed.
The ADM stated the resident rooms had limited space.
The ADM stated he wanted to ensure the residents were transferred safely and based on the details he learned about Resident #1's transfer, it was not a safe transfer. He stated there should always be 2 staff when providing a transfer using a mechanical lift and the staff should stop and get help if it was not properly working.
Review of the mechanical lift User Manual, undated, read in relevant part, 2.
Safety Operating the Lift: Although [name of company] recommends two assistants be used for all lift preparation, transferring from and transferring to procedures, our equipment will permit proper operation by one assistant.
The use of one assistant is based on the evaluation of the health care professional for each individual case.
Review of the facility policy, Routine Procedures, Hydraulic Lift, undated, read in relevant part, It is the policy of the facility to either provide Hydraulic lift transfers when necessary for safety measures.
Procedures: Equipment: Hydraulic lift: 2 person at all times.
455754 08/21/2025
Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218
The facility failed to document wound care dressing changes on the Treatment Administration Record (TAR) for Resident #4 on 08/15/2025, 08/16/2025, and 08/17/2025.
These failures placed residents at risk for missed treatments and care which could result in the wound deterioration, and development of infection.
Findings included:
Record review of Resident #4's face sheet, dated 08/21/2025, revealed the resident was [AGE] years old male and admitted to the facility on [DATE] with diagnoses of surgical after care following surgery, muscle wasting and atrophy (loss of skeletal muscle mass), depression (lowering of a person's mood), old myocardial infarction (blockage of blood flow to the heart muscle), and muscle weakness.
Record review of Resident #4's admission MDS assessment, dated 05/05/2025, revealed the resident's BIMS was 11 out of 15, indicated the resident had moderate cognitive impairment and required partial/moderate assistance (helper does less than half the effort) to sit to stand and chair to bed transfer, and supervision or touching assistance (helper provides verbal cues or touching /steadying and /or contact guard assistance as resident completes activity) to toilet transfer.
Record review of Resident #4's comprehensive care plan, dated 05/01/2025, revealed [Resident #4] has a stage 3 pressure ulcer to coccyx - buttock area.
For interventions - Administered treatment as ordered and monitor for effectiveness.
Record review of Resident #4's physician orders, dated 05/01/2025, revealed the resident had the orders of cleans coccyx - buttock area - with normal saline and apply Triad paste and leave open to air, one time a day for wound care.
Record review of Resident #4's treatment administration record, from 08/01/2025 to 08/31/2025, revealed there were empty blanks (no nurses' initials) on 08/15/2025, 08/16/2025, and 08/17/2025 for wound care to Resident #4's coccyx - buttock area - once a day.
During an interview on 08/21/2025 at 9:00 a.m. with Resident #4 stated he did not have any pain at this time and received wound cares from nurses.
During an interview on 08/19/2025 at 3:59 p.m. with RN-J stated she provided wound care to Resident #4 on 08/15/2025, 08/16/2025, and 08/17/2025 as ordered, but she forgot documenting on Resident #4's treatment administration record because she was very busy at those dates.
Further interview with the RN-J stated she should have documented on Resident #4's treatment administration record after providing wound care on 08/15/2025, 08/16/2025, and 08/17/2025. It was RN-J's mistake, and the resident might have improper wound care due to lack of documentations.
During an interview on 08/19/2025 at 4:00 p.m. with DON stated RN-J should have documented on Resident #4's treatment administration record after she provided wound care to the resident. It was basic nursing responsibility, and if they did not document correctly, it might cause improper wound care to Resident #4 due to lack of communications.
Record review of the facility policy, titled Nursing Documentation, date 10/2024, revealed The following items should be noted in the resident chart - medication and/or treatment administration.
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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.