Northeast Rehabilitation And Healthcare Center
Northeast Rehabilitation and Healthcare Center in San Antonio, TX — inspection on October 17, 2025.
Found 2 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 interview on [DATE] at 4:08 p.m., the Medical Director stated Resident #7's physician was not available and her providers were not allowed to be interviewed unless she was present.
She stated she looked through the call center log and they had been notified when the fall happened.
She stated they (facility) had been given orders to monitor for neuros.
The Medical Director stated the representative for the physician's office notified her (on [DATE]) she incorrectly stated (when interviewed) that there was an order to send the resident out to the hospital.
The Medical Director stated she listened to the call (original call on the date of fall) and the RN just gave orders to monitor and do neuro checks and no orders to send to the hospital.
The Medical Director stated there was no one-set of professional standards of practice for when a resident had an unwitnessed fall, hit their head, and was on anticoagulants.
She stated it would depend on the si[TRUNCATED]
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/17/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Northeast Rehabilitation and Healthcare Center
603 Corinne St San Antonio, TX 78218
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 10/14/2025 at 3:34 p.m., the DON stated she reviewed the SBAR documentation by LVN C.
She stated every fall triggered a separate UDA [SH4] that should have been completed.
She stated the SBAR was a new form for the staff, and she thought maybe it was misunderstood by staff and that was why it was incorrectly documented as not clinically significant.
The DON stated a skin/injury assessment should be documented after a fall and a pain assessment should be documented.
The DON stated the word monitor was not a specific MD order.
She stated if the doctor said something specific, they would add it as an order.
She stated the SBAR checklist was the order or the place to document back what the physician response was to the notification.
She stated LVN C marking other and na for orders should have been more specific.
During an interview on 10/15/2025 at 4:11 p.m., the DON stated they document exceptions and they were required to follow up with expectations with what intervention was put in place.
She stated they put a note for the intervention in the medical record.
The DON stated Resident #7 was unhappy with the TV being too loud with her roommate and needing to be moved was not a reason to document.
The DON stated Resident #7 did not have a family to notify about the move, so no notification was required to be documented.
The DON stated what should be documented included any change of condition, and behaviors that required interventions, any complaints from the resident such as pain, any refusals, any changes from baseline.
She stated it was important to document in the medical record so monitoring and interventions were in place.
Record review of the facility's policy titled Administration-Content of Medical Records last revised August 2007 revealed: All physicians, nursing staff and other health care professionals involved in the resident's care will be responsible for making prompt, appropriate entries in the record. 6.
List of contents of the medical record: Licensed Nurses Notes, other assessments ( .bowel and bladder, skin, etc.)
Facility ID: