San Antonio Wellness & Rehabilitation
SAN ANTONIO WELLNESS & REHABILITATION in SAN ANTONIO, TX — inspection on September 11, 2025.
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
During an interview on 09/11/2025 at 02:14 p.m., the DON stated Resident #1 was moved to the secure unit due to having been exit seeking and combative.
The DON stated the family was informed about the changes and had told her (the DON) to not call them about Resident #1.
The DON stated Resident #1's emergency contact had told her that she did not want to be bothered with Resident #1 right then.
The DON stated there was no signed consent for the room change.
During an interview on 09/11/2025 at 02:14 p.m. (entered room during DON interview), the ADMIN stated there was not a signed consent for Resident #1's room change in her chart. He stated he was unaware if Resident #1's family was notified immediately about Resident #1's move to the secure unit or if they provided room change consent. He stated he was aware that Resident #1's family had told him, the DON, and the ADON not to contact them regarding Resident #1.
He stated he did recall Resident #1 exhibited behaviors after admission but could not provide details of Resident #1's move to the secure unit.
Attempted interview with MD C on 09/11/2025 at 03:22 p.m.
Call back not received.
Record review of policy titled, Resident Rights, date revised 08/2020, revealed All residents have a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility including those specified in this policy.
The Facility will protect and promote the rights of the resident. A. Be informed about what rights and responsibilities he or she has. C.
Choose a physician and treatment and participate in decisions and care planning, including involving representatives and considering personal and cultural preferences;.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/11/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
San Antonio Wellness & Rehabilitation
One Heartland Dr San Antonio, TX 78247
SUMMARY STATEMENT OF DEFICIENCIES
During an observation and interview on 09/10/2025 at 12:10 p.m., Resident #1 stated the facility is very nice and she gets along with almost everyone.
She stated she currently had a private room but would like a roommate.
She stated her prior roommate was moved after it was discovered the roommate was taking Resident #1's personal items to another room. Resident #1 did not state she wanted to leave the secured unit and did not state why she was on the secured unit.
She stated the activities director took the residents outside to do fun activities and the staff were amazing. Resident #1 did not appear upset, stressed, or agitated during the conversation and subsequent observations regarding her placement in the secured unit.
During an interview on 09/10/2025 at 03:57 p.m., CNA A, a CNA on the secure unit, stated Resident #1 had not exhibited exit-seeing behaviors and was easily re-directed if she appeared to be wandering aimlessly. CNA A stated Resident #1's wandering happened mostly when Resident #1 had forgotten something and was looking for it.
During an interview on 09/10/2025 at 04:00 p.m., LPN B, a nurse on the secure unit, stated she had never seen Resident #1 try to elope or even act as if she wanted to elope.
She stated Resident #1 would sometimes wander because she was looking for something she had forgotten.
She stated Resident #1 had poor short-term memory but was easily redirected.
She stated Resident #1 will sometimes go to the exit door to look through the window and put her hands on the bar, but she knows the door is locked and does not try to exit. LPN B stated she was not aware of Resident #1 having had an elopement attempt and had not been told by other staff of an attempt.
She stated Resident #1's only exhibited behavior was being forgetful.
During an interview on 09/10/2025 at 04:18 p.m., the ADON stated residents did not have to have an order for placement on the secure unit if there was an elopement attempt.
The ADON stated Resident #1 came to the facility for skilled services originally, not long-term care, but she tried to elope from the rehabilitation unit.
She stated residents could be moved to the secure unit for their safety.
The ADON could not explain why there was not an elopement assessment done for Resident #1 prior to her placement since the initial assessment revealed no risk.
The ADON could not explain why the second elopement assessment, with a moderate risk and a created date of 06/16/2025, was entered into Resident #1's today, 09/10/2025.
During an interview on 09/11/2025 at 02:14 p.m., the DON stated Resident #1 did not have an order for having been on the secure unit.
She stated Resident #1 was moved to the secure unit due to having been exit seeking and combative.
The DON stated Resident #1's move to the secure unit was care planned from the time of her transfer.
During an interview on 09/11/2025 at 02:14 p.m. (entered room during DON interview), the ADMIN stated he could not provide details of why Resident #1's did not have orders for her move to the secure unit but did recall Resident #1 had exhibited behaviors right after her admission.
Attempted interview with MD C on 09/11/2025 at 03:22 p.m.
Call back not received.
Record review of policy titled, Wandering & Elopement, date revised 08/2020, revealed the purpose of the policy, To enhance the safety of residents of the Facility and a policy statement, The Facility will identify residents at risk for elopement and minimize any possible injury as a result of elopement.
The policy procedure did not include a process or indications for residents to be evaluated for the secure unit.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/11/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
San Antonio Wellness & Rehabilitation
One Heartland Dr San Antonio, TX 78247
SUMMARY STATEMENT OF DEFICIENCIES
During an observation on 09/10/2025 at 11:58 a.m., Resident #2 was noted on the secure unit. Resident #2 was not interviewable.
During an interview on 09/11/2025 at 09:15 a.m., Resident #2's resident representative and guardian stated Resident #2's care at the nursing facility had been amazing.
She stated Resident #2 was provided the care she required, was aware Resident #2 was on the secure unit, and she and Resident #2 had not had any issues with the staff or other residents on the unit.
Attempted interview with MD C on 09/11/2025 at 03:22 p.m.
Call back not received.
Record review of policy titled, Physician Orders, date revised 06/2020, revealed the purpose, This will ensure that all physician orders are complete and accurate.
The policy statement revealed The Medical Records Department will verify that physician orders are complete, accurate and clarified as necessary.
The Procedure included, VI.
Documentation pertaining to physician orders will be maintained in the resident's medical record.
Facility ID: