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Complaint Investigation

The Enclave

February 26, 2026 · San Antonio, TX · 18803 Hardy Oak
Citations 1
CMS Rating 1/5
Beds 142
Provider ID 676425
Healthcare Facility
The Enclave
San Antonio, TX  ·  View full profile →
Inspection Summary

THE ENCLAVE in SAN ANTONIO, TX — inspection on February 26, 2026.

Found 1 citation. 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.

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Inspection Findings

FF0761
Pharmacy Service Deficiencies

Based on observation, interview, and record review the facility failed to ensure, in accordance with

temperature controls and permitted only authorized personnel to have access to the keys for 1 of 1 treatment carts (TC #1) reviewed for medication storage.

The facility failed to ensure the treatment cart was locked.

This failure could place residents at risk of medication misuse and drug diversion.

Findings included: During observation on 2/26/26 at 6:59 am, TC #1 was observed to be unlocked and unattended by the state investigator and HR.

Further observation revealed a bottle of betadine in the basket affixed to the side of the cart.

There were no staff at the nurses' station and there were residents moving about the facility. HR said TC #1 was not supposed to be unlocked. HR further stated he did not know who was responsible for the cart at the time because he was Human Resources, but that the Treatment Nurse had just arrived at the facility.

During an interview on 2/26/26 at 7:03 am, the TN said the night nurse was responsible for the treatment cart, as that nurse worked the night shift and would have provided treatments for the residents. An interview was attempted on 2/26/26 at 1:47 pm with LVN A without success.

During an interview on 2/26/26 at 2:05 pm, the DON said she expected medication/treatment carts to be locked when not in use and unattended, adding medications/treatments must be secured and not left outside/on top of the cart.

The DON said the facility did have mobile residents.

The DON said any staff in the facility could pass by a medication/treatment cart and lock it, but the nurse assigned to the cart was responsible for locking it when the cart was not in use/unattended.

The DON said it was important to keep medication/treatment carts locked for the safety of the residents/visitors.

The DON further stated this was important so that the residents were unable to get into the cart and access medications/treatment that were in the cart.

The DON said unlocked medication/treatment carts put residents at risk because they could ingest or take anything in the unlocked cart.

The DON further stated a resident, or visitor could pass by a cart and take any medication/treatment left outside the cart if the cart was not being monitored.

Record review of the facility's policy titled, Medication Cart Use and Storage revised January 2023, revealed: .Responsible Disciplines Licensed Nurses, C.M.A.'s.The medication cart and its storage bins should be kept closed, secured and/or in the line of sight when not in use.

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

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SAN ANTONIO, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from THE ENCLAVE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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