Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Estates At Shavano Park during CMS and state inspections, most recent first.
A resident with a history of respiratory failure, CHF, and pneumonia was receiving supplemental oxygen as documented in her care plan and vital signs records, but the MDS assessment failed to indicate oxygen use. The MDS Nurse relied on MARs, which did not show oxygen administration, and did not initially check other records, resulting in an inaccurate assessment.
A resident with a history of respiratory and cardiac conditions was given oxygen therapy at 2 LPM via nasal cannula without a physician's order. The care plan and clinical records documented ongoing oxygen use, but no order was present. Staff interviews confirmed the absence of an order and acknowledged that facility policy requires one before administering oxygen.
A licensed nurse failed to fully cover a wound with the prescribed dressing and did not date or initial wound dressings for two residents during wound care, contrary to facility policy. These actions were observed during care for residents with complex medical needs, including diabetic foot ulcers and stage four pressure ulcers. Interviews revealed uncertainty among staff regarding competency assessments and wound care procedures.
Two residents requiring contact or enhanced barrier precautions did not receive care in accordance with infection control protocols. Staff failed to post required isolation signage for a resident with C. diff and did not perform hand hygiene between glove changes during wound care for both residents. Open wound care supplies were also placed directly on a resident's bed, and facility policies for hand washing and use of personal protective equipment were not consistently followed.
A resident with a history of respiratory and cardiac conditions was receiving supplemental oxygen, as documented in her care plan and clinical records. However, the MDS assessment failed to indicate oxygen use because the MDS Nurse relied on the MARs, which did not reflect oxygen administration, instead of reviewing all relevant clinical documentation. Facility leadership confirmed the responsibility for accurate MDS completion and acknowledged the potential for an inaccurate care plan due to this omission.
A resident with a history of respiratory and cardiac conditions was given oxygen therapy at 2 LPM via nasal cannula without a physician order, despite this intervention being included in the care plan and documented in clinical records. Staff interviews and facility policy confirmed that a physician order was required for oxygen administration, but none was present while the resident received ongoing oxygen therapy.
The facility failed to maintain proper infection control as several residents' Foley catheter bags were observed touching the floor, posing a risk of contamination. Despite having care plans and staff training, the catheter bags of five residents were improperly positioned, indicating a systemic issue in catheter care management.
A facility failed to accurately code a resident's diagnosis of anxiety on the MDS assessments, despite the resident receiving buspirone for anxiety. The MDS RN confirmed the discrepancy, which could risk improper care. The DON acknowledged the potential impact on the resident's well-being.
A facility failed to maintain a medication error rate below 5%, with an observed rate of 11.54% due to untimely administration of medications. Two residents experienced delays in receiving their prescribed medications, bumex and gabapentin, which were administered significantly later than scheduled. Interviews with staff revealed a misunderstanding of the facility's policy on medication administration timing, contributing to the high error rate.
A resident with a history of hemiplegia, atrial fibrillation, and hypertension received Amlodipine Besylate and Carvedilol outside of physician-ordered parameters, with medications administered despite vital signs being outside specified limits. Multiple LVNs were involved, and the DON was unaware of these errors, indicating a lack of communication and adherence to medication administration policies.
A resident with hemiplegia and hemiparesis was not provided with a required divided plate during a meal, leading to difficulties in eating. Despite the resident's care plan and dietary orders specifying the need for a divided plate, the facility failed to provide it, and staff did not intervene until prompted by a state surveyor. The facility's policy mandates the provision and supervision of assistive devices, which was not adhered to in this instance.
A resident with intact cognition was referred to using a 'sippy cup' on their meal ticket, despite their meal plan specifying a two-handle cup or mug with a lid. Staff interviews revealed that this terminology was commonly used by the dietary department and kitchen staff. The dietary manager acknowledged the inappropriate terminology only after state surveyors raised the issue, and subsequently changed it to '2 handle cup or mug with lid'.
Failure to Accurately Document Oxygen Therapy on MDS Assessment
Penalty
Summary
The facility failed to ensure that the assessment accurately reflected a resident's status by not indicating that the resident received oxygen on her Quarterly MDS assessment. The resident, who had a history of acute respiratory failure with hypoxia, congestive heart failure, pneumonia, and high blood pressure, was observed and documented as receiving supplemental oxygen via nasal cannula. Her care plan included interventions for oxygen therapy, and vital sign records confirmed oxygen administration during the MDS look-back period. However, the MDS assessment did not reflect this, as the section for oxygen use was not checked. The MDS Nurse stated that she relied on the Medication Administration Records (MARs), which did not indicate oxygen use, and did not initially review the vital signs section that documented oxygen administration. Upon review, the MDS Nurse acknowledged the oversight and confirmed that the resident did receive oxygen during the look-back period. Interviews with facility leadership confirmed that the MDS Nurse was responsible for ensuring the accuracy of assessments, and that inaccurate documentation could result in an inaccurate plan of care.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A deficiency was identified when a resident with a history of acute respiratory failure with hypoxia, congestive heart failure, pneumonia, and high blood pressure was administered oxygen at 2 liters per minute via nasal cannula without a physician's order. The resident's care plan included oxygen therapy, and clinical records documented ongoing oxygen administration on multiple dates. However, review of the physician's order summary revealed no order for oxygen administration, despite the resident receiving it regularly. Observations confirmed the resident was receiving oxygen, and staff interviews acknowledged the absence of a physician's order for this treatment. Facility staff, including an LVN and the Executive Clinician, confirmed that oxygen therapy should only be provided with a physician's order and that the lack of such an order could result in unmonitored treatment. The Executive Director also stated that all treatments, including oxygen, require a physician's order and proper documentation in the clinical record and care plan. The facility's own policy on oxygen administration requires verification of a physician's order prior to providing oxygen, which was not followed in this case.
Failure to Ensure Nurse Competency in Wound Care Procedures
Penalty
Summary
The facility failed to ensure that licensed nurses possessed and demonstrated the necessary competencies and skills to provide proper wound care for two residents. Specifically, the Assistant Director of Nursing (ADON) did not fully cover a resident's wound bed with calcium alginate dressing as ordered by the physician, and on two separate occasions, did not date or initial wound dressings after providing care to two different residents. These actions were observed during wound care procedures and were not in accordance with the facility's wound care policy, which requires dressings to be labeled with the date, time, and staff initials. One resident involved was a female with a history of enterocolitis due to clostridium difficile, diabetes mellitus, and peripheral vascular disease, who had a diabetic foot ulcer requiring daily wound care. During wound care, the ADON failed to fully cover the wound with the prescribed dressing and did not label the dressing on a subsequent day. The second resident was a male with diagnoses including unsteadiness, malnutrition, colostomy status, and a stage four pressure ulcer. The ADON also failed to date and initial the dressing after wound care for this resident. Interviews with facility staff revealed a lack of clarity regarding responsibility for staff competency assessments and uncertainty about whether wound care competencies were included in staff checks. The ADON acknowledged not realizing the errors at the time and recognized that not labeling dressings could result in confusion for subsequent staff. The facility's wound care policy and competency documentation indicated requirements for proper wound care procedures, including labeling of dressings, which were not followed during the observed incidents.
Failure to Maintain Infection Control Practices During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for two residents who required specialized precautions due to their medical conditions. For one resident with a diagnosis of Clostridium difficile (C. diff) and a diabetic foot ulcer, the facility did not post appropriate contact isolation signage upon or immediately after notification of the isolation order. During wound care procedures for this resident, the Assistant Director of Nursing (ADON) did not perform hand hygiene between glove changes, and open wound care supplies were placed directly on the resident's bed, contrary to infection control protocols. The resident was unaware of the need for contact precautions, and the required signage was not present at the time of initial observation. For the second resident, who had a stage four pressure ulcer and a colostomy, the ADON also failed to sanitize her hands between glove changes while providing wound care. Both residents had care plans and physician orders that specified the need for enhanced barrier precautions, including the use of gowns and gloves during high-contact care activities. Facility policy required hand washing with soap and water after contact with residents with infectious diarrhea, such as C. diff, and after removing gloves, but these procedures were not consistently followed by staff during the observed care events. Interviews with facility staff, including the ADON, the Vice President of Clinical Services, and the Administrator, confirmed that the expected standard was for staff to wash their hands before and after care, as well as between glove changes, especially for residents on isolation precautions. The lack of proper signage and failure to adhere to hand hygiene protocols during wound care for both residents were directly observed and documented by surveyors, constituting a deficiency in the facility's infection prevention and control practices.
Failure to Accurately Document Oxygen Therapy on MDS Assessment
Penalty
Summary
The facility failed to ensure that the assessment accurately reflected a resident's status by not indicating that the resident received oxygen therapy on the Quarterly MDS assessment. The resident, who had a history of acute respiratory failure with hypoxia, congestive heart failure, pneumonia, and high blood pressure, was observed and documented as receiving supplemental oxygen via nasal cannula. The care plan included interventions for oxygen therapy, and the electronic clinical record showed oxygen administration during the MDS look-back period. However, the MDS assessment did not reflect this, as the section for oxygen use was not checked. The MDS Nurse stated that the omission occurred because she relied on the Medication Administration Records (MARs), which did not indicate oxygen administration, rather than reviewing the vital signs section that documented oxygen use. Upon review, the MDS Nurse acknowledged that the resident did receive oxygen during the look-back period and that the MDS should have been marked accordingly. Interviews with facility leadership confirmed that the MDS Nurse was responsible for ensuring assessment accuracy and that an inaccurate MDS could result in an inaccurate plan of care.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A resident with a history of acute respiratory failure with hypoxia, congestive heart failure, pneumonia, and high blood pressure was observed receiving oxygen at 2 liters per minute via nasal cannula. The resident's care plan included an intervention to administer oxygen at this rate to maintain blood oxygen saturations above 92%. However, review of the physician's order summary and clinical records revealed there was no physician order for oxygen administration, despite documentation and observation confirming the resident was receiving oxygen therapy on multiple dates. Interviews with facility staff, including an LVN, the Executive Clinician, and the Executive Director, confirmed that oxygen therapy should only be administered with a physician's order and that the resident did not have such an order in place. The facility's own policy on oxygen administration also requires verification of a physician's order prior to providing oxygen. The lack of a physician order for ongoing oxygen therapy constituted a failure to provide respiratory care consistent with professional standards of practice.
Improper Foley Catheter Bag Management
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by the improper handling of Foley catheter bags for several residents. Observations revealed that the catheter bags of five residents were found touching the floor on multiple occasions. This improper positioning of the catheter bags was noted during various times and locations, including dining rooms and hallways, indicating a systemic issue in the facility's handling of catheter care. Resident #27, a female with intact cognition, was observed twice with her Foley catheter bag on the floor. Despite having a care plan for her indwelling catheter due to stage 4 pressure injuries, there were no specific interventions for managing the catheter bag. Similarly, Resident #38, with moderately impaired cognition and a neurogenic bladder, was observed with her catheter bag touching the floor. Resident #9, who has severe cognitive impairments and a history of pressure injuries, was also seen with her catheter bag dragging on the floor on two separate occasions. Resident #2, with intact cognition but suffering from hemiplegia and a traumatic brain injury, was observed with his catheter bag dragging on the floor under his wheelchair. Resident #49, with moderately impaired cognition and obstructive uropathy, was seen with his catheter bag making contact with the floor. Interviews with staff, including LVNs and CNAs, confirmed that the catheter bags should not touch the floor due to infection risks. However, the facility's policies and training did not effectively prevent these occurrences, as evidenced by the repeated observations of catheter bags improperly positioned.
Inaccurate Coding of Resident Diagnosis on MDS
Penalty
Summary
The facility failed to ensure that the quarterly comprehensive assessment accurately reflected the status of a resident, specifically regarding the coding of the resident's diagnosis. The resident, who was receiving buspirone for anxiety as per physician's orders, had a diagnosis of Adjustment Disorder with Anxiety. However, the Minimum Data Set (MDS) assessments did not reflect this diagnosis, despite the medication administration records indicating the use of an anti-anxiety medication. This discrepancy was confirmed by the MDS RN, who acknowledged that the MDS assessments did not accurately reflect the resident's diagnosis. The failure to accurately code the resident's diagnosis on the MDS assessments could place the resident at risk for improper or incorrect care and services necessary for their well-being. The facility's policy requires that all persons completing any portion of the MDS Resident Assessment Form must sign the document, attesting to the accuracy of the information. The Director of Nursing (DON) acknowledged that these failures could impact the resident's physical, mental, and psychosocial well-being.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 11.54% due to three errors out of 26 opportunities. These errors involved two residents and one medication aide (MA). The errors were primarily related to the untimely administration of medications, which were not given within the prescribed time window. Specifically, medications for two residents were administered significantly later than scheduled, which could potentially affect the therapeutic outcomes. Resident #52, a male with chronic kidney disease, hypertensive heart disease with heart failure, and hypertension, was affected by the untimely administration of medications. His care plan included interventions for fluid overload and pain management, requiring the administration of diuretics and analgesics as ordered. On the day of the observation, the resident's medications, bumex and gabapentin, were administered almost two hours past the scheduled time of 7:00 AM. Similarly, Resident #18, a female with type 2 diabetes mellitus and neuropathy, experienced a delay in receiving her medication. Her care plan also required timely administration of gabapentin for neuropathy pain. The medication was administered over two hours late. Interviews with staff, including the MA and the Director of Nursing (DON), revealed a misunderstanding or misapplication of the facility's policy, which allows for a one-hour window before and after the scheduled time for medication administration. However, the observed delays exceeded this window, contributing to the facility's high medication error rate.
Medication Administration Errors in Resident Care
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the administration of medications outside of physician-ordered parameters. The resident, who had a history of hemiplegia, atrial fibrillation, and hypertension, was prescribed Amlodipine Besylate and Carvedilol with specific instructions to hold the medications if the systolic blood pressure was less than 110 or the heart rate was less than 60 beats per minute. Despite these parameters, the medications were administered multiple times when the resident's vital signs were outside the specified limits. The medication administration records revealed that Amlodipine Besylate was given to the resident on several occasions when the heart rate was below 60 beats per minute, and Carvedilol was administered when either the heart rate was below 60 or the systolic blood pressure was below 110. These errors occurred over a period of time and involved multiple licensed vocational nurses (LVNs), indicating a pattern of non-compliance with the physician's orders. Interviews with the nursing staff and the Director of Nursing (DON) highlighted a lack of awareness and communication regarding the administration of medications outside of parameters. The DON was not informed of these occurrences, and the expectation was that any deviation from the prescribed parameters should be reported to the physician and monitored for adverse effects. The facility's policy on medication errors emphasized adherence to physician's orders and professional standards, which was not followed in this case.
Failure to Provide Required Assistive Eating Equipment
Penalty
Summary
The facility failed to provide special eating equipment for a resident who required it, specifically a divided plate, which was necessary for the resident's assistance while eating. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, was observed struggling with a regular, flat, undivided plate during a meal. This struggle included spilling coleslaw after attempting to pick up the bowl it was in. Despite the resident's care plan indicating the need for a divided plate, the appropriate equipment was not provided, and staff did not intervene until prompted by a state surveyor. The resident's medical records indicated a need for a divided plate and other assistive devices as part of their dietary orders. The facility's policy stated that assistive devices should be provided, maintained, and supervised for residents. However, during the meal observation, the resident did not receive the required divided plate, and the staff failed to notice or correct this oversight. The Director of Nursing acknowledged that the assistive device should have been on the tray and that the nurse responsible for checking meal tickets should have ensured the correct equipment was provided.
Inappropriate Terminology on Meal Tickets Affects Resident Dignity
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as evidenced by the use of inappropriate terminology on meal tickets. A resident, who had intact cognition and required setup or clean-up assistance with eating, was referred to using a 'sippy cup' on their meal ticket. This terminology was used despite the resident's meal plan specifying the use of a two-handle cup or mug with a lid. The resident expressed that while the term did not personally bother them, they understood how it could be bothersome to others. Staff interviews revealed that the term 'sippy cup' was commonly used by the dietary department and kitchen staff, and it was printed on meal tickets without correction. The dietary manager acknowledged the inappropriate terminology only after state surveyors raised the issue, and subsequently changed the term to '2 handle cup or mug with lid' on meal tickets. The facility's policy on Quality of Life - Dignity emphasized the importance of caring for residents in a manner that promotes dignity and respect, which was not adhered to in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 623 citations issued within 25 miles in the last 12 months — including the 15 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Shavano Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Heights On Huebner | 3.2 mi | — | 17 | 0 |
| Patriot Heights Health Care Center | 3.8 mi | — | 1 | 1 |
| The Heights At Medical Center | 4.3 mi | — | 0 | 0 |
| Wurzbach Nursing And Rehabilitation | 4.5 mi | — | 0 | 0 |
| Remington Transitional Care Of San Antonio | 4.7 mi | — | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Estates At Shavano Park.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.