Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Inspiration Hills Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, incontinence, and multiple comorbidities received incontinent care during which a CNA failed to follow the facility’s hand hygiene and glove use practices. After initially washing hands, the CNA used bare hands to adjust the bed and then donned gloves without re-washing, handled clean wipes, performed perineal care, and then used the same soiled gloves to prepare a clean brief and bed pad before finally removing gloves and washing hands. The CNA later acknowledged this was inconsistent with facility policy, while the DON and ADON/Infection Preventionist confirmed that staff are required to perform hand hygiene before donning gloves, between glove changes, and after contact with room surfaces, as outlined in the facility’s written hand hygiene policy and prior staff training.
A resident with severe cognitive impairment and a history of combative and resistant behaviors during care did not have a comprehensive, person-centered care plan that addressed these issues. Despite multiple documented incidents of aggression, refusal of care, and self-injury, the care plan was not updated in a timely manner to include interventions or measurable objectives for managing these behaviors, contrary to facility policy and best practices.
Surveyors identified multiple failures in food storage and handling, including a dirty ice maker used for resident hydration, open and unlabeled food items in a medication refrigerator, and unrefrigerated thickened water and nutritional drinks on medication carts. Staff were unaware of manufacturer requirements for refrigeration after opening, and facility practices did not align with professional standards or internal policies.
Surveyors found that the facility did not develop or implement comprehensive care plans for multiple residents, including those on hospice, with wandering behaviors, or with contractures. For example, a resident on hospice had no care plan interventions for comfort, while others with orders for Wanderguard devices or psychotropic medications lacked specific care plan details and monitoring. Additionally, two residents with contractures did not have consistent or appropriate interventions documented or implemented.
Three dependent, cognitively impaired residents did not receive multiple scheduled showers, with documentation showing missed care and no evidence of refusals or rescheduling. Staff interviews revealed inconsistent communication and documentation practices, and the facility did not follow its policy requiring proper recording of showers and staff participation.
Surveyors found that hand sanitizer was stored in unsecured locations accessible to residents, including those with cognitive impairment, and that a resident with severe cognitive impairment and a recent fall was repeatedly observed in bed without required fall mats in place. These deficiencies placed residents at risk for injury due to inadequate supervision and lack of safety devices.
A resident with severe cognitive impairment and multiple physical diagnoses experienced a fall resulting in injury. Although the facility's investigation identified new interventions such as lowering the bed, ensuring the call light was within reach, and using fall mats, these were not incorporated into the resident's care plan. Observations confirmed that some interventions were implemented, but the care plan was not updated to reflect all planned changes.
A resident with diabetes, dementia, and vision problems did not receive timely ophthalmology evaluation after a missed appointment due to lack of family accompaniment. The facility failed to reschedule the appointment or ensure follow-up, resulting in continued vision difficulties and delayed care.
Two residents with significant contractures and severe cognitive impairment did not receive appropriate contracture management devices or interventions as ordered and care planned. One resident's left palm protector was not applied as required, and another resident with a right hand contracture had no assistive device in place, despite care plans and policies calling for such interventions. Staff interviews confirmed a lack of consistent application and monitoring of these devices.
Surveyors found that the facility's medication error rate was 8.11%, exceeding the acceptable threshold. Two residents were affected: one received medications for anxiety and personality disorder over an hour late due to staff scheduling practices, and another had a vitamin supplement documented as given but not actually administered, with no proper notation in the eMAR. These errors were attributed to staff scheduling, workload, and failure to follow documentation policy.
A resident with severe cognitive impairment and multiple medical conditions was given Carvedilol on several occasions when their blood pressure or heart rate was below the physician-ordered parameters. Nursing staff administered the medication despite these out-of-range vital signs, and facility leadership was either unaware or indicated that nurses could use their judgment in such cases, contrary to policy.
A CNA was observed leaving a resident's room wearing soiled gloves and carrying unbagged, soiled linen into the hallway, contrary to facility policy requiring linens to be bagged before transport and gloves to be removed before exiting. Additionally, a CMA used a reusable blood pressure cuff on two residents without cleaning it between uses, and no sanitizing wipes were found in the medication cart, despite facility policy requiring equipment to be cleaned between residents.
Failure to Follow Hand Hygiene and Glove Use Practices During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program during incontinent care for one resident. The resident was an elderly female with multiple diagnoses, including unspecified cerebral infarction, contracture of the left hand, neuromuscular bladder dysfunction with incontinence, unspecified dementia with psychotic disturbance, and constipation. A quarterly MDS showed a BIMS score of 06, indicating severe cognitive impairment, and documented that she was dependent on staff for toileting hygiene and was frequently incontinent of bowel and bladder. Her care plan identified potential or actual skin integrity impairment related to fragile skin, incontinence, limited mobility, and hemiplegia, with an intervention to keep skin clean and dry, but did not include a specific focus or problem for incontinent care. During an observation of incontinent care, two CNAs provided care to the resident. CNA A initially washed her hands, then used bare hands to manipulate the bed control and bed frame to position the resident for care. Without washing her hands after touching these room surfaces, CNA A donned clean gloves and handled clean wet wipes, arranging them on a clean surface. After completing perineal care with those gloves, CNA A used the same soiled gloves to grab and prepare a clean brief and clean bed pad. Only after preparing these clean items did CNA A remove the soiled gloves and wash her hands, then don clean gloves to place the prepared brief and bed pad under the resident, and incontinent care was completed. In interviews, CNA A acknowledged that she should have washed her hands after touching the bed control and bed frame and before donning gloves, and that she should have removed gloves, washed hands, and applied new gloves before touching the clean brief and bed pad. She stated that facility policy required handwashing after every glove change and after touching room items, and that failure to follow this could lead to infections such as UTIs. The DON and the Assistant DON/Infection Preventionist both confirmed that staff were expected to wash hands before donning gloves, between glove changes, and after touching items in the resident’s environment, consistent with facility policy. Record review showed CNA A had prior competency evaluations in handwashing, PPE use, and pericare, and had completed an infection control training course. The facility’s hand hygiene policy required hand hygiene before and after resident contact, after contact with objects in the resident’s vicinity, and after removing gloves, which was not followed during this observed episode of care.
Failure to Timely Update Care Plan for Resident with Combative Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with severe cognitive impairment and a history of combative and resistant behaviors during care. Despite multiple documented incidents where the resident refused care, became aggressive, scratched, hit, and bit staff, and engaged in self-injurious behaviors, the care plan did not include specific focus areas or interventions addressing these behaviors. Progress notes and interviews confirmed repeated episodes of aggression and resistance, including refusal of showers, combative actions during nail care, and self-inflicted injuries, yet these issues were not incorporated into the resident's care plan in a timely manner. Staff interviews revealed that the care plan was not updated to reflect the resident's behavioral challenges until after several incidents had occurred. The social worker and MDS coordinator acknowledged that the care plan should have been revised to include interventions for resistance to care and combative behaviors, but this was delayed due to workload and oversight. The director of nursing also confirmed that the care plan should have been updated following a significant incident where the resident became combative and injured herself during nail care. The facility's own policy requires that comprehensive, person-centered care plans be developed and revised as residents' conditions change, incorporating identified problem areas and associated risk factors. However, the care plan for this resident did not meet these requirements, as it lacked measurable objectives, timeframes, and interventions to address the resident's medical, nursing, and psychosocial needs related to her aggressive and resistant behaviors.
Deficient Food Storage, Preparation, and Distribution Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, as evidenced by multiple observations and interviews. The ice maker was found to have a black substance build-up inside, despite a contracted cleaning company having recently serviced it and a policy stating it should be cleaned at least monthly. There was no internal schedule for cleaning the ice machine outside of the contracted service every six months, and both the DON and Administrator acknowledged the risk of illness from using ice from a dirty machine. Additionally, water pitchers and ice chests containing ice from the machine were observed being used for resident hydration. Further deficiencies were observed in the handling and storage of food and drink items. Two open, undated, and unlabeled food containers were found in the medication refrigerator, which the DON confirmed should not have contained food items. Multiple open containers of thickened lemon-flavored water and nutritional drinks intended for residents were found unrefrigerated on medication carts, despite manufacturer instructions requiring refrigeration after opening. Staff interviews revealed a lack of awareness regarding proper storage requirements, and the facility practice was to keep these items unrefrigerated on the carts. The DON disagreed with the need for refrigeration and deferred to the facility pharmacist, but no follow-up was provided before the survey concluded.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, as identified through observations, interviews, and record reviews. For one resident receiving hospice services, the care plan did not include any focus area, goals, or interventions related to hospice care, despite orders indicating the resident was on hospice and staff acknowledging that such planning should be present. This omission meant that the resident's comfort and end-of-life needs were not addressed in the care plan. Another resident with a history of wandering and an order for a Wanderguard device did not have care plan interventions addressing the use or monitoring of the device, nor were there interventions for the resident's wandering tendencies. Documentation failed to reflect the presence or monitoring of the Wanderguard, and care plans for psychotropic medications lacked specificity regarding the medications, related diagnoses, and symptoms to monitor. Similarly, another resident with wandering behaviors did not have care planning related to wandering or increased observation, and their care plan also lacked specific details about medication management. For two residents with contractures, the facility failed to implement or identify appropriate care plan interventions. One resident had orders and therapy recommendations for a palm protector to prevent further contracture, but interviews revealed inconsistent application and lack of staff awareness regarding the intervention. The other resident had a contracture but no orders or restorative nursing program in place, and the care plan only included general interventions without specific devices or monitoring. These failures were contrary to facility policy and placed residents at risk of not receiving care and services related to their identified needs.
Failure to Provide Scheduled Showers and Document Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically personal hygiene and scheduled showers, for three residents who were dependent on staff for these tasks. Documentation showed that one resident missed 8 out of 13 scheduled showers, another missed 8 out of 13, and a third missed 4 out of 14 scheduled showers within a one-month period. All three residents were severely cognitively impaired, as indicated by their BIMS scores, and required total staff assistance for bathing according to their care plans. None of the care plans documented any behaviors of refusal related to showers or other care. Record reviews confirmed that the missed showers were not documented as refusals or rescheduled, and there was no evidence in the electronic health records or care plans to suggest that the residents declined care. Interviews with staff revealed that if a CNA was unable to provide a scheduled shower, the expectation was to communicate this to the nurse and document it, but this was not consistently done. The DON was unaware that residents were not receiving scheduled showers and stated that documentation was only available in the electronic health record, with no additional records to support that showers were provided or refused. Facility policy required that the date, time, and staff involved in showers or tub baths be recorded in the resident's ADL record or medical record. However, the lack of documentation for the missed showers indicated that the facility did not follow its own policy or ensure that dependent residents received the necessary care for personal hygiene as scheduled.
Failure to Prevent Accident Hazards and Ensure Use of Safety Devices
Penalty
Summary
Surveyors identified that the facility failed to ensure the resident environment was free from accident hazards and did not provide adequate assistance devices to prevent accidents. During observations, hand sanitizer bottles were found stored on top of EBP carts and in unlocked drawers, making them accessible to residents, including those with altered cognition. Staff and administration confirmed that this was the usual storage method, and there was no documentation of the hand sanitizer in the facility's MSDS book in case of ingestion. The facility relied on staff monitoring to prevent resident access to these hazardous substances, but no physical barriers or secure storage were in place. Additionally, a resident with severe cognitive impairment, muscle weakness, and a history of falls was observed multiple times in bed without fall mats present, despite a recent fall from bed that resulted in a facial injury and a hospital transfer. The care plan for this resident included interventions such as a lowered bed, call light within reach, and fall mats, but the fall mats were not in place during repeated observations. These failures were noted across all resident halls reviewed and placed residents at risk for injury due to inadequate supervision and lack of required safety devices.
Failure to Revise Care Plan After Fall Investigation
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident following a fall incident, despite conducting an investigation and identifying new interventions. The resident, an elderly female with severe cognitive impairment and multiple diagnoses including muscle wasting, atrophy, and unsteadiness, experienced a fall from her bed that resulted in a facial injury. The facility's investigation after the fall identified interventions such as lowering the bed, ensuring the call light was within reach, and using fall mats. However, these interventions were not incorporated into the resident's care plan. Observations conducted after the incident showed that while the bed was lowered and the call light was within reach, fall mats were not present as planned. A review of the resident's care plan revealed that it had not been updated to include the new interventions identified during the investigation, with the most recent updates predating the fall. Interviews with the DON confirmed that changes were made in practice, but the care plan was not revised to reflect these interventions.
Failure to Reschedule Ophthalmology Appointment for Resident with Vision Impairment
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain vision abilities by not rescheduling an ophthalmology appointment after a missed visit. The resident, an older adult with diagnoses including type 2 diabetes mellitus, dementia, and cognitive deficits following cerebrovascular disease, had a standing order for ophthalmology evaluation and treatment. Documentation showed that the resident had previously been referred to an ophthalmologist for retinal and cataract evaluation due to complaints of blurred and watery vision, with diagnoses of cataracts and proliferative diabetic retinopathy with macular edema. The initial ophthalmology appointment was missed because the family member who was supposed to accompany the resident did not attend, and the facility was informed that the appointment would need to be rescheduled. Despite this, there was no evidence in the medical record that the appointment was rescheduled or that further action was taken to ensure the resident received the necessary evaluation. Interviews with facility staff revealed a lack of awareness regarding the missed appointment and the need for rescheduling. The resident continued to experience vision difficulties, impacting her ability to participate in activities, and was unsure about her vision care history. The absence of follow-up and coordination resulted in a delay in the resident receiving appropriate ophthalmology care as ordered.
Failure to Provide Contracture Management Devices and Interventions for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to provide appropriate care and services to maintain or improve range of motion (ROM) for two residents with limited ROM. For one resident, who had a history of cerebral palsy, contractures, and severe cognitive impairment, the care plan and physician's orders specified the use of a left palm protector to address a left hand contracture. Despite these orders and documentation indicating the device should be applied five times per week, multiple observations over several days revealed that the palm protector was not in place. Interviews with CNAs confirmed that they did not apply any device to the resident's hand to prevent further contracture, and the restorative nursing program for this intervention had only recently been initiated. For another resident with a history of CVA, apraxia, and severe cognitive deficit, the care plan included passive and active ROM exercises to prevent contractures, but there was no evidence of an occupational therapy program or physician's orders for a contracture management device. Observations showed the resident had a right hand contracture with no assistive device in place. The facility's contracture prevention policy required risk assessment, care planning, and implementation of prevention programs, but these steps were not fully carried out for this resident. Interviews with facility staff, including the DON and DOR, revealed a lack of consistent monitoring and implementation of contracture management interventions. The DON acknowledged that not utilizing a palm protector could increase contractures and that a device for the second resident had been requested but not obtained. The failures in applying and monitoring prescribed devices and interventions contributed to the deficiency in providing appropriate care for residents with limited ROM.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 8.11% based on three errors out of 37 opportunities. Two residents were directly involved in these errors. In one instance, a certified medication aide (CMA) administered Fingolimod HCl and Sertraline HCl to a resident for personality disorder and anxiety, respectively, at 9:34 AM, despite both medications being ordered for administration at 8:00 AM. The delay was attributed to the facility's practice of timing routine morning medications for 9:00 AM due to CMA work schedules, although the physician orders specified an earlier time. The Director of Nursing (DON) and the administrator confirmed that CMAs' schedules and budgetary constraints contributed to the delay, and that nursing staff were expected to assist if delays were anticipated. In another instance, a CMA documented the administration of Cholecalciferol 1000 units for vitamin deficiency to a resident at 9:49 AM, but this medication was not observed as administered during the medication pass. The facility's policy requires that any dose withheld, refused, or given at a time other than scheduled must be properly notated in the electronic medication administration record (eMAR) and explained in the resident's progress notes, which was not done in this case. These actions and inactions resulted in residents not receiving medications as prescribed or not receiving them at all, as observed and documented by surveyors.
Medication Administered Outside Physician Parameters
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including dysphagia, cerebral infarction, and HIV, was administered Carvedilol outside of the physician-ordered parameters. The resident's care plan included monitoring and recording medication side effects, and the medication order specified that Carvedilol should be held if the systolic blood pressure (SBP) was less than 110 or the heart rate (HR) was less than 60. Despite these instructions, the medication administration record showed that Carvedilol was given on three occasions when the resident's SBP or HR was below the specified thresholds. Interviews with facility staff revealed that the ADON was unaware of medications being given outside of parameters, while the DON stated that if vital signs were out of range, the nurse could use their judgment to administer the medication but must notify the physician. The facility's policy required obtaining and recording vital signs as necessary prior to medication administration. The failure to adhere to these parameters resulted in the resident receiving medication inappropriately, as documented by the surveyors.
Infection Control Breaches in Linen Handling and Equipment Cleaning
Penalty
Summary
A certified nursing assistant (CNA) was observed exiting a resident's room while wearing soiled gloves and carrying unbagged, soiled linen into the hallway. The CNA acknowledged the breach, stating that the facility's process is to bag soiled linens before leaving a resident's room and to avoid wearing soiled gloves in the hallway. The CNA explained that the presence of the survey team caused him to act quickly and not follow proper procedures. The Director of Nursing (DON) confirmed that the facility's expectation is for linen to be bagged prior to exiting a resident's room and acknowledged awareness of the incident. Additionally, a certified medication aide (CMA) was observed using a reusable blood pressure cuff on two residents consecutively without cleaning or sanitizing the device between uses. The CMA stated that she typically cleans the device every two to three residents and was unsure of the facility's policy regarding cleaning between residents. The Assistant Director of Nursing (ADON), who also serves as the Infection Preventionist, stated that equipment should be cleaned between every resident and that sanitizing wipes are available and should be stored in the medication carts. However, no cleaning agent was found in the medication cart during the observation. Facility policies reviewed indicated that reusable equipment should not be used for another resident until appropriately cleaned and that gloves should be removed promptly after use, with soiled linen handled in a way that prevents contamination.
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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.
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Nursing homes near San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Morningside Manor | 1.7 mi | — | 2 | 0 |
| Oak Park Nursing And Rehabilitation Center | 2 mi | — | 23 | 0 |
| Golden Estates Rehabilitation Center | 2.4 mi | — | 4 | 0 |
| The Atrium Rehabilitation Center | 2.4 mi | — | 1 | 0 |
| Sorrento | 2.8 mi | — | 1 | 0 |
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