7302 Oak Manor Dr, San Antonio, TX 78229 · Bexar County · (210) 344-8537
170 certified beds, about 118 residents a day · For profit - Individual · Medicare and Medicaid since 1988
CMS Care Compare ratings, data as of September 1, 2026 · CCN 455789 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on March 13, 2026, inspectors cited 14 health deficiencies (the Texas average is 9.4, the national average 9.2).
Of 60 health citations since October 2023, 1 was rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists 1 fine totaling $9,280 in the last three years; the largest was $9,280, and the latest is dated November 12, 2024.
Nurses and nurse aides worked 3.19 hours per resident per day, against 3.39 across Texas and 3.86 nationally. Registered nurses accounted for 0.18 of those hours.
50.0% of nursing staff left within the year CMS measured (Texas average 55.3%).
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 60 health citations on file.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing in accordance with the comprehensive assessment and plan of care for 1 of 12 residents (Resident #12) reviewed for behavioral health services. The facility failed to ensure Resident #12's physician orders for behavioral health services (psychological care services) were followed to ensure the resident was evaluated and treated for mental illness and behaviors. This failure could place residents at risk for diminished quality of life due to the lack of treatment and prevention to maintain resident safety.
Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source for 1 of 3 residents (Resident #12) reviewed for transfers. The facility failed to assist Resident #12's family with coordination and planning of a transfer at their request to another facility. This deficient practice could place residents at risk for residents being isolated away from family and friends.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instruction needed to provide effective and person-centered care of the resident that meets professional standard of quality of care within 48 hours of admission for 1 of 8 residents (Resident #7) whose medical records were reviewed for accuracy in that: The facility failed to develop a baseline care plan within 48 hours of Resident #7's admission to the facility. This failure could place residents at risk of not receiving needed care and treatment.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #7) reviewed for comprehensive care plans in that: The facility failed to ensure that there was a comprehensive care plan on file in the electronic health record for Resident #7 on 7/21/2026. These failures could place residents at risk of not having their individual care needs met and could result in a decreased quality of life.
Inspectors wroteBased on interviews and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #5) out of 8 residents reviewed for medical records in that: Facility staff did not document details of a facility reported incident that reportedly occurred on 6/26/2026 at 5:00 p.m. in Resident #5's electronic health record. This failure could affect residents whose records were maintained by the facility and could place the residents at risk for errors in care and treatment.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 4 residents (Resident #2 and #3) reviewed for MDS assessment accuracy.1. The Quarterly MDS Assessment for Resident #2 failed to accurately document the percentage of calories the resident received through the gastrostomy tube (a tube inserted into the stomach to administer medications and nutritional supplements; a feeding tube).2. The 5-Day MDS Assessment for Resident #3 failed to accurately document the resident had an indwelling urinary catheter. This failure could lead to residents not receiving the required care and decreased quality of life.
Inspectors wroteBased on interviews and record reviews, the facility failed to maintain medical records on each resident that were complete and accurately documented for 1 of 4 residents (Residents #1) reviewed for consents for accurate medical records. The facility failed to ensure LVN A documented wound care was provided to Resident #1 on 05/24/2026. This failure could place residents at risk for inaccurate medical records.
Inspectors wroteBased on interview and record review, the facility with more than 120 beds failed to employ a qualified social worker on a full-time basis, for 1 of 1 social services staff reviewed for qualifications of Social Worker. The facility failed to employ a full-time social worker since April 15, 2026 when the facility was licensed for 170 beds. This failure could place residents at risk of social service and psychosocial needs not being met.
Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that include measurable objectives and time frames to meet residents' medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 1 of 7 residents (Residents #1) reviewed for care plans. The facility failed to update Resident #1's care plan to reflect that Resident #1 did not have a video monitoring device in her room. This failure could place residents at risk of not having their needs met and not receiving appropriate care.
Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 4 of 5 residents (Residents #16, #35, #68 and #94) reviewed for abuse. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. The facility failed to discard a pan of chicken pot pie with discard date 03/04/2026. The facility failed to ensure boxes of food products were stored properly on the top shelf in the walk-in freezer. These failures could place residents at risk for food borne illness.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. The facility failed to ensure Resident #82's personal refrigerator was less than 41 degrees Fahrenheit. The facility failed to ensure Resident #106's personal refrigerator was cleaned and did not have 2 Styrofoam containers with no date or label. The facility failed to ensure Resident #85's personal refrigerator's freezer was properly functioning and not iced. These failures could place residents at risk for food borne illness.
Inspectors wroteBased on interview and record review, the facility failed to ensure that the resident had the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 1 (Resident #4) of 8 residents reviewed for resident rights. The facility failed to obtain informed consent for the use of Ziprasidone HCL (an antipsychotic medication) for Resident #4. This failure could place residents who receive psychotropic medications at risk of receiving medications without consent, knowledge of possible side effects of the medications, or other treatment options.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 13 residents (Resident #5) reviewed for assessments. The facility failed to ensure Resident #5's quarterly MDS submitted 2/24/2026 accurately reflected that she does not use a restraint device. This failure could result in residents receiving inappropriate care.
Inspectors wroteBased on observation, interview, and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's care planning for 1 of 8 residents (Resident #100) reviewed for PASARR services. The facility failed to ensure Resident #100's PASRR Level 1 Screening was completed accurately with mental illness diagnosis to secure a Level 2 Evaluation by the Local Authority. This deficient practice could place residents at risk of not receiving services identified by the local authority.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 13 residents (Resident #81) reviewed for care planning. The facility failed to ensure Resident #81's comprehensive care plan accurately reflected the required safety interventions for smoking. This failure could result in residents not receiving the level of intended care.
Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the resident has a right to be treated with respect and dignity for 1 of 8 (Resident #74) residents reviewed for grooming in that: Resident #74 had facial hair on upper lip and chin. This failure could place residents with unwanted facial hair at risk of low self-esteem.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 of 13 residents (Resident #81) reviewed for accidents and hazards. The facility failed to ensure Resident #81 was supervised while smoking on 3/10/2026. This failure could result in injury.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 8 residents (Resident #4) reviewed for medically related social services. The facility failed to ensure Resident #4 was assisted in obtaining psychology/psychiatry consultation as ordered by physician on 1/29/2026 and developing interventions that are targeted and meaningful to the resident. This failure could place residents who have a mental illness diagnoses at risk of not receiving needed mental and psychosocial counseling services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental services to meet the needs of 1 of 8 (Resident #12) residents reviewed for dental services. The facility failed to ensure Resident #12 received dental services when she had a broken tooth that caused her discomfort. This failure could place residents at risk of not receiving needed dental care and a decreased quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 21 meals on the Week 4 menu reviewed food and nutrition services. This facility failed to ensure the residents , who consumed this meal, received a balanced dinner meal that included a protein, in accordance with established national guidelines, on Tuesday 03/10/2026 (Day 24 of the Week 4 menu). This failure could place residents at risk for a decline in health status due to inadequate or inappropriate nutritional intake, weakness, and weight loss.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #76) reviewed for infection control. The facility failed to ensure CNA C performed hand hygiene while providing incontinence care to Resident #76. This failure could lead to infection or illness.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to post the following information on a daily basis: Facility name, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered nurses, Licensed practical nurses or licensed vocational nurses, Certified nurse aides, or retain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater for 4 of 4 (3/10,11,12,13/2026) days in that: 1. The facility did not have the facility name, the total number and actual hours worked by nursing staff 2. The facility failed to retain 18 months of the Nurse Staffing Postings. [...]
Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 3 of 4 resident hallways (Hallway 100/300/400) reviewed for physical environment. 1. The facility failed to ensure resident room [ROOM NUMBER], located on hallway 100, had repaired a yellow stain around the toilet bowl with missing caulking 2. The facility failed to ensure resident room [ROOM NUMBER], located on hallway 100, had repaired a black stain mark on the lower bathroom door measuring 2x1 ft. 3. The facility failed to ensure resident room [ROOM NUMBER] located on hallway 300 had repaired a chipped piece of bathroom tile which measured approximately 2x2 inches and a broken piece of floor molding which measured approximately 2x2 inches on the right side wall adjacent to the bathroom. 4. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise Resident Care Plans after each assessment for 1 of 7 Residents (Resident #1) whose records were reviewed for care plans. The facility failed to ensure Resident #1's care plan was revised to reflect the use of oxygen. This deficient practice could place Residents at risk of not receiving the care and services they needed.
Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 4 dining rooms (Station 4 dining room) observed for resident rights. The facility failed to ensure CNA W and CNA X were not using their personal phones while in the dining room, sitting with residents on 12/18/24. This failure could place residents at risk of not being treated with dignity and respect.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for 3 of 30 residents (Resident #22, Resident #31, and Resident #53) reviewed for quality of care. 1. The facility failed to ensure Resident #22's Humalog KwikPen insulin (a lightweight pen that is prefilled with insulin, a hormone that helps the body use glucose for energy) was given per physician order. 2. The facility failed to ensure Resident #31's HgA1c lab (a blood test that measure the average blood sugar level of the past 3 months) was drawn every 3 months as per physician order. 3. The facility failed to ensure Resident #53's Midodrine HCl (a medication used to treat low blood pressure) was given per physician order. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and included the appropriate identifying accessory and cautionary labeling instructions, and failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 30 residents (Residents #37, #22, and #53) reviewed for pharmaceutical services, in that: 1. The Hall 100 Nurse's cart contained a Glargine Kwik Pen for Resident #37 which was marked with an open date of 11/3/2024, making it past 28 days from its open date, meaning it was expired. 2. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions for 2 of 4 medication carts (Hall 100 Nurse's and Medication Aide carts) reviewed for medication labeling and storage, in that: 1. The Hall 100 Nurse's cart contained a plastic bag which contained (3) opened and used Lispro insulin Kwik Pens for Resident #29, but only one of the Lispro Kwik Pens had an open date, resulting in no way for the Nurse to tell how long the other (2) pens had been opened, and if they were past their expiration dates. 2. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: 1. In a refrigerator, there were foods that were not labeled with the name of the food product and discard dates. 2. In the walk-in refrigerator, there were food products that needed to be discarded as it was past their use-by dates. 3. Dietary Aide T and [NAME] U had nose rings while handling food. 4. In the food preparation area, there were personal beverages and outside food in a to-go container. 5. Dietary Aide V documented the refrigerator temperature was 42*F on 12/01/2024. Dietary Aide V did not assess what could have caused this temperature reading, which was the kitchen's protocol. 6. [...]
Inspectors wroteBased on interviews and record review, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 1 of 5 residents (Resident #62) reviewed for clinical records. 1. The facility failed to ensure LPN J accurately documented on Resident #62's MAR (Medication Administration Record) when on 12/02/2024 she held the physician ordered Losartan Potassium (a blood pressure medication) because the resident's blood pressure was outside the approved range. 2. The facility failed to obtain signed consents for antipsychotic medications for Resident #73 who was administered Risperdal Oral Tablet 0.5 MG (Risperidone) related to bipolar disorder). [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 4 of 12 residents (Residents #74, #20, #40 and #54) reviewed for infection control in that: 1. The facility failed to ensure CNA-Q followed proper infection control practices by not changing gloves and sanitizing hands after touching privacy curtain to pull it around the bed, then proceeding with catheter and peri-care with Resident #74. 2. [...]
Inspectors wroteBased on interview and record review, the facility failed to provide notice to residents of the change as soon as was reasonably possible when changes in coverage were made to items and services covered by the Medicare and/or Medicaid state plan for 2 of 3 residents [Resident #95, Resident #001] reviewed for Medicaid and Medicare Coverage Liability Notices. The facility failed to ensure Resident # 95 and Resident #001 were provided a Skilled Nursing Facility Advance Beneficiary Notice of non-coverage Form CMS-10055 [SNF ABN] that informs a Medicare beneficiary that Medicare will no longer pay for skilled services when discharged from skilled services at the facility prior to completion of covered stay or covered days being exhausted when he/she was discharged from Medicare Part A skilled nursing services. [...]
Inspectors wroteBased on interview, and record review the facility failed to ensure the comprehensive assessment accurately reflected the resident's status for 2 (Resident #26 and Resident #49) of 3 residents reviewed for accuracy of assessments. 1. The facility failed to accurately code Resident #26's smoking status on his modified significant change comprehensive assessment. 2. The facility failed to accurately code Resident #49's smoking status on his significant change comprehensive assessment. These failures could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.
Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan including the minimum healthcare information necessary to properly care for the resident within 48 hours of the resident's admission, for 1 (Resident #30) of 30 residents reviewed, in that: Resident #30's baseline care plan was not completed within 48 hours of the resident's admission on [DATE]. This failure could place newly admitted residents at risks of not receiving the proper care and continuity of services.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission for 1 of 2 residents (Resident #13) reviewed for physician services. The facility failed to ensure Resident #13 was seen by a physician within the first 30 days of his admission to the facility. This failure could place the residents at risk for medical conditions not being identified, care needs not being met, and a decline in health status.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents' pharmacist medication regimen review recommendations were reviewed by the resident's attending physician and the physician documented what, if any, action has been taken to address them, for 1 of 6 residents (Residents #2) whose records were reviewed for pharmacy services. After 11/18/24 medication review for Resident #2, the facility failed to add a doctor's order as was recommended by the pharmacist and approved by MD D. This failure could place residents at risk for significant health status declines.
Inspectors wroteBased on interview and record review, the facility failed to ensure labratory services were provided to meet the needs of the resident in accordance with professional standards of practice, and for 1 of 30 residents (Resident #31) reviewed for labratory service. The facility failed to ensure Resident #31's HgA1c lab (a blood test that measure the average blood sugar level of the past 3 months) was drawn every 3 months as per physician order. These failures could place residents at risk of not receiving care to maintain optimum health and placing them at risk for decline in health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow menus for 1 of 1 resident meals (dinner meal on 12/18/2024) reviewed for menus in that: The facility failed to follow the menu for residents on pureed diets for the dinner meal on 12/18/2024. This failure could place residents who consume food prepared by the facility kitchen at risk of not having their nutritional needs met and/or weight loss.
Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 1 of 2 residents (Resident #22) reviewed for hospice services. The facility failed to maintain required hospice forms and documentation, that included the current hospice plan of care to ensure Resident #22 received adequate end-of-life care. This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, and misappropriation of property for 1 of 6 residents (R #2) reviewed for abuse. The facility did not properly monitor or put in place preventative measures for R #2 to prevent an act of sexual abuse on 05/04/2024 by R#1. On 05/04/24 around 9:30 PM, R #1, intoxicated and aggressive, was not monitored and left unsupervised in his room for 15 minutes. R #1 left his room and was found at 9:45 PM by CNA C engaged in a sexual act with R#2 (non-consenting adult). R#1 had undressed R#2's top and engaged in sucking her breast. The non-compliance was identified as PNC. The IJ began 05/04/24 and ended 11/25/24. The facility had corrected the non-compliance before the survey began. [...]
Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical and nursing needs for 1 of 6 residents (R# 1), reviewed for care plans. R#1's care plan did not contain measurable goals and objectives for alcohol use and abuse from, although the resident had five documented episodes of alcohol intoxication or smelled of alcohol. This non compliance was identified and corrected prior to entrance. This failure could place residents at risk for not receiving the care and treatments listed in the care plan and could lead to a diminished quality of life associated with alcohol use and abuse.
Inspectors wroteBased on interviews and record review, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for clinical records. The facility failed to ensure Resident #1's EMR reflected accurate wound care documentation on 10/24/2024,10/26/2024,10/27/2024 and 10/31/2024. These deficient practices could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide reasonable accommodation of resident needs 2 of 10 resident rooms (Resident #328 and Resident #26) reviewed for call lights, in that: The facility failed to ensure Resident #328's and Resident #26's call light were within reach and placed for easy access. The deficient practice could place residents at risk of not receiving care or attention when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 3 of 3 residents (Resident #29, Resident #40, Resident #79) reviewed for dialysis in that: The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Resident #29, #40, and #79. This deficient practice could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menu was followed for 1 of 1 (lunch meal) observed for planned menus, in that: 1. The facility failed to ensure all residents received roasted red potatoes with their lunch meal on 11/14/2023. 2. The facility failed to ensure carrot cake was served with their lunch meal on 11/14/2023. These failures could place residents at risk for dissatisfaction, poor intake, and diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, reviewed for kitchen sanitation, in that: 1. The facility failed to ensure dented cans were not in the dry storage room, on a rack: a. A pineapple tidbits can with a dent in the top corner of the can b. A Manwich original can with small dents in the can. 2. The facility failed to maintain the cleanliness of the ice maker found within the kitchen. 3. The facility failed to ensure that sanitizing buckets were not near containers of food. 4. The facility failed to ensure there were use-by dates in the freezers and refrigerators. 5. The facility failed to ensure a clear, plastic wrapped tuna sandwich, dated 11/12/23, was thrown away. [...]
Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were accurately documented for 2 of 32 Residents (Resident #6 and Resident #79) reviewed for medical records, in that: 1. The facility failed to ensure Resident #6's medication administration was documented at the time it was administered. 2. The Facility failed to properly document Resident #79's return from dialysis assessment. This failures could place residents at risk for improper care due to inaccurate records.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 4 units (unit 400) reviewed for infection control, in that: 1. The biohazard room for Unit 400 was not kept locked. 2. Staff were not wearing droplet precautions PPE in hallway 200. These failures could place residents at-risk for infection due to improper care practices.
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside, for 1 of 8 Residents (Resident #64) reviewed for the ability to call for staff, in that: The facility failed to ensure that Resident #64 had a functional call light system. This failure could place residents at risk for injury and diminished self-esteem, due to the inability to call for assistance.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 1 of 4 units (unit 400) observed for environment, in that: 1. The facility failed to ensure potential hazards were locked up and kept out of resident rooms. This deficient practice could place residents at risk of a diminished quality of life due to an unsafe environment.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior for 1 of 10 Resident's (Resident #16) reviewed for environment. The facility failed to ensure the broken and missing tiles in the restroom in Resident #16's bathroom was repaired. The facility failed to ensure that Resident #16's shower was clean. These failures could affect the residents and place them at risk for not having a safe and sanitary homelike environment.
Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 7 residents (Resident #38) whose assessments were reviewed, in that: Resident #38's quarterly MDS incorrectly documented the resident as receiving an anticoagulant medication. This failure could place residents at-risk for inadequate care due to an inaccurate assessments.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 32 residents (Residents #59) reviewed for accidents and hazards in that: The facility failed to ensure Residents #59 did not have 3 disposable razors in his rooms. This failure could place residents at risk of harm or injury and contribute to avoidable accidents.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents who need respiratory care were provided such care, consistent with professional standards of practice for 1 of 2 resident (Resident #63) reviewed for respiratory care. Facility failed to clean and replace the filter for Resident #63's oxygen concentrator. This deficient practice could affect residents who receive oxygen therapy which could contribute to respiratory infections.
Inspectors wroteBased on observations, interviews and record reviews failed to accommodate residents' food preferences for 1 of 8 (Resident #11) residents reviewed for food preferences, in that: Resident #11's lunch meal tray on 11/14/23 did not follow her dislike of chocolate. This could affect all residents with food preferences and could result in a decrease in resident choices and diminished interest in meals.
Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to ensure accurate administration and documentation of medications for 2 of 12 residents (Residents #1 and #2) reviewed for pharmacy services and medication administration in that: The facility failed to administer medications as prescribed for Residents #1 and #2. This failure placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.
Inspectors wroteBased on interview, and record review, the facility failed to ensure that all visitors enjoy full and equal visitation privileges consistent with resident preferences for 1 of 5 residents (Resident #1) reviewed for Visitation Rights, in that: The facility put stipulations on the form of Resident #1's visits with family members that went against the resident's choices. This deficient practice could place residents at risk for decreased quality of life, depression, and isolation.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 2 residents (Resident #3 and #7) reviewed for care plans. The facility failed to ensure proactive, measurable interventions were in place to address focus areas listed involving falls and other injuries for Residents #3 and #7. Different interventions were not identified after each fall to prevent future falls. [...]
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the resident(s) environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents, for 1 of 16 residents (Resident #12) reviewed for accident hazards and supervision, in that; Resident #12 had one unauthorized, unchaperoned elopement events on 8/12/2023, without the facility providing adequate safety interventions to prevent further elopement risks. This failure placed residents at risk for harm, injury, or death due to elopement.
15 fire safety citations on file: 6 on March 13, 2026, 6 on December 19, 2024, 3 on November 17, 2023.
| Date | Penalty | Amount or length |
|---|---|---|
| November 12, 2024 | Fine | $9,280 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Texas | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.19 | 3.39 | 3.86 |
| Registered nurses | 0.18 | 0.43 | 0.69 |
| All nursing staff on weekends | 3.13 | 2.98 | 3.42 |
| Nurse aides | 1.97 | ||
| Licensed practical nurses | 1.04 | ||
| Nursing staff turnover (share who left in a year) | 50.0% | 55.3% | 45.8% |
| Registered nurse turnover | not reported | 54.6% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.62 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.22 on weekdays and 3.13 on weekends, 3% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.19 in April to June 2025 to 3.19 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.19 | 0.18 | 3.22 | 3.13 | 0.0% | 0 of 90 | 118 |
| Oct to Dec 2025 | 3.04 | 0.16 | 3.08 | 2.94 | 0.0% | 0 of 92 | 120 |
| Jul to Sep 2025 | 3.14 | 0.13 | 3.21 | 2.98 | 0.0% | 0 of 92 | 120 |
| Apr to Jun 2025 | 3.19 | 0.10 | 3.27 | 3.00 | 0.0% | 0 of 91 | 118 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Texas, Jan to Mar 2026 | 3.33 | 0.40 | 3.50 | 2.93 | 2.2% | 0.7% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Texas, all employers | |||
| CNAs (nursing assistants) | $18.03 | $16.97 to $20.71 | 88,680 |
| LPNs and LVNs | $29.92 | $27.46 to $32.89 | 57,560 |
| Registered nurses | $46.14 | $38.06 to $50.53 | 271,380 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Texas | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 17.5 | 15.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.3 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.2 | 0.8 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.6 | 3.3 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 9.1 | 1.5 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 17.0 | 14.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.2 | 3.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 23.0 | 9.6 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 25.6 | 25.7 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 13.7 | 12.3 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.3 | 2.2 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.3 | 2.1 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Oak Park Nursing and Rehabilitation Center's Medicare short-stay residents. How to read these, and what Medicare pays for.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
US median of homes 51.5% · Texas: 116 better, 50 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 17 eligible stays.
10.3% this home
No different from the national rate
US median of homes 10.7% · Texas: 0 better, 9 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 76 eligible stays.
7.3% this home
No different from the national rate
US median of homes 7.1% · Texas: 4 better, 11 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 34 eligible stays.
46.1% this home
Median of homes: Texas57.3% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 52 residents counted.
0.0% this home
Median of homes: Texas0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 79 residents counted.
1.2% this home
Median of homes: Texas1.3% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 79 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Texas98.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 5 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: BOOKER HOSPITAL DISTRICT.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Booker Hospital District | 5% or greater direct ownership interest | Organization | 100% | 06/01/2022 |
| Hoover, Shawn | Corporate director | Individual | 06/01/2022 | |
| Oak Park Operations Inc. | Operational/managerial control | Organization | 06/01/2022 | |
| Schindele, William | Operational/managerial control | Individual | 06/01/2022 | |
| Billy Schindele 2020 Irrv Tr | Adp of the SNF | Organization | 06/01/2022 | |
| Oak Park Leasing Inc | Adp of the SNF | Organization | 06/01/2022 | |
| Sherry Schindele Irrv Tr | Adp of the SNF | Organization | 06/01/2022 | |
| Trident LTC, Inc. | Adp of the SNF | Organization | 06/01/2022 | |
| Trident One Leasing LLC | Adp of the SNF | Organization | 06/01/2022 | |
| Aziz, Wesam | Adp of the SNF | Individual | 06/01/2022 | |
| Moore, Jonathan | Adp of the SNF | Individual | 06/01/2022 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Texas. NursingHomeClear cannot take or act on complaints.