Buena Vida Nursing and Rehab-San Antonio
5027 Pecan Grove, San Antonio, TX 78222 · Bexar County · 222 certified beds · avg 67 residents/day · certified since Dec 1, 1984
Abuse citation flag (CMS)SFF Candidate
Part of chain: CREATIVE SOLUTIONS IN HEALTHCARE (149 facilities, chain avg rating 2.1★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Feb 13, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
▲ Immediate jeopardy, one-off · Jan 16, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Sep 6, 2025 (Past Non-Compliance)
▲ Immediate jeopardy, repeated · Oct 6, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Oct 7, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Oct 6, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Oct 7, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Oct 6, 2025 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Oct 7, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (49)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 13, 2026 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Mar 5, 2026 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Feb 13, 2026 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 16, 2026 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 16, 2026 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Oct 6, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Oct 6, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Oct 6, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Oct 6, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Oct 6, 2025 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Oct 6, 2025 | B · Minimal risk, repeated | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · from a complaint |
| Aug 29, 2025 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Aug 29, 2025 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Aug 29, 2025 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Aug 29, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 29, 2025 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Aug 29, 2025 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Aug 29, 2025 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| Aug 29, 2025 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Aug 29, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 29, 2025 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Aug 29, 2025 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Aug 29, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Aug 29, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Jul 11, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Feb 13, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Nov 18, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Nov 18, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Nov 18, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Nov 1, 2024 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Nov 1, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Aug 19, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Jul 12, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Jul 12, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jul 12, 2024 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Jul 12, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 12, 2024 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Jul 12, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jul 12, 2024 | D · Potential for harm, one-off | The facility did not dispose of garbage and refuse properly. |
| Jul 12, 2024 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
| Jul 12, 2024 | D · Potential for harm, one-off | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Jul 3, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jul 3, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Jul 3, 2024 | D · Potential for harm, one-off | The facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. · from a complaint |
| Jul 3, 2024 | D · Potential for harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Jun 2, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jun 2, 2023 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Jun 2, 2023 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Jun 2, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (9 → 13).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 4 | 0 | E |
| 2024 | 19 | 0 | E |
| 2025 | 21 | 3 | K ▲ |
| 2026 | 5 | 2 | J ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $174,889.
| Date | Type | Amount / length |
|---|---|---|
| Feb 13, 2026 | Fine | $14,508 |
| Jan 16, 2026 | Fine | $9,113 |
| Aug 29, 2025 | Fine | $151,268 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.14 | 3.46 | 3.95 | bottom 34% in Texas; bottom 19% in the U.S. |
| Registered Nurse hours | 0.29 | 0.44 | 0.69 | bottom 25% in Texas; bottom 8% in the U.S. |
| Weekend total nurse staffing | 2.85 | 3.04 | 3.50 | bottom 44% in Texas; bottom 23% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.23 | 0.34 | 0.48 | bottom 31% in Texas; bottom 17% in the U.S. |
| Total nursing staff turnover (%) | 0.0 | 55.3 | 45.8 | — |
| RN turnover (%) | 0.0 | 54.6 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.93, RN 0.27, weekend 2.66. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 1/5 · long-stay residents: 1/5 · short-stay residents: —/5
Who owns this facility
Government - Hospital district
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| West Wharton County Hospital District | Organization | Direct Ownership Interest | NOT APPLICABLE | 09/01/2022 |
| Blake, Gary | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2022 |
| Blake, Gary | Individual | ADP of the SNF | NOT APPLICABLE | 09/01/2022 |
| Blake, Malisa | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2022 |
| Bowers, Sean | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2024 |
| Cisneros, Alfred | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/18/2008 |
| Cobb, Travis | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/05/2022 |
| Cooper, Stephen | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/22/2022 |
| Dixon, Anna | Individual | ADP of the SNF | NOT APPLICABLE | 04/14/2025 |
| Hardin, Sherrie | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/04/2024 |
| Huggins, Linda | Individual | Corporate Director | NOT APPLICABLE | 09/01/2022 |
| Kerzee, Richard | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/24/2007 |
| Korenek, Patricia | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/05/2018 |
| Panther, Randy | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| San Antonio IV Enterprises LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 09/01/2022 |
| San Antonio IV Enterprises LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/07/2025 |
| Soechting, Paul | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/22/2024 |
| Strack, Joe | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/11/2022 |
| Thompson, Johnny | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Willig, Zachary | Individual | Corporate Director | NOT APPLICABLE | 01/01/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Pecan Valley Rehabilitation and Healthcare | 0.1 mi | San Antonio, TX | ★★★★☆ | 4/5 | |
| Southeast Nursing & Rehabilitation Center | 0.5 mi | San Antonio, TX | ★★☆☆☆ | 1/5 | |
| Highland Nursing Center | 1.1 mi | San Antonio, TX | ★☆☆☆☆ | 2/5 | |
| The Rio at Mission Trails | 2.4 mi | San Antonio, TX | ★☆☆☆☆ | 2/5 | |
| Normandy Terrace Nursing & Rehabilitation Center | 2.5 mi | San Antonio, TX | ★☆☆☆☆ | 1/5 | abuse |
| Windsor Mission Oaks | 3.7 mi | San Antonio, TX | ★★★☆☆ | 3/5 | |
| River City Care Center | 4.7 mi | San Antonio, TX | ★☆☆☆☆ | 2/5 | abuse |
| San Jose Nursing Center | 5.6 mi | San Antonio, TX | ★★★☆☆ | 3/5 | |
| Parklane West Healthcare Center | 6.2 mi | San Antonio, TX | ★☆☆☆☆ | 1/5 | |
| San Antonio North Nursing and Rehabilitation | 6.4 mi | San Antonio, TX | ★☆☆☆☆ | 1/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 455390.