F 0727
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on
a full time basis.
Based on interview and record review, the facility failed to utilize the services of a registered nurse for at
least eight consecutive hours per day, seven days per week for 5 days out of 30 (11/5/23, 11/12/23,
11/23/23, 11/25/23, and 11/26/23) reviewed for nursing services, in that:
The facility did not utilize the services of a registered nurse for at least eight consecutive hours per day,
seven days per week on 11/5/23, 11/12/23, 11/23/23, 11/25/23, and 11/26/23.
This deficient practice could place all residents at risk of not receiving adequate care.
The findings included:
Record review of the facility's Daily Staffing Posting revealed the following:
11/05/23 - 1 RN Manager for the 6 am - 6 pm shift and 0 RNs for the 6 am - 6 pm shift
11/12/23 - 0 RN Managers for the day and 0 RNs for the day
11/23/23 - 2 RN Managers for the day and 0 RNs for the day
11/25/23 - 0 RN Managers for the day and 0 RNs for the day
11/26/23 - 0 RN Managers for the day and 0 RNs for the day
Record review of the facility's Daily Punches revealed the following:
11/05/23 - No RN punches for the day
11/12/23 - No RN punches for the day
11/23/23 - No RN punches for the day
11/25/23 - ADON B punched in from 4:30 pm - 8:00 pm
11/26/23 - No RN punches for the day
During an interview on 12/1/23 at 3:15 pm, the DON clarified that the RN staffing according to the time
punch was correct. The DON said she was aware the facility was required to utilize the services
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
675883
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675883
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/01/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Southeast Nursing & Rehabilitation Center
4302 E Southcross Blvd
San Antonio, TX 78222
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0727
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
of a registered nurse for at least eight consecutive hours per day, seven days per week. She added RN
coverage was necessary to supervise LVNs, CNAs and MAs and to follow proper guidelines and protocols.
The DON said RNs received additional training, such as, critical thinking and ensuring residents received
appropriate care. She added she was always available by email and phone. The DON said not utilizing the
services of a registered nurse for at least eight consecutive hours per day, seven days per week may affect
the residents because staff did not receive responses to inquiries as quickly. The DON said she was not
sure there was one responsible party to ensure the facility utilized the services of an RN for eight
consecutive hours per day, seven days per week because the facility did not have a policy regarding RN
coverage.
During an interview on 12/1/23 at 3:21 pm, ADON B said that she prepared the Daily Staffing Posting for
11/5/23, 11/12/23, 11/23/23, 11/25/23, and 11/26/23. She said she was not aware the facility was required
to utilize the services of a registered nurse for at least eight consecutive hours per day, seven days per
week. ADON B said RNs were required for supervision of the LVNs but was not sure how not having an RN
could affect the residents. ADON B said it was the responsibility of ADON C and herself to complete the
staffing schedules.
During an interview on 12/1/23 at 3:30 pm, ADON C said that she was not aware the facility was required to
utilize the services of a registered nurse for at least eight consecutive hours per day, seven days per week.
ADON C said it was her responsibility along with ADON B to complete the staffing schedules. She added
that it was possible that not having an RN could affect residents negatively but was not sure how.
During an interview on 12/1/23 at 3:49 pm, the Administrator said the facility did not have a written policy
regarding RN coverage. He added the facility needed to have RN coverage for 8 hours every day according
to state regulations. The administrator said he was not aware the facility did not have RN coverage on
11/5/23, 11/12/23, 11/23/23, 11/25/23, and 11/26/23 for eight consecutive hours. He added the
Administrator and DON were responsible for ensuring the facility had proper RN coverage.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675883
If continuation sheet
Page 2 of 2
