Cycle 1
Health 2025-07-31 · Fire 2025-07-31
4 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
San Antonio, TX
Lakeside Nursing And Rehabilitation Center
5-star overall rating with 4-star inspections with $14,611 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
8707 Lakeside Parkway, San Antonio, TX
(210) 510-3200
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
118
Certified beds
Average residents
108
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2012-10-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.06
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.46
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.78
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
3.40
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,734
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9889
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.12
Baseline 21.84% · Performance 19.14% · Measure score 5.12 · Achievement 4.95 · Improvement 5.12
Healthcare-associated infections
4.39
Baseline 7.37% · Performance 6.52% · Measure score 4.39 · Achievement 4.39 · Improvement 3.06
Total nurse turnover
3.35
Performance 50.00% · Measure score 3.35 · Achievement 3.35 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.22
Baseline 2.95 hours · Performance 3.43 hours · Measure score 1.22 · Achievement 1.22 · Improvement 1.18
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.82% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 94 · Observed rate 11.7% · Lower 95% interval 7.85% |
| Discharge to community | 44.5% |
50.57%
6.1 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 38.1% · Lower 95% interval 33.44% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 119 · Denominator 119 |
| Falls with major injury | 1.68% |
0.77%
0.9 pts worse
|
Numerator 2 · Denominator 119 |
| Discharge self-care score | 47.87% |
53.69%
5.8 pts worse
|
Numerator 45 · Denominator 94 |
| Discharge mobility score | 45.74% |
50.94%
5.2 pts worse
|
Numerator 43 · Denominator 94 |
| Pressure ulcers or injuries, new or worsened | 0.84% |
2.29%
1.5 pts better
|
Numerator 1 · Denominator 119 · Adjusted rate 0.6% |
| Healthcare-associated infections requiring hospitalization | 6.52% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 4% · Lower 95% interval 3.49% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 169 |
| Staff flu vaccination coverage | 77.51% |
42%
35.5 pts better
|
Numerator 162 · Denominator 209 |
| Discharge function score | 53.19% |
56.45%
3.3 pts worse
|
Numerator 50 · Denominator 94 |
| Transfer of health information to provider | 94.59% |
95.95%
1.4 pts worse
|
Numerator 35 · Denominator 37 |
| Transfer of health information to patient | 93.1% |
96.28%
3.2 pts worse
|
Numerator 27 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 57 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.9 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.3%
2.2 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.0% · Q4 2.1% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.7% |
2.7%
About the same
|
11.4%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.8% · Q3 0.0% · Q4 2.5% · 4Q avg 2.7% |
| Percentage of long-stay residents who lose too much weight | 0.9% |
3.3%
2.4 pts better
|
5.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 0.0% · Q4 1.2% · 4Q avg 0.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.2% |
18.9%
0.7 pts better
|
19.6%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 15.0% · Q3 18.9% · Q4 20.2% · 4Q avg 18.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.7% |
10.8%
5.1 pts better
|
16.7%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 6.5% · Q3 5.8% · Q4 6.7% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.9% |
15.4%
0.5 pts worse
|
16.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 27.8% · Q3 10.9% · Q4 4.1% · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.4% |
16.1%
7.7 pts better
|
14.9%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 19.7% · Q3 2.4% · Q4 8.6% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.1% |
15.0%
2.1 pts worse
|
19.8%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 17.4% · Q3 12.0% · Q4 16.7% · 4Q avg 17.1% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
4.2%
2.4 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 2.1% · Q3 1.5% · Q4 0.7% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.1% |
12.0%
4.9 pts better
|
12.0%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.1% · Observed 7.5% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.2% |
88.0%
11.2 pts better
|
79.7%
19.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.5% |
25.9%
6.4 pts better
|
23.9%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.5% · Observed 18.9% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-21 · Fire 2024-06-21
9 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-04-26 · Fire 2023-04-26
11 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-07-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-07
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-31
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-21
D · Potential for more than minimal harm
2025-07-31
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-08-21
D · Potential for more than minimal harm
2025-07-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-21
D · Potential for more than minimal harm
2025-07-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-21
D · Potential for more than minimal harm
2024-06-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-21
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-21
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-21
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-21
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-21
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-21
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-21
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-21
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-07-17
K · Immediate jeopardy
2024-02-16
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-02-06
K · Immediate jeopardy
2024-02-16
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-02-06
K · Immediate jeopardy
2024-02-16
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-02-06
D · Potential for more than minimal harm
2023-09-13
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-04-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-04-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-04-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-17
C · Minimal harm
2023-04-26
F848 · Administration Deficiencies
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-03-16
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-04-03
F · Potential for more than minimal harm
2023-03-02
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2023-03-24
E · Potential for more than minimal harm
2023-03-02
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-03-24
Penalties and ownership
What sits behind the stars
$14,611
2024-02-16
Fine
Fine · fine $14,611
Fine
Ownership
West Wharton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Alonzo, Carlos
Operational/Managerial Control · Individual
Atique, Rashid
Operational/Managerial Control · Individual
Burnam, Soon
Corporate Officer · Individual
Crystal Lake Healthcare, Inc.
Operational/Managerial Control · Organization
Keetch, Chad
Corporate Officer · Individual
Thompson, Johnny
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Westover Hills Rehabilitation And Healthcare
San Antonio, TX
4-star overall rating with 3-star inspections with $20,156 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Windemere At Westover Hills
San Antonio, TX
3-star overall rating with 2-star inspections with $8,281 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Legend Oaks Healthcare and Rehabilitation - West S
San Antonio, TX
5-star overall rating with 4-star inspections with $8,632 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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