San Pedro Manor
515 W Ashby Pl · San Antonio, TX · 78212 · 2107325181
150 certified beds Government - Hospital district Chain: The Ensign Group
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
RN staffing in the bottom 10% nationally
0.29 registered-nurse hours per resident per day, vs a 0.58 national median and 0.75 benchmark.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 4 of 5 Inspections: 3 of 5 Staffing: 2 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 3.58 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.29 | 0.55–0.75 |
| Weekend hours / resident-day | 3.27 | ≈ weekday level |
| Nursing turnover / year | 47% | median 45% |
| Fines (3-yr window) | 2 · $24,285 |
Inspection citations (30 in the current record)
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Potential for harm · D April 30, 2026 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected May 4, 2026 · Resident Rights
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Potential for harm · D August 8, 2025
Keep residents' personal and medical records private and confidential.
Corrected August 9, 2025 · Resident Rights
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Potential for harm · E August 8, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected August 9, 2025 · Quality of Life and Care
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Potential for harm · E August 8, 2025
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected August 9, 2025 · Nutrition and Dietary
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Potential for harm · E August 8, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected August 9, 2025 · Nutrition and Dietary
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Potential for harm · E August 8, 2025
Provide and implement an infection prevention and control program.
Corrected August 9, 2025 · Infection Control
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No harm found · C August 8, 2025
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected August 9, 2025 · Resident Rights
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Potential for harm · D July 30, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected July 31, 2025 · Infection Control
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Potential for harm · D July 17, 2025 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected July 18, 2025 · Resident Assessment and Care Planning
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Potential for harm · E May 9, 2025 · found via complaint
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected June 6, 2025 · Environmental
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Actual harm · G June 27, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected August 5, 2024 · Quality of Life and Care
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Potential for harm · F June 27, 2024 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected August 5, 2024 · Nutrition and Dietary
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Potential for harm · E June 27, 2024
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected August 5, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 27, 2024
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected August 5, 2024 · Resident Assessment and Care Planning
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Potential for harm · D June 27, 2024
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected August 5, 2024 · Quality of Life and Care
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Potential for harm · D June 27, 2024
Ensure that residents are free from significant medication errors.
Corrected August 5, 2024 · Pharmacy Service
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Potential for harm · E June 27, 2024
Provide and implement an infection prevention and control program.
Corrected August 5, 2024 · Infection Control
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Potential for harm · D June 27, 2024 · found via complaint
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected August 5, 2024 · Resident Rights
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Potential for harm · E June 27, 2024 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected August 5, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 27, 2024 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected August 5, 2024 · Resident Assessment and Care Planning
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Potential for harm · E June 27, 2024 · found via complaint
Keep all essential equipment working safely.
Corrected August 5, 2024 · Environmental
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Potential for harm · E June 27, 2024 · found via complaint
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected August 5, 2024 · Environmental
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Immediate jeopardy · J May 17, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected December 22, 2023 · Quality of Life and Care
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Potential for harm · D May 17, 2024 · found via complaint
Provide and implement an infection prevention and control program.
Corrected May 18, 2024 · Infection Control
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Potential for harm · D April 2, 2024 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected April 3, 2024 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| June 27, 2024 | Fine | $14,063 |
| June 27, 2024 | Payment Denial | 72 days |
| May 17, 2024 | Fine | $10,222 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 455689 · certified since February 18, 1987. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.