Hearth Record

San Pedro Manor

A nursing home in San Antonio, Texas 78212

515 W Ashby Pl, San Antonio, Texas 78212. (210) 732-5181.

CMS’s own record, on Care Compare

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The short answer

Record last released by CMS on Oct 28, 2026.

The last 24 months 26 citations in 8 months of the last 36. Last cited Aug 2026. Most serious: immediate jeopardy to health or safety (J). Every month

Each figure’s source sits beside it, in its section below.

What these words mean8
Star ratings
CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
Inspection (survey)
A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
Deficiency, citation, violation
What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
Scope and severity (A to L)
CMS grades each nursing home deficiency with a letter. A to C: no actual harm, with potential for minimal harm. D to F: no actual harm, but potential for more. G to I: actual harm. J to L: immediate jeopardy. Within each band, the letter rises as more residents were affected or could be: one or a few, a pattern, or widespread. Source: CMS, nursing home scope and severity grid (State Operations Manual, chapter 7).
Nurse staffing hours
The hours registered nurses, licensed practical nurses and nurse aides worked, per resident per day, from the payroll records each home sends CMS. Source: CMS, Payroll-Based Journal.
Fines and payment denials
A fine (civil money penalty) is money CMS makes a nursing home pay when it falls short of federal rules. A payment denial means Medicare and Medicaid stop paying for new admissions until the home meets the rules again. Source: CMS; 42 CFR 488.430 and 488.417.
Immediate jeopardy
CMS’s most serious finding: the place’s failure to meet a rule caused, or was likely to cause, serious injury, harm, impairment or death to someone in its care. Source: CMS; 42 CFR 489.3.
Capacity
The most people the licence or certification lets the place care for at once: residents, children, beds or apartments, as the state counts them. It isn’t how many are there now. Source: Each state’s licensing agency.

What did inspectors find?

8 health citations at the latest inspection cycle

The Texas average is 9.6.

Last standard inspection Aug 8, 2025.

Most serious in three years: immediate jeopardy to health or safety (J), at a complaint inspection on May 17, 2024

Source:

CMS, Provider Information, State and US Averages and Health Deficiencies. Released Oct 28, 2026. Updated monthly.

When those citations happened

26 citations in 8 months of the last 36. Last cited Aug 2026. Most serious: immediate jeopardy to health or safety (J). The last 3 years, to Nov 5, 2026.

26 citations by month over the last 3 years. Each cell is one month.
JanFebMarAprMayJunJulAugSepOctNovDec
2023 Dec
2024 JanFebMarAprMayJunJulAugSepOctNovDec
2025 JanFebMarAprMayJunJulAugSepOctNovDec
2026 JanFebMarAprMayJunJulAugSepOctNov

Hover or focus a month to read it.

No visit on record Visited, nothing cited A stronger orange is more serious, on its source’s own levels, read onto four bands: from the least serious it publishes to the most
Source:

Hearth Record drew this from the dates and levels in the source’s own records.

All 26 citations in the last three years

Grouped by inspection, newest first. Each carries , from A, the least serious, to L, the most. 14 came from complaint inspections.

Source:

CMS, Health Deficiencies. Released Oct 28, 2026. Updated monthly.

Aug 30, 2026: complaint inspection1 citation
  • 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.

    Rule F0761. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 31, 2026.

Apr 30, 2026: complaint inspection1 citation
  • Immediately tell the resident, the resident’s doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    Rule F0580. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 4, 2026.

Aug 8, 2025: standard inspection6 citations
  • Keep residents’ personal and medical records private and confidential.

    Rule F0583. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 9, 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.

    Rule F0690. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 9, 2025.

  • Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

    Rule F0804. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 9, 2025.

  • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Rule F0812. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 9, 2025.

  • Provide and implement an infection prevention and control program.

    Rule F0880. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 9, 2025.

  • Ensure residents have reasonable access to and privacy in their use of communication methods.

    Rule F0576. C: no actual harm, potential for minimal harm. Correction date, as CMS recorded it: Aug 9, 2025.

Jul 30, 2025: complaint inspection1 citation
  • Provide and implement an infection prevention and control program.

    Rule F0880. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jul 31, 2025.

Jul 17, 2025: complaint inspection1 citation
  • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    Rule F0842. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jul 18, 2025.

May 9, 2025: complaint inspection1 citation
  • Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

    Rule F0921. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jun 6, 2025.

Jun 27, 2024: standard inspection6 citations
  • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Rule F0689. G: actual harm. Correction date, as CMS recorded it: Aug 5, 2024.

  • Develop and implement policies and procedures to prevent abuse, neglect, and theft.

    Rule F0607. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 5, 2024.

  • PASARR screening for Mental disorders or Intellectual Disabilities

    Rule F0645. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 5, 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.

    Rule F0693. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 5, 2024.

  • Ensure that residents are free from significant medication errors.

    Rule F0760. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 5, 2024.

  • Provide and implement an infection prevention and control program.

    Rule F0880. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 5, 2024.

Jun 27, 2024: standard and complaint inspection5 citations
  • 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.

    Rule F0584. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 5, 2024.

  • Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

    Rule F0609. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 5, 2024.

  • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    Rule F0842. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 5, 2024.

  • Keep all essential equipment working safely.

    Rule F0908. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 5, 2024.

  • Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

    Rule F0925. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 5, 2024.

Jun 27, 2024: complaint inspection1 citation
  • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Rule F0812. F: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 5, 2024.

May 17, 2024: complaint inspection2 citations
  • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Rule F0689. J: immediate jeopardy to health or safety. From a complaint. Correction date, as CMS recorded it: Dec 22, 2023.

  • Provide and implement an infection prevention and control program.

    Rule F0880. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 18, 2024.

Apr 2, 2024: complaint inspection1 citation
  • Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

    Rule F0755. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 3, 2024.

Is it certified, and in good standing?

  • Certified for Medicare and Medicaid since Feb 18, 1987.
  • Not on CMS’s special focus list.
  • No abuse icon from CMS.
  • No change of ownership in the last 12 months.
  • CMS lists its ownership as government, hospital district.
  • 150 certified beds.
Source:

CMS, Provider Information. Released Oct 28, 2026. Updated monthly.

Has it been fined or penalized?

  • 2 fines in the last three years, $24,285 in all.
  • 1 Medicare payment denial in the last three years.
  • 14 citations in the last three years came from complaint inspections.
Source:

CMS, Penalties and Health Deficiencies. Released Oct 28, 2026. Updated monthly.

Fines and payment denials, newest first
DateKindAmount
Jun 27, 2024Medicare payment denialNot given
Jun 27, 2024Fine$14,063
May 17, 2024Fine$10,222

Who does the caring?

3.79 nurse hours per resident per day

The Texas average is 3.42.

CMS publishes staffing about four months after the fact.

Source:

CMS, Provider Information and State and US Averages. Released Oct 28, 2026. Updated monthly.

Staffing measures
MeasureThis homeTexas average
Nurse hours per resident per day3.793.42
Of which registered nurses0.250.44
At weekends3.372.99
Nursing staff turnover47.3%50.8%
Registered nurse turnover75%49.8%
Administrators who left1Not given

Who owns it?

  • Uvalde County Hospital Authority owns 100% directly since Feb 1, 2021.
  • West Ashby Healthcare, Inc. runs it.
  • 9 owners or officers are people: Beverly S Gutierrez (runs it (operational or managerial control)); Beverly S Gutierrez (on the governing body (managing control)); Beverly S Gutierrez (additional disclosable party (controls, leases property to, or provides services to the home)); Joshua Every (runs it (operational or managerial control), 0%); Joshua Every (on the governing body (managing control)); Joshua Every (additional disclosable party (controls, leases property to, or provides services to the home)); Chad Keetch (corporate officer); Adam Apolinar (corporate officer); Soon Burnam (corporate officer, 0%).
  • No private-equity firm among the owners CMS lists.
  • No real-estate investment trust among the owners CMS lists.
Source:

CMS, All Owners. Checked Nov 5, 2026. Updated monthly.

CMS, Provider Information. Released Oct 28, 2026. Updated monthly.

Organisations CMS lists
OrganisationRoleShareSince
Uvalde County Hospital AuthorityOwns 5% or more directly100%Feb 1, 2021
Ensign Services Inc.Additional disclosable party (controls, leases property to, or provides services to the home)Oct 13, 2020
West Ashby Healthcare, Inc.Runs it (operational or managerial control)0%Feb 1, 2021
West Ashby Healthcare, Inc.Additional disclosable party (controls, leases property to, or provides services to the home)Oct 13, 2025
515wap, LLCAdditional disclosable party (controls, leases property to, or provides services to the home)Feb 1, 2021

How do residents fare?

  • CMS rates its quality measures 5 of 5 (Texas average 3.8).
Source:

CMS, Provider Information and State and US Averages. Released Oct 28, 2026. Updated monthly.

CMS’s star ratings, from 1 to 5
MeasureRating
Overall rating4 of 5
Health inspections3 of 5
Staffing2 of 5
Quality measures5 of 5

How does it compare nearby?

  • Among the 12 nearest homes, within 3.7 miles, this one had the 9th most health citations at the latest inspection cycle (8; the middle value was 10.5).
Source:

CMS, Provider Information. Released Oct 28, 2026. Updated monthly.

What the record doesn’t say

  • Complaints that didn’t lead to a citation aren’t published.
  • Inspections reach CMS’s data about six weeks after they happen, and staffing about four months after.
  • CMS publishes the inspectors’ full written findings in a separate monthly file, which isn’t loaded yet.
  • Fines and Medicare payment denials are the only enforcement CMS publishes; state licence actions aren’t included.

Sources

  • Centers for Medicare & Medicaid Services, Provider Information (4pq5-n9py).

    Released Oct 28, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

  • Centers for Medicare & Medicaid Services, Health Deficiencies (r5ix-sfxw).

    Released Oct 28, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

  • Centers for Medicare & Medicaid Services, Penalties (g6vv-u9sr).

    Released Oct 28, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

  • Centers for Medicare & Medicaid Services, All Owners (afe44b85-cc6d-40d7-b5df-00ae8910d1d2).

    Checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

  • Centers for Medicare & Medicaid Services, State and US Averages (xcdc-v8bm).

    Released Oct 28, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).

If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.

Source:

This copy of the record was made on Nov 5, 2026.

From the home

The public record above comes first. Anything the home adds will appear here, below it, and say who wrote it.

Replies

None. Replies aren’t open yet. When they open, the home will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.

Paid listing

None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the home”, and paying will never change a finding, a rating or the order of results.

How to read a record

Four things every record does, shown on an example record made up for this guide.

An example record, made up for this guide

An example nursing home

Made up for this guide: no real place is shown

Not fully inspected in over two years (CMS flag)

11 health citations at the latest inspection cycle

The state average is 14.3.

Source:

CMS, State and US Averages and Health Deficiencies. Released Oct 28, 2026. Updated monthly.

From the homeNone yet. Replies and paid listings aren’t open, and when they open they will sit here, below the record.

1 of 4

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Who published it, when, and how often it changes sit beside each fact, with a link to the agency’s own file.

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