Map showing the location of SAN PEDRO MANOR in SAN ANTONIO, Texas
515 W ASHBY PL, SAN ANTONIO, TX, 78212

Overall Score

CMS Five-Star Quality Rating
4/5Above averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • TexasAbove 69% of peers1,167 rated homes · average 2.8★
  • Bexar CountyAbove 80% of peers62 rated homes · average 2.4★
  • United StatesAbove 61% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point3★+0.2 vs TX avg
  • StaffingCan add or remove a star2★−0.1 vs TX avg
  • Quality measuresCan add or remove a star5★+1.2 vs TX avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles3★Above only 46% of peersTX avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover2★Above only 37% of peersTX avg2.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 68% of peersTX avg3.8★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.40hrsAbove 63% of peersTX avg3.40Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.35hrsAbove only 41% of peersTX avg0.44Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better45%Above 67% of peersTX avg51%RN turnover58%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$24,285Above only 45% of peersTX avg$55,368Fines · denials2 · 1
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
32citations
9inspection dates
1actual harm (G–I)
1immediate jeopardy (J–L)
Aug 8, 2025most recent

Citations by monthMar 2023 – Aug 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Aug 8, 20256 citationsCycle 1worst E · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Aug 9, 2025
  2. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareE · patternCorrected Aug 9, 2025
  3. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Aug 9, 2025
  4. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Aug 9, 2025
  5. F576Ensure residents have reasonable access to and privacy in their use of communication methods.Resident RightsC · widespreadCorrected Aug 9, 2025
  6. F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Aug 9, 2025
Jul 30, 20251 citationCycle 1worst D · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Jul 31, 2025
Jul 17, 20251 citationCycle 1worst D · no actual harm
  1. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Jul 18, 2025
May 9, 20251 citationCycle 1worst E · no actual harm
  1. F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalE · patternCorrected Jun 6, 2025
Jun 27, 202412 citationsCycle 2worst G · actual harm$14,063, payment denial
  1. F693Ensure 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.Quality of Life and CareD · isolatedCorrected Aug 5, 2024
  2. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Aug 5, 2024
  3. F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Aug 5, 2024
  4. F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Aug 5, 2024
  5. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Aug 5, 2024
  6. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Aug 5, 2024
  7. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Aug 5, 2024
  8. F584Honor 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.Resident RightsD · isolatedCorrected Aug 5, 2024
  9. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Aug 5, 2024
  10. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Aug 5, 2024
  11. F908Keep all essential equipment working safely.EnvironmentalE · patternCorrected Aug 5, 2024
  12. F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalE · patternCorrected Aug 5, 2024
May 17, 20242 citationsCycle 2worst J · immediate jeopardy$10,222
  1. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected May 18, 2024
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Dec 22, 2023
Apr 2, 20241 citationCycle 2worst D · no actual harm
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Apr 3, 2024
May 12, 20235 citationsCycle 3worst F · no actual harm
  1. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected May 15, 2023
  2. F814Dispose of garbage and refuse properly.Nutrition and DietaryD · isolatedCorrected May 15, 2023
  3. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected May 15, 2023
  4. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected May 15, 2023
  5. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected May 15, 2023
Mar 23, 20233 citationsCycle 3worst E · no actual harm
  1. F839Employ staff that are licensed, certified, or registered in accordance with state laws.AdministrationE · patternCorrected Mar 24, 2023
  2. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Mar 27, 2023
  3. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Mar 27, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.40hrsAbove 63% of peers±0.00 vs TX avg
  • Registered nursesRN hours only0.35hrsAbove only 41% of peers−0.09 vs TX avg
  • Licensed practical nursesLPN hours1.14hrs
  • Nurse aidesCNA hours1.91hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.00hrs
  • Texas average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better45%Above 67% of peersTX avg 51%
  • RN turnoverRegistered nurses only58%Not ranked by CMS
  • Administrators who leftIn the past year3Leadership changed
  • Occupancy150 certified beds · ~97 residents a day64%Above only 42% of peersTX avg 67%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $24,285In fines
  • 2Fines
  • 1Payment denial
  • $55,368TX avg in fines
Above only 45% of peersFewer fines than 45% of rated homes in Texas

Actions on record

  1. Jun 27, 2024Civil money penalty$14,063
  2. Jun 27, 2024Denial of payment for new admissionsfrom Jul 31, 2024
  3. May 17, 2024Civil money penalty$10,222

Ownership

As filed with CMS

Structure

Ownership type
Government - Hospital district
Chain
The Ensign Group324 facilities in the chain3.2★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Uvalde County Hospital Authority
Operational or managerial control
  • West Ashby Healthcare, INC.
  • Joshua Every
  • Beverly Gutierrez
Corporate officers
  • Adam Apolinar
  • Soon Burnam
  • Chad Keetch

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 455689 · 515 W ASHBY PL, SAN ANTONIO, TX, 78212.
  • Percentiles compare this facility with every rated nursing home in Texas and Bexar County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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