Retama Manor Nursing: Unlicensed Admin, Security Fails, TX
SAN ANTONIO, TX - Federal inspectors found significant safety and regulatory violations at Retama Manor Nursing Center/San Antonio West during a January 10, 2025 complaint investigation, including compromised security systems for residents with dementia and operation without a properly licensed administrator for over a month.
Critical Security System Failures Put Residents at Risk
The most serious violation identified by inspectors carried an "immediate jeopardy" designation, indicating that facility conditions posed an immediate threat to resident health and safety. The citation focused on the facility's inadequate supervision and security measures for residents prone to wandering, a critical safety concern in nursing homes that care for individuals with dementia and cognitive impairments.
Inspectors documented that while the facility maintained an elopement binder identifying seven current residents with wandering behaviors, the security infrastructure designed to protect these vulnerable individuals had significant gaps. The maintenance supervisor, who had only been employed at the facility since October 2024, revealed concerning practices regarding the facility's door alarm systems.
During interviews, the maintenance supervisor disclosed that several critical exit doors had their alarms routinely turned off during business hours. Most notably, the B-Hall exit door alarm was being deactivated throughout the day to accommodate deliveries, while the A-hall courtyard door alarm was turned off during work hours and only reactivated on weekends. This practice created dangerous windows of opportunity where residents with dementia could potentially leave the facility undetected.
The facility's approach to managing these security systems demonstrated a fundamental misunderstanding of the continuous nature of wandering risks. Residents with dementia who are prone to elopement can attempt to leave at any time, regardless of delivery schedules or business operations. The intermittent deactivation of alarm systems created periods where the most vulnerable residents lacked adequate protection.
Medical Significance of Elopement Prevention Systems
Wandering and elopement represent serious medical risks for residents with dementia and cognitive impairments. When individuals with memory disorders leave a controlled environment, they face immediate dangers including exposure to extreme weather, traffic accidents, falls, dehydration, and becoming lost with no ability to find their way back. Studies indicate that individuals with dementia who elope from care facilities face a significantly increased risk of serious injury or death within 24 hours if not quickly located.
The cognitive changes associated with dementia affect spatial orientation, judgment, and the ability to recognize danger. Residents may not understand that they are in an unsafe location or may become confused about their surroundings. This makes continuous monitoring and properly functioning security systems essential components of safe dementia care.
Effective elopement prevention requires multiple layers of protection, including properly functioning door alarms, wander guard devices for at-risk residents, and staff training on recognition and response protocols. The systematic compromise of these safety measures at Retama Manor created an environment where residents faced unnecessary and preventable risks.
Facility Operated Without Licensed Administrator
In addition to the security failures, inspectors found that Retama Manor had been operating without a properly licensed nursing home administrator, violating federal regulations that require continuous licensed oversight. The facility terminated its previous licensed administrator on November 8, 2024, and hired an unlicensed employee to fill the position 24 days later.
Employee B, who lacked the required nursing home administrator license, served in the administrator role for 39 days while preparing to take the licensing examination scheduled for January 23, 2025. During this period, the facility attempted to provide oversight through Administrator C, a licensed administrator from another facility who visited once or twice weekly for a few hours.
This arrangement violated federal requirements that mandate nursing homes maintain continuous licensed administrative oversight. Licensed administrators undergo specialized training in healthcare regulations, resident rights, quality assurance, and facility management. The administrator serves as the primary point of accountability for ensuring the facility complies with all federal, state, and local requirements affecting resident care and safety.
The regional director acknowledged awareness of the 30-day grace period for filling administrator positions but failed to ensure compliance with licensing requirements. When questioned about potential harm to residents, the regional director stated he "could not say that residents would be harmed with an unlicensed administrator to manage the facility," demonstrating insufficient understanding of the regulatory protections these licensing requirements provide.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
San Antonio West Nursing and Rehabilitation in San Antonio, TX was cited for violations during a health inspection on January 10, 2025.
During interviews, the maintenance supervisor disclosed that several critical exit doors had their alarms routinely turned off during business hours.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.