Inspection Report

Retama Manor: Immediate Jeopardy in Memory Care, TX

November 1, 2025

San Antonio, TX

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San Antonio West Nursing And Rehabilitation

SAN ANTONIO, TX - Federal health inspectors cited Retama Manor Nursing Center with immediate jeopardy violations after finding that residents in the facility's memory care unit faced dangerous situations due to inadequate staffing and supervision protocols.

![Retama Manor Nursing Center in San Antonio, Texas](https://images.nursinghome411.org/facility-photos/675002.jpg)

Critical Safety Lapses in Memory Care Unit

During a January 2025 inspection, surveyors discovered that the facility's Memory Care Unit (MCU) repeatedly operated with insufficient staffing, placing 13 vulnerable residents at serious risk. The MCU houses residents with dementia and cognitive impairments who require specialized supervision to prevent wandering and potential harm.

The most serious incident occurred when the unit was left with only one certified nursing assistant (CNA) for several hours during multiple shifts. Federal regulations require continuous supervision of memory care residents, particularly those with documented behavioral concerns and elopement risks.

"Staff to redirect resident to other activities," according to one care plan for a resident with documented aggressive behaviors who had been known to throw objects and exhibit physical aggression toward others.

Inspectors observed that between January 26-29, the MCU frequently operated below minimum staffing requirements. On one documented occasion, a single staff member was responsible for all 13 residents, including three individuals identified as high-risk for aggressive behaviors and wandering attempts.

Medical Significance of Staffing Violations

Memory care units require specialized staffing ratios because residents often experience confusion, agitation, and unpredictable behaviors related to dementia. When understaffed, facilities cannot provide the constant supervision these residents need to prevent falls, resident-to-resident altercations, or dangerous wandering episodes.

The facility's own policy mandated two CNAs in the memory care unit at all times, with walkie-talkie communication systems for emergencies. However, inspectors found these protocols were not consistently followed, creating dangerous gaps in supervision during critical periods.

Research demonstrates that adequate staffing in memory care prevents serious injuries and reduces behavioral incidents. When residents don't receive appropriate redirection and supervision, they may become increasingly agitated, leading to falls, physical altercations, or attempts to leave the secured area.

Systemic Medication Management Failures

The inspection revealed widespread problems with medication administration affecting multiple residents. One medication aide administered late medications to five different residents on a single day, with some medications delivered nearly two hours past their scheduled times.

Critical medications affected included seizure medications (levetiracetam), diabetes drugs (metformin), blood pressure medications (carvedilol), and antibiotics (Bactrim). These delays can have serious medical consequences: seizure medications must maintain consistent blood levels to prevent breakthrough seizures, while diabetes medications help control blood sugar levels that can become dangerous if not properly managed.

The facility also stored expired insulin medications for at least three diabetic residents. Inspectors found insulin pens and vials that had expired by 19 to 59 days but were still available for administration. Using expired insulin can result in inadequate blood sugar control, potentially leading to diabetic emergencies.

According to medical protocols, insulin should be discarded within 28 days of opening, and all medications must be administered within one hour of their scheduled time to maintain therapeutic effectiveness.

Pressure Ulcer Care Deficiencies

Three residents with pressure ulcers did not receive proper preventive care according to their physician orders and care plans. Two residents with heel pressure ulcers were observed without the required offloading boots that protect wounds from further pressure damage.

Pressure ulcers develop when sustained pressure restricts blood flow to skin and underlying tissues. Without proper offloading devices, these wounds can worsen rapidly, leading to deeper tissue damage, infections, and prolonged healing times.

A third resident who required repositioning every two hours to prevent pressure ulcer development was observed in the same position over multiple two-hour periods. Proper repositioning maintains blood circulation and prevents the formation of new pressure wounds, which can become life-threatening if they progress to advanced stages.

Activities Program Dissolution

The facility operated without a qualified activities director since November 2024, leaving residents without structured programming. Federal regulations require nursing homes to provide ongoing activities designed to meet residents' physical, mental, and psychosocial needs.

"The facility had not had an Activity Director for a few months and the prior Activity Director comes when she can," one resident reported, adding that residents tried to organize their own activities to avoid boredom.

Multiple residents reported spending most of their time watching television with no other stimulation. One resident noted that vendors occasionally visited for an hour daily, but no comprehensive activities program existed. The lack of meaningful activities can lead to depression, increased confusion in residents with dementia, and overall decline in quality of life.

Additional Issues Identified

The inspection documented several other concerning practices that compromised resident safety and care quality:

Wander Guard Malfunction: A resident with documented elopement risk had a non-functioning wander guard alarm system that failed to activate when she attempted to exit the secured area.

Inadequate Nutrition Monitoring: One resident experienced a 10-pound weight loss (representing 4.9% of body weight) without proper assessment or intervention by the registered dietitian, despite facility policies requiring action for weight losses exceeding 5%.

Food Safety Violations: Kitchen staff failed to properly label and date food items, left medication carts unlocked and unattended, and did not follow required food texture modifications for residents with swallowing difficulties.

Infection Control Lapses: Staff failed to follow enhanced barrier precautions for residents with urinary tract infections and indwelling medical devices, potentially spreading resistant infections to other vulnerable residents.

The facility implemented corrective measures during the inspection, including mandatory staff education on dementia care, reinforcement of the two-CNA requirement for the memory care unit, and provision of walkie-talkie communication systems. Federal surveyors will conduct follow-up monitoring to ensure sustained compliance with safety requirements.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Retama Manor Nursing Center/san Antonio West from 2025-01-30 including all violations, facility responses, and corrective action plans.

Additional Resources

Editorial Standards

Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).

Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.

Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.

Last verified: June 21, 2026 · Our methodology

Quick Answer

San Antonio West Nursing and Rehabilitation in San Antonio, TX was cited for immediate jeopardy violations during a health inspection on January 30, 2025.

The MCU houses residents with dementia and cognitive impairments who require specialized supervision to prevent wandering and potential harm.

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.

Frequently Asked Questions

What happened at San Antonio West Nursing and Rehabilitation?

The MCU houses residents with dementia and cognitive impairments who require specialized supervision to prevent wandering and potential harm.

How serious are these violations?

These are very serious violations that may indicate significant patient safety concerns. Federal regulations require nursing homes to maintain the highest standards of care. Families should review the full inspection report and consider whether this facility meets their safety expectations.

What should families do?

Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in San Antonio, TX, (5) Report any new concerns directly to state authorities.

Where can I see the full inspection report?

The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from San Antonio West Nursing and Rehabilitation or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 675002.

Has this facility had violations before?

To check San Antonio West Nursing and Rehabilitation's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.