Retama Manor: Immediate Jeopardy in Memory Care, TX
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.
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.
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 20, 2026 · Our methodology
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.