San Antonio West Nursing: Broken Steam Table Served Cold Food - TX
The steam table at San Antonio West Nursing and Rehabilitation stopped working on Tuesday, August 12. By the morning of August 15, when a state inspector arrived, it had been broken for three days. Staff had been pouring hot water into the non-functioning unit and holding food on the stovetop in an attempt to keep temperatures up. It wasn't working. Foods on the steam table were sitting in the danger zone, the range between 41 and 135 degrees Fahrenheit where bacteria multiply rapidly.
A kitchen employee, whose name was redacted in the inspection report, told the inspector that food was cold on the steam table and was served cold to residents. She said temperatures would start acceptable when food left the stove but dropped rapidly once transferred to the broken unit. She wasn't aware of any resident complaining of illness.
The Food Service Supervisor told the inspector something that explains why residents kept receiving cold meals for three days running. The facility, she said, had hoped the steam table could be repaired quickly, by August 13. It couldn't. Two vendors tried and failed. So the workaround continued: hot water poured into a unit that couldn't heat it, food held on burners until the last possible moment before transfer.
The dietician visited the facility on August 13, the day after the breakdown, and became aware of the problem. Her recommendation was to place boiling water in the non-working steam table and hold hot foods on the stove or oven until meal service. That is the same workaround staff had already been attempting.
The administrator confirmed to the inspector that a purchase order for a new steam table had been placed on August 14, two days after the breakdown. She said a menu review had been conducted and a decision made not to serve cold foods. The Director of Nursing said no foodborne illnesses had resulted from the cold food served during the equipment failure.
The inspector returned on August 18. The steam table was still not operating. This time, breakfast was being served off the stovetop, transferred into a roaster with hot water, then plated. A test tray of eggs, sausage, and waffles measured within acceptable temperature range using that method. The kitchen employee said a microwave was available to reheat food if a resident complained it was cold. She expected the new steam table to arrive that week.
The administrator told the inspector on August 18 that the new unit was expected Wednesday, August 20, eight days after the original breakdown. Until it arrived, the facility planned to continue using the roaster method or serve cold foods.
When the inspector asked for the facility's policy on maintaining essential kitchen equipment in working condition at 8:00 AM on August 15, the administrator didn't have one. At the inspection's close on August 18 at 3:00 PM, she still hadn't produced one. A record review confirmed the facility had no such policy.
An invoice for the steam table purchase existed but carried no date.
The violation was cited at the minimal harm level. The inspector noted that the failure placed residents at risk for foodborne illness and food contamination. No residents were reported to have become sick.
What the record shows is a kitchen operating for days without a functioning piece of equipment central to food safety, with staff improvising workarounds that the facility's own temperature logs showed were insufficient to keep hot food hot. The fix that finally worked, the roaster method, came after a dietician's visit and three days of serving food that had gone cold by the time it reached residents.
The new steam table was due to arrive on August 20. Whether it did, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for San Antonio West Nursing and Rehabilitation from 2025-08-18 including all violations, facility responses, and corrective action plans.
Additional Resources
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.
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Last verified: October 16, 2026 · Our methodology
San Antonio West Nursing and Rehabilitation in San Antonio, TX was cited for violations during a health inspection on August 18, 2025.
The steam table at San Antonio West Nursing and Rehabilitation stopped working on Tuesday, August 12.
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.