San Antonio West Nursing: Cold Food Safety Violations - TX
The facility's steam table stopped working, but staff continued serving potentially dangerous cold food to residents from August 12 through August 15, creating what inspectors called "risk of bacteria build up and food borne illnesses."
The dietician had visited on August 13 and discovered the broken equipment. She told facility managers exactly what to do: place boiling water in the non-working steam table and keep hot foods on the stove or in the oven until serving time.
Nobody listened.
When inspectors arrived August 15, they found breakfast service in violation of basic food safety. The facility's own policy, dating to 2001, clearly stated that temperatures between 41 and 135 degrees Fahrenheit create a "danger zone" that "promotes the rapid growth of pathogenic microorganisms that cause foodborne illnesses."
The Director of Nursing, serving as the infection preventionist, refused to explain her decision. When inspectors asked why she didn't advise the facility to stop serving cold food to residents, she stated "she preferred not to answer the question."
She did say no residents had suffered food borne illnesses from the cold food.
During a telephone interview at 11:10 AM on August 15, the dietician described her mounting frustration with the facility's response. She had last visited Wednesday, August 13, and "became aware of the non-working steam table." She explained to staff that "cold food should not be served to residents because of the danger of food borne illnesses."
The dietician had tested lunch temperatures on August 13. They met regulations. But she made specific recommendations to prevent problems: use boiling water in the broken steam table, hold hot foods on working equipment until service time.
The facility ignored her advice.
Staff never told the dietician that Thursday's meals were served cold. They never mentioned Friday morning's cold breakfast either. She only learned about the continued violations when inspectors arrived August 15.
By then, she was recommending more drastic measures: serve cold lunch items like sandwiches, buy roasters or thermal plates, or bring in catering. Anything to avoid the continued safety violations.
Temperature logs from August 15 showed the kitchen could cook food properly. Items reached the required minimum of 165 degrees before staff placed them on the broken steam table, where temperatures dropped into the bacterial danger zone.
The facility's 14-day menu confirmed what residents received that Friday morning: eggs, cheese tacos, and sausage. All served cold despite available alternatives.
Three residents received tube feeding and didn't eat from the kitchen. The remaining residents consumed the potentially contaminated breakfast.
The facility's 24-hour report from August 15 showed no residents with diagnosed foodborne illnesses. But food safety experts know symptoms can take hours or days to appear, and elderly residents face heightened risks from bacterial contamination.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "some" residents. The finding represents a breakdown in basic food service safety that continued for days despite clear warnings from the facility's own nutritional consultant.
The dietician's August 15 recommendations revealed the scope of available solutions the facility had rejected. Roasters cost far less than the potential medical treatment for foodborne illness. Thermal plates could have maintained safe temperatures. Even switching to cold menu items would have eliminated the bacterial risk entirely.
Instead, managers chose to serve hot food at cold temperatures, creating exactly the conditions their own policy identified as dangerous. The Director of Nursing's refusal to explain her decision-making process left inspectors without insight into how the facility balances resident safety against operational convenience.
The broken steam table became a test of the facility's commitment to basic safety protocols. For four days, San Antonio West Nursing failed that test, serving breakfast that met cooking standards but violated serving standards designed to protect the health of vulnerable elderly residents.
The inspection found a facility where equipment failures revealed deeper problems with safety culture and communication. When professional recommendations conflict with operational ease, residents end up eating cold eggs while administrators decline to answer questions about their choices.
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: 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 20, 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.
When inspectors arrived August 15, they found breakfast service in violation of basic food safety.
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.