San Antonio West Nursing: Wound Care Records Missing - TX
The resident, who had her right leg amputated below the knee, was readmitted to the facility in July with multiple serious conditions including diabetes, kidney disease, and liver cirrhosis. When inspectors observed her on September 2, bandages covered her amputation site.
"They are supposed to change her amputation wound daily but they don't always do it daily," she told investigators.
Her treatment records revealed a more troubling pattern. Wound care was ordered four times weekly — Monday, Wednesday, Friday, and Sunday. But staff failed to mark treatments as completed on August 13, August 18, and August 24.
The resident's cognitive assessment showed moderate impairment. She was dependent for transfers and needed substantial help to move from sitting to lying. A manual wheelchair was required for mobility, and she had experienced falls since admission.
LVN A explained to inspectors that Wound Care Nurse B typically handled the resident's care. The nurse was absent on one of the missed days, so LVN A performed the treatment but forgot to document it.
"She performed the care, but must have failed to mark completed on the treatment administration record," according to the inspection report.
LVN A couldn't explain why Wound Care Nurse B failed to document treatments on the other days when she was present.
The facility's director of nursing acknowledged the documentation failures during her September 4 interview. Her response was stark: "We can't say that it was done. That's the issue."
The resident's comprehensive care plan specifically identified potential complications from her below-knee amputation that required surgical wound care as ordered by her physician. With diabetes complicating her healing process, consistent wound care was critical to preventing infection and other serious complications.
Federal inspectors determined the documentation failures could place residents at risk of not receiving necessary care or receiving treatments more frequently than ordered. Without accurate records, staff cannot track whether critical wound care has been provided or identify patterns that might indicate problems.
The inspection was conducted in response to a complaint about the facility's care practices.
For an amputee with diabetes and multiple other conditions, missed or improperly documented wound care can lead to serious infections, delayed healing, or additional amputations. The resident's medical complexity — including immunodeficiency and chronic kidney disease — made consistent documentation even more crucial for tracking her response to treatment.
The facility's treatment administration record serves as the official documentation that ordered care was provided. When treatments go unmarked, there's no way to verify that vulnerable residents received the medical care their doctors prescribed.
LVN A's admission that she "must have failed to mark completed" on at least one occasion suggests a pattern of casual documentation practices for critical wound care. The fact that Wound Care Nurse B also failed to document treatments on multiple days indicates the problem extended beyond a single staff member's oversight.
The director of nursing's blunt assessment — "we can't say that it was done" — captured the fundamental problem with the facility's record-keeping. For residents depending on complex medical care, undocumented treatments are effectively invisible, leaving no trail to verify that ordered care was actually provided.
The resident's statement that wound changes don't happen daily as scheduled aligned with the documentation gaps inspectors discovered. Her direct observation of inconsistent care matched the official records showing missed documentation on multiple dates.
With her moderate cognitive impairment and physical dependence, the resident relied entirely on staff to provide and document her wound care. The missing records meant there was no way to verify she received the surgical wound care her physician had specifically ordered to prevent complications from her recent amputation.
The inspection found that documentation failures put residents at risk of receiving inadequate care or excessive treatments. For the amputee at San Antonio West Nursing, the undocumented wound care left a dangerous gap in the record of her critical medical treatment.
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 2025-09-04 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 September 4, 2025.
When inspectors observed her on September 2, bandages covered her amputation site.
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.