San Antonio West Nursing: Wound Care Records Failures - TX
The inspection at San Antonio West Nursing and Rehabilitation, completed September 4, 2025, was triggered by a complaint. Investigators focused on one resident, identified in the report as Resident #1, whose case raised questions about whether required wound care was being performed and whether anyone would know if it wasn't.
When an inspector visited on September 2, the resident was sitting with bandages covering the stump of her right leg. She said staff were supposed to change the dressing daily. They didn't always do it daily, she told the inspector.
The records told a more specific story. Her physician had ordered wound care four times a week, on Mondays, Wednesdays, Fridays, and Sundays. The treatment administration record for August showed three dates, the 13th, the 18th, and the 24th, where staff had not marked the treatment as completed. All three fell on the scheduled days.
The resident is a woman whose admission record, dated the same day as the inspector's visit, listed her age and a set of diagnoses that made consistent wound care critical: type 2 diabetes with hyperglycemia, osteonecrosis of the right foot, chronic kidney disease, cirrhosis of the liver, atrial fibrillation, and muscle weakness. She had been readmitted to the facility on July 21. A cognitive assessment from early August placed her in a range suggesting moderate impairment. She was dependent for transfers, needed substantial help moving in bed, had a functional limitation in her lower extremity, and had already experienced falls since her admission.
Her care plan, dated August 14, specifically noted the risk of complications from the amputation and required surgical wound care as ordered.
When investigators interviewed LVN A on September 3, the nurse said Wound Care Nurse B was the person who typically handled the resident's wound care. LVN A said Wound Care Nurse B had been absent on one of the days in question, though she couldn't remember which one. On that day, LVN A said she had stepped in and performed the care herself. She said she must have forgotten to mark it as completed. As for the other two undocumented dates, when Wound Care Nurse B was the one responsible, LVN A said she wasn't sure why the record hadn't been signed off.
The director of nursing confirmed the gaps during an interview the following day. She acknowledged that the treatment administration record had not been marked as completed on August 13, August 18, or August 24. Her explanation of the consequences was direct: "We can't say that it was done. That's the issue."
That framing, offered by the facility's own nursing director, captures the problem exactly. The record is not just an administrative formality. For a diabetic patient with a fresh surgical amputation, a wound that goes untreated, or is treated less frequently than ordered, can deteriorate quickly. Without documentation, there is no way to know whether the care happened, whether it was effective, or whether the wound's condition on any given day reflected what staff had or hadn't done.
The inspection report classified the violation as carrying minimal harm or potential for actual harm. Investigators reviewed three residents and found the documentation failure in one.
What the records cannot answer, and what the facility's director of nursing essentially acknowledged, is the question the resident herself was already asking from her wheelchair: whether anyone was actually coming, on the days they were supposed to come, to change the bandages on what remained of her right leg.
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.
Download the official CMS inspection PDF from Medicare.gov
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 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.
The inspection at San Antonio West Nursing and Rehabilitation, completed September 4, 2025, was triggered by a complaint.
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.