Buena Vida Nursing and Rehab: Privacy Violation Found - TX
That sequence of events, documented by federal inspectors at Buena Vida Nursing and Rehab-San Antonio, captures what happened to a woman identified only as Resident 5 on October 1, 2025. She was lying in bed, her foley catheter bag attached to the side of the bed and facing an open door, its contents visible to anyone passing in the hallway. There was no privacy cover on the bag.
She was in her bed because she had nowhere else to go. Her records showed she had suffered a stroke and was living with diabetes and a kidney condition that had required a catheter. A clinical assessment from August 2025 gave her a cognitive score of 4 out of 15, indicating severe impairment. She depended on staff for everything: moving in bed, transferring, bathing, toileting. She could not reposition the bag herself.
There was a doctor's order in her chart, dated for October 2025, that read: ensure foley bag is in privacy bag while in bed or wheelchair, every shift, for foley care. The order was not followed that afternoon.
LVN D, who was assigned to the resident that day, told inspectors she noticed the uncovered bag before lunchtime. She looked for a privacy cover and could not find one. She reported it to the interim director of nursing. The inspection report does not say what happened after that. The bag was still uncovered when inspectors observed the room at 1:17 p.m.
One minute later, inspectors spoke with the resident. She told them staff would often move the bag to the opposite side of the bed for privacy. She said she was not bothered if people could see it.
That statement matters, but it does not resolve the question the inspection raises. A woman with a cognitive score of 4 may not register the exposure as a problem. Severe cognitive impairment, by definition, affects a person's ability to assess their own situation and advocate for their own comfort. The order existed for a reason. The care plan, written in September, noted the catheter. The facility had trained its nurses on privacy covers. The infrastructure for protecting her dignity was documented. It just wasn't applied.
The administrator, interviewed two days after the observation, told inspectors that all catheter bags should have privacy covers, that some bags have a shaded side that can be turned outward, and that any staff member who spotted an uncovered bag was supposed to notify the charge nurse or nursing management. The administrator said staff had received training. Then the administrator said the facility had no specific policy on foley bag privacy covers.
That gap — training without a written policy, an order without a cover, a nurse who reported the problem and still couldn't fix it — is what inspectors cited. The deficiency was rated at the lowest level of harm, minimal harm or potential for actual harm, affecting a small number of residents. No immediate jeopardy was declared. No pattern was identified across other residents, though inspectors reviewed eight residents with catheters and found the problem with one.
What the inspection does not resolve is how long the bag had been uncovered before LVN D noticed it before lunch. The observation happened at 1:17 p.m. The prior shift would have been responsible for the bag that morning. The report does not say whether anyone checked it then.
The resident's room faced the hallway. The door was open.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Buena Vida Nursing and Rehab-san Antonio from 2025-10-06 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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 14, 2026 · Our methodology
Buena Vida Nursing and Rehab-San Antonio in SAN ANTONIO, TX was cited for violations during a health inspection on October 6, 2025.
She was lying in bed, her foley catheter bag attached to the side of the bed and facing an open door, its contents visible to anyone passing in the hallway.
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.