San Antonio West Nursing: Wound Care Failures - TX
The inspection, completed October 25, 2025, found the facility caused actual harm to the resident, identified in records as Resident 1.
Treatment Nurse LVN C told inspectors she could not remember why she never entered admission orders for the five wounds. When asked why she skipped his weekly wound assessment on October 9, she said she might have been interrupted and forgot to go back. Then she offered a second explanation: "Once you start, you can't stop and if you stop, he won't let you go back to him."
That was her account of why a man with five documented wounds went without a required weekly assessment.
The regional clinical resource, a corporate nurse brought in to review the case, told inspectors she went through Resident 1's clinical record herself and found no admission treatment orders for any of the five wounds. She said the orders weren't entered until October 14 or 15, roughly two weeks after he was admitted. She noted the resident had been assessed by a wound care nurse practitioner before he left the facility, which he did against medical advice.
The Director of Nursing told inspectors she had walked the floor daily and seen wound dressings on the resident's feet, dated with that day's date, so she believed wound care was being provided. She acknowledged the care wasn't documented on his treatment administration record. She said that appeared to be because the orders were never entered in the first place.
She reviewed the October 9 wound assessments herself during the inspection. Four assessments had been completed that day, covering wounds on his sacrum, lower left leg, left lateral foot, and left big toe. The five wounds on his left rear thigh, right heel, groin, right big toe, and right ankle had no corresponding assessments. The DON said the harm from missing a weekly wound assessment was straightforward: without it, there was no way to know whether a wound was healing or getting worse.
The administrator told inspectors the same thing in slightly different words. Not having a treatment order, she said, could result in the plan of care not being followed. Missing the weekly assessment could cause a decrease in the skin's integrity.
Both the administrator and the DON identified the treatment nurse as the person responsible for entering wound orders at admission and for completing the weekly assessments. Neither offered an explanation for why the gap went undetected for two weeks.
The facility's own wound care policy, dated 2021, states that before providing wound care, staff must verify a physician's order exists. It also requires documentation of the type of care given and the date and time it was provided. Neither requirement was met for five of Resident 1's wounds during the first portion of his stay.
What the record shows is a man with multiple open wounds who was admitted, assessed incompletely, and left without formal orders governing his care for roughly two weeks. The nurse responsible said she might have been interrupted. The DON said she could see the dressings were dated, so she assumed care was happening. The corporate nurse, reviewing the chart after the complaint was filed, confirmed the orders simply weren't there.
Resident 1 left the facility against medical advice before the inspection was complete. Whether his wounds healed, worsened, or required further treatment after he left is not reflected in the inspection record.
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 2025-10-25 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 7, 2026 · Our methodology
San Antonio West Nursing and Rehabilitation in San Antonio, TX was cited for violations during a health inspection on October 25, 2025.
The inspection, completed October 25, 2025, found the facility caused actual harm to the resident, identified in records as Resident 1.
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.