Resident #1 received regular-textured meals daily despite physician orders for bolus feedings only twice per day. The woman had stopped wearing dentures and required pureed foods after a swallow study documented her inability to handle solid textures safely.
Her family watched the feeding failures unfold meal after meal. "The dining staff were forgetful and didn't follow the tray slips at every meal," the resident's responsible party told inspectors during an October phone interview. "The staff seemed to forget she had a swallowing problem and would cough and vomit when fed solid foods."
The resident was too weak to sit upright on her own or hold utensils, yet staff provided no assistance during meals. She "used to throw up a lot" before the swallow study led to diet modifications, her family member said.
On the morning inspectors arrived, kitchen staff had delivered scrambled eggs to the woman's room. Her family member noted she "probably could have eaten the scrambled eggs with her hands this morning and would have been fine, but she had to have supervision at all times while eating."
Nobody provided that supervision.
RN A told inspectors he was "unaware of pleasure trays for Resident #1" and confirmed she should not have received regular textured foods. He acknowledged she needed assistance with utensils due to weakness and inability to sit upright independently.
LVN C said the resident "should not have received any regular textured foods due to her bolus feedings, twice per day." The nurse confirmed the woman could not feed herself due to weakness and declining health, and should receive only the liquid feedings according to hospice orders.
The administrator revealed she was "unaware Resident #1 was receiving a pleasure tray at every meal." More troubling, she told inspectors the facility had no policy regarding therapeutic diets.
Yet the facility's own meal service policy, dated just five months earlier, explicitly required staff to serve "diets in accordance with physician orders" and check that "everything is included on the meal tray that is required by the diet card."
The policy instructed staff to "remove dome lid from the tray and check to be sure everything is included on the meal tray that is required by the diet card, and the resident's preference." It directed workers to "cut up meats and assist the resident as needed" and "use adaptive utensils, when appropriate."
None of this happened for Resident #1.
Instead, kitchen staff delivered regular meals while nursing staff remained unaware of the orders they were violating. The resident's family brought their own food, adding to the confusion. "The family would bring regular textured candy and muffins to Resident #1, and the HN had given bolus feeding orders, so it was a battle to keep the feeding orders straight and keep everyone safe and happy," according to the inspection report.
The battle was lost daily at mealtimes.
The facility policy promised that "alternative foods, readily available foods, or supplements should be offered in accordance with diet restrictions, when a resident consumes less than half of the meal." But for this hospice patient, the wrong foods kept coming regardless of consumption levels or documented swallowing difficulties.
Federal inspectors found the dietary violations put residents at risk of choking, aspiration, and other serious complications. The resident's family described her overall care as merely "fair" and noted she had "never been denied food" but received the wrong textures that caused distressing symptoms.
The inspection revealed a breakdown in communication between dietary staff, nursing staff, and administration that left a vulnerable hospice patient at risk during what should have been carefully monitored end-of-life care.
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 2025-11-20 including all violations, facility responses, and corrective action plans.
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