Inspection Report

Retama Manor Nursing: Unlicensed Admin, Security Fails, TX

October 7, 2025

San Antonio, TX

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San Antonio West Nursing And Rehabilitation

SAN ANTONIO, TX - Federal inspectors found significant safety and regulatory violations at Retama Manor Nursing Center/San Antonio West during a January 10, 2025 complaint investigation, including compromised security systems for residents with dementia and operation without a properly licensed administrator for over a month.

Critical Security System Failures Put Residents at Risk

The most serious violation identified by inspectors carried an "immediate jeopardy" designation, indicating that facility conditions posed an immediate threat to resident health and safety. The citation focused on the facility's inadequate supervision and security measures for residents prone to wandering, a critical safety concern in nursing homes that care for individuals with dementia and cognitive impairments.

Inspectors documented that while the facility maintained an elopement binder identifying seven current residents with wandering behaviors, the security infrastructure designed to protect these vulnerable individuals had significant gaps. The maintenance supervisor, who had only been employed at the facility since October 2024, revealed concerning practices regarding the facility's door alarm systems.

During interviews, the maintenance supervisor disclosed that several critical exit doors had their alarms routinely turned off during business hours. Most notably, the B-Hall exit door alarm was being deactivated throughout the day to accommodate deliveries, while the A-hall courtyard door alarm was turned off during work hours and only reactivated on weekends. This practice created dangerous windows of opportunity where residents with dementia could potentially leave the facility undetected.

The facility's approach to managing these security systems demonstrated a fundamental misunderstanding of the continuous nature of wandering risks. Residents with dementia who are prone to elopement can attempt to leave at any time, regardless of delivery schedules or business operations. The intermittent deactivation of alarm systems created periods where the most vulnerable residents lacked adequate protection.

Medical Significance of Elopement Prevention Systems

Wandering and elopement represent serious medical risks for residents with dementia and cognitive impairments. When individuals with memory disorders leave a controlled environment, they face immediate dangers including exposure to extreme weather, traffic accidents, falls, dehydration, and becoming lost with no ability to find their way back. Studies indicate that individuals with dementia who elope from care facilities face a significantly increased risk of serious injury or death within 24 hours if not quickly located.

The cognitive changes associated with dementia affect spatial orientation, judgment, and the ability to recognize danger. Residents may not understand that they are in an unsafe location or may become confused about their surroundings. This makes continuous monitoring and properly functioning security systems essential components of safe dementia care.

Effective elopement prevention requires multiple layers of protection, including properly functioning door alarms, wander guard devices for at-risk residents, and staff training on recognition and response protocols. The systematic compromise of these safety measures at Retama Manor created an environment where residents faced unnecessary and preventable risks.

Facility Operated Without Licensed Administrator

In addition to the security failures, inspectors found that Retama Manor had been operating without a properly licensed nursing home administrator, violating federal regulations that require continuous licensed oversight. The facility terminated its previous licensed administrator on November 8, 2024, and hired an unlicensed employee to fill the position 24 days later.

Employee B, who lacked the required nursing home administrator license, served in the administrator role for 39 days while preparing to take the licensing examination scheduled for January 23, 2025. During this period, the facility attempted to provide oversight through Administrator C, a licensed administrator from another facility who visited once or twice weekly for a few hours.

This arrangement violated federal requirements that mandate nursing homes maintain continuous licensed administrative oversight. Licensed administrators undergo specialized training in healthcare regulations, resident rights, quality assurance, and facility management. The administrator serves as the primary point of accountability for ensuring the facility complies with all federal, state, and local requirements affecting resident care and safety.

The regional director acknowledged awareness of the 30-day grace period for filling administrator positions but failed to ensure compliance with licensing requirements. When questioned about potential harm to residents, the regional director stated he "could not say that residents would be harmed with an unlicensed administrator to manage the facility," demonstrating insufficient understanding of the regulatory protections these licensing requirements provide.

Impact on Quality of Care and Resident Safety

The combination of security system failures and unlicensed administration created compounding risks for residents. Licensed administrators are responsible for ensuring that safety protocols, including elopement prevention systems, are properly implemented and maintained. Without proper administrative oversight, critical safety measures may not receive the attention and resources necessary to protect vulnerable residents.

Federal regulations require nursing homes to provide adequate supervision to prevent accidents and ensure resident safety. This includes maintaining functional security systems for residents with wandering behaviors and ensuring that all safety protocols are consistently followed. The documented failures at Retama Manor represented systemic breakdowns in both areas.

The facility's practice of routinely disabling security alarms during business hours suggested inadequate policies and procedures for balancing operational needs with resident safety. Best practices in nursing home security management require continuous alarm functionality with alternative procedures for managing deliveries and maintenance activities that do not compromise resident protection.

Additional Issues Identified

Beyond the major violations, inspectors noted several concerning patterns in the facility's operations. The maintenance supervisor's relatively recent hire date suggested potential turnover issues in key positions responsible for facility safety systems. The facility's elopement prevention program, while maintaining required documentation for at-risk residents, failed in its practical implementation due to the compromised alarm systems.

The oversight arrangement involving Administrator C from another facility created potential conflicts of interest and divided attention that could affect decision-making and accountability. Proper facility administration requires full-time, dedicated leadership focused solely on the specific needs and challenges of the individual facility.

Staff interviews revealed that while 35 employees had received training on elopement protocols, wandering prevention, and door alarm systems, the actual implementation of these safety measures was compromised by administrative decisions to disable critical security components during routine operations.

The facility's response included immediate interventions to address the security failures and commitments to maintain proper alarm functionality. However, the violations highlighted the need for comprehensive review of safety protocols and administrative oversight to ensure sustainable compliance with resident protection requirements.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Retama Manor Nursing Center/san Antonio West from 2025-01-10 including all violations, facility responses, and corrective action plans.

Additional Resources

Editorial Standards

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: August 5, 2026 · Our methodology

Quick Answer

San Antonio West Nursing and Rehabilitation in San Antonio, TX was cited for violations during a health inspection on January 10, 2025.

During interviews, the maintenance supervisor disclosed that several critical exit doors had their alarms routinely turned off during business hours.

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.

Frequently Asked Questions

What happened at San Antonio West Nursing and Rehabilitation?

During interviews, the maintenance supervisor disclosed that several critical exit doors had their alarms routinely turned off during business hours.

How serious are these violations?

Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.

What should families do?

Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in San Antonio, TX, (5) Report any new concerns directly to state authorities.

Where can I see the full inspection report?

The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from San Antonio West Nursing and Rehabilitation or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 675002.

Has this facility had violations before?

To check San Antonio West Nursing and Rehabilitation's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.