SAN ANTONIO, TX - Federal inspectors issued an immediate jeopardy citation to Retama Manor Nursing Center following serious safety violations in the facility's memory care unit that left vulnerable residents with dementia at risk of harm due to inadequate supervision and staffing failures.
Critical Staffing Failures in Memory Care Unit
The inspection revealed dangerous understaffing in the facility's memory care unit (MCU), where residents with severe cognitive impairments require constant supervision. During multiple observation periods from January 26-29, 2025, inspectors documented that only one certified nursing assistant (CNA) was assigned to supervise 13 residents in the MCU, violating the facility's own safety protocols.
The understaffing situation became particularly hazardous when the lone CNA would leave the unit to assist other residents, leaving the memory care residents completely unsupervised. This practice directly contradicted the facility's policy requiring two CNAs to be present in the MCU at all times, with one aide required to remain with residents even during emergencies.
The violation reached immediate jeopardy status - the most serious category of nursing home deficiency - because residents with severe dementia face significant risks when left unattended. These individuals may wander, fall, become agitated, or engage in behaviors that could harm themselves or others. Without proper supervision, residents are vulnerable to injuries, medication errors, choking incidents, and other life-threatening situations.
Medical research consistently demonstrates that individuals with dementia require structured environments with adequate supervision. The cognitive impairments associated with dementia affect judgment, spatial awareness, and the ability to recognize danger. When supervision breaks down, residents may attempt to leave the facility, enter restricted areas, or engage in repetitive behaviors that could result in injury.
Medication Administration Failures Put Residents at Risk
Inspectors identified systematic failures in medication management affecting eight residents, including critical delays in administering seizure medications and the storage of expired insulin that could have life-threatening consequences.
On January 27, 2025, a medication aide administered multiple medications significantly late to five residents. Most concerning was a nearly two-hour delay in seizure medication (levetiracetam) for a resident with a documented seizure disorder. Seizure medications must be administered precisely on schedule to maintain therapeutic blood levels and prevent breakthrough seizures, which can cause brain damage or death.
The same medication aide delivered other critical medications late, including: - Blood pressure medication (carvedilol) delayed by 20 minutes for a resident with hypertension - Diabetes medication (metformin) delayed by over an hour for a diabetic resident - Anti-psychotic medication (divalproex) delayed for a resident with schizophrenia - Antibiotic treatment delayed for a resident with a serious urinary tract infection
These delays compromise medication effectiveness and can lead to dangerous fluctuations in blood sugar, blood pressure, and seizure activity. For residents with complex medical conditions, even short delays can trigger medical emergencies requiring hospitalization.
Expired Insulin Creates Dangerous Health Risks
Perhaps most alarming was the discovery of expired insulin stored in medication carts and available for administration to diabetic residents. Inspectors found insulin that had expired by as much as 59 days, stored at improper temperatures, and lacking proper labeling.
Three residents were affected by this medication storage failure: - One resident's diabetes injection pen had expired 19 days earlier - Another resident had three insulin vials expired by up to 59 days - A third resident's insulin had expired 45 days prior to discovery
Expired insulin loses its potency and effectiveness in controlling blood sugar levels. When diabetic residents receive ineffective insulin, their blood glucose can spike to dangerous levels, potentially causing diabetic ketoacidosis - a life-threatening condition that can lead to coma or death. Conversely, if expired insulin retains some effectiveness but at unpredictable levels, residents face risks of severe low blood sugar episodes that can cause unconsciousness, brain damage, or cardiac arrest.
Proper insulin storage requires refrigeration before use and careful monitoring of expiration dates. Multi-dose insulin vials should be discarded after 28 days once opened, regardless of the printed expiration date. The facility's failure to follow these basic safety protocols placed diabetic residents in immediate danger.
Memory Care Unit Policy Violations
The facility had established appropriate policies for memory care unit operations but failed to implement them consistently. Internal policies required two CNAs in the MCU at all times with radio communication systems to maintain contact with nursing staff outside the unit.
However, inspectors observed multiple instances where only one CNA was present, and radio protocols were not followed consistently. One CNA stated during interviews that when help was needed, "they would stay in the MCU and call via the 2-way radios provided," but observations revealed gaps in this communication system.
The facility's Preference for Activity and Leisure (PAL) system, designed to help staff understand individual residents' triggers and preferred interventions, was underutilized. While the facility had developed PAL profiles for 12 residents, staff demonstrated inconsistent knowledge of these individualized care approaches that are essential for managing residents with behavioral symptoms of dementia.
Medical Context and Industry Standards
Federal regulations require nursing homes to provide adequate supervision and ensure medication safety as fundamental aspects of resident care. The Centers for Medicare & Medicaid Services considers immediate jeopardy citations appropriate when facility practices create imminent risk of serious injury, harm, impairment, or death.
Memory care units require specialized staffing ratios because residents with dementia cannot advocate for themselves or recognize dangerous situations. Industry best practices recommend enhanced supervision ratios in specialized dementia care units, typically requiring more staff per resident than general nursing home populations.
Medication timing windows established by the Institute for Safe Medication Practices allow for administration within one hour before or after scheduled times for most medications. However, certain medications like seizure drugs and insulin require more precise timing due to their narrow therapeutic windows and potential for serious adverse effects when delayed.
Additional Issues Identified
The inspection also documented several secondary violations that contributed to the overall pattern of inadequate care:
- Failure to report medication administration delays to supervisory staff as required by facility protocols - Inadequate staff training on dementia care techniques and de-escalation strategies - Inconsistent implementation of behavior management programs for residents with cognitive impairments - Insufficient oversight of medication aide practices and adherence to safety protocols
Facility Response and Corrective Actions
Following the immediate jeopardy citation, Retama Manor implemented emergency corrective measures including mandatory retraining for all staff on dementia care and medication administration. The facility's medical director conducted immediate in-service training sessions attended by 54 staff members on understanding dementia and appropriate resident care techniques.
The facility also established enhanced staffing protocols requiring two CNAs in the memory care unit during all shifts, implemented improved radio communication systems, and created mandatory reporting procedures for medication delays. Weekly monitoring will continue for four weeks to ensure sustained compliance with safety requirements.
The immediate jeopardy determination was lifted on January 29, 2025, after inspectors verified that corrective measures were in place and functioning effectively. However, the facility remains under increased scrutiny to demonstrate sustained compliance with federal safety standards.
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 2025-01-30 including all violations, facility responses, and corrective action plans.
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