San Antonio West Nursing: Cold Food Violations - TX
Federal inspectors arrived at the facility on August 15, 2025, and what they found was a problem already in progress. The dietician had first learned about the broken steam table two days earlier, on August 13, when she visited the facility and took the temperature of the lunch meal herself. The temperatures met regulation that day. She gave staff clear instructions: fill the non-working steam table with boiling water, hold hot foods on the stove or oven until service, and keep things moving.
Nobody told her it wasn't working.
On Thursday, August 14, food went out cold. On Friday morning, August 15, it happened again. Breakfast that day was supposed to be eggs, cheese tacos, and sausage. The dietician didn't find out about either meal until the surveyor walked through the door.
"The facility did not inform her that the food was cold on Thursday and the Friday breakfast meals," the inspection report states.
The moment the surveyor arrived on August 15, the dietician found out and changed course entirely. She told staff to serve a cold lunch, buy roasters or thermal plates, and hold out for a replacement steam table. Catering, she said, was her last option.
The core concern was straightforward. Food sitting between 41 and 135 degrees Fahrenheit is sitting in what the facility's own 2001 food preparation policy calls the "danger zone," a temperature range that promotes rapid growth of the pathogens that cause foodborne illness. The dietician said cold food should not be served to residents because of exactly that risk. The facility's temperature log from August 15 showed that food had been cooked to at least 165 degrees before it was placed on the non-working steam table. What happened to those temperatures while the food sat on a broken piece of equipment, waiting to be served, is not recorded.
Three residents at the facility were on tube feeding and did not eat from the kitchen. The 24-hour report from August 15 reflected no residents with foodborne illnesses. The inspection was classified as minimal harm or potential for actual harm, affecting some residents.
But the timeline matters. The dietician had a plan. It required staff to tell her when things went wrong. They didn't. Two meals went out cold across two days before an outside surveyor's presence forced the issue into the open. The dietician learned about it not because anyone at the facility picked up the phone, but because federal inspectors showed up.
What the inspection report doesn't answer is who decided not to call her. It doesn't say whether anyone on staff flagged the cold food internally, whether anyone checked temperatures after the food left the stove and reached a resident's plate, or whether the residents who received those cold breakfasts on August 14 and the morning of August 15 were told anything about it.
The steam table was already on order when inspectors arrived. A replacement was coming. The dietician had solutions ready. None of that changes what residents were served in the two days between her first visit and the moment a federal surveyor made the problem impossible to ignore.
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 2025-08-18 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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 22, 2026 · Our methodology
San Antonio West Nursing and Rehabilitation in San Antonio, TX was cited for violations during a health inspection on August 18, 2025.
Federal inspectors arrived at the facility on August 15, 2025, and what they found was a problem already in progress.
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.