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Complaint Investigation

San Antonio West Nursing And Rehabilitation

August 18, 2025 · San Antonio, TX · 636 Cupples Rd
Citations 4
CMS Rating 1/5
Beds 135
Provider ID 675002
Healthcare Facility
San Antonio West Nursing And Rehabilitation
San Antonio, TX  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

San Antonio West Nursing and Rehabilitation in San Antonio, TX — inspection on August 18, 2025.

Found 4 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0584
Resident Rights Deficiencies

DON stated: she observed today 8/15/25 at 2:50 PM that Resident #1's bed light fixture had no light

the bed overhead light was important for the provision of nursing care and services.

The DON stated

#2].

The DON stated she was not aware of the roommate complaining.

The DON stated by nursing practice the window blinds needed not to be broken to improve on a resident's quality of life.

During an interview on 8/18/25 at 9:38 AM, the Administrator stated the facility hired a new maintenance director a month ago [July 2025] who had been attempting address the back log of work orders.

The administrator stated she prioritized plumbing issues, and the work order for Resident #1 had not been addressed. [at time of the abbreviated survey the Maintenance Director was not available for an interview, nor the old maintenance director was available for a telephone interview]

Record review of facility's Work Order log dated 6/17/25 reflected work a work order to replace/fix Resident #1's window blind and another work order dated 6/17/25 to fix LIGHT NOT WORKING.

Record review of facility's Resident Rights policy dated 2018 read: .Employees shall treat all residents with kindness, respect, and dignity.

Thes rights include the resident's right to.a dignified existence.

Record review of the facility's Safe and Homelike Environment, dated 2025, read: .In accordance with resident's rights, the facility will provide a safe, clean, comfortable and homelike environment.

675002 08/18/2025

San Antonio West Nursing and Rehabilitation 636 Cupples Rd San Antonio, TX 78237

interview on 8/15/25 at 11:10 AM, the Dietician stated she last visited the facility on Wednesday

took the temperature of the lunch meal on 8/13/25 and the temperatures met regulation.

The Dietician

hot foods on the stove or oven until the meal was to be served from the steam table.

The Dietician stated the facility did not inform her that the food was cold on Thursday (8/14/25) and the Friday (8/15/25) breakfast meals.

The Dietician stated on 8/15/25 [arrival of surveyor] she again became aware of the issue of cold foods and made the recommendations to serve a cold lunch and buy roasters or thermal plates until the steam table was delivered.

The Dietician stated catering was her last option.

Record review of facility's Temperature Log dated 8/15/25 reflected that the food cooked met the minimum temperature of 165F before placed on the non-working steam table.

Record review of the facility's 14-day menu for Week 3 reflected the breakfast menu for 8/15/25 included: eggs. cheese taco, and sausage.

Record review of facility's list dated 8/15/25 of residents on tube feeding reflected that 3 residents did not eat from the kitchen.

Record review of facility's 24 report dated 8/15/25 reflected no residents with food borne illnesses.

Record review of facility's Food Preparation and Service dated 2001 read, .The ?danger zone' for food temperature is between 41 ?F' and 135 ?F'.

This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illnesses.

675002 08/18/2025

San Antonio West Nursing and Rehabilitation 636 Cupples Rd San Antonio, TX 78237

During an interview on 8/15/25 at 8:25 AM, The FSS stated that the July Food Temperature Log for the lunch meal from 7/9/25 to 7/21/25 and 7/23/25 to 7/31/25 were not documented.

The FSS stated that the breakfast meal from 7/24/25 to 7/31/25 and the dinner meal from 7/30/25 to 7/31/25 were not documented.

The FSS did not have an explanation for the lack of documentation involving food temperatures on the latter dates.

During telephone interview on 8/15/25 at 11:10 AM, the Dietician stated that she was aware of the lack of documentation on the July 2025 Food Temperature log.

The Dietician stated she verbally counseled the kitchen staff on documentation and provided an in-service on documentation of the food temperature logs.

The Dietician stated her negative findings for the July 2025 documentation was written in the Sanitation Report given to the facility on 8/13/25 with a rating of unsatisfactory.

Record review of facility's Quality Assurance Evaluation-Dining report dated 8/6/25 authored by the Dietician reflected a rating of unsatisfactory for incomplete food temperature logs.

Record review of facility's Food Preparation and Service dated 2001 read, .The ?danger zone' for food temperature is between 41 ?F' and 135 ?F'.

This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illnesses.

Record review of facility's dietary polices did not reveal a policy on documenting food temperatures on a daily base per meals prepared. [Surveyor on 8/15/25 at 8:00 AM requested from the Administrator a policy on documenting food temperatures. At exit on 8/18/25 at 3:00 PM, the Administrator had not provided the surveyor with a policy on documenting food temperatures.]

675002 08/18/2025

San Antonio West Nursing and Rehabilitation 636 Cupples Rd San Antonio, TX 78237

Observation of food temperatures of food items on the steam table reflected hot foods were in the danger zone.

During an interview on 8/15/25 at 8:15 AM, [NAME] A stated the steam table was not operating since Tuesday 8/12/25. [NAME] A stated that the food was cold on the steam table and served cold to the residents. [NAME] A stated efforts that were made to keep the food hot by regulation, 165 F at steam table and 135F when served by keeping the food on the stove until transferred to the steam table and putting hot water in the steam table.

The [NAME] stated from the start of the food cycle the breakfast meal met temperatures and the temperatures were recorded on the temperature log sheet.

However, [NAME] A stated that the hot food on the steam table rapidly dropped in temperature and served cold to residents. [NAME] A stated she was not aware of any resident complaining of foodborne illnesses from the cold food.

During an interview on 8/15/25 at 8:25 AM, the FSS stated that the steam table was not operating since Tuesday (8/12/25) and the facility had made efforts to repair the steam table without success.

The FSS stated cold foods were served to the residents because the facility hoped that the steam table could be repaired in a short time by 8/13/25.

The FSS stated measures taken to keep the food hot included pouring hot water into the non-working steam table and holding foods in the oven or stove top until ready to be transferred to the steam table.

During a joint interview on 8/15/25 at 9:45 AM, with the Administrator and DON, the Administrator stated the steam table has not operating since Tuesday (8/12/25) and a new steam table purchased order was made on 8/14/25.

The Administrator stated that the efforts made included to repair the steam by two different vendors; and heating from the stove, and hot water added to steam table.

The Administrator stated a menu review was done, and decision was made not to serve cold foods.

The DON stated there had been no foodborne illnesses resulting from the cold food served from the non-operating steam table.

During telephone interview on 8/15/25 at 11:10 AM, the Dietician stated that she visited the facility on Wednesday (8/13/25) and became aware of the non-operating steam table.

The Dietician stated she recommended to the facility to place boiling water in the non-working steam table and hold hot foods on the stove or oven until the meal was to be served from the non-operating steam table.

Observation and interview on 8/18/25 at 8:45 AM, of kitchen reflected that the steam table was still not operating.

Observation further reflected the breakfast food was served off the stove top and was placed in a roaster with hot water and then transferred to a plate. [The latter option for cooking foods was made by the facility's dietician].

Surveyor Test tray of a regular meal (eggs, sausage, and waffles) reflected the holding temperature was within regulation. [NAME] A stated that if a resident complained of cold food the microwave was available to re-heat the food. [NAME] A stated she expected the arrival of the steam table this week.

During an interview on 8/18/25 at 9:25 AM, the Administrator stated the arrival of the steam was expected this Wednesday 8/20/25.

The Administrator stated the facility would employ the options of serving cold foods or using the roaster until the arrival of an operating steam table.

Record review of facility's invoice undated reflected the purchase of a steam table.

Record review of facility's policies did not reflect a policy on maintaining essential equipment to include kitchen equipment in operation condition. [Surveyor on 8/15/25 at 8:00 AM requested from the Administrator a policy on maintaining essential equipment. At exit on 8/18/25 at 3:00 PM, the Administrator had not provided the surveyor with a policy on maintaining essential equipment.]

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in San Antonio, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from San Antonio West Nursing and Rehabilitation or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.