San Antonio West Nursing And Rehabilitation
Inspection Findings
F-Tag F0842
F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews and record reviews, the facility failed to maintain medical records that were compete and accurately documented for 1 of 3 residents (Resident #1) reviewed during the complaint investigation. The facility failed to ensure that Resident #1's treatment administration record noted treatments on 8.13.2025, 8.18.2025, and 8.24.2025 as required by the orders noted on the electronic medical record. This failure could place residents at risk of not receiving necessary care and services or receiving care and services more often than ordered.Findings include: During an observation and interview
on 09022025 at 1:00 PM, Resident #1 was observed with bandages on her right leg covering a below the knee amputation. She stated, they are supposed to change her amputation wound daily but they don't always do it daily. Record review of Resident #1's admission record, dated 09.02.2025, reflected a [AGE] year-old female who was readmitted to the facility on 07.21.2025 with diagnoses of other osteonecrosis of
the right foot, encounter for orthopedic after care following a surgical amputation, immunodeficiency, type 2 diabetes mellitus with hyperglycemia, atrial fibrillation, cirrhosis of the liver, and chronic kidney disease, muscle weakness (generalized). Record review of Resident #1's MDS assessment completed on 08.07.2025 revealed a BIMS score of 12 which suggests moderate impairment of the resident's cognitive function. Resident #1 was coded as dependent for transfers and needing substantial/maximal assistance to roll left/right or move from sitting to lying. Resident #1 was coded as having a functional limitation in range of motion on one side of the lower extremity and uses a manual wheelchair to ambulate. Resident #1 was coded as having falls since Admission/Entry. Record review of Resident #1's Comprehensive Care Plan, dated 08.14.2025, reflected potential complications related to the below the knee amputation of the right leg that required surgical wound care as ordered by the physician. Record review of Resident #1's order administration record revealed that wound care for the below knee amputation of the right leg was to be performed four times each week on Monday, Wednesday, Friday, and Sunday. Record review of Resident #1's treatment administration record for the month of August revealed staff had failed to mark completion of wound care treatment on 08.13.2025, 08.18.2025, and 08.24.2025. During an interview on 09.03.25 at 12:55 PM, LVN A revealed that Wound Care Nurse B would have usually performed the wound care for Resident #1. LVN A stated, Wound Care Nurse B was absent on one of the days but could not remember which day, so she performed the care, but must have failed to mark completed on the treatment administration record. LVN A stated, she was not sure why Wound Care Nurse B did not mark completed for the days she administered care. During an interview on 09.04.25 at 12:55 PM, the DON revealed that
the treatment administration record was not marked as completed on 08.13.2025, 08.18.2025, and 08.24.2025. She stated that implications for not marking the treatment as completed was that We can't say that it was done. That's the issue.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
San Antonio West Nursing and Rehabilitation in San Antonio, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.