San Antonio West Nursing And Rehabilitation
San Antonio West Nursing and Rehabilitation in San Antonio, TX — inspection on October 25, 2025.
Found 2 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
put back into bed and the wound dressings needed to be changed.In a follow-up telephone interview
why orders were not written for Resident #1's wounds on his left rear thigh, right heel, groin, right
on 10/09/2025 for his wounds on his left rear thigh, right heel, groin, right hallux and right lateral malleolus was because she might have been interrupted during her wound assessments and forgot to go back to finish the assessment on those wounds. LVN C stated with Resident #1, Once you start, you can't stop and if you stop, he won't let you go back to him.In an interview on 10/25/2025 at 11:55 a.m., the Regional Clinical Resource (corporate nurse), stated Resident #1 was assessed by Wound NP OO before he left the facility AMA.In an interview on 10/25/25 at 3:34 p.m., the Regional Clinical Resource stated she reviewed Resident #1's clinical record and could not find any admission treatment orders for his wounds on his left rear thigh, right heel, groin, right hallux and right lateral malleolus; and the orders for those wounds were started on either 10/14/2025 or 10/15/2025.
The Regional Clinical Resource said when she spoke to the DON, the DON stated the treatment nurse provided wound care to Resident #1's wounds when he would let her. In an interview on 10/24/2025 at 2:57 p.m., the DON stated when she would do her daily rounds in the facility, she had observed that Resident #1 had wound dressings on both of his feet which were dated with that day's date, so she knew the wound care nurse was providing the wound care.
The DON stated wound care was to be documented on the resident's TAR, but it was not documented on Resident #1 because it looked like there was an error due to orders that were not in the chart for the wounds.
The DON reviewed Resident #1's wound assessments completed on 10/09/2025 and stated there were only 4 wound assessments done for the sacrum, left lower rear leg, left lateral foot and left hallux wounds.
The DON stated the Treatment Nurse was responsible for ensuring the weekly wound assessments were completed and the harm of not completing a weekly wound assessment was that it would be difficult to determine if the wound was healing or deteriorating.
The DON said the procedure for ensuring admission treatment orders were transcribed for wounds was the treatment nurse's responsibility; and the harm of not having a treatment order could result in wound care not being provided to the resident.In an interview on 10/24/2025 at 3:38 p.m., the Administrator stated the treatment nurse, or the admitting nurse was responsible for entering the treatment orders for wounds into the resident's clinical record upon admission; and not having a treatment order for wounds could result in the resident's plan of care not being followed.
The Administrator said the treatment nurse was responsible for completing the weekly wound assessments and not having it completed could result in not following the plan of care and cause a decrease in the skin's integrity.
Record review of the facility's policy Wound Care, dated 2021, revealed The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.Preparation 1.
Verify that there is a physician's order for this procedure. 2.
Review the resident's care plan to assess for any special needs of the resident.Documentation.
The following information may be recorded in the resident's medical record, if applicable: 1.
The type of wound care given. 2.
The date and time the wound care was given.
675002 10/25/2025
San Antonio West Nursing and Rehabilitation 636 Cupples Rd San Antonio, TX 78237
During an interview on 10/24/25 at 2:10 p.m., LVN Q stated
jeopardy to resident health or Reporting involved documenting in TELS.
During an interview on 10/24/25 at 2:25 p.m., Staff R safety (Social Worker) stated the highlights were: prevention by cleanliness and Resident rooms should not have leftover food.
Staff R stated, Report by documenting in the maintenance binder and notify
training involved shutting windows and keeping rooms cleaned.
Staff S stated residents were to be kept clean and received incontinent Care; and report any COC on wounds to nursing staff.
During an interview on 10/24/25 at 2:30 p.m., Staff T (Maintenance) stated prevention training included: maintain the facility and seal any openings in screens or windows.
Staff T stated Notify nursing staff if insects or rodents were seen in the facility and document in the maintenance log.
During an interview on 10/24/24 at 2:35 p.m. the Maintenance Director stated he received no W/O to seal windows or screens during the time of the incident on 10/16-10/17/25.
The Maintenance Director added prior to the incident the facility did not have fly lights.
During an interview on 10/24/25 at 2:38 p.m.
Staff U (Kitchen) stated: highlights of the training included to keep kitchen and facility clean and practice hygiene; and Report W/O to management.
During an interview on 10/24/25 at 2:39 p.m.
Staff V (kitchen) stated: prevention of pests through cleaning and checking; and Reporting of pests through W/O.
During an interview on 10/24/25 at 2:40 p.m.
Staff W (kitchen) stated training involved keep the kitchen clean and the facility and throw out trash and inspect dumpsters.
Staff W stated Report to the administrative staff about any issues with insects.
During an interview on 10/24/25 at 2:41 p.m.
Staff X (kitchen) stated: in-service stressed to keep the facility and kitchen clean as a prevention measure against pests.
Staff X stated to check on the appearance of residents.and Report immediately if insects were on ceiling lights
During an interview on 10/24/25 at 1:42 p.m., LVN I stated the highlights of training included: prevention through spraying and keeping rooms clean. LVN I stated Reporting involved to report to the DON and put in the maintenance log.
During an interview on 10/24/25 at 1:43 p.m., CNA J stated the highlights were: check rooms for food and drinks. CNA J stated the environment involved to make sure it was kept clean. CNA J stated Reporting to the charge nurse and any COC and to document.
During an interview on 10/24/25 at 1:52 p.m., CNA L stated the highlights of training included: prevention by keeping the facility clean. CNA L stated Check that residents were bathed as a prevention measure. CNA L stated to Report to housekeeping and the Administrator any room change.
During an interview on 10/24/25 at 1:54 p.m., CNA M stated the training emphasized prevention of pests by having the resident cleaned and showered; and ensuring trash was removed. CNA M stated Report on TELS and report to DON and COC.
During an interview on 10/24/25 at 2:50 p.m., Staff Y (Rehab) stated highlights of training included: cleanliness in rooms and no clutter and no food.
Staff Y stated check on resident odors and cleanliness as prevention.
Staff Y added to Check on wound dressings; and inform the nursing staff if the residents appear dirty and unkempt.
During an interview on 10/24/25 at 2:51 p.m., Staff Z (Rehab) stated: prevention of pests included rooms needed cleaning and windows sealed; and Residents should be clean and kept clean.
Staff Z stated Report issues to the nursing staff.
During an interview on 10/
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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.