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
FORM CMS-2567 (02/99) Previous Versions Obsolete
hospital bed with a foley catheter bag on the side of the bed. Resident #2 was being fed a meal by a staff member. Resident #2 was nonverbal and unable to respond to questions. During an interview with CNA A,
on 12/19/2025 at 9:11 a.m., CNA A stated Resident #2 returned from the hospital at the beginning of November with a foley catheter. CNA A stated Resident #2 would drink fluids throughout the day and stated
he would change his foley catheter bag, just about every hour during the shift. CNA A stated he would provide peri care to Resident #2 by cleaning the foley insertion area and tubing when providing peri care throughout the day. CNA A stated Resident #2's foley bag would become full very quickly due to the number of fluids that Resident #2 would consume throughout the day. CNA A stated he would notify the nurse if a resident's foley catheter bag were leaking and the nurse would replace the bag. CNA A stated he would document foley care in the EMR under a task for incontinent care. During an interview with LVN C, on 12/19/2025 at 9:51 a.m., LVN C stated Resident #2 was readmitted to the facility in November with a foley catheter. LVN C stated residents with foley catheters would have orders for cleaning the foley catheter site and emptying the bag each shift and replacing the foley bag and tubing monthly. LVN C stated the nurses were responsible for entering foley catheter orders into the physician orders and administration orders and stated any resident with a foley should have had orders for foley care. LVN C stated the nurses would document foley care on the administration record. LVN C stated Resident #2's foley bag was changed, about every 2 hours because his foley bag would fill up quickly. LVN C stated it was important for a resident to have foley orders so the nurses can document on the resident's care, to show that I did it.During an
interview with the DON, on 12/19/2025 at 12:51 p.m., the DON stated a resident who was admitted to the facility with a foley catheter should have had foley catheter orders on the administration record. The DON stated the nurses were responsible for obtaining foley catheter orders for care and stated the facility had standing orders for foley catheters to be changed monthly and prn and foley catheter care provided every shift. The DON stated the foley order was entered into the EMR on 11/04/2025 but was not activated on the administration record, for some reason. The DON stated it was important for the foley orders to be in the administration record so the task could be completed and there would have been a record that the task was completed. The DON stated a resident who did not receive foley catheter care could develop an infection.Record review of a facility policy titled, Catheter Care, date implemented 05/02/2025, revealed, 1.
Catheter care will be performed every shift and as needed by nursing personnel. 8. Empty drainage bags when bag is half-full or every 3 to 6 hours. Record review of a facility in-service attendance record dated, 11/25/2025, revealed, foley catheter care: ensure foley catheter care is performed every shift and when completing incontinent care. Foley catheter to be changed monthly. The document revealed 27 staff signatures.
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If continuation sheet
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.