San Antonio West Nursing And Rehabilitation
San Antonio West Nursing and Rehabilitation in San Antonio, TX — inspection on April 10, 2026.
Found 12 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
physician of consent form that needs to be completed.
She stated charge nurses are expected to
notify NP W that Form 3713 is required. LVN C stated that administering psychotropic medications
04/10/2026 at 2:42 p.m., LVN X stated psychotropic medications cannot be administered or ordered without consent forms being signed by RP.
She said she was not familiar with Form 3713 requiring a physician signature for specific medications.
She stated Nursing Facility H has a psychotropic medication form and she will obtain consent prior to medication administration. LVN X stated that without accurate consent form being completed prior to medication administration can be harmful to the residents and she would need to check their vitals and monitor them.
During an interview on 4/10/2026 at 3:36 p.m., ADMIN revealed she was not familiar with psychotropic consents to provide information on compliance.
During an interview on 4/10/2026 at 5:20 p.m., ADON E revealed she, ADON L and the DON are responsible for ensuring psychotropic medication consents including Form 3713 are signed and completed.
She noted that the impact of not having completed Form 3713 could negatively impact residents as medications would be delayed, and this could impact their behaviors, cause them stress, anxiety, and delay in their overall care.During an observation and interview on 4/10/2026 at 5:20 p.m., ADON L revealed that Resident #86 was admitted with psychotropic medications, start date unknown, and a psychotropic medication form had been secured for him.
ADON L was observed to review Resident #1's EMR and psychotropic medication consent hard copy binder and stated Form 3713 should have been there, but she could not find it.
She noted there was a consent form completed, but it was not the required form and was not signed by NP W.
She noted that she would start working on the accurate psychotropic medication form for Resident #86 and submit to NP W for a signature.On 04/10/2026 at 07:01 p.m., an emailed request for a facility policy on Medication Consent was sent. A policy was not received.
675002 04/10/2026
San Antonio West Nursing and Rehabilitation 636 Cupples Rd San Antonio, TX 78237
During an interview on 04/10/2026 at 05:28 p.m., the ADMIN stated all residents needed to have their call light within reach.
She stated everyone was responsible for that.
She stated she was not very familiar with Resident #77; however, the impact of the call light having been out of reach was that the resident was not able to call for assistance.
Record review of facility policy, Call Lights: Accessibility and Timely Response, dated as revised 05/13/2025 and implemented 05/16/2025, revealed Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance.
Call lights will directly relay to a staff member or centralized location to ensure appropriate response.
Policy Explanation and Compliance Guidelines: .5.
Staff will ensure the call light is within reach of resident and secured, as needed.6.
The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.
675002 04/10/2026
San Antonio West Nursing and Rehabilitation 636 Cupples Rd San Antonio, TX 78237
During an observation on 04/09/2026 at 2:47 p.m.
Resident of room [ROOM NUMBER] was not present in his room for an interview.During an observation on 04/09/2026 at 2:47 p.m.
Resident room [ROOM NUMBER] was vacant and did not have a resident assigned to the room.
During an interview on 04/09/2026 at 3:00 p.m., the ADMIN revealed the maintenance director resigned from his position about two weeks back as he became overwhelmed with the plumbing issues at Nursing Facility H.
She noted she was aware of the need for repairs, minor maintenance, touch ups, walls, and sprucing up the secured unit, but her focus since she started in her role as ADMIN was to get Nursing Facility H up to code to pass inspections.
She stated she planned to work on the secured unit touchups next as this was the resident's home and it should feel and look comfortable and homelike.
She stated she planned to take a walk through the rooms in the secured unit with corporate staff to note the minor repairs.
Record review of the facility's policy titled, State of Resident's Rights in Texas, dated 08/2022, revealed .You have a right to: 2.
Safe, decent, and clean conditions.
675002 04/10/2026
San Antonio West Nursing and Rehabilitation 636 Cupples Rd San Antonio, TX 78237
complete Form 1012 and notify the Local Authority to conduct a PE.
She stated that once a
the Local Authority to determine if a resident qualifies for services.
She stated she wants to ensure
loss of beneficial services.
Record review of policy titled, Comprehensive Care Plans, date revised 05/05/2025, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and services that are identified in the resident's comprehensive assessment and meet professional standards of quality. c.
Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASRR recommendations.
Record review of policy titled, admission Criteria, date revised December 2016, revealed .8.
Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-admission Screening and Resident Review program (PASARR) to the extent practicable. 9.
Potential residents with mental disorders or intellectual disabilities will only be admitted if the State mental health agency has determined (through the pre-admission screening program) that the individual has a physical or mental condition that requires the level of services provided by the facility.
Record review of policy titled, Conducting an Accurate Resident Assessment, date revised 05/05/2025, revealed .The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of theresident's status at the time of the assessment, by staff qualified to assess relevant care areas.8. To ensure accuracy in the MDS coding of a diagnosis of schizophrenia, supportive documentation must be present in the medical record and should include, but is not limited to, evaluation(s) of the resident's physical, behavioral, mental, psychosocial status, and comorbid conditions, ruling out physiological effects of a substance (e.g., medication or drugs) or other medical conditions, indications of distress, change in functional status, resident complaints, behaviors, symptoms, and/or state Preadmission Screening and Resident Review (PASRR) evaluation.
675002 04/10/2026
San Antonio West Nursing and Rehabilitation 636 Cupples Rd San Antonio, TX 78237
noted that not developing and implementing person-centered care plans could negatively impact the
provide to a resident.
She noted that if a care plan is not updated or accurate it could have a negative
Record review of policy titled, Care Planning - Interdisciplinary Team, dated Qtr. 3, 2018, revealed .Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.
Record review of policy titled, Comprehensive Care Plans, date revised 05/05/2025, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and services that are identified in the resident's comprehensive assessment and meet professional standards of quality. 3.
The comprehensive care plan will describe, at a minimum, the following: a.
The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. c.
Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASRR recommendations. 5.
The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive, quarterly MDS assessment and when a resident experiences a status change 6.
The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment.
The objectives will be utilized to monitor the resident's progress .
Record review of policy titled, Secure unit placement, date revised 06/10/2025, revealed .3.
Written findings and the factual basis for the placement are documented in the health information record.5.
The IDT team to evaluate place of a resident in a secure environment.6.
The evaluation team shall re-evaluate as needed.
675002 04/10/2026
San Antonio West Nursing and Rehabilitation 636 Cupples Rd San Antonio, TX 78237
to administration, and the potential risk of not checking was administering the wrong dosage of
guidance related to injections or insulin.
675002 04/10/2026
San Antonio West Nursing and Rehabilitation 636 Cupples Rd San Antonio, TX 78237
Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals
1 of 3 medication carts (A- hall medication cart) reviewed for medication storage.
The facility failed to ensure a vial of insulin was labeled with the expiration date.
This failure could result in residents receiving expired medications.
Findings included: In an observation and interview on 4/10/2026 at 7:46 AM, a vial of insulin (a medication used to treat elevated blood sugar levels) was observed in the top drawer of the A-hall medication cart without an expiration date. LVN C was unsure when the vial had been opened.
She said all insulin vials and pens should be labeled with the date they are opened and the date they expire to ensure residents do not receive expired medications. In an interview with the DON on 4/10/2026 at 10:00 AM, she said the facility policy is to label all insulins with the date they are opened and the date they expire, and the nursing staff was primarily responsible for this duty.
She said the potential harm to residents was receiving expired insulin that is ineffective for treating elevated blood sugar.
Record review of the facility titled Storage of Medication dated 10/3/2018, reflected the following: .9.
Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location.
Medications must be stored separately from food and must be labeled accordingly.The policy did not contain guidance regarding the labeling of medication to indicate expiration.
675002 04/10/2026
San Antonio West Nursing and Rehabilitation 636 Cupples Rd San Antonio, TX 78237
sugars and large protein portions would not affect his blood sugars, which could improve his blood
Record review of the facility's policy Therapeutic Diets, revised October 2017, reflected . 2. A
may delegate this task to a registered or licensed dietitian as permitted by state law. 4. A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as a part of treatment for a disease or clinical condition, to modify specific nutrients in the diet.
675002 04/10/2026
San Antonio West Nursing and Rehabilitation 636 Cupples Rd San Antonio, TX 78237
if a frozen food item, still frozen, was unlabeled.
She stated she had not observed anyone coming into
04/10/2026 at 05:28 p.m., the ADMIN stated the impact of not having an internal thermometer in a
of the food, allowing food temperatures to be monitored and stored appropriately.
She stated she expected facility guests to come to the front, check in as a guest, and when going to the kitchen, to follow proper hand hygiene and wear hair restraints.
She stated the possible impact of a guest not following the protocol could be that hair and improper hygiene could negatively affect the residents' food.
She stated the impact of not taking the walk-in freezer temperature in the morning was the food might not have been stored at appropriate temperatures.
She stated the impact of not having a label on the pork ribs was the label allowed staff to ensure it was in a date range that ensured the food was safe for the facility to serve.
Record review of the facility's policy, Food Receiving and Storage, dated as revised October 2017, revealed Policy StatementFoods shall be received and stored in a manner that complies with safe food handling practices.Policy Interpretation and Implementation.8.
All foods stored in the refrigerator or freezer will be covered, labeled and dated (?use by' date).12.
Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements.
Record review of the facility's policy, Food Safety Requirements, dated as copyright 2026, revealed Policy:It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities.
Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety.Policy Explanation and Compliance Guidelines: .7.
Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. d.
Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contaminating food. e.
Hairnets should be worn when cooking, preparing, or assembling food, such as stirring pots or assembling the ingredients of a salad.8.
Additional strategies to prevent foodborne illness include, but are not limited to: a.
Preventing cross-contamination of foods.
Record review of the FDA Food Code 2022, https://www.fda.gov/food/retail-food-protection/fda-food-code, accessed 04/13/2026 revealed: 4-204.112 Temperature Measuring Devices.The placement of the temperature measuring device is important.Therefore, the temperature measuring device must be placed in a location that is representative of the actual storage temperature of the unit to ensure that all time/temperature control for safety foods are stored at least at the minimum temperature required.2- 402 Hair restraints2-402.11 Effectiveness.(A) Except as provided.Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers.(B) Label information shall include:(1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; .(3) An accurate declaration of the net quantity of contents; .
675002 04/10/2026
San Antonio West Nursing and Rehabilitation 636 Cupples Rd San Antonio, TX 78237
During an interview on 04/10/2026 at 03:15 p.m., RN O, Resident #14's care manager for Hospice G, stated she was Resident #14's hospice care manager since the middle to late October 2025. RN O stated Resident #14's oxygen had not been discontinued but changed from continuous to PRN. RN O stated she was not sure of Nursing Facility H's protocol, but some facilities wanted the hospice care plans either faxed or emailed.
She stated she was not the one typically responsible for faxing those documents over.
She stated the most recent hospice care plan for Resident #14 was dated Wednesday, 04/08/2026.
She stated she did not send the care plans over but would give the facility nurse the most recent order if she received the order prior to her weekly visit, otherwise the orders would be given verbally to the nurse.
She stated Resident #14's most recent order was dated 04/08/2026, which she was given by the physician after her weekly visit, so she let the nurse, LPN J know.
She stated she did not have a copy of the order.
She stated the impact of the facility not having Resident #14's most recent hospice care plan was Resident #14 may not be receive the proper medication if the facility and hospice were not on the same page with medications; however, Resident #14 had been stable.
During an interview on 04/10/2026 at 04:40 p.m., the DON stated there was a hospice binder located at the nurses' station that the hospices delivered.
She stated she could not state if anyone checked the binders for documentation.
She stated she did not know who was responsible and had forgotten about that task.
She stated the impact of a resident not having a current hospice care plan was if the hospice care plan had changed and the facility was not updated on the change, then the facility was not following the same plan of care.
During an interview on 04/10/2026 at 05:28 p.m., the ADMIN stated the nurse managers, the ADONs and the DON, were responsible for coordinating with the hospices for changes in their resident's plan of care and were responsible for holding the hospices accountable in providing the documentation.
Record review of Hospice G contract with Nursing Facility H, dated as contract was entered into on 01/05/2025, by Nursing Facility H and Hospice G.
The contract revealed under Definitions.Plan of Care (POC): A written individualized plan of services necessary to meet the patient-specific needs. It includes all patient care physician orders, and planned interventions for problems identified during patient assessments, to ensure that care and services are appropriate to the severity level of each patient and family's needs.Under I.
Responsibilities of Hospice: .F.
Information/Documentation provided to Facility on admission and ongoing: 1.
Most recent Hospice plan of care, .G.
Coordination/Continuity of Care: . 5.
Ensure that each resident's written plan of care includes both the most recent Hospice plan of care and a description of the services furnished by the Facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
Under II.
Responsibilities of Facility: .H.
Maintain an accurate medical record that all services furnished and events regarding care that occurred at the facility.
All services will be furnished according to the agreement.
Required documentation provided by Hospice will be included in a designated area/section.
Facility will ensure that these forms are not removed. On 04/10/2026 at 07:01 p.m., an emailed request for a facility policy on Hospice was sent. A policy was not received.
675002 04/10/2026
San Antonio West Nursing and Rehabilitation 636 Cupples Rd San Antonio, TX 78237
The facility failed to ensure LVN C utilized proper PPE when administering insulin to Resident #89.
This failure could result in the spread of infection.
Findings included:
Record review of Resident# 89's admission Record dated 4/10/2026 reflected a [AGE] year-old male admitted to the facility on [DATE].
Relevant diagnoses included type 2 diabetes mellitus with hyperglycemia [when the body develops resistance to insulin, leading to elevated levels of blood sugar].
Record review of Resident #89's significant change MDS submitted 3/17/2026 reflected a BIMS score of 08, which indicated moderately impaired cognition.
Record review of Resident #89's Order Summary Report dated 4/10/2026 reflected the following:Enhanced Barrier Precautions r/t indwelling medical device: indwelling foley catheter every shift [sic] (order date 3/13/2026) In an observation and interview on 4/10/2026 at 7:34 AM, Resident #89's doorway was observed to have a sign indicating Resident #89 required EBP. A caddy on the door was observed to contain PPE supplies, including disposable gowns. LVN C was observed administering insulin to Resident #89 without donning a disposable gown upon entry to the room. LVN C stated Resident #89 was on EBP due to the presence of the foley catheter, and she should have worn a gown before administering the insulin.
She said she forgot because was overthinking the observation.
She said the risk to residents of not wearing PPE as required was the spread of infection. In an interview on 4/10/2026, ADON E said she is also the Infection Preventionist for the facility.
She said LVN C should have worn PPE when administering insulin to Resident #89, and the risk was the spread of infection.
In an interview on 4/10/2026 at 10:00 AM, the DON said the facility policy was to don PPE before providing care to residents on EBP.
She said the failure to wear PPE could lead to infection.
Record review of the facility policy titled Enhanced Barrier Precautions dated 4/11/2025, reflected the following: .b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room .
The facility failed to
quality of life.
Findings include:In an observation on 4/7/2026 at 12:35 PM, approximately 10 small flying insects that resembled gnats were observed flying in the dining area and hallway adjacent to the dining area during lunch. In an observation on 4/9/2026 at 12:14 PM, revealed Resident #44 received lunch during an interview in the dining room.
Approximately 5 small flying insects that resembled gnats were flying above his food. He was observed swatting the flies away from his food as he ate lunch. In an observation and interview on 4/10/2026 at 11:21 AM, LVN E stated the flying insects observed in the secured units nursing station were gnats.
She stated that issues with gnats have been ongoing and sometimes it's worse.
She could not give the length of time the gnats had been observed.
She stated she had not reported the issue but everyone knew about it.
She revealed she was unaware of treatment for the gnats. In an interview with the ADMIN on 4/10/2026 she revealed she was aware of intermittent issues with insects in the facility.
She was unaware of the flying insects observed in the secured unit hallway and dining area.
She provided the Pest Control policy and the last 3 treatment invoices.
Record review of the pest sighting log on 4/10/2026 revealed gnats in the following areas: B Hall room [ROOM NUMBER] on 2/18/2026, room [ROOM NUMBER]A on 3/11/2026, and room [ROOM NUMBER] on 3/31/2026.
Record review of the 2/27/2026 and 3/25/2026 pest control invoices reflected past treatment for gnats by the contracted pest control company with fly boards and pressurized fly bait.
Record review of a facility policy entitled Pest Control, revised May 2008, read: Policy StatementOur facility shall maintain an effective pest control program.I.
This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.
675002 04/10/2026
San Antonio West Nursing and Rehabilitation 636 Cupples Rd San Antonio, TX 78237
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.