San Antonio West Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at San Antonio West Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jan 30, 2025

  Based on observations, interviews, and record reviews the facility failed to protect the residents right to be free from physical abuse by Resident #83 and #55, for 3 of 13 residents (Residents #55, #61, and #83) reviewed for physical abuse and neglect. 1. On 1/11/2025 on or about 11:00 AM Resident #61 was physically battered by Resident #83, to include a face punch, his hair pulled, and drug by his foot across the floor. 2. On 4/9/2024 Resident #61 entered Resident #55 room and began to use the restroom when Residents #55 and #61 began forcing each other's hands away from one another. 3. On 4/22/2024 Resident #61 was punched in the nose by Resident #55. 4. On 8/12/2024 Resident #61 was punched in the face by Resident #55 when he entered Resident #55's room. […]

• Immediate jeopardy, isolatedF925Oct 25, 2025

  Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that it was free of pests and rodents for 1 of 7 residents (Resident #1) reviewed for pest control program. The facility failed to ensure Resident #1 was not found with maggots in his right stage 3 heel wound on 10/16/25. Resident #1 refused an ER referral when the maggots were found and was sent to the emergency room a day after the maggots were discovered. An IJ was identified on 10/23/25. The IJ template was provided to the facility on [DATE] at 3:25 p.m. […]

• Immediate jeopardy, isolatedF689Jan 10, 2025

  Based on observation, interview, and record reviews the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 out of 8 residents (Resident #1 and Resident #2) reviewed for accidents and supervision, in that: 1. Resident #1 was an elopement risk and provided interventions to include a wander guard and checks to ensure proper placement. On 5/25/24 Resident #1 removed his wander guard and eloped from the facility. 2. Resident #2 was an elopement risk with interventions to include structured activity to distract from wandering. On 6/6/24, Resident #2 eloped from the facility. The noncompliance was identified as a PNC. The PNC IJ began on 5/25/2024 and ended on 6/6/2024. The facility had corrected the non-compliance before the survey began. […]

• Immediate jeopardy, isolatedF580Sep 20, 2024

  Based on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status in either life-threatening conditions or clinical complications for one of six residents (Resident #5) reviewed had a change of condition. The facility failed to notify the wound care physician, primary care physician, and Resident #5's resident representative of changes observed with Resident #5's wound, which resulted in the wound becoming an unstageable pressure ulcer (a wound that is covered by slough(debris that appears tan, yellow, green or brown in color) and eschar (hard… […]

• Immediate jeopardy, isolatedF686Sep 20, 2024

  Based on observation, interview and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of six residents reviewed (Resident #5) for pressure ulcers. 1. The facility failed to ensure Resident #5 received services and treatment orders to prevent sacral and left heel pressure ulcers from developing. 2. […]