Inspection·December 19, 2025

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 observation, interviews and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 4 residents (Resident #2) reviewed for accuracy of medical records.Resident #2 did not have foley catheter orders in Resident #2's November 2025 administration orders when he readmitted from the hospital with a foley catheter on 11/03/2025. This deficient practice could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment. Findings included:Record review of Resident #2's undated face sheet revealed Resident #2 was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included retention of urine (inability to empty the bladder completely), schizophrenia (a chronic mental illness characterized by delusions, hallucinations, and disorganized thinking) and profound intellectual disabilities (a severe condition characterized by significant limitations in cognitive abilities and adaptive functioning).Record review of Resident #2's 5-day MDS assessment, dated 11/10/2025, revealed Resident #2 had short term and long-term memory deficits and severely impaired cognitive skills for decision making. Section H- Bladder and Bowel revealed Resident #2 had an indwelling foley catheter (a medical device that helps drain urine from the bladder) and was frequently incontinent with bowels. Record review of Resident #2's undated comprehensive care plan revealed Resident #2 had an indwelling catheter related to urinary retention, revision date 11/06/2025. An intervention revealed, change catheter per physician orders, date initiated 11/06/2025 and clean the catheter insertion site daily with mild soap and water. Ensure the drainage bag is changed per facility protocol, date initiated 11/06/2025. Record review of Resident #2's hospital discharge summary, admit date [DATE] and discharge date [DATE], revealed, 10/12 foley placed by urology and Flomax started. 10/15 voiding trial but foley later replaced on 10/18 and next Cath change should be done in about 2 weeks. Record review of a facility document titled admission Report, dated 11/03/2025, revealed Resident #2 had a foley catheter for urinary retention. Record review of Resident #2's November 2025 medication and treatment administration record revealed an order for enhanced barrier precautions related to an indwelling foley catheter every shift, start date 11/05/2025. The administration record did not reveal any orders for foley catheter care. Record review of Resident #2's physician order summary report revealed an order, foley catheter 16F (size of catheter) with 30cc balloon (component of the foley catheter). Change every month and PRN. Change drainage bag every 15th of the month and prn, dated 11/04/2025.Record review of Resident #2's nursing progress note, dated 11/04/2025, revealed Resident #2 admitted with a foley catheter intact. Record review of an EMR document titled, Task: B&B - Urinary Continence revealed Resident #2 was coded as, continence not rated due to indwelling catheter on 11/20/2025, 11/21/2025, 11/22/2025,11/23/2025, 11/24/2025 and 11/25/2025. During an observation of Resident #2, on 12/18/2025 at 4:05 p.m., Resident #2 was lying in a (continued on next page) 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 Page 1 of 2 Event ID: 675002 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Antonio West Nursing and Rehabilitation 636 Cupples Rd San Antonio, TX 78237 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)