Inspection·November 1, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for 1 of 6 resident rooms, observed for housekeeping and maintenance, in that: 1. Resident #2's bed foot board was broken and hanging on the bedframe. 2. Resident #2 was sleeping in bed without linen. These failures could lead to resident injury and a diminished quality of life. The findings were: Record review of Resident #2'a face sheet, dated 11/1/24 reflected a male age [AGE]. The resident was readmitted on [DATE] with diagnoses that included: dementia (primary). Record review of Resident's quarterly MDS dated [DATE] reflected resident's BIMS score was documented as 1 (severely impaired). B/B was documented as incontinent; and resident required one staff assistance for bathing. Resident was ambulatory with staff supervision. Record review of Resident #2's CP, undated, reflected the resident received ADL for transfer, mobility, and occasional incontinence. Record review of the facility's MS Maintenance application for the month of October 2024 did not reflect an order for fixing Resident #2's bed. [Failure was nursing staff not reporting the broken bed to the Maintenance Supervisor. Also, nursing staff when rounding for the nursing practice of every two hours failed to observe that the Resident's bed had no linen.] Record review of Resident #2's physician orders for the month of October 2024 reflected the resident was prescribed Sertraline 50 mg 1 tablet per day for depression. Observation and interview on 10/31/24 at 10:00 AM, Resident# 2 was sitting on a W/C staring out the window; alert and oriented person and place; interview-able in Spanish. Observation reflected that Resident #2's bed foot board was broken and off the frame; the bed had no linen. The Resident stated, .the foot board had been broken .there was no linen my bed . The resident stated he had been sleeping on the bed for 24 hours without linen and the foot board had been broken and loose for 24 hours. The resident stated he was sad over not having linen, but he did not want to complain to the staff. (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 4 Event ID: 455390 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 455390 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buena Vida Nursing and Rehab-San Antonio 5027 Pecan Grove San Antonio, TX 78222 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)