Health inspection·July 11, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for 1 of 8 residents (Resident #1) reviewed for abuse and neglect. The facility did not report to the State Survey Agency (HHSC) an alleged romantic relationship between Resident #1 and LVN A, as reported by Resident #1 to the DON, and LVN A to the ADON. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. The findings included: Record review of Resident #1's admission record, undated, reflected a [AGE] year-old resident with an initial admission of 02/03/2025 and diagnoses including acute respiratory failure with hypoxia (a condition where the lungs cannot adequately oxygenate the blood) and quadriplegia (paralysis of all four limbs). Record review of Resident #1's BIMS Assessment reflected that Resident #1 had a BIMS score of 9, reflecting moderate cognitive impairment. Record review of Resident #1's Care Plan, undated, did not indicate that Resident #1 had a history of sexually inappropriate behavior toward residents or staff. Record review of Resident #1's Progress note, dated 05/13/2025, reflected that Resident #1 requested to be sent to the emergency room for evaluation that day due to started to cough while asleep and had difficulty catching his breath. Record review of the Intake Investigation Worksheet #1009602 dated 0514/2025 revealed facility reported residents' allegations of abuse and neglect and not wanting to return to the facility. Neither self-report nor addendums revealed concern for possible sexual abuse or exploitation. Record review of the Provider Investigation Report (PIR), dated 05/19/2025, reflected that Resident #1 complained about the facility at the hospital, but when the DON went to speak with him at the hospital, Resident #1 declined the complaints, saying he was angry and just wanted to go to where LVN A worked. The PIR did not reflect possible sexual abuse or exploitation.Interview on 07/10/2025 at 3:55 PM, the facility's previous DON (DON C), who was the DON at the facility at the time of the incident, stated that she initially she went to the hospital to check on Resident #1 because of the complaints he had at the hospital of the facility, including pest control issues and being left soiled for a long time. Resident #1 recanted the complaints to DON C, stating he was just upset due to them firing LVN A, and wanted to live where she was because they were in a relationship. DON C stated that she had heard from Resident #1's Stepsister, LVN B, that she had a suspicion Resident #1 and LVN A were having a relationship. DON C stated she had reported LVN A to the Texas Board of Nursing on 05/22/2025 out of an abundance of caution due to the allegations of LVN A having a physical relationship with Resident #1. DON C stated LVN A had not been fired, but had changed her employment to PRN status. Interview on 07/10/2025 at 4:22 PM, LVN B stated she had informed the DON, at the time, DON C, that she felt Resident #1 was having a relationship with LVN A. LVN B stated that everything seemed normal at first for a working relationship between a nurse and a patient, but toward the end of LVN A working at the Page 1 of 2 455390 455390 07/11/2025 Buena Vida Nursing and Rehab-San Antonio 5027 Pecan Grove San Antonio, TX 78222

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility, she became hostile toward LVN B. LVN B stated that she did not know the extent of their relationship and whether it was sexual or not, because shortly after going to the hospital, Resident #1 ceased communication with LVN B and she had not heard from him since. LVN B stated she was aware Resident #1 had similar behaviors at a previous facility, but had not told any facility staff or administration of these behaviors. Interview on 07/10/2025 at 4:42 PM, ADON D stated she never had a concern of a sexual relationship between Resident #1 and LVN A. She stated she observed that Resident #1 and LVN A were friendly and LVN A would hang out in his room frequently. ADON D stated she did complete a verbal conversation with LVN A, and reprimanded her for spending too much time with Resident #1 and that she should focus on all residents equally. ADON D stated that DON C returned from the hospital after visiting Resident #1 and identified concerns of a possible inappropriate relationship. ADON D stated that staff members were questioned and interviewed regarding potential sexual abuse and/or inappropriate relationships between residents and staff. ADON D stated that during investigations she informs the ADM and the ADM reports to the state as necessary. Interview on 07/11/25 at 10:30 AM, Resident #1 stated that he did not have a relationship with LVN A. Resident #1 stated that they were friends and stated, she was my age, and we were able to click together. Resident #1 denied any sexual encounters and inappropriate interactions with LVN A. Interview on 07/11/2025 at 2:40 PM, the ADM stated that, during the course of the investigation of Resident Neglect for Resident #1, she should have identified that an allegation of inappropriate relationship between Resident #1 and LVN A should have been recognized as possible abuse, and HHSC should have been notified. The ADM stated Resident #1 was not in the facility at the time of the investigation. The ADM stated that the incident should have been reported to the state. The ADM stated after DON C visited with Resident #1, the investigation was expanded to include sexual abuse and exploitation. Record review reflected LVN A's most recent shift worked at the facility was 04/29/2025, at which time her employment status changed to PRN . Further review reflected LVN A was suspended pending the facilities investigation and terminated when the investigation was concluded. An interview with LVN A was attempted on 07/10/2025 at 2:00 PM, LVN A did not answer the attempt for a phone interview. Record Review of Complaint Form to TBON, date submitted 05/22/2025, reflected Resident #1 as the patient involved in the complaint, and LVN A as the nurse being reported to the TBON. The description of incident is as follows: Resident and LVN had multiple situations where they were physically involved per resident and LVN. LVN stated to resident she had been fired due to this discovery. This promoted [sic] resident to ask to be transferred to hospital. Resident then reported to hospital social worker that he did not want to return to facility due to wanting to go where Nurse [LVN A] is now working. This caused social worker to report situation to be reported to state. This facility has also self-reported this situation.Review of the facility's Nursing Policy and Procedure Manual, Version 03-1.0 F.7. revealed, The facility will report .any and all investigations concerning reports of abuse, neglect, exploitation .to the state survey and certification agency. 455390 Page 2 of 2