Inspection·March 22, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and neglect for 1 of 1 facility in that: Residents Affected - Few The ADM did not follow the ANE policy and procedures by not reporting a serious injury of unknown source to HHSC when: Resident #1 fell, went to the hospital, and received 6 sutures to her forehead. This could affect all resident that had a fall and could result in further injuries. The Findings were: Record review of policy Abuse/Neglect dated 2003 reflected The resident had the right to be free of abuse, neglect misappropriation of resident property and exploitation. E: Reporting, Facility employees must report all allegations of abuse, neglect exploitation mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report the allegation to HHSC. 1. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. B. if the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. Record Review of Resident #1's admission Record dated 3/18/2025 reflected she was [AGE] years old; she was admitted on [DATE] and she had Hospice services. Record Review of Resident #1 diagnoses reflected dementia (a general term for a decline in mental ability that interferes with daily life, encompassing various conditions affecting memory, thinking, and reasoning.), major depressive disorder (a common and serious mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life), Parkinson's disease (a progressive neurodegenerative disorder that affects the brain's ability to produce and use dopamine), joint pain, and metabolic encephalopathy (a condition where the brain's function is impaired due to a disturbance in the body's metabolism). Record Review of Resident #1's significant change MDS dated [DATE] reflected a BIMS score of 00/15 (severely cognitively impaired), she had disorganized thinking evidenced by fluctuating and inattention. Resident #1 had verbal behaviors present 4-6 days, she had no upper/lower extremity impairment, she required substantial max assistance for toileting, upper/lower body dressing, and putting on footwear. Resident #1 was frequently incontinent, had falls, weighed 116 pounds, was on hospice services, and was receiving physical therapy services. Record Review of Resident #1's Care Plan reflected she had diagnoses of osteoarthritis, (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 8 Event ID: 455444 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 455444 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesa Vista Inn Health Center 5756 N Knoll Dr San Antonio, TX 78240 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)