Inspection·March 30, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 3 residents (Resident #3) reviewed for infection control: Residents Affected - Few The facility failed to ensure CNA A changed her gloves and washed or sanitized her hands after they became contaminated during incontinent care, before touching Resident #3's clean linen and clean brief. This failure could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #3's admission Record (face sheet) dated 03/30/2025, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (a progressive decline in memory, thinking, reasoning and problem-solving that interferes with daily life activities), vitamin D deficiency (inadequate intake of a mineral that can lead to a loss of bone density), schizophrenia (a chronic and severe mental disorder characterized by a disconnection from reality, often involving hallucinations, delusions, and disorganized thinking or behavior), bipolar disorder (a chronic mental disorder with extreme shifts in mood and behavior), depressive disorder (a mental health condition characterized by persistent feelings of sadness, hopelessness and loss of interest), and high blood pressure. Record review of Resident #3's most recent Quarterly MDS Assessment, dated 02/15/2025, revealed a BIMS score of 15 out of 15 indication her cognitive skills for daily decision making were intact, required substantial/maximal assistance with toileting and was always incontinent of bowel and bladder. Record review of Resident #3's Care Plan for ADL Self Care Performance Deficit, initiated 06/18/2020, revealed under interventions the resident required assistance of 2 staff for toileting. Observation on 03/26/2025 from 2:38 p.m. to 3:00 p.m. of CNA A and the DON provide incontinent care to Resident #3 revealed CNA A wiped the resident's front perineal (region located between genitals and the anus) area, then with the same soiled gloves, touched the bed linen without changing her gloves. CNA A then provided pericare (washing the genitals and anal area) to the resident's buttocks, removed the soiled brief, removed the soiled gloves, and used sanitizer. The CNA put on clean gloves and wiped fecal material from Resident #3's legs with her gloved hands, then with the same soiled gloves CNA A touched the resident, rolled the resident to her back, and continued to cleanse the (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: 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 03/30/2025 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)