Inspection·August 29, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of 12 residents (Resident #6), in that: Resident #6's care plan did not include a focus area or interventions for Resident #6's ordered hospice care diagnosis. This failure placed residents at risk of not receiving appropriate end of life care, a decreased quality of life, mismanagement of medications, and hospitalization. The findings included: Record review of Resident #6's admission Record dated 08/29/2025, reflected a [AGE] year-old female resident admitted to the facility on [DATE]. Record review of Resident #6's Medical Diagnosis report dated 08/29/2025 reflected diagnoses including senile degeneration of the brain (the brain's cells are damaged, leading to problems with memory, judgment, personality, and the ability to perform daily tasks) and cerebral atherosclerosis (when fatty plaques build up on the inside of the arteries in the brain, making them narrower and harder). Record review of Resident #6's MDS dated [DATE] documented a BIMS score of three out of 15, which suggested a severe cognitive impairment (lots of difficulty with memory, judgment, personality, and making decisions that affected care and daily life). Further review showed Resident #6 received hospice services while a resident in the facility. Record review of Resident #6's Order Summary report dated 08/29/2025, showed an active order for Admit to Hospice with Dx: Cerebral atherosclerosis, dated 01/04/2024. Record review of Resident #6's Comprehensive Care Plan, printed on 08/29/2025 reflected a focus area dated 01/24/24 and revised on 02/07/2024 for Resident requires hospice as evidenced by terminal illness. Hospice DX: Senile Degeneration of the Brain. During an interview on 08/29/2025 at 1:12 PM, when asked about the care plan process for hospice diagnoses the DON stated, typically what is on the order is what we put on the care plan. When asked if there was any reason why the diagnoses on the hospice order and the hospice care plan would not match, the DON stated, they should match. When asked what the expectation for care planning medical diagnoses was, the DON stated, they [the care planned diagnosis] should match the [medical] diagnoses and the order. When asked what some the risks of not care planning appropriate hospice diagnoses were, the DON stated increased or decreased quality of care. During an observation and interview on 08/29/2025 at 1:12 PM, the DON reviewed Resident #6's electronic orders and care plan and stated the hospice order DX did not match the care planned diagnosis, and they should always match. The DON stated that she was responsible for ensuring the ordered hospice diagnoses matched the care planned diagnosis. The DON stated that she would ensure that Resident #6's hospice care plan diagnosis matched the order. Record review of the facility's policy titled Comprehensive Care Planning with no date, reflected the following: The comprehensive care plan will describe the following -The services that are to be furnished to attain or maintain the resident's highest practicable (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 08/29/2025 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)