Inspection·November 24, 2025

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete residents with total privacy by closing the door, privacy curtains, blinds, and only exposing the area to be treated. LVN A further stated it was important to respect the residents' privacy and dignity because not doing so could cause the residents embarrassment. During an interview on 10/17/25 at 3:34 pm, ADON B said she and LVN A should have knocked on Resident #3's door and closed the blinds prior to providing resident care to maintain the resident's privacy. ADON B said she thought she and LVN A must have forgotten to close the blinds in Resident #3 room, before assessing/treating her wounds, because Resident #3 was in a private room, but they closed the door. ADON B further stated not knocking or letting a resident know what was going to be done was a dignity issue. ADON B said not closing the blinds in Resident #3's room during care may have made her feel exposed. ADON B further stated privacy should be provided to residents any time resident care was provided, including when clothes were changed, in the restroom and during transfers. ADON B said it was all o the nursing management's responsibility to educate staff and ensure policies/procedures were reinforced. During an interview on 10/17/25 at 5:16 pm, the DON said privacy should always be provided to the residents. The DON further stated that privacy curtains should be pulled all the way around the bed and blinds closed during resident care because it could affect the residents' dignity. The DON said residents that could not communicate may not be able to verbalize discomfort but may also be affected and so privacy should always be provided and dignity maintained. The DON said it was the responsibility of all the nursing managers to ensure that residents' privacy/dignity was respected. Record review of a webpage titled Exercising Your Rights as a Nursing Facility Resident, by the state long-term care ombudsman program, at chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://ltco.texas.gov/sites/ltco/files/documents/nf-residents-rights-bo and dated October 2024, revealed: .You have the right to be treated with dignity and respect.The facility must ensure your privacy in the following areas: Your room Medical treatment. Event ID: Facility ID: 455444 If continuation sheet Page 2 of 4 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 11/24/2025 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)

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 observations, interviews, and record reviews, 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 diseases and infections for 3 of 5 residents (Resident #2, Resident #3, and Resident #4) reviewed for infection control. The facility failed to ensure staff wore PPE during wound care for Resident #2 who was on enhanced barrier precautions. The facility failed to ensure LVN A and ADON B appropriately doffed (removed) PPE after providing care to Resident #3 and Resident #4. This deficient practice could put residents at risk for infection. Findings included: 1. Record review of Resident #2's admission Record, dated 10/17/25, revealed the resident was re-admitted to the facility on [DATE] with diagnoses which included: Type 1 Diabetes (condition in which the pancreas makes little/no insulin, resulting in high blood sugar) and Peripheral Vascular Disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Record review of Resident #2's Care Plan, dated 8/29/25, revealed: Resident is on enhanced barrier precautions.Gloves and gown should be donned (put on) if any of the following activities are to occur.high-contact activity. During observation of Resident #2's wound to the right lower leg, on 10/16/25 beginning at 4:44 pm, revealed LVN A, accompanied by ADON B, approached Resident #2 in her bedroom and explained the procedure. Further observation revealed LVN A removed the dressing to the left lower leg, exposing the wound for observation without donning PPE (includes, but is not limited to gown and gloves). During an interview on 10/17/25 at 12:48 pm, LVN A said he felt rushed and nervous during the observation of care to Resident #2's wound to the right lower leg on 10/16/25. LVN A further stated he honestly forgot to don PPE. LVN A said it was important to wear PPE during resident care so that it limited the spread of infection to the residents and staff. During an interview on 10/17/25 at 3:34 pm, ADON B said Resident #2 was on EBP. ADON B further stated they (LVN A and ADON B) did not wear PPE because they thought the state investigator just wanted to see the wound, adding that Resident #2's wound was not a pressure wound, and that was why she thought they did not need to wear PPE. ADON B further stated they should have worn PPE because the wound was going to be exposed. ADON B said PPE should be worn any time a resident had an open wound and/or indwelling devices. ADON B further stated EBP was to provide protection and to avoid the spread of infections. 2. Record review of Resident #4's admission Record, dated 10/17/25, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #4's quarterly MDS assessment, dated 9/10/25, revealed the resident's cognitive skills for daily decision making was severely impaired. During observation of wound care to Resident #4's right and left heels, on 10/17/25 beginning at 10:19 am, revealed LVN A, accompanied by ADON B, approached Resident #2 in her bedroom, explained the procedure, and completed wound care. Further observation revealed ADON B removed the glove on her left hand and continued to remove the glove on her right hand by grasping the glove, on the palm area, with her left ungloved hand. Further observation revealed LVN A removed his gloves, after which LVN A and ADON B removed their gowns by grasping the gown in the front and pulling away from the body. During an interview on 10/17/25 at 12:48 pm, LVN A said when he removed his gown he should have grabbed the gown from the back because the front was contaminated and not doing so could possibly spread infections. Record review of Resident #3's admission Record, dated 10/17/25, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Vascular Dementia (Brain damage caused by multiple strokes). During observation of wound care to Resident #3's left heel, on 10/16/25 beginning at 4:16 pm, revealed LVN A, Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455444 If continuation sheet Page 3 of 4 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 11/24/2025 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete accompanied by ADON B, approached Resident #2 in her bedroom, explained the procedure, and completed wound care. Further observation revealed ADON B removed the glove on her left hand and continued to remove the glove on her right hand by grasping the glove, on the palm area, with her left ungloved hand. During an interview on 10/17/25 at 3:34 pm, ADON B said when she removed dirty gloves, she pulled one glove and tucked her fingers of the ungloved hand inside of the other glove and pulled it off. ADON B said she thought that was how she removed her gloves after wound care for Resident #3 and Resident #4. ADON B said it was important to remove contaminated gloves as recommended to keep their hands as clean as possible and decrease the risk of contamination/infection. ADON B said when wound care was completed for Resident #4, she removed her gloves first. ADON B further stated she was not supposed to touch the front of the gown without gloves and was supposed to pull the contaminated gown from the back when not wearing gloves because the back of the gown was considered clean. ADON B said not removing a contaminated gown correctly could increase the risk for infection/spread of bodily fluids. ADON B said she and the DON were responsible for ensuring infection control practices were followed by facility staff. During an interview on 10/17/25 at 5:16 pm, the DON said when removing PPE, if gloves were worn the gown could be grabbed from the front and pulled off but when gloves were removed before the gown, the gown should be pulled from the back. The DON said when gloves were removed, it should be done by pinching the first glove and pulling off and then go underneath the second glove and remove. The DON said gloves were removed in that manner to reduce contamination and limit exposure to other residents. The DON further stated PPE should be worn by staff any time hands on care was provided to residents, even when observing a wound. The DON said when a resident was on EBP PPE should be donned before entering the resident's room and doffed before exiting the resident's room. The DON further stated PPE was required for any resident with indwelling catheters and/or wounds. The DON said when providing care for a resident on EBP staff were required to wear PPE to protect the residents from organisms entering open area on the body. The DON further stated not following EBP could worsen infections. The DON said she was responsible for ensuring infection control practices were followed, adding that it was a team effort. Record review of the facility's policy titled Infection Control Plan: Overview updated 3/3023, reflected: .5. Gowns and protective apparel 1. Gowns and protective apparel are worn to provide barrier protection and reduce the opportunity for transmission of microorganisms.to prevent contamination of clothing and to protect skin of personnel from blood and body fluid exposures. Record review of CDC Infection Control webpage at chrome extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.cdc.gov/infection-control/media/pdfs/Toolkits-PPE-Sequence-P. dated October 2014, reflected: HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 1 1. GLOVES Using a gloved hand, grasp the palm area of the other gloved hand and peel off first glove Hold removed glove in gloved hand Slide fingers of ungloved hand under remaining glove at wrist and peel off second glove over first glove.3. GOWN.Unfasten gown ties, taking care that sleeves don't contact your body when reaching for ties Pull gown away from neck and shoulders, touching inside of gown only.HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 2 1. GOWN AND GLOVES.Grasp the gown in the front and pull away from your body so that the ties break, touching outside of gown only your gloves at the same time, only touching the inside of the gloves and gown with your bare hands. Event ID: Facility ID: 455444 If continuation sheet Page 4 of 4