Health inspection·May 9, 2025

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed establish and 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 1 of 2 (3rd floor)community shower rooms in that: The 3rd floor shower room had 2 shower stalls that had drains with gobs of hair. There was brown substance under 1 shower chair, and floors were dirty with darkened areas and brown substance droppings on 1 of the shower stalls. 30 possible residents could use the 3rd floor shower room. This could affect all resident that shower in the 3rd floor shared shower and could result in infections. The Findings were: Observation on 5/6/2025 at 4:21 PM The 3rd floor shower room had 2 shower stalls that had drains with gobs of hair. There was brown substance under 1 shower chair, and floors were dirty with darkened areas and brown substance droppings on 1 of the shower stalls. Interview on 5/6/2025 at 4:22 PM with CNA A stated he provided a resident a shower earlier today, he cleaned the shower chair with shampoo and had not disinfectant the shower chair, because the facility did not have anymore products to disinfect the shower chair. CNA A stated the night shifts were to stock the shower rooms. CNA A stated after each resident use, the shower chairs were cleaned between residents. CNA A stated the hsk staff clean the shower stalls and the CNAs clean any feces and shower chairs. Interview on 5/6/2025 at 4:31 PM with RN B observed the 3rd floor shower room, floors were dirty, shower grates had lots of hair, and feces on the shower room floor. RN B notified maintenance the shower room on 3rd floor needed a deep cleaning. Interview on 5/6/2025 at 4:36 PM, the ADON stated CNAs were supposed wipe the resident shower chairs after each use with disinfectant wipes. The Hsk clean the shower stalls, floors, and drainage. The ADON stated the Hsk staff leaves at 4:00 PM. The ADON stated the DON was in charge of the nursing task and the Maintenance/Hsk supervisor was in charge of the hsk task in the shower rooms. Interview on 5/6/2025 at 4:42 PM, the Maintenance Assistant C stated staff were supposed to use disinfected wipes to disinfect the resident shower chairs, between use. Hsk did not clean up feces, 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: 455689 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 455689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Pedro Manor 515 W Ashby Pl San Antonio, TX 78212 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)