Health inspection·July 17, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which are complete; and accurately documented for 1 of 4 residents (Resident #1) reviewed for documentation. Resident #1's electronic medical record did not contain complete and accurate documentation regarding whether his falls on 5/28/25 and 7/12/25 were witnessed by nursing staff or unwitnessed. This failure could result in residents' records not accurately documenting interventions, monitoring, and information provided to the interdisciplinary team as to whether a resident fall was witnessed or unwitnessed. The findings were:Record review of Resident #1's face sheet, dated 7/17/25, reflected resident was a male aged 74 admitted on [DATE] and re-admitted [DATE] and discharged [DATE] (hospital) with diagnoses that included: nontraumatic intracranial hemorrhage (residual effects from a stroke), epilepsy (seizure disorder), abnormalities of gait and mobility (difficulty with ambulation), lack of coordination, and tinnitus (ringing in the ear). The RP was listed as: Guardian. Record review of Resident #1's quarterly MDS dated [DATE] reflected the resident's BIMS score was 1 which indicated severe cognitive impairment. The resident required set-up for transfer and had no impairments in range of motion. W/C was listed as an assistive device. Record review of Resident #1's fall risk score dated 7/12/25 reflected a score of 11 which indicated high risk for fall. Record review of Resident #1's Nurse Note dated 5/28/25 authored by LVN A reflected: resident had a witnessed fall without injury in the common area. Record review of Resident #1's CP dated 5/28/25 reflected witnessed fall with the new intervention of staff to be in-serviced, and optometry referral. Record review of Resident #1's Incident report authored by LVN A documented a conflict on whether the resident's fall on 5/28/25 was witnessed or unwitnessed. The incident report Box for fall was checked for unwitnessed. Record review of Resident #1's CP dated 7/12/25 reflected an unwitnessed fall with no injury; intervention was the placement of Dycem (adhesive) on the resident's W/C. Record review of Resident #1's Nurse Note dated 7/12/25 at 5:45 PM authored by LVN B reflected the fall was witnessed. Record review of the Resident's Incident Report dated 7/12/25 reflected the fall was not witnessed. Observation and interview of Resident #1 on 7/16/25 at 1:00 PM reflected, resident was in an ICU bed, alert and oriented to self. An O2 pulse meter was placed on the resident's head. His left elbow had multiple scratches and generalized bruising and was red in color. The resident could not recall any information regarding his falls on 5/28/25 and 7/12/25. The resident was able to state that he was not abused or neglected in the facility. The resident was unable to state any fall prevention measures that were in place at the nursing home. During an interview on 7/16/25 at 1:05 PM, the ICU RN stated: Resident #1 was admitted on [DATE] around midnight and given a CT scan at 2:00 AM. The CT scan revealed a small hemorrhagic contusion in the right frontal lobe (small bleeding in the front of the brain) not requiring a surgical intervention, The RN stated that the resident had dementia and was confused (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 07/17/2025 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)