Health inspection·January 16, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure in response to allegations of abuse, were reported immediately, but not later than 2 hours after the allegation was made, when the events that caused the allegation involved abuse for 1 of 5 Residents (Resident #1) whose records were reviewed for abuse. CNA A reported to nursing staff that CNA B slapped Resident #1 on the right upper thigh. Nursing staff failed to follow the chain of command and report it to the ADM right away which delayed the ADM in reporting the allegation of abuse to the State Survey Agency within 2 hours. This deficient practice could affect any resident and contribute to further resident abuse. The findings were: Review of Resident #1's face sheet, dated 1/16/24, revealed she was admitted to the facility on [DATE] with diagnoses including Dementia and Personal History of (healed) traumatic fracture. Review of Resident #1's quarterly MDS assessment, dated 12/12/23 with a BIMS score of 2 reflective of severe cognitive impairment. Review of Resident #1's Care Plan revised 12/13/23 revealed she had severe impaired cognitive function or thought process related to cognitive decline and she was resistive to care related to dementia. One of the interventions included for staff to allow the resident to make decisions about treatment regimen, to provide sense of control. Review of Review of PIR involving Resident #1 revealed on 1/1/24, revealed CNA A alleged CNA B slapped Resident #1 on her right thigh during care when Resident became combative. Further review revealed CNA A also reported the allegation of abuse to LVN D and LVN E. Both staff advised CNA A to report it to the ADM; however, neither one of the charge nurse's reported the allegation of abuse to the ADM. Review of facility in-service on their policy, Abuse Prevention and Prohibition Program, dated 1/2/24 revealed the ADM reviewed the policy including reporting abuse and neglect with nursing staff. It was noted the designated abuse coordinator was the ADM and staff who had knowledge of abuse and or neglect should report directly to him. Observation and interview on 1/10/24 at 11:26 AM revealed Resident #1 sitting in a wheelchair along the wall in front of the nurses station. She was friendly and engaged in simple conversation. Page 1 of 13 455762 455762 01/16/2024 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #1 presented as being alert and oriented to self. She stated she was doing well and did not express any concerns related to abuse/neglect. Resident #1 did not answer any questions pertaining to the allegation of abuse. She starred blankly when asked questions and did not respond. Interview on 1/10/24 at 4 PM with the ADM revealed the allegation of resident abuse involving Resident #1 was reported late and not within 2 hours as required per regulation because nursing staff failed to report the allegation to him right away. He stated he learned about the incident on the morning of 1/2/24, the day after the incident, 1/1/24. He stated CNA A approached 2 separate LVN's on the night of the incident, LVN D and LVN E and both instructed her to report it directly to him. The ADM stated CNA A did not contact him to report what she witnessed. The ADM stated staff should report any allegations of abuse directly to him. However, in this case the charge nurses should have also reported the allegation to ensure it was reported right away. He stated he provided had a lengthy in-service for staff regarding reporting abuse and neglect. Interview on 1/11/24 at 12:30 PM with CNA B, AP, involving Resident #1 revealed she worked 3:00 PM to 11:00 PM on the night of the incident. She stated the on-coming CNA B came in early and was already on the hall. She stated Resident #1 was yelling and screaming. She stated she had just showered Resident #1 about 30 minutes prior. CNA B was already on the hall and was walking towards Resident #1's room. She walked in right behind CNA B. She stated Resident #1 was still on the bed but had stripped her bed, taken off her brief and clothes and was completely nude on the bed. CNA B stated Resident #1 was combative, striking out and kicking. She told the Resident stop it, you weren't acting like this when your {family member} was here. CNA B stated Resident #1 at one point kicked towards her stomach and she caught her leg and told Resident #1 you can't kick me on the stomach, I'm pregnant. She stated the CNA B told her she couldn't hit the Residents and responded and said I didn't hit her. I caught her leg so she wouldn't kick me in the stomach. CNA B stated she would never hit any of her residents, she stated she had a good rapport with them and would not hurt them in any way. Interview on 1/12/24 at 10:01 AM with CNA A revealed she confirmed she reported to work early for the 11 PM to 7 AM shift on 1/1/24. Her and CNA B went into Resident #1's room together. Resident #1 was yelling and screaming. Upon entering the room Resident #1 had thrown her belongings including linens on the floor and she was nude. She was very aggravated. CNA A stated Resident #1 was kicking her legs and CNA B told the Resident you're not going to hurt my baby and slapped the Resident on the right thigh. She commented, and no she was not trying to block her kick, she raised her hand and slapped the Resident on the thigh. CNA A stated she did not see any marks on Resident #1. She stated she got mad and left and reported what she saw to LVN D and LVN E. She stated she did not report the allegation to the ADM and later learned she was supposed to also call the ADM. She stated she had been in-serviced about reporting allegations of abuse and neglect right to the charge nurse and the ADM right away. Interview on 1/13/24 at 11:55 AM with LVN D revealed CNA A reported she witnessed CNA B slap Resident #1 on the right thigh when she became combative. LVN D stated she pulled CNA A aside and made sure she understood correctly because it was not in CNA B's character to hit a resident. LVN D stated CNA A reiterated she saw CNA B hit Resident #1. At this point she instructed CNA A to report it to her charge nurse and the ADM because she was not working on the same side of the facility. LVN D stated she should have also directly reported the allegation of abuse to the ADM to ensure it was reported per facility policy. LVN D stated she attended an in-service regarding reporting allegations of abuse and neglect to the ADM right away. Review of a facility policy, Abuse Prevention and Prohibition Program, undated, read: IX 455762 Page 2 of 13 455762 01/16/2024 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Reporting/Response, B. Administrator, or his/her designee, as Abuse Coordinator i. in order to facilitate reporting, ensure confidentiality and promote order at the Facility, the Administrator, or his/her designee, shall be the individual who reports known or suspected instances of abuse of resident at the facility to the proper authorities. ii. Facility Staff will report known or suspected instances of abuse to the Administrator, or his/her designee. D. The Facility will report allegations of abuse, neglect, exploitation,, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents that qualify as a crime. See AN-01-Form E-Initial Report-Facility Reported incident. i. immediately, but no later than 2 hours after forming the suspicion-if the alleged violation involves abuse or results in serious bodily injury to the state survey agency. 455762 Page 3 of 13 455762 01/16/2024 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good oral hygiene for 1 of 5 Residents (Resident #2) whose records were reviewed for adl care. Residents Affected - Few Nursing staff failed to clean Resident #2's lips and brush her teeth after breakfast. This deficient practice could affect dependent residents and contribute to poor oral hygiene, tooth decay, infections and decline in physical condition The findings were: Review of Resident #2's face sheet, dated 1/16/24, revealed she was admitted to the facility on [DATE] with diagnoses including Dementia and Cognitive Communication Deficit. Review of Resident #2's annual MDS assessment, dated 12/22/23, revealed her BIMS score was severely cognitively impaired and she was dependent for oral care. Review of Resident #2's Care Plan, revised on 12/20/23 revealed she had a communication problem and one of the interventions was to anticipate needs. Further review revealed Resident #2 had a self-care ADL performance deficit but did not address her need for assistance with oral care. Review of Resident #2 task form (including personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands) dated 1/3/24 to 1/16/24 revealed Resident #1 was totally dependent and required full staff assistance for oral care. Further review revealed on 1/10/24 it reflected Resident #2 received assistance at one time at 9:27 AM. Observation and interview on 1/10/24 at 10:50 AM revealed Resident #2 was lying in bed in a low position. Observation of Resident #2's mouth revealed her top front teeth were crooked and protruding; her lips had a white hardened film around her top and lower lips outlining the entire mouth; lower teeth had brown build up. Resident #2 was Spanish speaking and presented as alert to self with confusion. Resident #2 answered yes/no to questions and when asked if someone had cleaned her mouth, she said, no. When asked if she wanted her teeth cleaned she said, yes. Interview on 1/10/24 at 11:10 AM with LVN C revealed she had rounded on residents on her hall this morning including Resident #2. LVN C asked what was going on with Resident #2's lips. LVN C stated she probably needed oral care. Observation on 1/10/24 at 11:11 AM revealed LVN C entered Resident #2's room LVN C stated Resident #2 had lost a lot of weight and maybe that's why her top teeth were protruding. LVN C stated Resident #2 needed oral care evidenced by the white film. She stated Resident #2's lips looked dry and needed swabbing to remove the white film. LVN C stated Resident #2 would get a lot of build up daily and the aides should clean her lips every morning. She had Resident #2 open her mouth and LVN C stated it did not look like staff had provided oral care deeply; thorough cleaning. She stated Resident #2 had brown build up on her lower teeth. LVN C stated usually the aides would provide oral care but she would also assist when she fed Resident #2 but did not provide oral care on this date. 455762 Page 4 of 13 455762 01/16/2024 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 1/10/24 at 11:15 AM with CNA F revealed she would assist residents with hygiene first thing in the morning by wiping down their face and she would brush their teeth as needed. She stated technically she was supposed to brush the resident's teeth after meals but did not usually get to it twice daily rather once daily. CNA F stated she had not completed oral care for Resident #2 and stated she would get build up around her lips. She stated Resident #2 was dependent on staff to clean her lips and brush her teeth. CNA F stated she concentrated on completing showers after making her 1st round and had not had a chance to get back to assist Resident #2. Interview on 1/12/24 at 2:48 PM with ADON G revealed it was standard practice for the CNA's to assist residents who required assistance with hygiene including oral care and showers. She stated the charge nurses were responsible for ensuring it was done and to report any problems to her. ADON G stated no one had said anything to her about the CNA's not providing Resident #2 with oral care. Interview on 1/16/24 at 11:25 AM with the DON revealed she expected staff to provide residents who required assistance with adl care including oral care as needed and per resident preference. Review of a facility policy, Care and Services, undated, read: Purpose is to ensure through an interdisciplinary team (IDT) process, that all residents receive the necessary care and services based on an individualized comprehensive assessment process. Policy Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being of in an environment that enhances quality of life in the scope of a long-term care facility. Care and services are provided inn a manner that consistently enhances self-esteem and self-worth. 455762 Page 5 of 13 455762 01/16/2024 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 4 resident (Residents #3 and #20) reviewed for incontinent care, in that: 1. While providing incontinent care for Resident #3, CNA H did not pull back Resident #3's foreskin. 2. While providing incontinent care for Resident #20, CNA G used a back to front motion to clean Resident #'s buttocks. CNA G did not clean Resident #20's anal area. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: 1. Record review of Resident #3's face sheet, dated 01/16/2024, revealed an admission date of 05/04/2021, and a readmission date of 12/03/2023, with diagnoses which included: Hemiplegia (Paralysis of one side of the body),Dementia (decline in cognitive abilities), Anxiety (A group of mental illnesses that cause constant fear and worry), Macular degeneration (medical condition which may result in blurred or no vision in the center of the visual field), Type 2 diabetes mellitus (high level of sugar in the blood), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), chronic kidney disease(gradual loss of kidney function). Record review of Resident #'3's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 3 indicating severe impairment. Resident #3 required extensive assistance and was frequently incontinent of bladder and bowel. Review of Resident #3''s care plan, dated 06/05/2023, revealed a problem of has occasional bladder incontinence and is at increased risk for UTI (unrinary tract infection) or impaired skin integrity and an intervention of OCCASIONAL INCONTINENCE: Check [ .] frequently and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. Observation on 1/12/2024 at 2:15 p.m. revealed while providing incontinent care for Resident #3, CNA H did not pull back Resident #3's foreskin and did not clean Resident #3's glans.(distal end of the human penis) During an interview on 1/12/2024 at 2:27 p.m., CNA H confirmed she had not pulled the foreskin of the resident. She stated she did not know she had to pull back the foreskin. She confirmed receiving training in infection control and incontinent care. During an interview with the DON on 01/12/2024 at 3:27 p.m., ., she confirmed the foreskin, if present had to be pulled back to clean the resident's glans. The DON revealed the staff received training on infection control and incontinent care at least annually. The staff skills were check yearly. The ADON spot check the staff while they provided care for infection control and quality of care. 455762 Page 6 of 13 455762 01/16/2024 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0690 Level of Harm - Minimal harm or potential for actual harm Review of annual skills check for CNA H revealed CNA H passed competency for Perineal care/incontinent care on 08/16/2023. Review of facility policy, titled Perineal care, dated 06/2020, revealed pull back the foreskin on uncircumcised male and clean under it. Residents Affected - Few 2. Record review of Resident #20's face sheet, dated 01/16/2024, revealed an admission date of 07/27/2023, and a readmission date of 12/22/2023, with diagnoses which included: Metabolic encephalopathy (brain function is disturbed by another health condition), Hypothyroidism (under active thyroid), Type 2 diabetes mellitus (high level of sugar in the blood), Peripheral vascular disease (narrowing of blood vessels), Hyperlipidemia (high level of lipids (fat) in the blood), Hypertension (high blood pressure). Record review of Resident #'20's 5 days MDS, dated [DATE], revealed the resident had a BIMS score of 12 indicating mild impairment. Resident #20 required extensive assistance and was always incontinent of bladder and bowel. Review of Resident #20''s care plan, dated 01/10/2024, revealed a problem of has bowel and bladder incontinence r/t Confusion. She is at risk for UTI's and impaired skin integrity and an intervention of Monitor/document for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observation on 1/12/2024 at 2 p.m. revealed while providing incontinent care for Resident #20, CNA G wiped Resident #20's buttocks in a back to front motion. She also did not clean between Resident #20's butt cheeks (anal and peri anal area) During an interview on 01/12/2024 at 2:09 p.m. with CNA G, she confirmed she had wiped Resident #20's buttocks in a back to front motion She said she thought she was using the correct technique. She confirmed receiving training on incontinent care from the facility. During an interview with the DON on 01/12/2024 at 3:27 p.m., ., she confirmed the correct motion to clean the residents during perineal care was front to back to prevent fecal matter from contacting the urethra and possibly cause an infection. The DON revealed the anal and peri anal area had to be clean. The DON revealed the staff received training on infection control and incontinent care at least annually. The staff skills were check yearly. The ADON spot check the staff while they provided care for infection control and quality of care. Review of annual skills check for CNA G revealed CNA G passed competency for Perineal care/incontinent care on 08/16/2023. Review of facility policy, titled Perineal care, dated 06/2020, revealed moving from front to back, using a clean wash cloth/cleansing wipe for each stroke. Further review revealed wash, rinse and dry buttocks an peri anal area without contaminating the perineal are. 455762 Page 7 of 13 455762 01/16/2024 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skillss and techniques to provide nursing and related services for 2 of 4 residents (Residents #3 and #20) by 2 of 4 certified staff (CNA G and CNA H) reviewed for competent staff, in that: 1. While providing incontinent care for Resident #3, CNA H did not pull back Resident #3's foreskin. 2. While providing incontinent care for Resident #20, CNA G used a back to front motion to clean Resident #'s buttocks. CNA G did not clean Resident #20's anal area. These failures could place residents at risk for not receiving nursing services by adequately trained and certified aides and could result in a decline in health and infection. The findings included: 1. Record review of Resident #3's face sheet, dated 01/16/2024, revealed an admission date of 05/04/2021, and a readmission date of 12/03/2023, with diagnoses which included: Hemiplegia (Paralysis of one side of the body),Dementia (decline in cognitive abilities), Anxiety (A group of mental illnesses that cause constant fear and worry), Macular degeneration (medical condition which may result in blurred or no vision in the center of the visual field), Type 2 diabetes mellitus (high level of sugar in the blood), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), chronic kidney disease(gradual loss of kidney function). Record review of Resident #'3's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 3 indicating severe impairment. Resident #3 required extensive assistance and was frequently incontinent of bladder and bowel. Review of Resident #3''s care plan, dated 06/05/2023, revealed a problem of has occasional bladder incontinence and is at increased risk for UTI (urinary tract infection) or impaired skin integrity and an intervention of OCCASIONAL INCONTINENCE: Check [ .] frequently and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes. Observation on 1/12/2024 at 2:15 p.m. revealed while providing incontinent care for Resident #3, CNA H did not pull back Resident #1's foreskin and did not clean Resident #3's glans (distal end of human penis) During an interview on 1/12/2024 at 2:27 p.m., CNA H confirmed she had not pulled the foreskin of the resident. She stated she did not know she had to pull back the foreskin. She confirmed receiving training in infection control and incontinent care. During an interview with the DON on 01/12/2024 at 3:27 p.m., she confirmed the foreskin, if present had to be pulled back to clean the resident's glans. The DON revealed the staff received training on infection control and incontinent care at least annually. The staff skills were check yearly. The ADON spot check the staff while they provided care for infection control and quality of care. 455762 Page 8 of 13 455762 01/16/2024 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0726 Level of Harm - Minimal harm or potential for actual harm Review of annual skills check for CNA H revealed CNA H passed competency for Perineal care/incontinent care on 08/16/2023. Review of facility policy, titled Perineal care, dated 06/2020, revealed pull back the foreskin on uncircumcised male and clean under it. Residents Affected - Few 2. Record review of Resident #20's face sheet, dated 01/16/2024, revealed an admission date of 07/27/2023, and a readmission date of 12/22/2023, with diagnoses which included: Metabolic encephalopathy (brain function is disturbed by another health condition), Hypothyroidism (under active thyroid), Type 2 diabetes mellitus (high level of sugar in the blood), Peripheral vascular disease (narrowing of blood vessels), Hyperlipidemia (high level of lipids (fat) in the blood), Hypertension (high blood pressure). Record review of Resident #'20's 5 days MDS, dated [DATE], revealed the resident had a BIMS score of 12 indicating mild impairment. Resident #20 required extensive assistance and was always incontinent of bladder and bowel. Review of Resident #20''s care plan, dated 01/10/2024, revealed a problem of has bowel and bladder incontinence r/t Confusion. She is at risk for UTI's and impaired skin integrity and an intervention of Monitor/document for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observation on 1/12/2024 at 2 p.m. revealed while providing incontinent care for Resident #20, CNA G wiped Resident #20's buttocks in a back to front motion. She also did not clean between Resident #20's butt cheeks (anal and peri anal area) During an interview on 01/12/2024 at 2:09 p.m. with CNA G, she confirmed she had wiped Resident #20's buttocks in a back to front motion She said she thought she was using the correct technique. She confirmed receiving training on incontinent care from the facility. During an interview with the DON on 01/12/2024 at 3:27 p.m., ., she confirmed the correct motion to clean the residents during perineal care was front to back to prevent fecal matter from contacting the urethra and possibly cause an infection. The DON revealed the anal and peri anal area had to be clean. The DON revealed the staff received training on infection control and incontinent care at least annually. The staff skills were check yearly. The ADON spot check the staff while they provided care for infection control and quality of care. Review of annual skills check for CNA G revealed CNA G passed competency for Perineal care/incontinent care on 08/16/2023. Review of facility policy, titled Perineal care, dated 06/2020, revealed moving from front to back, using a clean wash cloth/cleansing wipe for each stroke. Further review revealed wash, rinse and dry buttocks an peri anal area without contaminating the perineal are. 455762 Page 9 of 13 455762 01/16/2024 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0791 Provide or obtain dental services for each resident. 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 ensure they assisted residents in obtaining routine dental care for 1 of 5 Resident (Resident #2) whose records were review for dental services. Residents Affected - Some Nursing staff failed to refer Resident #2 for dental services since her admission; for 6 months. This deficient practice could affect residents in need of dental services and result in the development of infections and a decline in physical condition The findings were: Review of Resident #2's face sheet, dated 1/16/24, revealed she was admitted to the facility on [DATE] with diagnoses including Dementia and Cognitive Communication Deficit. Review of Resident #2's annual MDS assessment, dated 12/22/23, revealed her BIMS score was severely cognitively impaired and she was dependent for oral care. Review of Resident #2's Care Plan, revised on 12/20/23 revealed she had a communication problem and one of the interventions was to anticipate needs. Further review revealed Resident #2 had a self-care ADL performance deficit but did not address her need for dental care as evidenced by the condition of her teeth. Review of Resident #2 task form (including personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands) dated 1/3/24 to 1/16/24 revealed Resident #1 was totally dependent and required full staff assistance for oral care. Further review revealed on 1/10/23 it reflected Resident #2 received assistance one time at 9:27 AM. Review of in-house dental visit dated 11/1/23 and 11/22 /23 revealed Resident #2 was not seen by the in-house dentist. Review of the list of residents to be seen by the dentist on 1/17/24 revealed Resident #2 was not on the list. Observation and interview on 1/10/24 at 10:50 AM revealed Resident #2 was lying in bed in low position. Observation of Resident #2's mouth revealed her top front teeth were crooked and protruding and her lower teeth had brown build up. Resident #2 was Spanish speaking and presented as alert to self with confusion. Resident #2 answered yes/no to questions and when asked if she had pain in her mouth, she stated no. Observation on 1/10/24 at 11:11 AM revealed LVN C entered Resident #2's room LVN C stated Resident #2 had lost a lot of weight and maybe that's why her top teeth were protruding. LVN C stated Resident #2 needed oral care evidenced by the white film. She stated Resident #2's lips looked dry and needed swabbing to remove the white film. LVN C stated Resident #2 would get a lot of build up daily and the aides should clean her lips every morning. She had Resident #2 open her mouth and LVN C stated it did not look like staff had provided oral care deeply; thorough cleaning. She stated Resident #2 had brown build up on her lower teeth. LVN C stated usually the aides would provide oral care but she would also assist when she fed Resident #2 but did not provide oral care on this date. 455762 Page 10 of 13 455762 01/16/2024 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation and interview on 1/12/24 at 3:00 PM revealed ADON G assessed the condition of Resident #2's teeth and gums. ADON G stated Resident #2's upper teeth were crooked and protruding making it difficult for Resident #2 to keep her mouth closed. ADON G further stated Resident #2 had corrosion to the upper teeth; she had a receding gum line on her lower gum and build up on her lower teeth. She stated Resident #2 needed to see a dentist. ADON G stated usually nursing staff would let the SW know of a resident's need for dental care. The SW would refer the resident to the facility dentist for dental care. ADON G stated the dentist made quarterly visits but commented the dentist had not been in the facility for months. ADON G stated she would ensure Resident #2 was put on the list for residents needed dental care for the next visit. Interview on 1/16/24 at 11:25 AM with the DON revealed she was brand new to the facility and was not sure about the referral process for dental care but usually the SW would take care of the referrals. The DON stated she expected staff to let the SW know when residents required dental care so the SW would refer the resident to the in-house dentist. The DON stated they had a newly hired SW as of last week and stated she was not sure the last time the dentist was in the building because she was also a new hire. Interview on 1/16/24 at 12:00 PM with the ADM revealed he was not sure who was responsible for referring residents for dental services but stated he took the task on upon hire. He stated the next in-house dental visit would take place on 1/17/24. He provided a list of residents who received dental care on 11/1/23, 11/22/23 and he provided a list of residents who were on the list to be seen on 1/17/24. Upon review Resident #2 was not on any of the list. Review of the list of residents to be seen by the dentist on 1/17/24 revealed Resident #2 was not on the list. Interview on 1/16/24 at 2:45 PM with the ADM revealed he stated that nursing staff had not told him that Resident #2 needed dental care so he did not added her to the list for dental care on 1/17/24. Review of a facility policy, Dental Services, undated, read: Purpose: All residents receive appropriate oral care, including denture care, if applicable on a daily basis. Policy: 1. It is the responsibility of each staff member within the nursing department to ensure good oral care for each resident. Procedure: Refer and/or assist residents to obtain dental services as indicated for routine and emergency dental care including making appointments for the resident, if needed or requested. A. Routine services include but are not limited to: i. Annual inspections, ii. Dental cleaning, fillings, and x-ray as needed, iii. Minor dental plate adjustments, iv. smoothing of broken teeth. 455762 Page 11 of 13 455762 01/16/2024 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

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 4 residents (Resident #3) reviewed for infection control, in that: Residents Affected - Few While providing incontinent care for Resident #3, CNA H touched the fall matt on the floor with her bare hands and did not wash her hands before putting her gloves on and starting providing care. CNA H did not change gloves and sanitize or wash her hands before touching Resident #3's clean brief. These failures could place residents at-risk for infection due to improper care practices. The findings include: Record review of Resident #3's face sheet, dated 01/16/2024, revealed an admission date of 05/04/2021, and a readmission date of 12/03/2023, with diagnoses which included: Hemiplegia (Paralysis of one side of the body),Dementia (decline in cognitive abilities), Anxiety (A group of mental illnesses that cause constant fear and worry), Macular degeneration (medical condition which may result in blurred or no vision in the center of the visual field), Type 2 diabetes mellitus (high level of sugar in the blood), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), chronic kidney disease(gradual loss of kidney function). Record review of Resident #'3's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 3 indicating severe impairment. Resident #3 required extensive assistance and was frequently incontinent of bladder and bowel. Review of Resident #3''s care plan, dated 06/05/2023, revealed a problem of has occasional bladder incontinence and is at increased risk for UTI (urinary tract infection) or impaired skin integrity and an intervention of OCCASIONAL INCONTINENCE: Check [ .] frequently and as required for incontinence. Wash, rinse and dry perineum.(space between the anus and scrotum in the male ) Change clothing PRN (as needed) after incontinence episodes. Observation on 1/12/2024 at 2:15 p.m. revealed while providing incontinent care for Resident #3, CNA H touched the fall matt on the floor with her bare hands and moved it away from the bed. CNA H, then, put her gloves on and started to provide care for Resident #1 but did not sanitize or wash her hands. Further observation revealed CNA H, after cleaning Resident #3's buttocks, touched Resident #3's clean brief without changing her gloves and sanitizing or washing her hands. The resident had a large loose bowel movement. During an interview on 1/12/2024 at 2:27 p.m., CNA H confirmed she had touched the fall matt with her bare hands and did not clean her hands before putting her gloves on and starting care. CNA H verbally confirmed she did not change her gloves and sanitize her hands after cleaning Resident #3's buttocks. She confirmed receiving training in infection control and incontinent care. During an interview with the DON on 01/12/2024 at 3:27 p.m., ., she confirmed staff should sanitize or wash their hands after touching a fall matt and before putting gloves on. The DON confirmed staff should change gloves and sanitize or wash their hands after cleaning a resident and before 455762 Page 12 of 13 455762 01/16/2024 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few touching clean briefs. The DON revealed the staff received training on infection control and incontinent care at least annually. The staff skills were check yearly. The ADON spot check the staff while they provided care for infection control and quality of care. Review of annual skills check for CNA H revealed CNA H passed competency for Perineal care/incontinent and infection control care on 08/16/2023. Review of facility policy, titled Hand hygiene, dated 06/2020, revealed facility staff and volunteers must perform hand hygiene procedures in the following circumstances [ .] after contact with [ .] after contact with intact and non intact skin, clothing and environmental surfaces of residents with active diarrhea even if gloves are worn 455762 Page 13 of 13