Health inspection·December 2, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status for one (Resident #1) of five residents reviewed for notification of changes. The facility failed to notify Resident #1's family when she expired (died) on [DATE]. This failure could result in the resident's family/RP not being aware of the resident's condition. The findings included: Record review of Resident #1's face sheet dated [DATE] revealed an [AGE] year-old female, admitted on [DATE] and readmitted on [DATE] with diagnoses which included displaced fracture of seventh cervical vertebra, subsequent encounter for fracture with routine healing (a break in the small bones of the neck that was healing), hypertension (elevated blood pressure) and anxiety disorder. The face sheet indicated Resident #1 was discharged on [DATE] (location not specified). Record review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMs score of 3 which indicated a severe cognitive impairment with partial to substantial assistance required for ADL. Record review of Resident #1's discharge MDS assessment dated [DATE] revealed the resident died in the facility on [DATE]. Record review of Resident #1''s General Progress Note dated [DATE] revealed facility staff conducted CPR on the resident until EMS arrived and took over. Time of death was called at 12:02 p.m. ([DATE]) and police arrived to assess scene. Record review of Resident #1's General Progress Note dated [DATE] by the DON indicated the physician was notified of local police arrival (at the facility) and ongoing investigation. Nursing staff instructed by police to not speak with residents, enter room or contact families. During an interview on [DATE] at 1:05 p.m., the ADON stated police conducted an investigation of the death of Resident #1 because another resident saw Resident #1 fall to the floor and thought he saw her roommate hitting her with a croc (a type of foam shoe) or a purse. The ADON stated the facility had conducted an investigation and no other residents or staff heard or saw anything. She stated because the police were involved in the death investigation, they (police) told them (facility staff) that they were not allowed to notify the family of Resident #1 of her death. She stated the police told the management in a group. She stated she was in the office, as well as the DON and Administrator. The ADON stated because they had been told not to tell the family due to the investigation, the family was not notified of Resident #1's death. She stated on [DATE] the family called to check on Resident #1. The ADON stated she took the call and confirmed she died but was not able to offer any other details. She stated she gave the family the phone number of the police officer and told them to call the police for additional information. The ADON stated the family was very upset about it. During an interview on [DATE] at 1:54 p.m., the DON stated on [DATE], she received a call that Resident #1 had fallen, and as they were getting her back in bed, she coded. She stated another resident approached EMS personnel as they were attempting to resuscitate the resident and stated he saw another resident hit her with a shoe. The DON Page 1 of 2 675171 675171 12/02/2025 Crestway Nursing & Rehabilitation 7181 Crestway Dr San Antonio, TX 78239

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated this resulted in a police investigation. She stated the results of the investigation after an autopsy was complete was that Resident #1 died as a result of a clot in her lungs. Attempted interview on [DATE] at 2:45 p.m. with the family of Resident #1. No return call was received. During an interview on [DATE] at 3:41 p.m., the local police department investigator stated he told the facility staff they were not to notify Resident #1's family of her death due to the investigation. He stated sternly, it was the local law enforcement responsibility to notify next of kin, not the facilities. During an interview on [DATE] at 4:07 p.m., the DON stated they had asked the police officer if they were okay to notify the family of Resident #1 of her death. She stated the police officer told her, the ADON and Administrator who were all in the office together no. The DON stated he said, don't notify family. The DON stated the police officer stated they would get the medical examiner report first because it was a crime scene and they needed to talk (interview) the family first. The DON stated she did not specifically notify the police officer of their requirements to notify the family of a change of condition. She stated during the investigation itself, facility policy had come up because the police officer originally told them they could not investigate. The DON stated she told the police officer it was their policy to investigate, and he had replied that the police were doing the investigation. The DON stated after the police left the facility conducted their own investigation. The DON stated their policy stated family should be notified timely. She stated she as well as other facility staff wanted to notify them right then and there. She stated they wanted to make sure the important things were completed. She stated because she was unable to do it, she documented it in Resident #1's medical record. During an interview on [DATE] at 4:15 p.m., the Administrator stated an investigator with the local police department told them not to notify family because it was a crime scene and next of kin had to identify the body for the medical examiner. The Administrator stated yesterday ([DATE]), the family called and was frustrated they had received a call from the medical examiner's office to notify them of the death. The Administrator stated she gave the family the name and phone number of the investigator and told them they would need to reach out to the investigator for information. The Administrator stated she did not tell the investigator their facility policy required notification of the family because he firmly told them it was a crime scene, and this is how it goes. The Administrator stated she wanted to notify the family and staff had asked the police if they could. She stated the investigator reiterated to the facility as a team; they could not notify the family. During an interview on [DATE] at 4:31 p.m., the Administrator stated she did not reach out to the Ombudsman, HHSC Program Management or the Medical Director for advice. She stated they discussed the death and police involvement with the Medical Director but not specifically the law enforcement request to not notify. Record review of the facilities policy Change of Condition Notification policy, last revised 06/2020 revealed: Purpose: To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. II. The Facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative when the resident endures a significant change in their condition cause by, but not limited to: A. An injury/accident B. A significant change in the resident's physical, cognitive, behavioral or functional status. V. Family Notification: A. The licensed Nurse will notify the resident, the resident's responsible party, or the family/surrogate decision-makers of any changes in the resident's condition as soon as possible. 675171 Page 2 of 2