Health inspection·February 2, 2024

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 interview and record reviews, the facility failed to ensure, in accordance with accepted professional standards and practices , maintain medical records on each resident that accurately documented for 1 of 3 residents (Resident #1) reviewed for accurate medical records, in that: LVN A signed the Narcotic sheet for Resident #1 and had not initialed MAR (medication administration record), indicating inaccurate documentation. This deficient practice could result in misinformation about the professional care provided. The findings included: Record review of Resident #1's face sheet dated 2/1/2024 revealed a [AGE] year-old female who was admitted to the facility on 12//30/22 with diagnoses that included: [Left hemiplegia] paralysis of limbs on the left side of the body, [Schizoaffective disorder] a mental health problem where you experience psychosis as well as mood symptoms, and [ Anxiety] a feeling of fear, dread, and uneasiness. Record review of Resident #1's care plan, dated 7/14/23, revealed, focus Choices end of life care, Hospice Care elected, Administer medications as ordered by a physician. Record review of Resident #1's quarterly MDS assessment, dated 3/22/2023, revealed the resident did not have a BIMS section left blank indicating the resident was unable to complete interview. Record review of Resident #1's physician orders for June 2023 revealed an order for Morphine Sulfate (concentrate) solution 20 mg/ml ( Milligrams / Milliliter): Give one ml sublingually every two hours as needed for pain. Record review of Resident #1's Narcotic sheet for June 2023, revealed Resident #1 had received Morphine one ML sublingually on 6/23/23, 6/26/23 and 6/28/23. Record review of Resident #1's MAR (medication administration record) for June 20223 revealed medication Morphine had not been signed on the MAR on 6/23/23, 6/26/23, and 6/28/23. Resident #1 was unable to be interviewed due to discharge from the facility on 7/8/23. LVN A was unable to be interviewed due to no longer being employed by a facility as of 9/1/23. (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: 675858 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 675858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Nursing & Rehabilitation 5437 Eisenhauer Rd San Antonio, TX 78218 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)