Inspection·December 13, 2023

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals for 1 (Resident #1) of 5 residents reviewed for special eating equipment and assistance when consuming meals, in that: Residents Affected - Few The dietary staff failed to provide Resident #1 with a plate guard to meet Resident #1's need for assistance with eating related to Resident #1's right side weakness. This failure could place residents at risk for harm by weight loss, diminished independence, and self-esteem. The findings included: A record review of Resident #1's admission record dated 12/11/2023 revealed an admission date of 07/21/2023 with diagnoses which included hemiplegia following cerebral infarction [ right sided paralysis after a stroke]. A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 06 out of a possible score of 15 which indicated severe cognitive impairment. A record review of Resident #1's care plan dated 12/11/2023 revealed Resident #1 was to have a plate guard attached to his meal plate [a device that clips around the edge of the plate where a person can scoop food against using only 1 hand]. During an observation on 12/11/2023 at 12:02 PM revealed Resident #1 seated in the dining room with a plate of food before him. Continued observation revealed resident #1 was not eating but just sat staring at the plate of food. Further observation revealed there were no assistive devices for facilitation of eating on the plate and or table. A record review of Resident #1's meal ticket upon the table revealed Resident #1 was to have a plate guard on the plate, Adaptive Equipment: Plate Guard. During an interview on 12/11/2023 at 12:03 PM Resident #1 stated he was not eating due to the food being cold after he could not scoop his food. (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: 675896 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 675896 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River City Care Center 921 Nolan St San Antonio, TX 78202 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)