Health inspection·April 12, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure the care plan reflected the resident's status for 1 of 3 residents (Resident #1) reviewed for care plan assessments. The facility failed to accurately document Resident #1's care plan dated 2/21/2024 which revealed the resident needed appropriate footwear and was ambulatory and could propel her wheelchair. This deficient practice could place residents at risk of inadequate care. Findings included: Record review of Resident #1's face sheet revealed resident was a [AGE] year-old female admitted to the facility 01/06/2023 with diagnoses that included: pulmonary embolism (a blood clot that traveled to the lung), stage 3 chronic kidney disease, dementia without behaviors, and protein-calorie malnutrition. During an interview on 4/18/2024 at 3:13:PM with the POA of Resident #1, stated Resident #1 stopped walking in December of 2022 around the week of Christmas. Record review of Resident #1's Annual MDS dated [DATE], the resident had a BIMS (Brief Interview of Mental Status) score of 99(resident was unable to complete the interview), she was coded for upper and lower extremity impairments, and mobility device was coded as a wheelchair. Record review of Resident #1's Care Plan dated 2/21/2024 revealed the resident was at risk for falls with the interventions that included appropriate footwear for locomotion in wheelchair and ambulation in the halls. Record review of Resident #1's Care Plan dated 2/21/2024 revealed the resident was care planned for limited physical mobility with interventions that stated resident was totally dependent on staff for ambulation/locomotion, she was dependent on staff for bed mobility with 2 person assistance; all transfers using a lift. Record review of Resident #1's physician orders revealed the resident was admitted to hospice on 10/28/2023 with the diagnosis of senile degeneration of the brain. During observation on 4/12/2024 at 9:05AM Resident #1 was in bed laying on her right side. The bed was at a safe height and a fall mat was in place adjacent to the bed. She was contracted in fetal (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 3 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 04/12/2024 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)