Health inspection·August 8, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop and implement a care plan to meet the resident's needs for 1 of 3 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan accurately documented the resident's need for supervision when actively eating/drinking. These failures could place residents at risk of their needs not being met. The findings include: Record review of Resident #1 's face sheet, dated 8/6/25, reflected an [AGE] year-old male who was admitted to the facility on [DATE] and discharged to hospital on 7/12/25. Resident #1 had diagnoses which included: heart failure, acute respiratory failure, prostate cancer, pacemaker, Bell's Palsy (dripping of the face), dementia (decline in mental ability), anxiety (a feeling of unease), lack of coordination, and dysphasia (difficulties swallowing). The RP was listed as: family member. Record review of Resident#1's quarterly MDS, dated [DATE], reflected a BIMS score of 03, indicative of severe impairment in cognition. The ADLs for eating was documented as independent and support was set-up. Record review of Resident# 1's Care Plan, dated 2/17/25, reflected the goals and interventions included: Eating as Set up assistance. Record review of Resident#1's Physician' Orders, dated July 2025 reflected: Diet was listed as controlled carb diet; soft and bite texture, Nectar/Mildly Tick consistency. The physician order, revised 11/12/24, reflected the resident required standard swallowing precautions: and Supervision and assistance with positioning and set up of meal tray every shift. Record review of Resident #1's SP evaluation, dated 1/16/24, authored by the SP, read: .Oral Phase=Mild. [mildly impaired to chew and managing food in month]. Record review of Resident #1's SP evaluation, dated 2/19/25, authored by the SP, read: .Supervision for Oral Intake=Distant Supervision. During an interview on 8/6/25 at 10:11 AM, the SP stated: she saw the resident several times and the resident had difficulties with swallowing. The SP evaluation on 01/16/24 reflected a mild oral dysphasia to effectively manage food in his mouth. The SP stated the last evaluation on swallowing was done on 2/19/25 and the findings demonstrated the resident [#1] had mild oral and pharyngeal (second stage of swallowing) and no overt signs of aspiration. The SP stated the resident required close supervision in feeding; distant supervision. The SP defined distant supervision as a staff member being present or within eyesight when feeding or drinking occurred by the resident. The SP stated based on the SP findings after 2/19/25, a staff should not lose eyesight of the resident when the activity of eating or drinking occurred. During an interview on 8/6/25 at 3:44 PM, the Dietician stated: the resident was on a diabetic diet (controlled carbs), soft bite texture, and nectar mildly thicken. The Dietician stated the resident required supervision for eating. The Dietician stated supervision meant the staff had to be in proximity when Resident #1 ate for safety reasons. During an interview on 8/6/25 at 5:10 PM, the DON stated: the process of accurate clinical documentation started with assessments and then completion of the care plan. The DON stated the SP assessment, dated 2/19/25, that Resident#1 required distant supervision and the physician order stated the (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: 676041 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 676041 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mission at Blue Skies of Texas East 4949 Ravenswood Dr San Antonio, TX 78227 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)