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
interview and record review, the facility failed to ensure a comprehensive care plan must be reviewed and
revised by the interdisciplinary team after each assessment, including both the comprehensive and
quarterly review assessments for 1 of 24 residents (Resident #60) reviewed for care plans, in that:
The facility failed to update Resident #60's care plan after the resident's physician discontinued the
resident's order for CBD 2.5 mg : THC 2.5 mg gummies.
This deficient practice could cause confusion for staff members responsible for medication administration
and place residents at risk of receiving improper care.
The findings were:
Record review of Resident #60's face sheet, dated 11/13/2023, revealed the resident was a [AGE] year old
male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including: normal pressure
hydrocephalus (when cerebrospinal fluid builds up inside the skull and presses on the brain), cirrhosis of
liver (a degenerative disease of the liver resulting in scarring and liver failure), and seizures.
Record review of Resident #60's quarterly MDS, dated [DATE], revealed a BIMS score of 00 which
indicated severe cognitive deficit.
Record review of Resident #60's MDS history in his electronic medical record revealed the following: A
quarterly MDS dated [DATE], a quarterly MDS dated [DATE], and a 5-Day MDS dated [DATE].
Record review of Resident #60's care plan, revised 08/17/1023, revealed, [Resident #60] uses Gummies 1
CBD 2.5 mg : 1 THC 2.5 mg r/t Anxiety disorder. Date Initiated: 04/17/2023.
Record review of Resident #60's physician orders revealed an order for: Gummies 1 CBD 2.5 mg : 1 THC
2.5 mg, give 1 gummy at bedtime. Order date: 04/10/2023, Start date: 04/11/2023. Further record review of
Resident #60's physician orders revealed the order was discontinued on 05/02/2023.
Record review of Resident #60's TARs for the months of April 2023 and May 2023 revealed the resident
received the CBD : THC gummies as ordered.
During an interview with the DON on 11/14/2023 at 12:05 p.m., the DON stated the resident's order was
started and stopped several times at the request of the resident's responsible party and finally
(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:
676297
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
676297
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/15/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Rio at Mission Trails
6211 S New Braunfels Ave
San Antonio, TX 78223
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)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
discontinued by the resident's physician on 05/02/2023. The DON further stated Resident #60's care plan
did not accurately reflect the resident's order status and should have been updated to remove the focus
area of the resident's use of the CBD : THC gummies. The DON acknowledged some resident care plans
had not been properly updated and they were in the process of trying to hire another MDS staff member.
During an interview on 11/15/2023 at 2:50 p.m. with the MDS LVN, she stated she was initially responsible
for updating the care plans for the skilled residents and had a partner who was responsible for updating the
care plans for the long-term residents. Her partner left her position approximately one month prior and she
was now responsible for updating all care plans. The MDS LVN further acknowledged the focus area of
Resident #60's use of the CBD : THC gummies should have been removed months ago; her former partner
missed removing the entry after the two quarterly MDS assessments and she missed removing the entry
after the recent 5-Day assessment, claiming the error was an oversight.
Review of facility policy GP MC 03-18.0, Comprehensive Care Planning, undated, revealed, The resident's
care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS
assessment, and revised based on changing goals, preferences and needs of the resident and in response
to current interventions.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676297
If continuation sheet
Page 2 of 2
