Health inspection·March 22, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to promote and maintain the residents' right to be treated with respect and dignity for 2 of 8 residents (Residents #2 and #3) reviewed for dignity and respect, in that: 1. The facility failed to provide Resident #2 assistance with eating his 03/21/24 lunch service for at least 10 minutes while he was waiting with food that was in front of him and other residents were able to eat. 2. The facility failed to allow Resident #3 to receive her food preferences and Resident #3 felt upset because she was not being heard or accommodated by the facility. This deficient practice could place residents at risk of psychosocial harm due to diminished self-image and could place residents needing assistance at risk for diminished quality of life, loss of dignity, and self-worth. The findings included: 1. Record review of Resident #2's admission record revealed an admission date of 02/23/2024 with diagnoses which included unspecified lack of coordination and muscle weakness. Record review of Resident #2's annual MDS assessment dated [DATE] revealed Resident #2 had a BIMS of 08 out of 15 indicating moderate mental cognition impairment. Record review of Resident #2's care plan, undated, revealed, [Resident #2] ADL self-performance deficit with an intervention of EATING: The resident requires assistance to eat, initiated 02/25/24. And [Resident #2] has a nutritional problem r/t DM 2 with an intervention to include Monitor and report to MD as needed for any s/s of: decreased appetite, N/V, unexpected weight loss, c/o stomach pain ., initiated 02/25/2024. During an observation and interview from 1:02 PM to 1:12 PM on 03/21/24, Resident #2 had his lunch meal tray in front of him without being touched by him. He stated he needed someone to fed him because he cannot feed himself. He further revealed he was hungry and has been waiting. No observation of when the lunch meal tray was placed in front of him, but the first time his lunch meal tray was noted to be in front of Resident #2, untouched, was at 1:02 PM . Observation at 1:12 PM revealed staff assisting Resident #2 with his meal. Page 1 of 7 676331 676331 03/22/2024 Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224

F 0550 Level of Harm - Minimal harm or potential for actual harm During an interview on 03/21/24 at 3:15 PM, Resident #2 stated that he waited for someone to come feed him for 15 minutes. He was hungry and was upset that he wanted to eat but needed to wait for someone to help feed him. He revealed that staff members (couldn't identify who) say that he can feed himself. Resident revealed that he wouldn't eat in the dining room or ask for help if he didn't need help. He revealed the last time he tried to feed himself, he got dirty from the foods. Residents Affected - Few During an interview on 03/21/24 at 4:11 PM, the DON revealed she was unaware if Resident #2 needed help being fed. The DON stated reading care plans would need to be reviewed. During an interview and record review on 03/22/24 at 9:10 AM, SLP A revealed she evaluated Resident #2 in February 2024 because Resident #2 reported an issue with his shoulder and could not feed himself. SLP A assessed Resident #2, reflected on 02/24/24 Speech Therapy Evaluation and Plan of Treatment, and found that Resident #2 needed someone to physically feed Resident #2. During an interview on 03/22/24 at 9:35 AM, Director of Rehab (DOR), revealed Resident #2 did need assistance with eating. She further revealed staff were good about sitting down next to resident physically feeding Resident #2 right after the tray was set in front of him. She further revealed this should be the procedure to follow. 2. Record review of Resident #3's admission record revealed an admission date of 08/24/2022 with diagnoses which included cognitive communication deficit (difficulty with communication). Record review of Resident #3's annual MDS assessment dated [DATE] revealed Resident #3 had a BIMS of 15 out of 15 indicating intact cognition. Record review of Resident #3's care plan, undated, revealed, [Resident #3] is at risk for impaired nutrition [related to] variable PO intake, obesity, and comorbidities: with an intervention to include Monitor and report to MD as needed for any s/s of: decreased appetite, N/V, unexpected weight loss, c/o stomach pain ., initiated 09/03/2022. During an observation and interview on 03/22/24 at 1:00 PM, Resident #3 had grill cheese sandwich with potato chips on her 03/22/24 lunch meal tray ticket. However, when her lunch meal came to her room, there were tater tots instead of potato chips. Resident #3 revealed this made her feel bad because she would look forward to food and then not receive the foods she ordered. During an interview on 03/22/24 at 1:44 PM, the Dietary Supervisor revealed potato chips were offered today, however, they ran out of potato chips and had to give tater tots instead. He further revealed it was important to follow residents' preferences to keep them feeling happy and obliging to them in their home. He also revealed it was important for residents to be fed appropriately and encourage intake, so they receive the appropriate nutritional value from the foods, and they did not decline. Record Review of the facility's policy Resident Rights, undated, reflected, Our residents have certain rights and protections under federal and state law that help ensure they receive the care and services necessary. One essential job function is to protect and promote our residents' rights. 1. Be treated with respect and dignity. There was no policy on following meal tray tickets provided prior to exit. 676331 Page 2 of 7 676331 03/22/2024 Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224

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 observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 8 residents (Resident #1 and #5) reviewed for care plans. The facility failed to care plan Residents #1 and #5 allergies to lactose. This failure could have placed residents at risk of not having their needs identified and met. The findings included: 1. Record review of Resident #1's admission record revealed an admission date of 02/08/2024 with diagnoses which included gastrointestinal hemorrhage (gastrointestinal bleeding) and gastro-esophageal reflux disease with esophagitis (stomach acid repeatedly flows back into the tube connecting your mouth and stomach). Record review of Resident #1's annual MDS assessment dated [DATE] revealed Resident #1 had a BIMS of 05 out of 15 indicating severe mental cognition impairment. Record Review of Resident #1's care plan and admission record revealed no mention of a Lactose Allergy. Record Review of Resident #1's weight history reflected no weight loss since admission. 2. Record review of Resident #5's admission record revealed an admission date of 05/19/2022 with diagnoses which included moderate protein calorie malnutrition. Record review of Resident #5's annual MDS assessment dated [DATE] revealed Resident #2 had a BIMS of 00 out of 15 indicating severe mental cognition impairment. Record Review of Resident #5's care plan and admission record revealed no mention of a Lactose Allergy. Record Review of Resident #5's weight history reflected no weight loss for approximately 2 years. Record Review of Resident #1's 03/21/24 breakfast meal tray ticket reflected ALLERGY LACTOSE. Record Review of Resident #5's 03/21/24 lunch meal tray ticket reflected ALLERGY LACTOSE. During an interview on 03/21/24 at 04:11 PM, the DON revealed she was not aware if allergies should be listed on care plans. and she would speak with MDS Coordinators to check. During an interview 03/21/24 at 06:16 PM, MDS Coordinator B and MDS Coordinator C revealed dietary allergies needed to be care planned and on the residents' admission record for proper patient care. They further revealed an allergic reaction could occur. 676331 Page 3 of 7 676331 03/22/2024 Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 03/22/24 at 11:12 AM, CNA/MA D revealed when she was providing care to residents, she looked at the admission Record and allergies should be listed in the allergy category so she did not give anything to the resident that they could be allergic to. She further revealed it was important to be aware of allergies to avoid negative reactions. Record review of the facility's policy Menu Planning, dated 2013, reflected, Significant information pertaining to individual's diets and response to the diets are recorded in the medical record. Record review of the facility's policy Comprehensive Person-Centered Care Planning, revised 08/2017, reflected, The baseline care plan will include minimum healthcare information necessary to properly care for a resident including, but not limited to: b) Physician orders, c) Dietary orders . 676331 Page 4 of 7 676331 03/22/2024 Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224

F 0803 Level of Harm - Potential for minimal harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure the menu was followed for 1 of 3 meals observed in that: Residents Affected - Many The lunch meal for 03/21/24 included mushrooms in a Chicken Enchilada Casserole that was not called for in this recipe. This failure could affect residents by contributing to dissatisfaction, poor intake, and weight loss. The findings included: Record Review of the recipe for Chicken Enchilada Casserole did not include mushrooms in it's list of Ingredients. Record Review of the facility's menu on 03/21/24 revealed lunch was to include Chicken Quesadilla casserole. During observation and interview on 03/21/24 at 01:30 PM of lunch meal revealed the Chicken Enchilada Casserole had mushrooms in it. The Dietary Supervisor confirmed 03/21/24 included Chicken Enchilada Casserole. During an interview on 03/22/24 at 01:44 PM, the Dietary Supervisor revealed he would sometimes not follow the recipes to make the foods elevated. He also revealed it was important for residents to be fed appropriately and encourage intake, so they receive the appropriate nutritional value from the foods, and they did not decline. Record review of the facility's policy Menu revised 09/2017, reflected, If any meal served varies from the planned menu, the change and the reason for the change are noted on the posted menu in the kitchen and/or in the record book used solely for recording such changes. 676331 Page 5 of 7 676331 03/22/2024 Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that each resident received and the facility provided food that accommodated resident allergies, intolerances, and preferences for 2 of 2 residents (Resident #1 and #4) reviewed for dietary services, in that: 1. The facility failed to ensure that Resident #1's breakfast meal on 03/21/24 did not include any products with lactose as was read on her meal tray ticket. 2. The facility failed to ensure that Resident #4's lunch meal on 03/21/24 did not include mixed vegetables as was reflected on his lunch meal tray ticket. This deficient practice could affect residents with preferences/dislikes, and place them at-risk by contributing to poor intake and/or weight loss. The findings included: 1. Record review of Resident #1's admission record revealed an admission date of 02/08/2024 with diagnoses which included gastrointestinal hemorrhage (gastrointestinal bleeding) and gastro-esophageal reflux disease with esophagitis (stomach acid repeatedly flows back into the tube connecting your mouth and stomach). Record review of Resident #1's annual MDS assessment dated [DATE] revealed Resident #1 had a BIMS of 05 out of 15 indicating severe mental cognition impairment. Record Review of Resident #1's care plan and admission record revealed no mention of a Lactose Allergy. Record Review of Resident #1's nursing progress note, authored by RN E, on 03/21/2024 at 09:27 AM read, f/u with resident, pt consumed 1% milk and is lactose intolerant. No adverse reactions noted at this time. Pt states she is feeling well. Will continue to monitor Pt through out my shift and report to oncoming nurses. Record Review of Resident #1's weight history reflected no weight loss since admission. During an interview and observation on 03/21/24 at 08:51 AM, the Resident Care Coordinator confirmed Resident #1 was served 1% low fat milk and she should have not been served the milk. Resident #1's diet on her 03/21/24 breakfast meal tray ticket reflected DIET: MS (Mechanical Soft), NAS (No Added Salt), ALLERGY LACTOSE. Food Likes listed: LACTOSE FREE MILK with Food Dislikes: DAIRY PRODUCTS. During an interview on 03/21/2024 at 10:30 AM, the Dietary Supervisor revealed Resident #1 had sausage with gravy on her 03/21/2024 breakfast tray. He was unaware if the gravy had any dairy products in it as Resident #1 was not allowed to have dairy products at mealtime. Attempted interview of Resident #1 for 03/21/2024 lunch service with no success. During an observation on 03/21/24 at 11:03 AM, the package of gravy that was served for 03/21/24 676331 Page 6 of 7 676331 03/22/2024 Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few breakfast meal tray reflected ingredients that included dairy such as nonfat milk, whey (milk), whey protein concentrate (milk), and sodium caseinate (milk). Further observation of the gravy package reflected notation of CONTAINS: WHEAT, MILK, SOY. During an interview on 03/21/24 at 04:11 PM, the DON revealed the nursing staff was following Resident #1 for any adverse effects related to consuming food products with lactose as Resident #1 had an allergy to Lactose. 2. Record review of Resident #4's admission record revealed an admission date of 09/29/2022 with diagnoses which included protein calorie malnutrition. Record review of Resident #4's annual MDS assessment dated [DATE] revealed Resident #4 had a BIMS of 12 out of 15 indicating intact cognition. Record Review of Resident #4's care plan revealed [Resident #4] has a potential nutritional problem . with an intervention of Monitor and report to MD as needed for any s/s of: decreased appetite, N/V, unexpected weight loss, c/o stomach pain . Record Review of Resident #4's weight history reflected relatively stable weight for 9 months, except when due to an amputation. During observation and interview on 03/21/24 at 05:55 PM, Resident #4's 03/21/24 supper meal tray ticket reflected Food Dislikes: MIX VEGETABLES. Resident #4 confirmed he received mixed vegetables and did not like these. The Dietary Supervisor came by and offered Resident #4 a substitute, but Resident #4 declined. During an interview on 03/22/24 at 01:44 PM, the Dietary Supervisor revealed he would sometimes not follow the recipes to make the foods elevated. He stated when he did this, he did pay attention to likes and dislikes. He further revealed it was important to follow residents' preferences to keep them feeling happy and obliging to them in their home. He also revealed it was important for residents to be fed appropriately and encourage intake, so they receive the appropriate nutritional value from the foods, and they did not decline. 676331 Page 7 of 7