Health inspection·March 17, 2025

F 0583 Keep residents' personal and medical records private and confidential. 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 protect the confidentiality of personal and medical records for 14 (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15) of 14 residents and involving one (LPN A) of six staff observed for confidentiality of records. Residents Affected - Some The facility failed to ensure LPN A would not leave a Vital Signs Flow Sheet Report on a 200-East Hall medication cart exposing 200-East Hall residents' personal information. This failure could affect residents by placing them at risk for loss of privacy and dignity. The findings included: During an observation on 200-East Hall on 03/13/2025 at 09:18 a.m., revealed an unattended and visible Vital Signs Floor Sheet Report, dated 03/13/2025 for shift 6A-6P (06:00 a.m. to 06:00 p.m.). The staff identified on the document was LPN A, CNA B for 06:00 a.m. to 12:00 p.m., and CNA C for 12:00 p.m. to 06:00 p.m. The document was observed facing up on an unattended, locked medication cart half-way down 200-East Hall. The document displayed 14 resident's names with their assigned room numbers (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15 residing in rooms from 201 to 215) and included information such as: blood pressures, pulses, respirations, oxygen saturations, temperatures, if continent or incontinent, and identified two residents on dialysis with their appointment time. Resident #2 and Resident #8, were listed on the report. Staff, residents, and facility guests were not observed standing or walking down the 200-East hall near the medication cart the time of observation. During an interview on 03/13/2025 at 05:41 p.m., LPN A revealed medication aides were responsible for taking the residents' vital signs. She stated the medication aides would give her a copy of their vital signs document and keep a second copy for their use when they enter the information into the computer. She stated the vital signs document should not be in view of everyone. During an interview on 03/14/2025 at 02:19 p.m., ACNO D revealed her expectation was that no personal protected information would be visible to anyone passing by on the facility halls. She stated that personal protected information was each resident's personal information and other people should not have access to their information. During an interview on 03/17/2025 at 10:07 a.m., ACNO E revealed she asked the facility staff to Page 1 of 15 676447 676447 03/17/2025 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

F 0583 Level of Harm - Minimal harm or potential for actual harm carry a blank sheet to put over their vitals report or to carry the report in their pocket. She revealed a vital report having been visible would be a HIPAA violation. Record review of Resident #2's admission Record, dated 03/13/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Residents Affected - Some Record review of Resident #2's progress note, titled CSC- BIMS Evaluation, dated 03/05/2025 at 11:01 a.m., reflected Resident #2 had a BIMS score of 4.0, which indicated he was severely cognitively impaired. During an interview on 03/17/2025 at 10:50 a.m., Resident #2 stated, I don't know what that is when asked how he felt about his blood pressure, pulse, and room number being visible on a document on the facility hall. Record review of Resident #8's admission Record, dated 03/17/2025, reflected a [AGE] year-old female. She was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #8's admission MDS, signed as completed on 03/10/2025 by the RN Assessment Coordinator, reflected Resident #8 had a BIMS score of 14.0, which indicated she was cognitively intact. During an interview on 03/17/2025 at 11:02 a.m., Resident #8 stated, I don't like everyone to know my information when asked how she felt about her blood pressure, pulse, and room number being visible on a document on the facility hall. During an interview on 03/17/2025 at 02:26 p.m., the CNO revealed she expected staff to keep the vitals report in binders. She revealed a vital report included patient health information that should remain confidential. Record review of facility policy, Medical Records, dated as last revised 05/2023, reflected, Purpose: To establish guidelines for the contents, maintenance, and confidentiality of patient Medical Records that meet the requirements set forth in Federal and State laws and regulations, and to define the portion of an individual's healthcare information, whether in paper or electronic format, that comprises the medical/dental record. Under Procedure, the policy included Ensuring the privacy of protected health information (PHI) by logging out of laptops when not in use or keeping paperwork concealed and Each resident's protected health record will be filed, stored, restricted from public access . 676447 Page 2 of 15 676447 03/17/2025 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of care within 48 hours of a resident's admission for three (Resident #1, Resident #2, and Resident #3) of four residents reviewed for baseline care plans. The facility failed to complete a baseline care plan within 48 hours of admission that addressed the services that were being provided for Resident #1, Resident #2, and Resident #3. This failure could place newly admitted residents at risk for not receiving the care, services, and continuity of care to meet their needs. Findings included: Record review of Resident #1's admission Record, dated 03/13/2025, reflected a [AGE] year-old female. She was admitted to the facility on [DATE] and discharged on 03/10/2025 to an acute care hospital. Record review of Resident #1's Medical Diagnosis EMR tab, undated and accessed on 03/12/2025, reflected Resident #1 had diagnoses which included syncope (fainting) and collapse, unspecified fall, and hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness of one side of the body). Record review of Resident #1's progress note, titled Nursing Evaluation (Admit,Readmit,Qtly,Annual Sig Change) [sic], dated 03/03/2025 at 03:13 p.m., reflected Resident #1 had severely impaired vision, was dependent on device for mobility, independent for fluid intake during meals, incontinent of bowel and bladder, could not demonstrate fine motor skill, could not safely transfer self with minimal assistance, and could not bear weight through at least one lower extremity. Record review of Resident #1's Initial/Baseline Care Plan, dated and locked 03/04/2025, reflected no selections for functional abilities- self-care, no selections for functional abilities- mobility, no selections for activities of daily living focuses with goals or interventions, and no selectins for mobility devices. Record review of Resident #1's admission MDS, signed as completed on 03/12/2025 by the RN Assessment Coordinator, reflected Resident #1 had a BIMS score of 06, which indicated she was moderately cognitively impaired. She was documented as needed some help for self-care with requiring supervision or touching assistance for eating and oral hygiene, substantial/maximal assistance with toileting hygiene and lower body dressing, partial/moderate assistance with walking 10 feet, and dependent for walking 50 feet with two turns and 150 feet. She was documented as occasionally incontinent of urine and frequently incontinent of bowel. Record review of Resident #1's Care Plan, undated and accessed on 03/14/2025, reflected all care planned focuses, goals, and interventions initiated on 03/12/2025. Record review of Resident #2's admission Record, dated 03/13/2025, reflected a [AGE] year-old male. 676447 Page 3 of 15 676447 03/17/2025 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

F 0655 He was admitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #2's Medical Diagnosis EMR tab, undated and accessed on 03/13/2025, reflected Resident #2 had diagnoses which included encounter for surgical aftercare following surgery on the digestive system, pneumonia (a lung infection), and schizophrenia (a chronic mental illness characterized by delusions, hallucinations, and disordered thinking). Residents Affected - Some Record review of Resident #2's Nurse-to-Nurse Report Sheet, dated 03/04/2025 at 09:53 p.m. by LPN F, reflected LPN F received report on Resident #2 by a hospital nurse prior to his transfer to the facility. The report included under Weight bearing Status, Resident #2 was bedbound and required two-person assist for all care needs. Incontinent of Urine and Stool were both noted to be highlighted on the report sheet. Record review of Resident #2's progress note, titled Nursing Evaluation (Admit,Readmit,Qtly,Annual Sig Change) [sic], dated 03/05/2025 at 09:50 a.m., reflected Resident #2 was bed bound, required extensive physical assistance for fluids, incontinent of bowel and bladder, could not demonstrate fine motor skill, could not safely transfer self with minimal assistance, and could not bear weight through at least one lower extremity and have good trunk control. Record review of Resident #2's Initial/Baseline Care Plan, dated and locked 03/05/2025, reflected no selections for functional abilities- self-care, no selections for functional abilities- mobility, no selections for activities of daily living focuses with goals or interventions, and no selectins for mobility devices. Record review of Resident #2's Entry MDS, signed as completed on 03/05/2025, did not include information regarding Resident #2's self-care and mobility needs. Record review of Resident #3's admission Record, dated 03/17/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Record review of Resident #3's Medical Diagnosis EMR tab, undated and accessed on 03/17/2025, reflected Resident #3 had diagnoses which included encounter for other orthopedic aftercare (care provided after a corrective or preventative treatment on deformities, disorders, or injuries of the bones or muscles), spinal stenosis (a condition where the spinal column narrows and compresses the spinal cord), and muscle wasting and atrophy (a shrinking of muscle or nerve tissue). Record review of Resident #3's progress note, titled Nursing Evaluation (Admit,Readmit,Qtly,Annual Sig Change) [sic], dated 02/25/2025 at 05:50 p.m., reflected Resident #3 had no nutritional risks, was dependent on device for mobility, continent of bowel and bladder, had a condom catheter, could not demonstrate fine motor skill, could not safely transfer self with minimal assistance, and could bear weight through at least one lower extremity and have good trunk control. Record review of Resident #3's Initial /Baseline Care Plan, dated and locked 02/26/2025, reflected no selections for functional abilities- self-care, no selections for functional abilities- mobility, no selections for activities of daily living focuses with goals or interventions, and no selectins for mobility devices. Record review of Resident #3's admission MDS, signed as completed on 03/03/2025 by the RN Assessment Coordinator, reflected Resident #3 had a BIMS score of 10, which indicated he was mildly 676447 Page 4 of 15 676447 03/17/2025 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cognitively impaired. He was documented as having upper extremity impairment on both sides, had used a walker and wheelchair in the last 7 days, needed supervision or touching assistance for eating and oral hygiene, substantial/maximal assistance with toileting hygiene and lower body dressing, and dependent for walking all distances. He was documented as occasionally incontinent of urine and bowel. Record review of Resident #3's Care Plan, undated and accessed on 03/14/2025, reflected the following focuses and interventions: - Focus: The resident has impaired visual function., date initiated 02/26/2025 with Intervention: Keep call light and other key items within reach., date initiated 02/26/2025. - Focus: The resident has difficulty hearing at times., date initiated 02/26/2025 with Intervention: Face guest when speaking to them., date initiated 02/26/2025. - Focus: The resident is incontinent., date initiated 02/26/2025 with Interventions initiated on 02/26/2025: - BRIEF USE: the resident uses disposable briefs. Change as needed, - Clean peri-area with each incontinence episode., - INCONTINENT: Check every 2-3 and as needed for incontinence. Wash, rinse and dry perineum (area of skin between the genitals and the anus). Change clothing PRN after incontinence episodes., and - SKIN: Provide skin care with each incontinent episode. - Focus: The resident is at risk for falls., date initiated 02/26/2025 with Interventions initiated on 02/26/2025: - Anticipate and meet the resident's needs., - Ensure bed brakes are locked, and - Review information on past falls and attempt to determine cause of falls . - Focus: The resident has had an actual fall on 2/25/25 r/t Poor Balance, was assisted and witnessed by staff, date initiated 02/27/2025 with Interventions initiated on 02/27/2025 including: - Ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to al requests for assistance. and - PT consult for strength and mobility. - Focus: The resident has bowel incontinence., date initiated 02/26/2025 with Interventions initiated on 02/26/2025: - Check resident every two hours and assist with toileting as needed, 676447 Page 5 of 15 676447 03/17/2025 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

F 0655 - Provide pericare after each incontinent episode, Level of Harm - Minimal harm or potential for actual harm - Provide resident with adequate time to eliminate to minimize incontinent episodes, and - SKIN: Provide skin care with each incontinent episode. Residents Affected - Some The Care Plan did not include an additional focus or interventions for ADL transfer and mobility needs. During an interview on 03/13/2025 at 05:33 p.m., RN G stated the baseline care plan was based off the initial nursing assessment with input from the dietary and therapy department. He stated the ADLs are first and must absolutely be part of the baseline care plan. He stated the initial nursing assessment was done by the direct care nurse, but they did not complete the baseline care plan. He stated he believed it was the admission nurse's duty to complete the baseline care plan. During an interview on 03/13/2025 at 05:41 p.m., LPN A revealed the direct care nurses did not complete the admissions documents for new residents. She stated the direct care nurses would receive a nurse-to-nurse document and usually a verbal report from the admissions nurse regarding new resident's ADL needs. During an interview on 03/13/2025 at 05:55 p.m., RN H stated the baseline care plan was completed by the admissions nurse. During an interview on 03/14/2025 at 01:49 p.m., CNA B revealed for new residents she would not receive a report on the new resident's ADL needs from a nurse or be provided any documentation. She stated that the nurse would receive a report, but she would typically have to ask the resident directly and learn about the resident's needs through observation. She stated if she did receive any type of report, it would come from the CNA leaving from the prior shift; however, she stated that the prior shift CNA would typically be gone or leaving at the time of her arrival for her shift, and they would not do a shift-to-shift report. During an interview on 03/14/2025 at 02:56 p.m., LPN I revealed for new residents, the direct care nurses would receive a nurse-to-nurse document and then provide a verbal report to the next nurse coming on shift. She stated oncoming nurses would also have the nursing assessment reports, which would include documentation on the resident's needs. During an interview on 03/14/2025 at 04:06 p.m., the DOR revealed the facility had therapy staff present seven days a week and new resident evaluations were generally done on the same day of admission, but always completed 24-48 hours from admission. She stated for initial communication of resident ADL needs, the nurses would receive a nurse-to-nurse report; however, once the therapy department assessed the resident, the therapy department would typically provide a verbal report to the direct care nursing staff of the resident's safe transfer needs and any restrictions. She stated the direct care staff had access to the therapy evaluations in the EMR for review. During an interview on 03/14/2025 at 04:37 p.m., LPN J revealed for new residents, she would know the resident's needs from the communication from the transferring hospital and through observing the resident. She stated some residents would be admitted with orders for feeding assistance and the nurse-to-nurse report may include a meal texture recommendation. She stated she could not recall any evaluations or documents available that showed a new resident's ADL needs, only the daily nurse notes 676447 Page 6 of 15 676447 03/17/2025 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

F 0655 on their observations of the resident during their shift. Level of Harm - Minimal harm or potential for actual harm During an interview on 03/14/2025 at 05:11 p.m., LPN F revealed for her part of the baseline care plan, she would receive a detailed report from the transferring hospital for continuation of care and upload the nurse-to-nurse report to the new resident's chart. She stated following that step, the direct care nurse would initiate a nurse admission assessment and one of the facility RNs, typically the CNO or RN E would open a baseline care plan. She stated that once she completed the nurse-to-nurse report and the medication reconciliation and the direct-care nurse completed the head-to-toe assessment, the RN would initiate the care plan with the information from those documents and may ask clarifying questions if needed. She stated she would give a physical copy of the nurse-to-nurse report to the direct care staff. She stated that if direct care staff did not have consistent knowledge of a resident's ADL needs, it would impact the resident greatly because their care would be inconsistent. Residents Affected - Some During an interview on 03/17/2025 at 02:26 p.m., the CNO revealed baseline care plans were done within 72 hours of admission. She stated that the baseline care plan needed to be initiated by herself or a facility RN. She stated that she would try to go through the baseline care plans to make sure they were as accurate as possible, including capturing any changes in the resident's care. She revealed the baseline care plan would have any information that the facility had captured for the resident, including generally having the initial therapy evaluations. She stated it might include if the resident required a Hoyer transfer, needed feeding assistance, or the resident's ability to walk. She stated the baseline care plan would include whatever information the facility knew about the resident. She stated ADL needs were communicated to direct-care staff verbally, on the nurse-to-nurse report sheet, and during CNA-to-CNA walking rounds. She stated the CNAs going off shift were supposed to do a verbal report and walking round with the CNAs coming on shift prior to leaving. She stated that if there were any changes in the resident's status or needs, the ACNO would let their staff know. She revealed that if the direct care staff's knowledge of a resident's needs were inconsistent, it could cause harm. Record review of facility policy, Care Plan, dated as last revised 04/2024, reflected, POLICY: 1. A baseline care plan is developed for each resident upon admission, but no later than 48 hours of admission, to the facility. This care plan includes minimum health care information necessary to properly care for the resident. 2. Required Components of the Baseline Care Plan a. Initial goals based on admission orders i. Services planned to attain or maintain resident's highest practical physical, mental, and psychosocial well-being including but not limited to: ADLs, Nutrition, Fall Risk, Skin Integrity and Pain Management b. Dietary Orders c. Therapy services . 676447 Page 7 of 15 676447 03/17/2025 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 ensure the residents received treatment and care in accordance with professional standards of practice for one (Resident #2) of four residents reviewed for physician orders for treatments. Residents Affected - Few The facility failed to follow physician orders and obtain Resident #2's weight during night shift every Tuesday per physician order schedule. This failure could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. The findings included: Record review of Resident #2's admission Record, dated 03/13/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Record review of Resident #2's Medical Diagnosis EMR tab, undated and accessed on 03/13/2025, reflected Resident #2 had diagnoses which included encounter for surgical aftercare following surgery on the digestive system, pneumonia (a lung infection), and schizophrenia (a chronic mental illness characterized by delusions, hallucinations, and disordered thinking). Record review of Resident #2's Entry MDS, signed as completed on 03/05/2025, did not include information regarding Resident #2's self-care and mobility needs. Record review of Resident #2's Care Plan, undated and accessed 03/13/2025, reflected the following focuses and interventions: - Focus: The resident has ADL self-care performance deficits and limitations in physical mobility. Activity Intolerance DX s/p ERCP, Dementia, date initiated 03/13/2025, with interventions, all initiated 03/13/2025 including: - -Eating: Supervision or touching assistance, - -Putting on/taking off footwear: Dependent, - -Chair/bed-to-chair transfer: Partial/moderate assistance, and - -Uses wheelchair. - Focus: Diet: Regular diet, pureed texture [sic] The resident has the potential for alterations in nutrition and hydration poor PO intake, cognitive deficits, date initiated 03/05/2025, with intervention Evaluate any weight changes. Determine percentage changed and follow facility protocol for weight change., date initiated 03/05/2025. Record review of Resident #2's Order Summary Report, dated as Active Orders as of: 03/13/2025, reflected: 676447 Page 8 of 15 676447 03/17/2025 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

F 0684 - Weights every night shift every Tue, order date 03/04/2025, start date 03/11/2025, and no end date. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #2's Treatment Administration Record, dated 03/01/2025 - 03/31/2025 and printed on 03/17/2025, reflected: Residents Affected - Few - Weights every night shift every Tue, order date 03/04/2025 at 10:55 p.m., had a blank space, without an entry for Wt and a chart code and staff identifier at NOC 1 for 03/11/2025. During an interview on 03/14/2025 at 02:19 p.m., ACNO D revealed the facility had residents with daily and weekly weights scheduled. She stated the residents in odd numbered rooms were scheduled to have their weights obtained by the night shift and the residents in even numbered rooms were scheduled to have their weights obtained by the day shift. She stated that if a weight was scheduled, it would pop up on the direct care nurse's and nurse aide's EMR. She stated that if a resident refused their weight to be taken, the staff should document that the resident refused. She stated that Resident #2 had a history of refusing a lot of things and it was likely that he refused his weight to be taken on Tuesday, 03/11/2025 and they should have tried to obtain it at a different time that day. She said that she wanted to say that the staff tried to obtain his weight three or four times, but she did not know if the staff documented that he refused. She stated the impact of the staff not obtaining his weight would be that his weight was not being tracked or monitored and then the staff would have no way of knowing if the resident had gained or lost weight over a course of time. She stated that the staff needed to document a refusal because it would show that they attempted to obtain a weight. During an interview on 03/14/2025 at 02:56 p.m., LPN I revealed she worked night shift, working from around 06:15 p.m. to 07:30 a.m. She revealed resident weights were obtained on Tuesdays for scheduled weekly weights. She stated that some residents are scheduled for weights during day shift and others on night shift. She stated she would often sit outside Resident #2's room and check on him every 10- 15 minutes during her night shift because he would often holler out at night and count out loud. She revealed that she did not recall if his weight was taken Tuesday night, 03/11/2025. She stated that if he had refused, the procedure was to document that he refused or that they were unable to obtain his weight. She stated if his weight was scheduled, it would have shown up on the Treatment Administration Record, but she did not remember if his did that night. She stated she worked Monday and Tuesday of that week, week of 03/11/2025. Record review of Resident #2's Weight Summary, undated and accessed on 03/17/2025, revealed Resident #2 was weighed on 03/14/2025 at 04:29 p.m. His weight history indicated a 7.4 pound or 4.4% weight loss in 9 days. Record review of Resident #2's progress note, titled *Health Status Note (nurses note), dated 03/14/2025 at 04:49 p.m., reflected Resident #2 was weighed. It noted Resident #2 was offered his supper tray, a shake, and an alternate meal and he refused. It noted Resident #2 stated he wanted to go back asleep. The note included that the dietitian was called and a new order for a dietary supplement was added to be given three times a day. During an interview on 03/17/2025 at 02:26 p.m., the CNO revealed scheduled weights were noted on the treatment sheet and on the EMR for the CNAs. She stated if a weight was not taken, the staff were to notify the managers and the managers would notify the doctor of the resident. She stated the resident's doctors typically wanted their residents weighed at least once a week and if the resident 676447 Page 9 of 15 676447 03/17/2025 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was refusing, the staff should document the refusal but try again to obtain the resident's weight for that week. She stated even if the weight was not taken on the scheduled day, the staff were to enter the weight on the day it was taken and ensure that the weekly weight was done. She stated that scheduled weights were to monitor for any significant changes. She stated Resident #2 was one of the residents that refused his weight to be taken on Tuesday, 03/11/2025. She stated staff tried to get him up again and he refused. She stated that the staff did eventually get his weight and she believed he had more shakes added to his orders. She stated that Resident #2 did not like to eat much, and his resident representative had reported he liked shakes. Record review of facility policy, Weight Policy, dated 11/2018, reflected, POLICY: 1. All residents will be weighed on admission, readmission, weekly for the first 4 weeks and then at least monthly. 2. Weekly weights will also be done with a significant change of condition, food intake decline that has persisted for more than one week, or with a physician order .4. Residents will be weighed using the same scale [sic] at the same time of day and in the same way each time they are weighed . 676447 Page 10 of 15 676447 03/17/2025 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 ensure the residents received treatment and care in accordance with professional standards of practice, to promote healing, prevent infection, and prevent new pressure ulcers from developing for one (Resident #2) of four residents reviewed for pressure ulcers. Residents Affected - Few In three observations over three days, the facility failed to follow physician orders and apply Prevelon boots (cushioned boots, also known as heel protectors, designed to lift the heel off the bed and help prevent heel pressure injures and provide pressure relief) as ordered for Resident #2. This failure could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. The findings included: Record review of Resident #2's admission Record, dated 03/13/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Record review of Resident #2's Medical Diagnosis EMR tab, undated and accessed on 03/13/2025, reflected Resident #2 had diagnoses which included encounter for surgical aftercare following surgery on the digestive system, pneumonia (a lung infection), and schizophrenia (a chronic mental illness characterized by delusions, hallucinations, and disordered thinking). Record review of Resident #2's Entry MDS, signed as completed on 03/05/2025, did not include information regarding Resident #2's self-care and mobility needs. Record review of Resident #2's Care Plan, undated and accessed 03/13/2025, reflected the following focuses and interventions: - Focus: The resident has ADL self-care performance deficits and limitations in physical mobility. Activity Intolerance DX s/p ERCP, Dementia, date initiated 03/13/2025, with interventions, all initiated 03/13/2025 including: - -Eating: Supervision or touching assistance, - -Putting on/taking off footwear: Dependent, - -Chair/bed-to-chair transfer: Partial/moderate assistance, and - -Uses wheelchair. - Focus: The resident has actual impairment to skin integrity r/t Pressure ulcer [sic] Left Heel ., date initiated 03/12/2025, with intervention Evaluate and treat per physician orders., date initiated 03/12/2025. Record review of Resident #2's Order Summary Report, dated as Active Orders as of: 03/13/2025, 676447 Page 11 of 15 676447 03/17/2025 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

F 0686 reflected: Level of Harm - Minimal harm or potential for actual harm - Prevalon [sic] boots WHILE IN BED OR SITTING IN CHAIR every day and night shift, order date and start date 03/06/2025 with no end date. Residents Affected - Few Record review of Resident #2's Treatment Administration Record, dated 03/01/2025 - 03/31/2025 and printed on 03/17/2025, reflected: - Prevalon [sic] boots WHILE IN BED OR SITTING IN CHAIR every day and night shift, order date and start date 03/06/2025 at 12:47 p.m., checked off at Day 0 time from 03/07/2025- 03/13/2025 and 03/15/2025 and at NOC 1 time from 03/06/2025- 03/08/2025 and 03/10/2025-03/16/2025. Day 0 for 03/14/2025 and 03/16/2025 were coded as 2, meaning Drug Refused per the chart code list. The space for NOC 1 on 03/09/2025 was blank, without a chart code and staff identifier. LPN A's initials were coded for the checked off dates 03/08/2025, 03/09/2025, and 03/13/2025 at Day 0 time. Record review of Resident #2's Initial Wound Evaluation & Management Summary document, dated 03/07/2025, reflected Resident #2 had a pressure wound on his left heel. It was sized 5.5 cm by 5.5 cm by not measurable with a surface area of 30.25 cm^2. It was staged as unstageable deep tissue injury with intact skin. It was noted to have been present on admission per staff report. Record review of Resident #2's Wound Evaluation & Management Summary document, dated 03/10/2025, reflected Resident #2 had a pressure wound on his left heel. It was sized 5.5 cm by 4.5 cm by not measurable with a surface area of 24.75 cm^2. It was staged as unstageable deep tissue injury with intact skin. The wound progress was noted to have improved as evidenced by decreased surface area. Record review of Resident #2's Wound Evaluation & Management Summary document, dated 03/17/2025, reflected Resident #2 had a pressure wound on his left heel. It was sized 5.0 cm by 3.8 cm by not measurable with a surface area of 19.00 cm^2. It was staged as unstageable deep tissue injury with intact skin. The wound progress was noted to have improved as evidenced by decreased surface area. During an observation on 03/13/2025 at 04:57 p.m., Resident #2 was observed lying in bed without Prevelon boots on his feet. During an observation on 03/14/2025 at 09:20 a.m., Resident #2 was observed sitting in a wheelchair next to the 2nd floor nursing station. He was observed to not have been wearing Prevelon boots. During an observation on 03/14/2025 at 11:37 a.m., Resident #2 was observed lying in bed without Prevelon boots on his feet. During an observation and interview on 03/17/2025 at 10:50 a.m., Resident #2 was observed lying in bed wearing Prevelon boots. Resident was observed asking LPN A to take the Prevelon boots off because they hurt. LPN A observed providing Resident #2 with education on their need to prevent further skin breakdown and encouraged him to allow her to keep them on him while he was in bed. He was observed to again ask for the Prevelon boots to be removed. Resident #2 stated when asked why he wanted the Prevelon boots off, I don't like them. During an interview on 03/17/2025 at 10:50 a.m., LPN A revealed today, 03/17/2025 was the first day Resident #2 received his Prevelon boots. She stated they were ordered previously, and they were waiting for them to arrive. 676447 Page 12 of 15 676447 03/17/2025 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 03/17/2025 at 02:26 p.m., the CNO revealed the facility had Prevelon boots in stock and there should not have been a delay in providing them to a resident. She stated Resident #2 does have a history of removing things and she was not made aware of the staff not having his Prevelon boots. She stated she did not know why Resident #2 did not have the Prevelon boots on. She stated the impact of him not having the boots on would depend on if he had any pressure points on his feet and if he did, it could cause pressure ulcers. Record review of facility policy, Foot Care, dated 07/2024, reflected, POLICY: This facility will ensure that all residents receive proper treatment and care to maintain mobility and good foot health by providing foot care and treatment in accordance with professional standards or practice including prevention of complications from a resident's medical condition including but not limited to: . and immobility affecting foot condition . 676447 Page 13 of 15 676447 03/17/2025 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record reviews, the facility failed to ensure all drugs and biologicals were stored in locked compartments for three (Cart 200-East Hall, Cart 200-West Hall, and Cart 300-West Hall) of six reviewed for drug storage. The facility failed to ensure medication carts, 200-East Hall and 200-West Hall on the second floor and 300-West Hall on the third floor were secured when unattended on 03/12/2025. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm, drug overdose, or drug diversion. Findings included: During an observation and interview on 03/12/2025 at 03:07 p.m., a medication cart on 200-West Hall was observed to be unlocked and unattended. Facility staff and residents were not observed around the unlocked medication cart. At 03:08 p.m., RN G was observed coming out of a resident room. RN G confirmed the medication cart was his and that the cart was unlocked. He stated he had just gone to quickly administer a Tylenol to one of his residents. He stated the medication drawers that were accessible included medications such as over the counter medications, stool softeners, insulin with insulin needles, thyroid medications, and lovenox injections (a blood thinner used to prevent and treat blood clotting). RN G stated the residents on his hall required assistance with ambulation and were not independently mobile. During an observation and interview on 03/13/2025 at 03:15 p.m., a medication cart on 300-West Hall was observed to be unlocked and unattended. Facility staff and residents were not observed around the unlocked medication cart. At 03:18 p.m., RN H was observed coming out of a resident room. RN H initially stated the medication was locked, then confirmed it was unlocked after checking. She stated her narcotics drawer was double locked and was never unsecured. She stated supplies that were accessible when the cart was unlocked included diabetic supplies, cleaning wipes, saline, oxygen supplies, prescription creams, Lidoderm patches (a numbing medication on an adhesive patch used to relieve pain), prescription medications, and breathing treatments, including albuterol (used to relax the muscles in the airway and increase air flow to the lungs). She stated she had quickly gone to one of her resident's rooms to assist him to use the restroom and empty his urinal. She stated she was only gone about two minutes. She stated all of the patients on her hall required assistance with mobility and were encouraged to use them call lights and not attempt ambulate on their own. During an observation and interview on 03/13/2025 at 05:47 p.m., a medication cart on 200-East Hall was observed to be unlocked and unattended. Facility staff and residents were not observed around the unlocked medication cart. At 05:48 p.m., LPN A identified the medication cart as hers. She stated she was checking resident blood sugar values and was only around the corner of the hall for a short time. She stated her residents required a lot of assistance and all required assistance with ambulation. She stated the medications in the cart were for the residents on the 200-East Hall but did not give detail of the medications that were accessible when the cart was unlocked. She did state that the narcotics were still locked with a separate lock. During an interview on 03/13/2025 at 05:33 p.m., RN G revealed that an unlocked cart would be a 676447 Page 14 of 15 676447 03/17/2025 Ignite Medical Resort San Antonio, LLC 6035 Eckhert Rd San Antonio, TX 78229

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some concern for patients because they could have possibly taken something from the cart. He stated the impact of this would depend on the type of medication taken. During an interview on 03/13/2025 at 05:41 p.m., LPN A revealed medication and treatment carts needed to be locked. She revealed the concern would be that anyone could have had access to the items in the cart and could walk away with them. During an interview on 03/13/2025 at 05:55 p.m., RN H revealed the concern for an unlocked medication cart was that someone could get into the cart and take something that they should not have access to and that does not belong to them. She stated that this could cause medical problems, including someone could get hurt. During an interview on 03/14/2025 at 02:19 p.m., ACNO D revealed her expectation for staff was that if they were not there and present in front of their medication carts, they were to lock it. She stated the impact of an unlocked medication cart was that someone could get into the cart and get into something that they shouldn't. That this could cause harm. She stated the impact would depend on what the person got into, the carts had injectables and medications, so the impact could range from nothing to anything. During an interview on 03/17/2025 at 10:07 a.m., ACNO E revealed her expectation was for medication carts to be always locked. She stated the impact of an unlocked medication cart was that one of the confused residents wandering around may get ahold of anything. During an interview on 03/17/2025 at 02:26 p.m., the CNO revealed her expectation was for medication carts to be always locked. She stated that the importance of securing carts was to make sure that no one goes into the cart and ingests something that they shouldn't. Record review of facility policy, 4.1 Storage of Medication, dated as copyrighted 2007 from the Nursing Care Center Pharmacy Policy & Procedure Manual, reflected, POLICY Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. PROCEDURES . 3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. 676447 Page 15 of 15