Hunters Pond Rehabilitation And Healthcare

F-F689- Incidents/Accidents

Level of Harm - Immediate Immediate Action jeopardy to resident health or safety o Medical Director notified of Immediate Jeopardy on 1/9/25 @ 1811 (6:11 p.m.).

Residents Affected - Few o Resident RP .was notified of Immediate Jeopardy on 1/9/25 @2002 (8:02 p.m.)

o Resident #1 was sent to [Hospital] on 1/4/25 and is no longer in the facility.

o The following in-services were conducted: Abuse and Neglect at 100% for all staff, Review of Kardex to determine who is a 2 person assist with ADL-bed mobility to all licensed nurses, CNA's and CMA' at 100%, OT and PT were in-serviced at 100% on evaluating new admissions to determine ADL-bed mobility status, and all licensed nurses were in-serviced at 100% to refer to special instructions in resident's care profile to ensure ADL-bed mobility documentation is accurate, starting on 1/9/25 and completed on 1/10/25 by 1 pm. Any employee not receiving in-services will not be allowed to work their shift until in-services have been received. In-services will be in person or via phone.

o An audit of resident ADL's- bed mobility to identify residents who require 2 persons assist completed at 100% by nursing and therapy services to be completed on 1/10/25 by 1 pm.

o Any resident's identified as 2 persons assist for ADL's-bed mobility will be added to the Kardex/Careplan and Special Instructions in the resident's care profile to be completed on 1/10/25 by 1 pm.

o CNA A (CNA A is the same person as MA A) was in-serviced 1:1 on 2 persons assist for ADLs- bed mobility and referring to Kardex for ADL- bed mobility status to be completed on 1/10/25 by 1pm.

o Residents safe surveys were starting on 1/9/25 and to be completed on 1/10/25 by 1pm.

o Residents safe surveys were starting on 1/9/25 and to be completed on 1/10/25 by 1pm.

Identification of Others Affected

All residents who require 2 persons assist with ADLs-bed mobility have the potential to be affected by this alleged deficient practice.

Systemic Change to Prevent Re-occurrence.

1. DON/ADON started in-services on Abuse and Neglect at 100% for all staff, Review of Kardex to determine who is a 2 person assist with ADL-bed mobility to all licensed nurses, CNA's and CMA's at 100%, all licensed nurses were in-serviced at 100% to refer to special instructions in resident's care profile to ensure ADL-bed mobility documentation is accurate to be completed on 1/10/25 by 1pm. Any employee not receiving in services will not be allowed to work their shift until in-services have been received. In-services will be in person or via phone.

2. Starting on 1/9/25 an audit of resident ADL's- bed mobility to identify residents who require 2 persons assist completed at 100% by nursing and therapy services to be completed on 1/10/25 by 1 pm.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 19 676331 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676331 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224

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 0689 3. Starting on 1/9/25 any resident's identified as 2 persons assist for ADL's-bed mobility will be added to the Kardex/Careplan and Special Instructions in the resident's care profile. Level of Harm - Immediate jeopardy to resident health or 4. Starting 1/9/25 any new residents will be evaluated by therapy services to determine if a resident requires safety 2 persons assist with ADL-bed mobility and will ensure it is added to Kardex/Care Plan and to special instructions in resident's care profile. Residents Affected - Few 5. Starting 1/9/25 any new hires, licensed and certified will receive all in-services before working their assigned shift.

6. Two MDS nurses will verify that all new assessments careplan and Kardex corelate with the plan of care.

A log with 2 verification signatures will be in place starting 01/10/25 and will be on-going.

7. All nurses CNAS and CMAS will complete a Bed mobility competency prior to working the floor. The competencies will be completed by 1-10-25 by 1:00pm.

8. All new hires will receive a bed mobility competency prior to working the floor.

Monitoring to ensure on-going compliance.

1. DON/Designee will ensure any resident requiring 2 persons assist with ADL-bed mobility is added to care plan/Kardex and special instructions of resident's care profile. Starting 1/9/25 and will continue for 90 days to ensure compliance and continued to be reviewed monthly during QAPI.

2. DON/Designee will review new admissions to ensure if a resident requiring 2 persons assist with ADL bed mobility it is added to the Kardex/Care Plan and special instructions of resident's care profile starting 1/9/24 and will continue for 90 days to ensure on going compliance and continued to be reviewed monthly during QAPI.

3. The plan will be reviewed with all nurse managers who will monitor staff when making rounds to ensure

the plan is being followed. The managers will be in-serviced and in-service will be completed on 1-10-25.

4. The DON /Administrator will observe 10 staff members a week for verification of proper use of care plans and Kardex. A tracking log will be in place showing verification of proper use and which employee was observed this will begin 1-10-25 and will be on going, until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance.

5. The DON/ ADON will verify MDS verification log is accurate by reviewing the log weekly. This process will start on 1-10-2025 and will be on going until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance.

6. DON/designee will observe 5 nursing staff weekly complete proper bed mobility, starting 1-10-25 and will be on going until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 19 676331 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676331 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224

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 0689 7. Summary of IJ and corrective action to be reviewed by QAPI monthly until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Level of Harm - Immediate jeopardy to resident health or The facility's POR Verification was as follows: safety

Record review of POR binder note stated Medical Director was notified of Immediate Jeopardy on 1/9/25 at Residents Affected - Few 6:11 PM.

Interview on 1/10/25 at 4:19 p.m., the Medical Director stated she had not spoken to the facility about an IJ, and it may have been in her call log. The Medical Director stated there are several reasons a resident might need more assistance with bed mobility and was based on the ability of the patient. She stated for example weight issues could require the resident to need more assistance. She stated the type of assistance needed was dependent on the residents needs and abilities.

Interview on 1/10/25 at 7:00 p.m., the DON she left a message on 1/9/25 for the Medical Director. The DON showed her call log and a call lasting 46 seconds at 6:11 p.m. was on the call log.

Interview on 1/8/25 at 3:00 PM, Resident #1's RP was interviewed and stated another emergency contact had more information about what happened to the resident the day of the fall and referred the surveyors to speak to that contact.

Review of EHR progress notes of Resident #1 stated RP was notified of Immediate Jeopardy on 1/9/25 at 8:02 PM.

Interview on 1/10/25 at 7:00 p.m., the DON stated she told the RP what happened and because of what happened and an IJ was called. The RP stated she would pass the message onto the emergency contact #2.

Record review of Resident #1's EHR progress notes dated 1/4/25 at 6:47 p.m. stated resident was transferred to [hospital] via EMS.

During an Observation on 1/9/25 at 8:53 a.m. Resident #1 was at the hospital. Resident #1 was asleep in bed and non-interviewable. The hospital Case Worker stated the resident had broken bones in her legs and was not a candidate for surgery. The Case Worker stated they were just making the resident comfortable and she would most likely discharge home as the family wanted.

Record review of in-service titled Abuse, Neglect, and Exploitation, dated 1/9/25 contained 143 of 143 scheduled staff signatures present in plan of removal binder.

Record review of in-service titled 2 Person Assist for ADL/Bed Mobility with Review of Kardex conducted on 1/9/25 with scheduled staff signatures present (89 total, 56 of 56 CNAs, CMAs, or HA signed the in-service, and 33 Licensed Nurses).

Record review of in-service titled Kardex and Bed Mobility, dated 1/10/25, showed PT, OT, and ST with 25 of 25 scheduled staff signatures present.

During an interview on 1/10/25 at 7:00 p.m., the DON stated she participated in training for staff by demonstrating to staff where to locate the kardex, special instructions, POC, and care plans.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 19 676331 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676331 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224

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 0689 During an interview on 1/10/25 at 2:23 p.m., the DON stated they gathered input from rehab department for any residents they had prior PT, OT, ST, evaluations done on, and CNAs input to compile a list of residents Level of Harm - Immediate who needed +2 assistance with bed mobility. jeopardy to resident health or safety Record review of active resident list was used to audit 115 residents and showed an updated list of residents with clarification of the type of mobility assistance they required. Residents Affected - Few

On 1/10/25 a random sample from taken from the Resident audit list. The kardex was reviewed of each resident and were updated with ADL-bed mobility status for bed mobility and transfers the following sampled residents:

Resident #2 +2, +2

Resident #3 +1, +1

Resident #4 +2, +2

Resident #5 +2, +1

Resident #6 +2, +2

Resident #7 +2, +2

Resident #8 +1, +1

Resident #9 +2, +2

Resident #10 +2, +1

Resident #11 +1, +1.

During an interview on 1/10/25 at 7:00 p.m., the DON stated every resident care plan was updated to state how many persons are required for assistance with bed mobility and transfers.

Record review of in-service titled 2 Person Assist for ADL/Bed Mobility with Review of Kardex conducted on 1/9/25 contained MA A's signature.

Interview on 1/10/25 with MA A at 6:17 p.m., she said LVN H did the in service with her 1 to 1, and another nurse watched her to the ADL portion.

During an interview on 1/10/25 at 7:00 p.m. the DON stated she re-iterated to MA A she should ask for assistance with a resident if she was unsure of the type of assistance the resident required. The DON stated MA A normally worked as a medication aide and may not have been as familiar with the type of assistance

the resident needed with mobility.

.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 19 676331 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676331 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224

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 0689 Record review of POR binder on 1/10/25 revealed 20 resident safe surveys were completed and no concerns were noted. Level of Harm - Immediate jeopardy to resident health or During an interview on 1/10/25 at 7:00 p.m. the DON stated the AITs and DONs came into help complete the safety safe surveys. Nothing was reported of concern.

Residents Affected - Few Record review of POR binder revealed a document, dated 1/10/25, for an Off Cycle QAPI with staff signatures present.

Record review on 1/10/25 a sample of residents' EHR Kardex for Resident #12, Resident #13, Resident #14, Resident #15, and Resident #16 were updated for 2 persons assist for transfers and bed mobility. Previously their kardex and care plans had not stated the number of staff needed for transfers.

Interview on 1/10/25 at 6:55 p.m., . MDS F stated the facility will determine new admissions mobility needs and document them for staff to reference by looking at the last 3 days of assessment documentation from the nurse after a resident is admitted . MDS F stated the nurse does the documentation for 3 days under the GG assessment then they compared it with therapy assessments. MDS F stated the DOR did a verbal with them

during daily meetings and would review the PT and OT documentation. They would verify it is accurate and matches the nurse and PT assessments. MDS F stated typically, PT, OT, or ST would try to see the Resident next day after admission for an assessment or if they were admitted early enough they could complete the assessment the same day.

During an interview on 1/10/25 at 7:00 p.m., the DON stated they would verify with MDS new admissions, the DOR will give them updates, and discuss anyone she had done an assessment on and require a 2 person assist.

Record review on 1/10/25 showed a log with one upcoming new hire notated to be trained at first shift so far.

During an interview on 1/10/25 at 7:00 p.m. the DON stated they had called in mostly everyone who was new to complete the in-service and training. The DON stated any new hires after that would train with HR to do

the sit-down orientation.

During an interview on 1/10/25 at 6:48 p.m. with MDS F said they started a log with new admissions from 1/9/25. They looked at them to make sure their ADLs were checked, the nurse completed the assessments until therapy was able to evaluate them. All 3 new admission residents had the assessments done. MDS F stated they planned to fill out the audit log weekly. MDS F stated they corrected all the care plans, kardex, and special instructions to specify if the resident needed one or two people to assist.

Record review of report dated 1/9/25, showed a new admission and discharge of residents in the facility with 3 residents on it for new admissions.

Record review of document titled new assessment/care plan/Kardex log, dated January 2025, showed 2 MDS nurses and the DON signed that they looked at the 3 new resident admissions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 19 676331 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676331 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224

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 0689 Interview on 01/10/25 at 4:07 p.m. ADON J stated the bed mobility competency were done by her LVN K, LVN H, and LVN L, and maybe LVN M. ADON J stated they watched staff they were training perform Level of Harm - Immediate perineal care and would guide them on the correct way as needed. jeopardy to resident health or safety Record review of documents titled Persons Needing Assistance with Bed Mobility, dated 1/9/25-1/10/25, showed 70 direct care staff (LVNs, RNs, CNAs, MAs, and HAs) completed skills check off for this Residents Affected - Few competency on 1/9/25 though 1/10/25. 12 staff from the staff list did not have competency check offs because they were either no longer working at the facility or were PRN staff that were not scheduled to work till after 1/10/25.

Interviews conducted on 1/10/25 between 3:49 p.m. to 7:44 p.m. with 20 staff (MA I, CNA S, CNA T, OT U, CNA V, CNA W, CNA Q, CNA Z, CNA D, CNA AA, CNA BB, CNA P, CNA CC, MA A, CNA Y, LVN K, LVN DD, and LVN C) from various shifts who all stated they received the in service and hands on training for residents who needed assistance with mobility and how to locate the information in the medical records.

During an interview on 1/10/25 at 7:00 p.m., the DON stated nurse managers will oversee training new hires, but they also planned to hire a staffing developer with a start date of 2.4.25 to assist with training. The DON stated she would review any resident requiring 2 persons assist with ADL-bed mobility was added to care plan/Kardex and special instructions of resident's care profile and review this in QUAPI meetings.

Record review of POR binder with in-services of nurse managers on 01/10/25 given by DON. All topics on

the POR were reviewed. 8 staff signed the in service.

Record review of document titled verification of care plan and kardex log had 4 staff names, 2 staff with additional required teachings, and signed off by the DON.

Record review of document titled verification log new assessment/careplan/kardex showed a log with the resident, date, and signature for both MDS and DON who verified it.

During an interview on 1/10/25 at 7:00 p.m. the DON stated verification of proper bed mobility log was completed by MDS G who observed two CNAs on 1/10/25. The log was filled out with this information and placed in the POR binder.

During an interview on 1/10/25 at 7:00 p.m. the DON stated they had an off cycle QAPI and discussed how

they were going to move forward. The DON stated they had the meeting on 1/10/25 and a log of this was placed in the POR binder.

On 1/10/25 at 8:55 p.m., the Administrator was notified the IJ was removed. While the IJ was removed on 1/10/25 at 8:50 p.m. the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to monitor the implementation of the plan of removal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 19 676331 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676331 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45857 potential for actual harm Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention Residents Affected - Few and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent

the development and transmission of communicable disease and infection for 2 of 8 residents (Resident #14 and Resident #16) reviewed for infection control

1. The facility failed to ensure CNA D used appropriate hand hygiene between glove changes when providing incontinent care to Resident #14.

2. The facility failed to ensure Resident #16's catheter bag was not laying on the floor.

These deficient practices could place residents at-risk for infection due to improper care practices.

The findings included:

1. Record review of the Admission Record, dated 1/8/25, reflected Resident #14 was a [AGE] year-old female originally admitted on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses that included morbid severe obesity due to excess calories, chronic kidney disease stage 3 (the kidneys are moderately damaged and are not filtering waste and fluid properly), unsteadiness on feet, cognitive communication deficit, and muscle weakness.

Record review of Resident #14's annual MDS assessment, dated 12/27/24, showed her memory was moderately impaired for daily decision making. Section H showed the resident was always incontinent of bladder and bowel.

Record review of the Resident #14's Care Plan, initiated 1/1/25 and revised 1/7/25, showed she was receiving imipenem (antibiotic) 500 mg three times a day for 7 days for a UTI with interventions to encourage adequate fluid intake, give antibiotics, monitor for side effects, and use enhanced barrier precautions. Resident #14 had bowel/bladder incontinence related to impaired mobility and muscle weakness initiated on 12/8/20 and revised on 12/17/24 with interventions to check as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. Observe/document for signs and symptoms of UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.

During an observation on 1/9/25 at 4:43 p.m., CNA D provided incontinent care to Resident #14. CNA D wiped the resident's peri area, removed her gloves, did not perform hand hygiene, and put on new gloves. CNA D wiped Resident #14's buttocks area did not remove her gloves. CNA D then applied medicated cream to the resident's buttocks. With the same gloves still on CNA D then put a new clean brief on Resident #14.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 19 676331 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676331 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224

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 0880 During an interview on 1/9/25 at 4:56 p.m., CNA D stated they were provided hand sanitizer to use in the room. CNA D stated she forgot to bring and use hand sanitizer during the incontinent care because she was Level of Harm - Minimal harm or nervous and wanted to hurry and finish. CNA D stated she was unsure if she should sanitize her hands potential for actual harm between each glove change but should change them when going from a dirty to a clean area to prevent infection to the resident. Residents Affected - Few

During an interview on 1/10/25 at 10:05 a.m., the DON stated staff should perform hand hygiene between when going from dirty to clean. The DON stated she was unsure if staff needed to perform hand hygiene between each glove change and stated she would need to look at the facility policy.

During an interview on 1/10/25 at 10:49 a.m., ADON J stated staff was expected to sanitize their hands between glove changes. ADON J stated one aide should handle the dirty tasks, such as cleaning the resident, while the other remains clean to manage clean tasks. ADON J stated once the resident is cleaned, gloves should be removed, hands sanitized, and new gloves put on before applying a clean brief. ADON J stated infections could occur if staff failed to perform proper hand hygiene.

2. Record review of the Admission Record, dated 1/8/25, reflected Resident #16 was a [AGE] year-old male originally admitted on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses that included urinary tract infection, bladder neck obstruction (a blockage in the bladder neck that prevents urine from flowing out of the body), obstructive and reflux uropathy (condition in which the flow of urine is blocked), acute kidney injury (a sudden condition that damages the kidneys and reduces their ability to filter waste from the blood), severe sepsis without septic shock (a stage of sepsis that occurs when the body's immune system overreacts to an infection and damages organs, but blood pressure remains normal), abnormalities of gait and mobility, cognitive communication deficit, colostomy status, and muscle weakness.

Record review of the Resident #16's Care Plan, initiated on 4/16/21 and revised last on 8/15/24, stated he had a suprapubic catheter with interventions to position catheter bag and tubing below the level of the bladder and away from entrance room door, had suprapubic catheter 16fr/10ml, provide catheter care every shift and as needed, measure urinary output, monitor and document intake and output as per facility policy, Monitor/record/report to MD for signs and symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns, and use enhanced barrier precautions.

Record review of Resident #16's physician orders, dated 1/8/25, reflected an order for suprapubic catheter cleanse suprapubic site with normal saline or soap and water, pat dry, and secure with split sponge gauze twice a day every shift, with a start date of 6/4/24, and no end date.

During an observation on 1/8/25 at 11:21 a.m., Resident #16 was in bed. His catheter bag was laying on the floor and did not have a cover or bag over it. The resident stated he did not know how it got on the floor. The resident stated he needed staffs' assistance to get in and out of bed.

During an interview on 1/8/25 at 11:22 a.m., CNA O stated the catheter bag should not be on the floor because it is dirty. CAN O stated she personally had not been in the room to check on Resident #16 that day but knew the other aides CNA P and CNA Q had. CNA O picked the bag up off the floor and emptied the contents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 19 676331 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676331 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224

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 0880 During an interview on 1/8/25 at 11:38 a.m., CNA Q stated she worked as restorative aide and had obtained Resident #16's weight that day. She stated she did move the catheter to obtain his weight but placed it back Level of Harm - Minimal harm or on the side of the bed off the floor. CNA Q stated she was not sure how the catheter bag got on the floor. potential for actual harm

During an interview on 1/8/25 at 12:00 p.m., CNA P stated Resident #16 often did not like to be bothered and Residents Affected - Few preferred to call staff for help. CNA P stated she had gone in his room earlier and he refused to let them change his sheet or provide care but did let them weigh him. CNA P stated she would let the nurse know if

he continued to refuse care. CNA P stated they usually put a cover over the catheter bags to keep it from being exposed, breaking open, or getting pulled on. CNA P stated the catheter bag should not be on the floor.

During an interview on 1/10/25 at 10:08 a.m., the DON stated the catheter should not be on the floor because of infection control.

Record review of the facility's policy titled Indwelling Urinary Catheter Care, dated 12/23, stated It is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and as needed (PRN) to promote hygiene, comfort, and decrease the risk of infection . 13. Maintain the drainage tubing below the level of the bladder. 14. Cover the drainage bag with a privacy bag to maintain dignity .

The DON was asked to provide a hand hygiene policy on 1/10/25 at 10:05 a.m. and it was not provided

before exit. The facility provided a policy over the steps of hand washing only.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 19 676331