Northeast Rehabilitation And Healthcare Center

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

facility did not correlate her death to the fall. The DON stated her expectation for an unwitnessed fall was always neuro checks and notification of the family and the physician. She stated if they hit their head, neuros. She stated if there was any deviation in neuros, they should notify the physician. The DON stated

she was aware Resident #7 hit her head, and they did neuro checks. She stated for a resident on anti-coagulants they tell the physician and let them decide. The DON said the facility did not have a policy to send the resident out to the hospital. She stated she did not know why some staff thought that was their policy. She said that had not been taught. She stated she had not spoken with Resident #7's physician about her fall or her death but knew he was aware because it was a required notification. The DON stated if LVN C had gotten an order to send out (to the hospital) then she should have sent the resident out, but she was not aware of it. The DON stated she was aware Resident #7 was bickering over TV volume with another resident. She stated a staff member (unknown) had asked if she could move the resident and she said yes. The DON stated that was not something the physician would need to be notified of. She stated

they had moved Resident #7 a few times because she would [NAME] with roommates and that was not a change of condition. The DON stated staff had been trained on de-escalation and redirection of residents, fall prevention training, and abuse and neglect (dates unknown). The DON stated this surveyor would need to speak with the Medical Director instead of the resident's physician. During an interview on [DATE REDACTED] at 4:08 p.m., the Medical Director stated Resident #7's physician was not available and her providers were not allowed to be interviewed unless she was present. She stated she looked through the call center log and

they had been notified when the fall happened. She stated they (facility) had been given orders to monitor for neuros. The Medical Director stated the representative for the physician's office notified her (on [DATE REDACTED])

she incorrectly stated (when interviewed) that there was an order to send the resident out to the hospital.

The Medical Director stated she listened to the call (original call on the date of fall) and the RN just gave orders to monitor and do neuro checks and no orders to send to the hospital. The Medical Director stated there was no one-set of professional standards of practice for when a resident had an unwitnessed fall, hit their head, and was on anticoagulants. She stated it would depend on the si[TRUNCATED]

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Northeast Rehabilitation and Healthcare Center

603 Corinne St San Antonio, TX 78218

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

she moved her to a different room across the hall. She stated it was verbal aggression and nothing physical had occurred. She stated both roommates were lying in bed, but Resident #7 just wouldn't stop. She wanted to fight with her roommate. LVN D stated they tried getting her to stop, she tried to close the curtain, but she declined to go to sleep and kept pulling the curtain over. LVN D stated she asked the roommate not to engage, but it continued so she decided to make the room change. LVN D stated after the room change Resident #7 was calm. She stated she did not document the verbal aggression and did not document the room change because as soon as the resident was moved to a new room, she was calm. She stated she also did not think about documenting it because it was just two roommates arguing. She stated she should have documented it in the medical record. During an interview on 10/14/2025 at 3:34 p.m., the DON stated

she reviewed the SBAR documentation by LVN C. She stated every fall triggered a separate UDA [SH4] that should have been completed. She stated the SBAR was a new form for the staff, and she thought maybe it was misunderstood by staff and that was why it was incorrectly documented as not clinically significant. The DON stated a skin/injury assessment should be documented after a fall and a pain assessment should be documented. The DON stated the word monitor was not a specific MD order. She stated if the doctor said something specific, they would add it as an order. She stated the SBAR checklist was the order or the place to document back what the physician response was to the notification. She stated LVN C marking other and na for orders should have been more specific. During an interview on 10/15/2025 at 4:11 p.m., the DON stated they document exceptions and they were required to follow up with expectations with what intervention was put in place. She stated they put a note for the intervention in

the medical record. The DON stated Resident #7 was unhappy with the TV being too loud with her roommate and needing to be moved was not a reason to document. The DON stated Resident #7 did not have a family to notify about the move, so no notification was required to be documented. The DON stated what should be documented included any change of condition, and behaviors that required interventions, any complaints from the resident such as pain, any refusals, any changes from baseline. She stated it was important to document in the medical record so monitoring and interventions were in place. Record review of the facility's policy titled Administration-Content of Medical Records last revised August 2007 revealed: All physicians, nursing staff and other health care professionals involved in the resident's care will be responsible for making prompt, appropriate entries in the record. 6. List of contents of the medical record: Licensed Nurses Notes, other assessments ( .bowel and bladder, skin, etc.)

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