Retama Manor Nursing Center/san Antonio West

F-F689 Free of Accidents/Hazards/Supervision/Devices called on 1/10/2025.

Interventions:

Interviews with staff total was 35 all staff were in serviced on Elopement/Wandering, Abuse/Neglect, Door Alarms and to check resident devices (wander guards every shift) and understood the elopement protocol.

Interviews on 1/8/2025 at 1:21 PM-5pm and 1/9/2025 at 1 PM-6 PM. Scheduled shift were 6-2 PM, 2-10 PM. 10pm-6 AM.

1. CNA J,

2. LVN F

3. CNA K

4. CNA L

5. CNA M

6. LVN N

7. CNA O

8. CNA P

9. CNA Q

10. CMA R

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 12 675002 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 675002 B. Wing 01/10/2025

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

Retama Manor Nursing Center/San Antonio West 636 Cupples Rd San Antonio, TX 78237

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 11. MDS

Level of Harm - Immediate 12. LVN S jeopardy to resident health or safety 13. LVN T

Residents Affected - Few 14. DOR (director of rehabilitation)

15. CNA U

16. CNA V

17. ADON

18. Maintenance Director

19. CNA Y

20. CNA Z

21. CNA AA

22. CNA BB

23. RN CC

24. CNA DD

25. LVN EE

26. CNAFF

27. [NAME] GG

28. Dietary HH

29. Hsk II

30. Hsk JJ

31. HSK KK

32. Laundry LL

Record review of the facility Elopement Binder had 7 current residents for wandering behavior, it contained face sheet and care plans for wandering.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 12 675002 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 675002 B. Wing 01/10/2025

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

Retama Manor Nursing Center/San Antonio West 636 Cupples Rd San Antonio, TX 78237

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 Observations on 1/10/2025 at 10am of residents in the elopement binder were checked for wander guard and were randomly checked at the door alarm throughout the day. Level of Harm - Immediate jeopardy to resident health or Observations and interview with the Maintenance Supervisor on 1/9/25 at 745 am-8:05 am stated he began safety employment in October at the facility; he stated that all of the facility doors were alarmed but the front door and the exit door for C-hall needed more attention for better security and are working properly now; the Residents Affected - Few Maintenance Director stated that he checks all facility exit doors for security purposes twice a day-at the beginning of his shift and the end of his shift; all of the facility exit doors were observed by Surveyor with the Maintenance Director as noted:

Facility Front door-alarmed and working

D-hall exit door-alarmed and working; the Maintenance Director stated that a new mag lock was installed and

he will provide paperwork for Surveyor

E-hall-exit door at the end of the hallway was alarmed and worked; door in lounge on hallway was alarmed and opened to outside open smoking area with two locked gates that were checked and secure.

A-hall-the door leads to a small courtyard area and was alarmed; the MD stated that the alarm is turned off and back on when he enters for the day and leaves at night and stays on during the w/c; the door stays locked without the alarm being on; the MD stated that the door stays alarmed on the w/e.

B-Hall- the exit door was alarmed; the MD stated he plans to purchase another mag lock for this door; he stated that he had been also turning this alarm on/off during his work hours to allow for multiple deliveries thru out the day and the door stays locked; Surveyor suggested that he keep this door alarmed at all times.

C-Hall-exit door alarmed and working.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 12 675002 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 675002 B. Wing 01/10/2025

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

Retama Manor Nursing Center/San Antonio West 636 Cupples Rd San Antonio, TX 78237

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 0836 Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted Level of Harm - Minimal harm or professional standards. potential for actual harm 26869 Residents Affected - Many Based on observation, interviews and record reviews, the facility's governing body failed to designate a person to exercise the administrator's authority when the facility did not have an administrator and secure a licensed nursing home administrator within 30 days.

The facility terminated Licensed Administrator A on 11/08/2024; hired Employee B, who was not a licensed administrator 24 days later and served in the capacity of the administrator for 39 days.

This failure could result in a decrease in the quality of care provided to the residents that could result in potential minimal harm to the resident.

The findings were:

Record review of the All Staff Active Listing, dated 1/4/2025, revealed Employee B was listed as the Administrator with a hire date of 12/02/2024.

Record review of an Application for Employment, signed digitally by Employee B on 12/13/24, revealed she applied for the Administrator position, had previously worked at another nursing home as an AIT, did not list

the school she attended and did not indicate she was a Licensed Nursing Facility Administrator.

Record review of the Administrator Job Description, signed by Employee B on 12/02/2024, revealed under Education and Experience requirement was Active NHA [Nursing Home Administrator] License.

Record review of an email dated 12/11/24 from Texas Health & Human Services Long Term Care Regulation, Licensing & Credentialling to Employee B revealed she received authorization to proceed with registration for the Licensed Nursing Home Administrator exam.

In an entrance conference on 01/04/2025 at 8:57 a.m., Employee B stated she was an AIT.

In a further interview on 01/04/2025 at 9:05 a.m., Employee B stated her title was Operations Manager and

the Administrator of the facility was Administrator C who was in the facility daily to monitor and assist Employee B.

Interview and observation on 01/04/2025 at 11:42 a.m., Administrator C, who had her name badge on that indicated she worked at Nursing Home D, stated her administrator's license was over Nursing Home D, not

this facility; she was in the facility once or twice a week for a few hours to oversee what AIT Employee B did

in the facility, and would come to the facility when HHSC surveyors were present.

Interview on 01/04/2025 at 12:37 p.m., Employee B stated she would take the licensed administrator's test at

the end of January 2025, pulled out her phone to look at and stated the test was on 01/23/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 12 675002 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 675002 B. Wing 01/10/2025

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

Retama Manor Nursing Center/San Antonio West 636 Cupples Rd San Antonio, TX 78237

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 0836 Interview on 01/05/2025 at 11:56 a.m., the HR Employee stated the previous Administrator A's last day she worked in the facility was 11/08/2024 and provided Administrator A's employee file. Level of Harm - Minimal harm or potential for actual harm Record review of Administrator A's employee file revealed her date of hire was 08/01/2022, was involuntarily terminated on 11/08/2024, and her Texas Nursing Home Administrator License was effective from Residents Affected - Many 03/11/2021 to 03/22/2025.

Interview on 01/05/2025 from 3:37 p.m. to 3:59 p.m., the facility's South Texas President [Regional Director] stated he has covered the facility since March 2024. He said Administrator A's last day in the facility was the date the HR Employee provided the surveyor. The South Texas President stated he was aware there was a 30-day grace period to fill the administrator position. He said when Employee B was interviewed, they were aware she was not a licensed administrator, but Employee B was what they were looking for regarding to fitting in with the facility and knew there would be another lull of 30 days before she was licensed. He stated Employee B would take the administrator license test in January 2025; and she was being overseen by Administrator C. The South Texas President stated he could not say that residents would be harmed with an unlicensed administrator to manage the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 12 675002