Retama Manor Nursing Center/san Antonio West

F-F600 Abuse and Neglect on 1/29/2025. Monitoring will be conducted weekly for 4 weeks to determine if compliance is being sustained. Sustained compliance or corrective actions will be discussed and documented in QAPI Meeting.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 19 675002 Department of Health & Human Services Printed: 09/10/2025 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 01/30/2025

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 0600 Social Services/designee will attend daily meeting Monday - Friday to be made aware of any newly identified behaviors or concerns. Social Services/designee will assure necessary notification to behavioral Level of Harm - Immediate health services are in place or make necessary appointments to have residents in need seen as soon as jeopardy to resident health or possible. safety

The QAPI committee will meet monthly, and facility interdisciplinary team will meet daily to review the Residents Affected - Some ongoing status of the corrections for this deficiency with the purpose to identify, evaluate, plan, implement, and address concerns or deficient practices identified as it relates, or to determine if compliance is being sustained. All corrections or steps taken and identified by QAPI will be documented.

Ad Hoc QAPI meeting will be held on 1/29/2025 with the Medical Director, Administrator and Director of Nursing to review and validate the plan of removal.

Involvement of Medical Director

The Director of Nursing notified the facility's Medical Director, of the Immediate Jeopardy tag on 1/29/2025.

The Administrator will be responsible for implementation of ensuring the adequate process regarding staffing requirements for increased supervision and minimize to support accident management. The new process/systems were initiated on 1/29/2025. Please accept this letter as our plan of removal for determination of the alleged Immediate Jeopardy issued 1/29/2025.

Plan of Removal Verification

Intermittent observations on 1/26/2025, 1/27/2025, 1/28/2025, and 1/29/2025 from 8:00 AM to 10:00 PM revealed 13 residents resided in the MCU to include residents #55, #61, and #83.

During an observation and interview on 1/29/2025 at 1:30 PM it was revealed that CNA D and MA E were staffing the MCU. MA E and CNA D stated they were assigned to the MCU and if they needed help, they would stay in the MCU and call via the 2-way radios provided. MA E stated LVN C had the radio while she was out of the MCU providing care for other residents.

Observation on 1/30/2025 at 5:25 PM in the memory care unit had 2 CNA's and 1 nurse/CNA.

Observation and interview on 1/30/2024 at 5:26 PM revealed LVN R had the other walkie talkie and could use to communicate with the CNAs in the MCU.

Observation and interview on 1/30/2025 at 5:24 PM revealed CNA U had a walkie talkie on her, and CNA B stated if one leaves the MCU, they can use the walkie talkie for emergency as well. Dr. x

During an observation on 1/29/2025 at 10:40 AM revealed Dr. X provided the in-service topic Understanding Dementia to staff in the facility's living room.

During an interview on 01/29/25 at 11:09 AM, Dr. X revealed he conducted an in-service to the facility staff

on helping residents with dementia. He revealed some interventions he taught to include getting to know residents, getting to know their triggers, and adjusting resident care accordingly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 19 675002 Department of Health & Human Services Printed: 09/10/2025 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 01/30/2025

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 0600 Record review of in-service/sign in sheet, dated 1/29/2025, reflected in-service topic Understanding Dementia with Facilitator Dr. X. further review revealed 54-staff signed the document. Level of Harm - Immediate jeopardy to resident health or Observation and interview on 1/30/2025 at 5:24 PM revealed CNA U had a walkie talkie on her, and CNA B safety stated if one leaves the MCU can use the walkie talkie for emergency as well.

Residents Affected - Some During an interview on 1/30/2025 5:29/2025 the DON stated he would hold an all-staff monthly meeting, beginning 2/12/2025, to cover aspects of behavioral care with a focus on de-escalation of behaviors, behavior management, wandering, dementia care and activities.

During an interview on 1/30/2025 at 5:38 PM the DON stated all the in-services have been completed for all staff and stated any staff who had not received the in service i.e., new staff, no one would be able to accept

a work shift until they received the in service.

During an interview on 01/30/25 at 07:00 PM, the Administrator revealed he informed the DON will ensure 2 CNAs will be always staffed back in MCU. They revealed when a staff member did not come in as scheduled, they would make sure to fill this position in. They further revealed they were actively hiring and searching for new staff members to be adequately staffed.

Record reviews of facility schedules, from 1/26/2025 to 1/30/2025, revealed the following staff usually worked the following shifts:

6:00 AM - 2:00 PM

LVNs RNs:

DON

ADON

LVN C

CNAs:

CNA G

CNA F

CNA A

MA E

CNA H

CNA I

2:00 PM - 10:00 PM

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 19 675002 Department of Health & Human Services Printed: 09/10/2025 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 01/30/2025

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 0600 LVN J

Level of Harm - Immediate RN K jeopardy to resident health or safety LVN L

Residents Affected - Some LVN W

CNAs

CNA B

CNA M

CNA N

CNA O

CNA P

CNA Q

10:00 PM to 6:00 AM

Nurses

LVN R

RN S

CNAs

CNA T

CNA U

During an observation on 1/30/2025 at 1:55 PM of the MCU revealed CNA B and CNA U staffed the MCU. It was observed CNA B had on his person the 2-way radio and RN K had the other 2-way radio while she documented at the nurse's station located outside of the MCU.

Record review of Resident - to Resident Altercations (2022) and unmanageable residents (2010) policy, in- service, dated 1/11/2025, indicated there is to be 2 CNA's on A hall at all times. If there is an emergency, 1 aide needs to always stay with the resident /residents, while the other aide goes to help, there will be a walkie talkie to communicate with A hall nurse and A hall CNAs in case of emergency. The Walkie talkie needs to always stay with the employee during their shift. Walkie talkies will be checked every shift to ensure

they are working properly. There will be a walkie talkie log to be initialed by nurses and CNA documenting

they are working properly every shift signed by 53 staff, to include CNA A, CNA B, LVN C, CNA D, and MA E.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 19 675002 Department of Health & Human Services Printed: 09/10/2025 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 01/30/2025

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 0600 A record review of the facility's in- service dated 1/29/2025 titled Abuse and Neglect had 89 staff signatures, to include CNA A, CNA B, LVN C, CNA D, and MA E. Level of Harm - Immediate jeopardy to resident health or A record review of the facility's in- service dated 1/29/2025 titled Understanding Dementia had 44 staff safety signatures, to include CNA A, CNA B, LVN C, CNA D, and MA E.

Residents Affected - Some A record review of the facility's in-service dated 1/29/2025 titled PAL (preference for activity and leisure) had 28 staff signatures.

Observation on 1/30/2025 at 7:03 PM revealed the MCU nurse station where the PAL (preference for activity and leisure) binder was located. The PAL (preference for activity and leisure) binder revealed 12 residents had their preferences, likes, dislikes, and plan for redirections and included triggers for behaviors.

A Record review of the undated PAL for Resident #55 revealed, Resident is a smoker, likes to eat in dining room.

A Record review of the undated PAL for Resident #61 revealed, he has been married [AGE] years. He worked as a driver. He has 2 children.

A Record review of the undated PAL for Resident #83 revealed, he was a body work. In jail for [AGE] years causing him to struggle with confinement and others in his space.

During an interview on 1/30/2025 at 1:58 PM LVN C stated she had the PAL documents in a binder kept at

the nurse station which aided in preferences and redirections for residents.

A record review of the facility's in-service dated 1/29/2025 titled monitoring weekly x4 weeks to determine compliance is being sustained had 2 staff signatures to include the DON.

During an interview on 1/30/2025 at 05:34 PM the DON stated he received the in service from the regional operations manager on 1/28/2025 to include the new policy to have 2 CNA staff in the MCU during all 3 shifts, to provide the MCU nurse and 1 CNA each a 2-way radio to facilit [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 19 675002 Department of Health & Human Services Printed: 09/10/2025 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 01/30/2025

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41937

Residents Affected - Some Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each Resident, for 8 of 16 residents (Residents #5, 20, #27, #38, #68, #69, #81, and #85) reviewed for pharmacy services.

1. On [DATE REDACTED] Medication Aide E administered late medications to Resident #20 at 10:49 AM:

a. Acetaminophen 325mg, (Tylenol) late by 1 hour and 49 minutes.

b. Levetiracetam 500mg (a medication to treat seizures) late by 1 hour and 49 minutes.

2. On [DATE REDACTED] Medication Aide E administered late medications to Resident #27 at 9:20 AM:

a. Carvedilol 12.5mg (used to treat high blood pressure) late by 20 minutes.

b. Divalproex 125mg (used to treat schizophrenia) late by 20 minutes.

3. On [DATE REDACTED] Medication Aide E administered late medications to Resident #38 at 10:51 AM:

a. Famotidine 20mg (used to reduce stomach acid) late by 1 hour and 51 minutes.

b. Docusate (a stool softener) 100mg late by 1 hour and 51 minutes.

c. Lamotrigine 100mg (used to prevent seizures) late by 1 hour and 51 minutes.

d. Sodium chloride 1gr (salt used to treat muscle weakness) late by 51 minutes.

4. On [DATE REDACTED] Medication Aide E administered late medications to Resident #68 at 10:23 AM:

a. Metformin 1000mg (used to treat diabetes) late by 1 hour and 23 minutes.

5. On [DATE REDACTED] Medication Aide E administered late medications to Resident #69 at 9:45 AM:

a. Bactrim 800mg / 160mg (a combination of 2 antibiotics; sulfamethoxazole and trimethoprim) late by 45 minutes.

6. An inspection on [DATE REDACTED] of the facility's treatment nurse medication cart revealed expired insulins for Residents #5, #81, and #85 as evidenced by the following:

a. Resident #5's liraglutide (an anti-diabetic medication used to treat type 2 diabetes, and chronic obesity) subcutaneous (under the skin) solution pen-injector was stored unrefrigerated, and available for administration, in the cart and was expired by 19 days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 19 675002 Department of Health & Human Services Printed: 09/10/2025 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 01/30/2025

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 0755 b. Resident #81's 3 injection vials of insulin lispro 100u/ml, were available for administration, stored unrefrigerated, unlabeled with an expiration date, and were expired by as much as 59 days. Level of Harm - Minimal harm or potential for actual harm c. Resident #85's 1 injection vial of insulin lispro 100u/ml, was available for administration, stored unrefrigerated, labeled with an expiration date of ,d+[DATE REDACTED], and was expired by 45 days. Residents Affected - Some

These deficient practices placed residents at risk for not receiving the therapeutic effects of their prescribed medications.

The findings included:

During an observation and interview on [DATE REDACTED] at 9:49 AM revealed MA E preparing and administering medications for residents within the facility. Further review revealed MA E's computer electronic medical

record display demonstrated MA E's assigned residents were highlighted in red. MA E stated she was late administering medications, specifically for Residents #20, 27, #38, #68, and #69. MA E stated her direct supervisor was the DON and she had not reported the late medication administration. Continued observation revealed she continued to administer medications to residents.

1. A record review of Resident #20's admission record dated [DATE REDACTED], revealed an admitted [DATE REDACTED] with diagnoses which included vascular dementia (parts of the brain are damaged due to a stroke) and convulsions (an electrical storm in the brain AKA seizures.)

A record review of Resident #20's quarterly MDS assessment dated [DATE REDACTED] revealed Resident #20 was a [AGE] year-old male admitted for long term care and assessed a BIMS score of 5 out of a possible 15 which indicated severely impaired cognition.

A record review of Resident #20's care plan dated [DATE REDACTED] revealed, (Resident #20) has a seizure disorder r/t (related to) Stroke Date Initiated: [DATE REDACTED] . Give medications as ordered. Observe/document for effectiveness and side effects.

A record review of Resident #20's physicians' orders revealed the physician prescribed for Resident #20 to receive levetiracetam 500mg twice a day at 8:00 AM and at 4:00 PM and acetaminophen 325mg three times

a day at 8:00 AM, noon, and at 4:00 PM.

A record review of the facility's Medication Admin Audit Report dated [DATE REDACTED] revealed MA E, on [DATE REDACTED], administered Resident #20 his acetaminophen 325mg and his levetiracetam 500mg at 10:49 AM late by 1 hour and 49 minutes.

2. A record review of Resident #27's admission record dated [DATE REDACTED] revealed an admitted [DATE REDACTED] with diagnoses which included hypertension (high blood pressure) and schizophrenia (a chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others.)

A record review of Resident #27's Quarterly MDS assessment dated [DATE REDACTED] revealed Resident #27 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 15 which indicated intact cognition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 19 675002 Department of Health & Human Services Printed: 09/10/2025 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 01/30/2025

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 0755 A record review of Resident #27's care plan dated [DATE REDACTED] revealed, (Resident #27) has Hx (history) of hallucinations. (Resident #27) states that this voice tells him bad things, including not to smoke, tells him he Level of Harm - Minimal harm or is overweight. Mr. Rico calls this voice/voices the devil . Administer medications as ordered Date Initiated: potential for actual harm [DATE REDACTED]

Residents Affected - Some A record review of Resident #27's physicians orders dated [DATE REDACTED] revealed the physician prescribed for Resident #27 to receive carvedilol 12.5mg and divalproex 125mg twice a day at 8:00 AM and again at 4:00 PM.

A record review of the facility's Medication Admin Audit Report dated [DATE REDACTED] revealed MA E, on [DATE REDACTED], administered Resident #27 his carvedilol 12.5mg and divalproex 125mg at 9:20 AM late by 20 minutes.

3. A record review of Resident #38's Admission record dated [DATE REDACTED] revealed an admitted [DATE REDACTED] with diagnoses which included epilepsy (a brain disease where nerve cells don't signal properly, which causes seizures. Seizures are uncontrolled bursts of electrical activities that change sensations, behaviors, awareness, and muscle movements), Gastroesophageal reflux disease (AKA GERD, occurs when stomach acid frequently flows back into the esophagus, leading to irritation and discomfort), constipation, and muscle weakness.

A record review of Resident #38's Quarterly MDS assessment dated [DATE REDACTED] revealed Resident #38 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 15 which indicated intact cognition.

A record review of Resident #38's care plan dated [DATE REDACTED] revealed, (Resident #38) has behavioral concern of insisting medications be given at a certain time and becoming angry when medications are not being given exactly when requested. (Resident #38) has been made aware of and

educated on medication administration window .

A record review of Resident #38's physicians' orders dated [DATE REDACTED] revealed the physician prescribed for Resident #38 to receive famotidine 20mg and docusate 100mg twice a day at 8:00 AM and again at 4:00 PM. Lamotrigine 100mg at 8:00 AM and again at 6:00 PM. Sodium chloride 1gr twice a day at 9:00 AM and again at 5:00 PM.

A record review of the facility's Medication Admin Audit Report dated [DATE REDACTED] revealed MA E, on [DATE REDACTED], at 10:51 AM, administered Resident #38 his famotidine 20mg, docusate 100mg, lamotrigine 100mg late by 1 hour and 51 minutes and sodium chloride 1gr late by 51 minutes.

4. A record review of Resident #68's admission record dated [DATE REDACTED] revealed an admitted [DATE REDACTED] with diagnoses which included diabetes type 2.

A record review of Resident #68's quarterly MDS assessment dated [DATE REDACTED] revealed Resident #68 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 6 out of a possible 15 which indicated severely impaired cognition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 19 675002 Department of Health & Human Services Printed: 09/10/2025 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 01/30/2025

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 0755 A record review of Resident #68's care plan dated [DATE REDACTED] revealed, (Resident #68) has impaired cognitive function/dementia or impaired thought processes r/t Dementia, Disease Process diabetes, . Administer meds Level of Harm - Minimal harm or as ordered. Date Initiated: [DATE REDACTED] potential for actual harm

A record review of Resident #68's physicians' orders dated [DATE REDACTED] revealed the physician prescribed for Residents Affected - Some Resident #68 to receive metformin 1000mg twice a day at 8:00 Am and again at 4:00 PM.

A record review of the facility's Medication Admin Audit Report dated [DATE REDACTED] revealed MA E, on [DATE REDACTED], at 10:23 AM, administered Resident #68 his Metformin 1000mg late by 1 hour and 23 minutes.

5. A record review of Resident #69's admission record dated [DATE REDACTED] revealed an admitted [DATE REDACTED] with diagnoses which included a urinary tract infection.

A record review of Resident #69's quarterly MDS assessment dated [DATE REDACTED] revealed Resident #69 was an [AGE] year-old male admitted for long term care and assessed with a BIMS score of 3 out a possible 15 which indicated severely impaired cognition.

A record review of Resident #69's care plan date [DATE REDACTED] revealed, Urinary Tract Infection, potential or actual r/t Diagnosis of BPH, Diagnosis of Urinary retention, Use of indwelling catheter dx (diagnosis) ESBL UTI (extended spectrum beta-lactamase urinary tract infection. ESBL-producing bacteria can't be killed by many of the antibiotics that doctors use to treat infections), Date Initiated: [DATE REDACTED] . Antibiotic per MD (medical doctor) order x 5days. Date Initiated: [DATE REDACTED]

A record review of Resident #69's physicians orders dated [DATE REDACTED] revealed the physician prescribed for Resident #69 to receive Bactrim 800mg / 160mg (a combination of 2 antibiotics; sulfamethoxazole and trimethoprim) twice a day at 8:00 AM and again at 8:00 PM.

A record review of the facility's Medication Admin Audit Report dated [DATE REDACTED] revealed MA E, on [DATE REDACTED], at 9:45 AM, administered Resident #69 his Bactrim 800mg / 160mg late by 45 minutes.

During a joint interview on [DATE REDACTED] at 4:04 PM with the operations manager and the DON, the DON stated

the expectation was for the medications to be administered with in 1 hour of the prescribed time. The DON stated his expectation was for MA E to have reported the potential late medication administration and MA E had not reported the late medication administration.

6. A record review of Resident #5's admission record dated [DATE REDACTED], revealed an admitted [DATE REDACTED] with diagnoses which included type II diabetes (a long-term condition which results in too much sugar circulating

in the blood. High blood sugar levels can lead to disorders of the circulatory, nervous, and immune systems.)

A record review of Resident #5's Quarterly MDS assessment dated [DATE REDACTED] revealed Resident #5 was a [AGE] year-old female admitted for long term care and assessed with a memory problem, Moderately impaired - decisions poor; cues / supervision required

A record review of Resident #5's care plan dated [DATE REDACTED] revealed, Alteration in Blood Glucose due to hyper/hypoglycemia dx. DMII, . Date Initiated: [DATE REDACTED] . Administer medications as ordered Date Initiated: [DATE REDACTED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 19 675002 Department of Health & Human Services Printed: 09/10/2025 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 01/30/2025

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 0755 A record review of Resident #5's physicians' orders dated [DATE REDACTED] revealed the physician prescribed for Resident#5 to receive liraglutide 18mg/3ml, 1.2mg injected under the skin daily at 8:00 AM. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on [DATE REDACTED] at 10:30 AM revealed LVN Z attending the nurse treatment cart on the facility's D-hall and was preparing to administer insulins prior to the noon meal. LVN Z Residents Affected - Some demonstrated the insulin stored on the unrefrigerated cart and revealed an insulin injection pen for Resident #5. The pen was labeled, liraglutide injection (Resident #5) 18mg/3ml, . date opened [DATE REDACTED] .exp. [DATE REDACTED] . discard pen 30 days after first use LVN Z stated she would not use the insulin pen because it was expired and would immediately discard the injection pen.

A record review of Resident #81's admission record dated [DATE REDACTED] revealed an admitted [DATE REDACTED] with diagnosis which included type II diabetes.

A record review Resident #81's quarterly MDS assessment dated [DATE REDACTED] revealed Resident #81 was a [AGE] year-old female assessed with a BIMS score of 14 out of a possible 15 which indicated intact cognition.

A record review of Resident #81's care plan dated [DATE REDACTED] revealed, Potential for complication hypo hyperglycemia r/t DMII. Date Initiated: [DATE REDACTED] . Medications/blood sugar check as ordered and as needed. Date Initiated: [DATE REDACTED]

A record review of Resident #81's physicians' orders dated [DATE REDACTED] revealed the physician prescribed for Resident #81 to receive insulin lispro 4 times a day at 6:30 AM, 11:30 AM, 4:30 PM, and at 8:00 PM, insulin lispro 100u/ml inject per sliding scale: if ,d+[DATE REDACTED] = 0; 151 - 250 = 2; . ,d+[DATE REDACTED] = 14 . subcutaneously

before meals and at bedtime for diabetes

A record review of Resident #85's admission record dated [DATE REDACTED] revealed an admitted [DATE REDACTED] with diagnoses which included type II diabetes.

A record review of Resident #85's quarterly MDS assessment dated [DATE REDACTED] revealed Resident #85 was a [AGE] year-old female admitted for long term care and assessed with a memory care problem, Severely impaired - never / rarely made decisions

A record review of Resident #85's physicians' orders dated [DATE REDACTED] revealed the physician prescribed for Resident #85 to receive insulin lispro three times a day at 6:30 AM, 11:30 AM, and at 4:30 PM, (insulin lispro) subcutaneously solution pen injector 100u/ml inject 10 unit subcutaneously before meals for diabetes

During an observation and interview on [DATE REDACTED] at 10:30 AM LVN Z demonstrated the insulin stored on the unrefrigerated cart and revealed a plastic bag which contained 4 insulin injection pen refill vials. The bag was labeled, (Resident #81) (the facility) (insulin lispro) 100u/ml cartridge qty: 15, [DATE REDACTED] . refrigerate

Observation of the 4 vials revealed:

1. 3ml glass vial insulin lispro 100u/3ml labeled with Resident #81's name, dated with an open date of [DATE REDACTED], observed ,d+[DATE REDACTED]'s full.

2. 3ml glass vial insulin lispro 100u/3ml labeled (Resident #81) [DATE REDACTED] observed full.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 19 675002 Department of Health & Human Services Printed: 09/10/2025 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 01/30/2025

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 0755 3. 3ml glass vial insulin lispro 100u/3ml unlabeled with a resident's name, dated with an open date , d+[DATE REDACTED] (no year), observed full. Level of Harm - Minimal harm or potential for actual harm 4. 3ml glass vial insulin lispro 100u/3ml labeled with Resident #85's name, undated, no open date noted, observed ,d+[DATE REDACTED] full. Residents Affected - Some LVN Z stated the vials were stored unrefrigerated, in a bag labeled Resident #81, however, LVN Z could not state who the insulin vials were intended for and could not state the date the vials were unrefrigerated. LVN Z stated she would discard the vials because they were unsafe to use.

During an interview on [DATE REDACTED] at 1:10 PM the DON stated the expectations and trainings for nurses who administer insulin was for the insulin to be labeled with an opened date and a dispose of date, to include a use span of 28 days. The DON stated all insulins older than 28 days and or unlabeled insulins should be discarded. The DON stated the risk for harm would be residents may not receive the therapeutic effects of their prescribed medications.

A policy regarding medication administration was requested on [DATE REDACTED] at 10:00 AM and as of [DATE REDACTED] was not provided; however, a policy titled Documentation of Medication Administration was provided. A record

review of the policy revealed no policy for timely medication administration.

A record review of the Institute for Safe Medication Practices website titled ISMP Acute Care Guidelines for Timely Administration of Scheduled Medication ismp-hosp-temp-MASTER.qxd accessed [DATE REDACTED] revealed, Medications administered more frequently than daily but not more frequently than every 4 hours (e.g., BID, TID, q4h, q6h) Administer these medications within 1 hour before or after the scheduled time.

A record review of the lirglutide manufactures website titled, Victoza (liraglutide) injection, Important Information accessed [DATE REDACTED], https://www.victoza.com/faq.html, revealed, Instructions for Use? You can use your Victoza pen for up to 30 days after you use it the first time. First Time Use for Each New Pen. How should I store Victoza?

Before use:

o Store your new, unused Victoza pen in the refrigerator between 36 F to 46 F (2 C to 8 C).

o If Victoza is stored outside of refrigeration (by mistake) prior to first use, it should be used or thrown away within 30 days.

Pen in use:

o Use a Victoza pen for only 30 days. Throw away a used Victoza pen 30 days after you start using it, even if some medicine is left in the pen.

o Store your Victoza pen at room temperature between 59 F to 86 F (15 C to 30 C), or in a refrigerator between 36 F to 46 F (2 C to 8 C).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 19 675002 Department of Health & Human Services Printed: 09/10/2025 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 01/30/2025

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 0755 A record review of the insulin lispro manufactures website titled [NAME].com/ck/a?!&&p=88304c2b6b2aae02 3b9ebee38f5cae217a125895e1f0391c2809d0dd502d8becJmltdHM9MTc0MDA5NjAwMA&ptn=3&ver=2&hsh Level of Harm - Minimal harm or =4&fclid=1aed91e9-b39d-6b[DATE REDACTED]b27c6a4d&psq=lispro+kwikpen+instructions&u=a1aHR0cHM6Ly9waS5s potential for actual harm aWxseS5jb20vdXMvaHVtYWxvZy1rd2lrcGVuLXVtLnBkZg&ntb=1, accessed [DATE REDACTED], revealed, INSTRUCTIONS FOR USE HUMALOG ([NAME]-ma-log) Residents Affected - Some (insulin lispro) injection, for subcutaneous use revealed, Do not use past the expiration date printed on the Label or for more than 28 days after you first start using. Store unused insulin in the refrigerator at 36 F to 46 F (2 C to 8 C).

o Do not freeze your insulin. Do not use if it has been frozen.

o Unused insulin may be used until the expiration date printed on the Label, if it has been kept in the refrigerator.

In-use:

o Store the insulin you are currently using at room temperature [up to 86 F (30 C)]. Keep away from heat and light.

o Throw away the HUMALOG insulin you are using after 28 days, even if it still has insulin left in it.

A record review of the facility's policy titled, Medication Labeling and Storage dated February 2023, revealed,

The facility stores all medications and biologicals and locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to the keys. Policy interpretation and implementation: medication storage; . compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trains or carts used to transport such items are not left unattended if open or otherwise potentially available to others. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. H residence medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. medication labeling; labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The medication label includes, at a minimum: the medication name, prescribed dose, strength, expiration date, when applicable, residents name, route of administration, and appropriate instructions and precautions. multi dose vials that have been opened or accessed (for example needle punctured) are gated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Multi dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 19 675002