River City Care Center

The facility failed to ensure Resident #3 did not have [a cleaning solution] at bedside on 05/28/26 and 05/29/26.

These failures could place residents at risk for negative adverse effects.

Findings included:

Record review of Resident #3's admission record, dated 05/26/26, reflected resident was a [AGE] year-old male, admitted [DATE], with diagnoses to include major depressive disorder and generalized anxiety disorder.

Record review of Resident #3's quarterly MDS assessment, dated 05/09/26, reflected that resident had a BIMS score of 13 out of 15, indicating intact cognition.

Record review of Resident #3's care plan, last care plan review completed 05/14/26, did not reflect that resident could have cleaning supplies/chemical agents in his room for personal use.

Observation on 05/28/26 at 08:12 AM revealed Resident #3 had [a cleaning agent] on the side of his bed.

During an interview and observation on 05/29/26 at 08:33 AM, LVN A confirmed that Resident #3 had [a cleaning agent] at his bedside.

She removed it from his room and revealed he was not allowed to have it in his room.

During an interview on 05/29/26 at 08:35 AM, CNA E revealed she had seen [a cleaning agent] in Resident #3's room, but she assumed he was allowed to have it in his room because she was new, because she expected other nursing staff who knew the resident more would take it out of his room because other staff had been providing resident care as well.

She further revealed she knew [a cleaning agent] should not be in a resident's room to keep residents safe.

During an interview on 05/29/26 at 12:40 PM, the ADM and the DON revealed Resident #3 was okay to have [a cleaning agent] in his room because he was alert and oriented, but in order to protect other residents they were going to put it in his care plan that him and his family bring in cleaning agents despite education, so nursing staff could monitor his room and keep any cleaning agents behind the nurse's station.

During an interview on 05/29/26 at 02:10 PM, the DON revealed it was important to not give residents that may not be alert and oriented access to cleaning agents to keep them safe.

During an interview on 05/29/26 at 02:18 PM, the ADM revealed that they did not have any residents that wandered into other residents' rooms at this facility.

She revealed the facility did not have to worry about a resident going into Resident #3's room so residents remained safe because they could not get the cleaning agent.Policies regarding accidents and hazards, prohibited items/items allowed in the facility (to include chemicals/cleaning supplies) were requested from the ADM on 05/29/26 at 09:27 AM and the ADM did not have these policies.

675896 05/29/2026

River City Care Center 921 Nolan St San Antonio, TX 78202

During an interview on 05/28/26 at 03:35 PM, the Dietary

anything they were allergic to.

During an interview on 05/28/26 at 03:39 PM, CNA C revealed he was

lactose and it was good to know now. He noticed Resident #2 did not drink lactose products, so it made sense.

During an interview on 05/28/2026 at 04:11 PM, the DON revealed they confirmed with Resident #2 that he had a lactose intolerance.

She revealed she was unaware of when lactose allergy was reflected in his electronic medical record and it should be on his meal tray tickets.

During an interview 05/28/2026 at 04:34 PM, the ADM and DON revealed it was important to follow meal tray tickets to ensure they have the right diet, right texture, and right resident.

During an interview on 05/29/26 at 11:56 AM, the RD reviewed Resident #2's electronic medical record remotely and his nutrition related assessments did not reflect Resident #2 having a lactose allergy.

She revealed Resident #2's lactose allergy was on his face sheet but she was not aware of when that was there because in his interviews he never mentioned having a lactose allergy.

She revealed it may have been a miss on our part and she was unaware of who communicated residents' allergies to the kitchen to put it on their meal tray ticket so that everyone involved in his care knew what foods to serve him and prevent problems due to allergies.

During an interview on 05/29/2026 at 01:38 PM, the DON revealed Resident #2's lactose allergy should have been communicated to the dietary department.

She revealed nursing staff could do that, and it was important in order for residents to not have reactions with foods.

Record review of the facility's policy Food Preference List, dated 2012, reflected . 2.

Information should be obtained by interview on all new residents. 3.

Tray cards are to be updated at least quarterly and reflect appropriate information from food preferences.

Generally, the dislikes are the most relevant on the tray card.

Record review of the facility's policy Resident Meal Service and HS Snack, dated, reflected 1.

Upon admission and periodically thereafter, the resident and/or family member will be interviewed by the dietary manager or designee to determine individual food preferences, dislikes, and allergies.

675896 05/29/2026

River City Care Center 921 Nolan St San Antonio, TX 78202

The facility failed to store sliced cheese in a sealed container on 05/28/26.3.

The facility failed to label a bag of onions and bell peppers with a discard date on 05/28/26.4.

The facility failed to ensure there was not a personal beverage in the food preparation area on 05/28/26.

These failures could place residents at risk for food borne illness.

The findings included: During an observation and interview on 05/28/26 at 08:39 AM revealed there was a missing temperature for 2 freezers and 1 refrigerator on May 2026 temperature log for 05/27/26 night temperature. [NAME] B revealed it was important to have the temperature logs up to date to ensure no food went bad.

During an observation and interview on 05/28/26 at 08:42 AM, revealed there was a bag of sliced cheese in the walk-in refrigerator that was not sealed and exposed to air. In the walk-in refrigerator, it was further revealed there was a bag of onions and bell peppers with no discard/use-by date.

The Dietary Manager and [NAME] B revealed foods that were stored in the refrigerator should have a discard date and be in a sealed bag to ensure the foods that were used for residents' meals were not old or became hard.

The Dietary Manager revealed temperatures needed to be documented to ensure proper food storage.

The Dietary Manager revealed all kitchen staff could ensure temperatures were recorded and food was stored properly but he oversaw everything.

During an interview and observation on 05/28/26 at 11:34 AM, revealed there was a personal beverage (open clear cup of fluid) in the food preparation area while [NAME] B was prepping 05/28/26 lunch. [NAME] B and the Dietary Manager revealed the personal beverage should not be in the food preparation area to prevent cross contamination and it belonged to Dietary Aide D.

During an interview on 05/28/26 at 11:37 AM, Dietary Aide D confirmed that he did have a personal beverage in the food preparation area, but he had just poured it and left the kitchen. He revealed he should not have a personal beverage in the food preparation area because it could cause cross contamination.

Record review of the facility's policy Daily Food Temperature Control, dated 2012, reflected . 3.

Temperatures are recorded on the Temperature Log form .

Record review of the facility's policy Refrigerator/Freezer Temperature Log (Instructions), dated 2012, reflected 1.

Dietary Services Manager will be the person responsible for making sure the temperature of the refrigerator/freezer is recorded on a daily basis. 7.

Take temperatures at the same time every morning and evening.

Record review of the facility's policy Food Storage and Supplies, dated 2012, reflected . 4.

Open packages of food are stored in closed containers with covers or in sealed bags.

Record

Review of the Food Code, U.S.

Public Health Service, U.S. FDA, 2022, U.S.

Department of H&HS, revealed, 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination.

Record review of the FDA Food Code 2022, U.S.

Department of H&HS, reflected, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days.

The day of preparation shall be counted as Day 1