San Antonio Wellness & Rehabilitation

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

discovered the roommate was taking Resident #1's personal items to another room. Resident #1 did not state she wanted to leave the secured unit and did not state why she was on the secured unit. She stated

the activities director took the residents outside to do fun activities and the staff were amazing. During an

interview on 09/11/2025 at 02:14 p.m., the DON stated Resident #1 was moved to the secure unit due to having been exit seeking and combative. The DON stated the family was informed about the changes and had told her (the DON) to not call them about Resident #1. The DON stated Resident #1's emergency contact had told her that she did not want to be bothered with Resident #1 right then. The DON stated there was no signed consent for the room change. During an interview on 09/11/2025 at 02:14 p.m. (entered room during DON interview), the ADMIN stated there was not a signed consent for Resident #1's room change in her chart. He stated he was unaware if Resident #1's family was notified immediately about Resident #1's move to the secure unit or if they provided room change consent. He stated he was aware that Resident #1's family had told him, the DON, and the ADON not to contact them regarding Resident #1.

He stated he did recall Resident #1 exhibited behaviors after admission but could not provide details of Resident #1's move to the secure unit. Attempted interview with MD C on 09/11/2025 at 03:22 p.m. Call back not received. Record review of policy titled, Resident Rights, date revised 08/2020, revealed All residents have a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility including those specified in this policy. The Facility will protect and promote the rights of the resident. A. Be informed about what rights and responsibilities he or

she has. C. Choose a physician and treatment and participate in decisions and care planning, including involving representatives and considering personal and cultural preferences;.

Event ID:

Facility ID:

If continuation sheet

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

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

San Antonio Wellness & Rehabilitation

One Heartland Dr San Antonio, TX 78247

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 0603 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

#1's family member and emergency contact #1 stated she did not understand why Resident #1 had been moved to a secure unit. She stated she was eventually told (unable to provide who told her or when) that Resident #1 had gone to the front desk and was asking where she (family member) was. The family member stated she wanted Resident #1 back on the general population hall and out of the secure unit. The family member stated she voiced this request to the facility during the care planning meeting. During an

observation and interview on 09/10/2025 at 12:10 p.m., Resident #1 stated the facility is very nice and she gets along with almost everyone. She stated she currently had a private room but would like a roommate.

She stated her prior roommate was moved after it was discovered the roommate was taking Resident #1's personal items to another room. Resident #1 did not state she wanted to leave the secured unit and did not state why she was on the secured unit. She stated the activities director took the residents outside to do fun activities and the staff were amazing. Resident #1 did not appear upset, stressed, or agitated during the conversation and subsequent observations regarding her placement in the secured unit. During an

interview on 09/10/2025 at 03:57 p.m., CNA A, a CNA on the secure unit, stated Resident #1 had not exhibited exit-seeing behaviors and was easily re-directed if she appeared to be wandering aimlessly. CNA

A stated Resident #1's wandering happened mostly when Resident #1 had forgotten something and was looking for it. During an interview on 09/10/2025 at 04:00 p.m., LPN B, a nurse on the secure unit, stated

she had never seen Resident #1 try to elope or even act as if she wanted to elope. She stated Resident #1 would sometimes wander because she was looking for something she had forgotten. She stated Resident #1 had poor short-term memory but was easily redirected. She stated Resident #1 will sometimes go to the exit door to look through the window and put her hands on the bar, but she knows the door is locked and does not try to exit. LPN B stated she was not aware of Resident #1 having had an elopement attempt and had not been told by other staff of an attempt. She stated Resident #1's only exhibited behavior was being forgetful. During an interview on 09/10/2025 at 04:18 p.m., the ADON stated residents did not have to have

an order for placement on the secure unit if there was an elopement attempt. The ADON stated Resident #1 came to the facility for skilled services originally, not long-term care, but she tried to elope from the rehabilitation unit. She stated residents could be moved to the secure unit for their safety. The ADON could not explain why there was not an elopement assessment done for Resident #1 prior to her placement since

the initial assessment revealed no risk. The ADON could not explain why the second elopement assessment, with a moderate risk and a created date of 06/16/2025, was entered into Resident #1's today, 09/10/2025. During an interview on 09/11/2025 at 02:14 p.m., the DON stated Resident #1 did not have an order for having been on the secure unit. She stated Resident #1 was moved to the secure unit due to having been exit seeking and combative. The DON stated Resident #1's move to the secure unit was care planned from the time of her transfer. During an interview on 09/11/2025 at 02:14 p.m. (entered room during DON interview), the ADMIN stated he could not provide details of why Resident #1's did not have orders for her move to the secure unit but did recall Resident #1 had exhibited behaviors right after her admission.

Attempted interview with MD C on 09/11/2025 at 03:22 p.m. Call back not received. Record review of policy titled, Wandering & Elopement, date revised 08/2020, revealed the purpose of the policy, To enhance the safety of residents of the Facility and a policy statement, The Facility will identify residents at risk for elopement and minimize any possible injury as a result of elopement. The policy procedure did not include

a process or indications for residents to be evaluated for the secure unit.

Event ID:

Facility ID:

If continuation sheet

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

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

San Antonio Wellness & Rehabilitation

One Heartland Dr San Antonio, TX 78247

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

in a wheelchair. She was noted as cognitively impaired and wandered aimlessly. She was noted as having ambulated and propelled self, and/or wanders and had intentionally or unintentionally attempted to leave

the community. She was not noted as having verbalized a plan to elope. Interventions were noted for Wander guard and/or secure environment placement. The elopement risk evaluation had a score of 15.0, imminent risk for elopement. Record review of Resident #2's Order Summary Report, dated 09/10/2025 at 04:42 p.m., reflected no orders for admission to the facility or orders for secure unit placement. Record

review of Resident 2's Order Recap Report, dated 09/11/2025 at 04:31 p.m., reflected the following orders:Admit to [facility name] under the care of [MD C] for long-term care in the MCU On hold from 04/27/2025 22:50 [10:50 p.m.] to 05/04/2025 22:49 [10:49 p.m.] On hold from 07/09/2025 07:01 [07:01 a.m.] to 07/10/2025 07:00 [07:00 a.m.], noted as discontinued with order date of 01/21/2025 and end date of 07/10/2025. Discontinue notation did not include reason, but one hold order included reason, sent to ER for evaluation and one resume order included reason, return from ER. -- May admit to secure unit Dx: DELUSIONAL DISORDERS On hold from 04/27/2025 22:50 [10:50 p.m.] to 05/04/2025 22:49 [10:49 p.m.]

On hold from 07/09/2025 07:01 [07:01 a.m.] to 07/10/2025 07:00 [07:00 a.m.], noted as discontinued with order date of 01/21/2025 and end date of 07/10/2025. Discontinue notation did not include reason, but one hold order included reason, sent to ER for evaluation and one resume order included reason, return from ER. - Admit to [facility name] under the care of [MD C] for LTC SERVICES., noted as discontinued with order date of 07/13/2025 and end date of 07/14/2025. Discontinue notation did not include reason.- ***Late entry for 7/13/25***Admit to [facility name] under the care of [MD C] for skilled services for HYPERTENSIVE URGENCY, noted as discontinued with order date of 07/14/2025 and end date of 07/15/2025. Discontinue notation did not include reason.- ***Late entry for 7/13/25***Admit to [facility name] under the care of [MD C] for skilled services for ATAXIA, UNSPECIFIED, noted as discontinued with order date of 07/15/2025 and end date of 08/25/2025. Discontinue notation did not include reason. Record review of Resident #2's care plan, undated and accessed 07/11/2025, revealed Resident #2 was admitted to and will reside in the facility's Memory Care Unit for ongoing care and supervision. R/T Diagnosis of: UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY & risk for elopement related to Elopement Evaluation risk score. Resides in MEMORY CARE UNIT. [Resident #2] is an elopement risk/wanderer AEB Disoriented to place, History of attempts to leave facility unattended, Impaired safety awareness, Resident wanders aimlessly, Significantly intrudes on the privacy or activities. The care plan focus was initiated on 01/21/2025 and created and revised on 03/20/2025. During an observation on 09/10/2025 at 11:58 a.m., Resident #2 was noted on the secure unit. Resident #2 was not interviewable.

During an interview on 09/11/2025 at 09:15 a.m., Resident #2's resident representative and guardian stated Resident #2's care at the nursing facility had been amazing. She stated Resident #2 was provided

the care she required, was aware Resident #2 was on the secure unit, and she and Resident #2 had not had any issues with the staff or other residents on the unit. Attempted interview with MD C on 09/11/2025 at 03:22 p.m. Call back not received. Record review of policy titled, Physician Orders, date revised 06/2020, revealed the purpose, This will ensure that all physician orders are complete and accurate. The policy statement revealed The Medical Records Department will verify that physician orders are complete, accurate and clarified as necessary. The Procedure included, VI. Documentation pertaining to physician orders will be maintained in the resident's medical record.

Event ID:

Facility ID:

If continuation sheet