The Rio At Mission Trails
The Rio at Mission Trails in San Antonio, TX — inspection on February 24, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a capping trial on [DATE], Resident #1 was not monitored, and no staff were physically present in her room. Resident #1 became unresponsive and had to be transported to the ER for treatment.
The facility did not have a policy/procedure in place for capping trials at the time of the incident. Resident #1 died at the hospital on [DATE].
This failure resulted in an IJ on [DATE] at 5:00 PM.
While the IJ was removed on [DATE] at 3:45 PM., the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that was not immediate jeopardy with a scope of isolated due to facility's need to evaluate the effectiveness of their plan of removal.
This failure could place tracheostomy residents recommended for a capping trail at risk for exacerbation of condition up to and including death.
The findings included:
Resident #1's face sheet, undated, revealed the resident was a [AGE] year-old admitted on [DATE], readmitted [DATE], transferred to hospital [DATE], and deceased [DATE].
Diagnoses included: stroke, cerebral aneurism (blood vessel weakness in the brain), diabetes, DVT (deep vein thrombosis) (blood clots in deep vein), HTN (hypertension), quadriplegic, and seizures.
Further review revealed the resident's RP was listed as a family member, and the resident's Code Status was Full Code.
Record review of Resident#1's admission note, dated [DATE] and [DATE], reflected the resident was admitted to the facility with a tracheostomy on both occasions.
Record review of Resident #1's admissions MDS, dated [DATE], reflected the resident was unable to answer questions in cognition, and had upper and lower extremity impairments due to a diagnosis of stroke.
Record review of Resident #1's Care Plan, dated [DATE], reflected: resident had a tracheostomy related to respiratory failure.
Interventions included tracheostomy care Q shift and Capping trials 30 mins_1 hour BID as tolerated .
Monitor respiratory rate, depth and quality .
Record review of Resident #1's physician's order, dated ,d+[DATE], reflected orders to administer capping trials for 30 minutes up to 1 hour twice per day on the day shift starting [DATE] and ending [DATE]; and use of nasal cannula at 3L/ minute during capping trials.
Record review of Resident #1's Pulmonologist note, dated [DATE] at 11:30 AM, reflected, resident tolerated the second capping trial on [DATE] well and was on a T piece for oxygen.
676297
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 676297 B.
Wing 02/24/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
The Rio at Mission Trails 6211 S New Braunfels Ave San Antonio, TX 78223