Sage Park San Antonio

Inspectors wroteBased on observation, interview, and record review, the 1 of 1 kitchen failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen. 1-The facility failed to have four kitchen staff complete their food handler certificates (Cook-I, DA-J, DA-K, DA-L) These failures could place residents at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the 1 of 1 kitchen failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen. 1. The facility failed to clean two wall vents which measured approximately 4x2 ft which were located across from the kitchen's freezer. 2. The facility failed to clean a 3x3 ft ceiling vent in the dry storage room. 3. The facility failed to clean a 3x3 ft ceiling vent located at the entrance to the dish room. 4. The facility failed to maintain proper hair restraints on two kitchen employees (Cook-G and DA-H) 5. The facility failed to maintain the required dish machine rinse temperature, and only reached 110 degrees Fahrenheit. 6.-The facility failed to clean the top surface of the dish machine in the kitchen's pantry room. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to establish and maintain, an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 4 of 29 residents (Residents #38, #39, #8 and #3) reviewed for incontinent care. 1. facility failed to ensure LVN C sanitized the blood pressure cuff when she used it between two residents (Residents #38 and #39) during medication pass. 2. The facility failed to ensure CNA D discarded her soiled gloves, sanitized her hands and put clean gloves on when she placed Resident #8's soiled brief in the trash can and continued to place clean items onto the resident. 3. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 2 of 27 resident rooms on (rooms [ROOM NUMBERS]) and the beauty salon and laundry room reviewed for environmental concerns.1-The facility failed to replace an overhead bathroom sink light cover in room [ROOM NUMBER].2-The facility failed to replace an overhead bathroom sink light cover in room [ROOM NUMBER].3-The facility failed to clean an 18 x 18 ceiling air vent in the beauty salon.4-The facility failed to clean an 18 x 18 ceiling air vent in the laundry room. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 16 residents (Resident #8) reviewed for accurate MDS assessments. The Facility failed to ensure Resident #8's fall status was accurately reflected on her quarterly MDS assessment, dated 11/14/2025. This deficient practice could place residents at risk of missed or inaccurate care.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 16 residents (Resident #8) reviewed for comprehensive person-centered care plans. The facility failed to ensure a care plan was developed to address Resident #8 as a fall risk and include interventions to prevent falls. This deficient practice could place residents at risk for falls and could result in injury.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 resident of 2 residents (Resident #3) reviewed for incontinent care. CNA D failed to pull back Resident #3's foreskin to clean his penis during incontinent care. This deficient practice could place residents risk of urinary tract infections (bacteria in the urine) or skin breakdown.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 5 residents (Residents #14 and #15) reviewed for oxygen therapy. The facility failed to replace a dirty and worn oxygen filter in Resident #14's oxygen concentrator, humidifier bottle was not changed and NC tubing was not bagged when not in use. 2. The facility failed to replace a dirty and dusty oxygen filter in Resident #15's oxygen concentrator, nebulizer mask was not bagged when not in use. These deficient practices could places residents at risk of respiratory infection and difficulty breathing.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed 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 1 (Medication Cart B and C Halls) of 2 medication carts reviewed for expired medications. The facility failed to ensure the Medication Cart for B and C Halls did not contain an expired bottle of Atropine 1% drops. This deficient practice could place residents at risk to receive expired medication with less effective results. Observation on 01/08/2026 at 08:20 am accompanied by LVN F when checking the Medication Cart for B and C Halls, revealed a plastic bottle of Atropine 1%, with an expiration date of 08/29/2025 was found on the cart. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable and in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for and 1 of 1 treatment cart (Treatment Cart) reviewed for medication storage. The facility failed to ensure RN A and the ADON did not leave the treatment cart unlocked when they went to perform a treatment on a resident. These deficient practices could place residents at risk of misappropriation of treatment medications and supplies.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 2 of 2 Dumpsters (Dumpsters #1 and #2) reviewed for garbage and refuse disposal. The facility failed to ensure Dumpster #1 and Dumpster #2 had lids that were completely closed This deficient practice could place residents at risk for exposure to germs and diseases carried by vermin and rodents.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 5 of 12 residents (Residents #15, #18, #5, #1, and #20) whose assessments were reviewed, in that: 1. Resident #15 had falls on 8/30/2024 and 9/5/2024 but Resident #15's Quarterly MDS dated [DATE] revealed falls after admission was not coded for falls after admissioon or readmission. 2. Resident #18 had been using oxygen per nasal canula at 2 liters continuously since admission, but the admission MDS dated [DATE] was not coded for oxygen use. 3. Resident #5 had a fall on 9/8/2021 but Resident #5's QMDS dated [DATE] revealed falls after admission was not coded for falls after admission or readmission. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: During observation of the kitchen on 10/08/2024 at 10:01AM with the DM revealed: 1. There was a bag of kernel corn left open in the walk-in freezer. 2. There was container with slices of turkey not labeled or dated in the walk-in cooler. 3. There was a bag with two rolls left open in the dry storage room. 4. There was a box of oatmeal with the top off in the dry storage room. 5. There were six containers of seasoning not closed in the dry storage room. 6. There were two backpacks stored on a shelf next to food in the dry storage room. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 1 of 5 residents reviewed for new admissions. (Resident #78) The facility failed to develop Resident #78's baseline care plan dated 10/01/2024 regarding the resident's physician order dated 10/01/2024 for colostomy care within 48 hours of admission on [DATE]. These failures could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise Resident Care Plans after each assessment for 1 of 12 Residents (Resident #1) whose records were reviewed for care plan revision/timing, in that: Resident #1's care plan dated 08/25/2022 was not updated after her quarterly MDS assessment, dated 09/05/2024, reflected she was always incontinence to bowel. These deficient practices could affect any resident and contribute to Residents not receiving the care and services they needed.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and safe environment to prevent accidents for 1 of 12 residents (Residents #20) reviewed for environment. The facility failed on 10/08/2024 when there was one used disposable razor found on the sink faucet of Resident # 20's bathroom. This deficient practice cause infection or other physical injuries to residents and even staff.

Inspectors wroteBased on observation, interview, and record review, 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 1 of 3 medication carts (A and B hall nursing cart) reviewed for pharmacy services. There was one medication (Benadryl itching stopping gel topical for skin use only) expired on 05/2021 found inside A and B hall nursing cart on 10/9/2024. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys to 1 of 12 residents (Resident #9) reviewed for medications at the bedside. Resident #9's ear wax remove kit was left unattended and unsecured on the nightstand at the resident's bedside on 10/08/2024. These failures could place residents at risk for misappropriation of property and could place residents at risk for accidents, hazards, and not receiving therapeutic effects.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #20) of 12 residents reviewed for accuracy and completeness of clinical records. Wound care nurse RN-C documented on the skin evaluation, dated 08/21/2024 Resident #20's deep tissue injury was to the resident's right heel, when the resident had deep tissue injury to his left heel on 10/10/2024. This failure placed facility residents at risk for lack of wound care or incorrect wound care due to misinformation by incomplete and inaccurate medical record.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 resident (Residents #1) of 12 residents reviewed for infection control. The facility failed on 10/08/2024 to discard in a red plastic bag, sealed, and placed in biohazard storage a Suction tube Yankauer (oral suction tool used in medical procedure) that was found opened, covered in the plastic bag, connected to the suction machine and was on Resident #1's nightstand. The Yankauer appeared to be dirty with brown colored residual. These deficient practices affect residents who require suction and could place residents at risk for cross contamination and infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 6 residents (Resident #1) reviewed for respiratory care, in that: 1. The facility failed to monitor Resident #1 to ensure she was connected to continuous oxygen in accordance with her physician's order. 2. The facility failed to accurately document Resident #1's oxygen saturation levels when they were discovered to be in the 60s as a result of not being connected to continuous oxygen in accordance with her physician's order. 3. The facility failed to accurately document Resident #1's change of condition in her progress notes upon discovering Resident #1 was not connected to continuous oxygen in accordance with her physician's order. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (Main Kitchen), in that: 1. The facility failed to ensure an items in the walk-in refrigerator and dry storage areas were dated and or discarded correctly 2. The facility failed to ensure equipment used to cook were properly and thoroughly cleaned. These deficient practices could place residents who ate food from the kitchen at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 2 isolation rooms and 3 of 7 residents (Resident #4, #78 and, #130) reviewed for infection control, in that: 1. Resident #4's room had personal protective equipment on the door but no sign to indicate the type of isolation the resident was under. 2. CNA B failed to wash or sanitize her hands or change her gloves after touching the privacy curtain and before starting perineal care. 3. RN C failed to wash or sanitize her hands and change gloves after cleaning a wound. These deficient practices could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 1 of 1 shower room observed for environment, in that: The facility failed to ensure potential hazards were locked up in the shower room. This deficient practice could place residents at risk of a diminished quality of life due to an unsafe environment.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 5 of 18 employees (CNA E, CNA F, CNA H, CNA J, LVN K, and RN M) reviewed for training, in that: The facility failed to ensure CNA E, CNA F, CNA H, CNA J, LVN K, and RN M completed QAPI training within the last year. These failures could affect residents and place them at risk of poor care or victimization due to lack of staff training.

Inspectors wroteBased on interview, and record review, the facility failed to develop a comprehensive person-centered care plan for each that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 resident (Residents #121) reviewed for care plans, in that: The facility failed to ensure Resident #121 Full code status was care planned. This deficient practice place residents at risk for not receiving proper care and services due to inaccurate care plans.

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 or 2 meals (lunch) reviewed for food meeting residents' needs, in that: The facility failed to ensure the pureed mashed potatoes and pureed chicken cutlet was a pudding consistency as required for food served to residents who received a pureed diet. This deficient practice could affect residents who received pureed meals from the kitchen by contributing to dissatisfaction, poor intake, choking, and/or weight loss.