Inspection Reports for Mystic Park Nursing and Rehabilitation Center
8503 Mystic Park, San Antonio, TX 78254, United States, TX, 78254
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
51% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 6
Date: Jan 24, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, assessment accuracy, incontinence care, pharmaceutical services, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity (staff entering rooms without knocking), inaccurate resident assessments, inadequate incontinence care, expired medications on nursing carts, improper food handling and storage, and failure to follow infection control protocols for a resident on enhanced barrier precautions.
Deficiencies (6)
Failure to treat residents with respect and dignity by entering rooms without knocking.
Inaccurate resident assessments for 3 residents, including incorrect medication and hospice status coding.
Failure to provide appropriate incontinence care and catheter care, including not cleaning all areas and catheter tubing touching the floor.
Expired medications found on two nursing carts.
Food service staff contaminated food by touching inside rims of plates; unlabeled and undated food found in resident's personal refrigerator.
Failure to follow infection control protocol by not wearing gown during suprapubic catheter care on a resident with enhanced barrier precautions.
Report Facts
Residents reviewed for assessment accuracy: 21
Residents reviewed for incontinence care: 3
Medication and nursing carts reviewed: 5
Residents personal refrigerators reviewed: 4
Employees trained in food handling in-service: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA K | Certified Nursing Assistant | Entered resident rooms without knocking, acknowledged should have knocked |
| MDS Nurse | Minimum Data Set Nurse | Entered resident rooms without knocking, acknowledged inaccurate MDS coding |
| DON | Director of Nursing | Provided expectations on knocking, confirmed inaccurate assessments and medication errors, confirmed infection control lapses |
| CNA-E | Certified Nursing Assistant | Failed to clean resident's right buttock during incontinence care |
| LVN L | Licensed Vocational Nurse | Confirmed medication details and assessment inaccuracies |
| RN-G | Registered Nurse | Acknowledged expired medication found on nursing cart |
| LVN-H | Licensed Vocational Nurse | Acknowledged expired medication found on nursing cart |
| DA A | Dietary Aide | Touched inside rim of plates while serving food |
| DA B | Dietary Aide | Touched inside rim of plates while serving food |
| DA C | Dietary Aide | Touched inside rim of plates while serving food |
| DS | Dietary Supervisor | Provided training and infection control guidance to dietary staff |
| LVN-I | Licensed Vocational Nurse | Acknowledged unlabeled and undated food in resident refrigerator |
| CNA-J | Certified Nursing Assistant | Failed to wear gown during suprapubic catheter care on resident with enhanced barrier precautions |
| RD | Registered Dietitian | Provided guidance on food handling and infection control |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 19, 2024
Visit Reason
The inspection was conducted based on complaints alleging failure to maintain a clean, comfortable, and homelike environment and failure to timely report suspected abuse, neglect, or injuries of unknown source for certain residents.
Complaint Details
The complaint investigation involved review of records and interviews related to residents #1, #2, #3, and #4. Resident #3 and #4's room had a persistent strong urine odor despite twice daily cleaning. Resident #1 had abrasions likely caused by extrapyramidal side effects movements that were not reported to the state. Resident #2 experienced an unobserved fall resulting in a hospital evaluation that was not reported to the state. The facility cited following a provider letter as reason for not reporting some incidents.
Findings
The facility failed to maintain a sanitary and comfortable environment for residents #3 and #4 due to persistent urine odor and inadequate housekeeping. Additionally, the facility failed to timely report suspected abuse or neglect involving residents #1 and #2, including unreported injuries and an unobserved fall requiring hospital evaluation.
Deficiencies (2)
Failure to provide a clean, comfortable, and homelike environment with housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 of 6 residents (Residents #3 and #4) reviewed for resident rights, including persistent strong urine odor in their shared room.
Failure to timely report suspected abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, for 2 of 6 residents (Residents #1 and #2).
Report Facts
Residents reviewed for rights: 6
Residents reviewed for abuse and neglect: 6
Size of abrasion: 9
Cleaning frequency: 2
Fall date: Aug 15, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN F | Registered Nurse | Conducted skin evaluation for Resident #1 and documented progress notes. |
| CNA A | Certified Nursing Assistant | Assigned to Resident #3 and commented on urine odor in room. |
| DON | Director of Nursing | Interviewed regarding urine odor, cleaning practices, and reporting of incidents. |
| Administrator | Facility Administrator | Interviewed regarding urine odor, cleaning practices, and reporting of incidents. |
| HK B | Housekeeping Staff | Interviewed about cleaning frequency and practices in Residents #3 and #4's room. |
| HK C | Housekeeping Staff | Interviewed about cleaning frequency and practices in Residents #3 and #4's room. |
| ADON | Assistant Director of Nursing | Interviewed regarding Resident #1's EPS movements and incident investigations. |
| LVN D | Licensed Vocational Nurse | Interviewed about Resident #2's fall incident. |
| CNA E | Certified Nursing Assistant | Interviewed about Resident #2's fall incident. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 28, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide pharmaceutical services that meet the needs of residents, specifically related to medication monitoring and hospice care coordination for Resident #1.
Complaint Details
The complaint investigation revealed that the facility failed to monitor Digoxin levels and parameters for Resident #1, who was on hospice care, resulting in digoxin toxicity and hospitalization. The facility also failed to coordinate hospice care planning and communication with hospice providers, leading to substandard care risk.
Findings
The facility failed to clarify orders for Digoxin regarding parameters and lab monitoring, failed to ensure pharmacist medication reviews every 30 days, and failed to coordinate hospice care planning effectively. These failures resulted in an Immediate Jeopardy (IJ) that was removed after corrective actions, but the facility remained out of compliance at a level of potential harm.
Deficiencies (2)
Failure to provide pharmaceutical services including accurate acquiring, receiving, dispensing, and administering of drugs to meet resident needs, specifically for Digoxin monitoring and pharmacist reviews.
Failure to collaborate with hospice representatives and coordinate hospice care planning, including communication with hospice medical director and attending physician.
Report Facts
Residents on Hospice: 19
Resident Medication Reviews: 102
In-service Training Signatures: 129
Digoxin Monitoring Signatures: 27
Medications with Parameters Signatures: 27
Care Plan for MDS Nurses Signatures: 2
New Admissions Weekend RN Supervisor Signatures: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN I | Admitting Nurse | Admitting nurse for Resident #1 who stated hospice nurse and himself reviewed medications including Digoxin. |
| DON | Director of Nursing | Provided statements about following physician orders for hospice residents and monitoring corrective actions. |
| Pharmacist | Conducted medication reviews and participated in corrective action audits. | |
| Administrator | Notified of Immediate Jeopardy and involved in plan of removal and QAPI meetings. | |
| Hospice Medical Physician | Provided orders for Resident #1 and stated no parameters or labs were ordered for Digoxin. | |
| LVN H | Licensed Vocational Nurse | Admitting nurse for Resident #1 who stated hospice nurse and himself reviewed medications including Digoxin. |
| RN L | Registered Nurse | Authored nurse note documenting Primary Care Physician was called regarding Resident #1. |
| LVN I MDS Nurse | MDS Nurse | Pulled reports of medications needing parameters and updated care plans for hospice residents. |
| Staffing Coordinator | In-serviced on not allowing new staff on floor without completing in-service on parameters. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 8, 2023
Visit Reason
The inspection was conducted to investigate complaints related to PASARR screening for mental disorders, kitchen sanitation, and infection prevention and control practices at Mystic Park Nursing & Rehabilitation Center.
Complaint Details
The complaint investigation revealed failures in PASARR screening for mental disorders, kitchen sanitation related to the ice maker, and infection control practices involving hand hygiene by two staff members (RN A and LVN B). The PASARR deficiency affected a few residents, the ice maker and infection control deficiencies affected few to some residents. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to ensure accurate PASARR Level I assessments for residents with mental disorders, maintain cleanliness of the kitchen ice maker, and enforce proper hand hygiene among staff, potentially placing residents at risk for inadequate care, foodborne illness, and infections.
Deficiencies (3)
Failed to ensure all Pre-admission Screening and Resident Review (PASARR) Level I residents with a mental disorder were provided with an accurate PASARR assessment.
Failed to maintain the cleanliness of the ice maker found within the kitchen, risking cross-contamination and foodborne illness.
Failed to maintain an infection prevention and control program; staff contaminated hands after washing and then provided care, risking resident infections.
Report Facts
Residents reviewed for PASARR Level I: 5
Residents affected by PASARR deficiency: 1
Staff reviewed for infection control: 5
Staff found deficient in infection control: 2
Severity rating for ice maker cleanliness: 3
Severity rating for ice maker cleanliness: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in infection control deficiency for contaminating hands after washing |
| LVN B | Licensed Vocational Nurse | Named in infection control deficiency for contaminating hands after washing |
| MDS Coordinator | Interviewed regarding PASARR screening deficiency for Resident #67 | |
| Administrator | Interviewed regarding PASARR screening deficiency | |
| DON | Director of Nursing | Interviewed regarding PASARR screening and infection control deficiencies |
| DM | Dietary Manager interviewed regarding ice maker cleanliness | |
| MS | Maintenance Supervisor interviewed regarding ice maker cleaning | |
| ADM | Administrator interviewed regarding municipal food inspection and ice maker | |
| RD | Registered Dietitian | Interviewed regarding ice maker inspections and severity ratings |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Oct 14, 2022
Visit Reason
The inspection was conducted as a standard annual survey of Mystic Park Nursing & Rehabilitation Center to assess compliance with regulatory requirements related to resident rights, care planning, accident prevention, dietary services, and food safety.
Findings
The facility was found deficient in multiple areas including failure to provide private space for resident council meetings, incomplete advance directives, inadequate comprehensive care plans for incontinence, failure to use fall mats for high-risk residents, improper perineal care, failure to provide special eating equipment, and unsafe food storage and handling practices.
Deficiencies (8)
Failed to provide a private space for residents' monthly council meetings for 11 of 13 residents reviewed.
Failed to maintain availability of the most recent survey results for residents to view.
Failed to ensure residents had the right to formulate an advance directive; Resident #237's DNR form was invalid due to missing physician license number and date.
Failed to develop and implement comprehensive care plans addressing bowel and bladder incontinence for 2 residents.
Failed to ensure fall mats were used for 2 residents at high risk for falls.
Failed to provide proper perineal/incontinent care to Resident #18, wiping in the wrong direction increasing risk of urinary tract infection.
Failed to provide special eating equipment (scoop plate) for Resident #20 as ordered.
Failed to procure, store, prepare, distribute and serve food in accordance with professional standards, including use of unpasteurized eggs served soft, expired and unsealed food items, and improper food storage.
Report Facts
Residents affected: 11
Residents reviewed for advance directives: 24
Residents reviewed for comprehensive care plans: 24
Residents reviewed for accidents and hazards: 2
Residents reviewed for perineal/incontinent care: 2
Residents reviewed for assistive devices: 2
Residents reviewed for food service safety: 1
Unpasteurized eggs remaining: 15
Packages of bread: 16
Hot dog buns: 4
Hot dog buns: 6
Hot dog buns: 12
Unsealed pasta bags: 2
Packages of dried cereal: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #99 | Resident Council Vice President | Interviewed about lack of resident council meetings and private meeting space |
| Activity Director | Interviewed about responsibility for resident council meetings and lack of private meeting space | |
| Director of Nursing | DON | Interviewed about resident council meetings, incomplete DNR, care plans, fall mats, and perineal care |
| Administrator | Admin | Interviewed about resident council meetings, incomplete DNR, care plans, fall mats, and food safety |
| Social Worker | Interviewed about advance directives and DNR process | |
| MDS Coordinator | Interviewed about care plan deficiencies for incontinence | |
| CNA A | Certified Nursing Assistant | Interviewed about fall mats usage for Resident #5 and Resident #17 |
| CNA B | Certified Nursing Assistant | Interviewed about fall mats usage for Resident #5 |
| Nursing Aide C | Certified Nursing Assistant | Interviewed about fall mats usage for Resident #17 |
| Restorative Aide D | Certified Nursing Assistant | Interviewed about fall mats usage for Resident #17 and scoop plate for Resident #20 |
| CNA E | Certified Nursing Assistant | Interviewed about improper perineal care for Resident #18 |
| RN F | Registered Nurse | Interviewed about scoop plate usage for Resident #20 |
| Dietary Manager | Interviewed about food safety violations including unpasteurized eggs and expired food | |
| Dietary Aide A | Interviewed about unawareness of unpasteurized eggs in kitchen |
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