San Antonio Behavioral Healthcare Hospital

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 08686 Based on observations in the patient units and the facility kitchen, the facility failed to maintain a clean and sanitary environment. These conditions had the potential to affect patient health, safety, and infection prevention practices. The findings include: Observations on patient units on 06/11/2026 from 1:15 PM to 2:50 PM revealed the following: 1. Dirty cabinets in a clean laundry room. 2. Clothing donations lying on a dirty floor. 3. Dirty floors on patient units. 4. Dirty shower curtains or no shower curtains in patient bathrooms. 5. Dust accumulations on patient televisions. 6. Dust accumulations on cabinets in patient day rooms. 7. Dust accumulations on handrails in patient hallways. 8. Dust accumulations on light fixtures in patient units. 9. Dirty towels left on floors in patient areas. 10. Empty soap dispensers next to the sick in patient day rooms. 11. Dust accumulations on windows in bedrooms. Interview on 06/11/2026 with facility chief financial officer and facility chief clinical director during the tour of the facility confirmed the above findings. Interview with Housekeeper A on 06/11/2026 at 2:30 PM revealed she was responsible for several patient units and was moved around to different units “often”. Observations in the facility kitchen on 07/01/2026 from 10:30 AM to 12:30 PM revealed the following: Hand washing/ice Station: 1. The hand washing/ice station was obstructed by equipment. 2. There was no evidence of routine monitoring or cleaning documentation for the ice machines (one in the dining area and one in the kitchen prep). 3. Both overhead light housings have visible dust accumulation. 4. The sink in the dishwashing room was plugged and held standing water. 5. The overall kitchen flooring was heavily soiled. 6. Food Storage: The fan in the cold fridge appeared to be leaking into the plastic container. 7. The oven had possible charred paper or debris inside that should be evaluated further as a potential fire hazard. 8. Refrigerator temperature logs were not current, with many entries dating back to dates in June 2026. There was no evidence of specific staff being assigned to monitor the refrigerator temperatures. 9 A dietary supervisor was observed handling a food thermometer with bare hands, demonstrated that it was operational, and returned it without sanitizing it prior to placing it back into service. 10. Open employee beverages were observed stored in various locations throughout the kitchen, including beneath shelving in storage areas. Interviews during above listed observations on 07/01/2026 with facility chief financial officer and facility dietary manager confirmed the above findings. Review of facility Infection Prevention for Housekeeping Policy, effective 07/15/2014 and last revised 01/25/2017, stated the following: Purpose: To promote a sanitary environment. Routine Cleaning of Horizontal Surfaces: In patient care areas, cleaning of non-carpeted floor and other horizontal surfaces will be done daily and more frequently if spillage or visible soiling occurs. Trash: Trash will be removed from all areas on a specific schedule to prevent spillage and odors. A daily list of areas to be cleaned by housekeeping included but was not limited to the following: Restroom: vents, whole shower, shower head, mirror, sink and toilet. Room: high dust, door frame, trash, floor, soiled linen, vents, walls and windows. - -”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 21863 Based on observation, review of documentation and staff interviews, the facility failed to ensure an effective infection control program which addressed the prevention and control of infections and communicable diseases, as they failed to provide a sanitary environment. Findings included: Review of Complaint Intake Information TX00478959 dated 11/13/23 indicated the following in part; Patient #1’s shower had mold on the wall and shower curtain. Facility staff were made aware however the response was that management had been informed and nothing would be done. Further review of the Intake Information indicated that due to the mold exposure; Patient #1 and other patients started to become sick. Observations conducted on 11/21/23 at 11:35 AM with the Director of Quality and Risk Management (DQRM) present in the Magnolia unit revealed the following: -Room 3088, the shower curtain had mold like substance with water stains on the bottom part and water was observed on the floor. The shower basin had fresh caulking placed between the shower basin and the floor that was done over the top of brown and black stains that appeared to be mold like and other types of stains. -Room 3083, the shower curtain had mold like substance with water stains on the bottom part. The floor along the shower basin had brown and black stains that appeared to be mold like and other types of stains. The caulking contained black and brown substance. -Room 3089 had a strong smell of sewage coming from the drain in the floor. -Room 3085 the shower curtain had mold like substance on the bottom part with water stains. Further observations at 11:50 AM in the Mustang unit revealed the following: Room B1704 , the shower curtain had excessive mold like substance on the bottom part and water stains. The floor along the shower basin had brown and black stains that appeared to be mold like and other types of stains. The caulking contained black and brown substance. There was a drawing of a penis like figure on the shower basin ledge which also contained a written name. Interview on 11/21/23 at 11:55 AM during the observations with the DQR confirmed the above findings. Record review of the facility’s MHT (Mental Health Tech’s) Environmental Checklist used to conduct environmental checks daily included the following: Patient Bedrooms/Patient Bathrooms, Initial one check per hall, per shift. “Patient bedrooms/patient bathrooms are clean and without odors, infection control issues, and/or excess equipment. Interview on 11/21/23 at 2:20 PM with the facility’s Chief Executive Officer (CEO) stated the shower curtains were re-usable and washed every 30 days unless soiled. The CEO stated that anyone can place a work order by using a QR code that will direct them to the web-based program used by maintenance. The CEO further stated they have problems with patients flushing things down the toilet which will cause a back up in the drains. Interview on 11/21/23 at 2:30 PM with the facility’s director of Housekeeping and Maintenance stated MHT’s are to complete Environment of Care rounds each shift and leadership conducts rotating rounds. The Director of Housekeeping and Maintenance stated there was a work order on 11/7/23 where a patient stated “sewage and mold coming up from the floor boards in her room” and that Room 3088 had water leaking under the floor tile.”