Inspection·December 3, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few worsening hematoma (closed wound where blood collects and fills a space inside your body because it can't flow or drain out) on the right side of her head and periorbital ecchymosis (describes bruising and discoloration around a person's eyes that resemble the dark circles around a raccoon's eyes). Further review revealed Impression:Moderate right anterolateral frontal scalp contusion/hematoma without underlying calvarial fracture.Focal recent extra-axial hemorrhage along the right convexity measuring 5 mm in thickness.Very thin posterior parafalcine subdural hematoma measuring 3 mm with suspected very slight involvement of the right cerebral tentorium. Suspect of 2 mm of leftward midline shift.Mild right-sided facial and preorbital soft tissue swelling.No acute facial bone fracture.No acute cervical spine fracture or dislocation. Observation and interview on 9/23/25 at 11:35 AM revealed Resident #1 was sitting at a table in the therapy room drinking coffee. Resident #1 easily engaged in conversation and stated she was doing fine. There were no noted visible bruising on Resident #1. Interview with ST A revealed Resident #1 was on their caseload r/t cognition and they were providing swallow training. ST A stated Resident #1 needed reminders to slow down when eating and drinking fluids. Interview on 9/23/25 at 11:45 AM with PTA B revealed Resident #1 was on their caseload for balance and gait training. Interview on 9/23/25 at 11:50 AM with the ADON and DON revealed on 9/2/25 during shift change the morning nurse reported Resident #1 had bruising to her left hand and right temporal area. She stated Resident #1 was unable to state what happened but denied any pain. The ADON stated Resident #1 ambulated independently, however, her gait was unsteady and would hold on to the rail while walking down the hall. The ADON stated she reviewed Resident #1's chart and it revealed she had a blood draw on 8/19/25 and thought that was probably why she had the bruise on her left hand. The DON stated the bruise was in the healing stages, yellow and greenish. She stated X-rays were completed with no findings. The ADON stated she reported the incident to the DON right after she learned about Resident #1's condition. She stated they did not know what happened. When asked who reported Resident #1's condition to the ADM, she looked at the DON. The DON stated they would have reported the incident the following day during their morning meeting. Surveyor asked when should a resident's change of condition be reported to the ADM? The DON stated right away so the ADM was aware and could report the incident to the State within the required time-frame. The DON stated it was either 2 hours or 24 hours. The DON stated it was important to report any changes and injuries of unknown origin to prevent further abuse. Interview on 9/23/25 at 12:20 PM with Resident #1's MD revealed he received a call regarding Resident #1's bruising on the temple. He stated staff followed protocol to monitor for any changes. He stated it was difficult to say what happened because Resident #1 was not able to state what happened but he suspected she had an unwitnessed fall. He stated staff monitored and later reported the bruise had become worse so he provided an order to send Resident #1 to the hospital. Interview on 9/23/25 at 2:01 PM with the ADM revealed an allegation of abuse or neglect or injury of unknown origin should be reported to HHSC within two hours per regulation. She stated she reported Resident #1's bruising within the two hours after she learned of the findings. The ADM stated staff was to report the findings to her right away regardless of the time and did not report to her until the following day. The ADM stated she talked to the DON about reporting the findings to her right away and completed an in-service with nursing staff. The ADM stated it was important that all allegations of abuse or neglect including suspicious injuries to prevent further abuse.Telephone interview on 9/23/25 at 4:18 PM with LVN C revealed during morning shift change the night nurse reported she noted a bruise on Resident #1's left hand and right temple. She stated she did not get any other details from the night nurse. LVN C stated she assessed Resident #1 and also noted a fading bruise to her left hand and a purple bruise about an inch in diameter on the right temple. She stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455444 If continuation sheet Page 2 of 4 Printed: 05/15/2026 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 455444 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesa Vista Inn Health Center 5756 N Knoll Dr San Antonio, TX 78240 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she did not note any other skin issues. She stated she called the MD, talked to the family member and reported the findings to the ADON/DON. LVN C stated anyone could report the findings to the ADM. LVN C stated the MD ordered X-rays. LVN C stated Resident #1 was her usual self throughout the day; she was ambulating on her own, liked to sit at the end of the halls and she would ask for snacks. LVN C also stated Resident #1 could be a finicky eater and was on baseline as well in this area. She stated the only change was the bruise on the right temple expanded and exceeded the temporal area; she commented It was lower. LVN C stated she worked the following day and noted Resident #1 was still at baseline, but the bruise around the temporal area was a dark red/purple and larger. She stated she called the MD and he provided an order for a skull series. LVN C stated Resident #1 was sent out to the hospital the following day or the day after. Telephone interview on 9/24/25 at 11:21 AM with LVN D revealed she worked the night shift. She stated at the beginning of [DATE] she noted bruising on Resident #1's hand. She stated actually one of the aides assisted Resident #1 for toileting, was holding Resident #1's hand and noted the bruising. LVN D stated it was at the beginning of the night shift. LVN D stated she could not remember which hand but she looked back in Resident #1's chart and noted she had a blood draw so thought maybe that's where the bruise came from. LVN D stated the bruise was in the healing stages, greenish/yellowish. She stated she asked Resident #1 about it and Resident #1 said she did not know but said it did not hurt. LVN D stated she usually reached out to the NP and called the daughter in law and reported the bruise. LVN D stated she thought maybe the MD reached back out to her. LVN D stated she wrote a progress note and initiated neuro-checks. She commented she initiated neuro-checks for everything especially when Resident #1 was not able to tell her what happened. She stated Resident #1 was at baseline with no changes. LVN D stated then during the early morning hours close to the end of her shift Resident #1 walked up to the nurse's station. She stated she was hungry. LVN D stated she sat Resident #1 down with her and noted petechiae(appear when tiny blood vessels called capillaries break) along her hairline. She stated the red area was like a pin mark. LVN D stated she assessed Resident #1 and did not see any other discoloration to her face/forehead. She also checked her head and there was no bruising or swelling. LVN D stated she kept Resident #1 at the nurse's station until the day nurse came in. They both looked her over and LVN C said she would initiate the paperwork (entering a note, incident report, call the doctor and let administration know. LVN D stated she worked the following day and staff had received an order to send Resident #1 out to the hospital. She stated the bruising on Resident #1's face/temporal area was pronounced (red with some purple) and the area was swollen. LVN D stated Resident #1 was still at baseline but there was a notable difference on the bruised area. LVN D stated Resident #1 went out to the hospital during the late night. Observation and interview on 9/25/25 at 12:05 PM in the secured unit revealed Resident #1 was lying in bed fully dressed, with shoes on and her legs crossed. The bed was in low position with the HOB at about 30-degree angle. Resident #1 stated she was doing well. Resident #1 did not express any concerns r/t abuse or neglect .and stated she did not remember having bruising on her forehead/hand. Review of a facility policy, Abuse/Neglect revised 3/29/18, read in relevant part The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. E. Reporting:2. When a suspected abused, neglected, exploited mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal repot to the Abuse Preventionist or designee. If the discovery occurs outside normal business hours, the Abuse Preventionist and/or designee will be called. 3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455444 If continuation sheet Page 3 of 4 Printed: 05/15/2026 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 455444 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesa Vista Inn Health Center 5756 N Knoll Dr San Antonio, TX 78240 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 0609 administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455444 If continuation sheet Page 4 of 4