Health inspection·November 3, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 11/2/2023 at 11:50 AM with LVN C, stated she never heard any staff threaten residents, even jokingly, and if she did, she would immediately report them to the ADON and the DON. Interview and observation on 11/2/2023 at 2:10 PM Resident #2 stated he did not remember the incident. Interview on 11/3/2023 at 9:21 AM, the DON stated CNA A admitted to her she told Resident #2 she would hit him back if he hit her but was joking. The DON stated she explained it was still considered verbal abuse. The DON stated her expectation was for staff to speak with residents kindly. The DON stated when Resident #2 was interviewed the day of the incident, Resident #2 stated CNA A did not threaten to hit him. The DON stated after the incident, in-services on abuse and neglect were completed with an emphasis on verbal abuse. Interview on 11/3/2023 at 10:46 AM, LVN D stated she never heard any staff speak unkindly with residents, and if she did she would inform the DON and the Administrator. An attempt to interview CNA A was made on 11/3/2023 at 1:07 PM with no answer. Record review of in-service training documentation reflected on 9/8/2023 an in-service was completed for abuse and neglect, which included who the abuse coordinator was, and what the requirements for reporting abuse included. 2. Record review of Resident #6's admission Record dated 11/3/2023 revealed he was admitted on [DATE], he was his own responsible party with diagnosis of age-related physical debility, muscle weakness, cortical age-related cataract bilateral, altered mental status, unsteadiness on feet and cognitive communication deficit. Record review of Resident #6's Quarterly MDS dated [DATE] revealed he was had no issues with hearing/vision, he was cognitively intact, no behaviors, he required supervision for transfers, eating and dressing. Record review of complaint intake 411604 revealed about three weeks ago, 3/10/2023 revealed Resident #6's roommate, Resident #7, hit Resident #6 over the head with a shoe while he was sleeping. Further review revealed Resident #6 reported the incident to nursing staff, and staff moved Resident #7 to another room. Record review of Resident #6's care plan, dated 10/27/2023, was documented resident had limited physical mobility and needs some assistance with ADLs, resident and a hearing impairment, resident had a risk for falls vision/hearing problems, impaired cognition, impaired mobility dated initiated on 6/15/2023. Record review for care plan was documented resident had impaired visual function related to cataracts. Record review of Resident #6's progress notes, dated 2/12/2023 at 5:50 AM (22:20), was struck out due to technical error. The progress note was documented This nurse was called over to room by Resident #6 reported at 6:30 AM he woke up to roommate hitting him with his own shoe. I was asleep and Resident #7 hit me with a shoe, and I said what's wrong with you, and he said is this our shoe mother fucker and I said yes, and he started hitting e with both my shoes. I pushed him out of the way and walked out the room. Resident #6 was verbally and physically abusive. Resident #6 walked over to nurse's station and reported incident to nightshift nurse. This nurse updated on call nurse. Resident #7 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455467 If continuation sheet Page 2 of 8 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 455467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Care Center of Alamo 8223 Broadway San Antonio, TX 78209 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 0600 was moved to unit B. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #6's incident report, dated 2/12/2023 at 6:30 AM, revealed Resident 36's room by LVN H documented this nurse was called over to room by Resident #6, he stated at 6:30 AM he woke up to roommate hitting him with his own shoe, while he was sleeping. Incident report stated Resident #6 stated Resident #7 started hitting him with both shoes he pushed him out of the way and walked out of room. Section: Immediate Action Taken was documented Resident #6 was verbally and physically abused. Resident #6 walked over the nurse's station. Resident #7 was moved to a different unit B. No injuries observed at time of incident. This incident was struck out due to technical error by DON. Residents Affected - Few 3. Record review of Resident #7's admission Record dated 11/3/2023 revealed he was admitted on [DATE] with diagnoses of dementia, muscle weakness age-related physical debility, glaucoma, cognitive communication disorder, need for assistance with personal care, and anxiety disorder. Record review of Resident #7's Quarterly MDS dated [DATE] he was severely cognitively impaired, and required extensive assistance with his ADLS, and use a wheelchair to mobilize. Record review of Resident #7's psychiatric notes dated 2/15/2023 revealed his diagnosis was anxiety dementia and insomnia. Psychiatric noted Resident #7 had a poor memory poor historian, judgment was poor, mood was neutral, risk of verbal aggression he was severely impaired for cognition and changed his psychiatric medications. Observation on 11/2/2023 at 2:13 PM with Resident #6 was in his room sitting in his bed, ambulatory, and had no injuries at the time. Further observation of Resident #6's room revealed he had no roommate at the time. Interview with Resident #6 on 11/2/2023 at 2:14 PM, Resident #6 stated Resident #7 hit him over the head with a shoe while he was sleeping. Resident #6 stated he still had headaches, hearing and vision issues. Resident #6 stated staff moved Resident #7 to another room but was not sent to hospital for an MRI. When the Surveyor asked Resident #6 if anything else happened or if he went to the hospital, Resident #6 stated he saw the MD and the MD ordered Tylenol. Interview on 11/3/2023 at 11:11 AM with Medical Records I stated she worked at facility since 2008 and was Resident #6's guardian angel at the time of incident. Interview with Medical Records I stated Resident #6 stated Resident #7 hit him while standing over him with his shoe. Resident #6 stated he reported to nurse and Resident #7 was moved to a locked unit. Medical Records I stated she was not sure if she had training after incident. Interview on 11/3/2023 at 12:45 PM with LVN H stated he remembered he was doing morning rounds and went into Resident #7's room. LVN H stated that Resident #6 had told him that Resident #7, the resident's roommate at the time, had starting to hit him on his head with his shoe and tried to push him away. LVN H stated Resident #7 was moved to another room, and he did the assessment and was not sure if Resident #6 had injuries or bruising. LVN H stated Resident #6 was not sent to the hospital on his shift. LVN H stated Resident #6 had not complained of headaches or hearing concerns from the incident and only saw Resident#6 on the weekends. LVN H stated was not sure if he received any training after the incident. Interview on 11/3/2023 at 1:00 PM with the night nurse for the date of incident with Resident #6 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455467 If continuation sheet Page 3 of 8 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 455467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Care Center of Alamo 8223 Broadway San Antonio, TX 78209 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 0600 and Resident #7, surveyor left a voicemail. Level of Harm - Minimal harm or potential for actual harm Observation on 11/3/2023 at 1:12 PM with Resident #7 lived in the secure unit and was sitting in TV room in his wheelchair. An interview with Resident #7 was attempted but the resident was not interviewable. Residents Affected - Few Interview on 11/3/2023 at 3:00 PM with the DON stated she remembered the incident with Residents #6 and #7 and the interventions were to move Resident #7 form room, he had a psychiatric visit, medications change and notified the Ombudsman. The DON stated the incident was brought up to the morning meeting, but it did not go any further. The DON stated she looked at the in-service book and could not find an in-service for staff after this incident. The DON stated she was not sure why Resident #6's progress note on incident with Resident #7 was struck out by her. The DON stated the incident was not reported to HHSC because there were no injuries. Record review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated September 2022, revealed, 6. upon receiving any allegations of abuse, neglect . or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 3. immediately is defined as: a. within 2 hours of an allegations involving abuse or result in serious bodily injury; or b. with 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Record review of the facility's, undated, policy titled Abuse, Neglect, and Misappropriation Prevention, revealed, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455467 If continuation sheet Page 4 of 8 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 455467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Care Center of Alamo 8223 Broadway San Antonio, TX 78209 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 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 5 residents (Resident #4) reviewed for misappropriation of resident property. Residents Affected - Few The facility failed to ensure Resident #4 was not subject to financial misappropriation of property by CNA G. CNA G misappropriated funds using the residents debit card totaling $477.54. This failure could place residents at risk for loss of money, possessions, and the feeling of loss. The findings include: Record review of Resident #4's face sheet, dated 11/2/2023, reflected a [AGE] year-old resident with an initial admission date of 8/21/2015. Resident #4 had diagnoses which included Congestive Heart Failure (A chronic condition in which the heart doesn't pump blood as well as it should), absence of left leg below knee, and type 2 diabetes. Record review of Resident #4's Quarterly MDS Assessment, dated 8/29/2023, reflected a BIMS score of 13, which indicated intact cognition. Record review of the facility provider investigation report written by the facility administrator, dated 11/3/2022, reflected the resident stated CNA G visited the resident over the weekend on her day off. The report reflected when CNA G was asked why she visited the resident over the weekend, CNA G admitted to taking Resident #4's debit card. Interview on 11/2/2023 at 11:15 AM, Resident #4 stated he did not want to talk about the incident as it had taken place so long ago and upset him. He stated he did not want the incident reported to the state or police and did not feel as though the incident should have been considered abuse. An interview of CNA G was attempted on 11/2/2023 at 1:49 PM. The phone was disconnected. Interview on 11/3/2023 at 9:19 AM, the DON stated misappropriation of resident property like this had not happened at the facility before or since the incident. The DON stated an in-service training had been completed after this in regard to abuse with a focus on misappropriation of resident property. The DON stated her expectations were that employees do not misappropriate resident property, and that it could cause feelings from residents of being taken advantage of. Record review of the facility's, undated, policy titled Abuse, Neglect, and Misappropriation Prevention, reflected Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455467 If continuation sheet Page 5 of 8 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 455467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Care Center of Alamo 8223 Broadway San Antonio, TX 78209 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 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 2 (# 6) residents in that: Resident #6 revealed Resident #7 hit him over the head with a shoe while he was sleeping. Resident #6 stated he still had headaches, hearing and vision issues. Resident #6 stated staff moved Resident #7 to another room but was not sent to hospital for an MRI. Nurse assessment and progress notes did not indicate any issues with headaches or injuries from the incident. This incident was not reported to the HHSC. This failure could affect any residents and could result in further injury or Abuse. The Findings were: 1. Record review of Resident #6's admission Record dated 11/3/2023 revealed he was admitted on [DATE], he was his own responsible party with diagnosis of age-related physical debility, muscle weakness, cortical age-related cataract bilateral, altered mental status, unsteadiness on feet and cognitive communication deficit. Record review of Resident #6's Quarterly MDS dated [DATE] revealed he was had no issues with hearing/vision, he was cognitively intact, no behaviors, he required supervision for transfers, eating and dressing. Record review of complaint intake 411604 revealed about three weeks ago, 3/10/2023 revealed Resident #6's roommate, Resident #7, hit Resident #6 over the head with a shoe while he was sleeping. Further review revealed Resident #6 reported the incident to nursing staff, and staff moved Resident #7 to another room. Record review of Resident #6's care plan, dated 10/27/2023, was documented resident had limited physical mobility and needs some assistance with ADLs, resident and a hearing impairment, resident had a risk for falls vision/hearing problems, impaired cognition, impaired mobility dated initiated on 6/15/2023. Record review for care plan was documented resident had impaired visual function related to cataracts. Record review of Resident #6's progress notes, dated 2/12/2023 at 5:50 AM (22:20), was struck out due to technical error. The progress note was documented This nurse was called over to room by Resident #6 reported at 6:30 AM he woke up to roommate hitting him with his own shoe. I was asleep and Resident #7 hit me with a shoe, and I said what's wrong with you, and he said is this our shoe mother fucker and I said yes, and he started hitting e with both my shoes. I pushed him out of the way and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455467 If continuation sheet Page 6 of 8 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 455467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Care Center of Alamo 8223 Broadway San Antonio, TX 78209 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 walked out the room. Resident #6 was verbally and physically abusive. Resident #6 walked over to nurse's station and reported incident to nightshift nurse. This nurse updated on call nurse. Resident #7 was moved to unit B. Record review of Resident #6's incident report, dated 2/12/2023 at 6:30 AM, revealed Resident 36's room by LVN H documented this nurse was called over to room by Resident #6, he stated at 6:30 AM he woke up to roommate hitting him with his own shoe, while he was sleeping. Incident report stated Resident #6 stated Resident #7 started hitting him with both shoes he pushed him out of the way and walked out of room. Section: Immediate Action Taken was documented Resident #6 was verbally and physically abused. Resident #6 walked over the nurse's station. Resident #7 was moved to a different unit B. No injuries observed at time of incident. This incident was struck out due to technical error by DON. 2. Record review of Resident #7's admission Record dated 11/3/2023 revealed he was admitted on [DATE] with diagnoses of dementia, muscle weakness age-related physical debility, glaucoma, cognitive communication disorder, need for assistance with personal care, and anxiety disorder. Record review of Resident #7's Quarterly MDS dated [DATE] he was severely cognitively impaired, and required extensive assistance with his ADLS, and use a wheelchair to mobilize. Record review of Resident #7's psychiatric notes dated 2/15/2023 revealed his diagnosis was anxiety dementia and insomnia. Psychiatric noted Resident #7 had a poor memory poor historian, judgment was poor, mood was neutral, risk of verbal aggression he was severely impaired for cognition and changed his psychiatric medications. Observation on 11/2/2023 at 2:13 PM with Resident #6 was in his room sitting in his bed, ambulatory, and had no injuries at the time. Further observation of Resident #6's room revealed he had no roommate at the time. Interview with Resident #6 on 11/2/2023 at 2:14 PM, Resident #6 stated Resident #7 hit him over the head with a shoe while he was sleeping. Resident #6 stated he still had headaches, hearing and vision issues. Resident #6 stated staff moved Resident #7 to another room but was not sent to hospital for an MRI. When the Surveyor asked Resident #6 if anything else happened or if he went to the hospital, Resident #6 stated he saw the MD and the MD ordered Tylenol. Interview on 11/3/2023 at 11:11 AM with Medical Records I stated she worked at facility since 2008 and was Resident #6's guardian angel at the time of incident. Interview with Medical Records I stated Resident #6 stated Resident #7 hit him while standing over him with his shoe. Resident #6 stated he reported to nurse and Resident #7 was moved to a locked unit. Medical Records I stated she was not sure if she had training after incident. Interview on 11/3/2023 at 12:45 PM with LVN H stated he remembered he was doing morning rounds and went into Resident #7's room. LVN H stated that Resident #6 had told him that Resident #7, the resident's roommate at the time, had starting to hit him on his head with his shoe and tried to push him away. LVN H stated Resident #7 was moved to another room, and he did the assessment and was not sure if Resident #6 had injuries or bruising. LVN H stated Resident #6 was not sent to the hospital on his shift. LVN H stated Resident #6 had not complained of headaches or hearing concerns from the incident and only saw Resident#6 on the weekends. LVN H stated was not sure if he received any training after the incident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455467 If continuation sheet Page 7 of 8 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 455467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Care Center of Alamo 8223 Broadway San Antonio, TX 78209 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 Interview on 11/3/2023 at 1:00 PM with the night nurse for the date of incident with Resident #6 and Resident #7, surveyor left a voicemail. Observation on 11/3/2023 at 1:12 PM with Resident #7 lived in the secure unit and was sitting in TV room in his wheelchair. An interview with Resident #7 was attempted but the resident was not interviewable. Residents Affected - Few Interview on 11/3/2023 at 3:00 PM with the DON stated she remembered the incident with Residents #6 and #7 and the interventions were to move Resident #7 form room, he had a psychiatric visit, medications change and notified the Ombudsman. The DON stated the incident was brought up to the morning meeting, but it did not go any further. The DON stated she looked at the in-service book and could not find an in-service for staff after this incident. The DON stated she was not sure why Resident #6's progress note on incident with Resident #7 was struck out by her. The DON stated the incident was not reported to HHSC because there were no injuries. Record review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated September 2022, revealed, 6. upon receiving any allegations of abuse, neglect . or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 3. immediately is defined as: a. within 2 hours of an allegations involving abuse or result in serious bodily injury; or b. with 24 hours of an allegation that does not involve abuse or result in serious bodily injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455467 If continuation sheet Page 8 of 8