Health inspection·May 12, 2023

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #27's Dialysis Communication Record, on the third section of the form for Information to be Completed by the Dialysis Center, dated 4/12/23, 4/26/23 and 5/8/23 were blank. During an interview and observation on 5/10/23 at 8:31 a.m., Resident #27 revealed she received dialysis treatments on Monday, Wednesday and Friday and pointed to a bandage on the right upper chest she identified as the access used for dialysis treatments. During an interview on 5/11/23 at 2:17 p.m., RN A revealed, Resident #27 would sometimes return to the facility without the dialysis communication record after having been to dialysis. RN A revealed, when the dialysis records are not returned, we do our due diligence to get the dialysis sheets back, but the dialysis clinics are so busy. RN A revealed the dialysis communication records were placed in a basket at the nurse's station and the records clerk would pick them up and scan them into the electronic record. RN A did not elaborate or offer information on what nursing was supposed to do when the dialysis communication forms were blank. During an interview on 5/11/23 at 3:13 p.m., LVN B revealed Resident #27 had dialysis treatments on Monday, Wednesday and Fridays. LVN B revealed, residents who went to dialysis were given a Dialysis Communication Record to take with them to dialysis and were to return the record to nursing after dialysis. LVN B revealed the third section of the Dialysis Communication Record was supposed to be filled out by the dialysis clinic staff. LVN B revealed she worked the evening shift and would receive the Dialysis Communication Record from Resident #27 after returning from dialysis. LVN B revealed, if the Dialysis Communication Record was not completed, she would make an attempt to call the dialysis clinic to get the information. LVN B revealed if she was unable to make contact with the dialysis clinic she would then pass the information in report to the oncoming shift to follow up on obtaining the information required on the Dialysis Communication Report. LVN B stated it was important for the Dialysis Communication Record be completed because it provided information on how much fluid the resident had, what their weight was pre and post dialysis, if any dietary recommendations were made or orders for labs or upcoming appointments. During an interview on 5/11/23 at 4:44 p.m., the DON revealed Resident #27 had scheduled dialysis treatments on Monday, Wednesday and Friday. The DON revealed Resident #27 had recently started having dialysis treatments beginning March 2023. The DON revealed, the third section of the Dialysis Communication Record was supposed to be completed by the dialysis clinic and the evening nurse who received the record in the facility should have called the dialysis clinic or notified the ADON or the DON that the record was incomplete. The DON stated it was important the Dialysis Communication Record was fully completed because the record provided information on baseline weights or new orders. The DON stated, the information obtained from the Dialysis Communication Record was important to determine the plan of care for Resident #27. Record review of the facility policy and procedure titled, End-Stage Renal Disease, Care of a Resident with, dated Quarter 2, 2022 revealed in part, .Resident with end-stage renal disease (ESRD) will be care for according to currently recognized standards of care .4. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, and may include: a. How the care plan will be developed and implemented .b. How information will be exchanged between the facilities . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455652 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 455652 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Creek Nursing and Rehabilitation 9014 Timber Path San Antonio, TX 78250 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observations, interviews, and record reviews, the facility failed to ensure that the menus were followed for 1 of 2 meals observed in that: Residents Affected - Few The findings were: Residents were served an item called Homestyle Macaroni & Cheese which did not follow the recipe provided and was identified as a vegetarian option on the recipe provided by the facility, however contained meat. This deficient practice could affect all residents who received meals and snacks from the kitchen by contributing to dissatisfaction, poor intake, and/or weight loss. The findings were: Observation in the kitchen on 05/10/2023 at 5:00 p.m. revealed meat was being prepared as part of the meal and was not included in the recipe for Homestyle Macaroni & Cheese but had been added to the dish. Observation in the dining room on 05/10/2023 at approximately 5:50 p.m. revealed Residents in the dining room were served Homestyle Macaroni & Cheese with added meat. Record Review of the Fall/Winter 22-23 menu, provided by the facility, revealed Homestyle Macaroni and Cheese would be served on 05/10/2023. Record Review of the Recipe for Homestyle Mac & Cheese did not include meat. Record Review of the facilities dietary substitution log did not include and correspondence regarding a substitution or addition of meat on the day Homestyle Macaroni & Cheese was listed on the daily menu or was served. The document provided did not show there had been any addition of meat to any item prepared in the previous month. Interview with the DM on 05/10/2023 at 5:03 p.m. revealed the DM did not call the dietician on that day or prior to 05/10/2023 to seek approval for adding meat to the recipe. During the interview with the DM, the DM stated the contracted dietician was busy and did not reply to her call initially, but then stated she did not call her to get approval for a change to the recipe. The DM stated she did not write the change to the recipe on the log. She said the residents did have a right to know what they are being served and she was supposed to have all substitutions approved by the dietician. The DM went on to say she served it two weeks ago and the residents liked it so she considered it a preference, she could not remember if she talked to the dietician about that change to the recipe either and could not provide documentation showing she addressed the recipe change with the dietician. When asked during the same interview, the DM was unable to state how much meat was added to the recipe in ounces or pounds, she stated she did not know how much the tube of meat she added weighed. Interview with the Administrator on 05/10/2023 at 5:29 p.m. revealed the kitchen staff should have called the dietician before changes were made to the facility menu. The Administrator did not know if the kitchen staff called the dietician but stated the staff should have called the dietician prior (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455652 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 455652 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Creek Nursing and Rehabilitation 9014 Timber Path San Antonio, TX 78250 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to making a change to the menu. When asked if residents had a right to know what they were going to be served for meals, the Administrator stated, Yes. Interview with Resident # 7 on 05/12/2023 at 11:09 a.m. stated, the other night we were supposed to get macaroni and cheese and it wasn't macaroni an cheese. Resident # 7 said, everybody feels like shit about the food, we don't get good meals around here and we don't get always what they say they are going to serve us. Interview with Resident # 182 on 05/12/2023 at 3:36 p.m. stated he did not like the food at all. Resident # 182 stated he felt angry and helpless because he cannot get food for himself and he felt the staff did not listen or care when he complained about the food or asked for a substitution. Record review of the training certificate provided for the DM revealed the DM had completed a dietary training course and was not a Registered Dietitian. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455652 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 455652 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Creek Nursing and Rehabilitation 9014 Timber Path San Antonio, TX 78250 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews 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 reviewed for sanitation in that: 1. Three 35-ounce bags of cereal in plastic bags opened and in plastic bags that were open. 2. One bag of macaroni noodles opened not labeled dated twisted at the top but not completely closed. 3. One 16-ounce bag of potato chips with no open date. 4. One 30-ounce Mexican style dehydrated beans, opened and partially used, with no open date or expirations date. 5. One box or grits opened and not completely sealed with no open date. 6. One package of hot dog buns partially covered with a green powdery substance varying in shades of green, covering approximately ninety percent of the remaining buns in the package. These failures could place residents at risk for food-born illness, and food contamination. Findings included: Observation on 05/09/2023 at 8:45 a.m. in the dry storage room revealed: -Three 35-ounce bags of cereal partially used and plastic bags opened and in plastic bags that were open, -One bag of macaroni noodles opened not labeled or dated twisted at the top but not completely closed, -One 16-ounce bag of potato chips with no open date, -One 30-ounce bag of Mexican style dehydrated beans opened and partially used with no open date or expirations date, -One box or grits opened and not completely sealed with no open date, and -One package of hot dog buns partially covered with a green powdery substance varying in shades of green on approximately ninety percent of the remaining buns in the package. During an interview on 05/09/2023 at 9:00 a.m., the DM stated all food in the dry storage area should be labeled and dated according to the policy and that food in the dry storage area should be completely sealed before it is put in that room if it is open or any portion is used. The DM further stated there should not be any molded bread in the dry storage room and further stated the staff need to be trained again on FIFO (first in first out) and labeling and dating again. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455652 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 455652 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Creek Nursing and Rehabilitation 9014 Timber Path San Antonio, TX 78250 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 05/10/2023 at 5:29 p.m., the Administrator stated all items should be stored according to the facility policy and that the DM had told her upon this surveyor's observation on 05/09/2023 that there were items not stored as they should be and about the old bread. Review of the facility policy titled Food Receiving and Storage, revealed 7. Dry food that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such food will be rotated using a first in -first out system; 14. e. Other opened containers must be dated and sealed or covered during storage. Record Review Revealed The U.S. Public Health Service, Food Code, dated 2017 revealed the following regarding marking the date of food when prepared and when the original container was opened: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (B) of this section. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455652 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 455652 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Creek Nursing and Rehabilitation 9014 Timber Path San Antonio, TX 78250 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, 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 and transmission of communicable diseases and infections for one resident (#71) of 4 observed for infection control in that: Residents Affected - Few CNA D failed to follow infection control requirements while performing incontinent care for Resident #71. This deficient practice could place residents at risk for infection. The findings were: Record Review of Resident #71's electronic face sheet dated 05/12/2023 revealed she was admitted to the facility on [DATE] with diagnoses of dementia, hydronephrosis (a condition where one or both kidneys become stretched or swollen as a result of build-up of urine inside them), ulcerative proctitis (an idiopathic mucosal inflammatory disease involving only the rectum), type 2 diabetes mellitus with hypoglycemia, need for assistance with personal care and muscle weakness. Record Review of Resident #71's quarterly MDS assessment with an ARD of 04/19/2023 revealed Resident #71 was always incontinent of bowel and bladder. Further review of the MDS revealed Resident #71's score was 99 indicating resident was unable to complete the interview on her BIMS. Record Review of Resident #71's comprehensive person-centered care plan revised date 04/08/2023 revealed At risk for impaired skin r/t bowel incontinence .will remain free from new areas of skin breakdown .Peri care as needed. Observation on 05/11/2023 at 12:39 p.m. of CNA D performed peri care for Resident #71. Peri care was performed on backside using single wipe each time. New brief put into place without changing gloves or sanitizing hands. Interview on 05/11/2023 at 12:50 p.m. with CNA D revealed they had training on hand hygiene and perineal care. CNA D stated she should have sanitized her hands and changed gloves prior to managing new brief. She stated not sanitizing her hands and donning new gloves could cause cross contamination and could result in the resident getting an infection. Interview on 5/11/2023 at 5:07 p.m. with DON regarding peri care performed by CNA D- he stated, CNA D should have changed her gloves due to infection control. Resident #71 could get an infection. Staff has had training for hand hygiene, facility policy/procedure, in-service. Record Review of CNA D's comprehensive clinical reviews dated 03/29/2023 revealed they were checked off for completing hand hygiene and perineal care. Review of the facility competency check list and procedure titled Perineal Care dated 3/2018, revealed wash and dry hands thoroughly. At anytime your hands/gloves get soiled, stop, remove gloves, hand hygiene, and start over again or resume. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455652 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 455652 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Creek Nursing and Rehabilitation 9014 Timber Path San Antonio, TX 78250 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 0880 Level of Harm - Minimal harm or potential for actual harm Review of the facility Handwashing/Hand Hygiene dated 8/2015 revealed .follow the handwashing/hand hygiene procedures to help prevent the spread of infections . Use an alcohol-based hand rub .After contact with a resident's intact skin. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455652 If continuation sheet Page 8 of 8