Health inspection·November 22, 2023

F 0580 - Nursing Progress Note, dated 11/16/23 and written by RN J: cooperated with indwelling catheter. Level of Harm - Minimal harm or potential for actual harm - Nursing Progress Note, dated 11/17/23 and written by LVN G: foley cath inserted on 2-10- pm shift. Residents Affected - Few Record review of Resident #1's hospital records, dated 11/18/23, revealed the following: Approximately 4 days ago patient was noted to irritable [sic] and not quite herself by family members. [The facility] staff placed a foley [an indwelling urinary catheter] . and found that patient had a UTI with elevated WBCs. During an interview on 11/19/23 at 2:50 p.m., CNA C stated she thought she took care of Resident #1 on Thursday morning (11/16/23). CNA C stated Resident #1 had a foley bag at the time and that was the first time she (CNA C) was working with the resident with the indwelling catheter bag. During an interview on 11/19/23 at 3:07 p.m., RN D stated the catheter was inserted on Thursday (11/16/23) to collect Resident #1's urine and was left in. During an interview on 11/20/23 at 3:55 p.m., LVN A stated he thought on 11/15/23 Resident #1's physician gave the order for an in-and-out catheter. LVN A stated he tried to do the in-and-out catheter once by himself and he was not successful. Then he went and consulted LVN B and they tried the in-and-out catheter again and about 10 mL of thick sedimentation-fluid came out during this second attempt. LVN A stated there was no order for the [indwelling] catheter and there was only an order for an in-and-out catheter. LVN A stated, we decided to leave it in and then take it out when enough urine had collected. LVN A stated on 11/16/23 the indwelling catheter was draining. LVN A stated on 11/17/23 he thought of discontinuing Resident #1's indwelling catheter that day but he forgot because he was a newly admitted resident. During an interview on 11/21/23 at 3:50 p.m., CNA K stated she worked with Resident #1 on 11/16/23 and 11/17/23. CNA K stated Resident #1 had an indwelling catheter during that time. During an interview on 11/22/23 at 10:21 a.m., Resident #1's RP stated she was Resident #1's POA and she was not aware Resident #1 had an indwelling catheter inserted until she visited Resident #1 and saw the foley catheter on Thursday, 11/16/23. Resident #1's RP stated she would like to be notified if the facility was going to insert an indwelling catheter in Resident #1. During an interview on 11/22/23 at 10:53 a.m., LVN G stated he worked with Resident #1 on Thursday and Friday and Resident #1 had an indwelling catheter at that time. During an interview on 11/22/23 at 11:20 a.m., Physician I stated she did not witness that Resident #1 had a foley catheter but had heard about what happened from the DON and ADON E. Physician I stated she heard Resident #1 had a UTI and was sent to the hospital. Physician I stated, I heard the night nurse went to get the urine sample and she used a foley catheter instead of doing and in-and-out [catheter] and she left the foley in and when the patient was sent out [to a local hospital] she had a foley. Physician I stated she was not notified of Resident #1's indwelling catheter being placed. Physician I stated he would like to be informed if an indwelling catheter being placed. During a follow-up interview on 11/22/23 at 11:53 a.m., LVN A stated he thought the foley catheter was in the correct place because there was a drainage coming through the indwelling catheter. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455652 If continuation sheet Page 2 of 6 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 11/22/2023 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/22/23 at 12:34 p.m., the DON stated an order was needed for an indwelling catheter. The DON stated when a staff member placed an indwelling catheter the physician, the patient, the family member, and the POA should be notified. When asked if he knew if anyone was notified of the insertion of Resident #1's indwelling catheter, the DON stated, we received an order to get an in and out [catheter] or to get into a cath. [The physician] knew that's how it was going to get it. When asked if Resident #1's family member was informed of the indwelling catheter placement, the DON stated, I don't know. When asked if the facility had a quality assurance process to ensure the appropriate parties are notified of an indwelling catheter placement, the DON stated ,we have our process for the change in condition to notify the family. When asked what sort of negative effects could occur to the patient if the appropriate parties aren't notified of the foley catheter placement, the DON stated, If I insert an [indwelling catheter] into the patient appropriately, I don't know if there's going to be a negative effect. But there's always a risk for any device going into the orifice . trauma, discomfort, whatever, but when it's done right, it's a sterile technique. Record review of a facility policy titled, Resident Rights, dated February 2021, revealed the following: These rights include the resident's right to: .be notified of his or her medical condition and of any changes in his or her condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455652 If continuation sheet Page 3 of 6 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 11/22/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure incontinent care was provided in accordance with appropriate treatment and service practices to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 residents (Resident #1) reviewed for incontinent care and catheter care, in that: Resident #1 had an indwelling urinary catheter inserted without a physician's order. This deficient practice could place residents at-risk for infection due to improper care practices. The findings were: Record review of Resident #1's face sheet, dated 11/19/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of other sequelae [a condition following a previous disease or injury] of cerebral infarction [stroke], dysphagia [difficulty swallowing] following cerebral infarction, heart failure, unspecified, unspecified atrial fibrillation [a quivering, irregular heartbeat], and muscle weakness (generalized.) Further record review of this face sheet revealed Resident #1's primary physician was Physician I and Resident #1 had an RP. Record review of Resident #1's quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS score of 2, signifying severe cognitive impairment. Further record review of Section H, revealed Resident #1 did not have an indwelling catheter. Record review of Resident #1's Change in Condition Form, dated 11/14/23 and written by ADON E revealed the following: discussed care with MD and received N.O. as follows: 1) STAT CBC, BMP, UA C&S (may use in and out catheter). Record review of Resident #1's orders, dated 11/19/23, revealed no order for an indwelling urinary catheter. Record review of Resident #1's care plan, dated 10/18/23, revealed no care plan in regards to an indwelling urinary catheter. Record review of Resident #1's nursing progress notes, obtained 11/19/23, revealed the following progress notes: - Nursing Progress Note, dated 11/15/23 and written by LVN A: Tried to collect a UA sample X2 it was only sedimentation no urine. Put a foley catheter to collect UA sample encouraged fluids. - Nursing Progress Note, dated 11/16/23 and written by RN J: cooperated with indwelling catheter. - Nursing Progress Note, dated 11/17/23 and written by LVN G: foley cath inserted on 2-10 pm shift. Record review of Resident #1's hospital records, dated 11/18/23, revealed the following: Approximately 4 days ago patient was noted to irritable [sic] and not quite herself by family members. [The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455652 If continuation sheet Page 4 of 6 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 11/22/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility] staff placed a foley [an indwelling urinary catheter] . and found that patient had a UTI with elevated WBCs. During an interview on 11/19/23 at 2:50 p.m., CNA C stated she thought she took care of Resident #1 on Thursday morning (11/16/23). CNA C stated Resident #1 had a foley bag at the time and that was the first time she (CNA C) was working with the resident with the indwelling catheter bag. During an interview on 11/19/23 at 3:07 p.m., RN D stated the catheter was inserted on Thursday (11/16/23) to collect Resident #1's urine and was left in. During an interview on 11/20/23 at 8:06 a.m., Hospital Nurse F stated she did not know why the facility had a urinary catheter in Resident #1 because Resident #1 did not have a stage 4 pressure ulcer and was not on any medications that reduce fluid in the body. During an interview on 11/20/23 at 10:22 a.m., LVN B stated she assisted Resident #1's nurse in placing an indwelling catheter in Resident #1. LVN B stated she did not know what the order was for the indwelling catheter as she was just assisting the other nurse. During an interview on 11/20/23 at 11:53 a.m., LVN G stated he took care of Resident #1 on Friday 11/17/23. LVN G stated there was no order for Resident #1's indwelling catheter and did not know why the indwelling catheter was placed. LVN G stated the only reason he could think of as to why Resident #1 had an indwelling catheter was because it was difficult to convince Resident #1 to eat or drink. When asked about the risk of not having an order for a urinary catheter, LVN G stated it could result in an increased risk of infection and injury to the urethra or bladder area if it is not put in correctly. During an interview on 11/20/23 at 3:55 p.m., LVN A stated he thought on 11/15/23 Resident #1's physician gave the order for an in-and-out catheter. LVN A stated he tried to do the in-and-out catheter once by himself and he was not successful. Then he went and consulted LVN B and they tried the in-and-out catheter again and about 10 mL of thick sedimentation-fluid came out during this second attempt. LVN A stated there was no order for the [indwelling] catheter and there was only an order for an in-and-out catheter. LVN A stated, we decided to leave it in and then take it out when enough urine had collected. LVN A stated he was thinking of discontinuing the indwelling catheter on 11/17/23, but he forgot because he had a new admission. LVN A stated he was supposed to get an order for the indwelling catheter but never got the order. During an interview on 11/22/23 at 11:20 p.m., Physician I stated she did not witness that Resident #1 had a foley catheter but had heard about what happened from the DON and ADON E, that Resident #1 had a UTI and was sent to the hospital. Physician I stated, I heard the night nurse went to get the urine sample and she used a foley catheter instead of doing and in-and-out [catheter] and she left the foley in and when the patient was sent out [to a local hospital] she had a foley. Physician I stated she was not notified of Resident #1's indwelling catheter being placed. During an interview on 11/22/23 at 12:34 p.m., the DON stated an order was needed for an indwelling catheter. The DON stated the usual criteria required to insert an indwelling catheter was: Obstruction [of the urinary tract], documented urinary retention, multiple wounds, if we noticed that [the resident] had abdominal pain and they haven't voided, end of life, monitoring [intake and output.] The DON stated on 11/15/23, Resident #1 had an order for a urine analysis and urine culture and sensitivity. When asked if he knew why the foley catheter was inserted, the DON stated, What I know is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455652 If continuation sheet Page 5 of 6 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 11/22/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that they [the staff] left it. It was an order to get a [urine analysis.] I didn't know anything Saturday [11/18/23] except [Resident #1] had an [indwelling catheter] and I was thinking she needed to go out. Now I know [Resident #1] had an [indwelling catheter] without an order. You can't get a clean catch [urine sample[ from [Resident #1], so it was supposed to be an in-and-out [catheter.] I don't know what [the staff] thought, other than that the [indwelling] catheter was left in and the night nurse collected the sample. When asked if the facility had a quality assurance process to ensure orders were in place for an indwelling catheter insertion, the DON stated, it's a policy that if you're going to insert a foley or do an in and out catheter or a process, it requires a doctor's order. Record review of a facility policy titled, Catheter Care, Urinary, revealed no verbiage regarding a valid rationales for the placement of an indwelling urinary catheter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455652 If continuation sheet Page 6 of 6