Health inspection·March 14, 2025

F 0921 [ROOM NUMBER]. Level of Harm - Minimal harm or potential for actual harm During observation rounds with the Maintenance Director on 3/12/25 from 8:55 am to 9:05 am the following observations were made on resident hallways 100, 200, 400, and 500: Residents Affected - Some 1-On the 100- resident hallway: a-there was a dirty 2x2 ft ceiling tile and a rusted ceiling air vent across from the storage room and a dirty 2x2 ft ceiling tile and a rusted air vent at the nurses station. 2-On the 200- resident hallway: a-there was a rusted air vent across from room [ROOM NUMBER], a rusted air vent across from room [ROOM NUMBER], and a rusted air vent across from room [ROOM NUMBER]. 3-On the 400- resident hallway: a-there was there was a dirty 2x2 ft ceiling tile and rusted air vent at the nurse's station and a dirty 2x2 ft ceiling tile and rusted air vent across from the therapy room, a rusted ceiling vent across from room [ROOM NUMBER], a dirty 2x2 ceiling tile across from room [ROOM NUMBER], and a dirty ceiling tile across from room [ROOM NUMBER]. 4-On the 500- resident hallway: a-there was a dirty 2x2 ceiling tile across from room [ROOM NUMBER], a rusted ceiling vent across from room [ROOM NUMBER], two dirty 2x2 ft ceiling tiles and a rusted ceiling vent across from room [ROOM NUMBER]. During an interview with the Maintenance Director on 3/12/25 at 9:10 am he stated that he felt the dirty ceiling tiles were caused by dirt from the air ducts in the ceiling that had not been cleaned in several years. He stated that the rusted ceiling vents needed to be cleaned or re-painted. The Maintenance Director stated that he was responsible for cleaning or replacing the ceiling tiles and cleaning or re-painting the ceiling air vents. The Maintenance Director stated that cleaning or replacing the ceiling tiles and cleaning or repainting the air vents had not been a work priority. The Maintenance Director stated that cleaning or replacing the ceiling tiles and cleaning or re-painting the air vents would improve the homelike environment for the residents. During an interview with the Administrator on 3/13/25 at 10:00am she stated she had not been aware of the dirty ceiling tiles or rusted ceiling vents. She stated that staff had used the TELS work order system to request repairs in the building and to her knowledge there were no pending work order requests related to the ceiling tiles or ceiling vents. The Administrator stated that cleaning or replacing the ceiling tiles and cleaning or repainting the ceiling vents would positively impact the resident's homelike environment. During an interview with the Maintenance Director on 3/14/25 at 8:30 am he stated that the dirty ceiling tiles that were noted during observation with the surveyor were cleaned and replaced as needed. The Maintenance Director stated that the facility would explore the process of having the ceiling air ducts cleaned. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455652 If continuation sheet Page 2 of 3 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 03/14/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy on Maintenance Service dated 12/09 revealed: The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. The building is to be maintained in good repair and free from hazards. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455652 If continuation sheet Page 3 of 3