Health inspection·May 12, 2023

F 0550 from a seated position. Level of Harm - Minimal harm or potential for actual harm Interview on 05/09/2023 at 12:15 p.m. with LVN A revealed Resident #72 needed feeding assistance. LVN A stated she was trained to feed residents while in a seated position; however there was no space to put a chair next to the resident. Residents Affected - Few Interview with Resident #72 on 05/09/2023 at 2:00 p.m. revealed Resident #72 did not respond to the surveyor's questions. In an interview on 05/12/2023 with the DON and Administrator, they stated that staff feeding residents in a standing position was inappropriate and it was a matter of dignity for the residents. Record review of the facility's policy 2-4 The Person Centered Dining Approach, 2013 revealed Person centered care allows individuals to live as normal a life as possible. To that end, person entered care and hospitality services are adapted as much as possible into the everyday living arrangement, including dining. The person centered dining approach focuses on each individual's needs related to food, nutrition and dining. 6. Staff will promote resident independence and dignity while dining, such as avoiding: Staff standing over residents while assisting them to eat. Record review of the facility's Resident Rights policy, revised 01/28/2021, revealed Resident Rights: (4) be treated with courtesy, consideration and respect . Respect and Dignity. You have the right to be treated with respect and dignity . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455689 If continuation sheet Page 2 of 11 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 455689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Pedro Manor 515 W Ashby Pl San Antonio, TX 78212 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 0641 Ensure each resident receives an accurate assessment. 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 the assessment accurately reflected the resident's status for 1 of 6 residents (Residents #74) whose assessments were reviewed. Residents Affected - Few Resident #74's Significant Change MDS dated [DATE], was coded to not be considered by the state level II PASRR while Resident #74 received PASRR services. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #74's face sheet, dated 05/10/2023, revealed the resident was admitted to the facility on [DATE] (original admission [DATE]) with diagnoses which included: attention deficit hyperactivity disorder, schizoaffective disorder, epilepsy, and unspecified mood affective disorder. Record review of Resident #74's PASRR Level 1 Screening, dated 09/01/2022, revealed there was evidence or an indicator Resident #74 was an individual that had an Intellectual Disability and there was evidence or indicators that Resident #74 was an individual that had a Developmental Disability (related condition) other than an Intellectual Disability. Record review of Resident #74's PASRR Evaluation dated 09/08/2022, revealed Resident #74 had a Developmental Disability other than an Intellectual Disability that manifested before the age of 22 with recommended services provided/coordinated by local authority being habilitation coordination, independent living skills training and specialized speech therapy. Record review of Resident #74's PASRR Comprehensive Service Plan dated 12/27/2022 revealed individual was PASRR positive for IDD (Intellectual Developmental Disability) and the MDS Coordinator was a meeting participant. Record review of Resident #74's Significant Change MDS, dated [DATE], revealed the resident was not considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. Record review of Resident #74's comprehensive care plan revised 02/10/2023 revealed Focus: PASRR Resident receiving ID/DD PASRR services for dx attention deficit hyperactivity disorder. During an interview on 05/12/2023 at 1:27 p.m. the MDS Coordinator stated he was not sure why he had marked no on the MDS for Resident #74. The MDS Coordinator further stated he was responsible for the completion of the MDS, and he might have just missed it. The MDS Coordinator stated he had just recently learned what to look for and he went to the Simple portal (program for PASRR documents and referrals) to check resident PASRR status. Record review of the facility's Resident Assessment and Associated Processes policy, revision/review dated 1.2022, revealed Policy: It is the policy of this facility that resident's will be assessed, and the finding documented in their clinical health record. These will be comprehensive, accurate, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455689 If continuation sheet Page 3 of 11 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 455689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Pedro Manor 515 W Ashby Pl San Antonio, TX 78212 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete standardized reproducible assessment of each resident and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified. Procedure: Comprehensive Assessment: includes the completion of the MDS (Minimum Data Set) .followed by and/or review of the comprehensive care plan. Comprehensive MDS assessments include Admission, Annual, Significant Change in Status Assessments and Significant Corrections to prior Comprehensive Assessment. 5. Assessment information will be used to develop, review, and revise the resident's comprehensive care plan. When applicable, recommendations from the pre-admission screening and resident review (PASARR) evaluation report will be incorporated into the resident's assessment, care planning and transitions of care. Event ID: Facility ID: 455689 If continuation sheet Page 4 of 11 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 455689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Pedro Manor 515 W Ashby Pl San Antonio, TX 78212 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, 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, in that: Residents Affected - Many 1. There was a bag of shredded cheese past its use-by date in the walk-in cooler. 2. There were two containers of milk that had been opened that were without labels indicating the date they had been opened. 3. The dish machine failed to reach the proper temperature during the wash cycle. 4. [NAME] C was wearing jewelry on her hand while preparing food in the kitchen. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 05/09/2023 at 9:00 a.m. revealed there was a bag of shredded Mozzarella cheese on a shelf in the walk-in cooler. The cheese had been removed from its original package and placed in a clear, gallon-sized, zipper-sealed bag. On the bag was hand-written, Came in 3/10, opened 3/15, exp. 4/5/23. Interview on 05/09/2023 at 9:02 a.m. with the DM revealed based on the facility's food storage policy, the cheese was well past its use-by date and should have been discarded. The DM further stated any staff member who stored food in the cooler was responsible for properly labeling and dating food and discarding food that was past its use-by date to prevent the food from potentially causing foodborne illness. 2. Observation on 05/09/2023 at 9:05 a.m. in the walk-in cooler revealed two one-gallon containers of milk; one gallon was 2% milkfat, and there was approximately one quart left in the container, and one gallon was whole milk, and there was half the container left. There was no label indicating the dates the gallons of milk came in, the dates they were opened, or the use-by dates. Interview on 05/09/2023 at 9:08 a.m. with the DM revealed the dietary staff who opened and stored the gallons of milk in the walk-in cooler should have labeled the milk with the dates they were opened and the use-by dates, because even though there was a best-by date on the milk, the quality of the milk began to deteriorate once the container is opened. The DM further revealed she had been in the position one month, and she trained all dietary staff on food safety and sanitation. 3. Observation on 05/09/2023 from 9:25 a.m. to 9:35 a.m. in the dish room revealed the temperature of the dish machine did not reach 120 degrees Fahrenheit during the wash cycle (the gauge on the dish machine indicated the minimum temperature during the wash cycle was 120 degrees Fahrenheit - at that temperature, the color on the gauge was green). The DM ran the dish machine four times in succession and the highest temperature the machine reached during the wash cycle as indicated by the gauge on the machine was 111 degrees Fahrenheit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455689 If continuation sheet Page 5 of 11 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 455689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Pedro Manor 515 W Ashby Pl San Antonio, TX 78212 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 - Many Interview on 05/09/2023 at 9:35 a.m. with the DM revealed she knew the machine needed to reach at least 120 degrees Fahrenheit during the wash cycle to ensure proper cleaning of the dishes and utensils, and she believed the machine was reaching the proper temperature because there was steam coming out of the machine, and she speculated that it was possible that the gauge on the machine was malfunctioning. Observation on 05/09/2023 at 9:40 a.m. revealed the DM ran the dish machine again and used her digital thermometer to measure the temperature of the water. The temperature on the thermometer read 110.5 degrees Fahrenheit. Record review of the Dish Machine Temperature Sanitation Log posted in the dish room revealed that the last posted temperature, taken during the dinner meal on 05/08/2023, was 120 degrees Fahrenheit for both the washing and rinse cycle. 4. Observation on 05/11/2023 at 10:30 a.m. in the kitchen revealed [NAME] C was standing in front of a steel food preparation table. [NAME] C was using the table-mounted can opener to open cans of sweet potatoes and pouring the contents into pans for the lunch meal. [NAME] C had two bracelets on her left wrist. Interview on 05/11/2023 at 10:32 a.m. with the DM revealed she observed [NAME] C with the bracelets on her left wrist, stating, I told her to take them off earlier. I trained her. She is new; only been here a few months. Interview on 05/11/2023 at 10:40 a.m. with [NAME] C revealed she knew she was not supposed to wear jewelry on her hands and arms while preparing food in the kitchen because of potential food contamination and transmission of foodborne illness, and she had forgotten to take them off before her shift. Review of facility policy 3-17 Food Storage, 2013, revealed, 14. Refrigerated Food Storage: f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. Review of Refrigerator & Freezer Storage Chart, undated, revealed, Product: Shredded cheese; Refrigerator: 1 month; Freezer: Don't freeze well. Product: Milk; Refrigerator: 7 days; Freezer: Don't freeze. Review of facility policy Resource: Sanitation of Dishes/Dish Machine, 2013, revealed: Type of Dish Machine: Low Temperature Dishwasher, Spray Type Dish Machines Using Chemicals to Sanitize; Wash Temperature - 120 degrees Fahrenheit; Finale Rinse Temperature or Sanitization: 50 ppm Hypochlorite. Review of facility policy 4-4 Employee Sanitation Practices, 2013, revealed, 3. Jewelry is kept at a minimum. Only a plain band such as a wedding band is allowed to be worn. Medical alert bracelets may not be worn. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, , ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455689 If continuation sheet Page 6 of 11 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 455689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Pedro Manor 515 W Ashby Pl San Antonio, TX 78212 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 - Many the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed:4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization -Temperature, pH, Concentration, and Hardness. A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under §7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, and shall be used as follows: (A) A chlorine solution shall have a minimum temperature based on the concentration and PH of the solution as listed in the following chart; mg/L pH 10 or Less pH 8 or Less 25-49 120 degrees F 120 degrees F 50-99 100 degrees F 75 degrees F Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed, 2-303.11 Jewelry Prohibition. Except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455689 If continuation sheet Page 7 of 11 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 455689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Pedro Manor 515 W Ashby Pl San Antonio, TX 78212 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, and record review, the facility failed to dispose of garbage and refuse properly for 3 of 4 waste receptacles in that: Residents Affected - Few There were two waste receptacles filled with waste that did not have tight fitting lids and one waste receptacle was overfilled and could not be closed outside the facility. These failures could place residents at risk for exposure to germs and diseases carried by vermin and rodents. The findings included: Observation on 05/10/2023 at 08:50 a.m. revealed there were four waste receptacles next to the dumpster outside the facility. One receptacle was closed with a lid; one receptacle could not be closed because the amount of waste in plastic bags inside the receptacle surpassed the top of the receptacle; one receptacle was overflowing with waste in plastic bags beyond the top and did not have a lid; and one receptacle was filled approximately 1/4th with loose waste and debris not sealed in a plastic bag. There were gnats too numerous to count flying around the dumpster and waste receptacles. Interview on 05/10/2023 at 9:12 a.m. with the Maintenance Director revealed the dumpster was usually emptied daily; however, the company that empties it did not come the day prior due to the weather. The Maintenance Director further stated his Maintenance Resource Advisor observed the previous day that the Dumpster was full and there was trash around the dumpster that needed to be disposed of properly. Interview on 05/10/2023 at 9:23 a.m. with the Administrator revealed he was aware there were waste receptacles without tight-fitting lids next to the dumpster that contained waste and that could potentially cause the proliferation of rodents and pests. Interview on 05/10/2023 at 9:27 a.m. with the DM revealed she was not aware there were waste receptacles without lids that were full of waste that morning, and this could contribute to the spread of disease from rodents and pests. Review of facility policy 4-25 Waste Disposal, 2013, revealed, 1. Prior to disposal, all waste shall be kept in leak-proof, non-absorbent, fireproof containers that are kept covered. 2. These containers are emptied as often as necessary throughout the day. Trash bags shall be sealed prior to removing them from the facility. Trash will be deposited into a sealed container outside the premises. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed: 5-501.13 (A) Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables and for use with materials containing FOOD residue shall be durable, cleanable, insect-and rodent-resistant, leakproof, and nonabsorbent. 5-501.112 Outside Storage Prohibitions. (A) REFUSE receptacles not meeting the requirements specified under 5-501.13(A) such as receptacles that are not rodent-resistant, unprotected plastic bags and paper bags, or baled units that contain materials with FOOD residue may not be stored outside. 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT. 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455689 If continuation sheet Page 8 of 11 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 455689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Pedro Manor 515 W Ashby Pl San Antonio, TX 78212 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 0814 containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. 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: 455689 If continuation sheet Page 9 of 11 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 455689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Pedro Manor 515 W Ashby Pl San Antonio, TX 78212 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation and interview the facility failed to keep confidential all information contained in the resident's records, regardless of the form or storage method of the records and failed to safeguard medical record information against loss, destruction, or unauthorized use for 1 of 1 facility. Residents' medical records were stored in an unlocked room on the 3rd floor that was being remodeled. Medical record sheets were out of their files and scattered on the floor in multiple places in the room. This failure could place resident identifiable information at risk of unauthorized use. The findings were: Observation on 5/9/23 at 9:20 a.m. revealed surveyors had been placed in a conference room on the 3rd floor. There were no residents on the floor as it was being remodeled and under construction. Observation on 5/9/23 at 3:30 p.m. revealed construction workers were working on the 3rd floor and walking in the hallway. An unknown staff member was standing in the hallway waiting on the elevator. Observation on 5/10/23 at 4:34 p.m. revealed on the 3rd floor directly across from the conference room hallway a door was open and revealed what appeared to be residents' records on the floor and in file boxes stacked in the room. There were boxes labeled medical records and boxes labeled 2015 and 2020 GA-GR and other boxes labeled with residents' names and dates and others not labeled. Observation further revealed signed Physician's Telephone order forms on the floor and other residents' medical records scattered on the floor. Some boxes were observed to be tilted and stacked up to 6 ft tall in different parts of the room and falling over. There were residents' medical records on the floor and scattered in the corner of the room between boxes. There was a bathroom and the light was on and the new floors in the room had been covered with paper protection and taped together at the seams. Multiple areas of the room had residents' medical records with diagnoses, medications, lab and x-ray results on the floor and footprints on them in one area as if they had been stepped on. Observed several boxes also labeled business office and what looked like thin folders with staff names as well. Many of the boxes were missing lids and had files sticking up out of them as if they had been gone through and not placed back in the box. The door did not have a lock. Observation on 5/10/23 at 4:34 p.m. revealed there were several construction workers walking in the hallway on the 3rd floor. In an interview on 5/10/23 at 4:45 p.m. the Administrator was notified of the opened and unlocked room with the medical records and stated he would take care of it. Observation on 5/11/23 at 8:40 a.m. revealed a worker was changing the doorknob on the room with the medical records and replacing it with a doorknob that had a key lock. In an interview on 05/11/23 at 1 p.m. Staff D stated the medical records in the room across from the conference room hallway were her shred records, and then stated the records in the room were from the previous facility owners and Staff D confirmed what the surveyor saw regarding 2015 and 2020 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455689 If continuation sheet Page 10 of 11 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 455689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Pedro Manor 515 W Ashby Pl San Antonio, TX 78212 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dates on boxes and stated again they were from previous facility owners and not current resident records. Staff D reported current residents' records were locked in her office and she and the Administrator were the only ones with keys to it. Staff D stated the medical records in the room on the 3rd floor should be locked and secured especially with the construction on the 3rd floor. Staff D stated the facility had contacted the previous facility owners to let them know the medical records were at the facility but had not heard anything back from them. Staff D stated the facility would not be shredding anything and would follow the medical records retention policy. Observation on 5/11/23 at 3:00 p.m. revealed in the conference room with the surveyors had been a metal shopping cart style cart with accordion files, binders, and boxes. On the top of the cart was a resident's large medical record. Upon examining the accordion folder type file, there was no cover and noted it was a resident's medical record and the resident's name is on the accordion file. There was also a large file box that had a resident's name; handwriting and different forms could be seen sticking out. There were no residents by those names on current resident roster dated 5/9/23 for this survey. Interview on 5/11/23 at 3:45 p.m. the DON and Staff D were informed of the cart in the conference room with resident's medical records in it. Staff D stated it might be from the audit and stated she would secure the records immediately. Observation on 5/11/23 at 5:30 p.m. revealed the metal cart in the conference room with resident's medical records on it was gone from the conference room. In an interview on 5/12/23 at 2:00 p.m. the Administrator stated the medical records that were in the room on the 3rd floor should have been secured. The Administrator further stated the facility's plan was to continue going through the medical records per retention policy and then calling the previous company again to ask them to collect their residents' and staff records. The Administrator stated the facility had a safe storage company they used and the previous company did not but if the records were sent to their safe storage company, they would be kept separate in case the company comes to get them. Review of the facility HIPAA compliance policy and procedure dated January 2017 indicated, Policy Statement Protected Health Information (PHI) will be safeguarded against unauthorized use, access, or disclosure in accordance with federal and state laws to prevent access by unauthorized persons.Secure shall be defined as inaccessible to unauthorized individuals, protected shall be defined as safe from environmental damage.2. Store all documents containing PHI in a secure, locked location with limited access to authorized workforce members. 9. Keep records and other documents out of public view and reach. 16. Secure and protect all records and documents from damage, loss, or destruction when an alternative storage space is needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455689 If continuation sheet Page 11 of 11