Health inspection·May 17, 2024

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's doctor orders, dated 12/04/2023, revealed the resident was placed on 1:1 supervision wherever he went. In addition, the resident was also placed on 15-minute checks from 12/04/2023 - 12/10/2023. Record review of Resident #1's comprehensive care plan dated 10/19/2023 noted resident identified as an elopement risk. The care plan was updated on 12/04/2023 to include the elopement incident. Residents Affected - Few During an interview on 05/14/2024 at 2:00 PM with the DON she stated the charge nurse on the 3rd floor was the last one to see the resident; the resident was sitting in a chair by the nurses' station and she had chatted with him. Shortly thereafter the resident walked past the nurses' station, took the elevator from the 3rd floor to the first floor, and exited the building. The alarm was found to be working but was not heard. During an interview on 05/14/2024 at 2:40 PM with the maintenance director he stated since Resident #1's elopement he conducted three elopement drills. A Code Silver is called. The drills were scheduled in the facility's building management system, like fire drills. During an interview on 05/14/2024 at 3:15 PM with the HR Director she stated that since the elopement incident the hours at the reception desk in the front lobby of the facility were extended to 9:00 PM. During an interview on 05/17/2024 at 12:42 PM with LVN C she stated Resident #1 was able to verbalize his needs, was easily redirected, and had no behaviors. He had never shown any inclination to leave the facility prior to the elopement incident and had not since. He does not leave the 3rd floor and go to the first floor of the facility without a staff member and was able to verbalize to staff when he would like to leave the floor. Observation on 05/15/2024 at 2:30 PM of the alarm response at the front door of the facility revealed it was functional and sufficiently loud to alert the staff of a potential elopement. Observation on 05/15/2024 at 2:40 PM of Resident #1 in his room revealed the resident was alert, oriented and well groomed. In an interview on 05/15/2024 at 2:41 PM with Resident #1 revealed he was very happy at the facility and the staff cared for him well. The DON was notified on 05/15/2024 at 2:45 PM that a past non-compliance IJ situation had been identified due to the above failures. The facility course of action prior to surveyor entrance included: -Resident #1 was initial placed on 1:1 supervision and moved to the closest room next to the nurses' station. -The facility contacted the alarm company, who significantly increased the volume of the alarm system, and changed the method of activating a code so it now goes through the phone system for broadcasting throughout the facility. Since the elopement incident, this resident has not had another elopement attempt and no other resident attempted to elope from the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455689 If continuation sheet Page 2 of 5 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 05/17/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few -Immediately after the elopement incident, the reception desk was manned for 24 hours. It was changed to 9:00 PM 2 1/2 weeks later, on 12/22/2023. -The facility increased training on the elopement policy to every other month. Training was conducted on 01/04/2024, 03/27/2024, and 05/08/2024. Record review of an in-service training, dated 12/04/2024, related to Elopement Policy and Protocol revealed 103 of 103 staff member signatures. Interviews were conducted with 22 employees who consisted of: ADONs (2), LVNs (3), Medication Aides (2), CNAs (3), HR Director, Social Worker, Activities Director, Medical Records Manager, Housekeeping Supervisor, OT (1), ST (1), PTA (1), Housekeepers (2), Laundry Aide (1) and Floor Technician (1) on 05/15/2024 from 10:00 AM to 12:30 PM revealed they had received in-services on Elopement Response. All were able to state the key elements of the Emergency Response Plan and elopement policy, which included: If a resident was discovered missing: - Note the last time the resident was seen - verify the resident didn't sign out, is at an appointment or had been discharged . Conduct a census verification and roll call. - Activate emergency response plan - Call Code Silver - Notify Administrator/DON/Maintenance Director - Search for the resident in resident rooms, bathrooms, showers, closets, recreation areas, and outside area - After 30 minutes, if the resident had not been located, call 9-11 - Call the resident's RP FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455689 If continuation sheet Page 3 of 5 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 05/17/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 2 residents (Resident #2) reviewed for infection control, in that: Residents Affected - Few CNA A did not change her gloves or wash her hands after touching Resident #2's privacy curtain, between change of gloves and, after providing incontinent care for Resident #2. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #2's face sheet, dated 05/16/2024, revealed an admission date of 01/20/2020 and, a readmission date of 09/30/2023, with diagnoses which included: Dislocation of right hip (thighbone separates from the hip bone), Chronic pain, History of urinary tract infection (infection in any part of the urinary system), Cerebellar ataxia (Lack of voluntary coordination of muscles movements originating in the cerebellum part of the brain)and, Hypertension (High blood pressure). Record review of Resident #2's Quarterly MDS assessment, dated 02/12/2024, revealed Resident #2 had a BIMS score of 15, which indicated no cognitive impairment. Resident #2 was indicated to always be incontinent of bowel and bladder and, required extensive assistance to total care with her acclivities of daily living. Review of Resident #22's care plan, dated 12/27/2021, revealed a problem of has bladder incontinence related to muscle weakness and debility with an intervention of Check as required for incontinence. Wash, rinse and dry perineum. Change clothing as needed after incontinence episodes Observation on 05/16/2024 at 10:52 a.m. revealed, while providing incontinent care for Resident #2, CNA A did not change her gloves or wash her hands after touching the privacy curtain to close it and before providing incontinent care for Resident #2. CNA A changed her gloves after cleaning Resident #2's genitals but did not sanitize her hands before putting clean gloves on. Further observation revealed CNA A changed her gloves after cleaning Resident #2's buttocks but did not sanitize her hands before putting clean gloves on and touching the new brief to fasten them for the resident. During an interview on 05/16/2024 at 11:00 a.m. CNA A confirmed she did not change her gloves or wash her hands after touching the privacy curtain and before starting to provide care. CNA A also confirmed she did not sanitized between change of gloves or before touching Resident #2's clean brief. She confirmed receiving infection control training within the year. During an interview with the DON on 05/16/2024 at 11:05 a.m., the DON confirmed the staff should have changed her gloves after touching the privacy curtain to prevent contamination and infection to the resident. She confirmed staff should sanitize their hands between change off gloves to prevent infection to the resident. The DON revealed the DON and the ADON provided training on infection control to the staff at least once a year. They checked the staff's skills once a year and did spot check when problems with infection control were noticed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455689 If continuation sheet Page 4 of 5 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 05/17/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of facility Nurse aide competency checklist perineal care-female (with or without catheter, undated, revealed wash hands. Wear gloves and follow Standard Precautions if contact with blood or body fluids is likely [ .] wash hands and put on clean gloves for perineal care. During an interview on 05/16/2024 at 1:38 p.m. with the DON, she revealed there was no other policy regarding when to change gloves and practice hand hygiene during incontinent care. Event ID: Facility ID: 455689 If continuation sheet Page 5 of 5