Health inspection·August 8, 2025

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 6 residents (Resident #92) reviewed for privacy, in that: CNA E and CNA F did not close completely Resident #92's privacy curtain while providing incontinent care. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.The findings include: Record review of Resident #92's face sheet, dated 08/07/2025, revealed an admission date of 01/09/2025, with diagnoses which included: Wernicke's encephalopathy (brain and memory disorder due to a lack of vitamin B1), Dysphagia (difficulty swallowing), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Hypertension (High blood pressure), and Asthma (Long-term inflammatory disease of the airways restricting airflow). Record review of Resident #92's Quarterly MDS assessment, dated 07/08/2025, revealed the resident had a BIMS score of 08, indicating she was moderately cognitively impaired. Resident #92 was always incontinent of bladder and bowel and, required total assistance with her ADLs. Record review of Resident #92's care plan, dated 01/17/2025, revealed a problem of has ADL Self Care Performance Deficit related to Wernicke's encephalopathy, Muscle weakness, with an intervention of Toileting Hygiene: Dependent. Observation on 08/07/2025 at 3:24 p.m. revealed CNA E and CNA F did not completely close the privacy curtains while they provided incontinent care for Resident #92, exposing the resident who could be seen if somebody entered the room. The privacy curtain was broken and was blocked on the rail, it could only be halfway closed. During an interview with CNA E and CNA F on 08/07/2025 at 3:38 p.m., CNA F confirmed the privacy curtains was not completely closed while they provided care for Resident #92 but it should have been to protect the resident's privacy. They did not know how long the privacy curtain had been broken. They confirmed they received resident rights training within the year. During an interview with the DON on 08/07/2025 at 3:40 p.m., she said privacy must be provided during care and Resident #92's privacy curtains should have been closed completely. She said she provided training, the staff received training on resident rights within the year and they do staff skills checks annually and as needed. Review of a policy, titled Resident Rights, undated, revealed They also will have the right to privacy, maintain privacy curtains for dressing and when providing care. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455689 If continuation sheet Page 2 of 7 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 08/08/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 2 resident (Residents #12 and #92 ) reviewed for incontinent care, in that: 1.While providing incontinent care, CNA G made multiple passes with the same wipe while cleaning Resident #12's buttocks. 2. While providing incontinent care for Resident #92, CNA E did not separate Resident #92's labias to clean the meatus (urinary opening) This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: 1.Record review of Resident #12's face sheet, dated 08/07/2025, revealed an admission date of 04/25/2024, and, a readmission date of 07/29/2025, with diagnoses which included: Type 2 diabetes mellitus (high level of sugar in the blood) , Dysphagia (difficulty swallowing), Hemiplegia (Paralysis of one side of the body), Resistance to multiple antimicrobial drugs, Hyperlipidemia(Elevated level of any or all lipids(fat) in the blood), Hypertension (high blood pressure), Chronic kidney disease stage 2 (gradual loss of kidney function). Record review of Resident #12's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 00 indicating severe cognitive impairment. Resident #12 required total assistance and was always incontinent of bowel. The resident had an indwelling catheter. Review of Resident #12's care plan, dated 05/09/2025, revealed a problem of has an indwelling urinary catheter due to urinary obstruction and an intervention of Monitor/record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observation on 08/07/2025 at 10:48 a.m. revealed while providing incontinent care for Resident #12, CNA G wiped Resident #12's buttocks making multiple passes with the same wet wipe. During an interview on 08/07/2025 at 11:07 a.m. CNA G, he said he had wiped Resident #12's buttocks making multiple passes with the same wet wipe. He said he was nervous and he knew to only do one pass per wipe. He stated doing multiple passes could cause a risk for infection for the resident. CNA G confirmed receiving training on incontinent care from the facility. During an interview with the DON on 08/07/2025 at 3:40 p.m., she confirmed a wet wipe should only be used for one pass, during perineal care. She stated doing multiple passes could possibly cause an infection. The DON revealed the staff received training on infection control and incontinent care at least annually. The staff skills were checked yearly. The DON said she spot checked the staff while they provide care for infection control and quality of care. Review of annual skills check revealed CNA G passed competency for Perineal care/incontinent care on 01/20/2025. Review of facility policy, titled Perineal care, undated, revealed wash peri-area using front to back strokes. 2.Record review of Resident #92's face sheet, dated 08/07/2025, revealed an admission date of 01/09/2025, with diagnoses which included: Wernicke's encephalopathy (brain and memory disorder due to a lack of vitamin B1), Dysphagia (difficulty swallowing), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Hypertension (High blood pressure), and Asthma (Long-term inflammatory disease of the airways restricting airflow). Record review of Resident #92's Quarterly MDS assessment, dated 07/08/2025, revealed the resident had a BIMS score of 08, indicating she was moderately cognitively impaired. Resident #92 was always incontinent of bladder and bowel and, required total assistance with her ADLs. Record review of Resident #92's care plan, dated 01/17/2025, revealed a problem of has ADL Self Care Performance Deficit related to Wernicke's encephalopathy, Muscle (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455689 If continuation sheet Page 3 of 7 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 08/08/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete weakness, with an intervention of Toileting Hygiene: Dependent. Observation on 08/07/2025 at 3:24 p.m., revealed while providing incontinent care for Resident #92, CNA E did not separate Resident #92's labia to clean the meatus (urinary opening). During an interview on 08/07/2025 at 3:37 a.m. CNA E, said she did not separate Resident #92's labia. She said she was nervous but she knew she had to clean between the resident's labia. She stated not cleaning between the labia could cause a risk for infection for the resident. She said she received training on incontinent care from the facility. During an interview with the DON on 08/07/2025 at 3:40 p.m., the DON said the staff had to clean between the resident's labia during female incontinent care. She stated not cleaning between the labia could cause a risk for infection for the resident. The DON revealed the staff received training on infection control and incontinent care at least annually. The DON said the staff skills were checked yearly. The DON said she spot checked the staff while they provided care for infection control and quality of care. Review of annual skills check revealed CNA E passed competency for Perineal care/incontinent care on 02/19/2025. Review of Facility's policy Perineal care female, undated, revealed First separate inner labia and wash down the center over the urethral area. Event ID: Facility ID: 455689 If continuation sheet Page 4 of 7 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 08/08/2025 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to prepare and provide food and drink that was palatable, attractive, and at a safe and appetizing temperature, for 3 of 29 residents (Resident #6, #43, and #93) reviewed for palatable and appetizing food, in that: 1. The facility served Resident #6 meals that were cold. 2. The facility served Resident #43 meals that were cold 3. The facility served Resident #93 meals that were cold. These failures could place residents at risk for a diminished quality of life by not receiving food and drink that is palatable, attractive, and at a safe and appetizing temperature. The findings included: 1. A record review of Resident #6's face sheet dated 08/05/25 revealed the latest admission date of 3/26/25 for a 54- year -old male with diagnoses which included type 2 diabetes mellitus( a condition in which the body has trouble controlling blood sugar), depression disorder (a condition in which there is persistent feeling of sadness) and chronic kidney disease( a condition in which the kidney function is impaired). A record review of Resident #6's quarterly MDS assessment dated [DATE] revealed Resident #6 had a BIMS of 15 (a condition in which the cognition is intact). A record review of Resident #6's care plan initiated on 2/28/21 revealed a deficit in activities of daily living. A record review of Resident #43's face sheet dated 8/5/25 revealed an admission date of 5/29/24 for a [AGE] year old male with diagnoses of anemia (a condition in which there is not enough red blood cells), COPD (a condition in which the lung function is diminished) , and muscle weakness ( a condition in which the muscle strength is poor). 2. A record review of Resident #43's annual MDS completed on 5/29/25 revealed a BIMS score of 13 (a condition in which the cognition is intact). A record review of Resident #43's care plan initiated on 7/4/23 revealed a deficit in activities of daily living. A record review of Resident #93's face sheet dated 8/5/25 revealed an admission date of 4/25/24 for a [AGE] year old female resident with diagnoses of blindness in the right eye, ( a loss of vision in one eye), essential hypertension ( a condition in which the blood pressure is high), and syncope ( a condition of temporary loss of consciousness) 3. A record review of Resident #93's quarterly MDS dated [DATE] revealed a BIMS of 13 (a condition in which cognition is intact). A record review of Resident #93's care plan initiated on 4/30/24 revealed a deficit in activities of daily living. During an interview on 8/5/25 at 12:15pm Resident # 6 stated that he eats in his room and his meals are often cold when served. Resident #6 stated that today's lunch was cold and he did not want to eat it. During an interview on 8/5/25 at 1:15pm Resident #93 stated she eats in the room and the breakfast when served is almost always cold. During an interview on 8/6/25 at 7:25am C.N.A.-A stated that the food tray racks have a plastic cover which is removed and when on the resident hallways the food trays are held in an open tray rack cart. During an observation on 8/6/25 at 7:40 am revealed a resident's serving of eggs had a recorded temperature of 94.82F (eggs per CMS should be maintained at 135F) and a resident's serving of sausage had a recorded temperature of 90.32F ( sausage per CMS should be maintained at 140F) During a phone interview on 8/6/25 at 10:15am a family member for Resident #93 stated the meals served are often cold. During a phone interview on 8/6/25 at 11:10am Resident #43 stated he eats in his room and the lunch and supper meals when served are sometimes cold. During an interview on 8/6/25 at 2:45pm the Activity Director stated that resident council meetings were held on 5/5/25 and 8/5/25 in which multiple residents reported that food is often cold when served. Record review of facility dietary policy noted under the Texas Food Establishment Rules dated 10/11/25 pages 68-73 revealed that food served would follow the established guidelines for temperature control. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455689 If continuation sheet Page 5 of 7 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 08/08/2025 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 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 facility in that: 1. The facility failed to replace or clean dirty overhead ceiling vents in the main kitchen area. 2. The facility failed to clean a rusty overhead ceiling vent cover in the dish room. These failures could place residents at risk for food borne illness. The findings included: Observation on 08/05/2025 from 9:20am until 9:45am of the kitchen with the Food Service Director revealed the following: a. There were 7 ceiling vents which each measured approximately 2x2 ft in the main kitchen area with visible dirt and dust particles and was stained. One of the 7 ceiling vents which was located over the standing floor freezer was not completely attached to the ceiling surface.b. There was a vent cover over the dish machine located in the dish room that had several spots of rust accumulation on the inside and outside of the vent cover. During an interview on 08/05/25 at 9:50am, the Food Service Director stated that she had placed a work order for the ceiling vents to be either cleaned/replaced but was not sure of the work order date. The Food Service Director stated she was responsible to submitting the work order request and having the ceiling vents cleaned or replaced which would promote cleanliness in the food service environment. During an interview on 8/5/25 at 10:50am the Maintenance Director stated that he had received a work order request to clean or replace the kitchen ceiling vents but did not know the date of the work order. The Maintenance Director stated that having clean ceiling vents would promote kitchen cleanliness in the food service environment. Record review of facility policy which referenced Texas Food Establishment Rules effective date 10/11/25 , Section 228.114 page 109 revealed the kitchen environment will be kept clean for all non-food contact surfaces. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. Event ID: Facility ID: 455689 If continuation sheet Page 6 of 7 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 08/08/2025 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 observation, 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 6 residents (Resident #92 ) reviewed for infection control, in that: The facility failed to ensure CNA E used proper infection control while providing incontinent care for Resident #92. These deficient practices could place residents at-risk for infection due to improper care practices The findings include: Record review of Resident #92's face sheet, dated 08/07/2025, revealed an admission date of 01/09/2025, with diagnoses which included: Wernicke's encephalopathy (brain and memory disorder due to a lack fo vitamin B1), Dysphagia (difficulty swallowing), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Hypertension (High blood pressure), Asthma (Long-term inflammatory disease of the airways restricting airflow). Record review of Resident #92's Quarterly MDS assessment, dated 07/08/2025, revealed the resident had a BIMS score of 08, indicating she was moderately cognitively impaired. Resident #92 was always incontinent of bladder and bowel and, required total assistance with her ADLs. Record review of Resident #92's care plan, dated 01/17/2025, revealed a problem of has ADL Self Care Performance Deficit related to Wernicke's encephalopathy, Muscle weakness, with an intervention of Toileting Hygiene: Dependent. Observation on 08/07/2025 at 3:24 p.m. revealed CNA E, after washing her hands, touched the room's door with her bare hands, did not sanitize her hands before putting gloves on and started to provide care for Resident #92. While providing incontinent care for Resident #92, CNA E changed her gloves multiple times but did not sanitize between change of gloves. After cleaning Resident #92's buttocks, CNA E removed the soiled briefs and without changing gloves and sanitizing her hands, she touched the clean brief to place them on Resident #92. During an interview with CNA E on 08/07/2025 at 3:38 p.m., CNA E stated she forgot to sanitize her hands before putting gloves on and between change of gloves because she was nervous. She stated not sanitizing her hands and change gloves could cause a risk of infection for the resident. She stated she received infection control from the DON with the last year. During an interview with the DON on 08/07/2025 at 3:40 p.m., the DON stated the door of the room was considered dirty and the CNA should have sanitized her hands prior to put her gloves on. The DON stated, the staf needed to sanitize their hands between change of gloves and they needed to change gloves and sanitize when going from a soiled area to a clean one. She confirmed the staff had received training on infection control within the year and the training was provided by herself. They also check the staff skills annually and as needed. Review of Facility's policy, titled Infection control, dated 03/2024, revealed Standard Precautions are infection prevention practices that apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. They are based on the principle that all blood, body fluids, secretions, and excretions (except sweat) may contain transmissible infectious agents. Standard Precautions include:a. Proper selection and use of PPE, such as gowns, gloves, facemasks, respirators, and eye protectioni. Use and type of PPE is based on the predicted staff interaction with residents and the potential for exposure to blood, body fluids, or pathogens (e.g., gloves are worn when contact with blood, body fluids, mucous membranes, non-intact skin, or potentially contaminated surfaces or equipment are anticipated).b. Hand hygiene; [ .] Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455689 If continuation sheet Page 7 of 7