Health inspection·February 16, 2024

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 record review and interview, the facility failed to complete an assessment which accurately reflected the resident's status for 4 of 24 residents (Residents #8, #32, and #33) reviewed for resident assessments, in that: Residents Affected - Some 1. The facility failed to complete a BIMS for Resident #8 prior to the submission of the resident's quarterly MDS. 2. The facility failed to complete a BIMS for Resident #32 prior to the submission of the resident's quarterly MDS. 3. The facility failed to complete a BIMS for Resident #33 prior to the submission of the resident's quarterly MDS. These failures could result in inadequate care due to an incomplete assessment of the residents' mental status. The findings included: 1. Record review of Resident #8's face sheet dated 2/16/2024, revealed the resident was a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included: Dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities), muscle wasting and atrophy (wasting or thinning of muscle mass), cognitive communication deficit (a difficulty with communication that is caused by a problem with thinking) and vascular dementia (a condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory). Record review of Resident #8's most recent MDS (quarterly), ARD/Target date 01/12/2024, revealed in Section C, Brief Interview for Mental Status (BIMS), the section was coded Not assessed. Further review of the residents EHR revealed the resident was present in the facility during the 7-day period for this assessment. Record review of Resident #8's prior MDS (quarterly), ARD/Target date 10/12/2023, revealed in Section C, Brief Interview for Mental Status (BIMS), the score was 7, indicating the resident had severely impaired cognition. 2. Record review of Resident #32's face sheet, dated 2/16/2024, revealed the resident was [AGE] year old female admitted to the facility on [DATE] with diagnoses that included anoxic brain damage (damage to the brain due to lack of oxygen supply), muscle wasting and atrophy, and vascular dementia. Record review of Resident #32's most recent MDS (quarterly), ARD/Target date 01/12/2024, revealed in Section C, Brief Interview for Mental Status (BIMS), the section was coded Not assessed. Further review of the residents EHR revealed the resident was present in the facility during the 7-day period for this assessment. Record review of Resident #32's prior MDS (quarterly), ARD/Target date 10/12/2023, revealed in Section C, Brief Interview for Mental Status (BIMS), the score was 4, indicating the resident had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455754 If continuation sheet Page 2 of 25 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 455754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218 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 severely impaired cognition. Level of Harm - Minimal harm or potential for actual harm 3. Record review of Resident #33's face sheet dated 2/16/2024, revealed the resident was a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities), muscle wasting and atrophy (wasting or thinning of muscle mass), and cognitive communication deficit (a difficulty with communication that is caused by a problem with thinking). Residents Affected - Some Record review of Resident #33's most recent MDS (Annual), ARD/Target date 01/21/2024, revealed in Section C, Brief Interview for Mental Status (BIMS), the section was coded Not assessed. Section C for the staff assessment was also blank. Further review of the residents EHR revealed the resident was present in the facility during the 7-day period for this assessment. Record review of Resident #33's prior MDS (quarterly), ARD/Target date 12/22/2023, revealed in Section C, Brief Interview for Mental Status (BIMS), the score was 00, indicating the resident had severely impaired cognition. During an interview with MDS LVN E on 02/16/2024 at 5:00 PM, MDS LVN E revealed she was responsible for completing MDS assessments for managed care residents and the social worker was responsible for the assessments for long-term care residents. MDS LVN E further stated she had been employed by the facility since June 2023, was able to complete MDS assessments for all the residents and had not done so due to a miscommunication. During an interview with the MDS Resource on 02/16/2024 at 5:30 PM, the MDS Resource revealed it was concerning the BIMS assessments were not completed for several residents. There was more than one MDS LVN on the staff and it was clear the teamwork was not effective. There was a change in social worker; however, even if there was no social worker, one MDS coordinator could have completed all the assessments, as the assessment only takes about five minutes. During an interview with the DON and MDS LVN F on 02/16/2024 at 5:58 PM, the DON and MDS LVN F, who was contacted by phone, revealed the residents' BIMS on the assessments was not completed prior to the ARD and should have been. The DON stated MDS LVN F could have completed the assessment if the social worker was not present, and MDS LVN F confirmed she could have done the assessments. MDS LVN F acknowledged the ARD needed to be checked daily to ensure the assessments were completed in a timely manner and accurately reflected the residents' status. When asked for a policy on completing BIMS, the DON stated the facility used the CMS RAI manual. Record review of CMS RAI Version 3.0 Manual revealed: C0100: Should Brief Interview for Mental Status Be Conducted? Coding Instructions: Code 0, no: if the interview should not be conducted because the resident is rarely/never understood; cannot respond verbally, in writing, or using another method; or an interpreter is needed but not available. Code 1, yes: if the interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter is needed, is available. Coding Tips. Attempt to conduct the interview with ALL residents. This interview is conducted during the look-back period of the Assessment Reference Date (ARD) and is not contingent upon item B0700, Makes Self Understood. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455754 If continuation sheet Page 3 of 25 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 455754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218 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 observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 residents (Resident #1) reviewed for indwelling urinary catheter care, in that: Resident #1's indwelling urinary catheter drainage bag was on the floor. This failure could place the residents with indwelling urinary catheter devices at risk for the development of new or worsening urinary tract infections. The findings included: Record review of Resident #1's face sheet, dated 2/14/2024, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included anoxic brain damage (damage to the brain due to lack of oxygen supply), dementia (a group of symptoms affecting memory, thinking and social abilities) with behavioral disturbance and agitation, and need for assistance with personal care. Record review of Resident #1's most recent quarterly MDS assessment, dated 02/23/2024, revealed the resident was severely cognitively impaired for daily decision-making skills and required an indwelling urinary catheter. Record review of Resident #1's comprehensive care plan, revision date 06/06/23, revealed the resident had an indwelling urinary catheter related to a stage 4 pressure ulcer with goals for the resident to show no signs or symptoms of a urinary tract infection and to remain free from catheter-related trauma. Interventions included: Monitor for s/sx of discomfort on urination and frequency; monitor/document for pain/discomfort due to catheter; 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; secure catheter to facilitate flow of urine, prevent kinking of tubing, and accidental removal. Record review of Resident #1's Order Summary Report, dated 02/23/2024, revealed the following orders: - Catheter type: Fr #16 ml 10 to closed urinary drainage system - diagnosis for use: PU Stage 4. - May flush Foley catheter as needed. - Check placement and reposition privacy bag & tubing below the level of the bladder every shift. - Change Foley catheter monthly on the 15th day of each month. Reinsert prn for accidental removal, dislodgement, obstruction of urine flow. - Change drainage bag monthly on 15th day of each month and prn. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455754 If continuation sheet Page 4 of 25 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 455754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218 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 - Monitor indwelling catheter output. Level of Harm - Minimal harm or potential for actual harm - Secure catheter with a leg strap/leg band to minimize catheter related injury and accidental removal or obstruction of urine outflow. Check placement of catheter care every shift. Monitor urethral site for s/s of skin breakdown, pain/discomfort, unusual odor, urine characteristic or secretions, catheter pulling causing tension. Residents Affected - Few - Change leg strap every week and as needed. Observation on 02/13/2022 at 2:06 PM revealed Resident #1's indwelling urinary collection bag was 3/4 outside the dignity bag and the dignity bag was on the floor next to the resident's bed. During an interview with the DON on 02/13/2024 at 2:15 PM the DON acknowledged Resident #1's indwelling urinary collection bag was mostly outside the dignity bag and the bag was on the floor. The DON stated the urinary collection bag should be completely inside the dignity bag and the dignity bag should be off the floor to prevent the potential for infection, and it was the responsibility of the charge nurse to ensure the indwelling urinary catheter bag was properly attached to the resident's bed frame. Nurses receive training on proper indwelling catheter care during orientation. Record review of the facility's policy titled, Indwelling Urinary Catheter Care, revised 12/23, revealed: It is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and as needed (prn) to promote hygiene, comfort, and decrease the risk of infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455754 If continuation sheet Page 5 of 25 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 455754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 3 of 3 residents (Resident #388, #9 and #65) reviewed for dialysis, in that: Residents Affected - Some The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Residents #388, #9 and #35. This deficient practice could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs. The findings included: 1. Record review of Resident #388's face sheet, dated 2/14/24 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dependence on renal dialysis (process of removing excess water, solutes and toxins from the blood in people whose kidneys can no longer perform these functions naturally), type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), end stage renal disease (condition in which the kidneys cease functioning on a permanent basis), and hypertension (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease). Record review of Resident #388's most recent comprehensive MDS assessment, dated 12/2/23 revealed the resident was moderately cognitively impaired for daily decision-making skills and received dialysis treatments. Record review of Resident #388's comprehensive care plan, revision date 11/7/23 revealed the resident had renal insufficiency related to end state renal disease and was scheduled for dialysis treatments on Monday, Tuesday and Wednesday with interventions that included, Dialysis Communication Form to be completed and filed/scanned in chart on dialysis days and to observe and report changes in mental status, lethargy, tiredness, fatigue, tremors and seizures. Record review of Resident #388's Order Summary Report, dated 2/14/24 revealed the following orders: - Dialysis Communication Form to be completed and filed/scanned in chart on dialysis days, with order date 2/13/24 and no end date - Hemodialysis 3 times a week every Monday, Wednesday, Friday with chair time 10:45 a.m., with order date 2/13/24 and no end date Record review of the Renal Dialysis Communication Forms for Resident #388 for the month of February 2024 revealed the following: - 2/2/24: The Dialysis Center Information section was missing a signature and the Facility Information Post Dialysis section was missing a blood sugar result - 2/12/24: The Facility Information Pre-Dialysis section was missing the blood pressure, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455754 If continuation sheet Page 6 of 25 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 455754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some temperature, pulse, and respiration. The Dialysis Center Information section was missing the post dialysis weight and order changes/recommendations was left blank. The Facility Information Post-Dialysis section was missing a blood sugar result. 2. Record review of Resident #9's face sheet dated 2/16/24 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] and 9/9/23 with diagnoses that included complications of amputation stump, end stage renal disease, acquired absence of right leg above knee, type 2 diabetes with diabetic chronic kidney disease and dependence on renal dialysis. Record review of Resident #9's most recent quarterly MDS assessment, dated 12/15/23 revealed the resident was moderately cognitively impaired for daily decision-making skills and received dialysis treatments. Record review of Resident #9's comprehensive care plan, revision date 6/6/23 revealed the resident had end stage renal disease with hemodialysis with interventions that included hemodialysis 3 times per week every Tuesday, Thursday and Saturday and Dialysis Communication Form to be completed and filed/scanned in chart on dialysis days. Record review of Resident #9's Order Summary Report, dated 2/16/24 revealed the following orders: - Dialysis Communication Form to be completed and filed/scanned in chart on dialysis days, with order date 5/18/23 and no end date - Hemodialysis 3 times a week, every Tuesday, Thursday and Saturday, with order date 5/18/23 and no end date Record review of the Renal Dialysis Communication Forms for Resident #9 for the month of January 2024 revealed the following: - 1/2/24: The Dialysis Center Information section was missing the post dialysis weight, whether the access site was intact, any precautionary measures, order changes/recommendations and Dialysis Staff signature - 1/4/24: The Dialysis Center Information section was missing the post dialysis weight, and any precautionary measures and the Facility Information Post-Dialysis section was missing a blood sugar result - 1/6/24: The Facility Information Pre-Dialysis section was missing the nurse's signature, the Dialysis Center Information section was missing the post dialysis weight, and any precautionary measures, order changes/recommendations. The Facility Information Post-Dialysis section was missing a blood sugar result. -1/9/24: The Dialysis Center Information section was missing the post dialysis weight, precautionary measures and order changes/recommendations. The Facility Information Post-Dialysis section was missing a blood sugar result and the shunt site checked for bruit or thrill, whether the dressing was intact and if there was bleeding were left blank. - 1/11/24: The Dialysis Center Information section was missing a dry weight, precautionary measures, order changes/recommendations and the Dialysis Staff signature was missing. The Facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455754 If continuation sheet Page 7 of 25 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 455754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Information Post-Dialysis section was missing a blood sugar results, and the shunt site checked for bruit or thrill, whether the dressing was intact and if there was bleeding were left blank. - 1/13/24: The Facility Information Pre-Dialysis section was missing a blood sugar result and medications administered. The Dialysis Center Information section was missing a dry weight and precautionary measures. The Facility Information Post-Dialysis section was missing a blood sugar result. - 1/16/24: The Facility Information Pre-Dialysis section was missing a blood pressure and pulse. The Dialysis Center Information section was missing the post dialysis weight, precautionary measure, order changes/recommendations and the Dialysis Staff signature. - 1/20/24: The Facility Information Pre-Dialysis section was missing a blood sugar result, medication administered and the nurse's signature. The Dialysis Center Information section was missing the post dialysis weight, precautionary measures, and order changes/recommendations. The Facility Information Post-Dialysis section was missing a blood sugar result. - 1/27/24: The Facility Information Pre-Dialysis section was missing a blood sugar result. The Dialysis Center Information section was missing a dry weight. The Facility Information Post-Dialysis section was missing a blood sugar result. - 1/30/24: The Facility Information Pre-Dialysis section was missing a blood sugar result. The Dialysis Center Information was missing the post dialysis weight, precautionary measures, order changes/recommendations and the Dialysis Staff signature. During an interview on 2/16/24 at 9:08 a.m., Resident #9 revealed he received dialysis treatments on Tuesday, Thursday and Saturdays. Resident #9 stated he was given a paper by the facility nurse to give to the dialysis staff. Resident #9 stated they (the dialysis staff) knew what to do with it and then the paper was given back to the resident to give to the facility nurse. 3. Record review of Resident #65's face sheet dated 2/16/24 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] and 3/19/23 with diagnoses that included dementia, cognitive communication deficit, need for assistance with personal care, end stage renal disease and dependence on renal dialysis. Record review of Resident #65's most recent comprehensive MDS, dated [DATE] revealed the resident was moderately cognitively intact for daily decision-making skills and received dialysis treatments. Record review of Resident #65's comprehensive care plan, revision date 6/6/26 revealed the resident had end stage renal disease with hemodialysis and interventions that included hemodialysis 3 times per week every Monday, Wednesday and Friday and Dialysis Communication Form to be completed and filed/scanned in chart on dialysis days. Record review of Resident #65's Order Summary Report, dated 2/16/24 revealed the following orders: - Dialysis Communication Form to be completed and filed/scanned in chart on dialysis days every day shift every Monday, Wednesday, and Friday with order date 4/4/23 and no end date -Hemodialysis 3 times a week every Monday, Wednesday and Friday, chair time at 5:00 a.m., with order date 5/15/23 and no end date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455754 If continuation sheet Page 8 of 25 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 455754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the Renal Dialysis Communication Forms for Resident #65 for the month of January 2024 revealed the following: - 1/3/24: The Facility Information Pre-Dialysis section was missing a blood sugar result, medication administered and whether the access site was intact. The Dialysis Center Information section was missing precautionary measures. The Facility Information Post-Dialysis section was missing a blood sugar result. - 1/5/24: The Facility Information Pre-Dialysis section was missing whether the access site was intact. The Dialysis Center Information section was missing any precautionary measures. The Facility Information Post-Dialysis section was missing a blood sugar result. - 1/8/24: The Facility Information Pre-Dialysis section was missing a blood sugar result, medication administered, whether the access site was intact and the nurse's signature. The Dialysis Center Information section was missing precautionary measures, and order changes/recommendations. The Facility Information Post-Dialysis section was missing a blood sugar result. -1/10/24: The Facility Information Pre-Dialysis section was missing a blood sugar result and medication administered. The Facility Information Post Dialysis section was missing a blood sugar result. - 1/12/24: The Facility Information Pre-Dialysis section was missing whether the access was intact. The Dialysis Center Information section was missing the pre-dialysis weight, and precautionary measures. The Facility Information Post-Dialysis section was missing a blood sugar result. 1/22/24: The Facility Information Pre-Dialysis section was missing a blood sugar result. The Facility Information Post-Dialysis section was missing a blood sugar result. 1/24/24: The Facility Information Post-Dialysis section was missing a blood sugar results and the shunt site checked for bruit or thrill, whether the dressing was intact and if there was bleeding were left blank. 1/29/24: The Facility Information Post-Dialysis section was missing the blood pressure, temperature, pulse, respirations and a blood sugar result. Record review of the Renal Dialysis Communication Forms for Resident #65 for the month of February 2024 revealed the following: - 2/5/24: The Facility Information Post-Dialysis section was missing a blood sugar result. - 2/7/24: The Facility Information Post-Dialysis section was missing a blood sugar results and the shunt site checked for bruit or thrill, whether the dressing was intact and if there was bleeding were left blank. - 2/12/24: The Facility Information Pre-Dialysis section was missing a blood sugar result and medication administered. The Dialysis Center Information section was blank, and the Facility Information Post Dialysis section was blank. During an observation and interview on 2/15/24 at 8:15 a.m., revealed Resident #388 had the left upper arm wrapped in gauze which the resident identified as the access site where he received dialysis (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455754 If continuation sheet Page 9 of 25 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 455754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some treatments. Resident #388 stated he was given paperwork to take with him to the dialysis clinic by the facility nurse. Resident #388 stated, the dialysis clinic takes the paperwork from the back of my wheelchair, it's like they know I have it, I think they put it back in my bag, I don't know, I think so, or maybe not I don't know. Resident #388 further stated he did not believe facility staff took back the paperwork after coming back from the dialysis clinic and believed the paperwork could still be in the resident's backpack. Resident #388 then retrieved the Renal Dialysis Communication Form, dated 2/12/24 from a bag sitting on the resident's bed. During an interview with LVN A on 2/16/24 at 9:28 a.m., LVN A revealed all the facilities associated with the company followed the same policy and procedure for dialysis. LVN A stated, before a resident went to dialysis, it was the facility's job to ensure the top portion of the Renal Dialysis Communication Form was completed before the resident went to dialysis. LVN A further revealed, once the resident returned from dialysis, the facility had to ensure the middle section of the form was completely filled out by dialysis staff and the bottom section was completed by the facility staff upon the resident's return from dialysis. LVN A stated, it the middle section of the Renal Dialysis Communication Form, reserved for the dialysis staff, was incomplete, the facility staff should be notifying the dialysis clinic either by phone or fax to obtain the information. LVN A stated the Renal Dialysis Communication Form had to be filled out completely before it was turned over to medical records. LVN A stated it was important to complete the Renal Dialysis Communication Form because it served as communication between the facility and the dialysis clinic on the resident's care and to document any significant change, such as a new order. An observation and interview on 2/16/24 at 10:05 a.m., the DON revealed the residents who received dialysis treatments were given a yellow folder which included a face sheet in case the resident was transported to the hospital, and the Renal Dialysis Communication Form. The DON further revealed, the top section of the form was filled out by the facility nursing staff, the middle section was completed by the dialysis clinic staff and the facility nursing staff completed the bottom section of the form upon the resident's return. The DON stated the former ADON used to be in charge of taking the Renal Dialysis Communication Form, checked them for completeness and then sent the forms to the medical records department to scan into the resident's record. The DON, after reviewing Resident #388, #9 and #65's Renal Dialysis Communication Forms revealed there were several missing items on most of all 3 sections of the forms. The DON stated she had been responsible for checking the Renal Dialysis Communication Forms for completeness but stated, I'm gonna be honest, I have not checked them this week. The DON further stated she wanted to check the form before they get scanned into the computer for completeness. The DON stated, after reviewing the Renal Dialysis Communication Forms revealed, It appeared the (former) ADON was making sure we were getting the communication sheets but not checking if they were actually completed. The DON revealed it was important to ensure the Renal Dialysis Communication Forms were complete because it gave information on how well the resident tolerated dialysis or how to take care of the resident if there should be any complications. The DON stated, the problem is we're not checking to make sure the form is completed, and the proper person signs it. Record review of the facility's policy and procedure titled, Dialysis (Renal), Pre- and Post-Care, revision date 12/2023 revealed in part, .It is the policy of this facility to .Participate in ongoing communication and collaboration with the dialysis facility regarding dialysis care and services .Collaboration and Communication of Care .The care of the resident receiving dialysis services will reflect ongoing communication, coordination and collaboration between the nursing home and dialysis staff .Staff will immediately contact and communicate with the attending physician/practitioner, resident/resident representative, and designated dialysis staff .regarding any significant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455754 If continuation sheet Page 10 of 25 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 455754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218 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 0698 Level of Harm - Minimal harm or potential for actual harm changes in the resident's status related to clinical complications or emergent situations that may impact the dialysis portion of the care plan .Documentation related to pre- and post-dialysis care will be placed in the clinical record and included .Communication between facility and dialysis staff or medical provider . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455754 If continuation sheet Page 11 of 25 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 455754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 60% based on 15 out of 25 opportunities, which involved 8 of 13 Residents (Residents #14, #24, #27, #36, #38, #56, #57, and #99) reviewed for medication administration, in that: Residents Affected - Some 1. The facility failed to ensure LVN B administered 8 medications within acceptable parameters for safe medication administration for Residents #14, #24, #36 #38, #56 #99 and #57. 2. The facility failed to ensure LVN C administered Resident #27's medications via PEG tube according to physician orders. 3. The facilty failed to ensure LVN C administered the correct medication to Resident #27 when LVN C administered a capsule of amantadine with out physician orders. These failures could place residents at risk for not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions. The findings included: 1. a. Record review of Resident #14's face sheet, dated 02/16/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included type II diabetes mellitus with hyperglycemia (a chronic (long-lasting) health condition that affects how your body turns food into energy and high blood sugar) and acute kidney failure. Record review of Resident #14's order summary report, dated 02/15/24 revealed the following: - Admelog SoloStar 100 UNIT/ML Solution pen-injector Inject as per sliding scale: if 150 - 199 = 2units; 200 - 249 = 4units; 250 - 299 = 6units; 300 - 349 = 8units; 350 - 399 = 10units call MD if BS > 400, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA .*Hold for BS less than 100*, order date 12/31/23 and no end date Record review of Resident #14's MAR, dated 02/15/24, revealed Admelog solostar was ordered for 6:30 a.m. and was documented as administered at 8:47 a.m. on 02/15/24, 2 hours and 17 minutes after the scheduled time. During an observation and interview on 02/15/24 at 8:30 a.m. this surveyor approached LVN B to observe medication administration. LVN B computer screen showed a list of residents highlighted red. LVN B stated the color meant the medications were late. LVN B stated she got into work late that morning. During an observation at 8:47 a.m. on 02/15/24 LVN B administered 2 units of admelog to Resident #14. b. Record review of Resident #24's face sheet, dated 02/15/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included type II diabetes mellitus with hyperglycemia (a chronic (long-lasting) health condition that affects how your body turns food into energy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455754 If continuation sheet Page 12 of 25 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 455754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218 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 0759 and high blood sugar) and hyperlipidemia (high cholesterol). Level of Harm - Minimal harm or potential for actual harm Record review of Resident #24's order summary report, dated 02/15/24 revealed the following: Residents Affected - Some -HumuLIN R 100 UNIT/ML Solution Inject as per sliding scale: if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units Give 12 units and call M.D, subcutaneously before meals for DM Record review of Resident #24's MAR, dated 02/15/24, Humulin R was ordered for 6:30 a.m. and was documented as administered at 9:00 a.m. on 02/15/24, 2 hours and 30 minutes after the scheduled time. During an observation at 9:07 a.m. on 02/15/24 LVN B administered 4 units of Humulin R to Resident #24. c. Record review of Resident #38's face sheet, dated 02/15/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included type II diabetes mellitus with hyperglycemia (a chronic (long-lasting) health condition that affects how your body turns food into energy and high blood sugar) and acquired absence of right leg above the knee. Record review of Resident #38's order summary report, dated 02/15/24 revealed the following: -Admelog SoloStar 100 UNIT/ML Solution pen-injector Inject 10 unit subcutaneously before meals related to TYPE 2 DIABETES MELLITUS WITH UNSPECIFIED COMPLICATIONS, order date 04/29/2023, and no end date. -Basaglar KwikPen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Glargine) Inject 25 unit subcutaneously at bedtime for DM *Hold for BS less than 100*, order date 11/23/23, and no end date. Record review of Resident #38's MAR, dated 02/15/24, revealed Amelog insulin ordered for 6:30 a.m. and was documented as administered at 9:20 a.m. on 02/15/24, 2 hours and 50 minutes after the scheduled time. The MAR also revealed Basaglar was ordered for 7:30 a.m. and was documented as administered at 9:39 a.m. on 02/15/24, 2 hours and 9 minutes after the scheduled time. During an observation at 9:19 a.m. on 02/15/24 LVN B administered 10 units of ademlog insulin and 50 units of basaglar insulin to Resident #38. d. Record review of Resident #99's face sheet, dated 02/15/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included type II diabetes mellitus with hyperglycemia (a chronic (long-lasting) health condition that affects how your body turns food into energy and high blood sugar) and acquired absence of left leg above knee. Record review of Resident #99's order summary report, dated 02/15/24 revealed the following: -Insulin Glargine-yfgn Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Glargine-yfgn) Inject 15 unit subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA, with an order date of 02/15/2024, and no end date. Record review of Resident #99's MAR, dated 02/15/24, revealed Insulin Glargine was ordered for 8:30 a.m. and was documented as administered at 10:21 a.m. on 02/15/24, 1 hours and 49 minutes after the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455754 If continuation sheet Page 13 of 25 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 455754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218 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 0759 scheduled time. Level of Harm - Minimal harm or potential for actual harm During an observation at 10:18 a.m. on 02/15/24 LVN B administered 15 units of insulin Glargine to Resident #99. Residents Affected - Some e. Record review of Resident #57's face sheet, dated 02/15/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included type II diabetes mellitus with hyperglycemia (a chronic (long-lasting) health condition that affects how your body turns food into energy and high blood sugar) and heart failure. Record review of Resident #57's order summary report, dated 02/15/24 revealed the following: -Insulin Glargine Solution 100 UNIT/ML Inject 10 unit subcutaneously one time a day for Diabetes, with an order date of 11/15/23, and no end date. Record review of Resident #57's MAR, dated 02/15/24, revealed Insulin Glargine was ordered for 7:30 a.m. and was documented as administered at 10:34 a.m. on 02/15/24, 3 hours and 4 minutes after the scheduled time. During an observation at 10:31 a.m. on 02/15/24 LVN B administered 10 units of insulin Glargine to Resident #57. f. Record review of Resident #56's face sheet, dated 02/15/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), unspecified dementia, delirium due to known physiological condition, and seborrheic dermatitis (Flaking skin (dandruff) on your scalp, hair, eyebrows, beard or mustache). Record review of Resident #56's quarterly MDS, dated [DATE], revealed the resident was moderately cognitively impaired. Record review of Resident #56 care plan, revised on 06/28/22, revealed Resident #55 had impaired cognitive function related to dementia as evidenced by altered thought process and chronic confusion. The care plan did not mention the resident may self administer medications. Record review of Resident #56's order summary report, dated 02/15/24 revealed the following: -Budesonide-Formoterol Fumarate Aerosol 160-4.5 MCG/ACT 2 puff inhale orally two times a day for COPD *Rinse mouth after use*, with a start date of 04/03/2023, and no end date. -Triamcinolone Acetonide Ointment 0.1 % Apply to affected area topically two times a day for Chronic Rash, with a start date of 02/02/22, and no end date. Record review of Resident #56's MAR, dated 02/15/24, revealed Budesonide inhaler was ordered to be administered at 8:30 a.m. and was documented as administered at 9:48 a.m. on 02/15/24, 1 hours and 18 minutes after the scheduled time. The MAR also revealed Triamcinolone ointment was ordered to be administered at 8:30 a.m. and was documented as administered at 9:48 a.m. on 02/15/24, 1 hours and 18 minutes after the scheduled time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455754 If continuation sheet Page 14 of 25 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 455754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation at 9:46 a.m. on 02/15/24 LVN B handed Resident #56 the Budesonide inhaler and the Resident used the inhaler himself. LVN B did not have him rinse his mouth out after using the inhaler. LVN B then handed Resident #55 a medicine cup of the triamcinolone ointment and resident #56 applied it to his own face. g. Record review of Resident #36's face sheet, dated 02/15/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), diagnoses that included type II diabetes mellitus with diabetic neuropathy (a chronic (long-lasting) health condition that affects how your body turns food into energy and high blood sugar, causing nerve damage) and unspecified dementia. Record review of Resident #36's annual MDS, dated [DATE], revealed the resident's cognition was intact. Record review of Resident #36 care plan, revised on 03/06/23, revealed Resident #36 was at risk for impaired cognitive function/dementia related to diagnosis of dementia. The care plan did not mention the resident may self-administer medications. Record review of Resident #36's order summary report, dated 02/15/24 revealed the following: -Anoro Ellipta 62.5-25 MCG/ACT Aerosol Powder, breath activated 1 inhalation inhale orally two times a day for COPD, with a start date of 11/05/22, and no end date. Record review of Resident #36's MAR, dated 02/15/24, revealed Anoro inhaler was ordered to be administered at 9:30 a.m. and was documented as administered at 11:48 a.m. on 02/15/24, 2 hours and 18 minutes after the scheduled time. During an observation at 11:54 a.m. on 02/15/24 LVN B handed Resident #36 the Anoro inhaler and the Resident administered the inhaler himself. 2. Record review of Resident #27's face sheet, dated 02/15/24 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included unspecified injury of head, cognitive communication deficit, seizures, and gastrostomy status (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach). Record review of Resident #27's quarterly MDS, dated [DATE], revealed the resident cognition was severely impaired. Record review of Resident #27's care plan, initiated on 10/23/23, revised on 11/28/2023, revealed Resident #27 Has nutritional problem or potential nutritional problem Protein calorie malnutrition, dysphagia (is a medical term for difficulty swallowing), GT (Gastrostomy Tube) feedings with risk for weight loss, with interventions to: -every shift FLUSH TUBING WITH 5ml-10ml WATER BETWEEN EACH MEDICATION ADMINISTRATION - FLUSH ENTERAL-TUBE WITH 30-50 ML OF WATER BEFORE AND AFTER MEDICATION ADMINISTRATION -MIX EACH MEDICATION WITH 5-10 ML OF WATER THEN ADMINISTER MEDS PER ENTERAL-TUBE (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455754 If continuation sheet Page 15 of 25 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 455754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218 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 0759 -MAY CRUSH / COMBINE MEDICATION FOR ADMINISTRATION IF NOT CONTRAINDICATED AND MIX WITH 4 OZ OF WATER. MAY USE SLOW PUSH TO FACILITATE CONSUMPTION Level of Harm - Minimal harm or potential for actual harm -ELEVATE HEAD OF BED AT 30-45 DEGREES WHILE FEEDING IS GOING ON Residents Affected - Some -RINSE SYRINGE AFTER EACH USE -INSPECT AND MONITOR GASTROSTOMY STOMA (a surgically made hole in the abdomen that allows body waste to be removed from the body directly through the end of the bowel into a collection bag) FOR SIGNS & SYPTOMS OF LOCAL INFECTION SUCH AS: REDNESS; PAIN; TENDERNESS; UNUSUAL ODOR, DRAINAGE OR DISCHARGE; HYPERGRANULATION (a common non-life threatening phenomena. Hypergranulation is characterised by the appearance of light red or dark pink flesh that can be smooth, bumpy or granular and forms beyond the surface of the stoma opening) OF TISSUE SURROUNDING STOMA. NOTIFY MD IF S/S NOTED -in the evening: *CHANGE ENTERAL ADMINISTRATION SET WITH EVERY FORMULA CHANGE* Date Initiated: 02/13/2024 Created on: 02/13/2024 Record review of Resident #27's order summary report, dated 02/15/24 revealed the following: -enulose solution 10 GM/15 ML give 30 mL enterally two times a day for constipation, with a start date of 10/23/23, and no end date. -levetiracetam 100 mg/mL give 15 mL enterally two times a day related to other seizures, with a start date 10/10/23 and no end date. -amatadine HCL syrup 50 mg/5ml give 100 mg enterally two times a day related to personal history of traumatic brain injury, with a start date of 10/10/23, and no end date. -apixaban tablet 5 mg give 1 tablet enterally two times a day for preventative -enteral feed order every shift flush enteral-tube with 30-50 ml of water before and after medication administration, with a start date of 10/10/23, and no end date -enteral feed order every shift flush tubing with 5ml-10ml water between each medication administration, with a start date of 10/10/23, and no end date. -enteral feed order every shift may crush/combine medication for administration if not contraindicated and mix with 4 oz of water. May use slow push to facilitate consumption. The start date was 10/10/23 and no end date. -enteral feed order every shift mix each medication with 5-10 ml of water then administer meds per enteral-tube, with a start date of 10/10/23, and no end date. -Nothing by mouth diet, nutritional needs met through enteral feeding, with a start date of 10/09/23, and no end date. During an observation at 3:00 p.m. on 02/15/24 LVN C prepared medication to Administer Resident #27 at the nurse medication cart. He took a plastic cup, a separate medication cup, measured 30 ml of enulose solution into the medication cup, poured the 30 mls of enulose into the plastic cup, measured (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455754 If continuation sheet Page 16 of 25 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 455754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 15 ml of levetiracetam into the medication cup, poured the 15 ml of levetiracetam into the plastic cup, opened a 100 mg capsule of amantadine (no order was found for this medication or documentation on the MAR) and emptied the contents into the plastic cup with the liquid medications, grabbed a 5 mg apixaban tablet with his bare hands, put the 5 mg tablet into a plastic bag and crushed the pill, stuck his bare index finger into the medication bag to open it up, and emptied the contents of the bag into the plastic cup with the other medications. LVN C then entered Resident #27's room, went to the sink and stated he got 30 mLs (30mls=1oz) of water out of the sink, grabbed a pair of gloves from a box on the wall in the residents room, checked the residents PEG tube for residual, returned the residual, drew up the medication mixture from the plastic cup, quickly pushed the medication mixture using the plunger with the syringe into the PEG tube, then drew up water the 30mLs of water, and flushed the PEG tube with the 30 mls of water. During an interview on 02/16/24 at 11:14 a.m. the DON stated when a nurse was late to work the staff coordinator was notified the employee was going to be late by the staffing agency or the staff member. The DON stated the ADON, or treatment nurse would take over administering medications to residents, so they were administered on time. The DON stated she did not know of any residents who could self-administer medications and staff should apply creams to the residents, but it was okay for residents to hold and inhale an inhaler on their own. The DON stated PEG tube medications should be administered with the amount of water the order states. Record review of the facility's policy, titled, Medication Administration, dated 05/2007, revealed, it is the policy of the facility to accurately prepare. Administer and document oral medications . essential point: 1. no medication is to be administered without a physician's written order. Record review of the facility's policy, titled, Medication Administration via Feeding Tube, dated 12/2023, revealed, it is the policy of the facility to ensure that medications administered via feeding tube are administered safely and accurately. A physicians order is required for the administration of any medication via feeding tube. Liquid dosage forms should be ordered if available. Tablets must be crushed prior to administration via feeding tube require a specific order. Guidelines 1. Follow the general professional standards for safe administration of medications by minimally checking the right resident, medication, time, dose, and route. 2. A physicians order is required for the administration of any medication via feeding tube. The order must specify the medication, dose route (tube), frequency, and volume of water to be administered with the medication. The amount of water used to flush, mix, and administer the medication must be considered when calculating the total free water prescribed by the physician .5. Liquid dosage forms should be ordered when available. Check with the pharmacist to determine if the liquid dosage form is available. Some liquid dosage forms are extremely viscous and may clog a small gauge feeding tube. Viscous liquid medications can be dissolved in 15-30 milliliters of warm water prior to administration .7. Tablets are crushed and capsules are open to facilitate mixing and administration. Tablets should be crushed to a fine consistency. Powder from crushed tablets or capsule contents should be dispersed well in 15-20 mL of water or another prescribed dilution. All the particles must be in solution prior to administering the medication. 8. Different medication should not be mixed together for administration .Procedure .9. Prepare prescribed medications for administration. Do not mix different medications. A. Crush tablets and dissolve in 15-20mL water or other appropriate liquid .b. empty capsule contents into 10mL water or other appropriate liquid .13. Flush the feeding tube with at least 30 mL of water or other prescribed flush. 14. Administer prescribed medication. Poor the liquified medication into the syringe and allow to flow by gravity into the tube never force fluid into the tube. Guidelines: 1. if administering several medications, administer each one separately. The tube should be flushed with at least 5mL of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455754 If continuation sheet Page 17 of 25 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 455754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218 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 0759 Level of Harm - Minimal harm or potential for actual harm water between medication .2. Fluh tube with at least 30mL of water or prescribed flush to clear tube and decrease chance of clogging .Documentation: record medication on medication administration record, record amount of water used to dissolve medication and for flushing the tube. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455754 If continuation sheet Page 18 of 25 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 455754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional standard for 2 of 13 residents (Resident #24 and Resident #81) reviewed for storage of drugs. 1. The facility failed to prevent an unlabeled IV bag of normal saline hanging on an IV pole in Resident #81's room. 2. The facility failed to ensure LVN B administered an insulin that had been open 41 days prior, 13 days past the expiration date, to Resident #24. 3. The facility failed to ensure LVN C did not leave a medicine cup containing 2 tablets of acetaminophen unsecured and unattended on top of the nurse medication cart. These deficient practices could place residents at risk of medication not meeting therapeutic levels, misuse and diversion. The findings were: 1. Record review of Resident #81's face sheet, dated 02/16/24, revealed Resident #81 was admitted to the facility on [DATE] with diagnoses of nondisplaced fracture of greater trochanter of right femur, subsequent encounter for closed fracture with routine healing (broken right leg bone) and multiple sclerosis (disease that affects the brain and spinal cord because the immune system attacks the nerves). Record review of Resident #81's admission MDS assessment, dated 01/22/24, revealed Resident #81 had BIMS score of 11, signifying moderate cognitive impairment. Record review of Resident #81's orders, dated 01/16/24, revealed Resident #81 had the following order, dated 02/11/24: Normal Saline Flush Intravenous Solution 0.9 % (Sodium Chloride Flush) Use 1000 ml intravenously every shift for hydration *75ML/HR [hour] TO RUN CONTINUOUSLY WITH NO STOP DATE*, and no end date. Observation on 02/14/24 at 248 p.m. revealed a bag of 0.9% sodium chloride was connected to Resident #81's IV to his right arm. The bag did not contain a label with the Residents name, formula, date prepared, name of person who hung the IV bag, start date for administration, or the expiration date. 2. Record review of Resident #24's face sheet, dated 02/15/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included type II diabetes mellitus with hyperglycemia ( a chronic (long-lasting) health condition that affects how your body turns food into energy and high blood sugar) and hyperlipidemia (high cholesterol). Record review of Resident #24's order summary report, dated 02/15/24 revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455754 If continuation sheet Page 19 of 25 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 455754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -HumuLIN R 100 UNIT/ML Solution Inject as per sliding scale: if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units ; 351 - 400 = 10 units; 401 - 450 = 12 units Give 12 units and call M.D, subcutaneously before meals for DM Record review of Resident #24's MAR, dated 02/15/24, Humulin R was ordered for 6:30 a.m. and was documented as administered at 9:00 a.m. on 02/15/24. During an observation at 9:03 a.m. on 02/15/24 LVN B planned to administer 4 units of Humulin R to resident #24. The vial of Humulin R insulin contained a label with an open date of 01/05/24. LVN B administered 4 units of the expired insulin to Resident #24 at 9:07 a.m. 3. Observation on 02/15/24 from 3:15 p.m. to 3:19 p.m. LVN C placed 2 tablets of 325 mg acetaminophen in a medication cup and placed it on top of the cart. LVN C then left the medication cart outside the main medication storage room and went inside the medication storage room. The cart with the acetaminophen was left unsecure and unattended for about 1 minute. During an interview on 02/15/24 at 3:31 p.m. LVN C stated he should not have left medication on top of the medication cart and walked away because another resident could have walked by and took the medication. During an interview on 02/16/24 at 11:14 a.m. the DON stated insulin expired 28 days after opening. The DON also stated the IV bag of saline should have contained a label with the nurses information, patient information, and the date they hung the IV bag. The DON stated staff should not have left medication on top of their medication carts unattended. Record review of the facility's policy titled, Nursing Clinical, Section: Care and Treatment, Subject: Medication and Access and Storage, dated 05/2007, revealed, it is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soil, or without secured closures are immediately removed from stock, disposed of according to procedures for medication destruction and reorder from the pharmacy, if a current order exists . Record review of the Facility's policy, titled Nursing Clinical, Section: Care and Treatment, Subject: Labeling of Medication and Biologicals, dated 05/2007, stated it is the policy of this facility that medications and biologicals are labeled in accordance with facility requirements, state and federal laws. Only the provider pharmacy modifies or changes prescription labels. Procedures: 1. each prescription medication label includes residents name, specific directions for use, including route of administration, . strength of medication . date and medication is dispensed, expiration date . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455754 If continuation sheet Page 20 of 25 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 455754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218 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 - Some 1. There was plastic storage container of food thickener in the dry storage room that was not properly sealed. 2. There was a clear plastic bag with pieces of raw bacon in the reach in cooler that was not sealed, labeled or dated. 3. There was a box containing individual portions of roll dough in the walk in freezer that was open and the bag inside the box was open. 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 02/13/2024 at 10:14 AM in the dry storage room revealed a white 10-gallon food storage container on a rack. The lid on the storage container was labeled Thickener 1/19/24 and was not properly sealed onto the container, exposing the contents to the ambient air in the dry storage room and potential contamination by pathogens, bacteria and pests. During an interview on 02/13/2024 at 10:16 AM with the DM he acknowledged the lid was not tightly sealed onto the container and the thickener inside the container was exposed to the ambient air in the dry storage room and potential bacterial and pest contamination. The DM stated all dietary employees were trained to label, date and completely seal all food stored in the dry storage room, and both he and the consultant dietitian provided training monthly. 2. Observation 02/13/2024 at 10:20 AM in the reach-in cooler revealed a clear plastic bag containing 5 pieces of raw bacon. The bag was placed in a quarter size 4 deep pan. The bag was not sealed and there was no label indicating the bag's contents or the date by which the bacon should be used or discarded. During an interview on 02/13/2024 at 10:22 AM with the DM he acknowledged the bag of bacon should have been properly sealed, labeled and dated with the use-by date, and stated the bag was probably not sealed and labeled because the staff was hurrying to prepare the breakfast meal. 3. Observation on 02/13/2024 at 10:26 AM in the walk-in freezer revealed a 15 lb. box containing individual 1-oz. units of white roll dough. The box was open and the bag inside the box containing the portions of dough was also open, exposing the contents to the ambient air in the freezer and subjecting the product to potential deterioration and spoilage. During an interview on 02/13/2024 at 10:27 AM with the DM he acknowledged both the bag holding the portions of roll dough in the box and the box were not properly sealed and the product was exposed to the ambient air of the freezer and potential deterioration. The DM further stated all staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455754 If continuation sheet Page 21 of 25 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 455754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218 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 storing food in both the coolers and freezers were responsible for properly sealing and labeling with the use-by date, and they were trained upon hire and periodically throughout the year. Record review of the facility's policy titled, Preventing Food Contamination From the Premises, undated, revealed: (a) Food Storage. (1) Food shall be protected from contamination by storing the food: (B) where it is not exposed to splash, dust or other contamination. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, 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 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, 2022, U.S. Department of H&HS, 3-305.11, revealed: Preventing Contamination from the Premises - Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455754 If continuation sheet Page 22 of 25 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 455754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 3 of 5 staff (LVN B, LVN C, and CNA G) reviewed for infection control, in that: Residents Affected - Some 1. The facility failed to ensure CNA G sanitized the blood pressure cuff between Resident #81, #83, #100, and #101. 2. The facility failed to ensure LVN B did not enter Resident #9's room without the proper PPE for droplet precautions. 3. The facility failed to ensure LVN C did not touch Resident #27's medication with his bare hands during administation. These deficient practices could place residents at-risk for infections. The findings included: 1. During an observation on 02/13/23 at 3:21 p.m. CNA G checked blood pressures using one wrist blood pressure cuff for residents on the C hallway. CNA G checked Residents #81, #83, #100, and #101 blood pressure and did not sanitize the cuff between each resident. During an interview on 02/13/23 at 3:40 p.m. CNA G stated she did not have any sanitizer wipes available to her while she checked residents blood pressures. CNA G stated she should sanitize the blood pressure cuff between each resident to prevent cross contamination. CNA G stated the ADON brought her sainting wipes by the time of the interview, and she could have asked for wipes prior if she did not find any available. 2. Record review of Resident #9's face sheet, dated 02/15/24 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: type II diabetes mellitus with chronic kidney disease (a chronic (long-lasting) health condition that affects how your body turns food into energy), dependence on renal dialysis, and end stage renal disease. Record review of Resident #9's order summary report, dated 02/15/24 revealed the following: - Droplet precautions d/t (due to) covid exposure x 10 days, order date 02/08/24, and no end date. During an observation on 02/15/24 at 10:45 a.m. Resident #9's room contained signage on the door to stop and see the nurse before entering the room, other signs on how to put on and remove PPE for droplet precautions, and a PPE cart outside the room. LVN B went into Resident #9's room with only a surgical face mask. LVN B then retrieved a binder from bag hanging on the resident's wheelchair and brought it out of the room. LVN B then attempted to take Resident #9's blood pressure at the nurses' station with an automatic arm blood pressure cuff. The cuff did not work and LVN B then placed the cuff on the counter in the nurses' station and did not sanitize it. LVN B then borrowed a wrist blood pressure cuff from another nurse. LVN B did not sanitize the wrist blood pressure cuff. LVN B then used the blood pressure cuff on Resident #9. LVN B then returned the wrist blood pressure cuff to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455754 If continuation sheet Page 23 of 25 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 455754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218 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 the other nurse. Level of Harm - Minimal harm or potential for actual harm During an interview on 02/15/24 at 10:55 a.m. LVN B stated she did notice the signage to put on the PPE. LVN B stated Resident #9's roommate had tested positive for COVID and Resident #9 was on droplet precautions, prophylactically (to prevent), or just in case, but she should have put on the PPE to go in his room and take his vitals just in case he tested positive later. LVN B stated the rules always changed and were difficult to follow. Residents Affected - Some 3. During an observation at 3:00 p.m. on 02/15/24 LVN C prepared medication to administer Resident #27 at the nurse medication cart. LVN C grabbed a 5 mg Apixaban tablet with his bare hands, put the 5 mg tablet into a plastic bag and crushed the pill, stuck his bare index finger into the medication bag to open it up, and emptied the contents of the bag into the plastic cup with the other medications. LVN C then entered Resident #27's room and administered the medications via a PEG tube. During an interview with LVN C on 02/15/24 at 3:00 p.m., LVN C stated he was unsure if a person could touch medications with their bare hands and he would need to find out if he could or not. During an interview with the DON on 02/16/24 at 11:14 a.m., the DON stated staff could not touch medications with their bare hands. The DON stated the staff were expected to wash their hands and put gloves on. The DON stated the staff were expected to sanitize the blood pressure cuff after each use to prevent the spread of infection. The DON stated staff are expected to follow droplet precautions for residents with the signnage on their doors which included an N95 mask, gown, face sheild, and gloves. Record review of the facility's policy titled, Infection Prevention and Control Program, dated 12/23, revealed, Policy, the infection prevention and control program is a facility wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of infection prevention and control program consists of coordination/ oversight, surveillance data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The program will be carried out by the facilities infection preventionist. that is the policy of the facility provide the necessary supplies, education, and oversight to ensure health care workers perform hand hygiene based on acceptable standards . scope of infection control and prevention program: .2. process surveillance is the review of practices by staff directly related to resident care period some considerations for this process may include, but are not limited to: a. hand hygiene, b. appropriate use of personal protective equipment (PPE) .e. Infection control practices during the provision of resident care and treatment .g. cleaning and disinfection production and procedures for environmental services and equipment, h. appropriate use of transmission based precautions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455754 If continuation sheet Page 24 of 25 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 455754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northeast Rehabilitation and Healthcare Center 603 Corinne St San Antonio, TX 78218 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 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents for 1 of 1 non-designated smoking areas, in that: Residents Affected - Few The facility failed to ensure there was a self-closing ash tray, fire blanket, or sign designating an area a smoking area. This deficient practice could result in harm to residents and staff due to improperly discarded and used cigarette butts if policies were not followed. The findings were: Observation on 02/14/2024 at 2:20 PM revealed Dietary Aide D sitting on top of a red metal trash can adjacent to the left wall of the facility. Further observation revealed there was no self-closing ash tray, fire blanket, or sign designating the area a smoking area. During an interview with Dietary Aide D on 02/14/2023 at 2:21 PM, Dietary Aide D revealed he was told by the Maintenance Supervisor that was the staff designated smoking area. Dietary Aide D acknowledged there was no sign designating the area as a smoking area and no self-closing ash tray. He stated he disposed of his cigarettes by placing them inside the red trash can. During an interview with the Administrator and the Maintenance Supervisor on 02/15/2023 at 12:50 PM, the Administrator and the Maintenance Supervisor stated the area where Dietary Aide D was observed smoking on 02/14/2024 was the staff smoking area, and it was missing a sign designating it as a smoking area, an approved self-closing ash tray and fire blanket. Both the Administrator and Maintenance Supervisor could not explain why those items were not present in the staff smoking area, and both acknowledged all the requirements for a smoking area were present in the smoking area designated for residents. Record review of the facility's policy titled, The Smoke Free Workplace Policy Number 212, Rev. May 2016, revealed: 1. Acting in accordance with OSHA regulations, the company prohibits the use of smoking materials when working near flammable substances or in non-smoking areas. 4. Smoking materials must be properly disposed of and exhaust ventilation fans, if available, must be used. 5. The company's smoking policy applies to all employees, residents/patients, visitors and other persons, including vendors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455754 If continuation sheet Page 25 of 25