Health inspection·October 6, 2023

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to promote resident self-determination through support of family choice for 1 of 8 residents (Resident #56) reviewed for resident rights. The facility did not follow Resident #56's and the family's request to not have resident be tube fed. This failure could place residents at risk for feelings of depression, lack self-determination and decreased quality of life. The findings included: Record review of Resident #56's electronic face sheet dated 10/05/23 revealed Resident #56 was initially admitted on [DATE] and was re-admitted [DATE]. His diagnoses included unspecified dementia, expressive language disorder, aphasia(loss of ability to understand or express speech), dysphagia(impairment in the production of speech), and unspecified protein-calorie malnutrition. Record review of Resident #56's quarterly MDS assessment, dated 09/21/23, revealed that BIMS should not be conducted and staff assessment for mental status was that resident's cognitive skills were moderately impaired, where decisions are poor, and cues/supervision was required. During an observation on 10/04/23 at 10:43 a.m., Resident #56 was receiving nutrition from tube feeding. There was an attempt to interview Resident #56. Resident was not appropriate for interview as evidenced by resident's inability to communicate during interview attempt. During a phone interview on 10/06/23 at 12:18 p.m., Resident #56's Responsible Party (RP) reported coming into the facility every morning, from 9 a.m. to 10 a.m., and resident ate breakfast during this time when she helps feed him, with no problem. Resident #56's RP felt that the tube feeding caused Resident #56 to have diarrhea and didn't want Resident to be tube fed. Resident #56's RP requested for Resident #56 to not be tube fed and said, but what can I do?. During a phone interview on 10/06/23 at 4:21 p.m., the RD revealed that she had tried many things for Resident #56 because of resident's poor intake and weight loss. She adjusted the tube feeding in various ways to make up for Resident #56's poor intake, but decided that nutrition provided to Resident #56 through tube feeding, solely, was the answer. The RD denied hearing concerns from Resident #56's wife about his tube feeding. Page 1 of 30 455762 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/06/23 at 8:17 p.m., the SW revealed that she was not familiar with Resident #56's tube feeding order and had not had a conversation with Resident #56's RP. The SW revealed that residents have the right to their own choices. Record Review of active orders as of: 10/06/2023 revealed an enteral feed order of Jevity 1.5 @60mls/hr x22hrs/day via pump to provide 1320ml, 1980kcals, 84g protein, and 1003ml free water per day. Record Review of a Nutrition/Weight Progress note, dated 09/18/23, by the RD recorded Some staff denies that resident asked to be removed from feeding but others say he asks all the time. They also say that wife asks for TF to stop so she can see if resident will eat but he is on TF d/t poor po intake. Record Review of Resident #56's Consent to Treatment, last revised Dec. 2018, was signed 08/25/23 by Resident's RP (wife). Consent to Treatment revealed, .you have the right, to the extent permitted by law, to refuse any treatment and the right to be informed of potential medical consequences should you refuse treatment. Record Review of the 'Resident Rights-Accommodation of Needs' facility policy dated 08/202 indicated, V. In order to accommodate residents' individual needs and preferences, Facility Staff attitude and behavior are directed towards assisting the residents in maintaining independence, dignity, and well-being to the extent possible according to residents' wishes. 455762 Page 2 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

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 observation, interviews and record reviews, the facility failed to accurately reflect the resident's status on the quarterly MDS for one (Resident #25) of 8 residents reviewed for MDS assessments in that: Residents Affected - Few The facility failed to properly code Resident #25's quarterly MDS assessment a 3 for always incontinent instead of 9 for not rated since he had an indwelling urinary catheter. This deficient practice could result in missed or inaccurate care. The findings included: Record review of Resident #25's electronic face sheet dated 10/04/2023 reflected he was initially admitted to the facility on [DATE]. His diagnoses included: unspecified focal traumatic brain injury (localized damage and includes contusion and lacerations), hemiplegia (one sided paralysis), aphasia (loss of ability to understand or express speech, caused by brain damage), and neuromuscular dysfunction of bladder (nerves and muscles do not work together well and may result in the bladder not filling or emptying correctly). Record review of Resident #25's quarterly MDS assessment with an ARD of 08/02/2023 reflected he scored a 4 out of 15 on his BIMS which signified his cognition was severely impaired. Further review reflected he had an indwelling urinary catheter. Record review of Resident #25's comprehensive care plan revised on 06/19/2023 revealed Focus .has a suprapubic catheter related to neurogenic bladder .position catheter bag and tubing below the level of the bladder. Review of Resident #25's Active Orders as of: 10/04/2023 reflected he had physician orders for his supra pubic catheter which was dated 05/09/2022. Observation on 10/04/2023 at 10:58 a.m. of Resident #25 revealed he was lying in bed getting a bed bath from CPS C. He had an indwelling urinary catheter. Interview on 10/6/2023 at 4:53 p.m. with MDS D, she stated that Resident #25's quarterly MDS was inaccurately coded a (3) instead of a (9) under the section for bladder incontinence because he had an indwelling urinary catheter. She stated it was important to know what the resident's condition is to provide the best care. Interview on 10/06/2023 at 6:00 p.m. with the DON, she stated that the MDS needed to accurately reflect the resident's condition and needs because the care areas go into the resident's comprehensive care plan which indicated the specific care for the resident. She stated that an inaccurate assessment could have resulted in resident #25 not not receiving the care he needed. She stated she was ultimately responsible to review the MDS data to ensure it was accurate. Record review of CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, October 2019 revealed The RAI process has multiple regulatory requirements .the assessment accurately reflects the resident's status. 455762 Page 3 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #95) out of 16 residents reviewed for care plans in that: The facility failed to ensure Resident #95 had a baseline care plan created within 48 hours when she was readmitted to the facility from the hospital. This deficient practice affects residents who are readmitted or new admissions and could result in decreased quality of care. The findings included: Record review of Resident #95's electronic face sheet dated 10/06/2023 reflected she was initially admitted to the facility on [DATE] and readmitted from the hospital on [DATE]. Her diagnoses included: cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), vascular dementia (problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage from impaired blood flow to the brain) and chronic cystitis without hematuria (a chronic condition causing bladder pressure, bladder pain and sometimes pelvic pain without blood in the urine). Record review of Resident #95's quarterly MDS assessment with an ARD of 09/02/2023 reflected she scored a 15out of 15 on her BIMS which indicated she was cognitively intact. Further review reflected she required extensive assistance with toilet use and personal hygiene. Record review of Resident #95's comprehensive care plan revealed she did not have a baseline care plan, and her comprehensive care plan from May 2023 had focused problems cancelled or resolved. Interview on 10/6/2023 at 4:53 p.m. with MDS D, she stated that Resident #95's baseline care plan was missed and her comprehensive care plan was not reactivated. She stated Resident #95's care plan should have been reactivated when she was readmitted to the facility on [DATE], but the MDS nurses were trying to catch up because the care plan person had recently left. Interview on 10/06/2023 at 6:00 p.m. with the DON, she stated that Resident #95 required a care plan and it was missed. She stated without a care plan, staff would not know what the resident needs were in response to her preferences and medical or psychological condition. Record review of the facility policy and procedure titled Care Planning revised October 24, 2022, reflected The facility will develop a person-centered Baseline Care Plan for each resident within 48 hours of admission. The Baseline Care Plan will include at least the following information: initial goals, physician orders, dietary orders, therapy services, social services and PASARR recommendations if applicable. 455762 Page 4 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 1 of 8 residents (Resident #56) reviewed for care plans, in that: The facility failed to implement Resident #56's comprehensive person-centered care plan to address ADL self-care of eating. This failure could affect residents who have care areas not addressed by the care plan by not having their needs met and putting them at risk of not receiving appropriate care. The findings included: Record review of Resident #56's face sheet dated 10/05/23 revealed Resident #56 was initially admitted on [DATE] and was re-admitted [DATE]. His diagnoses included unspecified dementia, expressive language disorder, aphasia, dysphagia, and unspecified protein-calorie malnutrition. Record review of Resident #56's quarterly MDS assessment, dated 09/21/23, revealed that BIMS should not be conducted and staff assessment for mental status was that resident's cognitive skills are moderately impaired, where decisions are poor and cues/supervision was required. Observation for 10/05/23 dinner revealed that resident ate 0-25% of his meal. During a phone interview on 10/06/23 beginning at 12:18 p.m., Resident #56's wife/responsible party (RP) reported coming into the facility every morning, 9 a.m. to 10 a.m., and resident ate breakfast during this time when she helps feed him, with no problem. During an interview on 10/06/23 at 3:43 p.m., CNA Z revealed that Resident #56 gets meal trays but doesn't eat them. CNA Z revealed that they kept these meal trays in his room throughout mealtime, even though he didn't eat. CNA Z revealed that resident didn't get assistance with eating. During a phone interview on 10/06/23 beginning at 4:21 p.m., the RD revealed that Resident #56 refuses to eat and doesn't need help with eating. Record Review of a Nutrition/Weight Progress note, dated 09/18/23, by the RD recorded Intake is poor at 0-25% of his regular, mechanical soft diet with thin liquids. Record Review of Resident #56's comprehensive care plan, dated 10/05/23, revealed a focus of ADL self care performance deficit r/t femure fx, CVA with hemi, muscle wasting and weakness. With an Intervention/task EATING: The resident requires (1) staff participation to eat. This intervention/task was initiated on 07/13/23. 455762 Page 5 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview with MDS-LVN K on 10/06/2023 at 4:56 p.m., MDS-LVN K revealed IDT meetings are held daily to discuss all skilled residents and their care areas. She stated care plans would be updated at that time. She added that recently the person responsible for these care plans had left and the team was trying to keep up. In an interview with the DON on 10/06/2023 at 6:08 p.m., the DON revealed the care plans were not in compliance but stated the importance of the care plan for staff to have the needed information regarding resident's specific needs. She added that a new staff member had been hired to focus on care plans and to make sure all were up to date. However, until she was fully oriented the team had continue to work to keep up with care plan updates. Record review of the facility's policy titled, Care Planning, revised October 24, 2022, revealed, To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. IX. Each resident's Comprehensive Care Plan will describe the following: A. Services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being; and The resident has the right to receive the services and/or items included in the plan of care. 455762 Page 6 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to review and revise the comprehensive person-centered care plan for 2 (Resident #74 and #101) out of 16 residents reviewed for comprehensive care plans in that: 1. The facility failed to ensure Resident #74's comprehensive care plan Interventions/Tasks were revised to reflect interventions taken after falls have occurred. 2. The facility failed to ensure Resident #101's comprehensive care plan was revised within the required timeframe. These failures could affect residents who are assessed and have care plans and places them at risk for not receiving necessary care. The findings included: 1. Record review of Resident #74's electronic face sheet dated 10/06/23 reflected he was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included muscle wasting and atrophy, difficulty in walking, unspecified lack of coordination, other mechanical complication of surgically created age-related osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue) without current pathological fractures, osteoarthritis (degeneration of joint cartilage and the underlying bone) of the knee. Record review of Resident #74's quarterly MDS assessment, dated 08/28/23 a BIMS score of 15/15, indicating Resident #74 was cognitively intact. Record review of Resident #74's comprehensive care plan revised on 08/24/23 reflected a focus of actual fall r/t incontinence, impaired mobility., 7/17/23 FALL IN RESTROOM SELF TX NO INJURY, and 8/22/23 fall from bed no injury. However, there were no revisions to add to 'Interventions/Tasks' revealed after 7/17/23 fall and 8/22/23 fall. During an interview and record review on 10/06/23 beginning at 6:08 p.m., the DON revealed that after a fall, there should be an immediate intervention, an incident report created, family contacted. The interventions should be documented in the care plan. Upon the DON's review of the Resident #74's care plan, the DON revealed that she didn't know why there were not any interventions to prevent future falls in Resident #74's care plan. During an interview on 10/06/23 at 7:18 p.m., MDS-LVN K revealed that the care plans hadn't been updated correctly by previous MDS nurse. During a record review and interview on 10/06/23 beginning at 9:45 p.m., the DON presented progress notes that showed interventions done for 07/17/23 and 08/22/23 falls. The progress note was created 7/19/2023 and 8/23/2023, respectively. The DON stated that the interventions were not documented in the care plan but were put in place for Resident #74. Record review of the facility's Nursing Manual-Nursing Care 'Fall Evaluation and Prevention' policy revealed The care plan should only specify a few interventions at a time so that the staff can 455762 Page 7 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few determine what intervention is not successful and needs to be changed FOLLOWING A FALL, THE FOLLOWING STEPS SHOULD BE UNDERTAKEN .The IDT team will review the plan of care and update the interventions as appropriate. Record review of CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, October 2019 revealed Care Plan Completion .the resident's care plan must be reviewed after each assessment, as required by §483.20, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. 2. Record review of Resident #101's face sheet, dated 10/06/2023, revealed an admission date of 09/07/2023 and diagnoses that included acute cholecystitis, other specified sepsis, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Type 2 diabetes mellitus with hyperglycemia and morbid (severe) obesity. Record review of Resident #101's admission MDS, dated [DATE], revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. Further review revealed under Section M, resident was at risk of developing pressure ulcers/injures and had a surgical wound. Resident #101 had a pressure reducing device for the bed and applications of ointments/medications. Review of Section N revealed resident had orders for and received insulin injections. Further review revealed under Section O that Resident #101 had orders for and received OT and PT services. Record review of Resident #101's Comprehensive Care Plan, date initiated 09/07/2023, revealed focus areas related to code status, allergies, anticoagulants, and antibiotic treatments. Physician orders for insulin/diabetic care, PT, OT, WBAT, skin treatments and jp drain were not addressed on the comprehensive care plan. Record review of Resident #101's Order Summary Report, Active Orders as of 10/06/2023, revealed orders with a start date of 09/08/2023 to include: apply barrier cream to abdominal folds, coccyx area, and groin area bid and PRN every day and evening shift, clean around jp drain site with N/S pat dry LOTA daily and PRN every day shift, clean removed jp drain site with N/S pat dry cover with dry dressing daily and PRN every day shift, OT to treat 5-7x/week for 60 days, skilled PT services 5x/week for 60 days, WBAT and insulin orders for Lispro Insulin per sliding scale and Tresiba FlexTouch at bedtime for Diabetes. Further review revealed orders dated 09/14/2023, resident may have Freestyle Libre blood sugar monitor at bedside every shift for bs monitoring. In an interview with MDS-LVN K on 10/06/2023 at 4:56 p.m., MDS-LVN K revealed IDT meetings are held daily to discuss all skilled residents and their care areas. She stated care plans would be updated at that time. She added that recently the person responsible for these care plans had left and the team was trying to keep up. MDS-LVN K confirmed Resident #101's care plan would have been prior to the staff member leaving and stated, that was a failure on his part. In an interview with the DON on 10/06/2023 at 6:08 p.m., the DON revealed the care plans were not in compliance but stated the importance of the care plan for staff to have the needed information regarding resident's specific needs. She added that a new staff member had been hired to focus on care plans and to make sure all were up to date. However, until she was fully oriented the team had continue to work to keep up with care plan updates. Record review of the facility's policy titled, Care Planning, revised October 24, 2022, revealed, To ensure that a comprehensive person-centered Care Plan is developed for each resident based on 455762 Page 8 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few their individual assessed needs. X. The Comprehensive Care Plan must be completed within 7 days after completion of the Comprehensive admission Assessment and must be periodically reviewed and revised by a team of qualified persons after each assessment, including the comprehensive and quarterly review assessments. V. The IDT will revise the Comprehensive Care Plan as needed at the following intervals: B. As dictated by changes in the resident's condition, D. to address changes in behavior and care and E. other times as appropriate or necessary. 455762 Page 9 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 ensure that a resident receives care consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 (Resident #25) of 4 residents reviewed for pressure sore prevention and management in that: Residents Affected - Few The facility failed to ensure Resident #25's heel protectors were on his feet during the 3 days of observations. This deficient practice affects residents at risk for skin breakdown and could result in pressure sores. The findings included: Record review of Resident #25's electronic face sheet dated 10/04/2023 reflected he was initially admitted to the facility on [DATE]. His diagnoses included: unspecified focal traumatic brain injury (localized damage and includes contusion and lacerations), hemiplegia (one sided paralysis), aphasia (loss of ability to understand or express speech, caused by brain damage), and neuromuscular dysfunction of bladder (nerves and muscles do not work together well and may result in the bladder not filling or emptying correctly). Record review of Resident #25's quarterly MDS assessment with an ARD of 08/02/2023 reflected he scored a 4/15 on his BIMS which signified he was severely cognitively impaired. Further review reflected he was at risk for developing pressure ulcers and required extensive assistance with his care. Record review of Resident #25's comprehensive care plan revised on 06/19/2023 revealed Focus .has potential/actual impairment to skin integrity r/t fragile skin .Interventions .heel protectors per orders .date initiated 09/12/2023. Record review of Resident #25's Active Orders as of: 10/04/2023 reflected HEEL PROTECTORS to bi-lateral feet always while in bed. every shift for preventative .Active 07/24/2023. Record review of Resident #25's Wound Consultation Form dated 06/28/2023 reflected he had a pressure sore to his sacrum. Under recommendations .low air loss mattress, gel cushion and heel protectors where checked. Observation on 10/03/2023 at 12:15 p.m. of Resident #25 revealed no heel protectors were on his feet. Observation on 10/04/2023 at 10:58 a.m. of Resident #25 revealed he was lying in bed on a low air loss mattress getting a bed bath performed by CPS C. No heel protectors were observed on his feet or in his room. Interview on 10/04/2023 at 11:00 a.m. with CPS C, he stated he was with Resident #25 five days a week. When asked where Resident #25's heel protectors were, CPS C stated he did not know about any heel protectors. 455762 Page 10 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0686 Level of Harm - Minimal harm or potential for actual harm Observation on 10/05/2023 at 4:25 p.m. with LVN D of Resident #25 revealed he did not have heel protectors on his feet. In an interview on 10/05/2023 at 4:30 p.m. with LVN D, she stated Resident #25 should have had heel protectors on and she did not check. Residents Affected - Few In an interview on 10/06/2023 at 6:00 p.m. with the DON, she stated the nurses needed to check residents and follow the provider orders. She further stated Resident #25 had previously had skin breakdown and he should have had the heel protectors on while in bed to prevent the development of pressure sores. Record review of the facility policy and procedure titled Pressure Injury Prevention revised 06/2020 reflected Purpose .to identify residents at risk for skin breakdown, implement measures to prevent and/or manage pressure injury and minimize complications. Record review of the facility policy and procedure titled Support Surface Guidelines revised on 06/2020 reflected The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk for skin breakdown .protection devices .pillows, foam wedges and heel protectors can be placed between the knees, ankles or heels when residents are supine or on their side. 455762 Page 11 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

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 observations, interviews and record reviews, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 ( Resident #25) out of 3 residents reviewed for indwelling urinary catheters in that: The facility failed to ensure Resident #25 had a leg strap to secure his indwelling urinary catheter tubing. The facility failed to ensure C NA B did not lift Resident #25's urinary catheter bag and tubing with urine in it above the resident's bladder when he assisted with incontinent care for the resident. This deficient practice affects residents with indwelling urinary catheters and could result in urinary tract infections and trauma to the stoma site. The findings included: Record review of Resident #25's electronic face sheet dated 10/04/2023 reflected he was initially admitted to the facility on [DATE]. His diagnoses included: unspecified focal traumatic brain injury (localized damage and includes contusion and lacerations), hemiplegia (one sided paralysis), aphasia (loss of ability to understand or express speech, caused by brain damage), and neuromuscular dysfunction of bladder (nerves and muscles do not work together well and may result in the bladder not filling or emptying correctly). Record review of Resident #25's quarterly MDS assessment with an ARD of 08/02/2023 reflected he scored a 4/15 on his BIMS which signified he was severely cognitively impaired. Further review reflected he had an indwelling urinary catheter. He was checked off as (3), always incontinent of bladder. Record review of Resident #25's comprehensive care plan revised on 06/19/2023 revealed Focus .has a suprapubic catheter related to neurogenic bladder .position catheter bag and tubing below the level of the bladder. Review of Resident #25's Active Orders as of: 10/04/2023 reflected he had physician orders for his supra pubic catheter which was dated 05/09/2022. Observation on 10/04/2023 at 10:58 a.m. of Resident #25 revealed he was lying in bed getting a bed bath from CPS C. His indwelling urinary catheter did not have a leg strap in place to anchor his tubing. Interview on 10/04/2023 at 11:00 a.m. with CPS C, he stated he was with Resident #25 five days a week. When asked by the surveyor CPS C stated he did not remember a leg strap for Resident #25's catheter tubing. Observation on 10/5/2023 at 2:00 p.m. of C NA A and C NA B perform catheter and incontinent care for Resident #25 revealed C NA A wiped the indwelling urinary catheter tubing toward the stoma site instead of away. C NA B lifted the indwelling urinary catheter tubing and drainage bag with urine 455762 Page 12 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few above the level of Resident #25's bladder twice when he turned the resident onto his left and right sides for cleaning. Interview on 10/05/2023 at 2:10 p.m. with C NA A, she stated she knew she should not have wiped toward the stoma site since it could bring bacteria into the site from the tubing and result in a bladder infection. She stated she was trained on catheter care. Interview on 10/05/2023 at 2:15 p.m. with C NA B, he stated he knew the catheter bag should not be lifted higher than Resident #25's bladder level because old urine could flow back into the bladder and cause an infection. He stated he was trained on catheter care. Observation on 10/05/2023 at 4:25 p.m. with LVN D of Resident #25 revealed he did not have a leg strap to secure his catheter tubing. In an interview on 10/05/2023 at 4:30 p.m. with LVN D, she stated Resident #25 needed to have a leg strap to secure his catheter tubing because it could be dislodged and cause pain. She stated that she would get one and did not know why he did not have one. In an interview on 10/06/2023 at 6:00 p.m. with the DON, she stated the nurses needed to check residents and follow the provider orders. She further stated Resident #25 needed to have a leg strap on his catheter tubing to prevent it from being dislodged. She stated that the C NA's do the catheter care and are trained. She further stated that the catheter tubing needed to be cleaned away from the stoma site not toward because of infection and the drainage bag should not be lifted higher than Resident #25's bladder level for the same reason. Review of C NA A's Skills Checks dated 05/2023 reflected she met all areas on the competency checklist which was dated 05/03/2023 for Catheter: Indwelling Urinary - Care of .Cleanse the proximal third of the catheter with soap and water, washing away from the insertion site. Review of C NA B's Skills Checks dated 05/2023 reflected he met all areas on the competency checklist which was dated 05/05/2023 for Catheter: Indwelling Urinary - Care of .Secure tubing to keep the drainage bag below the level of the bladder. Record review of the facility policy and procedure titled Catheter-Care revised on 06/2020 reflected Position the catheter, drainage system and bag utilizing gravity to facilitate drainage. The collecting bag will be kept below the level of the bladder .Anchor the catheter with a leg strap to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging of the catheter. 455762 Page 13 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure nurse aides can demonstrate competency in skills and techniques necessary to care for resident's needs, as identified through resident assessments and described in the plan of care for 2 residents (#25 and #92) of 2 residents observed for incontinent care and catheter care in that: 1. The facility faled to ensure C NA A did not wipe Resident #25's catheter tubing toward the site and not away to prevent contamination and C NA B raised the urinary drainage bag above the resident's bladder twice when turning him side to side. 2. The facility failed to ensure CNA B did not raide Resident #25's urinary drainage bag above the resident's bladder twice when turning him side to side. 3. The facility failed to ensure C NA A wiped Resident #92 thouroughly cleaned the Resident's perineal area and then turned the resident over and cleaned her anal area from back to front once when she performed incontinent care. These deficient practices affect residents who require catheter and incontinent care and could result in infection. The findings included: 1. Record review of Resident #25's electronic face sheet dated 10/04/2023 reflected he was initially admitted to the facility on [DATE]. His diagnoses included: unspecified focal traumatic brain injury (localized damage and includes contusion and lacerations), hemiplegia (one sided paralysis), aphasia (loss of ability to understand or express speech, caused by brain damage), and neuromuscular dysfunction of bladder (nerves and muscles do not work together well and may result in the bladder not filling or emptying correctly). Record review of Resident #25's quarterly MDS assessment with an ARD of 08/02/2023 reflected he scored a 4/15 on his BIMS which signified he was severely cognitively impaired. Further review reflected he had an indwelling urinary catheter. Record review of Resident #25's comprehensive care plan revised on 06/19/2023 revealed Focus .has a suprapubic catheter related to neurogenic bladder .position catheter bag and tubing below the level of the bladder. Review of Resident #25's Active Orders as of: 10/04/2023 reflected he had physician orders for care of his supra pubic catheter which was dated 05/09/2022. Observation on 10/5/2023 at 2:00 p.m. of C NA A and C NA B perform catheter and incontinent care for Resident #25 revealed C NA A wiped the indwelling urinary catheter tubing toward the stoma site instead of away. C NA B lifted the indwelling urinary catheter tubing and drainage bag with urine above the level of Resident #25's bladder twice when he turned the resident onto his left and right sides for cleaning. 455762 Page 14 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 10/05/2023 at 2:10 p.m. with C NA A, she stated she knew she should not have wiped Resident toward the stoma site since it could bring bacteria into the site from the tubing and result in a bladder infection. She stated she was trained on catheter care. Interview on 10/05/2023 at 2:15 p.m. with C NA B, he stated he knew the catheter bag should not be lifted higher than Resident #25's bladder level because old urine could flow back into the bladder and cause an infection. He stated he was trained on catheter care. 2. Record review of Resident #92's electronic face sheet dated 10/05/2023 reflected she was admitted to the facility on [DATE]. Her diagnoses included: dementia (loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), psychotic disturbance (affects brain function by altering thoughts, beliefs, or perceptions), and anxiety (a feeling of fear, dread, and uneasiness). Record review of Resident #92's quarterly MDS assessment with an ARD of 09/05/2023 reflected she was not a candidate for a BIMS which signified she was severely cognitively impaired. Further review reflected she was always incontinent of bowel and bladder and required extensive assistance with her care. Record review of Resident #92's comprehensive care plan revised on 09/12/2023 reflected Focus .has bladder incontinence .Interventions .check resident as required for incontinence. Wash, rinse, and dry perineum/ Observation on 10/05/2023 at 2:25 p.m. of C NA A perform incontinent care for Resident #92 revealed she went to put on her gloves and asked the surveyor if she should put the hand sanitizer on her gloves. She then used a clean wipe and wiped once down the middle of Resident #92's vaginal area, then turned the resident to her side and wiped once from the back to front over the anus to the vagina. In an interview on 10/505/2023 at 2:30 p.m. with C NA A, she stated she should have wiped more and from front to back to prevent cross contamination which could have resulted in a urinary infection. She stated she was trained on incontinent care. In an interview on 10/06/2023 at 6:00 p.m. with the DON, she stated that the C NA's did the catheter care and are trained. She further stated that the catheter tubing needed to be cleaned away from the stoma site not toward it because of the risk of introducing bacteria causing infection and the drainage bag should not be lifted higher than Resident #25's bladder level for the same reason. She stated that C NA A did not perform proper incontinent care for Resident #92 or catheter care for Resident #25 and would need to be retrained. She further stated that C NA B also did not appear to manage the catheter drainage bag appropriately and would require training. Review of C NA A's Skills Checks dated 05/2023 reflected she met all areas on the competency checklist which was dated 05/03/2023 for Catheter: Indwelling Urinary - Care of .Cleanse the proximal third of the catheter with soap and water, washing away from the insertion site. Further review of C NA's checklist reflected Perineal Care .for a female resident .separate labia, wash area downward from front to back .Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side. Do not reuse the same washcloth or water to clean the urethra or labia .rinse thoroughly and gently dry perineum .wash the rectal area thoroughly, wiping from the base of the labia toward and extending over the buttocks. 455762 Page 15 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of C NA B's Skills Checks dated 05/2023 reflected he met all areas on the competency checklist which was dated 05/05/2023 for Catheter: Indwelling Urinary - Care of .Secure tubing to keep the drainage bag below the level of the bladder. Record review of the facility policy and procedure titled Catheter-Care revised on 06/2020 reflected Position the catheter, drainage system and bag utilizing gravity to facilitate drainage. The collecting bag will be kept below the level of the bladder. Record review of the facility policy and procedure titled Perineal Care reflected For female residents: Separate the labia. Wash with soapy washcloth/cleansing wipe, moving from front to back, on each side of the labia and in the center over the urethra and vaginal opening, using a clean washcloth/cleansing wipe for each stroke, rinse thoroughly and dry. Turn resident to side, wash, rinse and dry buttocks and peri-anal area without contaminating perineal area. 455762 Page 16 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. Based on observations and interviews, the facility failed to ensure the drugs and biologicals used in the facility must be labeled and stored in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions and the expiration date when applicable and for 3 (200 Hall, 300 Hall and 600 Hall) of 6 medication carts in that: 1. The facility failed to ensure expired medications were not found on the 200 Hall and 300 Hall medication carts. 2. The facility failed to ensure the nurse and medication aide medication carts for 600 Hall were not left unattended and unlocked. These deficient practices affect residents who receive medications and could result in less potent or adverse effects and drug diversion. The findings included: 1. Observation on 10/06/2023 at 11:17 a.m. of medications in Hall 300 medication cart revealed a bottle of Retaire PM lubricant eye ointment for dry eyes with an expiration date of 02/2023. Interview on 10/06/2023 at 11:20 a.m. with MA E, revealed a new resident came in and he brought his own medications, and it was missed and still on the cart. She stated expired medications needed to be disposed of because their effectiveness may have diminished or they may cause and adverse response if taken. Observation on 10/06/2023 at 11:30 a.m. of medications in Hall 200 medication cart revealed a Lantus insulin pen 100 units/ml with a pharmacy sticker Once opened refrigerated or not discard in 28 days. The opened date on the box and on the vial was 07/28/2023. Further inspection revealed a bottle of atropine sulfate 1% solution, expiration date 09/16/2022. Interview on 10/06/2023 with LVN F revealed she did not know why the medications were on the cart. She stated that the expired medications needed to be removed because they could cause adverse reactions or be less effective. 2. Observation on 10/06/2023 at 4:23 p.m. of the 600 Hall Nurse's cart, sitting in the hallway outside of the nurse's station, revealed it was unlocked and unattended. In an interview with ADON J on 10/06/2023 at 4:29 p.m., ADON J locked the cart, walked away from the cart, and then returned and revealed the cart belonged to RN G who was down 600 Hall with a resident. ADON stated carts should never be left unlocked and unattended and proceeded to walk down the hall towards RN G. In an interview with RN G, ADON J, and the DON on 10/06/2023 at 4:32 p.m., RN G revealed she had gone down the hall and provided medication to a resident and did not realize she left the cart unlocked. The DON stated, this won't happen again, we have higher expectations of our nurses. 455762 Page 17 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 10/06/2023 at 4:25 p.m. of 600 Hall Nurse's Medication cart revealed it was left unlocked and unattended. Interview on 10/06/2023 at 4:30 p.m. with RN G, she stated she was in a resident room and forgot to lock the medication cart. She stated that someone could have taken any medications because it was not secured. Interview on 10/06/2023 at 5:30 p.m. with the DON, she stated medications should be secured and stored properly. She stated expired medications needed to be taken off the cart. She stated the medication carts were checked routinely by the pharmacy consultant. She stated that the Medication Aide called in sick and so RN G administered medications from both carts. Review of facility policy and procedure titled Storage of Medications effective date 09/2018 reflected expiration dates (beyond-use dates) shall be determine by the pharmacist at the time of dispensing .all expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining .medication room, carts, and medication supplies are locked when they are not attended by persons with authorized access. 455762 Page 18 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure that the menu was followed for 1 of 1 meal observed in that: Residents Affected - Some 1. The facility failed to ensure all residents received [NAME] Peas with Sauteed Onions with their lunch meal on 10/03/2023. 2. The facility failed to ensure [NAME] Peas with Sauteed Onions was prepared by the recipe. These failures could place residents at risk for dissatisfaction, poor intake, and diminished quality of life. The findings were: Record review of the facility's Day 10 menu for Tuesday 10/03/23 lunch meal revealed Meatloaf with Tomato Sauce, Scalloped Potatoes, [NAME] Peas with Sauteed Onions, Bread Slice/Margarine, Chocolate Pudding, Beverage of Choice, Water were to be served. Record review on 10/03/2023 at 12:32 p.m. revealed a daily menu board in the dining room that listed Meatloaf with Tomato Sauce, Scalloped Potatoes, [NAME] Peas with Sauteed Onions, Bread Slice/Margarine, Chocolate Pudding, Beverage of Choice, Water for the lunch meal. The menu revealed no indication that [NAME] Peas without Sauteed Onions were to be served. Record review of the recipe for [NAME] Peas with Sauteed Onions revealed that Onion, Yellow Fresh, peeled and diced was one of the ingredients for this recipe. During an observation of Tuesday 10/03/23 lunch at 12:32 p.m., revealed that the 15 residents in the dining room with [NAME] Peas with Sauteed Onions on their meal ticket did not receive this food item. These residents received [NAME] Peas without Sauteed Onions. During an observation and interview with Resident #35 on 10/03/2023 at 12:34 p.m., revealed Resident #35 lunch trays did not include green peas with sauteed onions. Resident #35's green peas were not eaten. Resident #35's visitor revealed that Resident #35 did not eat the peas because there was no salt and no pepper. Resident #35's visitor further revealed that the sauteed onions may have help the resident's intake, however, they were unable to know for sure. During an interview on 10/03/23 at 12:32 p.m., the DON revealed that the tray tickets for the lunch meal included [NAME] Peas with Sauteed Onions. DON stated that the food trays of a few residents did not have [NAME] Peas with Sauteed Onions. During an interview on 10/03/23 at 12:54 p.m., the Director of Nurtition Services (DNS) revealed that there were no sauteed onions put in the green peas and that sauteed onions should have been added to the green peas. Record Review of Nutrition Services Operational Manual policy titled Menus, dated 12/2020 revealed Food served should adhere to the written menu. 455762 Page 19 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 reviewed for food nutrition services, in that: 1. The facility failed to ensure [NAME] Y's hairnet was covering his mustache while preparing for lunch. 2. The facility failed to ensure that staff didn't wear facial jewelry while preparing foods. 3. The facility failed to maintain the cleanliness of the ice machine found within the kitchen. These failures could place residents at risk for food contamination and foodborne illnesses. The findings included: 1. Observation on 10/03/23 at 11:03 a.m. revealed [NAME] Y standing by the stove preparing lunch without his mustache covered by a hairnet. During an interview and observation on 10/03/23 beginning at 11:14 a.m., Director of Nursing Services (DNS) told [NAME] Y to cover his mustache and DNS revealed that [NAME] Y's hairnet that covered his mustache and beard sometimes fell down his face, exposing his mustache, because the hair net is too big to stay over his mustache. DNS further revealed that she had to keep an eye out for [NAME] Y's hairnet so that his mustache remained covered while working in the kitchen. During an interview on 10/06/23 at 7:07 p.m., DNS revealed that if staff don't wear hairnets that food is at risk for being contaminated and would affect the residents in a negative way. Record Review revealed that staff were trained on dress code on 9/14/23 at 2 p.m., including [NAME] Y. 2. During an observation on 10/05/23 at 10:15 a.m., Dietary Aide revealed that she wore a nose ring while she was preparing for lunch. Observation beginning at 11:57 a.m. on 10/05/23, the DNS told the Dietary Aide that she could not have a nose ring on while preparing food. Observation on 10/05/23 at 12:03 p.m. revealed that the Dietary Aide put a face mask on to cover her nose, after DNS told Dietary Aide that she could not wear a nose ring in the kitchen. 3. During an interview and observation with the DNS of the ice machine on 10/03/23 at 11:14 a.m., at least 6 black circles smaller than the size of a penny, inside of the ice machine, were pointed out to the DNS. DNS stated that if the ice machine was not cleaned daily, the condensation turned into black spots. DNS stated that the ice machine was probably not cleaned yesterday and today yet. DNS properly washed her hands and wiped down the inside of the ice machine with a paper towel without a sanitized paper towel. DNS stated that gloves are needed to clean the inside of the ice machine with a partially sanitized towel. DNS further revealed that they put a clean bag on top of the ice while 455762 Page 20 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some they cleaned the inside of the ice machine. DNS also revealed that maintenance did a deep clean of the ice machine every week but that the maintenance staff member that deep cleaned the ice machine left last week. During an interview and observation with the DNS on 10/05/23 at 10:25 a.m., the ice machine had a sign that read DO NOT USE on it. The DNS revealed that the ice machine had to be deep cleaned. Record Review of Nutrition Services Operational Manual policy titled Nutrition Services Personnel Guidelines, dated 12/2020 revealed 5. Facial hair is to be closely trimmed and beards are to be covered with hair restraint and 7. Jewelry, except for a watch and a plain ring, is prohibited. Dangling earrings and other body jewelry are not permitted for safety reasons. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 2-402.11, revealed, (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles. Record Review of Nutrition Services Operational Manual policy titled Ice Machine-Operation and Cleaning, dated 12/2020 revealed F. On no less than a monthly basis, remove the ice to wash the inside of the machine, G. Wash the inside of the machine using pot and pan washing solution and rinse well, H. Sanitize the inside of the machine using a sanitizing solution and a clean cloth., I. Allow the inside of the machine to air dry. Then refill machine with ice. Record review of US FDA Food Code, dated 2022, revealed Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as . ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. Some equipment manufacturers and industry associations, e.g., within the tea industry, develop guidelines for regular cleaning and sanitizing of equipment . and 3-304.11 Food Contact with Equipment and Utensils. FOOD shall only contact surfaces of: (A) EQUIPMENT and UTENSILS that are cleaned as specified under Part 4-6 of this Code and SANITIZED as specified under Part 4-7 of this Code; P (B) Single-service and single-use articles. 455762 Page 21 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to keep information that is resident-identifiable from the public for one Hallway (600) of 6 hallways observed and failed to maintain medical records in accordance with professional standards and practices for 1 resident (#25) out of 8 resident records reviewed in that: 1. The facility failed to prevent RN G from having identifiable resident information on top of her medication cart unattended. 2. The facility failed to ensure Resident #25's heel protectors were not initialed on his nursing MAR and that were never applied to his feet. These deficient practices could affect all residents whose records are maintained by the facility and could place them at risk for violation of privacy and errors in care and treatment. The findings included: 1. Observation on 10/05/2023 at 5:12 p.m. of the 600 Hall medication cart, sitting in the hallway outside of the nurse's station, unattended, revealed a printed list of resident's names by room number, physician, diagnosis, code status and precautions lying on top of the cart. Further review revealed additional hand-written information, such as the times medications were given. In an interview with RN G on 10/05/2023 at 5:15 p.m., RN G stated she had to go down the hall to tell a resident she couldn't have her medications now. In an attempt to interview RN G regarding the harm of leaving information accessible RN G pointed out that her computer screen wasn't open, adding and that's a good thing and avoided any direct questions. In an interview with the DON on 10/05/2023 at 6:10 p.m., the DON confirmed resident information should not be left out unattended and in full view. The DON stated that would be a risk of a resident's privacy being violated. Observation on 10/06/2023 at 4:23 p.m. of the 600 Hall medication cart, sitting in the hallway outside of the nurse's station, unattended, revealed an incident report propped up against the computer screen and a 3-ring binder with resident information folded open lying on top of the cart. In an interview with ADON J on 10/06/2023 at 4:29 p.m., ADON J picked up the binder and report, walked away from the cart and then returned and revealed the cart belonged to RN G who was down 600 Hall with a resident. ADON proceeded to walk down the hall towards RN G and stated confidential information should never be left out in view unattended. In an interview with RN G, ADON J and DON on 10/06/2023 at 4:32 p.m., RN G revealed she had recently been given the incident report to complete and then had to provide medication to a resident. The DON stated, this won't happen again, we have higher expectations of our nurses. 2. Record review of Resident #25's electronic face sheet dated 10/04/2023 reflected he was initially admitted to the facility on [DATE]. His diagnoses included: unspecified focal traumatic brain 455762 Page 22 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few injury (localized damage and includes contusion and lacerations), hemiplegia (one sided paralysis), aphasia (loss of ability to understand or express speech, caused by brain damage), and neuromuscular dysfunction of bladder (nerves and muscles do not work together well and may result in the bladder not filling or emptying correctly). Record review of Resident #25's quarterly MDS assessment with an ARD of 08/02/2023 reflected he scored a 4/15 on his BIMS which signified he was severely cognitively impaired. Further review reflected he was at risk for developing pressure ulcers and required extensive assistance with his care. Record review of Resident #25's comprehensive care plan revised on 06/19/2023 revealed Focus .has potential/actual impairment to skin integrity r/t fragile skin .Interventions .heel protectors per orders .date initiated 09/12/2023. Record review of Resident #25's Active Orders as of: 10/04/2023 reflected HEEL PROTECTORS to bi-lateral feet always while in bed. every shift for preventative .Active 07/24/2023. Record review of Resident #25's MAR dated 10/04/2023 revealed his heel protectors were signed off by nursing staff LVN D and RN H. Record review of Resident #25's Wound Consultation Form dated 06/28/2023 reflected he had a pressure sore to his sacrum. Under recommendations .low air loss mattress, gel cushion and heel protectors where checked. Observation on 10/03/2023 at 12:15 p.m. of Resident #25 revealed no heel protectors were on his feet. Observation on 10/04/2023 at 10:58 a.m. of Resident #25 revealed he was lying in bed on a low air loss mattress getting a bed bath performed by CPS C. No heel protectors were observed on his feet or in his room. Interview on 10/04/2023 at 11:00 a.m. with CPS C, he stated he was with Resident #25 five days a week. When asked where Resident #25's heel protectors were, CPS C stated he did not know about any heel protectors. Observation on 10/05/2023 at 4:25 p.m. with LVN D of Resident #25 revealed he did not have heel protectors on his feet. In an interview on 10/05/2023 at 4:30 p.m. with LVN D, she stated Resident #25 needed to have heel protectors on and she did not check. She admitted to signing off in his MAR that he had them on for October 3rd and 4th, but she did not know for sure. She stated she was too busy and just signed off on his clinical record. She stated he was at risk for skin breakdown and needed to have the heel protectors on and she would obtain them and put them on his feet. In an interview on 10/06/2023 at 3:58 p.m. with RN H who worked night shift on October 3rd and initialed off on Resident #25's heel protectors, she stated she never looked to see if the heel protectors were on the resident and admitted to initialing off on his MAR. She stated she was busy and realized it was the wrong thing to do. In an interview on 10/06/2023 at 6:00 p.m. with the DON, she stated the nurses needed to check 455762 Page 23 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents and follow the provider orders. She further stated Resident #25 had previously had skin breakdown and he should have the heel protectors on while in bed to prevent the development of pressure sores. She stated nurses should not falsify information in the clinical record because then the clinical record would not be accurate. Request on 10/06/2023 at 6:00 p.m. to the DON for a facility policy and procedure for Hipaa or clinical documentation in medical record yielded no results. Review of the facility policy and procedure titled Physician Orders revised date 6/2020 reflected the Licensed Nurse receiving the order will be responsible for documenting and implementing the order. 455762 Page 24 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to establish and 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 diseases and infections for 2 ( Residents #228 and #244) of 7 residents observed for infection control in that: Residents Affected - Few 1. The facility failed to ensure MA I did not pull plastic drinking cups from the side of her cart by sticking her finger in one pulling it apart from the others. MA I stacked up her medication cups with medications in them and carried them with her fingers around the rims when she brought them in to Resident #228. 2. The facility failed to ensure RN G did not contaminated the medication cup by placing her finger in the medication cup with medications prior to giving them to Resident #244. This deficient practice had the potential to affect residents in the facility by placing them at risk of contracting pathogens that could lead to infection. The findings included: 1. In an observation during medication pass on 10/04/2023 at 08:49 a.m. of MA I, revealed she took plastic drinking cups which were stacked from the side of her medication cart and pulled them apart from each other placing her bare finger in the cup she was going to use for Resident #244's medications. MA I put her medications into medication cups, stacked them on top of each other and carried them to the resident's room with her fingers around the rims. In an interview with MA I on 08:55 a.m., she stated she should not have fingered the drinking cup and the medication cups because of cross contamination and the potential for spreading infection. 2. In an observation during medication pass on 10/04/2023 at 4:00 p.m. of RN G, revealed she took Resident #228's medications into his room and decided to go and fill his water pitcher. She picked up his medication cup with medications inside to take back to her cart so that she could get water by her fingers and one finger was inside the cup. In an interview on 10/04/2023 at 4:15 p.m. with RN G, she stated she should not have picked up his medication cup with her two fingers, one inside and one outside because of cross contamination. In an interview on 10/06/2023 at 6:00 p.m. with the DON, she stated that medication aides and nurses know not to put hands or fingers in the cups to prevent the spread of pathogens that could cause infection. Review of the facility policy and procedure titled Medication-Administration (undated) reflected Purpose: To provide practice standards for safe administration of medications for residents in the facility. 455762 Page 25 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0941 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Based on interview and record review, the facility failed to provide effective communications mandatory training for 8 of 24 employees (MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X) reviewed for training, in that: The facility failed to ensure effective communication training was provided to MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X. This failure could place residents at risk of miscommunication and social isolation due to lack of staff training. The findings included: Review of Facility Staff Roster, undated, revealed: MA L - date of hire - 10/03/2022 CNA M - date of hire - 08/16/2018 CNA N - date of hire - 09/23/2022 CNA Q - date of hire - 08/16/2022 CNA R - date of hire - 07/26/2019 CNA B - date of hire - 12/13/2019 ADON W - date of hire - 07/10/2020 ADON X - date of hire - 05/15/2019 During a record review and interview with the HR Personnel on 10/06/2023 at 8:15 p.m., the HR Personnel revealed each month the corporate office would send down which trainings staff were to be completed and the DON would ensure trainings were completed. The HR Personnel stated since the DON just started a few weeks ago those trainings were completed by the previous DON and the records provided were all they were able to find. The HR Personnel further revealed the organization's orientation set, however the HR Personnel stated communication was not a part of that training. During an interview with the Administrator on 10/06/2023 at 8:40 p.m., the Administrator stated he was not aware of any other trainings other than those provided, however he would ensure communication was added to the list of required training for all staff. Request on 10/06/2023 at 8:55 p.m. to the DON and Administrator for a facility policy for staff training and development yielded no results. 455762 Page 26 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0942 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Based on interview and record review, the facility failed to provide the required education on the rights of the resident and the responsibilities of a facility to properly care for its resident for 8 of 24 employees (MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X) reviewed for training, in that: The facility failed to ensure education on the rights of the resident and the responsibilities of a facility to properly care for its residents was provided to MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings included: Review of Facility Staff Roster, undated, revealed: MA L - date of hire - 10/03/2022 CNA M - date of hire - 08/16/2018 CNA N - date of hire - 09/23/2022 CNA Q - date of hire - 08/16/2022 CNA R - date of hire - 07/26/2019 CNA B - date of hire - 12/13/2019 ADON W - date of hire - 07/10/2020 ADON X - date of hire - 05/15/2019 During a record review and interview with the HR Personnel on 10/06/2023 at 8:15 p.m., the HR Personnel revealed each month the corporate office would send down which trainings staff were to be completed and the DON would ensure trainings were completed. The HR Personnel stated since the DON just started a few weeks ago those trainings were completed by the previous DON and the records provided were all they were able to find. The HR Personnel further revealed the organization's orientation set included resident rights training however confirmed MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X had all been employed longer than one year. During an interview with the Administrator on 10/06/2023 at 8:40 p.m., the Administrator stated he was not aware of any other trainings other than those provided and confirmed the staff had been employed longer than one year therefore would have needed their annual resident's rights training. Request on 10/06/2023 at 8:55 p.m. to the DON and Administrator for a facility policy for staff training and development yielded no results. 455762 Page 27 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 8 of 24 employees (MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X) reviewed for training, in that: The facility failed to ensure that quality assurance and performance improvement training was provided to MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X. This failure could place residents at risk for injury or improper care due to a lack of training. The findings were: Review of Facility Staff Roster, undated, revealed: MA L - date of hire - 10/03/2022 CNA M - date of hire - 08/16/2018 CNA N - date of hire - 09/23/2022 CNA Q - date of hire - 08/16/2022 CNA R - date of hire - 07/26/2019 CNA B - date of hire - 12/13/2019 ADON W - date of hire - 07/10/2020 ADON X - date of hire - 05/15/2019 During a record review and interview with the HR Personnel on 10/06/2023 at 8:15 p.m., the HR Personnel revealed each month the corporate office would send down which trainings staff were to be completed and the DON would ensure trainings were completed. The HR Personnel stated since the DON just started a few weeks ago those trainings were completed by the previous DON and the records provided were all they were able to find. The HR Personnel further revealed the organization's orientation set, however the HR Personnel stated quality assurance and performance improvement was not a part of that training. During an interview with the Administrator on 10/06/2023 at 8:40 p.m., the Administrator stated he was not aware of any other trainings other than those provided. However, he would ensure QAPI was added to the list of required training for all staff. Request on 10/06/2023 at 8:55 p.m. to the DON and Administrator for a facility policy for staff training and development yielded no results. 455762 Page 28 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0946 Provide training in compliance and ethics. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide the required compliance and ethics training for 8 of 24 employees (MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X) reviewed for training requirements, in that: Residents Affected - Some The facility failed to ensure compliance and ethics training was provided to MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. The findings included: Review of Facility Staff Roster, undated, revealed: MA L - date of hire - 10/03/2022 CNA M - date of hire - 08/16/2018 CNA N - date of hire - 09/23/2022 CNA Q - date of hire - 08/16/2022 CNA R - date of hire - 07/26/2019 CNA B - date of hire - 12/13/2019 ADON W - date of hire - 07/10/2020 ADON X - date of hire - 05/15/2019 During a record review and interview with the HR Personnel on 10/06/2023 at 8:15 p.m., the HR Personnel revealed each month the corporate office would send down which trainings staff were to be completed and the DON would ensure trainings were completed. The HR Personnel stated since the DON just started a few weeks ago those trainings were completed by the previous DON and the records provided were all they were able to find. The HR Personnel further revealed the organization's orientation set, however the HR Personnel stated compliance and ethics was not a part of that training. During an interview with the Administrator on 10/06/2023 at 8:40 p.m., the Administrator stated he was not aware of any other trainings other than those provided. However, he would ensure ethics was added to the list of required training for all staff. Request on 10/06/2023 at 8:55 p.m. to the DON and Administrator for a facility policy for staff training and development yielded no results. 455762 Page 29 of 30 455762 10/06/2023 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0949 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide behavior health training consistent with the requirements and as determined by a facility assessment. Based on interview and record review, the facility failed to provide mandatory effective behavioral health training for 8 of 24 employees (MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X) reviewed for training, in that: The facility failed to ensure effective behavioral health training was provided to MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X. This failure could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. The findings included: Review of Facility Staff Roster, undated, revealed: MA L - date of hire - 10/03/2022 CNA M - date of hire - 08/16/2018 CNA N - date of hire - 09/23/2022 CNA Q - date of hire - 08/16/2022 CNA R - date of hire - 07/26/2019 CNA B - date of hire - 12/13/2019 ADON W - date of hire - 07/10/2020 ADON X - date of hire - 05/15/2019 During a record review and interview with the HR Personnel on 10/06/2023 at 8:15 p.m., the HR Personnel revealed each month the corporate office would send down which trainings staff were to be completed and the DON would ensure trainings were completed. The HR Personnel stated since the DON just started a few weeks ago those trainings were completed by the previous DON and the records provided were all they were able to find. The HR Personnel further revealed the organization's orientation set. However, he stated behavioral health was not a part of that training. During an interview with the Administrator on 10/06/2023 at 8:40 p.m., the Administrator stated he was not aware of any other trainings other than those provided however would ensure training on behavioral health was added to the list of required training for all staff. Request on 10/06/2023 at 8:55 p.m. to the DON and Administrator for a facility policy for staff training and development yielded no results. 455762 Page 30 of 30