Health inspection·September 11, 2025

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents had the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed for one of one resident (Resident #1) reviewed for room change. The facility did not provide Resident #1 with a written notice prior to a room change or the right to refuse on 06/16/2025. This deficient practice could place residents at risk for being displaced without notice and/or reason to accommodate other individuals.Findings included: Record review of Resident #1's admission Record, dated 09/10/2025, revealed a [AGE] year-old female admitted on [DATE]. Resident #1 was listed as her own responsible party with [family member] listed as financial Power of Attorney and Emergency Contact #1. Record review of Resident #1's Medical Diagnoses, undated and accessed 09/10/2025, revealed diagnoses including acute (present or experienced to a severe or intense degree) on chronic systolic (congestive) heart failure (a long-lasting condition resulting from the gradual decrease in the heart's ability to pump blood out to the rest of the body), senile degeneration of brain (loss of intellectual ability associated with old age), and unspecified dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Census tab on Resident #1's EMR, undated and accessed on 06/10/2025, revealed Resident #1 was moved from room [ROOM NUMBER]-B-A (rehabilitation unit) to 205-B (secure unit) on 06/16/2025. Record review of Resident #1's significant change MDS, dated [DATE], reflected a BIMS score of 05, indicating severe cognitive impairment. Record review of Resident #1's care plan, undated and accessed on 07/11/2025, revealed Resident #1 was an elopement risk related to dementia and impaired safety awareness. Resident #1 was noted to reside in the secure unit. The care plan focus was initiated and revised on 06/16/2025. Record review of Resident #1's progress notes, dated 06/13/2025 (day of admission) to 06/17/2025 (day after transfer to secure unit), indicated no documentation or notification to resident or emergency contact #1 about why a room change was made. Record review of Resident #1's EMR on 06/10/2025 did not reveal documentation of a notification to and/or consent by the resident or emergency contact #1 for a room change. During an interview on 09/10/2025 at 09:00 a.m., Resident #1's family member and emergency contact #1 stated she was never notified about and did not provide authorization for the room change that happened to Resident #1 on 06/17/2025. The family member did not understand why Resident #1 had been moved to a secure unit. The family member recalled she found out about the room change when another family member went to visit Resident #1. She stated she was eventually told (unable to provide who told her or when) that Resident #1 had gone to the front desk and was asking where she (family member) was. The family member stated she got no phone call, letter or verbal explanation as to why Resident #1 was moved. During an interview on 09/10/2025 at 12:10 p.m., Resident #1 stated the facility is very nice and she gets along with almost everyone. She stated she currently had a private room but would like a roommate. She stated her prior roommate was moved after it was Page 1 of 7 455762 455762 09/11/2025 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few discovered the roommate was taking Resident #1's personal items to another room. Resident #1 did not state she wanted to leave the secured unit and did not state why she was on the secured unit. She stated the activities director took the residents outside to do fun activities and the staff were amazing. During an interview on 09/11/2025 at 02:14 p.m., the DON stated Resident #1 was moved to the secure unit due to having been exit seeking and combative. The DON stated the family was informed about the changes and had told her (the DON) to not call them about Resident #1. The DON stated Resident #1's emergency contact had told her that she did not want to be bothered with Resident #1 right then. The DON stated there was no signed consent for the room change. During an interview on 09/11/2025 at 02:14 p.m. (entered room during DON interview), the ADMIN stated there was not a signed consent for Resident #1's room change in her chart. He stated he was unaware if Resident #1's family was notified immediately about Resident #1's move to the secure unit or if they provided room change consent. He stated he was aware that Resident #1's family had told him, the DON, and the ADON not to contact them regarding Resident #1. He stated he did recall Resident #1 exhibited behaviors after admission but could not provide details of Resident #1's move to the secure unit. Attempted interview with MD C on 09/11/2025 at 03:22 p.m. Call back not received. Record review of policy titled, Resident Rights, date revised 08/2020, revealed All residents have a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility including those specified in this policy. The Facility will protect and promote the rights of the resident. A. Be informed about what rights and responsibilities he or she has. C. Choose a physician and treatment and participate in decisions and care planning, including involving representatives and considering personal and cultural preferences;. 455762 Page 2 of 7 455762 09/11/2025 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0603 Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). 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 residents were free from involuntary seclusion and any physical restraint not required to treat the resident's medical symptoms for one of six (Resident #1) residents reviewed for involuntary seclusion.The facility failed to ensure Resident #1 met criteria to remain on the secure unit per secure unit criteria.This failure could place residents who resided on the secure unit at risk for feelings of isolation and anxiety.Findings included:Record review of Resident #1's admission Record, dated 09/10/2025, revealed a [AGE] year-old female admitted on [DATE]. Resident #1 was listed as her own responsible party with [family member] listed as financial Power of Attorney and Emergency Contact #1. Record review of Resident #1's Medical Diagnoses, undated and accessed 09/10/2025, revealed diagnoses including acute (present or experienced to a severe or intense degree) on chronic systolic (congestive) heart failure (a long-lasting condition resulting from the gradual decrease in the heart's ability to pump blood out to the rest of the body), senile degeneration of brain (loss of intellectual ability associated with old age), and unspecified dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 05, indicating severe cognitive impairment. Resident #1 was documented as having not exhibited any behavioral symptoms, including wandering. Record review of Resident #1's significant change MDS, dated [DATE], reflected a BIMS score of 05, indicating severe cognitive impairment. Resident #1 was documented as having not exhibited any behavioral symptoms, including wandering. Record review of Standard Assessment tab on Resident #1's EMR, undated and accessed on 06/10/2025 at 11:02 a.m., revealed one Elopement Risk Evaluation. The Evaluation had a risk score of 1.0, no risk. Record review of Resident #1's Elopement Risk Evaluation, dated and signed 06/13/2025, reflected Resident #1 was able to make decisions regarding daily living tasks and she was able to ambulate or mobilize in wheelchairs. The elopement risk evaluation had a score of 1.0, no risk for elopement. Record review of Resident #1's Elopement Risk Evaluation, dated and signed 06/13/2025, reflected Resident #1 was alert and oriented times 3, did not have a history of falls, was ambulatory, and had adequate vision. Resident #1 was noted to be able to stand but required assistance when standing and was unable to stand independently. She was documented as having taken 1-2 listed medications within the last 7 days. The care plan and interventions were not completed on the evaluation. The elopement risk evaluation had a score of 8.0, moderate risk for elopement. The risk evaluation was not completed or available in Resident #1's EMR until after investigation began, 09/10/2025 at 09:15 a.m. Record review of Resident #1's Order Summary Report, dated 09/11/2025, reflected no orders for secure unit placement. Record review of Resident #1's care plan, undated and accessed 09/11/2025, revealed Resident #1 was an elopement risk related to dementia and impaired safety awareness. Resident #1 was noted to reside in the secure unit. The care plan focus was initiated and revised on 06/16/2025. The care plan also included Resident #1 was at risk for elopement related to Elopement Evaluation risk score, date initiated and created 09/10/2025 (day of investigation entry, 09/10/2025 at 09:15 a.m.). Record review of Resident #1's progress notes, dated 06/13/2025 (day of admission) to 06/17/2025 (day after transfer to secure unit), indicated no documentation or notification to resident or emergency contact #1 about why a room change was made. Record review of Resident #1's Care Plan Conference, dated 08/12/2025 and signed 08/18/2025, revealed Resident #1, Resident #1's emergency contact, and another family member attended the care plan conference. The additional information revealed Family would like for her [Resident #1] to be evaluated to come out of skilled unit. During an interview on 09/10/2025 at 09:00 a.m., Resident Residents Affected - Few 455762 Page 3 of 7 455762 09/11/2025 San Antonio Wellness & Rehabilitation One Heartland Dr San Antonio, TX 78247

F 0603 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #1's family member and emergency contact #1 stated she did not understand why Resident #1 had been moved to a secure unit. She stated she was eventually told (unable to provide who told her or when) that Resident #1 had gone to the front desk and was asking where she (family member) was. The family member stated she wanted Resident #1 back on the general population hall and out of the secure unit. The family member stated she voiced this request to the facility during the care planning meeting. During an observation and interview on 09/10/2025 at 12:10 p.m., Resident #1 stated the facility is very nice and she gets along with almost everyone. She stated she currently had a private room but would like a roommate. She stated her prior roommate was moved after it was discovered the roommate was taking Resident #1's personal items to another room. Resident #1 did not state she wanted to leave the secured unit and did not state why she was on the secured unit. She stated the activities director took the residents outside to do fun activities and the staff were amazing. Resident #1 did not appear upset, stressed, or agitated during the conversation and subsequent observations regarding her placement in the secured unit. During an interview on 09/10/2025 at 03:57 p.m., CNA A, a CNA on the secure unit, stated Resident #1 had not exhibited exit-seeing behaviors and was easily re-directed if she appeared to be wandering aimlessly. CNA A stated Resident #1's wandering happened mostly when Resident #1 had forgotten something and was looking for it. During an interview on 09/10/2025 at 04:00 p.m., LPN B, a nurse on the secure unit, stated she had never seen Resident #1 try to elope or even act as if she wanted to elope. She stated Resident #1 would sometimes wander because she was looking for something she had forgotten. She stated Resident #1 had poor short-term memory but was easily redirected. She stated Resident #1 will sometimes go to the exit door to look through the window and put her hands on the bar, but she knows the door is locked and does not try to exit. LPN B stated she was not aware of Resident #1 having had an elopement attempt and had not been told by other staff of an attempt. She stated Resident #1's only exhibited behavior was being forgetful. During an interview on 09/10/2025 at 04:18 p.m., the ADON stated residents did not have to have an order for placement on the secure unit if there was an elopement attempt. The ADON stated Resident #1 came to the facility for skilled services originally, not long-term care, but she tried to elope from the rehabilitation unit. She stated residents could be moved to the secure unit for their safety. The ADON could not explain why there was not an elopement assessment done for Resident #1 prior to her placement since the initial assessment revealed no risk. The ADON could not explain why the second elopement assessment, with a moderate risk and a created date of 06/16/2025, was entered into Resident #1's today, 09/10/2025. During an interview on 09/11/2025 at 02:14 p.m., the DON stated Resident #1 did not have an order for having been on the secure unit. She stated Resident #1 was moved to the secure unit due to having been exit seeking and combative. The DON stated Resident #1's move to the secure unit was care planned from the time of her transfer. During an interview on 09/11/2025 at 02:14 p.m. (entered room during DON interview), the ADMIN stated he could not provide details of why Resident #1's did not have orders for her move to the secure unit but did recall Resident #1 had exhibited behaviors right after her admission. Attempted interview with MD C on 09/11/2025 at 03:22 p.m. Call back not received. Record review of policy titled, Wandering & Elopement, date revised 08/2020, revealed the purpose of the policy, To enhance the safety of residents of the Facility and a policy statement, The Facility will identify residents at risk for elopement and minimize any possible injury as a result of elopement. The policy procedure did not include a process or indications for residents to be evaluated for the secure unit. 455762 Page 4 of 7 455762 09/11/2025 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 interview and record review, the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were complete and accurately documented for two of six residents (Resident #1 and Resident #2) reviewed for medical records accuracy. 1. The facility failed to ensure Resident #1's orders for facility admission and for secure unit admission were reflected in the active orders. 2. The facility failed to ensure Resident #2's orders for facility admission and for secure unit admission were reflected in the active orders. These deficient practices could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment.Findings included: 1. Record review of Resident #1's admission Record, dated 09/10/2025, revealed a [AGE] year-old female admitted on [DATE]. Resident #1 was listed as her own responsible party with [family member] listed as financial Power of Attorney and Emergency Contact #1. Record review of Resident #1's Medical Diagnoses, undated and accessed 09/10/2025, revealed diagnoses including acute (present or experienced to a severe or intense degree) on chronic systolic (congestive) heart failure (a long-lasting condition resulting from the gradual decrease in the heart's ability to pump blood out to the rest of the body), senile degeneration of brain (loss of intellectual ability associated with old age), unspecified dementia (a general term for impaired ability to remember, think, or make decisions), and essential (primary) hypertension (high blood pressure). Record review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 05, indicating severe cognitive impairment. Resident #1 was documented as having not exhibited any behavioral symptoms, including wandering. Record review of Resident #1's significant change MDS, dated [DATE], reflected a BIMS score of 05, indicating severe cognitive impairment. Resident #1 was documented as having not exhibited any behavioral symptoms, including wandering. Record review of Standard Assessment tab on Resident #1's EMR, undated and accessed on 06/10/2025 at 11:02 a.m., revealed one Elopement Risk Evaluation. The Evaluation had a risk score of 1.0, no risk. Record review of Resident #1's Elopement Risk Evaluation, dated and signed 06/13/2025, reflected Resident #1 was able to make decisions regarding daily living tasks and she was able to ambulate or mobilize in wheelchairs. The elopement risk evaluation had a score of 1.0, no risk for elopement. Record review of Resident #1's Elopement Risk Evaluation, dated and signed 06/13/2025, reflected Resident #1 was alert and oriented times 3, did not have a history of falls, was ambulatory, and had adequate vision. Resident #1 was noted to be able to stand but required assistance when standing and was unable to stand independently. She was documented as having taken 1-2 listed medications within the last 7 days. The care plan and interventions were not completed on the evaluation. The elopement risk evaluation had a score of 8.0, moderate risk for elopement. The risk evaluation was not completed or available in Resident #1's EMR until after investigation began, 09/10/2025 at 09:15 a.m. Record review of Resident #1's Order Summary Report, dated 09/11/2025 at 12:01 p.m., reflected no orders for admission to the facility or orders for secure unit placement. Record review of Resident 1's Order Recap Report, dated 09/11/2025 at 04:36 p.m., reflected the following orders:- Admit to [facility name] under the care of [MD C] for skilled services., noted as discontinued with order date of 06/13/2025 and end date of 09/11/2025. Discontinue notation included reason, Admit to secure unit. Order updated.- ***Late entry for 6/13/25***Admit to [facility name] under the care of [MD C] for skilled services for HYPERTENSIVE URGENCY, noted as discontinued with order date of 06/15/2025 and end date of 06/16/2025. Discontinue notation did not include reason.- ***Late entry for 6/13/25***Admit to [facility name] under the care of [MD C] for skilled services for ACUTE ON CHRONIC SYSTOLIC (CONGESTIVE) 455762 Page 5 of 7 455762 09/11/2025 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 HEART FAILURE, noted as discontinued with order date of 06/16/2025 and end date of 07/03/2025. Discontinue notation did not include reason.- Admit to [facility name] under the care of [MD C] for long-term care/hospice on secure unit., noted as active with order date of 06/16/2025 and no end date. Order entered after investigation began, 09/10/2025 at 09:15 a.m. Record review of Order Audit Report, dated 09/11/2025 at 04:54 p.m., reflected the order Admit to [facility name] under the care of [MD C] for long-term care/hospice on secure unit., was created by the DON on 09/11/2025 at 04:48 p.m. Record review of Resident #1's care plan, undated and accessed 07/11/2025, revealed Resident #1 was an elopement risk related to dementia and impaired safety awareness. Resident #1 was noted to reside in the secure unit. The care plan focus was initiated and revised on 06/16/2025. During an interview on 09/10/2025 at 09:00 a.m., Resident #1's family member and emergency contact #1 stated she did not understand why Resident #1 had been moved to a secure unit. The family member stated she wanted Resident #1 back on the general population hall and out of the secure unit. The family member stated she voiced this request to the facility during the care planning meeting. During an observation and interview on 09/10/2025 at 12:10 p.m., Resident #1 stated the facility is very nice and she gets along with almost everyone. She stated she currently had a private room but would like a roommate. Stated her prior roommate was moved after it was discovered the roommate was taking Resident #1's personal items and taking them to another room. Resident #1 did not state she wanted to leave the secured unit and did not state why she was on the secured unit. She stated the activities director took the residents outside to do fun activities and the staff were amazing. Resident #1 did not appear upset, stressed, or agitated during the conversation and subsequent observations regarding her placement in the secured unit. During an interview on 09/10/2025 at 04:18 p.m., the ADON stated residents did not have to have an order for placement on the secure unit if there was an elopement attempt. The ADON stated Resident #1 came to the facility for skilled services originally, not long-term care, but she tried to elope from the rehabilitation unit. She stated residents could be moved to the secure unit for their safety. During an interview on 09/11/2025 at 02:14 p.m., the DON stated Resident #1 did not have an order for placement on the secure unit and Resident #1 did not have an active order for admission to the facility. She stated Resident #1's admission order was inactivated on 06/30/2025, when Resident #1 began hospice services. She stated she was not sure why or who inactivated Resident #1's admission order. The DON stated Resident #1's move to the secure unit was care planned from the time of her transfer. During an interview on 09/11/2025 at 02:14 p.m. (entered room during DON interview), the ADMIN stated he could not provide details of why Resident #1's did not have orders for her move to the secure unit and he was just informed by the DON that Resident #1 did not have an admission order. 2. Record review of Resident #2's admission Record, dated 09/11/2025, revealed a [AGE] year-old female initially admitted on [DATE] and re-admitted on [DATE]. Resident #2's family member was listed as Resident #2's responsible party and guardian. Record review of Resident #2's Medical Diagnoses, undated and accessed 09/11/2025, revealed diagnoses including ataxia (impaired balance or coordination), delusional disorders (a type of mental health condition in which a person cannot tell what is real and what is imagined), paranoid (unreasonably or obsessively anxious, suspicious, or mistrustful) schizophrenia (a chronic mental illness characterized by delusions, hallucinations, and disordered thinking), unspecified dementia, and essential hypertension. Record review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS score of 13, indicating mild cognitive impairment. Resident #2 was documented as having not exhibited any behavioral symptoms, including wandering. Record review of Resident #2's Elopement Risk Evaluation, dated and signed 01/21/2025, reflected Resident #2 was not able to make decisions regarding daily tasks and was able to ambulate or mobilize 455762 Page 6 of 7 455762 09/11/2025 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 in a wheelchair. She was noted as cognitively impaired and wandered aimlessly. She was noted as having ambulated and propelled self, and/or wanders and had intentionally or unintentionally attempted to leave the community. She was not noted as having verbalized a plan to elope. Interventions were noted for Wander guard and/or secure environment placement. The elopement risk evaluation had a score of 15.0, imminent risk for elopement. Record review of Resident #2's Order Summary Report, dated 09/10/2025 at 04:42 p.m., reflected no orders for admission to the facility or orders for secure unit placement. Record review of Resident 2's Order Recap Report, dated 09/11/2025 at 04:31 p.m., reflected the following orders:Admit to [facility name] under the care of [MD C] for long-term care in the MCU On hold from 04/27/2025 22:50 [10:50 p.m.] to 05/04/2025 22:49 [10:49 p.m.] On hold from 07/09/2025 07:01 [07:01 a.m.] to 07/10/2025 07:00 [07:00 a.m.], noted as discontinued with order date of 01/21/2025 and end date of 07/10/2025. Discontinue notation did not include reason, but one hold order included reason, sent to ER for evaluation and one resume order included reason, return from ER. -- May admit to secure unit Dx: DELUSIONAL DISORDERS On hold from 04/27/2025 22:50 [10:50 p.m.] to 05/04/2025 22:49 [10:49 p.m.] On hold from 07/09/2025 07:01 [07:01 a.m.] to 07/10/2025 07:00 [07:00 a.m.], noted as discontinued with order date of 01/21/2025 and end date of 07/10/2025. Discontinue notation did not include reason, but one hold order included reason, sent to ER for evaluation and one resume order included reason, return from ER. - Admit to [facility name] under the care of [MD C] for LTC SERVICES., noted as discontinued with order date of 07/13/2025 and end date of 07/14/2025. Discontinue notation did not include reason.- ***Late entry for 7/13/25***Admit to [facility name] under the care of [MD C] for skilled services for HYPERTENSIVE URGENCY, noted as discontinued with order date of 07/14/2025 and end date of 07/15/2025. Discontinue notation did not include reason.- ***Late entry for 7/13/25***Admit to [facility name] under the care of [MD C] for skilled services for ATAXIA, UNSPECIFIED, noted as discontinued with order date of 07/15/2025 and end date of 08/25/2025. Discontinue notation did not include reason. Record review of Resident #2's care plan, undated and accessed 07/11/2025, revealed Resident #2 was admitted to and will reside in the facility's Memory Care Unit for ongoing care and supervision. R/T Diagnosis of: UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY & risk for elopement related to Elopement Evaluation risk score. Resides in MEMORY CARE UNIT. [Resident #2] is an elopement risk/wanderer AEB Disoriented to place, History of attempts to leave facility unattended, Impaired safety awareness, Resident wanders aimlessly, Significantly intrudes on the privacy or activities. The care plan focus was initiated on 01/21/2025 and created and revised on 03/20/2025. During an observation on 09/10/2025 at 11:58 a.m., Resident #2 was noted on the secure unit. Resident #2 was not interviewable. During an interview on 09/11/2025 at 09:15 a.m., Resident #2's resident representative and guardian stated Resident #2's care at the nursing facility had been amazing. She stated Resident #2 was provided the care she required, was aware Resident #2 was on the secure unit, and she and Resident #2 had not had any issues with the staff or other residents on the unit. Attempted interview with MD C on 09/11/2025 at 03:22 p.m. Call back not received. Record review of policy titled, Physician Orders, date revised 06/2020, revealed the purpose, This will ensure that all physician orders are complete and accurate. The policy statement revealed The Medical Records Department will verify that physician orders are complete, accurate and clarified as necessary. The Procedure included, VI. Documentation pertaining to physician orders will be maintained in the resident's medical record. 455762 Page 7 of 7