Inspection·November 17, 2023

F 0558 muscle wasting and atrophy, and muscle weakness. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #26's MDS assessment, dated 9/2/23, revealed the resident's BIMS score was 9/15, which indicated moderate cognitive impairment. The resident was dependent on toileting hygiene. The resident needed partial/moderate assistance for lying to sitting on side of bed, sit to stand, and sit to lying. Residents Affected - Some Record review of Resident #26's care plan, revised 9/19/2022, revealed Resident #26 had a focus of [Resident #26] is high risk for falls . and interventions reflected to Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. During an interview and observation on 11/14/23 at 3:33 PM, CNA M placed Resident #26's call light within in their reach. CNA M had to pick up the call light that was on the floor, in between the wall and head of the bed frame, out of reach. CNA M resident revealed that call lights should be near all of the residents. CNA M revealed that Resident #26 used her call light to let staff know when she is wet. During an interview on 11/14/23 starting at 6:26 PM, the ADM revealed that every shift call lights were to be checked that they functioned and that they were within reach of the residents to ensure the safety of the residents. Record Review of the facility's Answering the Call Light policy, revised September 2022, revealed under General Guidelines, 5. Ensure that the call light is accessible to the resident when in bed . Record Review of the facility's Call System, Resident policy, September 2022, revealed under Policy Interpretation and Implementation, 1. Each resident is provided with a means to call staff directly for assistance from his/her bed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455789 If continuation sheet Page 2 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior for 1 of 10 Resident's (Resident #16) reviewed for environment. The facility failed to ensure the broken and missing tiles in the restroom in Resident #16's bathroom was repaired. The facility failed to ensure that Resident #16's shower was clean. These failures could affect the residents and place them at risk for not having a safe and sanitary homelike environment. The findings included: Record review of Resident #16's face sheet, dated 11/14/23 revealed Resident #16 was originally admitted on [DATE] with diagnoses that included reduced mobility, difficulty in walking, muscle weakness, and direct infection of hand. Record review of Resident #16's most recent quarterly MDS assessment, dated 10/2/23, revealed the resident had a BIMS of 15/15 that indicated Resident #16 was cognitively intact. Record review of Resident #16's comprehensive care plan, revised 10/4/22, revealed the resident was a risk for falls with an intervention that included The resident needs a safe environment. During an interview and observation on 11/16/23 at 03:43 PM , Resident #16 revealed cracks in the tile floor in the bathroom/shower area. Resident complained about this and a black substance in the bottom corner of his shower. During an interview and observation on 11/17/23 at 5:15 PM, the MS revealed that resident showers should be safe and clean. Tiles were observed to be missing between the bathroom area and the shower area. The MS revealed that the tiles in Resident #16's bathroom can be replaced, and the shower can be cleaned due to the dirt buildup that was present. The MS reported that housekeepers should have told their supervisor about the condition if Resident #16's bathroom/shower and the HSK would have reported to the MS, as needed. During an interview on 11/17/23 at 5:30 PM, HSK revealed that Resident #16's shower had black dirt build up in the corners. HSK further revealed that this should have been reported to her in order to address this. HSK reported the importance of ensuring showers are clean was to create a homelike environment for the residents. During an interview on 11/17/23 at 6:26 PM, ADM reported the housekeepers should ensure that showers were functional and clean between usage. Record Review of the facility's policy Homelike Environment revealed 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455789 If continuation sheet Page 3 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455789 If continuation sheet Page 4 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 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 interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 7 residents (Resident #38) whose assessments were reviewed, in that: Residents Affected - Few Resident #38's quarterly MDS incorrectly documented the resident as receiving an anticoagulant medication. This failure could place residents at-risk for inadequate care due to an inaccurate assessments. The findings were: 1. Record review of Resident #38's face sheet, dated 11/15/2023, revealed an admission date of 07/08/2014 and, a readmission date of 05/08/2023 with diagnoses that included: Dementia(decline in cognitive abilities), Seizures (uncontrolled shaking movements), Hyperlipidemia(Elevated level of any or all lipids(fat) in the blood), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Hypertension (High blood pressure) and, Malformation of coronary vessels (Heart artery is in the wrong spot or it started in the wrong spot). Record review of Resident #38's Physician orders and Medication administration record for November 2023 revealed orders for: Clopidogrel Bisulfate (used to prevent heart attack and stroke) Tablet 75 MG Give 1 tablet by mouth one time a day. Record review of Resident #38's Medication Administration Record for the month of November 2023 revealed Resident #38 received Clopidogrel Bisulfate Tablet 75 MG everyday, as per order, between 11/01/2023 and 11/07/2023. Record review of Resident #38's Quarterly MDS, dated [DATE], revealed the assessment indicated Resident #38 received an anticoagulant. Record review of Resident #38's Physician orders and Medication administration record for August 2023 revealed orders for: Clopidogrel Bisulfate Tablet 75 MG Give 1 tablet by mouth one time a day. Record review of Resident #38's Quarterly MDS, dated [DATE], revealed the assessment indicated Resident #38 received an anticoagulant. During an interview with the MDS nurse on 11/17/23 at 4:30 p.m., the MDS nurse verbally confirmed she had completed the MDS. The MDS nurse confirmed Resident #38's quarterly MDS was coded as the resident having received an anticoagulant when Resident #38 had received Clopidogrel (an antiplatelet) . The MDS nurse revealed she did not know why she had coded Clopidogrel as an anticoagulant. She verbally confirmed Clopidogrel was an antiplatelet and should not have been coded as an anticoagulant. The MDS nurse revealed the RAI was used as reference for the MDS and she had access electronically to the RAI on her computer. Record review of, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual,Version 1.18.11, October 2023, revealed, N0415E1. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455789 If continuation sheet Page 5 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455789 If continuation sheet Page 6 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 32 residents (Residents #59) reviewed for accidents and hazards in that: The facility failed to ensure Residents #59 did not have 3 disposable razors in his rooms. This failure could place residents at risk of harm or injury and contribute to avoidable accidents. The findings were: Record review of Resident #59's admission record dated 11/17/23, revealed diagnosis including cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, epilepsy, major depressive disorder, hemorrhagic disorder due to extrinsic circulating anticoagulants, and muscle weakness. Record review of Resident #59's MDS, dated [DATE], revealed the residents cognition was intact and the resident required limited assistance with personal hygiene. During an observation on 11/14/23 at 2:29 p.m. a cup contained 3 disposable razors next to the sink in the residents room. During an interview on 11/14/23 at 3:49 p.m. CNA P stated resident #59 should not have disposable razors in his room. CNA P stated the resident did shave himself and she would watch him and dispose of the razor when he was done shaving. CNA P stated she was unsure who left the razors in the resident's room. During an interview on 11/17/23 at 3:19 p.m. the DON stated she was unsure if residents were allowed to keep disposable razors in their rooms. The DON stated she thought they were allowed to keep electric ones. During a follow up interview on 11/17/23 at 3:50 p.m. the DON stated resident #59 has a high BIMS score and was allowed and had the right to have his own items. The DON stated it was a risk to potentially harm or injure other residents in a nursing home who could wonder into the room. During an interview on 11/17/23 at 5:46 p.m. the Administrator stated residents have the right to have razors and they go in the sharps containers when they are done with them. The Administrator stated a resident can go to the store and purchase razors and if staff see them out, they can dispose of the razors. During a follow up interview on 11/17/23 at 6:02 p.m. the Administrator stated if a CNA sees a razor out they educate the resident on how to store it and if the resident continues to leave them out after education, they would take away the razors. The Administrator stated if a CNA is helping the resident they would dispose of the razor in the sharps container. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455789 If continuation sheet Page 7 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy titled Statement of resident right, dated 09/2017, revealed You have a right to [ .] (2) safe, decent and clean conditions Record review of the facility's policy title Shaving the Resident, dated 02/2018, stated Purpose: The purpose of this procedure is to promote cleanliness and to provide skin care .Steps in the Procedure .If using a safety razor or disposable razor .11. Dispose of the razor in a designated sharps container. Event ID: Facility ID: 455789 If continuation sheet Page 8 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 who need respiratory care were provided such care, consistent with professional standards of practice for 1 of 2 resident (Resident #63) reviewed for respiratory care. Residents Affected - Few Facility failed to clean and replace the filter for Resident #63's oxygen concentrator. This deficient practice could affect residents who receive oxygen therapy which could contribute to respiratory infections. The findings were: Record review of Resident #63's face sheet, dated 11/14/2023, revealed Resident #63 was admitted on [DATE] with an original admission date of 02/08/2019 with diagnoses which included: chronic obstructive pulmonary disease with (acute) exacerbation, acute bronchitis, generalized anxiety, acute respiratory failure with hypoxia, personal history of other disease of the respiratory system and dependence on supplemental oxygen. Record review of Resident #63's Quarterly MDS, dated [DATE], revealed Resident #63's BIMS score was 15 with intact cognition with section O Special Treatments, Procedures and Programs of the MDS noting Resident #63 received oxygen therapy while a resident. Record review of Resident #63's care plan with an initiated date of 03/23/2021 and a targeted date 12/24/2023, revealed Resident #63 had a Focus: [resident name] has oxygen therapy r/t COPD and Interventions: Clean Oxygen air filter and change oxygen tubing every Sunday. Record review of Resident #63's physician order summary report, dated, 11/16/2023, revealed an order for Clean Oxygen air filter and change Oxygen tubing every Sunday every night shift every Sun. Observation and interview on 11/14/2023 at 11:31 a.m. Resident #63's oxygen filter noted to have dust particles and white from lint like substance gathered on the filter. Resident #63 stated the nurse changed the tubing every Sunday, but he did not think there was a filter on the concentrator. Observation and interview on 11/16/2023 at 3:50 p.m. Resident #63 was in his bed with oxygen being used watching television with bed in lowest position. Observation revealed Resident #63's filter in the same condition as prior observation with dust particles and covered in white lint like substance having not been changed or cleaned. During the observation LVN G revealed he was not sure when the filters for the concentrators were changed and did not know the protocol. LVN G further stated he would have to probably have to get another concentrator for the resident. During an observation and interview on 11/16/2023 at 4:00 p.m. the ADM stated the filter looked like it needed to be cleaned. The ADM further stated he was not sure of the protocol regarding cleaning or changing the filter and he would get policy. During an observation and interview on 11/16/2023 beginning at 4:05 p.m. the LVN G returned to Resident #63's and stated he did not know how to change the filter and again stated he may have to get another one to replace it. The DON entered Resident #63's room checked the filter on the oxygen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455789 If continuation sheet Page 9 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few concentrator then stated it looked as if it was a washable filter and should be cleaned. The DON stated the filter to the oxygen concentrator was dirty with a lint like substance on it. The DON further stated she felt the filter should have been cleaned when the tubing was changed once a week and as needed, but she would need to review the protocol. During an interview on 11/17/2023 at 10:43 a.m. the ADM stated there was not a policy which address concentrators, however the facility followed the manufacture recommendations and provided recommendations. During an interview on 11/17/2023 at 6:12 p.m. the DON stated by not cleaning or changing the filter of the oxygen concentrator it could cause the machine to malfunction, affect the quality of the air received by the resident and would not provide clean air. Record review of oxygen manufacture recommendations, revealed, under Maintenance section 7.3 Cleaning the Cabinet Filter: Caution! Risk of Damage; To avoid damage to the internal components of the unit: -DO NOT operate the concentrator without the filter installed or with a dirty filter. 1. Remove the filter and clean as needed. Environmental conditions that may require more frequent inspection and cleaning of the filter include, but are not limited to: high dust, air pollutants, etc. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455789 If continuation sheet Page 10 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 3 of 3 residents (Resident #29, Resident #40, Resident #79) reviewed for dialysis in that: Residents Affected - Some The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Resident #29, #40, and #79. This deficient practice could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs. The findings were: Record review of Resident #29's face sheet, dated 11/17/23 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with type 2 diabetes mellites, hyperlipidemia (elevated cholesterol), and Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease (condition in which the kidneys cease functioning on a permanent basis). Record review of Resident #29's most recent admission MDS assessment, dated 10/27/23, revealed the resident cognition was intact for daily decision-making skills and required dialysis treatments. Record review of Resident #29's comprehensive care plan, revision date 11/03/23 revealed the resident needs hemodialysis related to end stage renal disease initiated on 08/05/23 with interventions Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis Monday, Wednesday, Friday. Record review of Resident #29's Order Summary Report, dated 10/26/23 revealed the following: - Resident receives Dialysis M,W,F . chair time is 11 am with order date of 09/25/23 and no end date. - Resident has dialysis MWF @ 1050am with an order date of 11/10/23 and no end date. - CHECK VITALS POST DIALYSIS every evening shift every Mon, Wed, Fri with an order date of 11/16/23 and no end date. - CHECK VITALS PRE DIAYLSIS every shift every Mon, Wed, Fri with an order date of 11/16/23 and no end date. Record review of Resident #29's Dialysis Communication Form, Resident Assessment and Observation Post-Dialysis revealed incomplete documentation by the facility for: no date listed, 09/06/23, 09/13/23, 10/11/23, 10/16/23, 10/18/23, 10/30/23, 11/08/23, 11/13/23, and 11/15/23. The Post-Dialysis section of the Dialysis Communication form for the aforementioned dates were blank. The post assessment area on the form was to be completed by facility nurse upon return to the facility, requested: Blood pressure, respirations, pulse, temperature, pain, assessment of the AV site (area accessed for dialysis treatment), bruit/thrill (an abnormal sound that can be heard through an artery caused by turbulent blood flow due to narrowing of the artery, a blood clot or aneurysm. Thrill is an abnormal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455789 If continuation sheet Page 11 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some feeling that can be felt when palpating an artery) presence, bleeding, a nurse's signature, date and time. Various forms were also blank in the section for the dialysis center to fill out the resident's vitals and other pertinent information during dialysis. Record review of Resident #40's face sheet, dated 11/17/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with type 2 diabetes mellites with hyperglycemia (high blood sugar), hyperlipidemia (elevated cholesterol), end stage renal disease (condition in which the kidneys cease functioning on a permanent basis), and dependence on renal dialysis. Record review of Resident #40's most recent admission MDS assessment, dated 10/30/23, revealed the resident was severely cognitively impaired for daily decision-making skills and did not indicate the resident required dialysis treatments. Record review of Resident #40's comprehensive care plan, revision date 05/02/23 revealed the resident needs hemodialysis related to renal failure initiated on 03/25/21 with interventions Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis Monday, Wednesday, Friday. Monitor AV shunt/fistula to site for thrill and bruit Q shift . Record review of Resident #40's Order Summary Report, dated 10/26/23 revealed the following: -Resident attends .dialysis clinic .Monday, Wednesday, and Friday chair time of 1030 with order date 11/10/23 and no end date. - CHECK VITALS POST DIALYSIS every evening shift every Mon, Wed, Fri with an order date of 11/16/23 and no end date. - CHECK VITALS PRE DIAYLSIS every shift every Mon, Wed, Fri with an order date of 11/16/23 and no end date. Record review of Resident #40's Dialysis Communication Form, Resident Assessment and Observation Post-Dialysis revealed incomplete documentation by the facility for: no date listed, 09/06/23, 09/13/23, 09/20/23, 09/29/23, 10/16/23, 10/25/23, 11/10/23, and 11/13/23. The post assessment area on the form was to be completed by facility nurse upon return to the facility, requested: Blood pressure, respirations, pulse, temperature, pain, assessment of the AV site (area accessed for dialysis treatment), bruit/thrill (an abnormal sound that can be heard through an artery caused by turbulent blood flow due to narrowing of the artery, a blood clot or aneurysm. Thrill is an abnormal feeling that can be felt when palpating an artery) presence, bleeding, a nurse's signature, date and time. Various forms were also blank in the section for the dialysis center to fill out the resident's vitals and other pertinent information during dialysis. Record review of Resident #79's face sheet, dated 11/17/23 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with type 1 diabetes mellites and chronic kidney disease. Record review of Resident #79's most recent admission MDS assessment, dated 09/18/23, revealed intact cognition for daily decision-making skills and indicated the resident required dialysis treatments. Record review of Resident #79's comprehensive care plan, revision date 11/10/23 revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455789 If continuation sheet Page 12 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Level of Harm - Minimal harm or potential for actual harm resident needs hemodialysis related to renal failure initiated on 04/17/23 with interventions to Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis Monday, Wednesday, Friday. Assess shunt for any redness, swelling or pain. Record review of Resident #79's Order Summary Report, dated 10/26/23 revealed the following: Residents Affected - Some -Renal Dialysis Monday, Wednesday, and Friday chair time 0530 with order date 07/05/23 and no end date. - CHECK VITALS POST DIALYSIS every evening shift every Mon, Wed, Fri with an order date of 11/16/23 and no end date. - CHECK VITALS PRE DIAYLSIS every shift every Mon, Wed, Fri with an order date of 11/16/23 and no end date. Record review of Resident #79's Dialysis Communication Form, Resident Assessment and Observation Post-Dialysis revealed incomplete documentation by the facility for: 10/16/23, 10/23/23, 10/27/23, 10/30/23, 11/06/23, 11/08/23, and 11/13/23. The post assessment area on the form was to be completed by facility nurse upon return to the facility, requested: Blood pressure, respirations, pulse, temperature, pain, assessment of the AV site (area accessed for dialysis treatment), bruit/thrill (an abnormal sound that can be heard through an artery caused by turbulent blood flow due to narrowing of the artery, a blood clot or aneurysm. Thrill is an abnormal feeling that can be felt when palpating an artery) presence, bleeding, a nurse's signature, date and time. Various forms were also blank in the section for the dialysis center to fill out the resident's vitals and other pertinent information during dialysis. During an interview on 11/16/23 at 1:50 p.m. the DON stated they already had a plan of correction started for the dialysis communication forms. The DON stated they were in contact with the dialysis facilities to fill out their portion of the communication form. The DON stated facility staff is expected to fill out the communication form prior to dialysis and upon return from dialysis. The DON stated one dialysis center stated they had began logging if they received a communication form with the residents upon arrival for dialysis. The DON stated she stated doing an in service on November 13th, 2023 and LVN O had already completed it. The DON stated she had not yet in serviced the night shift nurses. During an interview on 11/16/23 at 1:58 p.m. LVN O stated he looked at resident #29 upon return from dialysis to the facility on [DATE]. LVN O stated looking at the resident meant he took the residents vitals and assessed the resident but did not document the findings. Record review of a nursing progress note, created on 11/16/23 at 2:18 p.m., revealed an effective date of 11/15/23 at 2:45 p.m. and stated Resident arrived at approx. 1045, BP 141/68, P 74, R 18, T 97.6, 96% RA, pt. denies pain, pressure dressing to LUE at HD site, bruit is audible, thrill is palpable, resident is assisted to bed, is assessed for BM incont. episode, is then up to power chair. [Resident] then proceeds to sign self out d/t goes off property to go smoke . The note was created by LVN O. During a follow up interview on 11/17/23 at 9:19 a.m. The DON stated the facility did not have a dialysis policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455789 If continuation sheet Page 13 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of document titled Performance Improvement Plan Pre-Post Dialysis Communication, dated 11/13/23, stated Pre-Post Dialysis Communication to include pre-post dialysis weight, V/S and medications administered and treatment provided to include but not limited to fluid removed and duration of dialysis has been identified as an area of improvement. DON/designee to in-service nursing department on filling the dialysis communication form to include all of the above upon transfer to dialysis and upon returning to the facility. Document will be maintained as part of the medical record. Ongoing visual observation of compliance will be done daily on dialysis days by DON/designee and document will be made part of medical record. Failure to receive the communication document, DON will contact the DON of dialysis center to obtain information needed for compliance. The document was signed by LVN O. Event ID: Facility ID: 455789 If continuation sheet Page 14 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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 (lunch meal) observed for planned menus, in that: Residents Affected - Some 1. The facility failed to ensure all residents received roasted red potatoes with their lunch meal on 11/14/2023. 2. The facility failed to ensure carrot cake was served with their lunch meal on 11/14/2023. These failures could place residents at risk for dissatisfaction, poor intake, and diminished quality of life. The findings included: Record review of the facility's, Fall/Winter 2023, Week 1 Day 3, menu revealed Onion Sage Chicken, Roasted Red Potatoes, Spinach, and Carrot Cake w/Cream Cheese Frosting were to be served with the lunch meal on 11/14/2023. Record review of the November substitution log revealed that substitutions did not include mashed potatoes for roasted red potatoes and chocolate cake for carrot cake w/cream cheese frosting. 1. During an observation and interview on 11/14/23 at 12:47 PM in the 400-hall dining room, the LVN H revealed Resident #9 had a regular diet and had mashed potatoes instead of roasted red potatoes. When compared to Resident #228's lunch meal tray card (regular diet), the LVN H reported that Resident #9 should've received roasted red potatoes instead of mashed potatoes. During an interview on 11/14/23 at 1:40 PM, the DM stated the last few trays in the 400-hall received mashed potatoes instead of roasted red potatoes. The DM was unable to quantify how many trays that this affected. The DM further stated the kitchen sometimes ran out of food because they have about 18 people that had double portions for their meals. The DM revealed that the substitution log was not filled out for the month of November yet, so the mashed potato substitution was not documented and not signed by the RD. During an interview on 11/16/23 at 10:14 AM, [NAME] K revealed during 11/14/23 lunch, the kitchen ran out of roasted red potatoes at the end of lunch service and the kitchen switched to serving mashed potatoes in place of the roasted red potatoes. 2. Record review of the posted 11/14/23 lunch daily menu revealed that chocolate cake was served instead of carrot cake w/cream cheese frosting. During an interview on 11/14/23 at 1:40 PM, the DM reported that the kitchen was not able to serve chocolate cake because the kitchen did not have yellow cake mix. The DM revealed that the substitution log was not filled out for the month of November yet, so the carrot cake substitution was not documented and not signed by the RD. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455789 If continuation sheet Page 15 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/14/23 at 1:40 PM, the DM stated Resident #11's 11/14/23 lunch meal tray ticket revealed that Resident #11 did not like chocolate. During a combined interview on 11/17/23 at 4:58 PM, the DON and the ADM revealed that the tray aides and nurses should have checked tray tickets before meals get delivered to the residents. Residents Affected - Some Record review of the facility's policy titled, Standardized Recipes, revised April 2007, Standardized recipes shall be developed and used in the preparation of foods 2. Standardized recipes will be adjusted to the number of portions required for a meal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455789 If continuation sheet Page 16 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observations, interviews and record reviews failed to accommodate residents' food preferences for 1 of 8 (Resident #11) residents reviewed for food preferences, in that: Residents Affected - Few Resident #11's lunch meal tray on 11/14/23 did not follow her dislike of chocolate. This could affect all residents with food preferences and could result in a decrease in resident choices and diminished interest in meals. The Findings were: Record review and observation of Resident #11's 11/14/23 lunch meal revealed that Resident #11's tray ticket included a dislike of chocolate, but Resident #11 still received chocolate cake. During an observation and interview on 11/14/23 at 12:56 PM in the 300-hall dining room, the CMA J stated Resident #11's meal tray ticket said that Resident #11 disliked chocolate. CMA J revealed that Resident #11 received chocolate cake for 11/14/23 lunch. Resident #11 stated she did not like chocolate and was not going to eat the chocolate cake. During an interview on 11/14/23 at 1:40 PM, the DM stated Resident #11's 11/14/23 lunch meal tray ticket revealed that Resident #11 did not like chocolate. The DM stated that the kitchen staff made sure that the residents' meal preferences on their meal tray tickets were followed before being sent out to the residents. During a combined interview on 11/17/23 at 4:58 PM, the DON and the ADM revealed that the tray aides and nurses should have checked tray tickets before meals get delivered to the residents. Record review of the facility's policy titled, Food and Nutrition Service, revised October 2017, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident 1. The multidisciplinary staff, including nursing staff, the attending physician, and the dietitian will assess each resident' nutritional needs, food likes, dislikes, and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization . 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455789 If continuation sheet Page 17 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 kitchen sanitation, in that: 1. The facility failed to ensure dented cans were not in the dry storage room, on a rack: a. A pineapple tidbits can with a dent in the top corner of the can b. A Manwich original can with small dents in the can. 2. The facility failed to maintain the cleanliness of the ice maker found within the kitchen. 3. The facility failed to ensure that sanitizing buckets were not near containers of food. 4. The facility failed to ensure there were use-by dates in the freezers and refrigerators. 5. The facility failed to ensure a clear, plastic wrapped tuna sandwich, dated 11/12/23, was thrown away. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. During an observation and interview on 11/14/23 during the initial kitchen tour starting at 9:23 AM, a pineapple tidbit cans was dented in the top corner. The DM stated that because the dent was so small that it did not have to be in the section where dented cans are placed. It was observed that other cans that were in the dented can section also had small dents. A Manwich can was also dented and was not put in the dented can section. This can was on the row on top of the dented can section. The DM further revealed that if the can was able to be opened that it was okay to keep. The DM revealed that dented cans needed to be put to the side so that air didn't get where the dent is. Record review of the facility's Food Receiving and Storage policy, revised November 2022, revealed Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. 2. During an observation and interview on 11/14/23 during the initial kitchen tour starting at 9:23 AM, the ice machine had brown stains inside of the ice machine and a white substance inside of ice machine. The DM revealed the ice machine is cleaned once a month. The DM further revealed that the ice machine is old and has brown spots and called the white substance, hard water build-up. The DM wiped the brown stains and some of it was able to disappear. It was observed that the paper towel that was used to clean the ice machine had some brown color on it. Record review of the facility's Food Preparation and Service policy, revised November 2022, revealed all food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455789 If continuation sheet Page 18 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. 3 During an observation and interview on 11/14/23 during the initial kitchen tour starting at 9:23 AM, 2 sanitizing buckets were on the lower shelf in the food preparation area. The buckets were next to 2 closed containers of individually wrapped food products. The DM revealed that this was okay but then moved these 2 buckets away from the food products. Record Review of the facility's Poisonous and Toxic Materials policy, revised April 2007, revealed 1. Only poisonous and toxic materials that are required to maintain kitchen sanitation shall be permitted in the pot washing and dishwashing areas, but may not be stored or used in the presence of food. And 3. When not in use, poisonous and toxic materials will be stored on shelves that are used for no other purpose, or stored in a place outside the food storage, food preparation, and cleaned equipment and utensil storage areas. Record review of facility's Food Receiving and Storage policy, revised November 2022, revealed soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage and labeled clearly. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. 4. During observations and interviews on 11/14/23 during the initial kitchen tour starting at 9:23 AM and on 11/16/23 at 10:25 AM, all of the prepared food products that were observed, did not quanitfy, did not have a use by date on them. The DM pointed out that the dates on food products in the fridge are when the foods were made and use by dates were not necessary. The DM further revealed the kitchen staff know that the food products are thrown away 3 days after the date on the food products. Record review of the facility's Food Preparation and Service policy, revised November 2022, revealed All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). Record review of the facility's Refrigerator and Freezers policy, reveised November 2022, revealed, Use by dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food are observed and use by dates are indicated once food is opened. 5. During an observation and interview on 11/16/23 at 10:25 AM, there was a tuna sandwich wrapped in a plastic bag for snacks for the residents. It was dated 11/12/23. The DM stated this was when the sandwich was made, and it should have been thrown out 11/15/23. The DM threw this sandwich dated 11/12/23 away. The DM further revealed that the kitchen staff know to throw prepared foods 3 days after the date that is on the food products. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455789 If continuation sheet Page 19 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the facility's Food Preparation and Service policy, reivsed November 2022, revealed Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022 U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Event ID: Facility ID: 455789 If continuation sheet Page 20 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 maintain clinical records in accordance with accepted professional standards and practices that were accurately documented for 2 of 32 Residents (Resident #6 and Resident #79) reviewed for medical records, in that: 1. The facility failed to ensure Resident #6's medication administration was documented at the time it was administered. 2. The Facility failed to properly document Resident #79's return from dialysis assessment. This failures could place residents at risk for improper care due to inaccurate records. The findings were: 1. Record review of Resident #6's face sheet, dated 11/17/2023, revealed the resident was admitted [DATE] and readmitted on [DATE] with diagnoses that included: paraplegia, chronic pain, pressure ulcer of right buttock stage 2, pressure ulcer of left ankle stage 4, pressure ulcer of right hip stage 4, pressure ulcer of sacral region stage 4, and pressure ulcer of left hip stage 4. Record review of Resident #6's MDS assessment, dated 10/21/2023, revealed the resident's cognition was intact. Record review of Resident #6's care plan, dated 11/17/2023, revealed Resident is on pain medication therapy. Record review of Resident #6's physician orders, dated 11/15/2023, revealed Norco Oral Tablet 10-325 MG (Hydrocodone- Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for pain, with a start date of 03/13/2023 and no end date. Record review of a document titled Medication Admin Audit Report, dated 11/15/23, revealed LVN S documented on 11/15/2023 at 3:12 p.m. that she administered Norco Oral Tablet 10-325 MG (Hydrocodone- Acetaminophen) at 4:30 p.m. on 11/14/2023 the day before. 2. Record review of Resident #79's face sheet, dated 11/17/23 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with type 1 diabetes mellites and chronic kidney disease. Record review of Resident #79's most recent admission MDS assessment, dated 09/18/23, revealed intact cognition for daily decision-making skills and indicated the resident required dialysis treatments. Record review of Resident #79's comprehensive care plan, revision date 11/10/23 revealed the resident needs hemodialysis related to renal failure initiated on 04/17/23 with interventions to Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis Monday, Wednesday, Friday. Assess shunt for any redness, swelling or pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455789 If continuation sheet Page 21 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Record review of Resident #79's Order Summary Report, dated 10/26/23 revealed the following: Level of Harm - Minimal harm or potential for actual harm -Renal Dialysis Monday, Wednesday, and Friday chair time 0530 with order date 07/05/23 and no end date. Residents Affected - Some - CHECK VITALS POST DIALYSIS every evening shift every Mon, Wed, Fri with an order date of 11/16/23 and no end date. - CHECK VITALS PRE DIAYLSIS every shift every Mon, Wed, Fri with an order date of 11/16/23 and no end date. During an interview on 11/16/23 at 1:58 p.m. LVN O stated he looked at resident #29 upon return from dialysis to the facility on [DATE]. LVN O stated looking at the resident meant he took the residents vitals and assessed the resident but did not document the findings. Record review of a nursing progress note, created on 11/16/23 at 2:18 p.m., revealed an effective date of 11/15/23 at 2:45 p.m. and stated Resident arrived at approx. 1045, BP 141/68, P 74, R 18, T 97.6, 96% RA, pt. denies pain, pressure dressing to LUE at HD site, bruit is audible, thrill is palpable, resident is assisted to bed, is assessed for BM incont. episode, is then up to power chair. [Resident] then proceeds to sign self out d/t goes off property to go smoke . The note was created by LVN O. Record review of facility policy titled Administering Medications, dated 04/2019, stated Policy heading, Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation .23. As required or indicated for a medication, the individual administering the medication record in the resident's medical record: a. the date and time the medication was administered . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455789 If continuation sheet Page 22 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 4 units (unit 400) reviewed for infection control, in that: Residents Affected - Some 1. The biohazard room for Unit 400 was not kept locked. 2. Staff were not wearing droplet precautions PPE in hallway 200. These failures could place residents at-risk for infection due to improper care practices. The findings include: 1. Observation on 11/16/23 1:45 p.m. revealed the biohazard room on hall 400 was left open. The door had a keypad but the door was left unlocked. Closed boxes marked biohazard were seen in the room as well as closed trash barrels. On the outside of the door there were signs for biohazard and authorized staff only. Observation on 11/16/23 at 2:00 p.m. revealed multiple CNAs seen entering the biohazard room after keying the code on the keypad. This surveyor tried to open the door and the door was still unlocked. During an interview and observation on 11/16/2023 at 2:08 p.m., ADON E. after entering the code, opened the door and stated nobody could enter the biohazard room without the code. This surveyor asked the ADON to open the door without entering the code. The ADON was able to open the door without the code and stated he did not know it was broken but he was going to report it immediately because it needed to be locked. During an interview on 11/17/23 at 4:47 p.m. the Administrator and the DON verbally confirmed the biohazard room should have been locked. They verbally confirmed the staff was trained about infection control annually. Review of facility policy titled Medical Waste Storage, dated May 2012, revealed Access to medical wastes storage areas are limited to facility personnel. 2. During an observation on 11/14/23 at 4:23 p.m. two double door were closed to a hallway and contained a sign that read Stop HOT ZONE PLEASE SEE NURSE BEFORE ENTERING. Another sign on the same door stated STOP DROPLET PRECAUTIONS EVRYONE MUST: clean their hands, including before entering and when leaving the room. Make sure their eyes, nose, and mouth are fully covered before room entry. Remove face protection before room exit. Two other signs showed how to put on PPE and how to remove PPE. A storage cart was located in the hallway outside the doors with PPE. Maintenance worker Q went through the double door into the hot zone with only an N95 mask on. During an observation on 11/14/23 at 4:33 p.m. A resident in the hot zone was heard yelling and banging. His call light was observed on since this surveyor entered the locked unit at 4:14 p.m. CNA R was observed putting on PPE to enter the hot zone. CNA R put on a gown, had on an N95 mask, and gloves. CNA R did not have on any eyewear. LVN S later came to help CNA R with the resident on the hot (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455789 If continuation sheet Page 23 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some unit. LVN S put on a gown, had on an N95 mask, and gloves. LVN S did not have on any eyewear. CNA R was observed touching and trying to help the resident off the floor. LVN S was observed entering the resident room on the hot zone to help with the resident on the floor. During an interview on 11/14/23 at 4:23 p.m. Maintenance worker Q stated from his understanding it was discretionary if he needed to put on all the PPE including a gown and eyewear. Maintenance worker Q stated he had no contact wit COVID positive residents behind the double doors and if he went into a resident room, he would put on full PPE. During an interview on 11/15/23 at 2:30 p.m. the DON stated the facility had a designated COVID unit. The DON stated they had a plastic bin outside the units double doors where staff was expected to put on gown, gloves, N95 mask, and a face shield for droplet precautions before going through the double doors onto the unit. The DON stated anyone like a maintenance worker or a doctor needed to put on full PPE before going on the unit. The DON stated it was not at the discretion of the staff if they wanted to put on full PPE. During an interview on 11/17/23 at 3:29 p.m. LVN S stated staff should wear a gown, googles or shield and shoe and hair covers are optional. LVN S stated on 11/14/23 she ran to help CNA R with the resident on the floor and forgot to put on her face shield. LVN S stated she forgot because of the urgency of the situation. LVN S stated the purpose of using eye protection is to protect yourself from droplets. During an interview on 11/17/23 at 3:36 p.m. CNA R on 11/14/23 she did have on eye ware that looked like glasses when she entered the COVID unit. CNA R stated she keeps the glasses in her locker. CNA R stated she did not have them currently because one on was in the COVID unit now and did not need to bring them to work. CNA R stated the purpose of the eye ware was to keep your eye covered and prevent you from getting the virus. Record review of a document titled COVID-19 Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 05/08/23, stated .2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection .Personal Protective Equipment Health Care Professionals who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH approved respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455789 If continuation sheet Page 24 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside, for 1 of 8 Residents (Resident #64) reviewed for the ability to call for staff, in that: Residents Affected - Some The facility failed to ensure that Resident #64 had a functional call light system. This failure could place residents at risk for injury and diminished self-esteem, due to the inability to call for assistance. The findings included: A record review of Resident #64's electronic face sheet, dated 11/14/23, revealed an admission date of 4/28/23, re-admitted [DATE], with diagnoses which included difficulty in walking, lack of coordination, and mild cognitive impairment. A record review of Resident #64's care plan revealed focus of [Resident #64] is high risk for falls r/t mild cognitive impairment with intervention Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Focus of Mrs. [NAME] has had an actual unwitnessed fall with no injury with intervention of Encourage pt to use call light for help. A record review of Resident #64's quarterly MDS assessment, dated 10/23/23, revealed Resident #64 had a BIMS score of 15, cognitively intact. Resident #64 needs set up or clean-up assistance for toileting hygiene. Resident #64 needs supervision or touching assistance for toilet transfer. During an observation and interview on 11/14/23 at 2:34 PM, Resident #64 needed help turning on the television (TV). Resident revealed not having a remote and pressed the call light to get help from staff. Resident revealed that the staff had not responded to her call light in the past, and the staff may not respond to this call light now. No staff appeared to answer the call light. Resident pressed the call light for a second time on 11/14/23 at 2:48 PM. It was observed that the light in the hallway that was triggered by the resident's call light was not turning on, revealing the call light was not turning working properly. During an observation and interview on 11/14/23 at 2:52 PM, LVN O checked to see if Resident #64's call light was working, revealing that Resident #64's call light was not working. LVN O further revealed that Resident #64 needed a functioning call light due to Resident #64 being a fall risk. During an interview on 11/14/23 starting at 6:26 PM, the ADM revealed that every shift call lights were to be checked that they functioned and that they were within reach of the residents to ensure the safety of the residents. A record review of facility's policy, Call System, Resident, dated September 2022, revealed 1. Each resident is provided with a means to call staff directly for assistance from his/her bed .3. The resident call system remains functional at all times . 5. The resident call system is routinely maintained and tested by the maintenance department. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455789 If continuation sheet Page 25 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 A record review of facility's policy, Answering the Call Light, revised September 2022, revealed 4. Be sure that the call light is plugged in and functioning at all times. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455789 If continuation sheet Page 26 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 1 of 4 units (unit 400) observed for environment, in that: 1. The facility failed to ensure potential hazards were locked up and kept out of resident rooms. This deficient practice could place residents at risk of a diminished quality of life due to an unsafe environment. The findings included: Review of Resident #231's face sheet dated 11/17/2023, revealed an admission date of 11/02/2023 with diagnostics which included: Cerebral ischemia (Insufficient blood flow to the brain), Type 2 diabetes mellitus (high level of sugar in the blood) , Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Aphasia (difficulty with language), and Hypertension (High Blood pressure). Review of Resident #231's admission MDS assessment dated [DATE], revealed Resident #231 had memory problem and was severely impaired. She was non verbal. Review of Resident #231's care plan dated 11/04/2023 revealed the resident was depedent of the staff for her acitivities of daily living. Observation on 11/14/2023 at 11:15 a.m. revealed a container of sani cloth (disinfecting wipes) on top of the sink counter in Resident's 231's room. The container had a hazard statement causes eye irritation. During an interview on 11/14/2023 at 11:21 a.m. with CNA F, the CNA verbally confirmed the sani cloth container should not have been left in the room. she did not know why it was left in the room and was going to give it to the nurse. During an interview on 11/17/2023 at 4:47 p.m. with the DON and the Administrator, they verbally confirmed the disinfecting wipes should not have been kept in a resident's room. They verbally confirmed the disinfecting wipes should have been kept under lock. The DON revealed the facility had no policy addressing hazardous items storage. Review of the facility policy titled Statement of resident right, dated 09/2017, revealed You have a right to [ .] (2) safe, decent and clean conditions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455789 If continuation sheet Page 27 of 27