Inspection·November 20, 2025

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Swallowing/Nutritional Status indicated she held food in her mouth and/or cheeks and had residual food in her mouth after meals. Her diet orders revealed she received a mechanically altered regular diet with pureed texture, mildly thick liquids, with fortified cereal at breakfast and sugar free nutritional shakes at every meal. She received 51% or more of her nutrition through tube feeding and received 501cc or more of her daily fluid intake through tube feeding.Record review of Resident #1's revised Care Plan dated 08/28/2025 indicated she was receiving hospice services related to Parkinson's Disease, COPD and Gastronomy Status with problem conditions of coughing and vomiting. Record review of Resident #1's revised care plan dated 08/28/2025 also reflected a focus of nutritional problems related to Parkinson's Disease, low vision and dysphagia with a goal of not developing complications related to obesity, including skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, and impaired mobility. Interventions were medications as ordered, monitoring/documenting/reporting to doctor signs and symptoms of dysphagia (holding food in mouth, several attempts at swallowing, coughing, pocketing food, and choking), nutritional supplements as ordered, resident needs assistance with all meals, RD to evaluate and make diet changes and weights as ordered. Resident #1 had a focus of potential for fluid deficit related to nutrition/hydration via tube feeding with a goal to be free from symptoms of dehydration and maintain moist mucous membranes and good skin turgor. Interventions were encourage resident to drink fluids of choice and monitor/document/report to MD signs and symptoms of dehydration, decreased or no urinary output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tone, new onset confusion, dizziness on standing/sitting, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, and dry/sunken eyes. Record review of Resident #1's revised Care Plan dated 08/28/2025 indicated she had a focus of requires tube feeding related to swallowing problems with a goal of free of aspiration through the review date of 12/19/2025, g-tube insertion site free of signs and symptoms of infection through the review date of 12/19/2025 and maintain adequate nutritional and hydration status, weight stability and no signs or symptoms of malnutrition or dehydration through the review date of 12/19/2025. Interventions were to change tube feed administration set/bag every 24 hours, check placement of feeding tube before administration of meds and/or fluids every shift, enteral feed order of Jevity 1.5 as a substitute for Glucerna, if not available. Enteral Feed Order every shift-inspect surrounding skin of stoma (a surgical opening in the abdomen through which liquid nutrients and medications can be delivered into the stomach) for redness, tenderness, swelling, irritation, ulceration, purulent (foul odor) drainage or signs of infection, observe for signs of intolerance, i.e., diarrhea, nausea/vomiting, constipation, abdominal distention/cramping, dehydration, fluid overload, aspiration, increased gastric residual or hypo/hyperglycemia (low blood sugar/high blood sugar), check tube for proper placement by visual inspection of aspirated (vomited) stomach contents before administering medication, initiating a feeding or when there is an interruption of feeding, or at least every shift for continuous feeding, elevate head of bed 30-45degrees during feeding and at least an hour after feeding to prevent aspiration/pneumonia and flush with 125ml water before and after meds and feedings. Record review of Resident #1's revised Care Plan dated 08/28/2025 revealed additional interventions were added on 09/30/2025 for bolus (concentrated volume of liquid nutrition administered directly into the stomach, over a short period of time through a feeding tube) feeding twice per day with Glucerna per g-tube via bolus at a rate of 325ml per feeding, 2 times per day, to provide 1000 calories per 24 hours. Resident #1 was on enhanced barrier precautions related to indwelling catheter and tube feeding/g-tube site.Record review of grievances filed against the facility revealed an unnamed physical therapy assistant filed a grievance on 08/29/2025 related to Resident #1's diet. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675002 If continuation sheet Page 2 of 4 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 675002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Antonio West Nursing and Rehabilitation 636 Cupples Rd San Antonio, TX 78237 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few grievance alleged an unnamed speech therapist had repositioned the resident for meal intake. It was reported Resident #1's tray contained chicken and rice which fell out of compliance with the pureed diet order. The grievance alleged chicken, and rice would require chewing and swallowing by Resident #1 in a way she was unable to perform. The grievance reflected an unnamed LVN, and the DM were notified. The grievance indicated the DM stated he would follow up with kitchen staff.An observation of Resident #1 on 10/01/2025 at 8:49AM revealed a breakfast tray of food on her over-the-bed table which consisted of regular texture scrambled eggs, refried beans, bread, juice, milk and water. There was also a bowl of hot cereal. Resident #1 was asleep with her call light clipped to her blanket. The meal ticket on her tray reflected she was to receive a pureed diet with thin (nectar) consistency liquids.An interview with CNA D on 10/01/2025 at 8:55AM reflected Resident #1 ate regular textured foods on a daily basis. She stated the resident received most of her nutrition through her tube feeding but received a pleasure feeding tray at every meal. She stated Resident #1 required assistance to eat and was unable to hold an eating utensil by herself. She stated Resident #1 was not currently receiving prompting or assistance to eat because she was asleep.An interview with the DM, DC and DA on 10/01/2025 at 10:34AM revealed Resident #1 had a diet order of regular diet, pureed texture with mildly thick (nectar consistency) liquids. The DM stated he was unsure why Resident #1 received regular textured foods at breakfast. The DM stated the DC and DA needed to answer as to why Resident #1 was served a regular texture tray of food. The DC and DA stated Resident #1 was receiving pureed texture foods on a pleasure tray at every meal. Neither were sure if there was an order in Resident #1's chart from a dietitian or doctor for the pleasure tray. The DM stated Resident #1 had received a pleasure tray every day since her admission and he had not heard of any issues with her receiving the tray. The DA stated the negative outcome of Resident #1 receiving improperly textured foods was choking and possible aspiration. The DC stated she would personally ensure Resident #1's food trays were being given in the prescribed texture. The DA stated he would ensure the food on all trays served to residents matched the diet orders on the tray ticket. The DM stated he would in-service all kitchen staff regarding dietary restrictions, therapeutic diets and appropriate textures.An interview with LVN B on 10/01/2025 at 1:28PM revealed Resident #1 received a pleasure tray at every meal. She stated Resident #1 received bolus feedings twice per day which provided 1000 calories from Glucerna. The bolus feedings took place at 9AM and 5PM and Resident #1 did not require supervision to eat the pleasure tray.An interview with the HN on 10/01/2025 at 1:42PM revealed Resident #1 had an irreversible nutritional deficit and would continue to lose weight. She stated Resident #1 was unable to sit upright by herself and should not be receiving pleasure trays with no supervision. She stated she had discussions with the DON multiple times regarding the pleasure trays, and nothing had been done to prevent Resident #1 from receiving them. The HN stated she had discussed the bolus feedings and pleasure trays with the RD several times. She stated the RD ignored the feeding orders, because she was trying to maintain Resident #1's weight and would not recognize the irreversible nutritional deficit that Resident #1 was experiencing, due to her declining health. An interview with the RD on 10/01/2025 at 2:18PM revealed Resident #1 had been on continuous feeding via G-tube with pleasure feedings three times a day, until last week. She stated Resident #1 was receiving continuous feeding due to consuming less than 25% of her pureed meals. She stated she was not aware of a physician's order for pleasure feedings; it was provided to the resident as a courtesy. She stated the regular textured foods observed on Resident #1's breakfast tray were not of worry to her, as they were all soft and did not require much chewing. She stated, I don't worry about eggs as much as I would a steak when it comes to aspiration issues. The RD stated it was a constant back-and-forth with the HN and family (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675002 If continuation sheet Page 3 of 4 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 675002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Antonio West Nursing and Rehabilitation 636 Cupples Rd San Antonio, TX 78237 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete regarding dietary orders. The family would bring regular textured candy and muffins to Resident #1, and the HN had given bolus feeding orders, so it was a battle to keep the feeding orders straight and keep everyone safe and happy.A phone interview with Resident #1's RR on 10/01/2025 at 2:40PM reflected the overall care of Resident #1 had been fair at the facility. She stated Resident #1 had not been eating solid foods for some time due to not wearing her dentures any longer. She stated the dining staff were forgetful and didn't follow the tray slips at every meal. The RR stated Resident #1 had never been denied food, but the staff seemed to forget she had a swallowing problem and would cough and vomit when fed solid foods. She stated staff did not help Resident #1 eat even though she could not sit upright on her own and was probably too weak to hold a utensil. The RR stated Resident #1 used to throw up a lot, so a swallow study was performed, and her diet was changed to pureed texture. The RR stated Resident #1 probably could have eaten the scrambled eggs with her hands this morning and would have been fine, but she had to have supervision at all times while eating.An interview with RN A on 10/01/2025 at 4:00PM reflected Resident #1 did not wear her dentures any longer and she should not have received any regular textured foods. He stated he was unaware of pleasure trays for Resident #1 and stated she could have eaten some finger foods on her own but needed assistance with any utensils due to being so weak and unable to sit upright on her own. An interview with LVN C on 10/01/2025 at 4:14PM reflected Resident #1 should not have received any regular textured foods due to her bolus feedings, twice per day. She stated Resident #1 could not feed herself due to weakness and decline in health. LVN C stated Resident #1 received hospice services and should receive only bolus feedings, according to the hospice orders.An interview with the Administrator on 10/01/2025 at 4:20PM revealed the facility had no policy regarding therapeutic diets. She stated she was unaware Resident #1 was receiving a pleasure tray at every meal. Record review of facility policy entitled Serving a Meal dated 05/15/2025 reflected the following:Diets should be served in accordance with physician orders. Residents should be encouraged to eat in the dining room, however, requests to remain in the room should be honored. Prepare the room or serving area for mealtimes (decreased noise levels, adequate lighting, position comfortably) and make sure hands and face are clean. Place the tray on the dining table or overbed table if the resident eats in their room. Remove dome lid from the tray and check to be sure everything is included on the meal tray that is required by the diet card, and the resident's preference. Arrange the dishes and silverware so the resident can reach them easily. It is often helpful to place a clean towel on the overbed tray prior to placing food, to prevent slippage of dishes and silverware. Open all cartons and give the napkin to the resident. Use clothing protectors as needed. Cut up meats and assist the resident as needed. Use adaptive utensils, when appropriate. Ensure the resident has everything they need before leaving the room. Check on the resident at regular intervals. Provide privacy by pulling the cubicle curtain, if desired by the resident. Place call light within reach if you are leaving the room. Residents are encouraged to feed themselves to the extent possible, and to consume all foods. Alternative foods, readily available foods, or supplements should be offered in accordance with diet restrictions, when a resident consumes less than half of the meal. Provide adequate time for resident to consume the meal and offer to reheat foods as needed. Use thickened liquids as provided by the dietary department. Event ID: Facility ID: 675002 If continuation sheet Page 4 of 4