Inspection·February 23, 2024

F 0563 Record review of facility policy dated 12/2023, titled Visitation, reflected The facility provides 24-hour access to all individuals visiting with the consent of the resident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675138 If continuation sheet Page 2 of 11 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 675138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inspiration Hills Rehabilitation Center 1939 Bandera Rd San Antonio, TX 78228 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Residents #17) reviewed for care plans. The facility failed to care plan Resident #17's use of Clopidogrel 75 mg (blood thinner). This failures could have placed residents at risk of not having their needs met. Record review of Resident #17's face sheet dated 2/21/2024 revealed a [AGE] year-old female admitted to the facility on [DATE] with the diagnosis that included: Alzheimer's disease (is a brain disorder that slowly destroys memory and thinking skills). Hepatitis C( is an inflammation of the liver caused by the hepatitis C virus.) Right hemiplegia( indicates paralysis on the right side of the body). Record review of Resident's # 17's Quarterly MDS Assessment , dated 2/21/2024, revealed a BIMS score of 12, which indicated moderate impaired cognition. Record review of Rresident 17's the Order Summary Report dated February 21, 2024, revealed the order Clopidogrel 75 mg, administer one tablet by mouth daily for hypertension. Record review of Care Plan, dated February 2024, did not reveal a care plan addressing use of medication Clopidogrel. In an Interview with the MDS Coord. on 2/22/2024 at 115 PM, she stated that clopidogrel was a blood thinner and not used for hypertension; She believes the original admitting nurse must have made a transcriber error when the resident was originally admitted in 2020, and no one had caught it. The MDS nurse added that the facility follows an interdisciplinary approach to care plans and the medication clopidogrel should be care planned. So the nursing team is on the same page in regard to resident's needs. In an interview with the DON on 2/23/2024 at 210 p.m., The DON stated that by the care plan not being updated on Resident # 17 to reflect that the Resident was on clopidogrel, a blood thinner, she risked not all team members being aware of the resident's needs. She added she was unaware that the care plan for Clopidogrel was not available but would ensure it was corrected. Record review of facility policy titled Care Planning Comprehensive, dated December 2023, revealed, Care Plan must reflect current recognized standards of practice for problem areas and condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675138 If continuation sheet Page 3 of 11 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 675138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inspiration Hills Rehabilitation Center 1939 Bandera Rd San Antonio, TX 78228 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents are free of any significant medication errors for 1 of 3 residents (Resident #63) reviewed for medication administration, in that: Residents Affected - Few The facility failed to prevent Resident #63 from being provided Midodrine, a medication designed to raise a person's blood pressure, while Resident #63 was assessed with blood pressure higher than the physician recommended parameters for providing the medication. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: Record review of Resident #63's face sheet dated 2/23/2024 reflected a [AGE] year-old resident with an initial admission date of 1/01/2024 and diagnoses including major depressive disorder, and seizures. Record review of Resident #63's most recent MDS assessment, dated 1/08/2024, reflected a resident with a BIMS summary score of 15 , indicative of intact cognition. Record review of Resident #63's Order Summary Report, dated 2/23/2024, reflected an order that read Midodrine HCl Oral Tablet 5 MG (Midodrine HCl) Give 1 tablet by mouth three times a day for hypotension [low blood pressure] hold for SBP> [greater than]120, [indicating to nursing staff that the resident should not receive the Midodrine if their systolic blood pressure was above 120]. Record review of Resident #63's Medication Administration Record, dated 2/23/2024, reflected that of the 64 times the resident was scheduled to be administered midodrine, 23 doses were administered out of physician parameters with Resident #63's systolic blood pressure being over 120: 1/06/2024 at 1:00 PM when Resident #63's systolic blood pressure was 129 administered by MA F; 1/12/2024 at 5:00 PM when Resident #63's systolic blood pressure was 148 administered by MA A; 1/20/2024 at 5:00 PM when Resident #63's systolic blood pressure was 128 administered by MA G; 1/29/2024 at 5:00 PM when Resident #63's systolic blood pressure was 131 administered by MA H ; 2/02/2024 at 9:00 AM when Resident #63's systolic blood pressure was 121 administered by LVN I; 2/03/2024 at 9:00 AM when Resident #63's systolic blood pressure was 135 administered by MA F; 2/03/2024 at 5:00 PM when Resident #63's systolic blood pressure was 146 administered by LVN J; 2/04/2024 at 9:00 AM when Resident #63's systolic blood pressure was 133 administered by MA G; 2/04/2024 at 1:00 PM when Resident #63's systolic blood pressure was 133 administered by MA G; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675138 If continuation sheet Page 4 of 11 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 675138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inspiration Hills Rehabilitation Center 1939 Bandera Rd San Antonio, TX 78228 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 0760 2/04/2024 at 5:00 PM when Resident #63's systolic blood pressure was 146 administered by MA G; Level of Harm - Minimal harm or potential for actual harm 2/06/2024 at 9:00 AM when Resident #63's systolic blood pressure was 133 administered by MA A; 2/08/2024 at 1:00 PM when Resident #63's systolic blood pressure was 127 administered by MA A; Residents Affected - Few 2/10/2024 at 9:00 AM when Resident #63's systolic blood pressure was 124 administered by MA G; 2/10/2024 at 1:00 PM when Resident #63's systolic blood pressure was 124 administered by MA G; 2/11/2024 at 9:00 AM when Resident #63's systolic blood pressure was 128 administered by MA G; 2/11/2024 at 1:00 PM when Resident #63's systolic blood pressure was 124 administered by MA G; 2/13/2024 at 9:00 AM when Resident #63's systolic blood pressure was 121 administered by MA A; 2/13/2024 at 1:00 PM when Resident #63's systolic blood pressure was 121 administered by MA A; 2/15/2024 at 9:00 AM when Resident #63's systolic blood pressure was 121 administered by MA A; 2/15/2024 at 1:00 PM when Resident #63's systolic blood pressure was 121 administered by MA A; 2/20/2024 at 9:00 AM when Resident #63's systolic blood pressure was 125 administered by MA A; 2/20/2024 at 1:00 PM when Resident #63's systolic blood pressure was 125 administered by MA A; 2/20/2024 at 5:00 PM when Resident #63's systolic blood pressure was 125 administered by MA A; Interview on 2/23/2024 at 2:34 PM, MA A stated she was not sure how the midodrine could have been given to Resident #63 out of parameters, and stated it was likely incorrect documentation of blood pressure due to keys on their keyboard sticking. MA A stated a risk to the resident for the medication being given out of parameters was that the resident could go to the hospital. Interview on 2/22/2024 at 5:00 PM in a group interview with the DON present, the Administrator stated that their expectation was for medications to be administered as ordered by the physician. Record review of facility policy, undated, titled Medication and Treatment Orders, reflected, Orders for medications and treatments will be consistent with principles of safe and effective order writing. Review of Lippincott procedures, Oral Drug Administration, revised 5/19/2022, accessed 11/27/2023, from: https://procedures.lww.com/lnp/view.do?pId=4420477, revealed, under the subheading Special Considerations, Assess parameters, such as blood pressure and pulse, as necessary before administering a medication with dose-holding parameters. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675138 If continuation sheet Page 5 of 11 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 675138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inspiration Hills Rehabilitation Center 1939 Bandera Rd San Antonio, TX 78228 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. 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 provide or obtain laboratory services, to meet the needs of its residents for 2 of 12 residents (Resident #32 and #60) reviewed for laboratory services, in that: Residents Affected - Few 1.) The facility failed to obtain the ordered labs for Resident #32 on 11/23/2023 in a timely manner. 2.) The facility failed to obtain the ordered lab for Resident #60 on 11/22/2023 in a timely manner. This failure could place residents at risk of not receiving timely diagnosis and treatment, and not receiving appropriate monitoring for health and well-being. Findings included: 1.) Record review of the admission Record printed 2/23/2024, revealed Resident #32 was an [AGE] year-old female originally admitted on [DATE] with an admitting diagnosis of chronic kidney disease, stage 4. Record review of the quarterly MDS assessment dated [DATE], revealed Resident #32 had a BIMS summary score of 6, indicative of severe cognitive impairment. Resident #32 was coded as moderate assistance [helper does more than half the effort] related to toileting. Resident #32 was documented as occasionally incontinent of both bowel and bladder. Active diagnoses included renal [kidney] insufficiency, renal failure, or end stage renal disease. Record review of Resident #32's Care Plan dated 10/19/2023, revealed a focus area of antibiotic therapy related to UTI as of 12/31/2023; with the following associated interventions: administer medications as ordered; report pertinent lab results to MD (revised 1/04/2024). Record review of Order Details revealed Resident #32 had a physician's order for a routine collection of urine to rule out UTI dated 11/23/2023 at 12:40 PM. Record review of the Progress Note for Resident #32 dated 11/29/2023 at 8:30 AM, authored by the MD, revealed, Resident #32 had some confusion, pending UA, and was status post fall. Record review of the Progress Note for Resident #32, authored by the NP dated 12/04/2024 at 9:00 AM, revealed: UA still pending for AMS . rounded with RN. Record review of the 24-Hour Report/Change of Condition Report dated 12/01/2023 revealed Resident #32 threw away UA. Review of the 24-Hour Report/Change of Condition Report dated 12/05/2023 revealed Resident #32 continues to throw away urine. No entries for any other dates for Resident #32 found. Record review of the final Laboratory Report revealed the sample for Resident #32 was collected on [Wednesday] 12/06/2023 which was 13 days after the original laboratory ordered date. The report indicated the sample was high for E. coli bacteria. 2.) Record review of the admission Record printed 2/23/2024, revealed Resident #60 was an [AGE] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675138 If continuation sheet Page 6 of 11 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 675138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inspiration Hills Rehabilitation Center 1939 Bandera Rd San Antonio, TX 78228 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 0770 year-old female originally admitted on [DATE]. Level of Harm - Minimal harm or potential for actual harm Record review of the quarterly MDS assessment dated [DATE], revealed Resident #60 had short- and long-term memory problems and disorganized thinking. Resident #60 was coded as supervision or touching assistance [helper provides verbal cues and/or touching/steadying and/or contact guard assistance] related to toileting. Resident #60 was documented as occasionally incontinent of both bowel and bladder. Active diagnoses included lack of coordination. Residents Affected - Few Record review of Resident #60's Care Plan printed 2/21/2024, revealed a focus area of ADL Self Care Performance Deficit, with a date initiated of 3/30/2023, revision on 1/15/2024; with the following associated interventions: require supervision with stand by assistance of 1 staff participation to use the toilet, initiated 3/30/2023. Care Plan did not address urinary tract infection. Record review of Order Details revealed Resident #60 had a physician's order for a routine collection of urine to rule out UTI dated 11/22/2023 at 1:29 PM. Record review of the Lab Results Report revealed the sample for Resident #60 was collected on [Monday] 11/27/2023 which was 5 days after the original laboratory ordered date. Report included: Originally Reported on [Tuesday] 11/28/2023 at 6:51 PM. The report indicated the sample was high for E. coli bacteria. Record review of progress note dated 11/29/2023 at 8:50 AM, authored by the MD, revealed, Resident #60 had positive urinalysis for E. coli and was stable after a mechanical fall with no signs of injury; at baseline; continue to monitor. Record review of Order Details revealed Resident #60 had a physician's order for nitrofurantoin [Macrobid] for urinary tract infection with an order date of 11/29/2023 at 10:03 AM, which was 7 days after the original laboratory order date. In an interview on 2/21/2024 at 5:16 PM, the DON stated the lab company the facility used would pick up the sample by the end of the next day after the order was written between Sundays through Thursdays. The DON stated when a physician ordered a routine lab the expectation was for it to be collected by the end of the next day. The DON stated on weekends, the staff were trained to enter the orders as a STAT [immediate] order, and collect the sample as soon as possible, and the lab company would pick up the sample the same day, within a few hours. The DON stated she would have to look into the reason why Resident #32's sample was not collected by the end of the next day after it was ordered. The DON stated a delay in collecting the sample could result in a delay in the physician being able to appropriately treat a potential illness. In an interview on 2/21/2023 at 5:46 PM, the ADON A stated Resident #32 had dementia, was independently toileting and ambulatory. ADON A stated Resident #32 would empty the collection hat of urine in the toilet despite repeated attempts at education and reminders. ADON A stated collecting the sample for Resident #32 was discussed at each shift change. ADON A stated it was luck that we were able to eventually able to collect the sample before Resident #32 dumped the collection hat of urine into the toilet. In an interview on 2/23/2024 at 11:44 AM, with the MDS Coord. present, ADON A stated, Residents #32 and #60 were both ambulatory and independent with toileting and would dump out the collection hat of urine into the toilet as both were easily confused and would not follow instructions or remember (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675138 If continuation sheet Page 7 of 11 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 675138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inspiration Hills Rehabilitation Center 1939 Bandera Rd San Antonio, TX 78228 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 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that staff had told them the nurses needed the urine. ADON A stated both Resident #32 and #60 would not be candidates for alternative collection methods such as straight catheterization. ADON A stated Resident #60 was also frequently combative during the provision of care and would not have submitted to an alternative testing method. Review of Lab and Diagnostic Test Results - Clinical Protocol, reviewed December 2023, revealed under the heading Assessment and Recognition: physician will identify, and order lab testing based on diagnostic and monitoring needs; staff will process test requisitions and arrange for test; testing source will report test results to the facility. Under the heading Deciding How Urgently to Contact the Physician: nurse will identify the urgency of communicating with the attending physician based on physician request, the seriousness of the abnormality, and the individuals current condition; should proceed as though the tests were ordered to assess the condition change or a recent onset of signs and symptoms. Under the heading Physician Responses: physicians will respond within an appropriate time frame . By end of next office day to a non-emergency message regarding a non-immediate lab test notification (for example, by late Wednesday afternoon for a call made on Tuesday). When necessary to help explain clinical decisions, a physician or mid-level practitioner should document the basis for conclusions about how the results were addressed. Review of Lippincott procedures, Urine Specimen Collection, Random, revised 12/10/2023, accessed 2/27/2024, from https://procedures.lww.com/lnp/view.do?pId=4419392&hits=urinalysis&a=true&ad=false&q=urinalysis revealed under the heading Introduction, Urine specimen allows screening for urinary and systemic disorders; a first-voided morning specimen should be used, if possible. Under the heading Implementation, review the practitioner's order; explain the procedure .according to their individual communication and learning needs to increase their understanding .and enhance cooperation.; instruct an ambulatory patient to void into .collection hat .send it immediately to the laboratory; document the procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675138 If continuation sheet Page 8 of 11 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 675138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inspiration Hills Rehabilitation Center 1939 Bandera Rd San Antonio, TX 78228 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide or obtain laboratory services ordered by physician assistant, nurse practitioner or clinical nurse specialist in accordance with state law, including scope of practice laws, to meet the needs of its residents for 1 of 12 residents (Resident #32) reviewed for laboratory services, in that: The facility failed to report laboratory results received on 12/08/2023 for Resident #32 in a timely manner to the physician. This failure could place residents at risk of not receiving timely diagnosis and treatment, and not receiving appropriate monitoring for health and well-being. Findings included: 1.) Record review of the admission Record printed 2/23/2024, revealed Resident #32 was an [AGE] year-old female originally admitted on [DATE] with an admitting diagnosis of chronic kidney disease, stage 4. Record review of the quarterly MDS assessment dated [DATE], revealed Resident #32 had a BIMS summary score of 6, indicative of severe cognitive impairment. Resident #32 was coded as moderate assistance [helper does more than half the effort] related to toileting. Resident #32 was documented as occasionally incontinent of both bowel and bladder. Active diagnoses included renal [kidney] insufficiency, renal failure, or end stage renal disease. Record review of Resident #32's Care Plan dated 10/19/2023, revealed a focus area of antibiotic therapy related to UTI as of 12/31/2023; with the following associated interventions: administer medications as ordered; report pertinent lab results to MD (revised 1/04/2024). Record review of Order Details revealed Resident #32 had a physician's order for a routine collection of urine to rule out UTI dated 11/23/2023 at 12:40 PM. Record review of the final Laboratory Report revealed the sample for Resident #32 included: Originally Reported on [Friday] 12/08/2023 at 6:35 PM. The report indicated the sample was high for E. coli bacteria. Record review of progress note for Resident #32, with an effective date of [Sunday] 12/10/2023 at 7:06 PM which was 2 days after the original laboratory report date, authored by LVN E revealed, UA results sent to doctor [MD]. New orders received and noted. Record review of Order Details revealed Resident #32 had a physician's order for nitrofurantoin [Macrobid] for urinary tract infection with the start date of 12/11/2023, which was 3 days after the results were communicated to the facility. Record review of the MAR revealed Resident #32 received a twice daily course of nitrofurantoin starting 12/11/2023 at 9:00 AM through 12/17/2023 at 5:00 PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675138 If continuation sheet Page 9 of 11 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 675138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inspiration Hills Rehabilitation Center 1939 Bandera Rd San Antonio, TX 78228 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 2/21/2024 at 5:16 PM, the DON stated the lab company the facility used would pick up the sample by the end of the next day after the order was written between Sundays through Thursdays. The DON stated when a physician ordered a routine lab the expectation is for it to be collected by the end of the next day. The DON stated on weekends, the staff were trained to enter the orders as a stat [immediate] order, and collect the sample as soon as possible, and the lab company would pick up the sample the same day, within a few hours. The DON stated she would have to look into the reason why Resident #32's sample was not collected by the end of the next day after it was ordered. The DON stated a delay in collecting the sample could result in a delay in the physician being able to appropriately treat a potential illness. In an interview on 2/21/2023 at 5:46 PM ADON A stated Resident #32 had dementia, was independently toileting and ambulatory. ADON A stated Resident #32 would empty the collection hat of urine in the toilet despite repeated attempts at education and reminders. ADON A stated collecting the sample for Resident #32 was discussed at each shift change. ADON A stated it was luck that we were able to eventually able to collect the sample before Resident #32 dumped the collection hat of urine into the toilet. In an interview on 2/23/2024 at 11:44 AM, with the MDS Coord. present, ADON A stated, Residents #32 was ambulatory and independent with toileting and would dump out the collection hat of urine into the toilet as she easily confused and would not follow instructions or remember that staff had told her the nurses needed the urine. ADON A stated Resident #32 would not be candidate for alternative collection methods such as straight catheterization. Review of Lab and Diagnostic Test Results - Clinical Protocol, reviewed December 2023, revealed under the heading Assessment and Recognition: physician will identify, and order lab testing based on diagnostic and monitoring needs; staff will process test requisitions and arrange for test; testing source will report test results to the facility. Under the heading Deciding How Urgently to Contact the Physician: nurse will identify the urgency of communicating with the attending physician based on physician request, the seriousness of the abnormality, and the individuals current condition; should proceed as though the tests were ordered to assess the condition change or a recent onset of signs and symptoms. Under the heading Physician Responses: physicians will respond within an appropriate time frame . By end of next office day to a non-emergency message regarding a non-immediate lab test notification (for example, by late Wednesday afternoon for a call made on Tuesday). When necessary to help explain clinical decisions, a physician or mid-level practitioner should document the basis for conclusions about how the results were addressed. Review of Lippincott procedures, Urine Specimen Collection, Random, revised 12/10/2023, accessed 2/27/2024, from https://procedures.lww.com/lnp/view.do?pId=4419392&hits=urinalysis&a=true&ad=false&q=urinalysis revealed under the heading Introduction, Urine specimen allows screening for urinary and systemic disorders; a first-voided morning specimen should be used, if possible. Under the heading Implementation, review the practitioner's order; explain the procedure .according to their individual communication and learning needs to increase their understanding .and enhance cooperation.; instruct an ambulatory patient to void into .collection hat .send it immediately to the laboratory; document the procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675138 If continuation sheet Page 10 of 11 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 675138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inspiration Hills Rehabilitation Center 1939 Bandera Rd San Antonio, TX 78228 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 - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 residents (Resident #17) reviewed for accuracy of medical records in that: The facility failed to ensure Resident # 17's medication, Clopidogrel 75 mg, was correctly listed on Face sheet , for use for hypertension instead of a blood thinner. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 residents (Resident #17) reviewed for accuracy of medical records in that: Resident # 17's medication, Clopidogrel 75 mg, was incorrectly listed for use for hypertension instead of a blood thinner. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: Record review of Resident #17's face sheet dated 2/21/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with the diagnosis that included: Alzheimer's disease( is a brain disorder that slowly destroys memory and thinking skills). Hepatitis C) is an inflammation of the liver caused by the hepatitis C virus). Right hemiplegia( indicates paralysis on the right side of the body). Record review of Resident's # 17's Quarterly MDS Assessment , dated 2/21/24, revealed a BIMS score of 12, which indicated moderate impaired cognition. Record review of the Order Summary Report dated February 21, 2024, revealed the order Clopidogrel 75 mg, administer one tablet by mouth daily for hypertension. During an interview with the DON on 02/22/23 at 1120 a.m., the DON stated that she was unaware that the medication profile for Resident # 17 listed clopidogrel for hypertension; She added that the intended listing for clopidogrel was a blood thinner and that she would ensure the error was corrected. Record review of facility policy titled Medication and Treatment Order, dated December 2023, Revealed Order for medicine must include clinical symptom or condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675138 If continuation sheet Page 11 of 11