Inspection·May 16, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medication class: vaginal and related products, mouth/throat/dental agents/dermatologicals with route of administration listed as topical. Order summary: Clotrimazole cream 1%: apply per ( additional directions topically two times a day for apply (sic) 4 drops into left ear 2 times a day for 21 days. Record review of an audit of Resident #1's physician order (electronic) revealed the order for Clotrimazole was placed into the computer by the MDS Coordinator on 5/12/2023 at 2:00 p.m. and was revised by Agency LVN A on 5/13/2023 at 8:54 p.m The original order date to start the medication was listed as 5/12/2023 and was revised to show a start date of 6/03/2023 by an unknown staff member. Record review of Resident #1's progress note dated 5/13/2023 revealed: Clotrimazole Cream 1% .pending pharmacy. Documented by LVN B. Record review of Resident #1's progress note dated 5/14/2023 revealed: Clotrimazole Cream 1% .pending pharmacy. Documented by LVN B. Record review of Resident #1's MAR for May 2023 revealed: Clotrimazole Cream 1%: apply to per additional directions topically two times a day for apply (sic) 2 ml topically in the morning 2 ml before bedtime for 21 days: with a start date of 5/12/2023 and a discontinue date of 5/14/2023. Record review of Resident #1's MAR for May 2023 revealed: Clotrimazole Cream 1% had 8 opportunities for administration on Friday, 5/12/2023 at 6:00 p.m. Saturday, 5/13/2023, Sunday, 5/14/2023 and Monday, 5/15/2023 each had two opportunities to administer and Tuesday, 5/16/2023 at 9:00 a.m. The MAR also revealed: -5/12/2023 at 6:00 p.m. documented by Agency MA C as not administered. -5/13/2023 at 9:00 a.m. documented by LVN B as not administered. -5/13/2023 at 6:00 p.m. documented by Agency LVN A as not administered. -5/14/2023 at 9:00 a.m. documented by LVN B as not administered. The medication administration record was marked with x on each opportunity and date past 5/14/2023 at 9:00 a.m. which indicated the medication was discontinued. During an observation/interview on 5/16/2023 at 1:35 p.m. of the 300-hallway medication cart with LVN D, Resident #1 exited his room and stated that he still had not received his ear drops and asked LVN D for the medication. LVN D responded that he would look and go talk to Resident #1. Resident #1 returned to his room and shut the door. LVN D stated Resident #1 had asked for the ear drops earlier in the morning at approximately 10:30 a.m. LVN D stated he was unable to locate any ear medication. LVN D stated he was going to tell Resident #1 that no medication was found and there were no orders found for ear medication. LVN D stated he got distracted and never got back to the resident. During an interview on 5/16/2023 at 1:45 p.m., Resident #1 stated he was frustrated because he went to an ENT doctor on Friday 5/12/2023 for medication because his left ear had been bothering him. He stated he was not in pain but had itching and a sensation that something did not feel right in the ear. Resident #1 stated the ENT gave him a prescription for ear drops to treat a fungal infection of the ear. Resident #1 stated he gave the prescription to the MDS Coordinator upon return to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675858 If continuation sheet Page 2 of 5 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 675858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Nursing & Rehabilitation 5437 Eisenhauer Rd San Antonio, TX 78218 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility on Friday 5/12/2023. He stated the MDS Coordinator told him she put the order in. He stated he still had not received the medication. He stated he went all weekend long without getting the medication. He stated he asked multiple staff members for his medication including the MDS Coordinator and LVN B. He stated LVN B said she had called the pharmacy and they were still waiting on the medication to arrive. Resident #1 stated LVN B stated on Sunday 5/14/2023 not to expect the medication because it was Mother's Day. Resident #1 stated on Monday 5/15/2023 he asked the MDS Coordinator about the medication and he stated she told him it was in the building and had arrived from the pharmacy. Resident #1 stated as of this interview he had still not been given the medication for his ear. During an observation/interview on 5/16/2023 at 2:00 p.m., LVN D pulled up Resident #1's medication administration on the computer. The medication Clotrimazole was not available to be administered on the LVN's administration records. LVN D stated based on the original medication order, the Clotrimazole was incorrectly classified as a cream instead of ear drops. He stated because it was listed first under vaginal cream that the order was confusing. He stated the order was placed on 5/12/2023 but had been edited and a new start date of 6/03/2023 had been entered. LVN D stated the start date of 6/03/2023 was why he could not see the medication and it was not available for administration. During an observation/Interview on 5/16/2023 at 2:05 p.m. LVN D was observed searching through the medication cart for the medication and was unable to locate the medication. The medication cart had medication grouped by category and the ear drops for the residents were located in the top drawer, but the Clotrimazole was not located. LVN D stated he had searched earlier for the medication too and had not been able to locate it. During an observation/interview on 5/16/2023 at 2:09 p.m., the MDS Coordinator stated on 5/12/2023 Resident #1 returned from an ENT appointment with orders for ear medication. She stated she put the order for ear medication in PCC and notified the ADON. The MDS Coordinator stated once an order was entered into PCC the program should automatically reflect on the MAR. She stated she did put the medication in the computer as a cream because that was the formulary that was available from a drop-down list. She stated because it said cream instead of ear drops, she wrote special instructions for ear drops that should populate on the MAR. The MDS Coordinator was observed reviewing the MAR as it appeared in PCC. After the review, she stated she could see that the instructions did not appear on the MAR. She stated that was not her intention for it to appear without directions for ear drops on the MAR when she entered the order. The MDS Coordinator stated staff had marked the MAR as not given because the medication was not available or they did not look for it. The MDS Coordinator stated on Monday, 5/15/2023 between 3-4 p.m., Resident #1 notified her that he had not received his medication and that it was pending over the weekend. The MDS Coordinator stated she notified the ADON who corrected it right away and found the medication. The MDS Coordinator stated today, 5/16/2023 at approximately 12:00 p.m. (after surveyor entrance to facility) she filled out a grievance for the medication and sent it to the DON and Administrator via email. During an observation/interview on 5/16/2023 at 2:37 p.m. the ADON stated her duties included infection control, weights, pharmacy recommendation and follow up with daily things but did not include chart (medical record) audits or reviews. The ADON stated on Monday, 5/15/2023 during morning meeting, a nurse, who she could not remember stated they were missing Resident #1's ear medication. The ADON stated she searched and found the medication stored with the creams. She stated the medication was a solution, not a cream so she moved it into the second drawer of the 300-hall medication cart. She stated she did not put it with the ear medication. She stated she put it with Resident #1's PEG tube medications because the nurses said they could not find it. The ADON stated she was aware that LVN D was not able to locate the medication on the 300-hall cart. She stated she helped LVN D look for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675858 If continuation sheet Page 3 of 5 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 675858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Nursing & Rehabilitation 5437 Eisenhauer Rd San Antonio, TX 78218 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and locate the ear drops (after surveyor intervention) and it was in the back of the drawer behind some other medication. The ADON stated staff were trained to notify her for missing medication or call the pharmacy if they could not find the medication. She stated on the weekend when she is not in the building staff should notify the pharmacy to see if the medication was already delivered. The ADON stated the Clotrimazole ear medication for Resident #1 was not administered. The ADON stated she first became aware of the new order for medication on Friday, 5/12/2023 when the MDS Coordinator told her Resident #1 had an order for ear drops. The ADON was observed reviewing the order for Clotrimazole as it appeared in the computer. After reviewing the order, the ADON stated she could see how the order, as entered could be confusing. She stated if the nurse opened the whole order for the ear medication the instructions for putting it in the ear would pop up. The ADON stated procedures for ordering new medication were after the order was received, they had to wait for the pharmacy to deliver. She stated depending on when it was ordered the medication could come the same day or the next day. She stated waiting 2-3 days or longer was too long. The ADON stated there was no training specifically on ordering new medications as it was basic nursing knowledge to call the pharmacy. The ADON stated it was important for residents to get their medication to relieve their symptoms. She stated Resident #1 was complaining and should have had his medication. During an interview on 5/16/2023 at 3:23 p.m. Agency Nurse LVN A stated she did not administer Resident #1's Clotrimazole ear drops. She stated she was passing medication on Friday 5/12/2023 and could not find the ear medication and did not administer it. She stated she asked another nurse (unknown name) for the ear drops and the other nurse said the medication was pending. LVN A stated she tried to re-order the medication on the computer, but it had already been re-ordered. LVN A stated Resident #1 told her about the ear drops. She stated she did not call the pharmacy to check on the status of the medication because the other nurse said it was already ordered and she took the nurse's word for it. LVN A stated she was trained to call the pharmacy. During an interview on 5/16/2023 at 4:12 p.m., LVN B stated she did not administer Resident #1's Clotrimazole ear drops on Saturday, 5/13/2023 or Sunday, 5/14/2023. She stated on Saturday, 5/13/2023 Resident #1 asked for his ear medication. She stated she found the order for Clotrimazole but not the medication. LVN B stated Resident #1 wanted to know why the medication had not come in. LVN B stated she called the pharmacy (unknown name) and was told she should be receiving the medication. She stated the facility received a shipment of medication but not the Clotrimazole. She stated she was told a new shipment would come in the evening on 5/13/2023 but no deliveries came. LVN B stated she was told there would be a midnight delivery of medication, so she passed it on the night nurse. LVN B stated on Sunday, 5/14/2023 the nurse (unknown name) told her the Clotrimazole had not come in. LVN B stated she told Resident #1 the medication did not come in. LVN B stated she told Resident #1 that it was Mother's Day, and no one was delivering on that day. LVN B stated Resident #1 was really frustrated but she told him there was nothing that could be done. LVN B stated she should have documented in the progress notes, but she did not. She stated she did not notify the physician that the Clotrimazole was not given. LVN B stated it never occurred to her to call the doctor. She stated she thought it could just be resolved on Monday, 5/15/2023. LVN B stated she did not notify management over the weekend that the medication was not administered. She stated it did not occur to her to call management. She stated she thought she could fix the situation and the problem would be solved. LVN B stated she searched for the medication. She stated she looked all through the 300-hallway medication cart, other medication carts for other halls and the medication room and could not find it. LVN B stated it was important for Resident #1 to get his ear drop medication because he obviously had something going on with his ear. She stated he needed the medication so (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675858 If continuation sheet Page 4 of 5 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 675858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Nursing & Rehabilitation 5437 Eisenhauer Rd San Antonio, TX 78218 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 0755 his left ear could heal. LVN B stated all medications were important. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/16/2023 at 4:34 p.m., the DON stated she was new to the facility and had only worked there for 4 days and was still on orientation. The DON stated the feedback she had received was that Resident #1 had complained that his ear drops were not being given. The DON stated if there was a pharmacy delay, which sometimes happens, then they need to communicate with the resident, the family, and the physician. The DON stated LVN B said she called the pharmacy several times but did not document her efforts. The DON stated medication was very important. She stated there was potential for discomfort to serious issues depending on the medication. The DON stated the nurses should have called the DON and the physician to get an alternate treatment if Resident #1's medication was not available. The DON stated her expectation was for staff to communicate effectively. She stated the ADON did not communicate this concern to her before today. She stated the MDS Coordinator brought up the issue this morning as a grievance. Residents Affected - Some Record review of a facility policy, titled Medication Administration last revised January 2023 revealed Resident medications are administered in an accurate, safe, timely, and sanitary manner. 2. Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route. 6. Administer medications as ordered by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675858 If continuation sheet Page 5 of 5