Inspection·October 13, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm residents were eating and other residents had not been served yet. Further observation revealed was Resident #2 propelling around asking staff for his lunch tray. Interview with Resident #2 revealed he kept asking for his lunch tray while another resident at the same table was eating. Resident #2 commented, he's eating pointing to his table mate. Resident #2's presented as being anxious and agitated as he continued to propel around asking for his lunch tray and throwing his hands up in the air. Residents Affected - Some During an interview on 10/13/23 at 12:42 PM with DA E stated the trays were served per hallway. DA E stated some of the residents chose to eat in the dining room and their lunch trays were provided off the cart. DA E confirmed Resident #2 was anxious and wanting his lunch tray. DA E commented, believe me if it was up to me I would give him his lunch tray but it's not ready. During an observation on 10/13/23 at 12:45 PM revealed a resident was sitting at the table with Resident #2 finished eating. Further observation revealed Resident #2 was still circling around asking for his lunch tray. Also noted about 6 other Residents had not been served either. 2. Record review of Resident #3's Face Sheet dated 10/13/2023 revealed Resident #3 was admitted to the facility on [DATE] with diagnosis including: dementia, major depressive order, and protein-calorie malnutrition. Record review of Resident #3's MDS dated [DATE] revealed a BIMS score of 4/15, which indicated the individual had severely impaired cognition. Record review of Resident #3's care plan revealed Resident #3 exhibits verbally abusive behaviors at times and is at risk for harm and not having their needs me in a timely manner becomes easily angry and agitated with an intervention of anticipating resident's needs, including food, initiated 09/03/2023. Record review of Resident #4's Face Sheet dated 10/13/2023 revealed Resident #4 was admitted to the facility on [DATE] with diagnosis including: cognitive communication deficit, depression, and protein-calorie malnutrition. Record review of Resident #4's MDS dated [DATE] revealed a BIMS score of 6/15, which indicated the individual had severely impaired cognition. Record review of Resident #4's care plan revealed Resident #4 has a communication problem related to Fear/Shyness with an intervention anticipate and meet needs., initiated 05/23/2023. During an interview on 10/13/23 at 11:30 AM, the DM reported that sometimes there were not enough nursing staff to pass out meal trays. The DM stated some residents may not be served in a timely manner due to lack of enough staff to pass out meal trays. The DM stated each table was served at once, however, it may take some time for meal trays to be passed out between tables. During an observation on 10/13/23 for lunch service, from 12:12 PM to 12:36 PM, there were no nursing staff present to pass out meal trays. Further observation revealed several tables had received their meal trays and were eating, while some tables had finished their plates and waited for seconds. During this time, it was observed that a few residents had still not received their lunch meal trays. During an observation and interview on 10/13/23 at 12:19 PM, Resident #3 still had not received his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 2 of 7 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 675883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southeast Nursing & Rehabilitation Center 4302 E Southcross Blvd San Antonio, TX 78222 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some lunch meal tray and reported being aggravated. Resident #3 stated sometimes he left the dining room because he did not get served on time and then came back to see if his meal arrived. During an observation and interview on 10/13/23 at 12:34 PM, Resident #4 received his lunch meal tray after several tables were served and had been eating and stated it made him feel upset that he did not get his tray on time. During an interview on 10/13/23 at 1:00 PM, the DON stated that nursing staff were important during meal times for safety and provided extra help for the residents. During an interview on 10/13/23 at 5:25 PM, CNA D stated she only saw one nursing staff in the dining room, in passing, and further stated that there should be more nursing staff available to help residents. 3. Record review of Resident #6's face sheet, dated 10/13/23, revealed he was admitted to the facility on [DATE] with a diagnosis to include Hypertensive Heart (high blood pressure caused by damage to the kidney's) and Chronic Kidney Disease (kidneys have become damaged over time) with heart failure and with Stage 5 Chronic Kidney Disease, or end Stage Renal Disease. Record review of Resident #6's quarterly MDS assessment, dated 8/23/23, revealed a BIMS of 4, indicating severe cognitive impairment, and it confirmed his diagnosis as aforementioned. Record review of Resident #6's Care Plan, revised on 6/23/23, revealed [Resident #6] receives dialysis related to renal failure and is at risk for the potential complications of dialysis. Resident has an AV fistula. Record review of Resident #6's physician orders dated October 2023 revealed an order dated 10/11/23, NPO @ midnight one time only for graph change left arm for 1 Day. During an observation and interview on 10/13/23 at 11:25 AM revealed Resident #6 was eating a sandwich in the dining room. Resident #6 stated he had just arrived from his appointment and expressed frustration and stated he left the facility early in the morning before breakfast and did not eat breakfast. Resident #6 stated he did not get a sack lunch to take with him, and commented, nobody helps around here; they don't care. Resident #6 stated he was angry that he did not have anything to eat. Further observation revealed Resident #6 ate one sandwich and accepted a second sandwich when staff offered it to him. During an interview on 10/13/23 at 11:40 AM with LVN F revealed she was not Resident #6's charge nurse and did not see him before he left for his appointment this morning. During an interview on 10/13/23 at 3:15 PM with LVN G revealed she and LVN F were the only nurses assigned and agreed to share D hall. LVN G stated Resident #6 was on D hall. LVN G stated she heard the night nurse say Resident #6 had an appointment this morning, and she saw Resident #6 leaving via ambulance but did not talk to the resident and did not know if he took a sack lunch with him. LVN G stated the kitchen would make sack lunches for resident's to take when they had dialysis or other appointments away from the facility. LVN G stated the nursing staff would have to let the dietary staff know a resident needed a sack lunch. LVN G stated she did not let the dietary staff know Resident #6 had an appointment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 3 of 7 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 675883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southeast Nursing & Rehabilitation Center 4302 E Southcross Blvd San Antonio, TX 78222 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 0550 Level of Harm - Minimal harm or potential for actual harm During an interview on 10/13/23 at 4:10 PM with the Staffing Coordinator revealed nursing staff had hall assignments and LVN G was the designated nurse for hall D. During an interview on 10/13/23 at 4:50 PM with LVN F revealed she and LVN G had not agreed to share hall D. LVN F stated she understood that LVN G was the charge nurse for hall D. Residents Affected - Some During an interview on 10/13/23 at 5 PM with the DON stated she expected the charge nurse to make contact with residents going out for appointments to ensure they were clean and had whatever they needed with them, including a sack lunch as needed. Further interview with the DON revealed there was an NPO for Resident #6 which meant he would not be given a sack lunch. However, stated the charge nurse should have told Resident #6 about the order. Record review of the facility's policy, Resident Rights, dated 2/23/16, revealed, 2. Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment including: a. The right to be fully informed in a language that he or she can understand of his or her total health status, including but not limited to his or her medical condition. b. The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: iii. The right to be informed, in advance, of changes to the plan of care. Respect and dignity. The resident has a right to be treated with respect and dignity including, c. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 4 of 7 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 675883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southeast Nursing & Rehabilitation Center 4302 E Southcross Blvd San Antonio, TX 78222 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 observations, interviews, and record reviews, the facility failed to ensure the care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 5 residents (Resident #1), reviewed for comprehensive care plans in that: Resident #1's care plan failed to address that the resident was exit seeking and a wander risk. These deficient practices could affect residents with comprehensive care plans and could result in missed or delayed continuity of care. The findings included: Record review of Resident #1's face sheet dated 10/12/2023 revealed Resident #1 had an initial admission on [DATE] with diagnoses that included major depressive order, cognitive communication deficit, disruptive mood dysregulation disorder (recurrent irritable or angry mood and severe temper outbursts that interfere with their ability to function at home, in school, or with their friends), vascular dementia with behavioral disturbance (deterioration of memory, language, and other thinking abilities). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score 10/15, which indicated resident is with moderately impaired cognition. Record review of Resident #1's Care Plan, dated, revealed a focus area Resident #1 likes to go to the corner store, initiated 09/26/2023, with Goal of Resident #1 will not have any problems getting to and from the store and Intervention of Resident knows to sign in and out of facility. Record review of progress note dated 09/04/2023 at 10:03 a.m., authored by the LMSW, revealed, Resident #1 on 08/31/2023 he attempted to leave the building and Resident #1 pushed his w/c out the door and began walking down the sidewalk indicating he was looking for a 'smoke shop'. Resident #1 was found behind the building lost and confused. They redirected him back into the building. During an interview on 10/12/2023 at 12:38 p.m., the LMSW revealed that Resident #1 always wanted cigarettes and would try to push the door, if he could. The LMSW stated Resident #1 did not make it out when the resident tried to leave the building because there had been some staff that could redirect Resident #1. The LMSW stated staff should know to make sure Resident #1 did not go outside due to his diagnosis. The LMSW revealed there was a behavior book at the nurse's station for reference and that resident behaviors were discussed in morning meetings to make staff were aware of their residents. During an interview on 10/12/2023 at 2:52 p.m., Nurse A revealed Resident #1 tried to sit outside frequently. Nurse A stated they had a person who monitored what residents sat outside, and staff knew what residents were allowed outside due to residents' behaviors and BIMS scores. Nurse A stated residents who were allowed outside, might be care planned. For new staff members, Nurse A stated they were educated on which residents that were allowed outside by word of mouth. Nurse A defined a wanderer as someone who tried to leave the building, and stated that some consequences of residents who leave the building and were not safe to do so, was that they would not know where they were going. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 5 of 7 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 675883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southeast Nursing & Rehabilitation Center 4302 E Southcross Blvd San Antonio, TX 78222 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 During an combined with MDS Nurse B and MDS Nurse C on 10/12/2023 beginning at 3:22 p.m., MDS Nurse B revealed that Resident #1 was aggressive and was a smoker. MDS Nurse B revealed that departments shared information about residents in their morning meetings and this was when they updated residents' care plans. MDS Nurse B revealed that updated care plans made sure that residents stay safe and everyone knew how to care for residents. MDS Nurse C stated an updated care plan was another way to make sure that residents received care, and that interventions were included to make sure the facility was meeting the goals for residents' in their care plans. During an interview on 10/12/2023 at 4:15 p.m., the Staffing Coordinator stated Resident #1 tried to go outside for cigarettes a couple of times. The Staffing Coordinator stated facility staff redirected Resident #1 and even went to get cigarettes for the resident instead. The Staffing Coordinator stated they let staff know to redirect Resident #1 and revealed that this should be care planned. During an interview on 10/13/2023 at 10:30 a.m., the LMSW stated that any resident who was exit seeking should have it noted in their care plan. The LMSW further stated that it would be harmful if residents eloped from the facility as the facility was located in a bad neighborhood. During an interview on 10/13/2023 at 11:24 a.m., the Administrator stated there was a binder for new staff to note what diagnoses residents had in order to know how to handle their residents. The Administrator taught employees about what certain diagnoses meant and what behaviors these residents had. The Administrator stated the education was an ongoing occurrence. During an interview on 10/13/2023 at 3:01 p.m., the LMSW stated there was a concern for Resident #1 to sign himself in and out of the building due to his dementia diagnosis because he was, not all there. The LMSW stated when the resident signed pertinent paperwork to his health, Resident #1 did not seem to understand what he signed. During an interview with the LMSW on 10/13/2023 at 3:44 p.m., the LMSW stated that if Resident #1 signed himself out to leave the building, that she felt safe for him to leave the building if a staff member followed him out. The LMSW stated that this intervention should be reflected in Resident #1's care plan. During an interview on 10/13/2023 at 4:01 p.m., the Administrator stated she started the process for residents to signed themselves out if they left the building and signed themselves back in for when they returned. The Administrator state this was to ensure that no residents went missing. The Administrator stated Resident #1 was flagged at the door, meaning he could not safely be allowed to leave building. The Administrator stated it should be care planned that Resident #1 was exit seeking. Record review of the facility's policy titled, Comprehensive Care Plans, dated 02/10/2021, revealed, Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs . and 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. And 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibility for carrying out the interventions, initially and when changes are made. Record review of the facility's policy titled, Missing Resident Policy, dated 10/24/2022, revealed, Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 6 of 7 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 675883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southeast Nursing & Rehabilitation Center 4302 E Southcross Blvd San Antonio, TX 78222 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 FORM CMS-2567 (02/99) Previous Versions Obsolete their person-centered plan of care addressing the unique factors contributing to wander or elopement risk. And 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. And 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Event ID: Facility ID: 675883 If continuation sheet Page 7 of 7