Inspection·January 13, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assistant for Resident #13 and call light was on the floor. CNA F stated the resident's call light must have fallen to the floor when performing incontinent care this morning. CNA F further stated the lack of accessibility of a call light could negatively affect any resident if they needed assistance. During an interview with LVN D on 01/10/2024 at 11:01 AM, LVN D stated she was the assigned nurse for Resident #13 and the resident's call light was out of reach for Resident #13. LVN D confirmed that it was not normal nursing practice for one resident to be left without a call light. LVN D stated the absence of the call light could constitute potential harm if the resident needed assistance. 2. Record review of Resident #19's face sheet, dated 01/10/2023, revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included: [schizoaffective disorder] is a mental health condition where you experience psychosis as well as mood symptoms, [Depression] is a mood disorder that causes a persistent feeling of sadness and loss of interest, and [ bipolar disorder] condition with extreme mood swings that include emotional high and lows. Record review of Resident #19's Quarterly MDS, dated [DATE], revealed a BIMS score 15, which indicated the resident was cognitively intact. Further review revealed that under section G, G0300, option #3 was selected, stating the patient was unsteady on feet and required assistance X 1. Record review of Resident #19's care plan, dated 11/02/2023, revealed Visual Function impairment. Keep call light within reach of resident. Observation and interview on 01/10/2024 beginning at 8:31 AM in Resident #19's room revealed the resident's call light was not visible. Further observation revealed Resident #19's call light was wrapped around the call light box. Resident #19 stated she did not have a call light and did not know where her call light was. Resident #19 stated, they (staff) took the call light, and she had last seen the call light, at night. During an interview with CNA E on 01/10/2024 at 8:55 AM, CNA E stated she was the assigned CNA for Resident #19 and noted the resident's call light was on the floor. CNA E stated Resident #19's call light must have fallen to the floor when making the resident's bed this morning. CNA E stated the lack of accessibility of a call light could negatively affect any resident if they needed assistance. During an interview with LVN D on 01/10/2024 at 11:01 AM, LVN D stated she was the assigned nurse for Resident #19's and that the call light was out of reach of Resident #19. LVN D stated it was not normal nursing practice for one resident to be left without a call light. LVN D stated the absence of the call light could constitute a potential fall if the resident needed assistance. During an interview with the DON on 01/10/2024 at 1:49 PM, the DON stated the facility had a call light policy and staff had been in-service many times to keep the call light within residents' reach. The DON stated Residents #13's and #19's care plan addressed the need for a call light within reach. The DON stated she did not know why the call lights were not within Residents #13's and #19's reach and the residents risked not having a way to ask for assistance if they needed some thing. Record review of the facility's policy, Call Light Response, dated 02/10/2021, revealed, Staff will ensure the call light is within reach of resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 2 of 30 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 01/13/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 8 residents (Resident #40) reviewed for advanced directives, in that: Resident #40's Out-of-Hospital Do Not Resuscitate (OOHDNR) was not dated by the resident and the physician at the time it was signed, and did not have the resident's name printed, rendering the document invalid. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. The findings include: Record review of Resident #40's face sheet, dated [DATE], revealed an initial admission date of [DATE] with a recent admission of [DATE] and diagnoses which included: atherosclerotic heart disease (narrowing or hardening of coronary arteries), tachycardia (heart rate that exceeds the normal resting rate), dysphasia with oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat) and peripheral vascular disease (PVD, systemic disorder that involves the narrowing of peripheral blood vessels). Further review of Resident #40's face sheet, revealed under the section, ADVANCE DIRECTIVE: DNR. Record review of Resident #40's Annual MDS, dated [DATE], revealed the resident's BIMS score was 04, which indicated severe cognitive impairment. Record review of Resident #40's Care Plan, with last review completed on [DATE], revealed, DNR: Date initiated: [DATE]. Do Not resuscitate orders will be honored per resident or legally appointed guardian's wishes. Update code status on a quarterly basis or as changes occur. Review of Resident #40's Order Summary Report, Active Orders as of [DATE], revealed an order, DNR, dated [DATE] with no end date. Record review of Resident #40's electronic clinical record revealed an OOH-DNR for Resident #40, signed by Resident #40, two witnesses and the physician. Further review revealed the physician had not dated the OOH-DNR and in Section A, Resident #40's name was not printed and there was no date. In an interview with the DON on [DATE] at 4:23 p.m., the DON confirmed all sections of the OOH-DNR must be fully completed to be valid. The DON revealed at the time Resident #40's OOH-DNR was completed the facility SW would have been responsible to assist with the completion and accuracy of the document. The DON further stated the SW had resigned unexpectedly last month and since that time nursing staff was responsible to assist residents with advanced directives. The DON stated there might be another copy of the OOH-DNR in medical records and would have them pull Resident #40's chart for review. In a follow up interview with the DON on [DATE] at 11:15 a.m., the DON revealed medical records had been unable to locate another copy of the OOH-DNR and Resident #40's code status was changed to FULL CODE. The DON revealed since Resident #40 was no longer able to sign for herself they had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 3 of 30 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 01/13/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete contacted Resident #40's attending physician to discuss the option of completing a new OOH-DNR by method of the physician signing either Section D or F to ensure Resident #40's wishes were followed. Record review of the facility's policy titled, Advance Directives/Advance Care Planning, revised 04/2015, revealed, It is the policy of this facility to recognize two fundamental rights of a person; the right to live and to continue treatment and the right to refuse or terminate unwanted treatment. This facility will honor a resident's wishes and advanced directives pertaining to his/her own medical treatment, including wishes to withhold treatment. In the absence of the Social Worker the Administrator appoints a staff member to assume the responsibility for advance directives and advanced care planning. Event ID: Facility ID: 675883 If continuation sheet Page 4 of 30 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 01/13/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview, and record review, the facility failed to ensure the residents' right to a safe, clean, comfortable, and homelike environment for 1 of 89 residents (Resident #38) reviewed for safe, clean, comfortable, and homelike environment, in that: In Resident #38's room, the cord for the window blinds was broken and cold air was entering the room via the window. This deficient practice could result in a loss of quality of life due to living in an uncomfortable home environment. The findings were: Record review of Resident #38's face sheet, dated 01/12/2024, revealed the resident was admitted on [DATE] with diagnoses which included: Major Depressive Disorder, Need for Assistance with Personal Care, and Unspecified Dementia. Record review of Resident #38's Quarterly MDS, dated [DATE], revealed a BIMS score of 9, which indicated moderate cognitive impairment. Record review of Resident #38's care plan, revised 09/10/2020, revealed, Visual Function (Impaired): [Resident #38] has impaired vision as evidenced by an inability to read regular print and is at risk for injury, falls, and a further decline in functional abilities Resident is able to see large print in a well illuminated room. Observation on 01/09/2024 at 2:05 p.m. revealed in Resident #38's room there was a rolled towel had been placed against the window. During an interview with Resident #38 on 01/09/2024 at 2.05 p.m., Resident #38 stated her bed was next to the window and stated a staff member had placed the towel in window because a draft of cold air could be felt emanating from under the window. Resident #38 stated she did not recall which staff member placed the towel or how long it had been in the window. Resident #38 further stated the towel helped to keep cold air from coming in under the window. Resident #38 stated the cords were meant for raising/lowering window blinds and opening/closing window blinds but were broken and therefore, she was unable to adjust the blinds. Resident #38 further stated she had difficulty seeing because the window blinds were permanently in a half-closed position. During an interview with CNA V on 01/09/2024 at 2:25 p.m., CNA V confirmed she cared for Resident #38 and stated she was unaware there was a rolled towel in the window of Resident #38's room and was unaware the window blinds were in disrepair. During an interview with the Maintenance Director on 01/11/2024 at 11:30 a.m., the Maintenance Director stated he was unaware there was a rolled towel in the window of Resident #38's room and was unaware the window blinds were in disrepair. Record review of the facility's policy titled, Resident Rights, dated 2/20/2021, revealed, 8. Safe (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 5 of 30 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 01/13/2024 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 0584 Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports of daily living safely. 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: 675883 If continuation sheet Page 6 of 30 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 01/13/2024 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 1 of 2 residents (Residents #93) reviewed for PASRR screening, in that: Residents Affected - Few Resident #93's PASRR Level 1 assessment did not accurately capture the resident's diagnosis of mental illness. These failures could place residents with an inaccurate PASRR Level 1 Evaluation at risk for not receiving care and services to meet their needs. The findings were: Record review of Resident #93's Face Sheet dated 1/10/24, revealed a [AGE] year-old male admitted to the facility on [DATE] with the diagnosis that included: [bipolar disorder] disorder associated with episodes of mood swings ranging from depressive lows to manic highs,[Post-traumatic stress disorder] mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety and [Periodontal disease] condition that's the result of infections and inflammation of the gums and bone that surround and support the teeth. Record review of Resident #93's Quarterly MDS, dated [DATE], revealed a BIMS score of 11, which indicated the resident was moderately cognitively impaired. Further review revealed the PHQ-9 Mood Assessment listed the resident's Active Diagnosis as, bipolar disorder. Record review of Resident #93's care plan, dated 10/3023, revealed Psychotropic drug use related to bipolar disorder with interventions that included administer medications as ordered. Record review of Resident #93's PASRR I screening, completed by the referring entity and dated 10/27/23, prior to admission on [DATE] indicated in Section C PASRR Screen questions C0100 asks, is there evidence or an indicator this individual has Mental Illness? The answer was 0 (0. No). During an interview with the MDS Coordinator A on 1/10/24 at 3:02 p.m., MDS Coordinator A stated, I work together with the local mental health authority to discuss PASRRs. The local authority can often give us the history of the person. MDS Coordinator A acknowledged Resident #93 had a diagnosis of bipolar disorder and post-traumatic stress disorder and the resident's PASSR 1 screening should have been redone as positive. MDS Coordinator A stated Resident #93 risked the opportunity to be screened by the local health authority for possible services offered, and she would get the PASSR 1 corrected and resubmitted. During an interview with the DON on 1/10/24 at 4:10 p.m., the DON stated it was her expectation that MDS Coordinator A reviewed all residents' medication orders to ensure no possible PASSR positive resident was missed, as Resident #93 risked the possibility of not receiving valuable services offered by the local health authority. Record review of facility's policy titled, Preadmission and screening resident review (PASSR) rules, dated , 4/26/2016 revealed, If the resident has a qualifying MI diagnosis and the nursing facility feels the resident should be positive they should talk to the referring entity and ask them to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 7 of 30 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 01/13/2024 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 0645 correct PL1. 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: 675883 If continuation sheet Page 8 of 30 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 01/13/2024 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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 24 residents (Resident #66) reviewed for comprehensive care plans, in that: Resident #66's care plan did not address the resident's psychological care and wound care being provided by the facility with goals or interventions. This deficient practice could result in a loss of quality of life due to residents receiving improper care. The findings were: Record review of Resident #66's face sheet, dated 01/12/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Senile Degeneration of Brain, Dementia, and Cognitive Communication Deficit. Record review of Resident #66's Quarterly MDS, dated [DATE], revealed a BIMS score of 06, which indicated the resident was severely cognitively impaired. Record review of Resident #66's care plan, revised 10/24/2023, revealed a problem, Resident has a behavior problem as evidenced by self-inflicted wounds on abdomen, with no corresponding goal or interventions listed. During an interview with MDS Coordinator A on 01/11/2024 at 4:50 p.m., MDS Coordinator A confirmed Resident #66's care plan was missing goals and interventions to address the resident psychological care and wound care related to the resident's behavior of self-inflicting wounds on themselves and further stated the this was an oversight. During an interview with the DON on 01/11/2024 at 5:00 p.m., the DON confirmed Resident #66 was receiving wound care and psychological care regarding her self-inflicted wounds. DON stated wounds had healed. Record review of Resident #66's clinical record as of 01/11/2023 revealed no wounds noted on the resident's weekly skin assessments for the preceding month's time. Record review of the facility's policy titled, Comprehensive Care Plans, implemented 02/10/2021, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 9 of 30 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 01/13/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 8 residents (Resident #8) for care plan revisions, in that: Resident #8's care plan was not revised to reflect the resident's change to DNR status after [DATE]; the resident's care plan still indicated the resident was Full Code. This failure could place residents at risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. The findings were: Record review of Resident #8's face sheet, dated [DATE], revealed an initial admission date of [DATE] with a recent admission of [DATE] and diagnoses which included: Alzheimer's disease, schizophrenia, type 2 diabetes mellitus with hyperglycemia (high blood sugar). Further review of Resident #8's face sheet, revealed under the section, ADVANCE DIRECTIVE: DNR: Do Not Resuscitate Order in Place. Record review of Resident #8's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 00, which indicated the resident was severely cognitively impaired. Record review of Resident #8's Care Plan, last review completed on [DATE], revealed, Full Code: [Resident name] has physician's orders that include a status of full code. Date initiated: [DATE]. The Goal: [Resident name] wishes will be followed daily and ongoing. Revision on 0111/2024. The Interventions: Monitor for changes in [Resident's name] code status and update as needed. Review at least quarterly. Revision on [DATE]. Record review of Resident #8's Order Summary Report, Active Orders as of [DATE], revealed an order, DNR: Do Not Resuscitate Order in Place, dated [DATE] with no end date. In an interview with MDS Coordinator A on [DATE] at 4:20 p.m., MDS Coordinator A stated typically the SW would update an OOH-DNR but added that anyone could revise a resident's care plan. MDS Coordinator A reviewed Resident #8's electronic record and confirmed the resident care plan should have been revised and stated, it was poor communication. MDS Coordinator A stated a resident's care plan being revised was very important because all staff needed to know the specifics of each resident to provide the residents' care. In an interview with the DON on [DATE] at 4:45 p.m., the DON stated revisions were to be made as changes occurred and were the responsibility of all disciplines. The DON further stated care plans were, one of many areas she had been trying to work on since taking this position. Record review of the facility's policy titled, Comprehensive Care Plans, date implemented [DATE], revealed, Policy Explanation and Compliance Guidelines: 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 10 of 30 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 01/13/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 were unable to carry out activities of daily living received necessary services to maintain grooming, and personal hygiene for 1 of 8 residents (Resident #37) reviewed for ADLs, in that: Residents Affected - Few The facility failed to ensure Resident #37 received or documented baths or showers between 12/21/2023 and 1/12/2024. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a diminished quality of life. Findings included: Record review of the admission Record revealed Resident #37 was a [AGE] year-old man admitted on [DATE]. Record review of Resident #37's quarterly MDS assessment, dated 10/09/2023, revealed primary medical condition category for admission was coded as medically complex conditions related to diabetes mellitus [a metabolic disorder in which the body has high sugar levels for prolonged periods of time]. Further review revealed the resident had a BIMS score of 3, which indicated the resident was severely cognitively impaired, the resident was dependent for shower/bathe as self. Further review revealed the resident was indicated to be at risk of developing pressure injuries upon formal clinical assessment; treatments included nutrition and hydration intervention, application of nonsurgical dressings, and application of ointments or medications. Record review of Resident #37's Care Plan, printed 1/12/2024 at 1:21 PM, revealed, no instructions related to ADLs; with the exception related to anticoagulant use with associated interventions: use a soft toothbrush; and electric razor for shaving. In an observation and interview on 1/11/2024 beginning at 12:00 PM, Resident #37 was laying in his bed in a droplet precaution isolation room, presented with uncombed and greasy hair. Resident #37 shook his head when asked if he had any concerns and problems. Resident #37 shrugged his shoulders when asked when he got his last bath. Resident #37 again shrugged his shoulders when asked if he received a bath 2 to 3 times per week. Resident #37 nodded his head when asked if he would like a bath more often. Resident #37 declined further interview. Record review of the facility's Shower Sheet Binder, reviewed on 1/11/2024, revealed no Shower Sheets for Resident #37 under any of the numbered date tabs. On 1/12/2024 at 5:00 PM the DON presented a Shower Sheet for Resident #37, dated 1/11/2024, signed by CNA R. In an interview with CNA H on 1/12/2024 at 3:25 PM, CNA H stated Resident #37 usually received a bed bath 3 times per week. CNA H stated he thought Resident #37 was on the bathing schedule for Mondays, Wednesdays, and Fridays. CNA H stated Resident #37 would not be able to tell you the date of his last shower but might be able to answer yes or no if the shower was provided earlier that day. CNA H stated he was not responsible for providing showers today to Resident #37. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 11 of 30 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 01/13/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview with CNA R on 1/12/2024 at 5:00 PM, CNA R stated she had provided bathing to Resident #37 earlier in her shift. CNA R stated she did not normally work the hallway where Resident #37 resided, she normally worked in the locked unit. CNA R stated she did not believe Resident #37 had missed a bath recently. CNA R stated there was no body odor or greasy hair to indicate the resident had not received a bath recently. CNA R stated she could not determine when Resident #37's last bath was before the one she gave him. In an interview with the DON on 1/12/2024 at 4:00 PM, the DON stated staff did not document showers in the EHR, and instead staff marked a paper Shower Sheet for each shower or bath provided. The DON stated the Wound and Skin Care nurse reviewed and followed up on any skin concerns from the Shower Sheets. The DON stated the binder included the current month's and the previous month's shower sheets. The DON stated the binder may have 3 months worth of shower sheets in it The DON stated she was not aware of any missed showers, but she would look into it and provide an update. The facility did not provide a hygiene or bathing policy prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 12 of 30 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 01/13/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as was possible for 1 of 6 resident halls (F Hall) reviewed for accidents and hazards, in that: 1. The shower room on the F Hall was unlocked and accessible to residents and had insulation in the floor from a hole in the ceiling. 2. A pipe emanating from the wall to the right of the kitchen's back door was leaking and resulted in standing water outside the back door of the kitchen. These deficient practices could lead to accidents and/or injury. The findings were: 1. Observation on 01/09/2024 at 2:10 p.m. revealed the shower room on F Hall was unlocked and accessible to residents. Further observation revealed there was a hole in the ceiling and insulation in the floor. During an interview with CNA V on 01/09/2024 at 2:20 p.m., CNA V stated the shower room was not currently in use due to repair work in progress. CNA V confirmed the presence of insulation on the floor and confirmed the door was unlocked, leaving the material accessible to residents. During an interview with the Maintenance Director on 01/11/2024 at 11:30 a.m., the Maintenance Director stated that the shower room on F hall was not in use due to repairs for a broken pipe. The Maintenance Director confirmed insulation was on the floor and accessible to residents and confirmed the material was potentially dangerous. 2. Observation on 01/12/2024 at 11:00 a.m. revealed there was a pipe emanating from the wall to the right of the kitchen's back door was leaking and a pool of standing water outside the back door of the kitchen. During an interview with the Dietary Manager on 01/12/2024 at 11:00 a.m., at the same time as the observation, the Dietary Manager stated the pipe was connected to the dish machine and the pool of standing water had been in place, for a few days. During an interview with the DON on 01/11/2024 at 5:00 p.m., the DON confirmed that insulation was potentially dangerous to residents and should not be located within their reach. The DON also stated she thought the leaking pipe outside the kitchen had been repaired, directed the Maintenance Director to repair it immediately, and confirmed that standing water could lead to the presence of mosquitoes. Record review of the facility's policy titled, Resident Rights, dated 2/20/2021, revealed,8. Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports of daily living safely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 13 of 30 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 01/13/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure incontinent bladder residents received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 2 of 12 residents (Residents #28 and #57) reviewed for indwelling catheters and perineal/incontinent care, in that: 1. The facility failed to ensure Resident #28 indwelling catheter was attached to prevent pulling or tugging to the urethra. 2. The facility failed to ensure Resident #57 foreskin was pulled back during perineal care. These failures could place residents at risk for discomfort, urethral trauma (injury to the duct in which urine is transported out of the body from the bladder), and urinary tract infections due to improper care. The findings were: 1. Record review of Resident # 28's face sheet, dated 01/11/24, revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included: [Hypospadias] birth defect in boys in which the opening of the urethra is not located at the tip of the penis, [Type 2 diabetes] is a condition that happens because of a problem in the way the body regulates and uses sugar as fuel, and [Obstructive uropathy] is a disorder of the urinary tract that occurs due to obstructed urinary flow. Record review of Resident # 28's Quarterly MDS, dated [DATE], revealed a BIMS of 15, which indicated the resident was cognitively intact, and under section H Bowel and Bladder, indwelling catheter was selected. Record review of Resident #28's care plan, dated 07/11/23, revealed the resident's care plan addressed the resident's urinary catheter with interventions, Use stabilizer or secure device. During an observation on 01/11/24 at 9:45 a.m. revealed Resident #28 had an indwelling foley catheter without a secure device. During an interview with Resident #28 on 01/11/24 beginning at 9:45 a.m., Resident #28 stated, They never give me that thing to keep this from pulling on my penis. During an interview LVN D on 01/11/24 at 11:30 a.m., LVN D stated she was the nurse for Resident #28 and confirmed the resident was supposed to be wearing a secure device to prevent the urinary catheter from pulling on the resident's urethra. LVN D stated she did not know why Resident #28 was not wearing a secure device. During an interview with the DON on 01/11/24 at 2:35 p.m., the DON stated Resident #28 should have been wearing a secure device to prevent the urinary catheter from possibly dislodging from the resident's urethra. The DON stated it was her expectation that all residents with a urinary catheter wore a secure device to prevent the catheter from pulling or possibly becoming dislodged. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 14 of 30 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 01/13/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm 2. Record review of Resident #57's face sheet, dated 01/12/24, revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses that included: [cerebral infarction] refers to damage to tissues in the brain due to a loss of oxygen to the area, [Left hemiplegia] is the paralysis of limbs on the left side of the body, and [Schizoaffective disorder bipolar type] mental illness with a combination of depression and hallucinations. Residents Affected - Few Record review of Resident #57's Quarterly MDS, dated [DATE], revealed a BIMS of 03, which indicated the resident was severely cognitively impaired, and under section GG Functional Abilities, toileting hygiene, substantial max assist was selected. Record review of Resident #57's care plan, dated 02/16/23, revealed ADL self-care with interventions that included toileting extensive assist was addressed on the resident's care plan. Record review of the Peri Care - Male competency training for CNA E, dated 10/19/22, revealed CNA E had satisfied the perineal/incontinent care requirements. During an observation of perineal/incontinent care for Resident #57 by CNA E on 01/11/2024 at 10:20 a.m. revealed CNA E did not pull Resident #57's foreskin to clean. During an interview with CNA E on 01/11/24 at 10:20 a.m., CNA E stated she forgot to pull Resident #57's foreskin to clean because she got nervous and forgot. CNA E stated that by her not completing this task, the resident risked possible urinary infection and accumulation of smegma. During an interview with the DON on 01/12/24 at 8:10 a.m., the DON stated CNA E should have pulled the foreskin back and cleaned Resident #57's penis as failure to perform proper perineal care. The DON further stated failure to perform proper perineal care risked possible urinary infections and accumulation of smegma. Record review of the facility's policy titled,Foley Catheter Guidelines, dated 2/2014 and revised 2/2016, revealed, use a secure devise to stabilize the catheter to reduce pulling. Record review of the facility's policy titled, Peri care for Men & Women accessed 1/18/23, Perineal Care: Peri-Care for Men & Women | CNA Free Training, revealed, For uncircumcised men, you'll need to pull the foreskin of the penis all the way back to the head. Clean the area around the urinary opening in a circular fashion, down to the shaft of the penis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 15 of 30 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 01/13/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide routine and emergency drugs and biologicals to its residents for 1 of 8 residents (Resident #85) reviewed for medication administration, in that: The facility failed to ensure Resident #85 was administered Cinacalcet [used to treat increased amounts of a certain hormone in people with long-term kidney disease who are on dialysis] as ordered 14 times between 08/21/2023 and 09/06/2023. This deficient practice could place all residents at risk for not receiving the intended therapeutic effect of medications as their ordered by their physician resulting in diminished health and well-being. The findings were: Record review of Resident #85's admission record, dated 01/12/2024, revealed the resident was a [AGE] year-old man admitted on [DATE]. Record review of Resident #85's quarterly MDS assessment, dated 11/27/2023, revealed the resident was admitted for medically complex conditions with other active diagnoses that included: renal insufficiency, renal failure, or End-Stage Renal Disease (ESRD). Further review revealed the resident was indicated to require dialysis while a resident at the facility, and the resident had a BIMS summary score of 13, which indicated the resident was cognitively intact. Record review of Resident #85's Care Plan, printed 1/12/2024 at 11:02 AM, revealed the focus area of, Dialysis: [Resident #85] receives dialysis related to renal failure, with a revision date of 08/04/2023; associated interventions did not include medication regimen. Further review revealed the additional focus area of, resident is on a consistent carbohydrates renal diet, with the following associated interventions: administer medications as ordered, date initiated 7/24/2023. Record review of Resident #85's Order Summary Report, dated 01/12/2024, revealed a physician's order for, Cinacalcet 30 MG: give 1 tablet by mouth in the evening for metabolic agent, with a start date of 07/22/2023. Record review of Resident #85's Progress Note, dated 08/14/2023 at 4:35 PM by LVN T, revealed, Cinacalcet has not come in. It had not been delivered. This nurse tried to call pharmacy a few weeks ago to check why it has not been delivered. Pharmacy states the cost is over $900 and we will need to ask the physician to write a script [prescription] for something comparable. Talked to NP today who asked me to call pharmacy. Pharmacy says we need a prior auth[orization] and says it's a billing issue. [NAME] closed at this time. Record review of Resident #85's MARs for August 2023 and September 2023 revealed the resident missed dosing of Cinacalcet on 08/21/2023, and 13 doses between 08/25/2023 to 09/06/2023. Resident #85 declined interviews on 1/12/2024 at 3:30 PM and a 4:15 PM.]. In an interview with the DON on 01/12/2024 at 11:30 AM, the DON stated she was not aware of any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 16 of 30 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 01/13/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm issues with Resident #85 not receiving his medication. The DON stated 14 doses of Cinacalcet that Resident #85 missed occurred before she started working at the facility. The DON stated the nurse who failed to administer the Cinacalcet to Resident #85 was no longer employed at the facility. The DON stated she expected medications to be administered as ordered and was unsure as to why Resident #85 did not receive Cinacalcet in August 2023 or September 2023. Residents Affected - Few Record review of the facility's policy titled, Medication - Treatment Administration and Documentation Guidelines, revised on 04/06/2023 revealed under the Process heading, 4.) Administer the medication according to the physician order. Record review of Lippincott procedures, Oral Drug Administration, revised 05/21/2023, accessed 1/17/2024, https://procedures.lww.com/lnp/view.do?pId=4420028, revealed under the heading Introduction, must ensure that the delivery schedule doesn't interrupt the resident's prescribed treatment plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 17 of 30 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 01/13/2024 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 0759 Ensure medication error rates are not 5 percent or greater. 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 a medication error rate was not 5% or greater. The facility had a medication error rate of 28%, based on 7 errors out of 25 opportunities, which involved (Resident #37) and 1 of 2 staff (LVN C ) reviewed for medication administration, in that: Residents Affected - Few LVN C failed administered medications to Resident #37 on 01/18/24 according to the physician's orders and per professional standards, which resulted in a 28% medication administration error rate. This deficient practice could place residents at risk of not receiving the therapeutic effects of their medications and possible adverse reactions. The findings are: Record Review of Resident #37's face sheet, dated 01/11/24, revealed a [AGE] year-old male with an admission date of 09/21/23 with a diagnosis that included: [Hypertension] when the pressure in your blood vessels is too high, [Dysphagia] is a medical term for difficulty swallowing, and [Atrial fibrillation] is an irregular and often very rapid heart rhythm. Record review of Resident #37's Quarterly MDS assessment, dated 10/09/23, revealed a BIMS score of 03, which indicated the resident was severely cognitively impaired. Record review of Resident #37's order summary report for January 2024 revealed orders for the following medications to be administered to the resident at 9:00 a.m.: - Aspirin chewable 81 mg, give one tablet via [gastrostomy tube ]is a tube inserted through the belly that brings nutrition directly to the stomach. - Keppra liquid 100 mg/ml give 10 ml daily via GT daily for mood disorder. - Vitamin D 1,000 IU give one capsule via GT daily for vitamin deficiency. - Memantine 5 mg, give one tablet via GT daily for dementia. - Digoxin 0.5 mg/ml, give 2.5 ML via GT daily for Chronic Atrial Fibrillation. - Gabapentin 300 mg, give one tablet via GT three times a day for Neuropathy. - Metoprolol 50 mg give one tablet via GT every 12 hours for Hypertension. Observation and interview during the medication pass on 01/18/24 beginning at 9:25 a.m. LVN C prepared Resident #37's medications. LVN C administered all of the resident's medications via GT and did not give the residual medicine left in the dispensing souffle cup. LVN C stated Resident #37 risked not receiving a full dose of the medications administered by her by not administering the residual medication left in the dispensing souffle cup. During an interview with the DON on 01/18/24 at 10:32 a.m., the DON stated that for all medications administered via GT, the nurse must add water to the souffle cup and then administer the residual (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 18 of 30 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 01/13/2024 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 0759 Level of Harm - Minimal harm or potential for actual harm medication via GT, ensuring that the full dose of medication was administered to the resident. The DON stated Resident #37 risked not receiving a full dose of medication by the nurse, not administering residual medicines left in the souffle cup. The DON stated the facility did not have a policy to address this deficient practice but referred the surveyor to the Drug Administration handbook, which a copy was in every medication cart. Residents Affected - Few Record review of Handbook of Drug Administration via Enteral Feeding Tubes, third edition 2015, accessed 1/11/24, https://rudiapt.files.wordpress.com/2017/11/handbook-of-drug-administration-via-enteral-feeding-tubes-2015.pdf, revealed, Draw 10 ml of water into the syringe and flush this via gastric Tube, [this will ensure that total dose is administered]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 19 of 30 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 01/13/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 3 medication carts (Medication Cart for Halls B & E) reviewed for medication storage, in that; The Medication Cart for Halls B & E Cart was not locked when it was left unattended in the common area of the 100 hallway. This deficient practice could place residents at risk of medication misuse or drug diversion. The findings were: Observation on 01/10/2024 at 6:31 AM, LVN I was preparing insulin administration and LVN I parked the Medication B & E Cart in the hallway outside of room [ROOM NUMBER]. Further observation revealed LVN I left the Medication B & E Cart unlocked and unattended in the hallway outside of room [ROOM NUMBER] to obtain a blood glucose reading from a resident in room [ROOM NUMBER]. LVN I returned to the cart, documented the reading, reviewed the EHR, and prepared a medication syringe for administration. LVN I returned to room [ROOM NUMBER] to administer the medication, leaving the cart again unlocked and unattended. The Medication B & E Cart included prescription and over-the-counter medications, including narcotic medications behind a second lock. The Medication B & E Cart was accessible to staff and visitors in the area, and at the time there were no witnessed residents in the immediate vicinity. During an interview with LVN I on 01/10/2024 at 6:40 AM, LVN I stated the Medication B & E Cart should be locked when unattended. LVN I stated it was the facility's policy to secure medication cart at all times. LVN I stated she knew the Medication B & E Cart should not have been left unattended, but was rushing, and nervous that a state surveyor was observing her. LVN I stated she forgot to lock the medication cart before leaving the cart unattended. LVN I stated that at this time of morning [6:30 AM] there would be very few residents on this hallway up and about. LVN I stated a negative outcome could occur if anyone inappropriately took a medication from the cart. During an interview with the DON on 01/10/2024 at 11:30 AM, the DON stated she had already heard the medication cart had been left unlocked and unattended during a blood glucose check and insulin administration. The DON stated her expectation was for the carts to be locked when left unattended during medication administration. The DON stated nurses were trained in this upon hire, during periodic in-services and during annual competency check-offs. Record review of the facility's policy titled, Medication Storage policy, implemented 1/20/2021, revealed a policy statement, all medications housed on our premises will be stored . sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Under the General Guidelines of the policy Explanation and Compliance Guidelines section, a.) all drugs and biologicals will be stored in locked compartments .c.) during a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 20 of 30 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 01/13/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Record review of Lippincott procedures, Oral Drug Administration, revised 5/21/2023, accessed 1/17/2024, https://procedures.lww.com/lnp/view.do?pId=4420477, revealed under the heading Reducing Medication Risk in an Older Adult, store medications in a secure, dry location away from sunlight. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 21 of 30 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 01/13/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm 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, in that: Residents Affected - Some 1. The ice machine cover was loose and was soiled on the outside. 2. The air fryer was soiled with crumbs inside the machine and contained oil which was dark in color and soiled with crumbs. 3. A staff member's personal jacket was hanging on the corner of a food storage rack in the pantry. 4. The freezer to the right of the door inside the pantry held two cases of frozen hamburger patties which were open, leaving the patties exposed to contaminants and frost. 5. The freezer to the left of the door inside the pantry help a case of frozen cookies and a case of missed vegetables which were open, leaving the patties exposed to contaminants and frost. 6. The drink machine had a sticky residue on the outside. The front sections and handles of each door of both freezers inside the pantry and the large refrigerator inside the kitchen were soiled with sticky residue. 7. The top of the dish machine was soiled with a sand-like residue. 8. Approximately 10 individual vanilla shake cartons and 10 individual milk cartons were left outside of refrigeration for over 30 minutes, until the items were no longer cold to the touch. 9. Chef P, Dietary Aide Q, and Dietary Aide U had goatees and/or beards and were not wearing beard guards. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings were: Observation on 01/12/2024 between 11:00 a.m. and 11:30 a.m. in the facility kitchen revealed: 1. The ice machine cover was loose and was soiled on the outside. 2. The air fryer was soiled with crumbs inside the machine and contained oil which was dark in color and soiled with crumbs. 3. A staff member's personal jacket was hanging on the corner of a food storage rack in the pantry. 4. The freezer to the right of the door inside the pantry held two cases of frozen hamburger (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 22 of 30 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 01/13/2024 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 0812 patties which were open, leaving the patties exposed to contaminants and frost. Level of Harm - Minimal harm or potential for actual harm 5. The freezer to the left of the door inside the pantry help a case of frozen cookies and a case of missed vegetables which were open, leaving the patties exposed to contaminants and frost. Residents Affected - Some 6. The drink machine had a sticky residue on the outside. The front sections and handles of each door of both freezers inside the pantry and the large refrigerator inside the kitchen were soiled with sticky residue. 7. The top of the dish machine was soiled with a sand-like residue. 8. Approximately 10 individual vanilla shake cartons and 10 individual milk cartons were left outside of refrigeration for over 30 minutes, until the items were no longer cold to the touch. 9. Chef P, Dietary Aide Q, and Dietary Aide U had goatees and/or beards and were not wearing beard guards. During an interview with the Dietary Manager on 10/24/2023 between 11:30 a.m. and 11:35 a.m., a walk-through of the facility kitchen was performed, and the Dietary Manager confirmed the Surveyor observations. The Dietary Manager confirmed she was responsible for kitchen sanitation and proper storage of food products and that the deficient practices were oversights. Record review of the facility's policy titled, Sanitation, revised December 2008, revealed, The food service area shall be maintained in a clean and sanitary manner. Record review of the facility's policy titled, Food Receiving and Storage, revised December 2008, revealed, Foods shall be received and stored in a manner that complies with safe food handling practices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 23 of 30 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 01/13/2024 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly, for 1 of 1 facility reviewed, in that: Residents Affected - Few There were a number of varied pieces of furniture and large durable medical equipment were haphazardly stacked near the portable storage units in the facility's back parking lot. This failure could lead to loss of quality of life due to and environment fostering the presence of insects and/or rodents. The findings were: Observation on 01/12/2024 at 11:00 a.m. revealed there were four wheelchairs, one bedframe, three overbed tables, one dresser, all in various states of disrepair, and assorted other refuse stacked near the portable storage units in the facility's back parking lot. During an interview with the Dietary Manager and Floor Technician W on 01/12/2024 at 11:04 a.m., the Dietary Manafer and Floor Technician W stated the assorted broken items had been in the back parking lot for, about a week. Record review of the facility's policy titled, Resident Rights, dated 2/20/2021, revealed, 8. Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports of daily living safely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 24 of 30 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 01/13/2024 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 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 interviews and record reviews, the facility failed to maintain medical records on each resident that were accurately documented for 1 of 8 residents (Resident #78) reviewed for accurate medical records, in that: 1. Resident #78's allergies were documented incorrectly to include acetaminophen [an over-the-counter medication to alleviate pain or fever]. 2. Resident #78's bathing assistance was listed as extensive assistance when he was independent or set up assistance. These deficient practices could affect place residents at risk of not receiving appropriate care through inaccurate documentation possibly resulting in deterioration in condition, exacerbation of disease process, undermedication, or a delay in assessments and treatment. The findings included: Record review of Resident #78's admission Record revealed the resident was a [AGE] year-old man admitted on [DATE], and under the heading, Other Information, the resident's allergies were listed as acetaminophen, and propoxyphene [one of the active medications in Darvocet, a narcotic pain reliever] no longer available]. Further review revealed the resident's admission Record did not address the resident's bathing needs. Record review of Resident #78's quarterly MDS assessment, dated 10/10/2023, revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact, the primary reason for Resident #78's admission was coded as medically complex conditions related to osteomyelitis [infection of the bone]. Further review revealed the resident's MDS did not address the resident's allergies, an in section GG Functional Abilities and Goals, the residents Self-Care Assessment was coded as substantial/maximal assistance with shower or bathe self. Record review of Resident #78's Care Plan, printed 1/11/2024 at 2:36 PM, revealed the focus areas of: - Pain, Verbal: [Resident #78] is at risk for pain, [takes] Norco [a narcotic used to treat moderate pain], gabapentin, and acetaminophen, with a goal of: relieved within a timely manner of receiving pain medications; and will not have any discomfort related to side effects of analgesia with a revision date of 01/11/2024. - ADLs: [Resident #78] has an ADL Self Care Performance Deficit; with the following interventions: Bathing: extensive assist, initiated 03/27/2023; with the following interventions: provide shower, shave, oral care, hair care, and nail care per schedule and when needed, initiated 03/27/2023. Record review of Resident #78's Order Summary Report, dated 01/12/2024, revealed the resident's allergies were listed as acetaminophen and propoxyphene, and an active physician's order for Norco tablet 7.5-325 mg (hydrocodone-acetaminophen): give 1 tablet by mouth every 4 hours as needed for pain, with a start date of 8/28/2023. Further review revealed Resident #78's physician orders did not address bathing assistance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 25 of 30 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 01/13/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #78's MAR for December 2023 revealed the resident received Norco on 12/18/2023 at 6:25 PM and 12/23/2023 at 8:15 AM. Record review of facility's EHR on 1/12/2023, revealed, under allergies tab, acetaminophen reaction hallucinations. Residents Affected - Few Record review of Medication Guide Norco, revised 03/2021, printed from the facility's EHR revealed instructions: Do not take Norco if you have .a known hypersensitive to hydrocodone or acetaminophen or any ingredient in hydrocodone and acetaminophen tablets. Record review of Integrated Patient Education - Medication Leaflets issued 12/06/2023, printed from the facility's EHR 1/12/2023, revealed: A severe and sometimes deadly problem called serotonin syndrome may happen if you take this drug .Call your doctor right away if you have .hallucinations. Record review of Resident #78's [NAME] [a single page indicating instructions on how to care for a resident], as of 01/11/2024, revealed the residents allergies were listed as acetaminophen and propoxyphene, and the resident was indicated to require extensive assistance for bathing. During an interview with Resident #78 on 01/10/2024 at 10:59 AM, Resident #78 stated he had not received a bath in a long time. Resident #78 stated he kept a washcloth and hand towel near his sink or in his closet so that he could, get cleaned up the best I can here in my room. When asked if he needed assistance to bathe the resident stated, Yeah, I need help to shower, but staff don't ever come to actually help me. During an interview with Resident #78 on 01/12/2024 at 11:30 AM, Resident #78 stated he had some pain but the pain was well controlled, and he rarely asked for Norco. Resident #78 stated he was not allergic to Tylenol [acetaminophen] at all. Resident #78 stated no one had asked him about his allergies, and he had not had any problems taking a Tylenol or Norco. During an interview with CNA H on 01/12/2024 at 3:25 PM, CNA H stated Resident #78 was scheduled for shower time on Mondays, Wednesdays, and Fridays. CNA H stated Resident #78 needed some assistance into the shower chair but was independent with bathing. CNA H stated Resident #78 had never informed him of a missed shower or needed additional help with showering. Record review of the facility's Shower Sheet Binder, reviewed on 01/11/2024 and on 01/12/2024, revealed there were no Shower Sheets for Resident #78. During an interview with the DON on 01/12/2024 at 4:00 PM, the DON stated she investigated the allergies as listed on the EHR for Resident #78. The DON confirmed Resident #78 was not allergic to acetaminophen, and further stated the resident did have an adverse reaction to Darvocet, which was a combination of acetaminophen and propoxyphene, before it was pulled from the market. The DON stated she expected residents' allergies to be reviewed for each resident prior to any medication administration. The DON stated the nurse should contact the prescriber whenever there were allergy conflicts with a residents' orders for clarification. The DON stated she would check with the pharmacist on how to adjust Resident #78's allergies to reflect Darvocet as an allergy, but not acetaminophen. The DON stated Resident #78 was independent with bathing as far as she knew. The DON stated Resident #78 was able to assert his needs and preferences and did so frequently. The DON stated the Shower Sheet Binder included 1-2 months, maybe 3 months of Shower Sheets for all the residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 26 of 30 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 01/13/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm During an interview with MDS Coordinator A on 01/12/2024 at 4:30 PM, MDS Coordinator A stated she did not believe there was any harm in listing Resident #78 as needing extensive assistance with bathing when he was independent with bathing. MDS Coordinator A stated she could understand the potential for harm if a resident were listed as independent with bathing but needed extensive assistance. MDS Coordinator A stated the MDS drove many aspects of the residents' Care Plan. Residents Affected - Few Record review of the facility's policy titled, Medication - Treatment Administration and Documentation Guidelines, revised on 4/06/2023, revealed no instructions to review Resident allergies prior to administration of medication. Review of Lippincott procedures, Oral Drug Administration, revised 05/21/2023, accessed 01/17/2024, https://procedures.lww.com/lnp/view.do?pId=4420477, revealed under the heading Implementation, Clinical Alert: Check the patient's medical record for an allergy .If an allergy or contraindication exists, do not administer the medication and notify the practitioner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 27 of 30 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 01/13/2024 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 0880 Provide and implement an infection prevention and control program. 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 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 diseases and infections for 1 of 1 facility, reviewed for infection control in that: Residents Affected - Some Staff of multiple disciplines were not utilizing appropriate PPE over multiple days and various shifts while the facility was experiencing a COVID outbreak. These failures placed all residents at risk for the spread of infection through cross-contamination of pathogens and illness which could result in a decline in health and well-being or even death. Findings included: Record review of COVID Positive Residents, dated 1/09/2024 provided by the DON, revealed 17 residents and 8 staff as COVID positive. In an observation on 1/09/2024 between 12:12 PM and 12:23 PM, CNA VV exited COVID positive room [ROOM NUMBER]. CNA VV did not change PPE gown, gloves or N95 mask and CNA VV was not wearing a face shield or goggles upon exit of room [ROOM NUMBER].; CNA VV then entered COVID positive room [ROOM NUMBER] without doffing or donning and wearing the same PPE gown, gloves and N95 without a face shield or goggles that was worn in room [ROOM NUMBER]. The CNA VV came out of room [ROOM NUMBER] and CNA VV then doffed PPE gown and gloves in the hallway. Observation of CNA VV revealed they did not discard N95 mask or obtain a new one. In an observation on 1/09/2024 at 12:19 PM LVN G was observed to be wearing an N95, when she began to don [to put on] PPE gown and gloves prior to entering COVID positive room [ROOM NUMBER]. LVN G was not wearing a face shield or goggles. LVN G exited the room without gown, gloves, face shield or goggles, wearing N95 mask and her prescription glasses on top of her head. LVN G did not discard N95 mask or obtain a new one. LVN G took meal tray cart with meals packaged in Styrofoam containers on it to another hallway. In an observation on 1/09/2024 at 12:24 PM, CNA H was observed wearing an N95 mask when he began to don PPE gown and gloves, prior to entering COVID positive room [ROOM NUMBER]. CNA H was not wearing a face shield or goggles. CNA H exited the COVID positive room [ROOM NUMBER] without gown, gloves, face shield or goggles. CNA H did not discard N95 mask or obtain a new one. In a group interview on 1/09/2024 between 12:31 and 12:55 PM, with LVN G and CNA H, LVN G stated the building has had COVID 4 or 6 times that she can remember. LVN G stated they doff [to remove] the PPE gown and gloves into a biohazard box located in the residents' rooms. LVN G stated she had not been trained to discard the N95 mask upon exiting a COVID positive room. CNA H stated he had not been trained to discard the N95 upon exiting a COVID positive room. CNA H questioned if he would be exposing himself to COVID by changing the mask in the hallway. CNA H stated he had not considered that he would be carrying COVID germs into another resident's room on the N95 mask he wore while working with a COVID positive resident. LVN G stated the infographics describing how to don and doff PPE which were posted on the doors of COVID positive rooms had been made in the peak of pandemic when a COVID outbreak usually had many more patients all at once. LVN G stated back then the facility had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 28 of 30 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 01/13/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm dedicated staff to care for COVID positive residents in hot zones and these signs did not apply now when staff were responsible for both COVID positive and non-COVID positive residents. LVN G stated that currently every hall, except the locked unit had a few COVID positive residents on it. LVN G stated that the only reason to discard the N95 mask would be if it were damp, soiled, or damaged. LVN G stated a new N95 mask is donned at the start of each shift. Residents Affected - Some In an interview on 01/09/2024 at 1:59 PM, the DON stated the facility currently had 16 residents that were COVID positive and 8 staff members that were COVID positive. The DON stated the outbreak started on Saturday 01/06/2024. The DON stated in-servicing was initiated immediately but was considered a refresher as all staff have been through a COVID outbreak at this facility. The DON stated her expectation is that staff wear N95 mask at all times and that staff would don PPE that included gown, gloves, face shield or goggles prior to entering a COVID positive room. DON stated her expectation was that, upon exit, staff should doff the gown and gloves into the biohazard box in the room. Upon exiting the room, the face shield or goggles should be sanitized or discarded, and the N95 mask should be discarded. In an observation and interview on 1/10/2024 at 5:20 AM, LVN I was observed sitting at the nurses' station not wearing a face mask. When asked why she was not wearing it, LVN I stated it was because she was taking a break and in a non-patient care area. LVN I stated that by not wearing a face mask she risked possible exposure of COVID to vulnerable residents and nursing staff. In an observation and interview on 1/10/2024 at 5:30 AM, LVN J was observed wearing a surgical mask while preparing to administer medications at the nurses' station. When asked why he was wearing a surgical mask and not an N95, LVN J stated he was wearing a surgical mask as he was told by his supervisor that this was enough protection from COVID during an outbreak. LVN J stated that residents did not risk exposure to COVID from him as he had been vaccinated for COVID. In an observation and interview on 1/10/2024 at 5:45 AM, LVN K; CNA L and CNA M were observed with an N95 mask worn incorrectly under the chin while rounding on hall C/D. When asked why they were wearing a N95 mask this way, LVN K stated they wear the mask on their chin and then pull it up as they go to a resident's room. When asked what the consequences to a resident by them wearing a N95 mask inappropriately, CNA L and CNA M responded that they risked exposing residents to COVID. In an observation and interview on 1/10/2024 at 6:05 AM, CNA N was observed entering a COVID positive room then entering a non-COVID positive room without discarding his N95 mask. When asked if he had changed masks between a COVID positive and COVID negative room, CNA N stated he was told that he must wear the same N95 mask all shift and at the end of shift throw it away and get a new one on next scheduled shift. In an interview on 1/10/2024 at 9:55 AM, HSKG O stated she doffs the gloves and gown at the resident's door and throws those items in a small trashcan in the hallway. HSKG O stated she tried to tell her supervisor there should be a trash inside the resident room; however, HSKG O was told continue to use the one in the hallway. HSKG O stated that most of the residents didn't like having a trashcan in their rooms. HSKG O stated she was told to change her mask at the end of the day, but she changes it before she leaves each hallway. In an observation and interview on 1/10/2024 at 10:00 AM, two EMS workers were observed to be exiting the building with a resident in transport to dialysis appointment. The receptionist stated she had left the desk briefly and doesn't recall if she is the one that let them in or maybe they didn't (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 29 of 30 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 01/13/2024 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 0880 see the sign upon entering. Level of Harm - Minimal harm or potential for actual harm In an observation and interview on 1/12/2024 at 10:04 a.m. DA P and DA Q were observed not wearing masks or beard guards while in the kitchen preparing meals for residents. DA P and DA Q both carried forward that they were preparing food and stated, I just took it [mask] off right now. Residents Affected - Some In an observation and interview on 1/12/2024 at 2:45 PM, CNA R and HSKG S, were observed wearing an N95 mask incorrectly with only the top strap around their head and the second strap loose under their chin. Gaps between the cheekbone/jaw area and the mask could be observed. Both stated no one had told them that that was wrong. CNA R stated the facility does not have the mask she prefers and the two straps over the top of her head are too tight and leave marks on her face. HSKG S asked this surveyor if it was incorrect to wear it that way. Redirected to her facility management. Record review of COVID Positive Residents, provided 1/12/2024 by the DON, revealed an increase to 21 residents currently COVID positive. Record review of In-Service, on the topic COVID-19, dated 1/06/2024, revealed signatures of the 26 staff members on duty. Content included Coronavirus Disease 2019, How Coronavirus Spread leaflet published by the CDC; undated COVID-19 Symptoms and Treatment leaflet, unknown source; undated Hand Hygiene leaflet, unknown source; undated COVID 10: What you need to know, published by the CDC in English and Spanish; undated and blurry, Sequence for Putting on PPE, published by the CDC; undated and blurry, How to Safely Remove PPE examples 1 and 2, published by the CDC; undated and blurry, bilingual English/Spanish, Respiratory Hygiene, Cough Etiquette, unknown source; undated and blurry, COVID-19 Stop the Spread of Germs infographic, published by the CDC; undated Cover Your Cough infographic, published by the CDC; undated, bilingual English/Spanish Wash Your Hands infographic, unknown source. Record review of facility's COVID-19 Response for Nursing Facilities, version 4.4 dated 11/28/2022, revealed, section 2. titled, To Do's for Nursing Facilities: .Staff who are caring for residents inside isolation or quarantine areas must wear an N95 and all CDC suggested PPE .Under the Section 4. titled, Immediate Response Guidelines, instructions to read PPE Donning and Doffing Infographic. Further instructions direct health care personnel, directly before exiting the isolation room, remove all PPE except respirator [N95 mask] and face shield or goggles; After exiting the isolation room, perform hand hygiene; Doff eye protection, then respirator respectively. If the facility is sharing staff among different cohorts [ of COVID positive residents] .must ensure they are following all infection prevention and control policies. Under section 5. Interim Guidance for .Outbreaks, under the subheading, PPE Use when Caring for Residents with COVID, staff should wear all suggested PPE; all suggested PPE includes N95 respirator, eye protection [face shield or goggles] gloves and gown. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 30 of 30