Inspection·March 31, 2023

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some scheduled with the previous primary care doctor in May of 2023. The DON stated the resident had not seen a cardiologist. The DON stated they normally took vitals on the resident to monitor his pacemaker. The DON stated they monitor for vitals for pulse below 60 beats per minute. The DON stated they would contact the provider if the pulse was below 60 bmp. The DON they stated should have been notifying the provider but there was no nursing notes documented for contacting the provider for pulse vitals that read below 60 beats per minute (bpm) in September of 2022. The DON stated the resident was sent to the ER on [DATE] for respiratory distress. The DON stated they did not need to perform cardiac resuscitation. Record review of Resident #13's pulse vitals below 60 bpm, dated 03/28/23, revealed .06/17/22-58 bpm irregular-new onset .06/23/22-59 bpm irregular-new onset .06/28/22-bpm irregular-new onset .06/29/22-58 bpm irregular-new onset .08/6/22-59 bpm regular .09/07/22-16 bpm regular .09/11/22-58 bpm regular .09/25/22-59 bpm regular .10/17/22-59 bpm regular .10/29/22-56 bpm regular .11/6/22-56 bpm regular . 01/15/23-56 bpm regular .01/28/23- 59 bpm regular Record review of the Facility's policy titled Pacemaker, Care of a Resident with a: the purpose of this procedure is to provide information about and guidance for the care of a resident with a pacemaker. Definition 1. an abnormality in the conduction of electrical impulses that affects the normal heart rate rhythm is an arrhythmia. 2. The two most common arrhythmias that require a pacemaker are sinus bradycardia and heart block. A. Sinus bradycardia occurs when the sinoatrial node is not functioning properly, resulting in an abnormally slow heart rhythm .3. Pacemakers are electronic devices that artificially stimulate the heart muscles with electrical impulses when the heart rhythm is too slow ([NAME] cardia). 4. pacemakers are programmed to sense the heart and respiratory rate and to administer electrical pulses when the heart rate falls below a set threshold. 5. pacemakers can be permanently implanted or temporary . Complications: 1. if the pulse generator or battery fails, or if the leads become displaced the pacemaker will not work properly, leading to [NAME] arrhythmias. Monitoring: 1. monitor the resident for pacemaker failure by monitoring for signs and symptoms of [NAME] arrhythmias .3. The pacemaker battery will be monitored remotely through telephone or an Internet connection. The resident cardiologist will provide instructions on how and when to do this. 4. The Resident will have an EKG as ordered, to monitor for changes in the heart's electrical activity. 5. Make sure the resident has a medical identification card that indicates he or she has a pacemaker. The medical record must contain this information as well. When the resident is transferred to another facility, this information must be communicated to the receiving facility in the discharge summary. 6. Pacemaker batteries and generator will be replaced by a cardiologist as needed, usually every five to eight years. Documentation: 1. for each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission: a. the name, address and telephone number of the cardiologist; b. type of pacemaker; c. type of leads; d. manufacturer and model; e. serial number; f. date of implant; g. paced rate; FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675896 If continuation sheet Page 2 of 13 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 675896 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River City Care Center 921 Nolan St San Antonio, TX 78202 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 - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, record review and interviews, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent accident for 33 of 33 residents living in the facility. There were 2 yellow gas cans containing 5 gallons of gasoline each observed in the laundry room. This deficient practice could affect residents who lived in the facility. The findings were: Observation on 03/31/2021 at 11:53 a.m. revealed two 2 yellow gas cans containing 5 gallons of gasoline each near the doorway of the laundry room where dirty laundry is brought in. During an interview with the Housekeeping Supervisor on 03/31/2023 at 12:10 p.m., the Housekeeping Supervisor explained, the two yellow containers in the laundry room, belonged to the Maintenance Department and had been in the laundry room since the previous morning. During an interview with the Maintenance Supervisor on 3/31/2023 at 12:30 p.m., the Maintenance Supervisor explained the two yellow containers, containing gasoline, were used for the generator during the power outage, the previous morning. He said, he placed them in the laundry area, the previous morning, after refilling them. He said, they should not have been placed there. During an interview with the Administrator on 03/21/2023 at 1:10 p.m., the Administrator explained the Maintenance Supervisor should not have stored the two yellow containers, containing gasoline, in the laundry area. The Administrator further stated , there is a specific designated separate storage area for items such as gas cans. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675896 If continuation sheet Page 3 of 13 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 675896 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River City Care Center 921 Nolan St San Antonio, TX 78202 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 observation, interview, and record review, the facility failed to ensure each resident who was incontinent of bowel/bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #32) reviewed for incontinent care, in that: CNA C did not use proper technique when providing incontinent care and catheter care to Resident #32. This deficient practice could place residents at risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #32's face sheet, dated 03/31/2023, revealed an initial admission date of 09/21/2022 with diagnoses that included neuromuscular dysfunction of bladder (occurs when a person's nerves, spinal cord, or brain have problems sending electrical signals to the bladder. This causes difficulty with urination). Record review of Resident #32's MDS, a Quarterly assessment dated [DATE], revealed under Section C her BIMS score was 03 out of 15, which indicated severe impaired cognition. Review of Section G functional status revealed the resident required extensive assistance and 2 plus person assist with toileting. Review of Section H urinary continence and bowel continence showed the resident had an indwelling catheter (a closed sterile system with a catheter and retention balloon that is inserted either through the urethra or suprapubically (above the pubic area) to allow for bladder drainage). Record review of Resident #32's care plan, dated 01/18/2023, revealed Indwelling Catheter and bowel incontinence with intervention to provide pericare after each incontinent episode. During an observation on 03/02/2023 at 4:07 p.m. CNA C provided incontinent care to Resident #32. Resident #32 had indwelling catheter through the urethra. CNA C washed her hands and explained the care she would be providing to Resident #32. CNA C cleansed Resident #32's anterior (front) perineal area and between the vaginal labia wiping front to back direction. CNA C then cleaned the posterior (back) perineal and buttocks area wiping in a back to front direction stopping at the perineum (area between the vaginal opening and anus) area each time. During an interview on 03/29/2023 at 12:11 p.m. CNA C stated she wiped the resident in a downward motion, from back to front, and swirl at the end. CNA C stated they were trained this was acceptable as long as they turned in an outward direction before they got all the way to the front vaginal area. During an interview on 03/02/2023 at 4:32 p.m. the DON stated CNA C had been a CNA for about a year. The DON stated she would need to check into how they were being trained with the turning motion. The DON stated regardless peri care should always be a front to back wiping motion to prevent moving germs towards the catheter or vaginal area. Record review of a document titled Inservice Training Attendance Roster, dated 08/14/2022, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675896 If continuation sheet Page 4 of 13 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 675896 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River City Care Center 921 Nolan St San Antonio, TX 78202 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 contained a checklist with CNA C's signature on it. Attached was a facility's policy titled Perineal Care, dated 02/2018, that reflected, Purpose: The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident skin condition. Preparation 1. review the resident's care plan to assess for any special needs of the resident . for a. female resident: a wet washcloth and apply soap or skin cleansing agent. B. Wash perineal area, wiping from front to back. 1) separate the labia and wash area downward from front to back. [note: if the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down to the catheter about 3 inches gently rinse and dry the area.] continue to wash the perineum moving from inside outward to the thighs, rinse the perineum thoroughly in the same direction, using fresh water and a clean washcloth. The resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. 4. Gently dry the perineum. C. Ask the resident to turn on her side with her top leg slightly bent able. D. rinse wash cloth and apply soap or skin cleansing agent. E. wash the rectal area thoroughly wiping from the base of the labia towards an extending over the buttocks. F. rinse and dry thoroughly. Record review of facility's policy tiled Catheter Care, dated 02/13/2007, reflected General Guidelines: 7. provide perineal care to the incontinent resident to prevent skin rashes and breakdown. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675896 If continuation sheet Page 5 of 13 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 675896 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River City Care Center 921 Nolan St San Antonio, TX 78202 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 assure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, for 2 of 9 residents (Resident #4 and Resident #17) reviewed for labeling and storage, in that: 1. The pharmacy label for Resident #4's prescription was missing an expiration date. 2. Resident #17's Carvedilol (medication used to lower blood pressure) was incorrectly labeled to administer the medication through the route of a percutaneous endoscopic gastrostomy (an endoscopic medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall) instead of by mouth. This deficient practice could affect residents prescribed medications in the facility and place them at risk for not receiving the correct medications. The findings were: 1. Record review of Resident #4's admission record, dated [DATE], revealed an admission date of [DATE] with diagnoses that included dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), type 2 diabetes (a condition results from insufficient production of insulin, causing high blood sugar), and hypertension (high blood pressure). Record review of Resident's #4's physician's order summary, dated, [DATE], revealed an order for insulin aspart solution n100 unit/mL inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6units; 301 - 350 = 8 units; 351 -400 = 10 units., subcutaneously before meals related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS with a start date of [DATE] and no end date. During an observation on [DATE] at 4:15 p.m. revealed LVN A administered aspart insulin to Resident #4. The vial of insulin contained the Resident information, the name of the medication aspart solution, the concentration 100 units/mL, and the expiration date had a black line through it and was not visible on the pharmacy label. During an observation and interview with LVN A on [DATE] at 9:12 a.m. revealed the cart contained several blister packs of medications and the expiration dates were not visible or had a black line through them. LVN A stated she could not see the expiration dates and was not sure why one had a black line through it. LVN A stated she knew they were not expired because she looked at the date on the pharmacy label for when it was dispensed from the pharmacy. LVN A stated she would notify the DON to alert the pharmacy of this issue. During an interview on [DATE] at 3:48 p.m. the DON stated they would need to talk to the pharmacy about the expiration dates not being visible on the prescription pharmacy labels. The DON stated the pharmacy said they did this when they were not able to read the expiration date. The DON stated the pharmacy stated they should also be adding an orange label that contained the missing information. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675896 If continuation sheet Page 6 of 13 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 675896 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River City Care Center 921 Nolan St San Antonio, TX 78202 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 The DON stated none of the prescriptions were coming with the orange labels and they planned to address that with the pharmacy. 2. Record review of Resident #17's admission record, dated [DATE], revealed an admission date of [DATE] with diagnoses that included dissection of cerebral arteries (is a tear of the inner layer of the wall of an artery) and essential hypertension (high blood pressure). Record review of Resident's #17's physician's order summary, dated, [DATE], revealed an order for Carvedilol Tablet 25 MG Give 1 tablet by mouth two times a day for htn May hold for Sbp<110 or HR < 60 with a start date of [DATE]. During an observation on [DATE] at 8:25 a.m. revealed MA B administered Resident #17 25 mg of Carvedilol. The blister pack of medication contained a label with directions to administered the 25 mg of carvedilol per the PEG tube twice a day. MA B stated Resident #17 used to have a PEG tube but had not had it for a while. MA B stated she would notify the charge nurse and place a order change sticker on the blister pack. During an interview on [DATE] at 3:48 p.m. the DON stated Resident #17 had a PEG tube when he was first admitted to the facility. The DON stated the pharmacy needed to correct the order on their end. The DON stated they had updated the order in the EMR and was not sure how the pharmacy had not had it updated on their end. The DON stated they should have put a change of direction sticker to eliminate any confusion. Record review of the Facility's policy titled Storage of Medications, dated 11/2022, stated Policy Heading: The facility stores all drugs and biologics in a safe, secure, and orderly manner. Policy interpretation and implementation: .4. drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675896 If continuation sheet Page 7 of 13 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 675896 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River City Care Center 921 Nolan St San Antonio, TX 78202 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 safety in the facility's only kitchen. Residents Affected - Some The facility failed to ensure food items in the freezer were dated, labeled, and sealed appropriately. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: Observations of the facility's kitchen freezer on 03/28/2023 at 10:35 a.m. revealed the following items were not labeled and or dated: - One bag of approximately 25 brown round items approximately 1.68 inches in diameter, identified as meatballs by the CDM, partially open, not completely sealed, (exposing the items previously identified as meatballs to air), unlabeled and undated. - One 5lb bag of item labeled heat and serve brats ,(a type of link like sausage also called bratwurst), approximately 50 percent full, unlabeled, and undated , with a white substance identified as ice (by the CDM), covering the items in the bag. - One unlabeled and undated gallon size plastic bag, enclosing items identified by the CDM as maybe tamales, with a white powdery substance identified as ice inside the bag. - One unlabeled and undated plastic bag of what was identified by the CDM as sausage rings - One unlabeled and undated package of approximately 50 items approximately 1 inch in diameter identified as flatwater cornbread by the DM, each covered in a white substance identified as ice by the DM. In an interview and observation on 3/28/2023 at 10:35 a.m., the CDM said, if we question an items in any way we just throw it away. She explained, the items described above should not have remained in the freezer and if at any point it was noted the items appeared to be compromised, in any way, they should be discarded to prevent compromising the Residents well- being. She further stated items in the freezer should have been closed, labeled, and dated but were not as they should have been. She threw them away after viewing them the items with Surveyor . According to the DM all kitchen staff was responsible for ensuring kitchen items were labeled and dated. In an interview on 03/30/23 11:04 a.m., the DM stated, the food items,stacked in front of the fans within the freezer, made the ice get in the bags I think . The DM further stated, Someone could get sick if they were served the food with the ice on it, and went on to say we would not serve the stuff that had the ice on it, but it should have been thrown away. The DM also stated, we should have had them in bags and labeled with name and date on each one when referring to the items viewed in the kitchen with the Surveyor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675896 If continuation sheet Page 8 of 13 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 675896 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River City Care Center 921 Nolan St San Antonio, TX 78202 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 Food Storage and Supplies Policy provided by the facility Administrator revealed: Level of Harm - Minimal harm or potential for actual harm 1. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened. Residents Affected - Some 6. If an item does not have a dated designated by the manufacture as an expiration date, then the item should be dated when it is received. A record review of the August 2021 version of the TFER reflected the following: (b) The department adopts by reference the U.S. Food and Drug Administration (FDA) Food Code 2017 (Food Code) and the Supplement to the 2017 Food Code. The U.S. Public Health Service, Food Code, dated 2017 revealed the following regarding marking the date of food when prepared and when the original container was opened: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (B) of this section. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675896 If continuation sheet Page 9 of 13 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 675896 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River City Care Center 921 Nolan St San Antonio, TX 78202 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 0912 Level of Harm - Potential for minimal harm Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation , interview, and record review the facility failed to ensure that 47 of 49 multiple occupancy Resident rooms provided a minimum of 80 square feet per resident room. Residents Affected - Many This deficient practice could affect all residents in need of at least 80 square feet of living space and could pose problems in the Residents' activities of daily living. The findings were: During an interview with the Administrator on 3/28/2023 at 6:10 p.m. the Administrator revealed she wanted to continue with the room waiver on all resident rooms, which did not meet the required square footage. Information provided revealed the following measurements for resident rooms: Rooms: #1 (146) 73 square feet with 1 bed in the room #2 (146) 73 square feet with 2 beds in the room #3 (147) 73.5 square feet with 2 beds in the room #4 (147.6) 73.8 square feet with 2 beds in the room #5 (147.1)73.5 square feet with 2 beds in the room #7 (147) 73.5 square feet with 2 beds in the room #9 (146.3) 73.1 square feet with 2 beds in the room #10 (146.3) 73.15 square feet with 2 beds in the room #11 (147.1) 73.5 square feet with 2 beds in the room #12 (147.1) 73.5 square feet with 2 beds in the room #13 (146.9) 73.4 square feet with 2 beds in the room #14 (146) 73 square feet with 2 beds in the room #15 (132.6) 66.3 square feet with 2 beds in the room #16 (138.4) 69.2 square feet with 2 beds in the room #17 (138.5) 69.2 square feet with 2 beds in the room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675896 If continuation sheet Page 10 of 13 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 675896 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River City Care Center 921 Nolan St San Antonio, TX 78202 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 0912 #18 (139.4) 69.7 square feet with 2 beds in the room Level of Harm - Potential for minimal harm #19 (139.6) 69.8 square feet with 2 beds in the room #20 (139.6) 69.8 square feet with 2 beds in the room Residents Affected - Many #21 (142.4) 71.2 square feet with 2 beds in the room #22 (148.403) 74.20 square feet with 2 beds in the room #23 (147.811) 73.91 square feet with 2 beds in the room #24 (148.282) 74.14 square feet with 2 beds in the room #25 (147.465) 73.73 square feet with 2 beds in the room #26 (148.664) 74.33 square feet with 1 bed in the room #27 (147.919) 73.96 square feet with 2 beds in the room #28 (146.937) 73.47 square feet with 2 beds in the room #29 (147.571) 73.79 square feet with 2 beds in the room #30 (152.176) 76.09 square feet with 2 beds in the room #32 (158.190) 79.10 square feet with 2 beds in the room #34 (149.669) 74.83 square feet with 2 beds in the room #35 (162.480) 81.24 square feet with 2 beds in the room #36 (148.516) 74.26 square feet with 2 beds in the room #37 (155.894) 77.95 square feet with 2 beds in the room #38 (150.499) 75.25 square feet with 2 beds in the room #39 (147.921) 73.96 square feet with 2 beds in the room #40 (147.244) 73.62 square feet with 2 beds in the room #41 (149.234) 74.62 square feet with 2 beds in the room #42 (157.707) 78.85 square feet with 2 beds in the room #43 (160.834) 80.42 square feet with 2 beds in the room #44 (157.169) 78.58 square feet with 2 beds in the room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675896 If continuation sheet Page 11 of 13 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 675896 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River City Care Center 921 Nolan St San Antonio, TX 78202 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 0912 #45 (157.169) 78.58 square feet with 2 beds in the room Level of Harm - Potential for minimal harm #46 (155.038) 77.52 square feet with 2 beds in the room #47 (153.302) 76.65 square feet with 2 beds in the room Residents Affected - Many #48 (153.728) 76.86 square feet with 2 beds in the room #49 (149.055) 74.53 square feet with 2 beds in the room #50 (148.311) 74.311 square feet with 2 beds in the room #51 (159.466) 79.73 square feet with 2 beds in the room Information provided by the facility on 03/28/2023 revealed a census of 33 Residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675896 If continuation sheet Page 12 of 13 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 675896 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River City Care Center 921 Nolan St San Antonio, TX 78202 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and interview the facility did not provide a safe, functional, sanitary comfortable, environment for residents, staff, and the public for 1 of 1 laundry facilities reviewed for environment, in that: Residents Affected - Few 1. Inside 2 of 2 dryers contained multiple area of unknown dark hard substance and medical tape. 2. 2 of 2 dryers had a thick layer of lint in the lint trap. This failure could place residents at risk of a diminished quality of life due to exposure to an environment that is uncomfortable, unsafe, and unsanitary. The Findings Were: During an observation on 03/31/23 at 11:45 a.m. revealed the facility's laundry room contained two dryers. The lint trap under both dryers was covered in a thick layer of lint. Some lint had fallen on the bottom of the dryer. A note was hanging on the side of the dryer reflecting to clean the lint trap every hour. The inside of one dryer contained 8 different areas of an unknown dark brown hard substance and medical tape stuck inside. The 2nd dryer had 5 areas of an unknown dark brown hard substance. The floor was dirty. The folding table had a package of crackers on it and a cup of condiments. The bottom shelf of the laundry folding table had unknown white substance. The top of one dryer had a toolbox and cardboard box stacked on top of each other and wedged in between the top of the dryer and ceiling. During an interview with the Housekeeping Supervisor on 03/31/23 at 12:07 p.m. she stated the dryer vents should not contain that much lint and should have been cleaned out so they would not catch fire. She stated they did not have a log to track when the lint was cleaned out. She stated the brown stains inside the dryers were melted plastic. She stated the substance should be removed to prevent it from ruining any residents' clothes. No policy was provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675896 If continuation sheet Page 13 of 13