Inspection·July 10, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few A]. She confirmed that he was her CNA .When asked if she had ever seen him with a water gun, she stated that he had brought one into her room recently and squirted her with it while she laid in bed. She reported that she was not bothered by this act but did think it bizarre behavior.[Resident #16] a resident on the same section of hallway/CNA assignment as the alleged victim, acknowledged that he knew [CNA A] as his weekend CNA. He confirmed that [CNA A] had brought a water gun to the facility and squirted him with it while in his room. He did not feel negatively toward this act and asked that [CNA A] not get in no trouble for this behavior . During an interview on 06/18/2025 at 11:44 a.m. Resident #12 stated she was terrified and scared when she awoke in her room to CNA A splashing water into her mouth with a pistol. Resident #12 stated CNA A had dropped a remote on her arm that caused her pain earlier that day and she told him not to do that again. Resident #12 stated CNA A told her he would do it as many times as he wanted. Resident #12 stated she reported the incident to CNA B on 05/28/2025. During an interview on 06/19/2025 at 12:08 p.m. CNA D stated she knew of an outdoor water activity where they threw water balloons but never saw or knew of any activities that involved water guns. CNA D stated no residents ever reported to her being squirted with a water gun. CNA D stated Resident #12 hallucinated before, but they did a UA (urine analysis), and she had a UTI. During an interview on 06/19/2025 at 1:01 p.m. CNA A stated there was an outdoor activity Resident #12 was never involved in and the water gun was left over from the facility activity. He stated he never sprayed any residents with a water gun only other staff in the dining room area. CNA A stated Resident #33 vouched for him that he never sprayed any residents with the water gun. He stated he was suspended pending the investigation around 05/29/2025 and terminated on 06/05/2025. CNA A stated if residents were squirted with a water gun and did not approve of it, it could make them mad and it would bother them. During an interview on 06/19/2025 at 1:24 p.m. Resident #33 stated she used to share a room with Resident #12, but she had since been moved due to her watching the TV loudly. Resident #33 stated Resident #12 had delusions of a man in the window or her family in the room that was not there. Resident #33 stated Resident #12 had a UTI that had caused her delusions and once treated she did not have any more. Resident #33 stated CNA A did squirt them with a water gun before, but she had fun and only wished she had a water gun to squirt him back. During an interview on 06/19/2025 at 3:06 p.m. the Administrator stated Resident #12 told her about the incident during her afternoon rounds . The Administrator stated Resident #12 told her about how the CNA A dropped the remote on her arm and the resident found it to be malicious. The Administrator stated Resident #12 told her about being squirted in the mouth by CNA A. The Administrator stated Resident #12 felt humiliated, embarrassed, and annoyed by CNA A's childish behavior. The Administrator stated Resident #12 had issues with clarity but after she interviewed a few other residents they also stated CNA A had squirted them with a water gun while they were in bed. The Administrator stated CNA A worked weekends only and was suspended during the investigation and later terminated after the investigation was completed. Record review of a facility incident summary for intake #1012723, dated 06/03/2025, revealed the immediate actions taken regarding CNA A and Resident #12 included: Nursing staff performed head to toe assessment on resident. CNA A was contacted and suspended. Trauma informed PRN assessment was completed with the resident. A report was filed with [city] police department. Messaged were left to inform family of alleged incident. RP [name] returned call and was notified on 06/02/2025. The conclusion revealed, The allegation that [CNA A] dropped a bed remote on resident's arm and stated that he would ‘do it as many times as he wanted' despite her protest is UNCONFIRMED. Findings: [CNA A] denies the allegation. There were no eyewitnesses to the alleged incident. No physical injury consistent with the event was documented during the head-to-toe assessment. No corroborating witness statements exist. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675896 If continuation sheet Page 2 of 16 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 07/10/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few document also revealed, The allegation that, later the same day, [CNA A] entered [Resident #12]'s room while she was sleeping and squirted a water gun in her mouth is PARTIALLY CONFIRMED. The use of a water gun on residents was confirmed by multiple witnesses, which lends credibility to [Resident #12]'s claim. However, the specific act of squirting water into her mouth while asleep could not be directly verified. The overall behavior pattern was confirmed, though the specific incident remains UNCONFIRMED. Findings: [CNA A] denies this specific incident but admits to having used a water gun on residents in common areas. Two other residents [#33, #16] independently confirmed that [CNA A] had brought a water gun into their rooms and squirted them with it. While those residents did not find the behavior harmful, they substantiated the pattern of bringing and using a water gun in resident areas. Staff members interviewed had no witnessed the behavior but also did not directly contradict the claims. The Administrator completed the summary. 2) During an interview on 6/18/25 at 11:44 a.m., Resident #12 stated CNA A's family member, CNA C after the incident, delivered a food tray to her room and put it down so hard she thought the food was going to fall off the tray. Resident #12 stated CNA C stated she would not come into the resident's room alone because the resident may tell people she hit her. The resident stated this made her feel guilty and a little afraid because she does not like to argue with people. During an interview on 07/08/2025 at 12:52 p.m., the Administrator stated she did not recall being informed on 06/19/2025 by HHSC Surveyor L that Resident #12 reported to the HHSC Surveyor L that CNA C had put Resident #12's food down so hard she thought the food would fall off the tray, CNA C told Resident #12 she could not take care of Resident #12 alone because Resident #12 may tell people CNA C hit her and Resident #12 reported feeling guilty and afraid after the interaction. The Administrator stated if she had been notified, she would have suspended CNA C and started an investigation into the allegation. During an interview on 07/08/2025 at 1:30 p.m., Resident #12 stated she remembered a female CNA going into her room and stated, she slammed my tray down really hard, and she had an angry look on her face. Resident #12 stated CNA C said, I just cannot be in here I have to have someone else with me because I don't want you to say I hit you. Resident #12 stated it scared her when the incident occurred and stated, she doesn't take care of she and she doesn't like to take care of me. Someone else brings me my meals. Resident #12 stated she told someone about the incident but did not remember who she told. During an interview on 07/08/2025 at 1:50 p.m., CNA C stated she had received training on abuse and neglect and reporting abuse and neglect to the Abuse Prevention Coordinator that CNA C identified as the Administrator. CNA C stated she was notified by RN K on 05/31/2025 that Resident #12 reported to RN K that CNA C was being mean to her. CNA C stated she immediately called the Administrator to report the allegation Resident #12 made against her and the Administrator told CNA C that she could not refuse to provide care to Resident #12. CNA C stated she also called and reported the allegation to the DON. CNA C stated she had the phone call logs to prove that she contacted the Administrator and the DON to report the allegation. CNA C stated she was never interviewed or suspended related to the allegation. During an interview on 07/08/2025 at 2:15 p.m., the Administrator stated she was presented an IJ template on 06/20/2025 and stated she signed the template without reading the information on the template that included the allegation against CNA C. The Administrator stated, after reading the template on 07/08/2025, the Administrator acknowledged that the allegation toward CNA C was on the template and stated she was suspending CNA C on 07/08/2025 and initiated an investigation into the allegation. The Administrator stated she recalled having a conversation with CNA C around the time of the investigation into CNA A but did not recall CNA C reporting to the Administrator that Resident #12 was alleging that CNA C was mean to Resident #12. During an interview on, 07/08/2025 at 2:39 p.m., the DON stated staff had received (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675896 If continuation sheet Page 3 of 16 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 07/10/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few training on abuse and neglect and all abuse allegations should be reported immediately to the Abuse Prevention Coordinator who was the Administrator. The DON stated she did not recall receiving a call from CNA C regarding an allegation made by Resident #12 on 05/31/2025. The DON stated intimidation was a form of abuse and should have been investigated immediately. During an interview, 07/08/2025 at 2:54 p.m., HHSC Surveyor L stated she met with the Administrator on 06/19/2025 at 3:06 p.m. and notified the Administrator of the allegation Resident #12 was making toward CNA C. HHSC Surveyor L stated she discussed retaliation with the Administrator due to the incident with CNA C occurring after CNA A was suspended and the fact that CNA C and CNA A were in a relationship. Record review of a facility IJ Template, dated 06/19/2025 at 11:06 a.m., revealed, Resident #12 stated CNA A's [family member], CNA C after the incident, delivered a food tray to her room and put it down so hard she thought the food was going to fall off the tray. Resident #12 stated CNA C stated she would not come into the resident's room alone because the resident may tell people she hit her. The resident stated this made her feel guilty and a little afraid because she does not like to argue with people. The template revealed, The Administrator stated CNA A was terminate and CNA C had called in for most of her shifts since the incident and has not worked with the resident. The template revealed, Resident #12 was terrified and scared. She also felt guilty and afraid from CNA C's visit. The template was signed by the Administrator and HHSC Surveyor L on 06/20.2025. Record review of the facility's Abuse/Neglect policy, dated 3/29/18, reflected The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility . This was determined to be an Immediate Jeopardy on 07/08/2025 at 4:40 p.m. The Administrator was notified of the IJ and provided the IJ Template 07/08/2025 at 5:06 p.m.On 07/08/2025 the facility provided a plan of removal titled: Plan of Removal F600. The plan of removal was accepted on 07/09/2025 at 2:18 p.m. It was documented as follows: Plan of Removal F600Problem: FREE FROM ABUSE AND NEGLECTInterventions:One on One in-service on Abuse Investigation with the Administrator/DON was conducted by the Regional Compliance Nurse on 7/8/2025. This in-service included reviewing and conducting timely investigations for allegations. Staff working with Alleged perpetrators (CNA A and CNA C) have been interviewed on 7/8/2025.The alleged perpetrator, CNA C, was suspended on 7/8/25.Resident safe surveys were completed on 7/8/25.Un-interviewable residents had a head-to-toe assessment completed on 7/8/25.The following in-services were initiated on 7/8/25 and any staff member not present or in-serviced on 7/8/25, will not be allowed to assume their duties until in-services have been completed. Any new employees or agency staff if utilized will receive the following in-services before first shift to be worked.All StaffAbuse/NeglectAbuse/Neglect ReportingWho to Report Abuse/Neglect toInservice included reporting timelines and abuse and neglect coordinator notification. The medical director was notified of the immediate jeopardy situation on 7/8/25 at 4:40 pm. Followed by a text message notification to him on 7/8/2025 notifying him of the active IJ issuance. On 5/28/2025, CNA A was presented with suspension via telephone. On 6/2/25 CNA A was terminated from employment. On 5/29/2025, a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675896 If continuation sheet Page 4 of 16 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 07/10/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few police report was filed regarding allegation of abuse from CNA A. Report Case Number: [case number] was taken by [Officer Name]. On 5/29/2025, a trauma informed assessment was completed for Resident #12 which was negative for findings that required follow up interventions. On 7/8/25 a second Trauma Informed Assessment was completed for resident #12.CNA C was interviewed by the Administrator and refused to comment or give a statement on 7/8/25.7/8/25 Staff that worked with perpetrator were interviewed and asked if they had noted any abuse by the alleged perpetrator.ADHOC QAPI discussed with IDT on 7/8/25. MonitoringDON/Admin/Designee will interview 5-10 staff weekly x 6-week situational abuse scenarios had how to address effective 7/8/25.DON/Admin/Designee will interview 5 residents how staff treat them weekly x 6 weeks effective 7/8/25.ADO/Regional Compliance Nurse will monitor weekly x 6 weeks monitoring tools for staff and resident interviews effective 7/8/25.The QA committee will review the findings monthly x 3 months and makes changes as needed. The Administrator will resolve once no further issues have been identified. Effective 7/8/25 The facility's POR verification was as follows: Record review of a facility in-service training attendance record, dated 07/08/2025 revealed it was conducted by RCN and was signed by the Administrator and DON. The topic was abuse and neglect to include timely reporting. Record review revealed 13 staff members were interviewed between 07/08/2025 -07/09/2025 regarding witnessing abuse or neglect by a staff member and all responses were no. Record review revealed 13 staff interviews were conducted, and no additional findings were identified with the staff interviews. Record review of an Employee Disciplinary Report, dated 07/08/2025 listed CNA C as the employee and revealed that CNA C was placed on an investigatory suspension. Record review of facility safe survey questions revealed 27 resident interviews were conducted. Resident # 45, 30, 47 and 46 voiced allegations toward staff members. All other interviews revealed no identified allegations of abuse or neglect. Record review revealed 13 residents had skin assessments completed on 07/08/2025 and 07/09/2025 and no concerns were identified. Record review of a facility in-service, dated 07/08/2025, instructed by the DON, listed the topic of the in-service Abuse and Neglect, and included the Administrator as the Abuse Coordinator and to report any and all abuse to the Administrator. The in-service contained 54 staff signatures. Record review of CNA A's employee disciplinary report revealed CNA A received an investigatory suspension on 05/28/2025. Record review of CNA A's payroll/personnel action form revealed CNA A was terminated from the facility with an effective date of 05/26/2025. Record review of a [city] police report revealed an Officer provided an intake [case number] on 05/29/2025. Type of offense was described as assault. Record review of Resident #12's trauma informed prn assessment, dated 05/29/2025 at 7:52pm revealed resident #12 voiced no trauma concerns. Record review of Resident #12's trauma informed prn assessment, dated 07/08/2025 revealed Resident #12 and Resident #12 ‘s RP identified childhood trauma. Record review of Resident #12 progress note, dated 07/08/2025, by the DON revealed [behavioral health company] and [psychiatry company] were called to follow up on recent allegations, behavioral changes and follow up on Resident #12's trauma informed assessment from 07/08/2025. Record review of a statement by the Administrator, dated 07/08/2025, revealed when CNA C was brought into the office to discuss the allegation against her on 07/08/2025, CNA C got upset and stated it was the Administrator's fault because the resident is making false accusations against staff, CNA C declined to sign the suspension paperwork and left the facility stating I need to get out of here before I say something I regret. Record review of an email from CNA C to the DON, dated 07/08/2025 at 10:18 p.m. revealed CNA C reported an incident with Resident #12 on 05/31/2025 to the DON and the Administrator in which Resident #12 was reporting to staff that CNA C was being mean to her. Record review revealed an Ad Hoc QAPI sign in sheet dated 07/08/2025 and listed 10 names that included the Administrator, DON, Medical Director via phone, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675896 If continuation sheet Page 5 of 16 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 07/10/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Dietary, Activity Director, MDS, Housekeeping, Regional Compliance Nurse, other and BOM/HR. Record review of the facility document revealed a weekly monitoring sheet for staff where it would be tracked for 6 weeks regarding abuse and neglect. The document revealed 3 staff members were interviewed on 07/09/2025 and indicated staff responded correctly to interview questions. Record review of a facility document revealed a weekly monitoring sheet where it would be tracked for 6 weeks which residents were monitored for abuse and neglect. The starting date was 07/09/2025 and listed 2 interviews conducted with no negative response and no incidents reviewed in stand up on 07/09/2025 or identified on facility rounds on 07/09/2025. During an interview with the Administrator on, 07/09/2025 at 3:27 p.m., the Administrator stated she and the DON were in-serviced by the Regional Compliance Nurse on 07/08/2025 regarding reviewing and conducting timely observations. The Administrator stated staff who worked with the alleged perpetrators CNA A and CNA C were interviewed on 07/08/2025 regarding observing or witnessing any abuse or neglect in relation to CNA A and CNA C. No additional allegations were identified or voiced. The Administrator stated the interviews were conducted with 13 employees. The Administrator stated CNA C was suspended on 07/08/2025 pending an investigation into the allegation. The Administrator stated safe surveys were conducted with 27 residents and 3 allegations of abuse were identified and reported to HHSC on 07/08/2025 and 07/09/2025 that included Resident #30, 45, 46 and 47. The identified employees were suspended, and an investigation was initiated. The Administrator said non-interviewable residents received a head-to-toe assessment that was completed on 7/8/25 and no issues or concerns were identified. The Administrator stated staff in-servicing began on 07/08/2025 and included all staff members. The Administrator verified there were 52 staff members, and all staff also received training on the [alert system notification] that was sent by text and email to all staff and included a PDF of the abuse policy. The Administrator stated there were 54 wet signatures on the in-services. The in-services topics included reporting on abuse and neglect, reporting protocols, who to report to and definitions of abuse and neglect. The Administrator stated the Medical Director was notified of the immediate jeopardy on 7/8/2025 at 4:40pm. The Administrator stated CNA A was suspended by telephone on 5/28/2025 and was terminated from employment on 6/2/2025 after the investigation. The Administrator stated a police report was filed on 5/29/2025 regarding an allegation of abuse by CNA A. The Administrator stated a case number was provided, and the resident declined to press charges. The Administrator stated a trauma informed assessment was completed on 5/29/2025 for Resident #12 and was negative for any findings at that time. The Administrator stated a second trauma informed assessment was completed for Resident #12 on 7/8/25 and the findings included mention of childhood trauma and resident was seen by an LPC on 07/08/2025 and 07/09/2025. The Administrator stated she attempted to interview CNA C on 07/08/2025 and CNA C refused to provide a statement. The Administrator stated she received a statement from CNA C on 07/08/2025 at 10:18 p.m. that was emailed to the DON. Staff members who had worked with CNA C were interviewed regarding observations of abuse or neglect and no allegations were identified from staff interviews. An Ad Hoc QAPI meeting was held on 07/08/2025 and staff in attendance included the MD by phone, Administrator, DON, Dietary Manager, Activity Director, Regional Compliance Nurse, Maintenance Director, MDS Coordinator, Housekeeping Supervisor and HR Director. The Administrator stated the Administrator or DON would interview 5-10 staff members weekly for 6 weeks. The interviews would consist of situational abuse scenarios and how to address abuse scenarios. The finding would be brought to the monthly QAPI meeting to review for 3 months. The Administrator stated the Administrator or DON would interview 5 residents weekly for 6 weeks related to staff treatment and the finding would be brought to the monthly QAPI meeting for review for 3 months. The Administrator stated the Regional Compliance Nurse or ADO would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675896 If continuation sheet Page 6 of 16 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 07/10/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete monitor the monitoring tools weekly for 6 weeks to ensure compliance. The Administrator stated the QA committee would be reviewing findings from the monitoring tools monthly for 3 months and will make changes to the plan as needed. During interviews on 07/10/2025 from 9:04 a.m. to 1:05 p.m., with 10 employees (2 CNAs , 1 MA, 2 LVNs, 2 housekeeping staff, 1 cook, 1 Dietary Aide, 1 Hospitality Aide) from the day shift (6 AM to 2 PM) and 4 employees (1 CNA, 2 LVNs and 1 RN) from 2pm -10 pm, and 2 employees (1 LVN and 1 CNA) who work double weekend shifts from 6a-10pm and 1 CNA from the night shift (10 PM to 6 AM) revealed staff had received in-service education on Abuse and Neglect, identified the Abuse Coordinator, how and when to contact the Abuse Coordinator. The staff members were able to identify and define types of abuse and neglect. During an interview, 07/10/2025 at 10:11 a.m., the RCN stated the Administrator and DON were reeducated on abuse and neglect on 07/08/2025. The RCN stated the education included the importance of the Administrator and DON ensuring facility staff were reporting abuse to them timely and reviewed the timeline they had to report. The RCN stated the Administrator and DON were told they had 2 hours to report abuse or neglect, and they were to report first and then investigate the allegations. The RCN stated she notified the Medical Director of IJ on 07/08/2025 and stated an Ad Hoc QAPI meeting was held at that time with the Medical Director. The RCN stated RCN and/or the ADO would review the facility monitoring tools weekly and would verify the monitoring tools by interviewing a random sample of residents and staff to validate the interviews are occurring weekly. The RCN and/or ADO would sign the weekly template to validate their review of the tools. During an interview on 07/10/2025 at 10:40 a.m., the Medical Director stated he was notified by the DON and RCN on 07/08/2025 about the IJ and discussed the plan of action and training conducted to address the IJ concerns. During an interview on 07/10/2025 at 11:37 a.m., CNA C stated she was suspended on 07/08/2025. CNA C stated she wrote a statement and sent it by email to the DON and CNA C stated her statement included information on CNA C reporting Resident #12's allegation on 05/31/2025 to the DON and the Administrator on that date. CNA C stated she provided the DON phone records to prove that CNA C called and spoke to the Administrator and DON on 05/31/2025. CNA C stated the phone records revealed CNA C called the Administrator on 05/31/2025 at 11:56 a.m. and there was no answer. The Administrator returned CNA C's call at 1:58 p.m. and the length of the call was 21 minutes. During an interview on 07/10/2025 at 1:55 p.m., the Administrator stated the training she received on 07/08/2025 by RCN included how to conduct investigations of abuse and neglect and the steps that needed to be included when conducting investigations. The Administrator stated 13 residents had head to toe assessments completed and no concerns were identified. The Administrator and DON were informed the Immediate Jeopardy was removed on 07/10/2025 at 4:10 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place. Event ID: Facility ID: 675896 If continuation sheet Page 7 of 16 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 07/10/2025 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 - Some 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. Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 2 of 3 medication cart (west medication cart and nursing treatment cart) and 1 of 2 medication (west medication storage room) storage rooms reviewed for storage of drugs. 1. The facility failed to ensure the west medication cart did not have loose pills and did not have an insulin vial with no open date. 2. The facility failed to ensure the west hall medication storage room fridge had a permanently affixed narcotic lock box. The box contained vials of liquid lorazepam (controlled benzodiazepine tranquilizer medication used to treat anxiety or seizures). 3. The facility failed to ensure the nurse treatment cart did not store the keys to the cart on the cart. This deficient practice could place residents at risk of medication misuse and diversion. The findings were: 1. Observation and interview on 6/20/25 at 9:35 a.m. revealed the west medication cart had two loose white pills and two loose pink pills in the top drawer. A vial of insulin belonging to Resident #23 did not have an open date on the vial. LVN E stated she was unsure where the pills came from or what they were. LVN E stated any loose pills should be discarded, not administered to residents, and threw them in the sharp's container. LVN E stated the insulin vials should have a open date written on the box and vial in case the box and vial get separated and you do not know when it was opened. During an interview on 6/20/25 at 1:28 p.m. the DON stated there should not be loose pills in the medication storage carts because they do not know what they are, and they should not be used. The DON stated staff were expected to label both the insulin vial and the box with an open date in case they get separated. 2. During an observation on 6/20/25 at 9:58 a.m. the west hall medication storage room contained a refrigerator for resident medications. Inside the fridge was a plastic box with a chain. The chain was connected to the inside of the fridge with a pad lock. The pad lock was not completely closed and the screws that secured the bracket to the fridge were weak, and came loose and unscrewed when the pad lock was manipulated. Resident's liquid lorazepam was in the cold narcotic storage box. During an observation and interview on 6/20/25 at 10:28 a.m. the DON demonstrated the lock was not fully closed or engaged but could not be opened. When the DON manipulated the pad lock one screw came out of the side of the fridge. The DON stated the nurses had the keys to the pad lock inside the fridge. The DON stated she was not sure why it was not fully locked but the way it was you could not turn the lock to open it. The DON stated she thought the box was still permanently affixed inside the fridge. 3. During an observation on 6/20/25 at 1:49 p.m. the nursing treatment cart had a white container (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675896 If continuation sheet Page 8 of 16 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 07/10/2025 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 - Some on the side of it. LVN F walked up to the cart grabbed the container, opened it, took the keys to the cart out, and unlocked the cart. LVN F stated residents did not know they keys were in the container to open the cart. During an interview on 6/20/25 at 1:53 p.m. the DON stated the key for the nursing treatment cart were not in the line of sight and residents did not know it was there. The DON stated it was acceptable to have the keys in an unlocked container on the cart. Record review of the facility's policy titled Medication Storage in the Facility, dated 2025, stated: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .9. Each States rule vary on securing the classes of controlled substances the facility will adhere to their individual State's rules as it relates, some states require that ALL classes of controlled substances be stored in the lock-box located in the medication cart to adhere to the required double locked/secured storage .13. outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures. are immediately removed from stock, disposed of according to the procedures for medication destruction . Record review of the facility's policy titled Recommended Medication Storage, dated 7/2012, stated Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that it is clear when the medication was opened. Below is a list of medications that require a date when opening and the recommended time frame the medication should be used. This is not an all-inclusive list and the manufacturer recommendations will supersede this list .INSULINS (Vials, Cartridge, Pens) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675896 If continuation sheet Page 9 of 16 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 07/10/2025 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 profession standards for food service safety for 1 of 1 facility in that: Residents Affected - Some 1. The facility failed to clean a ceiling vent. 2. The facility failed to clean a side wall panel air vent. 3. The facility failed to date an opened jar on mayonnaise in the refrigerator. 4. The facility failed to date two bags of cookie pieces in the storage room. 5. The facility failed to maintain a dish machine sanitation unit. These failures could place residents at risk for food borne illness. The findings included: Observation on 06/17/2025 from 9:15am until 9:45am with the Food Service Director revealed the following: a. There was a 3x2 foot overhead ceiling vent in the main kitchen area that was covered with dirt and dust particles. b. There was a 3x3 foot side wall ceiling vent next to the dish machine that was covered with dirt and dust particles. c. There was an opened one gallon jar of mayonnaise in the refrigerator that was not dated. d. There were 2 bags of 2 gallon size Oreo piece cookies in the storage room that were not dated. e. The dish machine did not record the sanitizer concentrate level after the dish machine cycle. During an interview on 06/17/25 at 9:50am, the Food Service Director stated the dirty ceiling and side wall vents did not allow a clean kitchen environment to be maintained The Food Service Director stated food items in the refrigerator and storage room had to be labeled for use by dates to be followed. The Food Service Director stated he was unaware of the dish machine sanitizer not working after each wash cycle and it was working properly the day before which was confirmed. The Food Service Director stated the sanitizer unit on the dish machine would be immediately fixed. He stated that the dish machine's use of the sanitizer was necessary for proper cleaning of dishware. During an interview with the Administrator on 6/17/25 at 10:00am stated that the dirty ceiling and side wall vents would be cleaned for a clean kitchen environment. She stated that dating of all food was necessary for the use by dates to be followed. The Administrator stated that the dish machine sanitizer unit would be immediately fixed and a same day repair by the dish machine service vendor was confirmed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675896 If continuation sheet Page 10 of 16 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 07/10/2025 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 Residents Affected - Some During an interview with the Maintenance Director on 6/18/25 at 7:25am stated he had not received a previous work order to clean the ceiling and side vents in the kitchen. Record review of facility policy entitled Cleaning Schedules in the Dietary Services Policy and Procedure Manual dated 2012 stated The Dietary department and all equipment in the dietary department will be cleaned on a regular scheduled basis. Record review of the facility policy entitled Left-Over Foods in the Dietary Services Policy and Procedure Manual dated 2012 stated Left-over foods shall be refrigerated, dated, label and properly covered promptly after meal service. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675896 If continuation sheet Page 11 of 16 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 07/10/2025 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 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 disease and infection for 1 of 8 residents (Resident #21) reviewed for infection control: Residents Affected - Few The facility failed to ensure Resident #21's indwelling urinary catheter bag was not on the floor. These failures could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #21's face sheet dated 6/20/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included sepsis due to streptococcus pneumoniae (life threatening condition that arises when the body's response to infection can cause tissue damage, organ failure, or even death), urinary tract infection (infection of the urinary tract), vesicoureteral-reflux with reflux nephropathy with hydroureter, bilateral (condition where urine flows backwards from the bladder to both ureters (muscular tubes that transport urine from the kidneys to the bladder)), dementia, and Parkinson's disease without dyskinesia (progressive movement disorder of the nervous system). Record review of Resident #21's significant change MDS assessment, dated 6/3/25, revealed the resident cognition was severely impaired for daily decision-making skills, required substantial assistance with bed mobility and transfers and utilized a catheter. Record review of Resident #21's Physician Order, dated 6/20/25, revealed the following: -Ensure foley bag is in privacy bag while in bed or wheelchair every shift, with a start date of 6/1/25, and no end date. -may change foley catheter using 16 fr 10mL bulb if leaking or blockage as needed for foley care, with a start date of 6/1/25, and no end date. Record review of Resident #21's comprehensive care plan revealed a care area, initiated 6/13/25, the resident had a indwelling catheter due to recurrent UTI infection and neurogenic bladder with interventions to Position catheter bag and tubing below the level of the bladder and in a privacy bag, and check tubing for kinks and maintain the drainage bag off the floor. Observation on 6/17/25 at 11:20 a.m. revealed Resident #21 was in bed sleeping and the indwelling urinary catheter draining to gravity on the left side of the bed. The catheter bag was visible from the doorway. The catheter bag was not in a dignity bag and was touching the floor. During an interview on 6/19/25 at 12:05 p.m., CNA D stated catheter bags should be inside a dignity bag and have a basin under them. CNA D stated a dignity bag and basin were added to the resident's catheter bag, but she was unsure who fixed it. CNA D stated the catheter bag needed a dignity bag and or basin so contamination from the floor would not happen or so no one could step on the bag. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675896 If continuation sheet Page 12 of 16 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 07/10/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 6/20/25 at 1:25 p.m., the DON stated the indwelling urinary catheter bag should not be touching the floor because there was a potential for infection. The DON stated there was a basin and dignity bag on the catheter at that time and someone probably moved it the other day. Record review of the facility policy titled Catheter Care, dated 2/13/2007, stated General Guidelines .10. 10. Be sure the catheter tubing and drainage bag are kept off the floor . Event ID: Facility ID: 675896 If continuation sheet Page 13 of 16 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 07/10/2025 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 Residents Affected - Many Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on interview and record review, the facility failed to provide the required 80 square feet per resident in 45 of 46 resident rooms (Rooms #2-5, #7, #9-30, #32, #34, #36-51) reviewed for bedroom measurement . The facility failed to ensure rooms measured the required 80 square feet per resident. This failure could impede the ability of residents living in these rooms to attain their highest practicable well-being. Findings included: During an interview on 6/18/25 at 4:00pm with Life Safety Inspector-G stated that all of the room measurements were taken for the listed rooms. Rooms: #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 (145.77) 72.82 square feet with 2 beds in the room #16 (145.77) 72.82 square feet with 2 beds in the room #17 (146.27) 73 square feet with 2 beds in the room #18 (145.23) 72.62 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 14 of 16 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 07/10/2025 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 #19 (145.23) 72.62 square feet with 2 beds in the room Level of Harm - Potential for minimal harm #20 (145.23) 72.62 square feet with 2 beds in the room #21 (145.53) 72.76 square feet with 2 beds in the room Residents Affected - Many #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 #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 (140.45) 70.23 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 #45 (157.169) 78.58 square feet with 2 beds in the room #46 (155.038) 77.52 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 15 of 16 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 07/10/2025 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 #47 (153.302) 76.65 square feet with 2 beds in the room Level of Harm - Potential for minimal harm #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 Residents Affected - Many #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 Record review of the Provider History Profile which was updated on 4/8/24 revealed an existing room size waiver from the re-certification survey with an exit date of 4/08/24. Interview and record review with the Administrator on 6/19/25 at 4:00pm provided a signed Form 3762-Room Size Waiver request form dated 6/4/25. The Administrator stated that the facility requested the same room size waiver be continued for the next year. The Administrator stated there had been no change in the number or size dimensions of the affected rooms requested for waiver consideration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675896 If continuation sheet Page 16 of 16