Inspection·October 14, 2022

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete had not taken place for the last 3 months. The admin stated the risks associated with not providing a private location for the residents council would be a lack of residents being respected and treated with dignity. Record review of the facility's Resident Council policy, titled Activities Programming, undated, indicated the facility supports the right of resident to organize and participate in resident groups in the facility. This policy provides guidance to promoting structure, order, and productivity in the group meetings. Event ID: Facility ID: 676012 If continuation sheet Page 2 of 17 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 676012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mystic Park Nursing & Rehabilitation Center 8503 Mystic Park San Antonio, TX 78254 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 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Potential for minimal harm Based on interview and observation, the facility failed to maintain the availability of the most recent survey results for 1 of 1 facility reviewed for rights to survey results, in that: Residents Affected - Many The facility failed to retain any previous survey results within the survey binder for residents to review. This failure could affect residents who resided in the facility and could result in a lack of awareness for visitors, family and residents regarding of the survey results and the plan of corrections submitted by the facility. The findings included: During the Resident Council Meeting interviews on 10/11/2022 between 10:02 AM and 11:02 AM, residents reported they were not familiar with what the survey inspection results were or where they were located. Observation on 10/13/2022 at 11:43 PM of the state survey binder revealed that the most recent survey results were not in the binder. In an interview on 10/14/2022 at 03:32 PM, the DON stated she was unaware that the previous survey results were not available in the survey book in the lobby. The DON stated that the responsibility of the keeping most recent survey results was the responsibility of the administrative team, including herself and the Administrator. The DON stated the reason the most recent survey results were not available was due to the previous owners of the facility did not retain the survey results within the state survey binder. The DON stated the risks associated with not having the most recent survey results available would be that the families would not have the ability to ask about prior inspection results or ask the facility about follow-up investigation. The DON stated the facility did not have a policy for survey results availability. In an interview on 10/14/2022 at 07:06 PM, the Admin stated he was unaware that the previous survey results were not available in the survey book in the lobby. The Admin stated the risk associated with not having the most recent survey results would be that the family and residents are not aware of the results of the survey. The Admin stated the facility did not have a policy on survey results availability. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 3 of 17 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 676012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mystic Park Nursing & Rehabilitation Center 8503 Mystic Park San Antonio, TX 78254 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 record review and interview, the facility failed to ensure residents' had the right to formulate an advanced directive for 1 of 24 residents (Resident #237) reviewed for advance directives. Resident #237's OOH-DNR form was invalid because the attending physician's license number and date signed were missing from the form. This failure could result in a resident's DNR not being executed. The findings included: Record review of Resident #237's clinical records revealed a OOH-DNR order lacking a primary physician date or license number. Record review of Resident #237's clinical record revealed a [AGE] year-old female admitted on [DATE] and diagnoses including: End stage renal disease, Anemia in chronic kidney disease multiple myeloma not having achieved remission, and diabetes. Record review of Resident #237's Social Services Assessment/Evaluation dated 10/05/2022 revealed a marked Yes under the question Resident has issued advance directives about his/ her care and treatment:. In an interview on 10/14/2022 at 2:40 PM, the Social Worker stated she began employment at the facility in August of 2022. The Social Worker stated the signing and receiving of DNR's for residents is solely dedicated to her role and included in her responsibilities. The Social Worker stated discussion of requested or existing code status takes place at admission and during the initial care plan meeting. The Social Worker stated she was unaware that Resident #237's DNR was incomplete. The SW stated the DNR was incomplete due to herself not evaluating the DNR properly upon reception. The Social Worker stated the facility would likely require a new DNR if the order did not include the date or physician's license number. She stated the risks associated with having an incomplete DNR would be an open liability to the facility. In an interview on 10/14/2022 at 03:20 PM, the DON stated she has been at the facility since 10/01/202. The DON stated she could not answer whether the DNR for Resident #237 was received on admission. The DON stated she was unaware that Resident #237's DNR was incomplete. The DON stated the current DNR within the clinical record for resident #237 was incomplete based on the missing physician license and date. The DON stated risks associated with having an incomplete DNR would be that the nurses would have to identify the code status during an instance of potential resuscitation and if resuscitation were to take place, then quality of life would be harmed. In an interview on 10/14/2022 at 07:00 PM, the Admin stated he was unaware Resident #237's OOH-DNR was incomplete. The Admin stated the risk associated with having an incomplete DNR would be a harm to the quality of life of the resident. Record review of facility advance directives policy, titled Advance Directive, undated, revealed that once receiving the complete advance directive to notify the attending physician in order to have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 4 of 17 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 676012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mystic Park Nursing & Rehabilitation Center 8503 Mystic Park San Antonio, TX 78254 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 the ability to input physician's orders for the resident. 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: 676012 If continuation sheet Page 5 of 17 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 676012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mystic Park Nursing & Rehabilitation Center 8503 Mystic Park San Antonio, TX 78254 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 the resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs that were identified in the comprehensive assessment, for 2 (Resident #97 and #96) of 24 residents reviewed for comprehensive care plans, in that: The facility failed to develop a comprehensive care plan that addressed Resident #97's bowel incontinence. The facility failed to develop a comprehensive care plan that addressed Resident #96's bowel and bladder incontinence. This failure could place residents at risk for not receiving the appropriate care and services needed to maintain optimal health. The findings included: Record review of Resident #97's comprehensive care plan revealed it did not indicate bowel incontinence. Record review of Resident #98's comprehensive care plan revealed it did not indicate bowel or bladder incontinence. Record review of Resident #97's face sheet indicated a [AGE] year-old male with diagnoses including: hypertension. Record review of Resident #98's face sheet indicated a [AGE] year-old male with diagnoses including: chronic respiratory failure, HIV, schizophreniform disorder, major depressive disorder, and dementia. Record review of Resident #97's MDS revealed an indication of bowel frequent incontinence. Record review of Resident #98's MDS revealed an indication of bowel and bladder frequent incontinence. In an interview on 10/14/2022 at 02:51 PM, the facility MDS coordinator stated she was unaware Resident #97's care plan did not indicate bowel incontinence or Resident #98's care plan did not indicate bowel and bladder incontinence. The MDS coordinator stated the residents' care plans are formulated by the ID Team and the person who completed the care goal will input that care plan goal. The MDS Coordinator stated that incontinence would be inputted by the nursing department, so the responsibility would be on the DON. The MDS Coordinator stated the previous MDS nurse did not identify the historic change in incontinence for Resident #97. In an interview on 10/14/2022 at 04:03 PM, the DON stated she was unaware of the Resident #97 and #98's incomplete comprehensive care plans. The DON stated that inputting nursing goals within the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 6 of 17 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 676012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mystic Park Nursing & Rehabilitation Center 8503 Mystic Park San Antonio, TX 78254 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 comprehensive care plan was the responsibility of the DON. The DON stated the risks associated with not having continence capacity in the comprehensive care plan would be the delay of incontinent care when needed which would result in a deficiency in quality of care. In an interview on 10/14/2022 at 07:04 PM, the Admin stated he was unaware of Resident #97 and #98's incomplete comprehensive care plans. The admin stated the risk associated with not completing the care plan would be inadequate quality of care. Record review of the facility policy related to comprehensive care planning, tilted Care Assessment, undated, revealed comprehensive care plans are to be completed by the ID Team to match the qualities and conditions of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 7 of 17 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 676012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mystic Park Nursing & Rehabilitation Center 8503 Mystic Park San Antonio, TX 78254 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident's environment remains as free of accident hazards as is possible for 2 of 2 residents (Resident #5 and #17) whose care was reviewed for accidents and hazards, in that: 1. Resident #5's fall mat (used to prevent injury from fall) was not used while the resident was in bed. 2. Resident #17's fall mat was not used while the resident was in bed. This deficient practice could place residents who were at risk for falls at risk for avoidable accidents and could result in a decline in physical condition. The findings were: 1. Record review of Resident #5's face sheet, dated 10/13/22 revealed a [AGE] year old female admitted on [DATE] with diagnoses that included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), convulsions, lack of coordination, abnormal posture and reduced mobility and need for assistance with personal care. Record review of Resident #5's most recent annual MDS assessment, dated 7/8/22, revealed the resident was severely cognitively impaired for daily decision-making skills, required 1-person physical assist with bed mobility and utilized a wheelchair. Record review of Resident #5's comprehensive care plan, undated, revealed the resident was at risk for falls with interventions that included fall mat (s) beside bed to prevent injury. Record review of Resident #5's most recent Fall Risk Evaluation, dated 10/5/22 revealed the resident was identified as a high risk for falls. Observation on 10/11/22 at 9:53 a.m. revealed Resident #5 in bed and two fall mats were observed folded up in the resident's closet located at the foot of the bed. Observation on 10/13/22 at 1:09 p.m. and again at 2:18 p.m. revealed Resident #5 in bed and no fall mats were seen in the resident's room. During an observation and interview on 10/13/22 at 2:37 p.m., CNA A stated, Resident #5 was considered a fall risk because the resident moved her body across the bed instead of laying in the middle of the bed. CNA A stated the resident moved from the COVID-19 hall and utilized fall mats while in the unit but when the resident moved to her present room, the mats didn't come with her. During an observation and interview on 10/14/22 at 11:01 a.m., CNA B stated Resident #5 was not a fall risk but could not explain or elaborate why the resident's bed was in the low position, only stating, for precaution. During an observation and interview on 10/14/22 at 2:57 p.m., the DON stated Resident #5's bed was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 8 of 17 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 676012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mystic Park Nursing & Rehabilitation Center 8503 Mystic Park San Antonio, TX 78254 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 in a low position to prevent injuries from falls. The DON stated a fall assessment was completed on 10/5/22 and had identified the resident at high risk for falls. The DON stated, Resident #5's fall mats were care planned and the fall mats should be used because if the resident should fall the fall mats should have been in place to prevent injury. 2. Record review of Resident #17's face sheet, dated 10/12/22 revealed a [AGE] year old male admitted on [DATE] and re-admitted on [DATE] with diagnoses that included hereditary spastic paraplegia (an inherited disorder characterized by progressive weakness and spasticity [stiffness] of the legs causing gait difficulties), severe intellectual disabilities, right knee contracture, muscle weakness, impulse disorder, restlessness and agitation and seizures. Record review of Resident #17's most recent annual MDS assessment, dated 7/28/22 revealed the resident was severely cognitively impaired for daily decision-making skills, required 1-person physical assist with bed mobility and utilized a wheelchair. Record review of Resident #17's comprehensive care plan, undated, revealed the resident had falls and interventions included bed in lowest position and fall mats placed on both sides of the bed. Record review of Resident #17's most recent Fall Risk Evaluation, dated 10/1/21 revealed the resident was identified as a high risk for falls. Observation on 10/11/22 at 3:00 p.m. revealed Resident #17 in bed and two fall mats folded up against the wall on the left side of the bed. Observation on 10/12/22 at 2:08 p.m. revealed Resident #17 in bed and two fall mats folded up against the wall on the left side of the bed. During an observation and interview on 10/12/22 at 2:38 p.m., Nursing Aide C stated, Resident #17 required total care and was at high risk for falls. Nursing Aide C stated, the fall mats in the resident's room were supposed to be on the floor next to the bed on both sides but the mats were in the way of the CNA's path and left no room for the wheelchair, so for that reason were folded up against the wall. Nurse Aide C stated he did not believe Resident #17 needed the fall mats because the resident's bed rails would help the resident from falling. During an observation and interview on 10/12/22 at 2:47 p.m., CNA A stated Resident #17 required total care and was considered a fall risk. CNA A stated, Resident #17 was supposed to utilize the fall mats to prevent injury from falls and the CNAs were responsible for ensuring the fall mats were being used. During an observation and interview on 10/12/22 at 2:51 p.m., Restorative Aide D, who identified himself as a CNA, stated, Resident #17 was considered a fall risk and he had assisted Resident #17 to bed today but had forgotten to place the fall mats on both sides of the bed. Restorative Aide D stated, it was the responsibility of the Aides to ensure the fall mats were being utilized to prevent injuries from falls. Record review of the facility policy and procedure titled, Fall Management System, undated, revealed in part, .This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 9 of 17 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 676012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mystic Park Nursing & Rehabilitation Center 8503 Mystic Park San Antonio, TX 78254 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 supervision, assistive devices and functional programs as appropriate to prevent accidents .It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complication if a fall occurs . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 10 of 17 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 676012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mystic Park Nursing & Rehabilitation Center 8503 Mystic Park San Antonio, TX 78254 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 #18) reviewed for perineal/incontinent care, in that: CNA E did not provide proper incontinent care to Resident #18. This deficient practice could affect residents who received perineal/incontinent care and place them at risk of increased urinary tract infections due to improper care. The findings were: Record review of Resident #18's face sheet, dated 10/14/22 revealed a [AGE] year old female admitted on [DATE] with diagnoses that included diabetes, dementia, urinary incontinence and history of urinary tract infections. Record review of Resident #18's most recent quarterly MDS assessment, dated 8/2/22 revealed the resident was severely cognitively impaired for daily decision-making skills and was frequently incontinent of bowel and bladder. Record review of Resident #18's Order Summary Report, dated 10/14/22 revealed an order for Cranberry Tablet 450 milligram two times a day for UTI (urinary tract infection) prophylaxis, with order dated 8/11/22 and no end date. Record review of Resident #18's comprehensive care plan, undated, revealed the resident had urinary incontinence with interventions that included, clean peri-area with each incontinence episode. Observation on 10/14/22 at 9:42 a.m., during perineal/incontinence care revealed CNA E wiped the resident's buttock area with a wipe, in the wrong direction, from a downward stroke to an upward stroke on two different occasions. During an interview on 10/14/22 at 10:00 a.m., CNA E stated, he had wiped in the wrong direction when providing perineal/incontinent care to Resident #18. CNA E stated, wiping in a downward stroke towards the resident's perineal area instead of wiping in an upward stroke away from the perineal area was considered cross contamination and could result in the resident developing a urinary tract infection. CNA E stated proper perineal/incontinence care was performed when wiping from front to back to prevent cross contamination. CNA E stated he had received in-service training on perineal/incontinence care about 2 months ago and had done a return demonstration with the former DON. CNA E stated he was nervous. During an interview on 10/14/22 at 2:32 p.m., the DON stated, proper perineal/incontinent care required wiping from top to bottom to prevent cross contamination which could result in the resident developing a urinary tract infection. Record review of the CNA Orientation and Skills Competency for CNA E, dated 9/16/22, revealed CNA E had satisfied the requirements for proper perineal care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 11 of 17 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 676012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mystic Park Nursing & Rehabilitation Center 8503 Mystic Park San Antonio, TX 78254 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 Record review of the facility policy and procedure titled, Incontinence Care, undated, revealed in part, .It is the policy of this facility to provide incontinence care for those residents requiring assistance with bladder and/or bowel incontinence. Staff providing incontinence care will do so while maintaining the dignity of the resident and providing care in a respectful manner .5. Wash peri-area using front to back strokes . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 12 of 17 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 676012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mystic Park Nursing & Rehabilitation Center 8503 Mystic Park San Antonio, TX 78254 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. 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 provide special eating equipment for 1 of 2 residents (Resident #20) reviewed for assistive devices in that: Residents Affected - Few Resident #20 was not provided with a scoop plate (helps scoop food onto utensils by providing the edge users need to load a utensil) at meals to minimize food spillage. This deficient practice could affect residents who required assistive devices for meals and could result in poor nutritional intake. The findings were: Record review of Resident #20's face sheet, dated 10/12/22 revealed a [AGE] year old female admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis (hemiplegia is defined as paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one-sided weakness, but without complete paralysis), epilepsy (seizure disorder), need for assistance with personal care, reduced mobility, dysphagia (difficulty swallowing), contracture of left hand (condition of shortening and hardening of muscles, tendons, or other tissue often leading to deformity and rigidity of joints) and muscle weakness. Record review of Resident #20's most recent quarterly MDS assessment, dated 8/2/22 revealed the resident was severely cognitively impaired for daily decision-making skills and required 1-person physical assist with eating. Record review of Resident #20's Order Summary Report, dated 10/12/22 revealed an order that included scoop plate for all meals with order date 10/3/22 and no end date. Record review of Resident #20's comprehensive care plan, undated, revealed the resident had a potential nutritional problem related to dysphagia with interventions that included, scoop plate for all meals (to improve patient's ability to self-feed and minimize food spillage). Observation on 10/11/22 at 12:33 p.m., revealed Resident #20 in the dining room holding a fork in her right hand eating lunch from a regular dinner plate. Observation of the resident's meal ticket on the table revealed scoop written on the meal ticket in black marker. During an observation and interview on 10/11/22 at 12:34 p.m., Restorative Aide D stated Resident #20 was supposed to have a scoop plate to help the resident scoop the food and bring it to her mouth without spilling. Restorative Aide D stated, it was the responsibility of the nurse checking the trays before it was delivered to the resident to ensure Resident #20 was given the scoop plate. During an observation and interview on 10/11/22 at 10:36 p.m., RN F stated, Resident #20 was supposed to have a scoop plate because the resident needed it to help her scoop up her food onto the spoon and to prevent spillage. RN F stated she was responsible for ensuring residents had their adaptive eating equipment when she checked the food trays. RN F stated, if Resident #20 was not provided with the scoop plate then the resident could possibly not be consuming the nutrition she needed. RN F stated, I missed it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 13 of 17 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 676012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mystic Park Nursing & Rehabilitation Center 8503 Mystic Park San Antonio, TX 78254 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 0810 Level of Harm - Minimal harm or potential for actual harm During an interview on 10/13/22 at 5:57 p.m., the DON stated, Resident #20 had a dietary order for the use of a scoop plate to assist the resident in getting a full spoon of food and if the resident was not being provided with the scoop plate it could likely result in the resident not receiving the required nutrition. A request for a policy and procedure on the use of adaptive equipment was not provided at the time of exit, 10/14/22. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 14 of 17 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 676012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mystic Park Nursing & Rehabilitation Center 8503 Mystic Park San Antonio, TX 78254 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 - Many 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 procure, store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation and storage, in that: 1. The walk-in refrigerator had a box of what was labeled 5 dozen unpasteurized eggs with 15 remaining eggs. The source of the eggs was unknown, and the eggs were served to residents soft (not fully cooked). 2. The food storage room had expired food items, unsealed food items, partially used food items with no open dates that were beyond the use by date and not labeled with received dates. 3. The walk-in freezer contained unsealed sausages. These deficient practices could place residents who eat food from the kitchen at risk of foodborne illness. The findings were: 1.Observation of the walk in refrigerator on 10/11/2022 at 10:51 am, with [NAME] A revealed the following: - 1 box labeled 5 dozen unpasteurized eggs with 15 eggs remaining 2. Observation of the walk in freezer on 10/11/2022 at 10:55 a.m., with the Dietary Manger revealed -1 package of items identified by the Dietary Manger as individual sausages in an open and unsealed package with no open date. 3. Observation of the dry storage area on 10/11/2022 at 11:17 a.m. revealed: - 1 5lb container of peanut butter which had been opened and partially used with no open date. - 1 package of Ready Thickened Tea with a use by date of 1/04/2019. - 16 packages of what was identified by the Dietary Manager as loaves of bread dated 08/14/2022 by the manufacturer. - 1 package of what was identified by the Dietary Manger as hot dog buns, with 4 remaining hot dog buns with a date of 8/26/2022 with a white powdery substance on the outside of 2 of the buns. - 1 package of what was identified by the Dietary Manager as hot dog buns, with 6 remaining of 12 labeled 06/09/2022 by the manufacturer. - 3 packages of what was identified by the Dietary Manager as hot dog buns, with 12 remaining buns dated 9/13/2022 by the manufacturer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 15 of 17 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 676012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mystic Park Nursing & Rehabilitation Center 8503 Mystic Park San Antonio, TX 78254 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 - 2 10 lb bags of uncooked pasta opened and unsealed Level of Harm - Minimal harm or potential for actual harm - 1 package of dried refried pinto beans opened and unsealed - 3 2 lb packages of dried cereal opened and unsealed Residents Affected - Many - 2 1 lb packages of dried cereal opened and unsealed During an interview with [NAME] A on 10/11/2022 at 10:51 a.m. she explained she used the unpasteurized eggs for the soft fried with Residents who received eggs with middles that were not cooked all the way through and had runny middles over the weekend. She did not say who purchased the eggs for her. She stated she was out and she told someone and then she had eggs in the kitchen. She did not identify or explain exactly how the eggs got into the kitchen. When asked if she knew that unpasteurized eggs that were not cooked all the way through should not be served to the Residents, she did not comment, looked at the Dietary Manger, and walked away. The Dietary Manager then said [NAME] A had to do something else and dismissed her from the interview. During an interview on 10/14/2022 at 11:30 a.m. with Dietary Aide A, he explained he was unaware there were unpasteurized eggs in the kitchen at the facility and that he had been told only pasteurized eggs are allowed in the facility kitchen. During an interview on 10/11/2022 at 10:52 a.m. with the Dietary Manager, he explained unpasteurized eggs are not supposed to be used in the kitchen. He did not know how the unpasteurized eggs got into the kitchen, stating it is important only pasteurized eggs are served to keep Resident from getting sick. The Dietary Manager further explained only fresh, properly stored and labeled items should be kept in any areas of the kitchen. He said he would not want his family members served old bread or opened food that was not fresh. During an interview with the Administrator on 10/11/2022 at 11:00 a.m., the Administrator stated there should not be unpasteurized eggs in the kitchen and they should not be served to the Residents. He stated he was unaware that any unpasteurized eggs were in the kitchen or were served to Residents. He further stated foods that are not approved to be used with the Residents should not be used in the kitchen and that is done to prevent food borne illness. He was unaware there were expired items in the kitchen, unpasteurized eggs, or food items that had been opened and not sealed properly. He went on to explain Residents should only be served foods according to the guidelines of the facility. Review of the facility's policy , provided by the Administrator titled Dietary Services with no date revealed it did not address food storage and preparation. Review of the U.S. Public Health Service Food Code, revealed the following: 1. The Code of Federal Regulations 21 CFR 101.17 Food Labeling warning, notice, and safe handling statements, paragraph (h) Shell eggs state in subparagraph (1), The label of all shell eggs, whether in intrastate or interstate commerce, shall bear the following statement: 'SAFE HANDLING INSTRUCTIONS: To prevent illness from bacteria; keep eggs refrigerated, cook eggs until yolks are firm, and cook foods containing eggs thoroughly.' (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 16 of 17 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 676012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mystic Park Nursing & Rehabilitation Center 8503 Mystic Park San Antonio, TX 78254 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 2. Level of Harm - Minimal harm or potential for actual harm Section 3-4 Destruction of Organisms of Public Health Concern, Subpart 3-401.11 (A) (A) Except as specified under (B) and in (C) and (D) of this section, raw animal FOODS such as EGGS, FISH, MEAT, POULTRY, and FOODS containing these raw animal FOODS, shall be cooked to heat all parts of the FOOD to a temperature and for a time that complies with one of the following methods based on the FOOD that is being cooked: (1) 63oC (145oF) or above for 15 seconds Residents Affected - Many 3. Section 3-501.19 Section 4 (D) A FOOD ESTABLISHMENT that serves a HIGHLY SUSCEPTIBLE POPULATION may not use time as specified under (A), (B) or (C) of this section as the public health control for raw EGGS. 4. Section 3-603.11, C (3) Consuming raw or undercooked MEATS, POULTRY, seafood, shellfish, or EGGS may increase your RISK of foodborne illness, especially if you have certain medical conditions. 5. Section 3-202.15 Package Integrity - Damaged or incorrectly applied packaging may allow the entry of bacteria or other contaminants into the contained food. If the integrity of the packaging has been compromised, contaminants such as Clostridium botulinum may find their way into the food. In anaerobic conditions (lack of oxygen), botulism toxin may be formed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 17 of 17