Inspection·December 8, 2023

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 12/09/23 at 5:35 p.m. with the DON revealed she was not aware about the PASARR for Resident #67 until the MDS Coordinator came and told her about Resident #67's PASARR. If a resident who has a PASRR Positive and was never referred to the Local Authorities to see if he qualifies, they could be missing out on services to enhance their ability. The facility's PASARR Policy, dated 11/2016 and revised on 01/2022, stated A. Coordinate with referring entities to ensure any person seeking admission to a Medicaid- Certified NF has a PASRR Level I Residents have received a PASRR Level I screening for mental illness (MI), intellectual disabilities (ID) or related disorders as known as developmental disabilities (DD) per the Medicaid Pre-admission Screening and Resident Review (PASRR) process. B. Coordinate with the local Intellectual/Development Disability and/or Local Evaluation is conducted when an individual's PASRR Level I screening indicates the individual may have ID, DD or MI . Event ID: Facility ID: 676012 If continuation sheet Page 2 of 6 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 12/08/2023 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 - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: The facility failed to maintain the cleanliness of the ice maker found within the kitchen. These failures could place residents at risk for cross-contamination and foodborne illness. The findings included: Observation and interview on 12/05/2023 at 9:08 AM revealed an ice maker in the kitchen with a dark gray substance built up inside the unit. The DM stated the local municipal inspectors evaluated the ice maker when they visited in October of 2023, and were then 1 week following the municipal inspection the MS notified the DM that a replacement for the entire unit was being planned. The DM stated the unit was currently in use and that she did not know what the dark gray substance was or how it materialized inside the unit. The DM stated the MS cleaned the unit every monthly and that the substance likely built up within that time. The DM stated she was not aware of what the risk to residents would be as she did not know what it was. Interview on 12/05/2023 at 10:42 AM, the MS stated he cleaned the ice maker quarterly with an emptying of the ice maker and deep cleaning the interior of the unit. The MS stated he was not aware of the dark gray substance built up inside the unit. The MS stated he was not aware of any replacement discussion for the ice maker unit and understood it to be a currently operating unit, however with constant cleanings required. Interview and record review on 12/06/2023 at 9:05 AM, the ADM stated he had the local municipal food inspection on 10/25/2023. The inspection checklist reflected a notation in the summary area that reflected Remove residue on inside attachment of ice machine. The ADM stated routine cleanings continued following the municipal food inspection and further stated the RD completed monthly inspections during each of her visits to the facility to evaluated the safety and continued use of the ice made from the ice maker. The RD inspection checklist, dated 09/22/2023 reflected ice maker interior cleaning to be at a 'severity' of 3 out of 3 with an indication for maintenance to address the concern. An additional RD inspection checklist, dated October, reflected the ice maker interior cleaning to be at a 'severity' of 2 out of 3 with an indication for maintenance to address the concern. The ADM stated these provided evidence pieces were able to absolve the facility of non-compliance as action was taken in response to the accumulation of substances within the ice maker unit. The ADM stated the photographs collected by the Surveyor were instances of potential uncleanliness and had never seen the dark gray substances before. The ADM stated the concern with residents consuming ice contaminated would be foodborne illness. Interview on 12/06/2023 at 10:04 AM, the RD stated she had been contracted at this facility since July of 2023. The RD stated she completed a documented inspection but visited generally three times per month. The RD stated on her company's inspection form they have deductions, where 1 means it was the first time seeing it or minimum severity, and 2-3 meant a worse issue, example of a 3 is arbitrary, she chose it, and the far end of the scale is like not having a menu or not documented temps, versus a 1 may be not documenting the dinner for a night. She stated the ice maker is inspected on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 3 of 6 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 12/08/2023 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 - Few that form where they look at the front of the unit, stick camera on the inside, looking for colored growth, buildup of gunk and saw the photos on the last month, she said it would not tell her anything, but did say she saw that before. She stated she sees changes from the previous months to the next. The RD stated she was not certain of the risks in contaminated ice to resident health as she cannot identify the substance. Facility policy specific to the ice maker or the explicit use of refrigerators was not received by the facility prior to exit. Record review of US FDA Food Code, dated 2022, revealed Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as . ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. Some equipment manufacturers and industry associations, e.g., within the tea industry, develop guidelines for regular cleaning and sanitizing of equipment . and 3-304.11 Food Contact with Equipment and Utensils. FOOD shall only contact surfaces of: (A) EQUIPMENT and UTENSILS that are cleaned as specified under Part 4-6 of this Code and SANITIZED as specified under Part 4-7 of this Code; P (B) Single-service and single-use articles. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 4 of 6 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 12/08/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 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 to help prevent the development and transmission of infections for 2 of 5 staff (RN A & LVN B) reviewed for infection control, in that: Residents Affected - Some 1. RN A and LVN B contaminated their hands after washing them and then provided care to Residents'. These deficient practices could place residents at-risk for infections. The findings included: 1. During an observation on 12/07/23 at 9:55 a.m. RN A planned to clean a resident wound. RN A washed her hands in the bathroom of the resident's room. RN A then touched the door to the bathroom after washing her hands. RN A then went to the resident's bedside, touched a pair of gloves with her hands, and put the gloves on. RN A then began to provide wound care to the resident. During an interview on 12/07/23 at 10:10 a.m. RN A stated proper hand washing consisted of washing your hands for 20 seconds with warm water and soap, drying your hands with a paper towel, and using a clean separate paper towel to turn off the water faucet. RN A stated she did not realize she touched the bathroom door after washing her hands. RN A stated if she would have realized she touched the bathroom door she would have washed her hands again because the door might be dirty, and she cannot guarantee the door is not dirty. RN A stated a resident's wound could become infected if she put on gloves with dirty hands and then provided wound care. During an observation on 12/08/23 at 11:22 a.m. LVN B planned to check a resident's blood sugar. LVN B turned on the water faucet to wash his hands. LVN B lathered his hands with soap. LVN B then rinsed the soap off his hands. LVN B then turned off the water faucet with his bare hands. LVN B then grabbed a paper towel to dry his hands. LVN B then returned to his medication cart to gather supplies to check the residents blood sugar. During an interview on 12/08/23 at 2:55 p.m. LVN B stated proper hand washing consisted of washing his hands for 20-30 seconds with soap and rinsing them with water. LVN B stated he then dries his hands with a paper towel and turns off the water with the paper towel. LVN B stated the purpose of using a paper towel to turn off the faucet was for infection control. LVN B stated I do not want to touch the faucet once my hands are cleaned. LVN B stated he did not recall that he touched the faucet with his bare hands to turn off the water. During an interview on 12/08/23 at 6:44 p.m. the DON stated proper hand washing consisted of washing your hands for 20 seconds with soap and water making sure to clean in between your fingers and cleaning your wrist, rinsing with water, grabbing a paper towel to dry your hands, and grabbing a new clean paper towel to turn off the faucet. The DON stated the purpose of washing your hands this way was to prevent infection. The DON stated a door was not clean, if you then grabbed clean gloves and did not only touch the inside cuff of the glove, the gloves then became dirty. Record review of the competency training titled, Hand Washing, dated 10/01/23 revealed RN A had satisfied the requirements for hand washing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 5 of 6 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 12/08/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the competency training titled, Hand Washing, dated 02/06/23 revealed LVN B had satisfied the requirements for hand washing. Record review of the facility's policy titled Hand Washing, no date, stated It is the policy of this facility to cleanse hands to prevent transmission of possible infectious material and to provide clean, healthy environment for residents and staff. Purpose: Hand washing is generally considered the most important single procedure for preventing nosocomial infections .Procedure: Handwashing 1. Wet hands apply soap to hands from soap dispenser. 2. Rub hands in circular motion for not less than twenty seconds. 3. Rub fingers between fingers for twenty seconds. 4. Rinse hands with warm water. 5. Dry hands with paper towel. 6. Turn off faucet with paper towel. 7. Discard paper towel in appropriate receptacle . Event ID: Facility ID: 676012 If continuation sheet Page 6 of 6