Inspection·April 28, 2024

F 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record reveiw of Residnet #1's progress notes dated 2/29/2024 @17:43 revealed Note Text: Resident(#1) c/o feeling very slightly nauseous and asked if he could have something to help. Order written per standing orders from Medical Doctor for Zofran prn for each nausea episode, 3/2/24 @23:54 c/o nausea, 3/18/2024 c/o nausea,3/20/24 c/o nausea, 4/12/2024 c/o nausea. Record review of the facility's pharmacy review dated 2/23/2024 by facility pharmacist indicated a review was completed on 2/23/2024 and the pharmacy review indicated no documentation or concerns with medication digoxin. Record review of the facility's pharmacy review dated 3/1/2024- 3/31/2024 did not include Resident #1 on the list being reviewed for March 2024. Record review of Resident #1's EMR progress notes dated 4/13/2024 reflected a change in condition/transfer form requesting Resident #1's family requesting resident be sent to hospital. Record review of Resident #1 required hospitalization on 4/13/2024 for complaints of nausea during the period of 2/23/2024- 4/13/2024(7 different dates), resulting in h hospital discharge diagnosis of nausea and vomiting due to digoxin toxicity. Lab values at the hospital revealed an elevated digoxin level of 3.7 with 2 being normal indicating digoxin toxicity. During an interview on 4/25/2024 at 12:41 pm LVN H stated he was the admitting nurse for Resident #1 when he was admitted to facility under hospice care. He stated the hospice nurse and himself went over the medications ordered by the hospice MD including digoxin. He further stated neither he nor the hospice nurse questioned the digoxin not having parameters and labs for potential toxicity. He stated normally digoxin when ordered has parameters and labs ordered. LVN H further revealed Resident #1 complained of nausea multiple times during the period of 2/29/2024-4/13/2024. LVN H said Resident #1 received nausea medication when he complained of nausea and it wass effecctive. During an interview on 4/25/2024 at 2:08 pm with the facility's Pharmacist revealed she had done a pharmacy review on 2/23/2024 and had not advised any changes to digoxin or need for labs or parameters because Resident #1 was on hospice services and hospice typically did not do labs . She stated digoxin usually had a parameter set for holding medication if heart rate was less than 60 and labs to be done every 6 months to check for toxicity. She further revealed there was no pharmacy review done in March 2024 as she stated resident was in and out of the hospital. Record review of the facility's policy entitled: Nursing Administration, Section: Care and Treatment, Subject: Pharmaceutical Services; Policy: It is the policy of the facility to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) to meet the needs of each resident. Procedures: The pharmacist, in collaboration with the facility and physician helps develop and evaluate the implementation of pharmaceutical services procedures that address the needs of the residents and reflect current standards of practice. Pharmacist schedules with the facility to review and audit charts. admission drug regimen reviews will be conducted within the first 7 days of admission and monthly thereafter. The Administrator and DON were notified of an IJ on 4/26/2024 at 6:02 pm and was given a copy of the IJ Template and a POR (plan of removal) was requested. The Plan of Removal was accepted on 4/28/2024 at 2:20 pm and included the following: The Mystic Park Plan of Removal 4-26-2024: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 2 of 12 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 04/28/2024 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 0755 IJ called per IJ template Quality of Care 684 Immediate Action Level of Harm - Immediate jeopardy to resident health or safety o Medical Director notified of Immediate Jeopardy on 4/26/24 at 7:30PM o Resident# 1 is no longer on Digoxin. Resident #1 returned to the facility on 4/19/2024 with digoxin discontinued. Residents Affected - Some o Resident #1 now has an order that reads no labs, x-rays, or invasive procedures to be done unless ordered by Hospice order is dated 4/26/24. o Primary Care Physician was called on 4/26/24 at 7:45PM o Resident #1 medications were reviewed on 4/26/2024 by the pharmacist to ensure no other medication that require parameters or routine labs are missing. No other Medications that may require parameters or lab monitoring were found. o An audit was completed on all Hospice residents and all residents to ensure no other medication that require parameters, routine labs or orders that reads no labs, x-rays, or invasive procedures to be done unless ordered by Hospice are in place Audit was started on 4/26/2024 at 6:05 pm and will be completed by 9:00AM 4/27/24. Audit was completed by Nurse managers. o Care plans were reviewed for all hospice residents by MDS nurses to ensure any hospice resident who requires Medications that may require parameters or lab monitoring have care plan in place to indicate monitoring or interventions for medications Audit started at on 4/26/24 and will be completed by 4/27/24 9:00AM. o The following in services were started on 4/26/24 and will be completed on 4/27/24 by 9AM -Abuse and Neglect all staff, Documentation of conversation with MD if MD does not want to order parameters or monitor labs for medications requiring monitoring -all licensed staff. Monitoring for signs and symptoms of digoxin toxicity for ·all licensed staff and Care plans for hospice residents to reflect monitoring or interventions for medications. All staff will receive in services prior to working a shift, any staff that has not received in servicing will not be allowed to work a shift until they have received in servicing. o An audit was started to ensure all residents in the facility have had a review done by the pharmacist for the month of April this audit was started on 4/26/24 and will be completed by 4/27/24. Identification of Others Affected. All Hospice residents have the potential to be affected by this alleged deficient practice. Currently there are 19 residents on Hospice. Systemic Change to Prevent Re-occurrence. 1. All new admissions will be reviewed to identify to ensure all medications that require parameters or lab monitoring are in place and orders. This process will start 4/26/2024 and will be monitored by the DON /DESIGNEE daily and will be monitored by the weekend supervisor on the weekends. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 3 of 12 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 04/28/2024 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 2. All new Hospice residents and new admissions care plans will be reviewed to ensure Medications that may require parameters or lab monitoring have care plan in place to indicate monitoring or interventions for medications. This process will start 4/26/24 and will be monitored by the DON /DESIGNEE daily and will be monitored by the weekend supervisor on the weekends. 3. All new hospice residents and new admissions will be reviewed to ensure medications that require parameters, routine labs or invasive procedures have an order that reads not to be done unless ordered by Hospice. This Process will start on 4/26/24 and will be monitored by the DON /DESIGNEE daily and will be monitored by the weekend supervisor on the weekend. 4. All new hired employees will receive in servicing on the topics listed in this plan of removal before working the floor, this process will start 4/26/2024. 5. Staffing coordinator will be in serviced on the process of new hire in servicing and will not schedule new staff on floor until in servicing has been received. Staffing Coordinator will be in serviced on 4/26/2024. 6. The pharmacist will exit with DON and review the list of residents to ensure all received a review and interventions are in place. This will start on 4/26/24. Monitoring 1.DON / DESIGN EE will review new admissions this includes Hospice admissions in the clinical meeting Monday thru Friday for appropriate orders and intervention. The weekend supervisor will review new Hospice admissions and notify the DON of any issues noted. This process will start on 4/26/2024. 2. An off cycle QAPI will be completed on 4/26/2024 to review the IJ template and plan of removal this will be completed by 4/27/2024 10:00AM. 3.Summary of IJ and corrective action to be reviewed by QAPI monthly until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. The surveyor verification of the Plan of Removal on 4/28/2024 was as follows: Record review of Nurse Noted dated 4/26/24 at 7:30 PM authored by the Administrator revealed the MD was notified (medical director). During an observation and interview on 4/27/24 at 3:15 Pm, Resident #1 was in the activity hall playing Bingo; alert and oriented X2. No injuries, bruises, or skin tears present. The resident mood was neutral, no signs of distress. Resident was sitting in a W/C. The resident stated that medications help, and he was aware of having taken in the past Digoxin. The resident was not sure whether he still had the Digoxin prescribed. The Resident stated he had no current side effects from any medications. Record review of Resident #1's clinical note dated 4/18/24, revealed that the medication Digoxin was discontinued. Record review of Resident #1's MD orders dated 4/26/24 at 5:00 PM authored by Hospice Medical Physician, revealed: no labs, x-rays, or invasive procedures to be done unless ordered by Hospice order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 4 of 12 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 04/28/2024 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 0755 is dated 4/26/24. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 4/27/24 at 3:24 PM, the DON stated the facility could not perform clinical interventions to include x-ray, labs, or invasive procedures unless ordered by the hospice physician or facility physician. The DON stated, if there was a misunderstanding in orders the facility would check with both physicians. Residents Affected - Some Record review of Resident #1's Nurse Note dated 4/26/24 at 7:45 PM authored by RN L revealed Primary Care Physician was called on 4/26/24 at 7:45PM. During an interview on 4/27/24 at 3:44 PM, the Pharmacist stated the Medication Regimen Review for Resident #1 (see above) was correct and accurate. Record review of facility's 19 audits of Hospice residents revealed: no issues with parameters involving labs, x-rays, and invasive procedures. During an interview on 4/27/24 at 3:50 PM, the DON stated the report was pulled of residents requiring parameters and checked that every one of the residents had the parameters as ordered by the physician. No resident had a parameter as an outlier. During an interview on 4/27/24 at 3:57 PM, LVN I MDS Nurse stated he pulled reports of medications that needed parameters with a focus on the 19 hospice residents and updated any care plans that needed revisions; but there were no major revisions. LVN I stated that MDS will check and put in parameters required for new admissions LVN stated that residents that might require parameters included: BP monitoring, insulin, and cardiac. LVN, I attended training (6A-2P) and the highlight of the training was that all medications that need parameters determined by the physician are captured in the orders and CP. In interviews on 04/27/24 from 4:00 PM. to 5:35 PM with 5 day shift (6 a.m. to 2 p.m.) nursing staff (4 LVNs, 1 RN,), 4 evening shift (2P-10P) , 3 LVN and 1 RN and 2 night shift (6 p.m. to 6 a.m.) nursing staff (1 LVNs, 1 RN) revealed they had been in-serviced on parameters, following MD orders, checking on hospice dioxygen monitoring, CP involving parameters, medication review of new admissions to include hospice and abuse and neglect. In interviews on 4/28/2024 from 11:01- 4 med aide (6-2/2-10pm shift- (4VM and 2 not set up), 3 LVN's( 6a-2pm) 7(cna's (work 6-2 and 2-10), 2- CMA, Housekeeping 3,dept heads(main, admit, ad, med rec),laundry(1 ) dietary(3) Abuse and neglect and medications if pertains to license. Record review Med aide 4/26/2024- in service 100% signature or via phone. Record review of in-service training signatures revealed: o Abuse and neglect 129 signatures (100%) completed 4/26/24. o Digoxin monitoring revealed 27 signatures (100% licensed nursing staff) o Medications with parameters revealed 27 signatures (100% licensed nursing staff) o CP for MDS Nurses: revealed 2 signatures (100%) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 5 of 12 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 04/28/2024 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 0755 o New Admissions -Weekend RN supervisor: revealed 1 signature (100%). Level of Harm - Immediate jeopardy to resident health or safety Record review of facility's 19 audits of Hospice residents revealed: no issues with parameters involving labs, x-rays, and invasive procedures. Residents Affected - Some During an interview on 4/27/24 at 3:50 PM, the DON stated the report was pulled of residents requiring parameters and checked that every one of the residents had the parameters as ordered by the physician. No resident had a parameter as an outlier. During an interview on 4/27/24 at 4:08 PM, the DON stated a log was created which included medications that required parameters and CP; and a separate tab for hospice stating to ask about orders for no labs, x-rays or invasive procedures. Record review of facility' admission sheet for 4/27/24 revealed no hospice admissions as of 4:19 PM. During an interview on 4/27/24 at 4:10 PM Admissions Coordinator stated no new hospice admissions as of 4:10 Pm on 4/27/24; the DON would verify the status of the resident before the residents. Record review of facility log titled New Log in-services revealed a section on training on Digoxin, abuse and neglect, and MD notification involving parameters and documentation, if applicable. During an interview on 4/27/24 at 4:35 PM, the Staffing Coordinator stated he was in-serviced on not allowing new staff on the floor unless they completed the in-service on parameters. Record review of in-service sheet dated 4/26/24 revealed Staffing Coordinator signed the in-service training sheet on parameters. Record review of Resident Medication Review List dated 4/26/24 revealed that 102 residents were reviewed, and interventions were in place. During telephone interview on 4/27/24 at 4:40 PM, the Pharmacist stated that she exited with DON and reviewed the list of residents to ensure all received a review and interventions were in place. This would start on 4/26/24 around 10:00 AM and ended the review at 4/27/24 around 10:30 AM. Record review of QAPI out of cycle meeting revealed meeting held on 4/27/24 at 8:40 AM; signatories included: MD, Administrator, DON, two department heads, and IP. During an interview on 4/27/24 at 4:48 PM, the Administrator stated: the meeting discussed the IJ template and the POR and to follow MD orders. The Administrator stated that QAPI for the next 90 days will continue to review compliance with the POR. On 4/28/2024 at 2:20 p.m., the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a level of potential harm with a scope identified as isolated because the facility's need to monitor the implementation and effectivness of their plan of removal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 6 of 12 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 04/28/2024 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 0849 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for one (Resident #1) of one resident reviewed for hospice services. The facility failed to contact the hospice service medical physician or nurse to clarify physician orders for Digoxin to be given with parameters and if lab should be done for Resident #1 . This failure resulted in the identification of an Immediate Jeopardy (IJ) on 4/26/2024 at 6:05 pm. The IJ template was provided to the facility on 4/26/2024 at 6:05 p.m. While the IJ was removed on 4/28/2024, the facility remained out of compliance at level of potential with a scope identified as isolated harm because of the facility's need to evaluate the effectiveness of their corrective actions. This deficient practice could place residents who receive hospice services at risk of receiving substandard care due to miscommunication between their hospice and facility caregivers. The findings were: Record review of Resident #1's face sheet, dated 4/25/2024, reflected a [AGE] year-old male admitted to the facility on [DATE] and a readmission on [DATE] with diagnoses which included coronary artery disease(Coronary artery disease (CAD) limits blood flow in your coronary arteries, which deliver blood to your heart muscle.) hypertension(High blood pressure, also known as hypertension, is when your blood pressure, the force of your blood pushing against the walls of your blood vessels, is consistently too high.), unspecified atrial fibrillation (an irregular and often rapid heart rhythm), vascular dementia(A condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory.), Diabetes Mellitus 2(A metabolic disorder in which the body has high sugar levels for prolonged periods of time.), and history of stroke. Record review of Resident #1's physician orders, dated 2/19/2024, revealed there was no order to monitor the parameters of the Digoxin or to have any labs done for checking the Digoxin level for toxicity. Physician order read: Digoxin 0.25 mg tab po daily. During an interview on 4/25/2024 at 11:57 am DON of Hospice stated the admitting hospice nurse do medication reconciliation when a resident is admitted to hospice services. The nurses go over each medication to make sure the order is correct. He stated he did not know if the two nurses (the hospice nurse and the facility nurse) questioned the digoxin order not having a parameter or to have lab ordered for a digoxin level. He stated when a resident is on hospice, labs are not typically done as this is part of the palliative care. During an interview on 4/25/2024 at 12:41 pm LVN I stated he was the admitting nurse for Resident #1 when he was admitted to facility under hospice care. He stated the hospice nurse and himself went over the medications ordered by the hospice MD including digoxin. He further stated neither he nor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 7 of 12 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 04/28/2024 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 0849 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the hospice nurse questioned the digoxin not having parameters and labs for potential toxicity. He stated normally digoxin when ordered has parameters and labs ordered. Record review of Resident #1's EMR progress notes dated 4/13/2024 reflected a change in condition/transfer form requesting Resident #1's family requesting resident be sent to hospital. Record review of Resident #1 required hospitalization on 4/13/2024 for complaints of nausea during the period of 2/23/2024- 4/13/2024(7 different dates), resulting in h hospital discharge diagnosis of nausea and vomiting due to digoxin toxicity. Lab values at the hospital revealed an elevated digoxin level of 3.7 with 2 being normal indicating digoxin toxicity. During an interview on 4/25/2024 at 12:41 pm LVN I stated he was the admitting nurse for Resident #1 when he was admitted to facility under hospice care. He stated the hospice nurse and himself went over the medications ordered by the hospice MD including digoxin. He further stated neither he nor the hospice nurse questioned the digoxin not having parameters and labs for potential toxicity. He stated normally digoxin when ordered has parameters and labs ordered. LVN I further revealed Resident #1 complained of nausea multiple times during the period of 2/29/2024-4/13/2024. LVN I said Resident #1 received nausea medication when he complained of nausea and it wass effecctive. During an interview on 4/25/2024 at 1:22 pm facility DON stated if a resident is on hospice services the facility nursing staff follow the physician orders that are provided by hospice. She stated Resident #1 had a physician order for digoxin 0.25 mg tab po daily and there were no parameters or labs ordered. She further stated if the hospice physician did not order any then we would not have parameters or do lab. DON said, I expect the nurses to follow physician orders. During a telephone interview on 4/28/2024 at 2:22 pm hospice medical physician stated he did not order parameters or lab for toxicity regarding Resident #1's Digoxin. He stated he does not typically have residents on digoxin and did not order parameters or labs. Resident #1 was already on digoxin when we admitted him to hospice services in January 2024 and I do not know who originally ordered it. He further revealed digoxin when taken can be toxic if other underlying diagnoses exist with a resident. He stated we all learned from this. The Administrator and DON were notified of an IJ on 4/26/2024 at 6:02 pm and was given a copy of the IJ Template and a POR (plan of removal) was requested. The Plan of Removal was accepted on 4/28/2024 at 2:20 pm and included the following: The Mystic Park Plan of Removal 4-26-2024: IJ called per IJ template Quality of Care 684 Immediate Action o Medical Director notified of Immediate Jeopardy on 4/26/24 at 7:30PM o Resident# 1 is no longer on Digoxin. Resident #1 returned to the facility on 4/19/2024 with digoxin discontinued. o Resident #1 now has an order that reads no labs, x-rays, or invasive procedures to be done unless ordered by Hospice order is dated 4/26/24. o Primary Care Physician was called on 4/26/24 at 7:45PM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 8 of 12 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 04/28/2024 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 0849 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some o Resident #1 medications were reviewed on 4/26/2024 by the pharmacist to ensure no other medication that require parameters or routine labs are missing. No other Medications that may require parameters or lab monitoring were found. o An audit was completed on all Hospice residents and all residents to ensure no other medication that require parameters, routine labs or orders that reads no labs, x-rays, or invasive procedures to be done unless ordered by Hospice are in place Audit was started on 4/26/2024 at 6:05 pm and will be completed by 9:00AM 4/27/24. Audit was completed by Nurse managers. o Care plans were reviewed for all hospice residents by MDS nurses to ensure any hospice resident who requires Medications that may require parameters or lab monitoring have care plan in place to indicate monitoring or interventions for medications Audit started at on 4/26/24 and will be completed by 4/27/24 9:00AM. o The following in services were started on 4/26/24 and will be completed on 4/27/24 by 9AM -Abuse and Neglect all staff, Documentation of conversation with MD if MD does not want to order parameters or monitor labs for medications requiring monitoring -all licensed staff. Monitoring for signs and symptoms of digoxin toxicity for ·all licensed staff and Care plans for hospice residents to reflect monitoring or interventions for medications. All staff will receive in services prior to working a shift, any staff that has not received in servicing will not be allowed to work a shift until they have received in servicing. o An audit was started to ensure all residents in the facility have had a review done by the pharmacist for the month of April this audit was started on 4/26/24 and will be completed by 4/27/24. Identification of Others Affected. All Hospice residents have the potential to be affected by this alleged deficient practice. Currently there are 19 residents on Hospice. Systemic Change to Prevent Re-occurrence. 1. All new admissions will be reviewed to identify to ensure all medications that require parameters or lab monitoring are in place and orders. This process will start 4/26/2024 and will be monitored by the DON /DESIGNEE daily and will be monitored by the weekend supervisor on the weekends. 2. All new Hospice residents and new admissions care plans will be reviewed to ensure Medications that may require parameters or lab monitoring have care plan in place to indicate monitoring or interventions for medications. This process will start 4/26/24 and will be monitored by the DON /DESIGNEE daily and will be monitored by the weekend supervisor on the weekends. 3. All new hospice residents and new admissions will be reviewed to ensure medications that require parameters, routine labs or invasive procedures have an order that reads not to be done unless ordered by Hospice. This Process will start on 4/26/24 and will be monitored by the DON /DESIGNEE daily and will be monitored by the weekend supervisor on the weekend. 4. All new hired employees will receive in servicing on the topics listed in this plan of removal before working the floor, this process will start 4/26/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 9 of 12 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 04/28/2024 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 0849 5. Staffing coordinator will be in serviced on the process of new hire in servicing and will not schedule new staff on floor until in servicing has been received. Staffing Coordinator will be in serviced on 4/26/2024. Level of Harm - Immediate jeopardy to resident health or safety 6. The pharmacist will exit with DON and review the list of residents to ensure all received a review and interventions are in place. This will start on 4/26/24. Residents Affected - Some Monitoring 1.DON / DESIGN EE will review new admissions this includes Hospice admissions in the clinical meeting Monday thru Friday for appropriate orders and intervention. The weekend supervisor will review new Hospice admissions and notify the DON of any issues noted. This process will start on 4/26/2024. 2. An off cycle QAPI will be completed on 4/26/2024 to review the IJ template and plan of removal this will be completed by 4/27/2024 10:00AM. 3.Summary of IJ and corrective action to be reviewed by QAPI monthly until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. The surveyor verification of the Plan of Removal on 4/28/2024 was as follows: Record review of Nurse Noted dated 4/26/24 at 7:30 PM authored by the Administrator revealed the MD was notified (medical director). During an observation and interview on 4/27/24 at 3:15 Pm, Resident #1 was in the activity hall playing Bingo; alert and oriented X2. No injuries, bruises, or skin tears present. The resident mood was neutral, no signs of distress. Resident was sitting in a W/C. The resident stated that medications help, and he was aware of having taken in the past Digoxin. The resident was not sure whether he still had the Digoxin prescribed. The Resident stated he had no current side effects from any medications. Record review of Resident #1's clinical note dated 4/18/24, revealed that the medication Digoxin was discontinued. Record review of Resident #1's MD orders dated 4/26/24 at 5:00 PM authored by Hospice Medical Physician, revealed: no labs, x-rays, or invasive procedures to be done unless ordered by Hospice order is dated 4/26/24. During an interview on 4/27/24 at 3:24 PM, the DON stated the facility could not perform clinical interventions to include x-ray, labs, or invasive procedures unless ordered by the hospice physician or facility physician. The DON stated, if there was a misunderstanding in orders the facility would check with both physicians. Record review of Resident #1's Nurse Note dated 4/26/24 at 7:45 PM authored by RN L revealed Primary Care Physician was called on 4/26/24 at 7:45PM. During an interview on 4/27/24 at 3:44 PM, the Pharmacist stated the Medication Regimen Review for Resident #1 (see above) was correct and accurate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 10 of 12 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 04/28/2024 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 0849 Level of Harm - Immediate jeopardy to resident health or safety Record review of facility's 19 audits of Hospice residents revealed: no issues with parameters involving labs, x-rays, and invasive procedures. During an interview on 4/27/24 at 3:50 PM, the DON stated the report was pulled of residents requiring parameters and checked that every one of the residents had the parameters as ordered by the physician. No resident had a parameter as an outlier. Residents Affected - Some During an interview on 4/27/24 at 3:57 PM, LVN I MDS Nurse stated he pulled reports of medications that needed parameters with a focus on the 19 hospice residents and updated any care plans that needed revisions; but there were no major revisions. LVN I stated that MDS will check and put in parameters required for new admissions LVN stated that residents that might require parameters included: BP monitoring, insulin, and cardiac. LVN, I attended training (6A-2P) and the highlight of the training was that all medications that need parameters determined by the physician are captured in the orders and CP. In interviews on 04/27/24 from 4:00 PM. to 5:35 PM with 5 day shift (6 a.m. to 2 p.m.) nursing staff (4 LVNs, 1 RN,), 4 evening shift (2P-10P) , 3 LVN and 1 RN and 2 night shift (6 p.m. to 6 a.m.) nursing staff (1 LVNs, 1 RN) revealed they had been in-serviced on parameters, following MD orders, checking on hospice dioxygen monitoring, CP involving parameters, medication review of new admissions to include hospice and abuse and neglect. In interviews on 4/28/2024 from 11:01- 4 med aide (6-2/2-10pm shift- (4VM and 2 not set up), 3 LVN's( 6a-2pm) 7(cna's (work 6-2 and 2-10), 2- CMA, Housekeeping 3,dept heads(main, admit, ad, med rec),laundry(1 ) dietary(3) Abuse and neglect and medications if pertains to license. Record review Med aide 4/26/2024- in service 100% signature or via phone. Record review of in-service training signatures revealed: o Abuse and neglect 129 signatures (100%) completed 4/26/24. o Digoxin monitoring revealed 27 signatures (100% licensed nursing staff) o Medications with parameters revealed 27 signatures (100% licensed nursing staff) o CP for MDS Nurses: revealed 2 signatures (100%) o New Admissions -Weekend RN supervisor: revealed 1 signature (100%). Record review of facility's 19 audits of Hospice residents revealed: no issues with parameters involving labs, x-rays, and invasive procedures. During an interview on 4/27/24 at 3:50 PM, the DON stated the report was pulled of residents requiring parameters and checked that every one of the residents had the parameters as ordered by the physician. No resident had a parameter as an outlier. During an interview on 4/27/24 at 4:08 PM, the DON stated a log was created which included medications that required parameters and CP; and a separate tab for hospice stating to ask about orders for no labs, x-rays or invasive procedures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 11 of 12 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 04/28/2024 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 0849 Record review of facility' admission sheet for 4/27/24 revealed no hospice admissions as of 4:19 PM. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 4/27/24 at 4:10 PM Admissions Coordinator stated no new hospice admissions as of 4:10 Pm on 4/27/24; the DON would verify the status of the resident before the residents. Residents Affected - Some Record review of facility log titled New Log in-services revealed a section on training on Digoxin, abuse and neglect, and MD notification involving parameters and documentation, if applicable. During an interview on 4/27/24 at 4:35 PM, the Staffing Coordinator stated he was in-serviced on not allowing new staff on the floor unless they completed the in-service on parameters. Record review of in-service sheet dated 4/26/24 revealed Staffing Coordinator signed the in-service training sheet on parameters. Record review of Resident Medication Review List dated 4/26/24 revealed that 102 residents were reviewed, and interventions were in place. During telephone interview on 4/27/24 at 4:40 PM, the Pharmacist stated that she exited with DON and reviewed the list of residents to ensure all received a review and interventions were in place. This would start on 4/26/24 around 10:00 AM and ended the review at 4/27/24 around 10:30 AM. Record review of QAPI out of cycle meeting revealed meeting held on 4/27/24 at 8:40 AM; signatories included: MD, Administrator, DON, two department heads, and IP. During an interview on 4/27/24 at 4:48 PM, the Administrator stated: the meeting discussed the IJ template and the POR and to follow MD orders. The Administrator stated that QAPI for the next 90 days will continue to review compliance with the POR. On 4/28/2024 at 2:20 p.m., the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a level of potential harm with a scope identified as isolated because the facility's need to monitor the implementation and effectivness of their plan of removal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676012 If continuation sheet Page 12 of 12