Health inspection·April 7, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm catheter 16F/10ml every month on the 15th and prn every night shift starting on the 15th and ending on the 16th every month, with a start date of 02/10/23, and no end date. Record review of Resident #25's care plan, dated 04/06/23, revealed a foley catheter presence with prostate enlargement and urine retention. Residents Affected - Few During an observation and interview on 04/04/23 at 12:19 p.m. Resident #25 stated he had a catheter and had not had any issues concerning infection of the catheter. The catheter was hanging from the side of the bed with no dignity cover. Urine was visible inside the bag. During an observation on 04/05/23 at 9:46 a.m. Resident #25 was observed walking in the hallway. He was using a walker and walking with a staff member. A catheter bag was hanging from the walker with no dignity cover and urine was observed in the bag. During an interview on 04/06/23 at 11:34 a.m. LVN A stated they used black color dignity bags to cover urinary catheters. LVN A stated they only use the dignity covers when the Resident was outside their rooms. During an observation and interview on 04/06/23 at 11:41 a.m. a dignity bag cover was present on Resident #25 catheter hanging on the side of his bed. Resident #25 stated he did not pay close enough attention to know if the dignity bag was covering his catheter prior to today. He stated he did not notice if it was on or not the day prior and it would not bother him if it was not on it. He stated everyone knows what it was. During an interview on 04/06/23 at 11:46 a.m. the DON stated catheters should have a dignity bag and he would need to check and see if they normally use them in the Resident rooms or not. He stated if a Resident normally has a dignity bag to conceal the urinary catheter unless the Resident insist on not having one. Record review of the Facility ' s Policy titled Dignity, dated 02/21, stated Policy statement: each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self worth and self esteem. Policy Interpretation and Implementation: 1. Residents are treated with dignity and respect at all times .12. demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents, for example: a. helping the resident to keep urinary catheter bags covered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676041 If continuation sheet Page 2 of 7 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 676041 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mission at Blue Skies of Texas East 4949 Ravenswood Dr San Antonio, TX 78227 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure their medication error rate was not 5 percent or greater and had a medication error rate of 38.46 percent with 26 medications administration opportunities observed with 10 errors for 1 of 5 residents (Resident #26) and 1 of 4 staff (LVN B) reviewed for medication administration in that: Residents Affected - Some 1. RN B did not observe administration of 1 25mg tablet of Carvedilol, 1 50 mg tablet of senior silver vitamin, 1 240 mg extended-release capsule of diltiazem, 1 20 mg tablet of furosemide, 1 cap full or 17 grams of polyethylene glycol powder with 6 oz of water mixture, 1 capsule of zeaxanthin/Lutein eye and mineral supplement, 1 100mg capsule of docusate, 1 40mg tablet of olmesa medox, 1 cut 1000mg tablet of calcium carbonate chewable in half to make 500mg, A supplement drink, and 2 capsules of a probiotic medications for Resident #26. This deficient practice could place residents at risk of not receiving therapeutic effects from their medications as intended by the prescribing physician order. The findings include: Record review of Resident #26's Physician orders, dated 04/06/23, revealed the following orders: *carvedilol tablet 25MG Give 1 tablet by mouth two times a day related to Paroxysmal atrial fibrillation (an abnormal heart rhythm (arrhythmia) characterized by rapid and irregular beating of the atrial chambers of the heart) with a start date of 07/18/22 and no end date, *Senior silver tablet adult 50 Give 1 tablet by mouth one time a day related to deficiency of other vitamins with a start date of 07/19/22 and no end date, *diltiazem capsule 240MG extended release Give 1 capsule by mouth one time a day related to Essential primary hypertension (high blood pressure) with a start date of 07/18/22 and no end date, *furosemide tablet 20MG Give 1 tablet by mouth two times a day related to Essential primary hypertension with a start date of 07/18/22 and no end date, *polyethylene glycol powder Give 17 gram by mouth one time a day related to constipation give with 4-8oz of liquid with a start date of 03/31/23 and no end date, *zeaxanthin/Lutein Oral Capsule (Multiple Vitamins w/ Minerals) Give 1 capsule by mouth one time a day related to disorder of the eye, *docusate Sodium Tablet 100 MG Give 1 tablet by mouth two times a day related to constipation with a start date of 07/28/22 and no end date, *olmesa medox tablet 40MG Give 1 tablet by mouth one time a day related to hypertension (high blood pressure) with a start date of 07/18/22 and no end date, *Calcium Carbonate Tablet Chewable 500 MG Give 1 tablet by mouth three times a day related to dietary calcium deficiency before meals with a start date of 03/17/22 and no end date, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676041 If continuation sheet Page 3 of 7 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 676041 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mission at Blue Skies of Texas East 4949 Ravenswood Dr San Antonio, TX 78227 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 0759 Level of Harm - Minimal harm or potential for actual harm *lactobacillus capsule Give 2 capsule by mouth one time a day related to deficiency of other vitamins with a start date of 07/29/22 and no end date. During an observation on 04/06/23 at 8:56 a.m. RN B dispensed the following medications for Resident #26: Residents Affected - Some *One 25mg tablet of Carvedilol, *One 50 mg tablet of senior silver vitamin, *One 240 mg extended release capsule of diltiazem, *One 20 mg tablet of furosemide, mixed 1 cap full or 17 grams of polyethylene glycol powder with 6 oz of water, *One capsule of zeaxanthin/Lutein eye and mineral supplement, *One 100mg capsule of docusate, *One 40mg tablet of olmesa medox, *One cut 1000mg tablet of calcium carbonate chewable in half to make 500mg, *A supplement drink, and *2 capsules of a probiotic for Resident #26. *RN B placed the pills mentioned above into 2 medicine cups. RN B placed the cups of medications and the cup of polyethylene glycol powder and water mixture on the bedside table in Resident #26's room. Resident #26 was sitting up in a chair in his room with the bedside table next to him. RN B asked the Resident was he was going to be okay. The Resident stated yes, and RN B left the room with the medications on the bedside table. During an interview on 04/06/23 at 9:41 a.m. RN B stated Resident #26 normally took all his medications in his room all at once. RN B stated she never left the medications at the bedside for the Resident. RN B stated she observed Resident #26 taking the first part of the medications. RN B said she waited till she saw the Resident put the medications in his mouth, asked if he was okay, and then left the room. RN B stated she would need to go back into the Residents room to know if he had taken his medications or not. During an observation and interview on 04/06/23 at 9:44 a.m. RN B went back to Resident #26's room. Resident #26 was sitting up at his chair. Two empty medicine cups were on the bedside table and the cup of polyethylene glycol powder mixture was still sitting on the bedside table. RN B stated the medicine cups were empty and he needed to finish the mixture with medication. During an interview on 04/06/23 at 11:56 a.m. Resident #26 stated he normally took his medications by himself. Resident #26 stated RN B was a good nurse and had informed him earlier that day she can no longer let him take his medications by himself. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676041 If continuation sheet Page 4 of 7 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 676041 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mission at Blue Skies of Texas East 4949 Ravenswood Dr San Antonio, TX 78227 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 04/07/23 at 11:25 a.m. the DON stated there were a couple of Residents that were able to self-administer medications. The DON stated Resident #26 would need to have an order and a care plan that allowed him to self-administer medications. Resident #26 did not have a physician order or care plan to self-administer medications. Record review of the Facility's policy titled Administering Medications, dated 03/2023, stated I. Purpose: The purpose of this procedure is to provide guidelines for the state administration of oral medications .III. Definitions: medication: any prescription medication, sample medication, herbal remedy, vitamin, with nutraceutical, vaccine, or over the counter drug: diagnostic and or contrast agent used on for administer to persons to diagnose, treat, or prevent disease or other abnormal conditions; radioactive medication, respiratory therapy treatment, parenteral nutrition, blood derivatives, and intravenous solutions; and any product designated by the Food and Drug administration has a drug .IV. Procedure .22. Residents self-administrator their own medications only if the attending physician, in conjunction with the interdisciplinary team (IDT), has determined that they have the decision-making capacity to do so safely. Event ID: Facility ID: 676041 If continuation sheet Page 5 of 7 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 676041 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mission at Blue Skies of Texas East 4949 Ravenswood Dr San Antonio, TX 78227 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 1 of 24 residents (Residents #15) and 1 of 5 staff (LVN C) reviewed for infection control, in that: Residents Affected - Few 1. LVN C did not sanitizer the scissors prior to cutting a bandage during wound care for Resident #15. 2. LVN C used the same paper towel to turn off the sink faucet and dry her hands prior to wound care for Resident #15. These deficient practices could place residents who receive wound care at-risk for infections. The findings included: During an observation on 04/06/23 at 10:20 a.m. LVN C prepared wound care supplies to treat Resident #15's left heel wound. LVN C put on clean gloves, cleaned the bedside table, removed the gloves, set up trash bag, cut wax paper for table, placed the wax paper on the table, taped the trash bag to the side of the bedside table, placed two cups on table, sanitized hands, put on clean gloves, grabbed gauze, put gauze in cup, removed gloves, poured Dakin in one cup, put Santyl cream in a medicine cup, put mupirocin in a separate medicine cup, placed an island dressing and cotton swabs placed on table. LVN C removed a pair of medical scissors from her shirt pocket and cut a piece of calcium alginate gauze without sanitizing the scissors prior. LVN C placed a box of gloves and hand sanitizer on the table. LVN C then put the scissors on top of the treatment cart. LVN A stated she was going to clean the scissors for LVN C. LVN C stated she did not need the scissors anymore. LVN C went to wash her hands in the Residents bathroom. LVN C turned on the water, wet her hands, dispensed soap, and lathered her hands. LVN C then rinsed her hands off, grabbed paper towels, turned off the water with the paper towels, dried her hands with the same paper towels, and discards the paper towels in the trash receptacle. LVN C then began wound care on Resident #15's left heel and placed the calcium alginate gauze she cut with the non-sanitized scissors in the open wound. During an interview on 04/06/23 at 10:44 a.m. LVN C stated she usually cleaned the scissors after she finished the treatment and before. LVN C stated she did not clean the scissors prior to staring wound care and cutting the calcium alginate gauze she covered the residents wound with. LVN C stated she should have cleaned the scissors before because they are no longer clean after she pulled them out of her pocket. LVN C stated handwashing should be done in the order of turning on the faucet, rinse your hands, get some soap, wash your hands, grab a paper to turn off the faucet, and grab a different paper towel to dry your hands. LVN C stated when she washed her hands prior to wound care she grabbed a paper towel in each hand and used one to turn off the sink and the other to dry her hands. During an interview on 04/07/23 at 11:33 a.m. the DON stated a clean paper towel should be used to dry your hands and a separate paper towel should be used to turn off the faucet because your hands or the sink could become contaminated again. The DON stated wound care equipment should also be cleaned prior to use or bacteria could be introduced to the residents wound. Record review of the Facility's document titled Employee in Service, dated 03/2023, stated infection control, wash your hands regularly with soap and water for at least 20 seconds .** always use a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676041 If continuation sheet Page 6 of 7 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 676041 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Mission at Blue Skies of Texas East 4949 Ravenswood Dr San Antonio, TX 78227 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete new clean paper towel to turn off the faucet, after washing your hands.** The document did not contain LVN C signature. Record Review of the Facility's Policy titled Wound Care, dated 10/2010, stated The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation .3. Assemble the equipment and supplies as needed. Date and initial all bottles and jars upon opening. Wipe nozzle, foil packets, bottle tops, ect., with alcohol pleget before opening, as necessary . Event ID: Facility ID: 676041 If continuation sheet Page 7 of 7