Health inspection·March 4, 2024

F 0686 Level of Harm - Actual harm Residents Affected - Few (cm): 3 Depth (cm): 3 . Skin Issue: #002: New. Issue type: Other skin issue. Location: Left lower leg. Other skin issue description: abrasion Length (cm): 9.5 Width (cm): 3 Depth (cm): 0. There was no mention of notifying Wound Care Nurse D or Wound Care NP C. - Nursing Progress Note written by Wound Care Nurse D, dated 11/22/23: Stage 4 Pressure Ulcer to Sacrum [tail bone area] assessed by Wound NP and Treatment Nurse. Current wound measurements this visit: 8.0x9.0x1.5cm and presents with undermining from 9 o'clock to 12 o'clock and tunneling [when the wound forms passageways underneath the surface of the skin] 2cm deep. Upon further assessment of wound Moderate amount of green serosanguineous [thin, watery discharge that contains a small amount of blood] drainage observed to wound bed with no foul odor. There was no mention of treating any wounds to Resident #1's right and left leg. - Nursing Progress Note written by LVN A on 11/28/23: Skin Issue: #001: No Change. Issue type: Other skin issue. Location: Right lower leg. Other skin issue description: abrasion Length (cm): 9.5 Width (cm): 3 Depth (cm): 3 . Skin Issue: #002: Needs Review. Issue type: Other skin issue. Location: Left lower leg. Other skin issue description: abrasion Length (cm): 9.5 Width (cm): 3 Depth (cm): 0. There was no mention of notifying Wound Care Nurse D or Wound Care NP C. - Nursing Progress Note written by Wound Care Nurse D on 11/29/23: Lower Extremity presents with Unstageable pressure ulcer measuring 10.0x3.5xUTDcm. Moderate amount of serosangenous [sic] drainage with foul odor noted, erythematous [red] and purple in color with slough [the yellow/white material in the wound bed] and eschar [a collection of dry, dead tissue within a wound] observed . Right Lower Extremity has developed an unstageable Pressure Ulcer measuring 7.0x4.0xUTD with mild amount of serous drainage [clear fluid that leaks out of wounds], intact eschar, and purple in color. Record review of a wound care progress note, dated 11/29/23 and written by Wound Care NP C, revealed: seen today for wound care follow up new ulcers noted to . bilateral LE [lower extremities.] Record review of Resident #1's all physician orders, obtained on 2/27/24, revealed the first wound care order for either of Resident #1's legs was the following order dated on 11/30/23: Left Lower Extremity Unstageable Pressure Ulcer Type of cleaning/irrigation solution: Cleanse with NS [Normal Saline which is a mixture of sodium chloride and water used to cleanse wounds, flushing lines, and treating dehydration]/Wound Cleanser, pat dry Primary dressing: Santyl [a topical medication used for removing damaged or burned skin to allow for wound healing and growth of healthy skin] Secondary dressing: Dakins [an antimicrobial solution used for wound care] soaked gauze 1/4 strength Secured With: Dry dressing every day shift. Observation on 2/27/24 at 10:27 a.m. revealed Resident #1 was in bed. Resident #1's heels were lifted from the bed with pillows. No heel-lifting boots were seen in the room. During an interview on 2/28/24 at 10:14 a.m., Resident #1's RP stated she was satisfied with the care of the facility and denied any concerns of neglect. Resident #1's RP stated she recalled that Resident #1's leg wounds first began in before December 2023. Resident #1's RP stated at the time Resident #1 wore heel-lifting boots and Resident #1 did not want to reposition his legs. Resident #1's RP stated sometimes if the staff reposition Resident #1's legs, Resident #1 will move his legs back to the same position. During an interview on 2/29/24 at 2:43 p.m., LVN A stated she was not currently employed by the facility and her previous position at the facility was an LVN A. LVN A stated when a wound was found (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676041 If continuation sheet Page 2 of 5 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 03/04/2024 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 0686 Level of Harm - Actual harm Residents Affected - Few she would notify Wound Care Nurse D and then Wound Care Nurse D would obtain wound care orders from either the wound care physician or the resident's physician. LVN A stated, [Resident #1] had abrasions [a minor injury where the skin rubs off] on either side of the outer part of his calves. They started as redness. I did contact [Wound Care Nurse D] and she said to just keep him clean and dry and open to air. So we didn't. We didn't write an order for that. And then I believe the wounds . maybe within a week and a half, the wounds became worse. [Wound Care Nurse D] got wound care orders for that. LVN A stated she could not remember specific dates related to the onset or the treatment of Resident #1's wounds. LVN A stated she notified Wound Care Nurse D when Resident #1's lower leg wounds first appeared but she did not recall if Resident #1's physician was notified. During an interview on 2/29/24 at 10:17 a.m., Wound Care Nurse D stated when a staff member found a new wound, the staff member would notify the wound care nurse soon as the wound is found. Wound Care Nurse D stated the wound care physician or the wound care nurse practitioner would typically be notified immediately if within business hours or by 8:00 a.m. the next day. Wound Care Nurse D stated, As soon as I'm notified I would give [the staff] a . standing order from our nurse practitioner just to clean it, bandage it up, or I'll go and evaluate [the wound] right away . It's not that I don't get involved [with abrasions], but we typically like to monitor . We do implement either a xeroform [a special type of wound dressing] or skin prep [a liquid that forms a protective barrier to help reduce friction during the removal of tapes and films from the skin depending on the severity of the abrasion. Normally we would treat the abrasion. When asked if an abrasion would typically require a physician notification or a wound care order, Wound Care Nurse D stated, yes. Wound Care Nurse D stated Resident #1's lower leg wounds began towards the end of November and she was first notified of the wound on . 11/28/23. Wound Care Nurse D stated she was informed the wounds were abrasions. Wound Care Nurse D stated she first saw Resident #1's wounds on 11/29/23. Wound Care Nurse D stated, [Resident #1] was using the [heel-lifting] boots. I know [the wound] started on the left leg. And from what I understood, they [the nurses] used a dressing basically on that leg. It was in the end of November, [the wound] started out as unstageable. Wound Care Nurse D stated the cause of the wounds to Resident #1's lower legs was the heel-lifting boots he wore at the time, which had since been discontinued. During an interview on 2/29/24 at 1:05 p.m., Wound Care NP C stated Resident #1 was one of her patients. Wound Care NP C stated Resident #1 had poor blood flow to his legs and Resident #1 was also prone to wounds because he was physically weak. When asked how soon she would like to be notified if a resident had a new wound, Wound Care NP C stated, It depends on the wound. If it's something [the staff] can manage, they're perfectly capable of it . But most of the time the new residents . [Wound Care Nurse D] will call me promptly. Wound Care NP C stated she would prefer to be notified within 24 hours. Wound Care NP C stated on 11/22/23 she saw Resident #1 and treated his sacral wound. Wound Care NP C stated Resident #1 refused examination of his legs. Wound Care NP C stated she first saw Resident #1's lower leg wounds on 11/28/23 and implemented wound care orders for his lower leg wounds at that time. When asked if she believed the delay in notification may have worsened his lower leg wounds, Wound Care NP stated, There's multiple factors and I can't say for sure. During an interview on 3/1/24 at 11:23 a.m., the DON stated he expected abrasions to be reported to Wound Care Nurse D as soon as possible, then Wound Care Nurse D will decided if the wound required wound care orders. The DON was aware new wounds were discovered on Resident #1's lower legs on 11/28/23, but he did not realize that LVN A did not report the wounds to the wound care nurse or the wound care practitioner until he was reviewing documentation on 12/5/23. The DON stated LVN A noted Resident #1 had abrasions to his lower legs on 11/21/23. The DON stated Resident #1 had poor circulation and would frequently (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676041 If continuation sheet Page 3 of 5 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 03/04/2024 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 0686 Level of Harm - Actual harm Residents Affected - Few refused wound care treatments and would also refuse turning. The DON stated ultimately, LVN A failed to report the abrasions. The DON stated, The root cause revealed the irritation was caused by the [heel-lifting] boots so after that the resident was followed and treated by the wound care nurse practitioner. We discontinued the [heel-lifting] boots so we off-load his heels in pillows. We in-serviced the CNAs and nurses on the use and care of residents with those boots. And we started doing the shower sheets. Even though he refused care, I found it hard to believe no one saw that. And they gave those to the wound care coordinator. When asked if the facility had a process to ensure residents' providers were notified of new wounds, the DON stated, we do that during the morning clinical meeting. We'll find out in the skin assessment and if [the staff] are reporting the problem. When asked what sort of negative affects could occur if providers were not notified of new wounds, the DON stated, they [the residents] won't receive the proper orders and treatments. During an interview on 3/4/24 at 9:27 a.m., LVN E stated she recalled seeing Resident #1's lower leg wounds when they first began in November 2023, but could not recall the specific dates. LVN E stated, I don't remember when, but I know the treatment nurse was there . I think it was a deep tissue injury. We'd turn him, but a lot of the times he would not allow us to turn him. During a follow-up interview on 3/4/24 at 9:43 a.m., Wound Care Nurse D stated on 11/22/23 she and Wound Care NP C treated Resident #1's sacrum and they had noted a deep tissue injury to Resident #1's left heel. Wound Care Nurse D stated Resident #1's had heel protection boots on during the treatment on 11/22/23 and the boots hid the dressing which covered Resident #1's lower leg wounds. Wound Care Nurse D stated she did not check Resident #1's legs because when she and Wound Care NP C treat a resident's wounds, they are only focused on the wounds they are aware of. During an interview on 3/8/24 at 2:10 p.m., Physician F stated he was not informed when Resident #1's wounds first began but cannot recall exactly when he was notified. Physician F stated the wound care nurse did not notify him of Resident #1's lower leg wounds. When asked if there could have been a different outcome if he was notified of Resident #1's leg wounds sooner, Physician F stated, There are times where I've recommended things and [Resident #1's Medical Power of Attorney] has not gone along with my suggestions. And . [Resident #1] will frequently be very angry with the staff if they attempt to even to touch him. So the real question is going to be the chicken or the egg. Who is really responsible for him for not getting the care he needed? Is it the staff or was it because he was recalcitrant [uncooperative] in regards of letting the staff do what they need to do? I have no way of knowing that. Record review of a facility policy titled, Wound Care, dated January 2024 revealed the following: The facility does not have the capability to manage complex wounds, Stage 2 or above. These are referred to a contract specialty wound care group which provides clinical evaluation and treatment plans and therapies through the services of one or more providers under the contract . If the Charge Nurse is the staff member entering the order into [the facility's electronic medical system] she/he will notify [Wound Care Nurse D] of the need for the referral as soon as possible. Record review of a facility policy titled, change in a Resident's Condition, dated December 2024, revealed the following: The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: .a need to alter the resident's medical treatment significantly. 2. Record review of Resident #1's physician orders, obtained on 2/27/24 revealed the following wound care orders: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676041 If continuation sheet Page 4 of 5 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 03/04/2024 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 0686 Level of Harm - Actual harm Residents Affected - Few - Left Heel Stage 3 Pressure Ulcer Type of cleaning/irrigation solution: Cleanse with NS/Wound Cleanser, Pat dry Primary dressing: Anasept [an antibiotic liquid used in wound care that helps prevent infection] Secured With: Dry Dressing every evening shift every Mon, Wed, Fri. - Right Lower Extremity Stage 4 Pressure Ulcer Type of cleaning/irrigation solution: Cleanse with NS/Wound Cleanser, pat dry Primary dressing: Anasept Secondary dressing: Dakins [an antimicrobial solution used for wound care] soaked gauze Secured With: ABD Pad [a highly absorbent dressing that provides padding and protection for large wounds], Kerlix [a type of bandage roll], and tape every evening shift every Mon, Wed, Fri. Observation on 2/27/24 11:48 a.m. revealed Wound Care Nurse D began the treatment to Resident #1's left heel. Wound Care Nurse D cleansed Resident #1's left heel with gauze soaked in wound cleanser, which used the last of her gauze soaked in wound cleanser. Wound Care Nurse D removed her soiled gloves, used hand sanitizer, and then put on a clean pair of gloves. Wound Care Nurse D next painted Resident #1's left heel with betadine (which was not part of the wound care orders for this wound) and pat the betadine dry. Wound Care Nurse D removed her soiled gloves, used hand sanitizer, and then put on a clean pair of gloves. Wound Care Nurse D completed the rest of wound care for Resident #1's left heel. Wound Care Nurse D did not obtain more gauze soaked in wound cleanser. Wound Care Nurse D then began the treatment to Resident #1's right lower leg. Wound Care Nurse D removed the old dressing on Resident #1's right lower leg, removed her soiled gloves, used hand sanitizer, and then put on a clean pair of gloves. Wound Care Nurse D cleansed Resident #1's right lower leg wound with Dakins solution (which was not part of the wound care orders for this wound) and applied Anacept. Wound Care Nurse D then completed the rest of the wound care for Resident #1's right heel. During an interview on 2/27/24 at 12:27 p.m., Wound Care Nurse D stated, I know I put the betadine first [on Resident #1's left heel] and then I realized it was a mistake. I was just a little confused. After I caught it, I realized it was supposed to be the Anacept . I cleansed [Resident #1's right lower leg], dried it, applied the Anacept and the Dakins. Wound Care Nurse D stated she was supposed to use the wound cleanser for Resident #1's right lower leg wound, but she ran out of wound cleanser. When asked what sort of negative affects could happen to the residents if their wound care wasn't done appropriately, Wound Care Nurse D stated, it could delay the healing. During an interview on 3/1/24 at 11:23 a.m., when asked if the facility had a quality assurance process to ensure wound care was done per properly, the DON stated when the nurse practitioner rounded, the facility was able to follow if the wounds are getting better. The DON stated wounds are also discussed in the facility's clinical morning meeting. When asked what sort of negative effects could occur to the residents if they did not receive their wound care properly, the DON stated, the wound will deteriorate or get worse. Record review of a facility policy titled, Wound Care, dated January 2024 revealed the following: DRESSING CHANGE PREPARATION . 1. Verify there is a physician's order for the procedure . 3. Assemble the equipment and supplies needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676041 If continuation sheet Page 5 of 5