Inspection·May 10, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete alive) because of the invalid OOH-DNR. The SW stated, the OOH-DNR was time sensitive and would need to be addressed immediately and the process would have to be started over again. A facility policy regarding Advance Directives was requested but not received by the time of the exit. Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated [DATE], accessed [DATE], revealed, Frequently Asked Questions for DNR: What happens if the form is not filled out correctly or EMS has doubts about any of the information? Health professionals can refuse to honor a DNR if they think: The form is not signed twice by all who need to sign it or is filled out incorrectly. Event ID: Facility ID: 676041 If continuation sheet Page 2 of 20 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 05/10/2024 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to respect the residents' right to confidentiality in his or her personal and medical records for 1 of 1 resident (Resident #14) reviewed for residents' rights, in that: Residents Affected - Few The facility failed to ensure LVN E locked the Medication Cart Computer screen and left Resident #14's information exposed. This failure could place residents at risk of resident-identifiable information being accessed by unauthorized persons. The findings included: Record review of Resident #14's face sheet, dated 5/10/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included rheumatoid arthritis (a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility), hypothyroidism (abnormally low activity of the thyroid gland resulting in slowing of metabolic changes in adults), dysphagia, mood disorder (feelings of distress, sadness or symptoms of depression, and anxiety), lack of coordination and chronic pain. Observation on 5/9/24 at 4:27 p.m. revealed the Medication Cart Computer screen was left open, unattended, and facing the hall with Resident #14's health information exposed from 4:27 p.m. to 4:36 p.m. During an interview on 5/9/24 at 4:36 p.m., LVN E revealed she had left the Medication Cart Computer Screen unattended to answer the phone and did not close the screen on the computer. LVN E stated, can't do that because it was a HIPAA violation. During an interview on 5/10/24 at 10:27 a.m., the DON revealed it was his expectation staff were to clear or push the walkaway button on the computer screen to protect resident information and was considered a HIPAA violation. Record review of the facility policy and procedure titled, HIPAA Security Agreement, undated, revealed in part, . (the Facility) considers maintaining the security and confidentiality of protected health information (PHI) a matter of its higher priority. All those granted access to this information must agree to the standards set forth in this Computer and Information Usage Agreement .Understand that the information accessed through all (Facility) computer(s) and information systems contains sensitive and confidential patient care .information which should only be disclosed to those authorized to receive it . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676041 If continuation sheet Page 3 of 20 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 05/10/2024 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 7 Residents (Resident #54) whose MDS records were reviewed for accuracy. Residents Affected - Few Resident #54's Quarterly MDS assessment dated [DATE] incorrectly documented the resident was discharged to a Short-term hospital. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #54's face sheet dated 5/08/2024 revealed Resident #54 was admitted to the facility on [DATE] with diagnoses that included: Angina Pectoris (chest pain), Atherosclerotic Heart Disease of Native Coronary Artery (plaque buildup that causes the inside of the arteries to narrow over time), Type II Diabetes (a disease that occurs when your blood sugar is too high). Record review of Resident #54's Discharge MDS assessment, dated 02/17/2024, revealed under section for identification, Discharge Status was coded as being discharged to Short-Term General Hospital. Record review of Resident #54's discharge progress note, dated 2/17/2024 11:04:25, showed Resident DC Home with Spouse, Resident breathing even and unlabored, Resident DC at baseline. Spouse Took all belonging During an interview on 05/09/2024 at 12:58 pm with LVN H, MDS Nurse - she verified the MDS indicated the resident was discharged to a General Short-Term Hospital. When asked where the resident was discharged to, she replied we've already established that. LVN H then stated, I'm correcting it now. During a phone interview on 5/10/24 at 10:34 am - LVN D stated she had written the discharge progress note for Resident #54 and verified the resident was discharged home and that her family member picked her up. She stated that the resident was not discharged to another facility. Record review of the CMS MDS 3.0 Manual dated October 2023 revealed in part, .The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. The MDS 3.0 is part of that assessment process and is required by CMS . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676041 If continuation sheet Page 4 of 20 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 05/10/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 8 residents (Resident #12, Resident #28, and Resident #44) reviewed for care plans. The facility failed to ensure Residents #12, #28 and #44 care plans reflected their need or placement on a secured memory care unit. This deficient practice places residents at risk for not receiving proper care and services due to inaccurate care plans. The findings included: Record review of Resident #12's face sheet, dated 05/09/2024, revealed Resident #12 was admitted on [DATE] with diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety and metabolic encephalopathy. Record review of Resident #12's admission assessment, dated 04/07/2024, revealed Resident #12's BIMS score was 00 for severe cognitive impairment. Record review of Resident #12's care plan with an initiated date of 04/09/2024 and a targeted date 07/07/2024, revealed no care plan addressing Resident #12's need or placement on a secured/memory care unit. Record review of Resident #12's Consent for admission to [name of unit] Secured Household dated 04/05/2024 revealed acknowledgment of resident placement on the secured household signed by Resident #12's legal representative. Observation on 05/7/2024 at 10:00 a.m. revealed Resident #12 on the secure/memory care unit tearful and staff providing her with her animated stuffed cat. Record review of Resident #28's face sheet, dated 05/08/2024, revealed Resident #28 was admitted on [DATE] with diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Record review of Resident #28's Quarterly assessment, dated 03/20/2024, revealed Resident #28's BIMS score was 00 for severe cognitive impairment. Record review of Resident #28's care plan with a revision date of 03/25/2024 and a targeted date 06/20/2024, revealed no care plan addressing Resident #28's need or placement on a secured/memory care unit. Record review of Resident #28's Consent for admission to [name of unit] Secured Household dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676041 If continuation sheet Page 5 of 20 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 05/10/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm 09/15/2023 revealed acknowledgment of resident placement on the secured household signed by Resident #28's legal representative. Observation on 05/07/2024 at 9:55 a.m. revealed Resident #28 in her bed with bed in the lowest position and fall mats to both sides on the secure/memory care unit. Residents Affected - Some Record review of Resident #44's face sheet, dated 05/09/2024, revealed Resident #44 was admitted on [DATE] with diagnoses which included: Parkinson's disease without dyskinesia, without mention of fluctuations, and dementia in other diseases classified elsewhere, unspecified severity, with agitation. Record review of Resident #44's admission assessment, dated 03/04/2024, revealed Resident #44's BIMS score was 00 for severe cognitive impairment. Record review of Resident #44's care plan with an initiated date of 03/04/2024 and a targeted date 06/04/2024, revealed no care plan addressing Resident #44's need and or placement on a secured/memory care unit. Record review of Resident #44's Consent for admission to [name of unit] Secured Household dated 03/13/2024 revealed acknowledgment of resident placement on the secured household signed by Resident #44's legal representative. Observation on 05/10/2024 at 11:10 a.m. revealed Resident #44 sitting in a recliner in the living room on the secure/memory care unit. During an interview on 05/10/2024 at 11:29 a.m. with Resident Assessment Coordinator she reviewed Resident #12, Resident #28, and Resident #44's care plans and stated the residents did not have a care plan for the secure/memory care unit. She further stated residents did not necessarily need a care plan for the use of the unit due to many other behaviors having been care planned. Resident Assessment Coordinator stated the secure/memory care unit would not typically be a focus on its own. She further stated the facility realized the residents could not come off the unit on their own but could come off the unit with an escort so did not feel it was a problem. During an interview on 05/10/2024 at 12:50 p.m. the ADM stated she did not know if the secure/memory care unit would be care planned or more the resident's diagnoses. The ADM further stated Alzheimer's and dementia would be the focus, not necessarily the specific household. During an interview on 05/10/2024 at 2:01 p.m. the DON stated residents on the secure/memory care unit would have a special care plan with the reason for the need. The DON further stated the Resident Assessment Coordinators were usually responsible for the care plans. The DON stated the importance of the care plans was so the staff when caring for the residents would be aware of any special needs. Record review of the facility's Care Plan - Comprehensive policy, effective February 2024, revealed Purpose: An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological will be developed for each resident. III Procedure: #3 Each resident's Comprehensive Care Plan has been designed to; a. Incorporate identified problem areas. b. Incorporate risk factors associated with identified problems. c. Build on resident's strengths. d. Reflect treatment goals and objectives in measurable outcomes. e. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676041 If continuation sheet Page 6 of 20 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 05/10/2024 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 0656 Identify the professional services that are responsible for each element of care. f. Aid in preventing or reducing declines in the resident's functional status and or functional levels. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676041 If continuation sheet Page 7 of 20 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 05/10/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 2 of 8 residents (Resident #4 and Resident #28) reviewed for accidents and hazards in that: Facility failed to ensure Resident #4, and Resident #28 did not have disposable razors left on bathroom counters. This failure could place residents at risk of harm or injury and contribute to avoidable accidents. The findings included: Record review of Resident #4's face sheet, dated 05/08/2024, revealed Resident #4 was admitted on [DATE] with diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Record review of Resident #4's Quarterly assessment, dated 05/01/2024, revealed Resident #4's BIMS score was 5 for severe cognitive impairment. Record review of Resident #4's care plan with a revision date of 03/22/2024 and a targeted date 06/18/2024, revealed Resident #4 had a Focus: [resident's name] is unable to make safe decisions due to dementia, schizoaffective in regards to her daily care and need for personal safety, wandering/elopement behaviors. It is in [resident's name] best interest that she reside on a secured memory care household . Record review of Resident #4's physician order summary report, dated, 05/08/2024, revealed an order dated, 08/25/2022, Admittance to secured unit for safety and specialized care due to patients Dementia or Alzheimer's related diagnosis, patient requires secured unit to meet her/his emotional, mental, and physical health needs due to cognitive impairment. Patient has a diagnosis of Dementia to support higher level of care. Observation on 05/07/2024 at 9:49 a.m. revealed on Resident #4's bathroom counter a green disposable razor. Observation and interview on 05/08/2024 at 9:14 a.m. revealed on Resident #4's bathroom counter a green disposable razor. Resident #4 was not able to describe or tell when or if she used the razor. During an observation and interview on 05/08/2024 at 9:40 a.m. CNA B was observed leaving Resident #4's room in which CNA B stated she had disposed of the shaving razor in Resident #4's bathroom by placing it in the sharp's container. CNA B further stated residents should not have disposable razors for safety reasons. Record review of Resident #28's face sheet, dated 05/08/2024, revealed Resident #28 was admitted on [DATE] with diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676041 If continuation sheet Page 8 of 20 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 05/10/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #28's Quarterly assessment, dated 03/20/2024, revealed Resident #28's BIMS score was 00 for severe cognitive impairment. Record review of Resident #28's care plan with a revision date of 03/25/2024 and a targeted date 06/20/2024, revealed Resident #28 had a Focus: [resident's name] has an ADL self-care performance deficit r/t Confusion, Dementia . and a Focus: [resident's name] does have Risk for Wandering/Elopement Identified. Observation on 05/07/2024 at 9:55 a.m. revealed on Resident #28's sink counter in a plastic cup two pink disposable razors. Observation on 05/08/2024 at 9:17 a.m. revealed on Resident #28 sink counter in a plastic cup two pink disposable razors. During an interview on 05/08/2024 at 9:24 with CNA A stated Resident #28 did have two disposable razors in her bathroom but was not aware if residents could or could not have disposable razors. She said she knew some had electric razors. During an interview on 05/08/2024 at 9:25 a.m. LVN C stated as a nurse she would typically remove disposable razors from resident's rooms but was not aware if the facility had a policy regarding disposable razors. LVN C further stated the secure/memory care unit did have resident who might wander, and Resident #4 and Resident #28 did not keep their room doors closed. LVN C stated as a nurse she would rather not have them on the floor due to they could be a hazard. During an interview on 05/09/2024 at 10:19 a.m. the DON stated the facility did not have an existing policy to address the storing of disposable razors, however they had swept the secure/memory care unit and the rest of the facility. The DON further stated unless the resident had behaviors or aggressive behaviors the resident should have been able to have the razors based on safety level and cognition, however razors should have probably not been on the secure unit in resident's rooms. Record Review of the facility's Shaving the Resident competency, no date, provided by the DON revealed, 'Basic Responsibility: Licensed Nurse and Nursing Assistant, General Infection Control Guidelines: #6 Dispose of disposable equipment appropriately. #7 Dispose of hazardous materials appropriately. #10 Dispose of needles and sharps appropriately. Equipment: #1 Disposable razor (should be stored in treatment cart) . Record review of the facility's The Mission Secured Household Policies and Procedures policy, dated September 2023, revealed Purpose: The Mission Certified Alzheimer's Household, from here on referred to as a secured household, will follow policies and procedures intended to promote quality of life and protect the safety and wellbeing of residents residing there, while following applicable laws and regulation pertaining to secured skilled nursing facilities (SNF). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676041 If continuation sheet Page 9 of 20 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 05/10/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #12) reviewed for enteral feeding tubes in that: LVN C did not check for residual volume prior to medication administration, did not flush the enteral feeding tube per physician's orders and administered the flush and medications with the syringe plunger instead of via gravity flow to Resident #12. These deficient practices could place residents receiving enteral nutrition and medications at increased risk of aspiration, infection, bloating discomfort, and not receiving the full benefit of the medications administered. The findings included: Record review of Resident #12's face sheet, dated 5/9/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included fracture of the sacrum, gastro-esophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach), aphasia (a disorder that impacts speech and the ability to communicate), severe protein-calorie malnutrition, and gastrostomy status (feeding tube). Record review of Resident #12's most recent admission MDS assessment, dated 4/7/24 revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #12's Order Summary Report, dated 5/9/24 revealed the following: - [Enteral] Open system container or gravity feeding - Change feeding administration set daily; label the formula container, syringe and administration set with resident's name, date, time, and nurse's initials, every shift, with order date 4/3/24 and no end date - Check and record residuals every shift. Contact physician if residual exceeds 100 ml every shift, with order date 4/3/24 and no end date - Flush 5-10 ml of water in between each medication every shift, with order date 4/6/24 and no end date - Flush feeding tube with 20 ml to 30 ml of water before and after medication administration every shift with order date 4/3/24 and no end date - Flecainide 150 mg, give 75 mg via PEG-Tube one time a day for A-Fib, hold for heart rate less than 60, with order date 4/6/24 and no end date - Multiple Vitamin, give 1 tablet via PEG-Tube one time a day for supplement, with order date 4/4/24 and no end date - Docusate Sodium 100 mg, give 1 tablet via PEG-Tube two times a day for constipation, with order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676041 If continuation sheet Page 10 of 20 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 05/10/2024 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 0693 date 4/10/24 and no end date Level of Harm - Minimal harm or potential for actual harm - Lyrica 75 mg, give 1 capsule via PEG-Tube two times a day for neuropathic pain, with order date 4/3/24 and no end date Residents Affected - Some - Metoprolol 25 mg tablet, give 1 tablet via PEG-Tube one time a day for hypertension - May crush medication per pharmacy, HOLD: Systolic blood pressure less than 110 AND Heart Rate less than 60, with order date 4/4/24 and no end date - Calcium Carbonate Oral Wafer, give 500 mg via PEG-Tube in the morning for supplement, with order date 4/10/24 and no end date Record review of Resident #12's comprehensive care plan, revision date 4/10/24 revealed the resident required tube feeding related to dysphagia (difficulty swallowing), resisting eating, swallowing problem and failure to thrive with interventions that included to check tube placement and gastric contents/residual volume per facility protocol and record; hold feed if greater than 100 cc aspirate and report to MD. Further review of the comprehensive care plan revealed to flush the feeding tube with 20 ml to 30 ml of water before and after medication administration and the resident was dependent with tube feeding and water flushes; see MD order for current feeding orders. Observation on 5/9/24 at 8:09 a.m., during the medication pass, revealed LVN C opened the port to Resident #12's feeding tube, and did not check for residual prior to administering the initial water flush. LVN C then pushed 60 ml of water instead of the ordered 20 ml to 30 ml with the syringe plunger instead of by gravity flow. LVN C continued with the medication pass and administered Flecainide, Multiple Vitamin, and Docusate Sodium all by pushing the medications with the syringe plunger instead of by gravity flow. LVN C, when administering the Multiple Vitamin, mixed the medication with 60 ml of water, instead of the ordered 5 ml to 10 ml. LVN C completed the medication pass and administered the final flush of 40 ml, instead of the ordered 20 ml to 30 ml with the syringe plunger instead of by gravity flow. During an interview on 5/9/24 at 8:31 a.m., LVN C stated she had checked Resident #12 for residual earlier at 7:40 a.m. when she administered Lyrica, Metoprolol, and Calcium Carbonate prior to observation by the State Surveyor beginning at 8:09 a.m. LVN C stated, medications given back-to-back via a feeding tube did not need to be checked for residual again. LVN C revealed she had administered an additional amount of water flush because Resident #12 was not taking fluids. LVN C stated she did not usually push the medications with the syringe plunger but, with Resident #12's feeding tube I have to be more forceful; we are supposed to do it by gravity as much as possible, I do but you have to be more rigorous with flushing. During an interview on 5/9/24 at 2:36 p.m., the DON stated, pushing the flush and the medications with the syringe plunger could traumatize the stomach. The DON revealed, he was not aware staff were pushing fluids and medications with the syringe plunger instead of by gravity flow. The DON stated it was his expectation staff were following policy and the policy was to administer water and medications with a syringe via gravity flow. The DON stated, must check for residual to ensure the feeding tube was patent, every time you open the peg tube port and introduce a medication or feeding, you must check for residual prior. The DON further stated, if there was a blockage you are only forcing fluids to go in and you want to make sure the digestive tract was working, and things are flowing out of the stomach. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676041 If continuation sheet Page 11 of 20 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 05/10/2024 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 0693 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 facility policy and procedure, titled Administering Medications Through an Enteral Tube, effective date August 2023 revealed in part, .PURPOSE To ensure residents receiving nutritional and/or hydration support via PEG-Tube receives safe medication administration according to MD orders and within nursing standards of practice .For gastrostomy tubes, check .gastric contents .Pull back gently on the syringe to aspirate stomach content .Flush tubing with 15 to 30 ml warm water (or prescribed amount) .remove syringe and clamp/close tubing .Reattach syringe (without plunger) to the end of the tubing .Administer medication by gravity flow .Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion .When the last of the medication begins to drain from the tubing, flush the tubing with 30 to 50 ml of water at room temp (or prescribed amount) . Event ID: Facility ID: 676041 If continuation sheet Page 12 of 20 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 05/10/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions and were stored in accordance with currently accepted professional principles for 2 of 7 medication carts (Household Treatment Cart and Household Medication Cart) reviewed for storage of drugs. 1. The facility failed to ensure the Household Treatment cart was locked and secured when it was left unattended. 2. The facility failed to ensure a change of direction label was used after the medication orders had changed for a medication package prescribed to Resident #46 in the Household Medication Cart. This deficient practice could place residents at risk of medication misuse and diversion. The findings included: 1. Observation on 5/8/24 at 10:51 a.m. revealed the Household Treatment Cart was left unlocked and unattended, facing the hallway next to the dining area. During an observation and interview on 5/8/24 at 11:09 a.m., RN G stated she had used the Household Treatment Cart to provide a treatment to a resident in the household. RN G opened the top drawer of the Household Treatment Cart and revealed there were tubes of topical medication, shaving razors, oxygen supplies and nail clippers. RN G stated, the Household Treatment Cart should not have been left unlocked because anybody can get into it, if they do they can eat it (medication tubes) or scratch themselves with the razors. During an interview on 5/8/24 at 2:34 p.m., the DON revealed it was his expectation that the medication/treatment carts should be locked and secured when not in use. The DON further stated, anybody could open the cart and take what's in it, and a resident could take a medication that did not belong to them. 2. Record review of Resident #46's face sheet, dated 5/10/24 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included cardiomegaly (an enlarged heart stemming from damage to the heart muscle), hyperlipidemia (elevated cholesterol), and hypertension (elevated blood pressure). Record review of Resident #46's most recent significant change MDS assessment, dated 4/29/24 revealed the resident was cognitively intact for daily decision-making skills. Record review of Resident #46's Order Summary Report, dated 5/10/24 revealed the following: - Carvedilol tablet 12.5 mg, give 1 tablet by mouth two times a day related to essential primary hypertension, hold for systolic blood pressure less than 100 or heart rate less than 50, with order date 4/24/24 and no end date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676041 If continuation sheet Page 13 of 20 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 05/10/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #46's comprehensive care plan, with revision date 5/7/24 revealed the resident had hypertension with interventions that included to give anti-hypertensive medications as ordered. Observation and interview on 5/9/24 at 4:36 p.m., during the medication pass, revealed LVN E obtained the Carvedilol medication package from the Household Medication Cart, intended for Resident #46. LVN E revealed, the label on the Carvedilol medication package did not match the physician's order for Resident #46. LVN E stated, the order for Carvedilol for Resident #46 indicated the resident was supposed to receive only one 12.5 mg tablet twice a day, but the medication package on the Carvedilol label indicated the resident would get two 12.5 mg tablets twice a day. During a follow-up interview on 5/9/24 at 4:47 p.m., LVN E stated the Carvedilol medication package prescribed to Resident #46 should have had a change order label to alert the person giving the medication that the order had changed. LVN E stated, if Resident #46 received the wrong dosage, the resident could be receiving too much of the Carvedilol and it could result in a drop in her blood pressure. LVN E further stated, what if another agency nurse comes in and doesn't follow the order? During an interview on 5/10/24 at 10:27 a.m., the DON stated, the labels on medications administered to the residents had to match the physician's orders, and if it did not, the medication package should have had a change in direction sticker to let the nurse know the order should match the label on the medication package. The DON stated, the nurses can't go off what's on the (medication) label, (they) have to follow the orders on the computer. The DON revealed, if the resident received the incorrect dosage the resident could have received over or under the intended dose, which could result in a drop in blood pressure, in Resident #46's case. Record review of the facility policy and procedure titled, Administering Medications, dated April 2023 revealed in part, .The purpose of this procedure is to provide guidelines for the safe administration of oral medications .Medications must be administered in accordance with the orders, including any required time frame .During administration of medication, the medication cart is kept closed and locked when out of sight of the medication nurse or aide .and all outward sides must be inaccessible to residents or others passing by . Record review of the facility policy and procedure titled, Physician Medication Orders, dated January 2023 revealed in part, .Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state .Orders for medications must include .Name of strength of drug .Dosage and frequency of administration . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676041 If continuation sheet Page 14 of 20 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 05/10/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 4 of 8 residents (Residents #12, #28, #33, and #44) reviewed for accuracy of medical records. Facility failed to ensure Residents #12, #28, #33 and #44 had physician orders for admission to the locked memory care unit. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: Record review of Resident #12's face sheet, dated 05/09/2024, revealed Resident #12 was admitted on [DATE] with diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety and metabolic encephalopathy. Record review of Resident #12's admission assessment, dated 04/07/2024, revealed Resident #12's BIMS score was 00 for severe cognitive impairment. Record review of Resident #12's care plan with an initiated date of 04/09/2024 and a targeted date 07/07/2024, revealed Resident #12 had a Focus: [resident's name] has an ADL self-care performance deficit r/t Confusion, Dementia . Record review of Resident #12's physician order summary report, dated, 05/09/2024, revealed no orders for Resident #12 to be admitted to the locked memory care unit. Observation on 05/7/2024 at 10:00 a.m. revealed Resident #12 on the secure/memory care unit tearful and staff providing her with her animated stuffed cat. Record review of Resident #28's face sheet, dated 05/08/2024, revealed Resident #28 was admitted on [DATE] with diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Record review of Resident #28's Quarterly assessment, dated 03/20/2024, revealed Resident #28's BIMS score was 00 for severe cognitive impairment. Record review of Resident #28's care plan with a revision date of 03/25/2024 and a targeted date 06/20/2024, revealed Resident #28 had a Focus: [resident's name] has an ADL self-care performance deficit r/t Confusion, Dementia . and a Focus: [resident's name] does have Risk for Wandering/Elopement Identified. Record review of Resident #28's physician order summary report, dated, 05/08/2024, revealed no orders for Resident #28 to be admitted to the locked memory care unit. Observation on 05/07/2024 at 9:55 a.m. revealed Resident #28 in her bed with bed in the lowest (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676041 If continuation sheet Page 15 of 20 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 05/10/2024 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 0842 position and fall mats to both sides on the secure/memory care unit. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #33's face sheet, dated 05/09/2024, revealed Resident #33 was admitted on [DATE] with diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Residents Affected - Some Record review of Resident #33's Significant Change assessment, dated 04/09/2024, revealed Resident #33's BIMS score was 00 for severe cognitive impairment. Record review of Resident #33's care plan with a revision date of 04/18/2024 and a targeted date 07/09/2024, revealed Resident #33 had a Focus: [resident's name] has a history of wandering (moving with no rational purpose, seemingly oblivious to needs or safety .Interventions: Re-assess [resident's name] for placement in a specially designed therapeutic unit per facility protocol. Record review of Resident #33's physician order summary report, dated, 05/09/2024, revealed no orders for Resident #33 to be admitted to the locked memory care unit. Observation on 05/07/2024 at 11:50 a.m. revealed Resident #33 sitting in the dining room on the secured/memory care unit waiting for his lunch. Record review of Resident #44's face sheet, dated 05/09/2024, revealed Resident #44 was admitted on [DATE] with diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety and Parkinson's disease without dyskinesia, without mention of fluctuations. Record review of Resident #44's admission assessment, dated 03/04/2024, revealed Resident #44's BIMS score was 00 for severe cognitive impairment. Record review of Resident #44's care plan with an initiated date of 03/04/2024 and a targeted date 06/04/2024, revealed Resident #44 had a Focus: [resident's name] has impaired cognitive function/dementia with impaired thought processes r/t Dementia, Impaired decision making, Short term memory loss. Record review of Resident #44's physician order summary report, dated, 05/09/2024, revealed no orders for Resident #44 to be admitted to the locked memory care unit. Observation on 05/10/2024 at 11:10 a.m. revealed Resident #44 sitting in a recliner in the living room on the secure/memory care unit. During an interview on 05/10/2024 at 11:10 a.m. LVN C stated the DON usually did the orders for the unit and residents had orders prior to being moved to the unit. During an interview on 05/10/2024 at 11:17 a.m. the DON stated Residents #12, #28, #33 and #44 did not have orders, however residents just needed to have consents and did not require orders to be admitted to the unit. The DON further stated the residents also had to have a diagnosis of Alzheimer's disease or dementia. During an interview on 05/10/2024 at 12:50 p.m. the ADM stated residents needed a diagnosis of Alzheimer's or dementia but did not necessarily have to have an order to be placed on the memory care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676041 If continuation sheet Page 16 of 20 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 05/10/2024 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 0842 unit. The ADM further stated consents were required prior to residents being placed on this unit. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy titled Physician Medication Orders, effective date, January 2023, revealed IV. Dementia Protocol: 3. The physician will order appropriate medications and other interventions to manage behavioral and psychiatric symptoms related to dementia (to included assignment to memory care unit, as need) based on pertinent clinical guidelines and regulatory expectations. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676041 If continuation sheet Page 17 of 20 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 05/10/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 7 residents (Resident #12 and #18) reviewed for infection control practices, in that: Residents Affected - Few 1. LVN C did not sanitize or wash her hands between glove changes and turned off the water faucet after washing her hands which contaminated her hands prior to administering medications to Resident #12. 2. RN F used gloves from her pocket to administer a pain patch to Resident #18. These deficient practices could place residents who receive medications at risk of infection or a decline in health. The findings included: 1. Record review of Resident #12's face sheet, dated 5/9/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included fracture of the sacrum, gastro-esophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach), aphasia (a disorder that impacts speech and the ability to communicate), severe protein-calorie malnutrition, and gastrostomy status (feeding tube). Record review of Resident #12's most recent admission MDS assessment, dated 4/7/24 revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #12's Order Summary Report, dated 5/9/24 revealed the following: - Lidocaine External Patch 5%, apply to left sacral topically one time a day for pain: on for 12 hours, off for 12 hours, with order date 4/4/24 and no end date - Flecainide 150 mg, give 75 mg via PEG-Tube one time a day for A-Fib, hold for heart rate less than 60, with order date 4/6/24 and no end date - Multiple Vitamin, give 1 tablet via PEG-Tube one time a day for supplement, with order date 4/4/24 and no end date - Docusate Sodium 100 mg, give 1 tablet via PEG-Tube two times a day for constipation, with order date 4/10/24 and no end date Observation on 5/9/24 at 8:03 a.m., during the medication pass, revealed LVN C applied the Lidocaine patch to Resident #12's lower mid back, removed her gloves, did not wash, or sanitize her hands, put on a new pair of gloves, and took the manual blood pressure cuff to obtain Resident #12's blood pressure. LVN C then removed her gloves, went to the sink to wash her hands with soap and water and then turned off the faucet with her bare hands, contaminating her hands prior to administering medications to Resident #12. LVN C, after administering medications to Resident #12, removed her gloves, did not wash, or sanitize her hands, and put on a new pair of gloves. LVN C then took a clean (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676041 If continuation sheet Page 18 of 20 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 05/10/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few disposable pad and wrapped Resident #12's feeding tube and fastened the abdominal binder. LVN C then removed her gloves, washed her hands with soap and water in the sink, and then turned off the faucet with her bare hands and took disposable towels to wipe down the counter around the sink. During an interview on 5/9/24 at 8:31 a.m., LVN C stated she did not wash or sanitize her hands when she put on a new pair of gloves and revealed it was important because you can spread germs, and the resident could get an MDRO (multi-drug resistant organisms; organisms resistant to at least one or more classes of antimicrobial agents), which we are trying to protect against. LVN C further stated she should have used a towel to turn off the faucet because using her bare hand was considered cross contamination. 2. Record review of Resident #18's face sheet, dated 5/10/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] and 3/21/24 with diagnoses that included orthopedic aftercare, pain in joint, muscle wasting and atrophy (wasting or thinning of muscle mass), lack of coordination, low back pain and pain in right hip. Record review of Resident #18's most recent admission MDS assessment, dated 3/8/24 revealed the resident was cognitively intact for daily decision-making skills. Record review of Resident #18's Medication Administration Record for May 2024 revealed the following: - Lidocaine Patch 5%, Apply to lower back topically one time a day for lower back pain. Remove patch in 12 hours at 8:00 p.m., with order date 3/12/24 and no end date Record review of Resident #18's comprehensive care plan, with revision date 3/19/24 revealed the resident had acute/chronic pain related to arthritis, and right hip pain with interventions that included to give pain medications as ordered and remove lidocaine patch to lower back at bedtime. Observation on 5/10/24 at 8:22 a.m., during the medication pass, revealed RN G removed the old Lidocaine patch from Resident #18's lower back, removed her gloves and turned them inside out into the old Lidocaine patch, and then retrieved a new pair of gloves from her right pocket and put them on to apply the new Lidocaine patch to Resident #18's lower back. During an observation and interview on 5/10/24 at 8:42 a.m., RN F emptied her right pocket to reveal a set of keys and a pair of scissors. RN F stated, she should not have put the gloves in her pocket because it was considered cross contamination which could have contaminated her gloves and could result in the resident developing a rash. During an interview on 5/9/24 at 2:36 p.m., the DON stated it was his expectation, when staff wash their hands they were to turn off the faucet with a disposable towel. The DON stated, once they wash their hands, take a towel, dry your hands, and then take a clean towel to turn off the faucet. You don't want to take back whatever is on the faucet back with you because you used your dirty hands to turn on the faucet. The DON stated hand hygiene between glove changes were expected because when you are taking your gloves off there is a chance you can contaminate your hands. You can introduce germs into the peg tube, in this case, and the resident could get diarrhea, or an infection. During a follow-up interview on 5/10/24 at 10:27 a.m., the DON revealed, placing gloves in your pocket would make the gloves dirty, was considered cross contamination and could result in the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676041 If continuation sheet Page 19 of 20 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 05/10/2024 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 0880 getting an infection. Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy and procedure titled, Infection Prevention and Control Program (IPCP), undated, revealed in part, .The .IPCP has been established to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .Prevention of infections is the first line of defense . Residents Affected - Few Record review of the facility Performance Evaluation Checklist for Handwashing/Hand Hygiene, dated 2022 revealed in part, .Rinsed hands thoroughly from wrist to fingertips, keeping fingertips down .Dry hands with paper towel and discard .Obtained a clean paper towel and turned off the faucet with a clean paper towel .Discarded towel appropriately without contaminating hands .Did not touch the inside of sink or faucet handles with clean hands . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676041 If continuation sheet Page 20 of 20