Health inspection·March 10, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few solution Pen-injector 100 unit/ml, inject as per sliding scale subcutaneously before meals and at bedtime for diabetes, with order date 2/25/23 and no end date. Observation on 3/8/23 at 4:14 p.m. during the medication pass revealed, LVN D placed an injection needle on the Humalog Pen-Injector, set the dial on the insulin pen at 2 units and administered the insulin to Resident #58 without priming the Humalog Pen-Injector first. During an interview on 3/8/23 at 4:26 p.m., LVN D stated, I don't even know what prime means; I've never done that. LVN D stated, she had not had an in-service on administering insulin since she had been in school. LVN D stated she had worked for the facility for the past 3 years. During an interview on 3/9/23 at 5:06 p.m., the DON stated, the insulin pen should have been primed to make sure there was no air in the pen and that would ensure the insulin dose dispensed was correct. The DON stated insulin not administered as prescribed could make the glucose level not come down to the expected level you would hope for and the negative outcome potentially could be the blood sugar would be under corrected. The DON stated nursing staff were provided competencies upon hire during orientation. Record review of the annual Clinical Competency Validation, Medication Administration - Licensed Nurse document for LVN D, dated 9/13/22 revealed she had satisfied the requirement for proper technique when storing, preparing and administering injectable (IM, sub-q) medications. Record review of the prescribing manufacturer's insert titled, Instructions for use Humalog KwikPen, revision date 4/2020 revealed in part, .Priming your pen .Prime before each injection .Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly .If you do not prime before each injection, you may get too much or too little insulin . 2. a. Record review of Resident #49's face sheet, dated 3/10/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included fracture of left femur (bone of the thigh or upper hind limb), orthopedic aftercare, osteoarthritis (when the protective cartilage that cushions the ends of the bones wears down over time), difficulty in walking, abnormalities of gait and mobility and lack of coordination. Record review of Resident #49's most recent admission MDS assessment revealed the resident was cognitively intact for daily decision-making skills, required 2-person physical assist with bed mobility and transfers and was treated with pain medication as needed. Record review of Resident #49's comprehensive care plan, initiated on 2/8/23 revealed the resident received pain medication therapy with interventions that included to administer analgesic pain medications as ordered by the physician. Record review of Resident #49's Order Summary Report, dated 3/10/23 revealed an order for Acetaminophen-Codeine tablet 300-30 mg, give 1 tablet by mouth every 6 hours as needed for severe pain, with order dated 2/7/23 and no end date. Observation on 3/9/23 at 7:45 a.m., during the medication pass revealed, LVN E dispensed 8 prescribed medications for Resident #49 into a medication cup and then took the Acetaminophen-Codeine 300-30 mg tablet from the medication bottle and dropped it on the medication cart counter. LVN E then took (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676216 If continuation sheet Page 2 of 11 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 676216 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Remington Transitional Care of San Antonio 5423 Hamilton Wolfe Rd San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a plastic spoon and scooped the Acetaminophen-Codeine 300-30 mg tablet into the medication cup with the other 8 pills. LVN E then administered the medications to Resident #49. 2. b. Record review of Resident #113's face sheet, dated 3/10/23 revealed a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included spontaneous bacterial peritonitis (infection of abdominal fluid within the abdomen such as a hole in the intestines or a collection of pus), sepsis (the body's extreme response to an infection), cirrhosis of liver (scarring of the liver caused by long-term liver damage), hepatic failure (liver failure), Cushing's syndrome (disorder caused by excessive production or administration of glucocorticoid hormones), cholelithiasis (gallstones, a hardened deposit within the fluid in the gallbladder), asthma and hypertension (high blood pressure). Record review of Resident #113's comprehensive care plan, initiated on 3/9/23 revealed the resident was treated with pain medication with interventions that included to administer analgesic medications as ordered by the physician. Record review of Resident #113's Order Summary Report, dated 3/10/23 revealed an order for Potassium Chloride ER (extended release) tablet, 10 meq (milliequivalent) one time a day for supplement, give 2 tablets to equal 20 meq, with order date 3/9/23 and no end date and an order for acetaminophen 325 mg tablet, give 2 tablets every 6 hours as needed for pain/fever with order dated 3/7/23 and no end date. Observation on 3/9/23 at 8:16 a.m., during the medication pass revealed, LVN E took Resident #113's Potassium Chloride ER tablet from the blister package, dropped it on the medication cart counter and scooped up the Potassium Chloride ER tablet with a plastic spoon and placed it in the medication cup. LVN E then dispensed 7 more pills into the same medication cup and administered them to Resident #113. Resident #113 then requested pain medication. LVN E returned to the medication cart, dispensed two acetaminophen 325 mg tablets, dropped one tablet on the floor and the other tablet fell on the medication cart counter. LVN E used the medication cup to scoop the acetaminophen 325 mg tablet from the medication cart counter and dispensed another tablet from the medication bottle. LVN E picked up the tablet from the floor and disposed it. LVN E then returned to Resident #113's bedside and administered the acetaminophen 325 mg tablets to the resident. During an interview on 3/9/23 at 8:41 a.m., LVN E stated she began her shift at 6:00 a.m. and had been using the same medication cart during the medication pass. LVN E stated she had sanitized the medication cart counter at the beginning of the shift, so dropping medications on the medication cart counter was ok. LVN E then stated the medication cart had been used and other objects had been placed on the medication cart counter so dropping a pill on the counter should have been discarded because it would be considered cross contamination. During an interview on 3/9/23 at 5:09 p.m., the DON stated, Best practice would be to discard the medications if the pill fell on the counter and get new pills. The DON stated the expectation was for LVN E to discard the pills and start over. The DON stated, dropping the pills on the medication cart counter could result in the resident being exposed to a contaminant and was considered cross contamination. Record review of the Clinical Competency Validation Medication Administration - Licensed Nurse form, dated 12/21/22 revealed LVN E had satisfied the requirements for preparing the medication cart for medication pass, including the following, Uses proper technique when storing, preparing, & (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676216 If continuation sheet Page 3 of 11 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 676216 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Remington Transitional Care of San Antonio 5423 Hamilton Wolfe Rd San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 administering oral medications .b. Pours medication into medication cup. Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy and procedure, titled Medication Administration, dated 10/24/22 revealed in part, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676216 If continuation sheet Page 4 of 11 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 676216 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Remington Transitional Care of San Antonio 5423 Hamilton Wolfe Rd San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 2 ice makers reviewed for food handling sanitation. 1. The facility failed to ensure the nutritional room ice machine was clean. These failures could place residents at risk for cross-contamination and foodborne illnesses. The findings include: Observation on 03/08/23 at 11:14 AM revealed a large black mass along the side of the condenser unit above the ice inside of the ice machine. The condenser unit was observed to be located directly above the ice with recently produced ice dropped directly from above. Interview on 03/08/23 at 10:16 AM, the DM stated the nutritional room is entirely the responsibility of the nursing department except for the refrigerator in that room. Interview on 03/08/23 at 11:46 AM, LVN G stated she provided ice to the residents upstairs from the ice maker in the nutrition room. LVN G stated if there was a concern with the ice maker, she would submit a work order which could be done anywhere. LVN G stated it was the responsibility of any nurse or CNA who got ice in the nourishment room to report a concern to the Maintenance Supervisor. Interview on 03/08/23 at 11:50 AM, the DON stated he could not identify the black substance on the side of condenser and that the MS regularly evaluated the ice maker. The DON stated to identify the black sustenance he would like for it be viewed and evaluated by maintenance and stated he would contact the MS immediately. The DON stated the MS confirmed the responsibility for evaluating the ice maker for needed service was the responsibility of the dietary department. Interview on 03/08/23 at 11:58 AM, the MS stated he checks the nutrition room's ice maker monthly and evaluates it for cleanliness. The MS stated the last cleaning was about 2 weeks ago and he normally does the cleaning in the middle of the month. The MS stated the ice maker will produce more buildup depending on the run time and humidity. The MS stated the concern was something that needs a full cleanout. The MS stated a full cleanout was one where all the ice was melted, and then all items are cleaned inside. The MS stated a full cleanout was the only service needed. The MS stated he did not remember the last time the ice maker received a full cleanout. The MS stated full cleanouts are not documented, only the regular cleanings. The MS stated he did not have any recollection of a work order request for the ice maker and that nursing can submit that digitally. The MS stated the risk associated with having a dirty or unclean ice maker would be a potential for contaminated water and thus cause contaminated ice for resident use. Interview on 03/08/23 at 1:22 PM, the ADM stated they have cleaned the ice maker after removing the ice and stated there was a breakdown of communication in that the dietary was not aware the ice maker was their responsibility. The ADM stated she was not aware of the ice maker's condition or cleanliness and stated she expects staff to report concerns with essential equipment to the MS to be serviced immediately. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676216 If continuation sheet Page 5 of 11 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 676216 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Remington Transitional Care of San Antonio 5423 Hamilton Wolfe Rd San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the facility's, undated, policy titled Logbook Documentation reflected Clean Interior: Sanitize interior of ice maker per manufacturer's instructions; Clean out and sanitize ice bin. It further reflected the last indicated date the service was completed was on 02/27/23. A record review of the August 2021 version of the TFER reflected the following: (b) The department adopts by reference the U.S. Food and Drug Administration (FDA) Food Code 2017 (Food Code) and the Supplement to the 2017 Food Code. Record review of the US Food Code, dated 2017, reflected (4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, cooking oil storage tanks and distribution lines, BEVERAGE and syrup dispensing lines or tubes, coffee bean grinders, and water vending EQUIPMENT: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676216 If continuation sheet Page 6 of 11 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 676216 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Remington Transitional Care of San Antonio 5423 Hamilton Wolfe Rd San Antonio, TX 78229 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 - Few 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 interview and record review, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible and systematically organized for 1 of 15 residents (Resident #4) reviewed for accuracy of medical records in that: 1. Resident #4 did not have a physician's order for code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop). This deficient practice could affect residents whose records were maintained by the facility and place them at risk for errors in care and treatment. The findings were: Record review of Resident #4's face sheet, dated [DATE] revealed an [AGE] year-old-female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included acute gastric ulcer with hemorrhage (bleeding, open ulcers in the digestive tract), paroxysmal atrial fibrillation (irregular heart beat that returns to normal within 7 days, on its own or with treatment), chronic iron deficiency anemia secondary to blood loss (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), pure hypercholesterolemia (genetic condition that causes the development of high LDL cholesterol levels), hypothyroidism (abnormally low activity of the thyroid gland resulting in slowing of metabolic changes in adults), cirrhosis of liver (scarring of the liver caused by long-term liver damage), heart disease, chronic obstructive pulmonary disease (diseases that cause airflow blockage and breathing-related problems) and hypertension (high blood pressure). Record review of Resident #4's most recent admission MDS assessment, dated [DATE] revealed the resident was cognitively intact for daily decision-making skills. Record review of Resident #4's comprehensive care plan, dated [DATE] revealed the resident was a full code with interventions that included to initiate CPR and call 911. Record review of Resident #4's Directive to Physicians and Family or Surrogates form, signed and dated by Resident #4 on [DATE] revealed, under Terminal Condition, Resident #4 requested all treatments other than those to keep me comfortable be discontinued or withheld and my physician allow me to die as gently as possible. The Directive to Physicians and Family or Surrogates form, under Irreversible Condition, revealed Resident #4 requested all treatments other than those needed to keep me comfortable be discontinued or withheld and my physician allow me to die as gently as possible. Further review of Resident #4's Directive to Physicians and Family or Surrogates form, under Additional Requests revealed Resident #4 requested the following, I do not want cardiac resuscitation, I do not want mechanical respiration, I do not want tube feeding, I do not want antibiotics and I do not want to be maintained in a condition or approaching a condition of what is known as a vegetative stated, and I want a treating physician and my agent designated in my Medical Power of Attorney of even date herewith to do all that is possible to avoid the administration of procedures which will only prolong the moment of death. Record review of Resident #4's Social Services Initial Evaluation and Social History document, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676216 If continuation sheet Page 7 of 11 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 676216 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Remington Transitional Care of San Antonio 5423 Hamilton Wolfe Rd San Antonio, TX 78229 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 dated [DATE] revealed the resident requested full code status. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #4's Order Summary Report for active orders as of [DATE] revealed there was no order for code status. Residents Affected - Few During an interview on [DATE] at 1:21 p.m., Resident #4's family member, who was visiting Resident #4 stated, Resident #4 was in DNR status and the family was looking into palliative care and hospice services. Resident #4's family member stated the resident had the DNR status for about a year and Resident #4 had been in and out of the hospital since [DATE]. Resident #4's family member stated the facility should have had a DNR document on file. During an interview on [DATE] at 1:22 p.m., Resident #4 stated she did not know about her code status, indicating she did not know if she was full code status or DNR status. During an interview on [DATE] at 1:37 p.m., LVN Charge Nurse A stated, a resident who was identified as DNR status would have a sign posted above the resident's bed. LVN Charge Nurse A stated, residents on her unit, including Resident #4, did not have a DNR status. LVN Charge Nurse A stated, a resident's code status could be found on the resident's physician's orders. LVN Charge Nurse A, after checking in the medical electronic record revealed, Resident #4 did not have an active order for code status. LVN Charge Nurse A stated, a physician's order for code status was necessary to confirm code status and in case something should happen then staff would know how to take care of the resident. LVN Charge Nurse A stated the admissions nurse was responsible for obtaining a code status order. LVN Charge Nurse A stated she had never done an admission. During an interview on [DATE] at 1:50 p.m., SW B stated, code status documentation, such as for a DNR, was provided at the time of admission. SW B stated the social worker would ask the resident directly if they had an advanced directive at the time of admission. During an interview on [DATE] at 1:50 p.m., SW C stated, the Directive to Physicians and Family or Surrogates form for Resident #4 did not constitute a DNR status and therefore did not make Resident #4 a DNR. SW C stated, the DNR would dictate how Resident #4 would be treated should the resident require CPR. SW C stated, it was negligence on their part because the resident's wishes needed to be respected. During an interview on [DATE] at 2:04 p.m., the Administrator stated, a code status for Resident #4 could be found under the physician's orders and any DNR documentation could be found under the miscellaneous tab in the electronic record. The Administrator stated, a resident's code status would not be on a sign on the wall in a resident's room. The Administrator stated LVN A made her aware Resident #4 did not have an order for code status after surveyor intervention and had given LVN A the directive to put an order in the resident's medical electronic record for a full code. The Administrator stated it was the SW's responsibility to have the code status discussion with the resident and/or the family about an advanced directive and if Resident #4 and/or family wanted the resident to become a DNR, the SW would help initiate that. The Administrator stated the nurse should be able to check if the resident had a DNR code status immediately on the face sheet and under the miscellaneous tab in the electronic record. The Administrator stated it was important to have an order for code status and a plan of care to abide by the resident's wishes. The Administrator stated an order for DNR or full code status could not be bypassed because it infringed on the resident's rights. During a follow up interview on [DATE] at 3:08 p.m., SW B stated, only nursing could input orders, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676216 If continuation sheet Page 8 of 11 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 676216 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Remington Transitional Care of San Antonio 5423 Hamilton Wolfe Rd San Antonio, TX 78229 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 so if Resident #4 was determined a DNR status, the information would have been provided to nursing during report and then the SW would have helped to initiate the documents needed for an advanced directive. SW B stated, if the information or paperwork was not provided, Resident #4 would automatically become a full code status. SW B stated it was the Social Worker's responsibility to help initiate the paperwork for the DNR. Residents Affected - Few A request for the policy and procedure for clinical records was made on [DATE] at 3:25 p.m. but was not provided by the Administrator. The Administrator stated, the facility used best practice to establish code status and attain an order from the physician for code status upon admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676216 If continuation sheet Page 9 of 11 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 676216 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Remington Transitional Care of San Antonio 5423 Hamilton Wolfe Rd San Antonio, TX 78229 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 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 3 of 8 residents (Resident #216, #49 and #56) observed for infection control in that: Residents Affected - Some 1. During the medication pass, LVN E did not sanitize the wrist blood pressure cuff used between Resident #216 and Resident #49. 2. LVN Treatment Nurse F placed several gloves in his pant pocket and used them during wound care for Resident #56. These deficient practices could place residents at risk of infection. The findings were: 1. a. Record review of Resident #216's face sheet, dated 3/10/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included hepatic failure (liver failure), hepatic encephalopathy (loss of brain function when a damaged liver doesn't remove toxins from the blood), cirrhosis of liver (scarring of the liver caused by long-term liver damage), liver cell carcinoma (a form of liver cancer), hyperlipidemia (high cholesterol) and hypertension (high blood pressure). b. Record review of Resident #49's face sheet, dated 3/10/23 revealed a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included fracture of left femur (bone of the thigh or upper hind limb), orthopedic aftercare, osteoarthritis (when the protective cartilage that cushions the ends of the bones wears down over time), difficulty in walking, abnormalities of gait and mobility and lack of coordination and hypertension (high blood pressure) Observation on 3/9/23 at 7:45 a.m. during the medication pass revealed LVN E exited Resident #216's room with the wrist blood pressure cuff and placed it on top of the medication cart counter. LVN E then prepared Resident #49's medications, took the same wrist blood pressure cuff used on Resident #216 and placed it on her own wrist. LVN E then went into Resident #49's room, removed the wrist blood pressure cuff from her own wrist and placed it on Resident #49's right wrist without sanitizing it. LVN E obtained Resident #49's blood pressure, removed the wrist blood pressure cuff and placed it back onto her own wrist. LVN E then returned to the medication cart, removed the wrist blood pressure cuff from her wrist and stored it in a drawer in the medication cart without sanitizing it. During an interview on 3/9/23 at 8:41 a.m., LVN E stated she had started her shift at 6:00 a.m. and had borrowed the wrist blood pressure cuff from the Treatment Nurse. LVN E stated she had initially used the wrist blood pressure cuff on Resident #216 and did not sanitize the wrist blood pressure cuff before using it to obtain Resident #216's blood pressure or prior to obtaining Resident #49's blood pressure. LVN E stated she had forgotten to sanitize the wrist blood pressure cuff between Resident #216 and Resident #49 and should have because it was considered cross contamination and the residents could be affected in that illness could be transferred from resident to resident. During an interview on 3/9/23 at 5:09 p.m., the DON stated it was the expectation for nursing staff to disinfect any equipment used between patient use and between patients to prevent cross (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676216 If continuation sheet Page 10 of 11 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 676216 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Remington Transitional Care of San Antonio 5423 Hamilton Wolfe Rd San Antonio, TX 78229 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some contamination. The DON stated, If we don't do that, we could potentially cross contaminate and the resident may come in contact with something like any sort of other patient's organisms. 2. Record review of Resident #56's face sheet, dated 3/5/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included urinary tract infection, HIV disease (human immunodeficiency virus, a virus that attacks the body's immune system), acute respiratory failure (develops when the lungs can't get enough oxygen into the blood), and kidney failure. Record review of Resident #56's Order Summary Report, dated 3/9/23 revealed an order for wound care to the buttock/rear BLE every day shift and as needed with order date 3/7/23 and no end date. Record review of Resident #56's comprehensive care plan, dated 3/8/23 revealed the resident had pressure ulcer development related to lack of mobility with interventions that included to administer treatments as ordered and monitor for effectiveness and wound care to the buttock/rear to bilateral lower extremities. Observation on 3/9/23 at 9:33 a.m., during wound care revealed, LVN Treatment Nurse F took several disposable gloves from a box mounted outside of Resident #56's room, placed the disposable gloves into the right leg pocket of his pants and then went into Resident #56's room to wash his hands. LVN Treatment Nurse F returned to Resident #56's bedside, took the disposable gloves out of his right leg pocket and placed them on the resident's bedside table with other wound care supplies. LVN Treatment Nurse F used all of the disposable gloves he had put into his right leg pocket during the wound care to Resident #56. During an interview on 3/9/23 at 10:11 a.m., LVN Treatment Nurse F stated he realized he should not have placed the disposable gloves into his pant leg pocket because it could be considered cross contamination. LVN Treatment Nurse F stated, I put other items in the same pocket and in doing so the resident could get a bacterial infection. During an interview on 3/9/23 at 5:18 p.m., the DON stated, LVN Treatment Nurse F should not have put the disposable gloves into his pocket because the gloves in the box were clean but when they come out of the box and placed in any other container they were no longer assumed clean. The DON stated, it was not considered to be in line with standard practice of care and the resident could potentially come in contact with some sort of potential contaminant inside of LVN Treatment Nurse F's pocket, or even on the table where he placed his gloves. Record review of the facility policy and procedure titled, Infection Prevention and Control Measure for Common Infections in LTC (Long Term Care) Facilities, undated, revealed in part, .Standard precautions are used for all resident care. They're based on a risk assessment and make use of common-sense practices and personal protective equipment that protect staff from infection and prevent the spread of infection among residents and staff .Standard precautions included .Practicing Hand Hygiene .Implementing correct Disinfection and Sterilization of instruments and devices .Hand hygiene refers to cleaning your hands by using hand washing techniques .Prior to direct contact with residents .After removing gloves . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676216 If continuation sheet Page 11 of 11