Health inspection·September 12, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation for 1 of 11 residents (Resident #1) reviewed for resident abuse. The facility failed to ensure Resident #1 was free from physical abuse as evidence by on 08/05/2025, in the resident's room CNA A pushed Resident #1 onto the bed forcefully and held Resident #1 by pressing on the resident's chest when Resident #1 tried to get up. The noncompliance was identified as a PNC. The IJ began on 08/05/2025 and ended on 08/08/2025. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of serious injury, physical harm, serious impairment or death.The findings included: Record review of Resident #1's face sheet, dated 09/11/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included hepatic encephalopathy (the loss of brain function when a damaged liver does not remove toxins from the blood), dementia (loss of memory and thinking ability), anxiety disorder (a mental health disorder characterized by feelings of worry), and delusional disorder (A delusion is an unshakable belief in something that's untrue. The belief isn't a part of the person's culture or subculture, and almost everyone else knows this belief to be false). Resident #1 was discharged to another nursing home on [DATE] because of the resident's wandering behaviors. Record review of Resident #1's admission MDS assessment, dated 07/05/2025, revealed the resident's BIMS was 8 out of 15, which indicated the resident had moderate cognitive impairment, had verbal behavioral symptoms directed toward others, such as threatening others, screaming at others, and/or cursing at others, and required partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) to sit to stand, chair to bed, and toilet transfer. Record review of Resident #1's comprehensive care plan, dated 07/19/2025, revealed [Resident #1] resistive to care related to refuses medication, refuses care, refuses showers, becomes easily agitated and refused to be redirected. For intervention - 1:1 supervision, educate resident/family/caregivers of the possible outcomes of not complying with treatment or care, encourages as much participation/interaction by the resident as possible during are activities, give clear explanation of all care activities prior to an as they occur during each contact, and if resident resists with activities of daily livings, re-assure resident, leave and return 5 to 10 minutes later and try again. Record review of the facility's Provider Investigation Report, dated 08/08/2025, revealed On 08/05/2025, [Resident #1] was being transferred to bed by [CNA-A] used abrupt force to place resident in bed. Further record review of the Provider Investigation Report revealed the facility suspended CNA-A immediately, and the facility nurse assessed Resident #1 on 08/05/2025 at 6:15 p.m., incident, contacted the local police and received a case number, physician and family were notified, staff educated on Page 1 of 4 676478 676478 09/12/2025 Harbor Valley Health and Rehabilitation 6211 Old Pearsall Road San Antonio, TX 78242

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few reporting abuse and neglect and resident rights and providing compassionate care to residents. Staff members and residents were interviewed. Record review of Resident #1's nurses notes, dated 08/05/2025, revealed At approximately 3:25 p.m., resident was observed by nurse ambulating in the hallway without wearing pants, and their brief was nearly falling down. Resident then entered another resident's room and stated, ‘I want to use the bathroom.' Resident was redirected appropriately. Staff attempted to explain and encourage the resident to return to their own room. During redirection, resident displayed aggressive behavior and attempted to physically strike the CNAs. Resident was safely guided back to their room by staff. Nurse attempted to administer Ativan as needed order for agitation; however, resident refused multiple times. CNAs assisted resident with hygiene, changing clothing, and ensuring resident's dignity and comfort were maintained. Will continue to monitor behavior closely and ensure safety of resident and others. Resident's family member was aware. Further record review of the resident's nurse note dated 08/05/2025 at 6:30 p.m. revealed The administrator along with the nurse manager notified this resident's family reported resident was being mishandled by a CNA. This nurse completed head to toe assessment. This nurse assessed pain level and asking the resident ‘Do you have any pain?' Resident denies any pain. Nurse observed that resident has no verbal/nonverbal indicated of pain. Resident family stay at the bed side while the nurse did head to toe assessment for resident. [CNA-A] removed from patient care. Medical doctor was notified. The resident denies pain at times and continues one on one due to wandering. Record review of Resident #1's incident report, dated 08/05/2025, revealed on 08/05/2025, [Resident #1] was being transferred to bed by [CNA-A] used abrupt force to place resident in bed, and [Resident #1]'s skin was dry and intact. No bruising was noted. Resident family was present when nurse do skin assessment for resident. [Resident #1] denies any pain or discomfort at this time. Observation on 09/11/2025 at 1:18 p.m. of the video footage dated 08/05/2025 inside Resident #1's room revealed CNA-A held both of Resident #1's arms behind him and approached Resident #1's bed. CNA A pushed Resident #1 onto the bed forcefully and held Resident #1 by pressing on the resident's chest when Resident #1 tried to get up. During an interview on 09/11/2025 at 1:20 p.m. with Resident #1's family member revealed he saw the video footage on 08/05/2025 and he thought CNA-A pushed Resident #1 onto the bed, so he notified the administrator immediately. Further interview with Resident #1's family member revealed Resident #1 did not have any abuse or neglect before this incident and after this incident. This was only incident related to abuse. Resident #1's family member said he thought Resident #1 was a little bit scared of the staff after this incident because the resident refused more cares, and Resident #1 was unable to interview because he was confused. During an interview on 09/10/2025 at 12:25 p.m., CNA-A stated Resident #1 was very aggressive and tried to enter a female resident's room on 08/05/2025, so CNA-A re-directed and guided Resident #1 to the resident's room. CNA-A said when he guided Resident #1, he was behind the resident and approached the bed, the resident tripped, lost his balance, and was about to fall. To prevent the actual fall, CNA-A pushed Resident #1 a little bit onto the bed. That was it, but later the facility told CNA-A to go to home, and the facility finally terminated CNA-A. During an interview on 09/10/2025 at 11:14 a.m., Sitter-B stated she was doing one to one supervision inside Resident #1's room on 08/05/2025, and Sitter-B saw Resident #1 was very aggressive to staff by throwing the television remote control and tried to hit staff, so CNA-A tried to re-direct and guide Resident #1 to the bed. Sitter-B said she did not see CNA-A push Resident #1 onto the bed, and she did not see any abuse to the resident. During an interview on 09/10/2025 at 10:09 a.m., the DON stated she saw the video footage on 08/05/2025 because Resident #1's family member showed it, and per the video footage, CNA-A hugged Resident #1 from behind the resident and guided the resident to the bed, then 676478 Page 2 of 4 676478 09/12/2025 Harbor Valley Health and Rehabilitation 6211 Old Pearsall Road San Antonio, TX 78242

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few forcefully pushed the resident onto the bed because the resident was trapped and about to fall, so CNA-A tried to prevent the fall, but the facility immediately suspended CNA-A and finally terminated the CNA because he hugged the resident and did not request help from other staff. The DON said the facility assessed Resident #1 and found no injury was noted, reported it to the family and doctor, and provided in-services to all staff regarding Rights, Compassionate Care, Abuse and Neglect, and how to take care of residents with aggressive behaviors. During an interview on 09/10/2025 at 10:44 a.m., the facility Administrator stated Resident #1's family member called and showed the video footage to the Administrator on 08/05/2025, and according to the scene on the video footage, CNA-A tried to guide Resident #1 to the bed and pushed the resident forcefully onto the bed to prevent a fall, but CNA-A did not request any help from other co-workers. That was why the administrator suspended CNA-A immediately and terminated the CNA on 08/08/2025. The Administrator said the facility assessed Resident #1 and found no injury was noted, reported it to the family and doctor, and provided in-services to all staff regarding Rights, Compassionate Care, Abuse and Neglect, and how to take care of residents with aggressive behaviors, and the Administrator said the facility did not have residents with wandering and aggressive behaviors. During interviews on 09/11/2025 from 2:00 p.m. to 2:43 p.m. with Residents #2, #3, #4, #5, #6, #7, #8, #9 and #10 revealed they felt very safe and did not have or see any abuse or neglect in the facility. During an interview on 09/12/2025 at 9:30 a.m., LVN-C stated LVN-C worked the evening shift (from 2 p.m. to 10 p.m.) and assessed Resident #1 on 08/05/2025 and noted the resident did not have any injury and denied any pain. Resident #1's behaviors after the incident occurred were not changed, and the resident never was scared of staff but still was aggressive sometimes. LVN-C said the facility staff received in-service trainings regarding Resident Rights, Compassionate Care, Abuse and Neglect, and how to take care of residents with aggressive behaviors, and the nurse said she learned that the resident had right for free from abuse, the definition of abuse, staff must report any abuse immediately to the abuse coordinator (The Administrator), and using therapeutic communication skills when taking care of resident with aggressive behaviors. During interview on 09/11/2025 from 1:24 p.m. to 1:59 p.m. with CNA-D, CNA-E, CMA-F, Housekeeper-G, CNA-H, LVN-I, CNA-J and LVN-K revealed they worked at morning shift (6 am to 2 pm) and sometimes evening shift (2 p.m. to 10 p.m.) at the facility and Resident #1's behaviors after this incident occurred were not changed, and the resident was never scared of staff and was still aggressive sometimes, and they received in-service trainings regarding Resident Rights, Compassionate Care, Abuse and Neglect, and how to take care of residents with aggressive behaviors, and they answered they learned that the resident had right for free from abuse, the definition of abuse, staff must report any abuse immediately to the abuse coordinator (The Administrator), and using therapeutic communication skills when taking care of resident with aggressive behaviors, such as keep voice at a conversation level, maintain eye contact, ask a few questions, and maintain a safe distance from the resident. During interview on 09/12/2025 from 10:00 a.m. to 11:15 a.m. with CNA-L, CNA-M, and CNA-N stated they worked the night shift (10 pm to 6 am) at the facility and Resident #1's behaviors after this incident occurred were not changed, and the resident was never scared of staff and was still aggressive sometimes, and they received in-service trainings regarding Resident Rights, Compassionate Care, Abuse and Neglect, and how to take care of residents with aggressive behaviors, and they answered they learned that the resident had right for free from abuse, the definition of abuse, staff must report any abuse immediately to the abuse coordinator (The Administrator), and using therapeutic communication skills when taking care of resident with aggressive behaviors, such as keep voice at a conversation level, maintain eye contact, ask a few questions, and maintain a safe distance from the resident. Record 676478 Page 3 of 4 676478 09/12/2025 Harbor Valley Health and Rehabilitation 6211 Old Pearsall Road San Antonio, TX 78242

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few review of CNA-A's employee profile revealed CNA-A was hired on 11/18/2024 and terminated on 08/08/2025 because of the incident of 08/05/2025. CNA-A's employee profiles revealed the facility conducted checking criminal background on 11/17/2024, and CNA-A completed in-services training regarding abuse and neglect on 11/25/2024 before he started working the floor. Record review of the facility's in-service training regarding Resident Rights related to residents to have right to live in safe condition, be free from abuse, and be free from any physical restraint, Compassionate Care related to take care care of not only physical well-being but also the emotional, social, and spiritual well-being, Abuse and Neglect related to types of abuse, how to prevent and screening procedures, and how to identify abuse, signs of abuse, and how to report abuse, and how to take care of residents with aggressive behaviors, such as keep voice at a conversation level, maintain eye contact, ask a few questions, and maintain a safe distance from the resident. revealed 98 Staff out of total 103 staff completed receiving these in-service trainings on 08/05/2025. Record review of the facility's policy, titled Abuse & Neglect Policy and Procedure, revised 08/10/2022, revealed The facility is charged with the safeguard of each resident and will follow a consecutive plan in the pursuit of maintaining a safe environment. Suspected actions or allegations of abuse including physical, mental, verbal, sexual, involuntary seclusion, neglect or misappropriation of property by any individual including resident to resident altercations with injury will be reported to local authorities, state, and federal agencies and other appropriate agencies as required by law. The noncompliance was identified as PNC. The IJ began on 08/05/2025 and ended on 08/08/2025. The facility had corrected the noncompliance before the investigation began. 676478 Page 4 of 4