Health inspection·November 14, 2025

F 0812 Level of Harm - Minimal harm or potential for actual harm know why he did not do anything. He stated it was important to follow the beard net policy and said, You don't want to contaminate the food with hair and other contaminants. Residents could be at risk of foodborne illness and other diseases. Review of the facility's Staff Attire policy, revised 01/2025, reflected, Procedures: 1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676478 If continuation sheet Page 2 of 4 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 676478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbor Valley Health and Rehabilitation 6211 Old Pearsall Road San Antonio, TX 78242 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 observations, interviews and record reviews, 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 1 (Resident #1) of 6 residents reviewed for infection control. The facility failed to ensure staff wore PPE when entering Resident #1's room on 11/12/25 at 8:00 a.m. This failure could place residents at risk of cross-contamination and infection. Findings include: Review of Resident #1's admission Record, dated 11/14/25, reflected she was an [AGE] year old female who was admitted to the facility on [DATE]. She had medical diagnoses including dementia (a set of symptoms that cause a significant decline in cognitive abilities like memory, thinking, and reasoning, to the point that it impairs daily life), weakness and COVID-19. Review of Resident #1's Quarterly MDS Assessment, dated 11/03/25, reflected she had a BIMS score of 2, which indicated she had severe cognitive impairment. Resident #1's COVID-19 vaccine was also not up to date.Review of Resident #1's Care Plan, revised 09/06/25, reflected she had diagnosis of COVID-19 and was at risk for developing respiratory complication including but not limited to impaired oxygen exchange and dehydration and decrease in mobility. One of the interventions included, isolation with droplet precautions in place, ensure proper signage is on doors and proper donning and doffing (putting on and taking off) is occurring when entering and exiting room or unit. Review of Resident #1's Electronic Monitoring Footage, dated 11/12/25 at 8:00 a.m., reflected Resident #1 was lying in bed in her room. A female staff member entered Resident #1's room with no PPE, placed a meal tray on Resident #1's bed side table next to Resident #1, woke Resident #1 and said, Buenos Dias (Good Morning), explained to Resident #1 that the meal tray was on the bed side table next to her, and exited her room. Review of the facility's Infection Report for November 2025 reflected Resident #1 had COVID-19 and was placed on droplet precautions on 11/05/25. Resident #1's infection resolved on 11/15/25. During an observation and interview on 11/12/25 at 10:31 a.m., Resident #1's room door was closed. There was a posting on her door that indicated she was on droplet precautions and staff were required to don and doff PPE before entering and exiting her room. There was a supply bin filled with PPE next to her room. Resident #1 was lying in an upright position in bed. Resident #1 stated she observed staff wear PPE before entering her room. During an interview on 11/12/25 at 1:25 p.m., Resident #1's RP stated she observed in-person and most of the time on camera the facility staff wearing PPE before entering and exiting Resident #1's room. During an interview on 11/13/25 at 3:11 p.m., LPN D stated she was most recently reeducated on infection control by the weekend supervisor in the Summer of 2025. She stated nurses were required to don PPE before entering and exiting residents' droplet precaution room. She stated that the Wound Care Nurse was the Infection Preventionist. She stated the Wound Care Nurse oversaw and ensured staff followed infection control protocols. She stated it was important to don PPE before entering and exiting residents' droplet precaution room and said, So we don't spread infection. Residents could be at risk of worsening sickness.During an interview on 11/14/25 at 10:29 a.m., the Wound Care Nurse stated she was the Infection Preventionist. She stated staff were reeducated on infection control quarterly by her and the ADONs. She stated she was unsure when she most recently reeducated staff on infection control. She stated staff were provided with the don and doff PPE posting or were required to notify the nursing staff if they did not know how to don and doff PPE. She stated she expected staff to don PPE, enter the room, provide care or service, doff PPE, perform personal hand hygiene and exit the room whenever residents were on droplet precautions. She stated that her, the DON, and ADONs oversaw and ensured staff followed infection control policy by Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676478 If continuation sheet Page 3 of 4 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 676478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbor Valley Health and Rehabilitation 6211 Old Pearsall Road San Antonio, TX 78242 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete conducting rounds every hour. She stated she knew it was important to don PPE before entering and exiting residents' droplet precaution room and said, To protect yourself and the resident. Residents could be at risk of developing infection if staff were not donning and doffing. During an interview on 11/14/25 at 10:49 a.m., ADON E stated the Wound Care Nurse was the Infection Preventionist. He stated he or the Wound Care Nurse reeducated staff on infection control monthly. He stated he expected staff to wear full PPE, which included gown, gloves, mask and face shield. He stated everyone at the facility was responsible for following the donning and doffing PPE policy. He stated it was important to don PPE before entering and exiting residents' droplet precaution room and staid, Primarily for infection control, and to prevent spread of infection, such as COVID-19. Residents could be at risk of possible infection. During an interview on 11/14/25 at 11:35 a.m., ADON F stated the Wound Care Nurse was the Infection Preventionist. She stated she was unsure when staff were most recently reeducated on infection control. She stated all staff who enter droplet precaution rooms must adhere to the donning and doffing PPE policy. She explained that staff were required to wear gown, gloves, face mask and face shield. She stated that the Wound Care Nurse, and the DON oversaw and ensured infection control policy was followed by conducting quarterly competencies on staff. She stated it was important to don PPE before entering and exiting residents' droplet precaution room and said, To prevent spread of infection. Residents could be at risk of infection spread. During an interview on 11/14/25 at 12:15 p.m., the NP stated Resident #1 recently had COVID-19. She stated Resident #1 was on droplet precautions. She stated she expected anyone who entered droplet precaution room to don and doff PPE before entering and exiting. She stated it was important to don PPE before entering and exiting residents' droplet precaution room and said, In order to keep COVID-19 from spreading and to protect everyone. Residents could be at risk for COVID-19 spread and epidemic. During an interview on 11/14/25 at 12:41 p.m., the DON stated the Wound Care Nurse was the Infection Preventionist. She stated she could not recall when she most recently in-serviced staff on infection control. She stated staff were responsible for donning and doffing PPE. She stated she expected staff to don and doff PPE before entering and exiting a droplet precaution room. She stated she, the Wound Care Nurse, and the ADONs oversaw and ensured infection control policy was followed by conducting quarterly competencies on staff. She stated it was important to don PPE before entering and exiting residents' droplet precaution room and said, To prevent infection spread. Residents could be infected. The surveyor requested the facility's infection control policy. During an interview on 11/14/25 at 1:28 p.m., the ADM stated the Wound Care Nurse was the Infection Preventionist. He stated he was unsure when staff were most recently in-serviced on infection control. He stated he was unsure if any reeducations were given related to infection control. He stated all direct care staff were responsible for following the infection control donning and doffing policy. He stated the DON, him, and ADONs oversee and ensure infection control was followed by conducting morning rounds and taking reports from staff. He stated it was important to don PPE before entering and exiting residents' droplet precaution room and said, To minimize the spread of infection and ensure resident safety from cross contamination. The surveyor requested the facility's infection control policy. The surveyor was not provided with the facility's infection control policy before exit on 11/14/25. Event ID: Facility ID: 676478 If continuation sheet Page 4 of 4