Health inspection·May 16, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's care plan dated 4/30/2025 was documented she had an ADL self-care performance deficit related to Dementia, impaired balance, I use a wheelchair to mobility. Interventions was documented Bathing/showering is totally dependent on staff for bathing and as necessary, she had a left-handed contracture, and she required 2 staff for Mechanical lift transfers. Record review of Resident #1's progress note dated 12/3/2024 at 9:37 AM by LVN A noted redness and clear discharge to Left eye with discoloration around Left eye, some inflammation noted, no facial grimacing noted with touch, pt with eye infection history with same symptoms. NP [NAME] notified, antibiotics started, and daughter notified. Record review of Resident #1's skin observation dated 12/3/2024 by LVN A was documented, noted redness and clear discharge to left eye with discoloration to left eye, some inflammation noted, no facial grimacing noted with touch, Resident #1's eye infection history with same symptoms. Record review of Resident #1's progress note dated 12/6/2024 at 4:30 PM with ADON notified administration of the discoloration surrounding resident's eye worsening. This nurse observed area in question. Area is dark red/purple in color, measuring 4.4 cm (l) x 3.2 cm (w). The resident initially does not grimace to touch but does pull face away upon more palpation. Record review of Resident #1's progress note 12/6/2024 at 6:04 PM ADON the staff immediately in-serviced on the importance of 2 person assist when using a Mechanical lift to transfer residents. Nursing to monitor resident's pain every shift for the next 3 days and treat or report to MD as appropriate. NP and RP notified. Record review of Resident #1's progress note dated 12/6/2024 was documented left eye worsening, nurse called the ADM, skull series x-ray was negative, started order to monitor for pain. In-service staff on Hoyer transfers and reporting incidents. Notified family, MD, DON, ADON. Record review of x ray dated 12/6/2025 of Skull x ray 2 views resulted in no fractures. X ray revealed osteoporosis. Record review of Resident #1's skin observation dated 12/7/2024 was documented included face, bruised. Observation on 5/15/2025 at 11:20 AM with CNAs H, O with resident revealed no concerns with Mechanical lift transfer. During interview on 5/15/2025 at 11:21 AM with CNA H and O stated they were trained on Mechanical lift transfers and to always have 2 staff. CANs stated they were trained to ask any nurse, such as DON, MDS, or MA. CNAs were trained not to do a mechanical lift transfer if don't have 2 staff. During interview on 5/15/2025 at 1:49 PM with CNA B worked for 2 years and worked the morning shift. CNA B stated she used a Mechanical lift transfer to take Resident #1 a shower, placed her back in the chair, lowered her down, took the sling down and noticed she had red eye. CNA B stated she notified LVN A about Resident #1's eye. CNA B stated she did not see Resident #1#s eye hit by Mechanical lift transfer. CAN B stated the ADON had told her she hit Resident #1 in the eye with the Mechanical lift transfer. CNA B stated it was not intentional that Resident #1 was hit in the eye and was an accident. CNA B stated no other staff was present at the time of Resident #1's Hoyer transfer and bath. CNA B stated everyone was busy and could not find anyone to help her with Resident #1's Hoyer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676498 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 676498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Village at Incarnate Word 4707 Broadway Street San Antonio, TX 78209 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 transfer. CNA B stated she was the only one in the shower room with the resident. CAN B stated the ADM, after watching the camera footage, told CAN B when she took off the sling from the mechanical lift, she hit Resident #1 in the eye. CNA B stated she did get suspended for 1 week and when she returned to work the facility was shorthanded. CNA B stated she did tell ADM that they were shorthanded, and they have hired some new CNAs. CNA B stated she was educated about the Mechanical lift transfers and having 2 staff at times. During an interview on 5/15/2025 at 3:09 PM with CNA C stated he had worked for 3 years and worked all 3 shifts. CNA C stated she was trained, the residents' that required a Mechanical lift transfer were to always have 2 staff. CNA C stated Resident #1 required a Mechanical lift transfer, she was not interviewable, she was alert, she could not carry a conversation, and certain people she would respond too. CNA C stated he was trained to always have a 2 people for Mechanical lift transfers and if could not find staff CNAs were not supposed to do the Hoyer Mechanical lift transfer. CNA C stated he did see Resident #1's eye was discolored around her eye, not her normal skin color, and looked like a bruise. CNA C stated he did not think it was Abuse. CNA C stated Resident #1 had a history of eye infections. During an interview on 5/16/2025 at 11:09 AM with the ADON, stated the Mechanical lift transfers must be always with 2 staff. The ADON stated she did not think this (Resident #1 eye bruise) was abuse and was an accident. ADON stated Resident #1 was treated with antibiotics due to an eye infection she had, because she had a history of eye infection. ADON stated the ADM asked her to look at Resident #1's eye, and when assessed it looked like a bruise to her. The ADON stated Resident #1's eye was bruised, this occurred on 12/2/2025 with CNA A during Mechanical lift transferring of Resident #1 into shower chair. ADON stated on camera footage looked like CNA C hit Resident #1's eye by accident, and Resident 31's face was struck by the bar of the Mechanical lift. The ADON stated CNA C was compassionate with residents. ADON stated LVN A did the skin assessment for Resident #1 on 12/3/2025. The ADON, stated from LVN A, Resident #1's eye appeared to be an infection. The ADON read LVN A's progress note for Resident #1 eye assessment and was documented, the eye had clear discharge to left eye with discoloration around the left eye, some inflammation noted. no facility grimacing noted with touch, order for antibiotics in place. The ADON stated CNA B did not know if she accidently hit resident with the Mechanical lift or not. ADON stated Resident #1's eye was an incident and was report to the STATE. The ADON stated she in-serviced all nursing staff on Mechanical lift transfers that always required 2- person. ADON stated an x-ray of skull series was negative for Resident #1, and she did not go to the hospital. The ADON stated the ADM would be responsible to make sure all nursing staff were trained on Mechanical lift, upon hire and in-service staff on new hire package on all transfers, including Mechanical lift lifts. During an interview on 5/16/2025 at 2:15 PM with DON, the ADON and HR Director stated all nursing staff were in -serviced on Mechanical lift transfer always have 2 staff, which was dated between 12/6/2025 to 12/23/2025 then continuous with new hires. The DON and ADON stated all nursing staff were trained on safe transfers. During interviews on 5/15/2025 to 5/16/2025 from 1:49 pm to 3:38 pm with 6 CNAs (B, C, F, H, I, L, and M), 4 LVNs (D, G, J, and N), 1 RN (E) and 1 MA (K) who confirmed they had received the facility in-service on Mechanical lift transfers conducted from 12/6/2024 to 12/23/2024 and ongoing with new staff. The nursing staff stated they were to use the Mechanical lift transfer machine using 2-nursing staff. The nursing staff stated if they could not find a nursing staff, they were not to do the Mechanical lift transfer with a resident. The nursing staff stated the Mechanical lift transfer training included safety measures and included the risk of injuries to residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676498 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 676498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Village at Incarnate Word 4707 Broadway Street San Antonio, TX 78209 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 Record review of the Mechanical lift transfers training dated 12/6/2024 to 12/23/2024 included, safe transferring required you to know how to properly use assistive devices and correct positioning. Knowing how to safely transfer the people in your care protects you from being injured, it also reduces the individual risk of injury an promotes their mobility. This course discusses how to perform safe transfers. All 34 of 34 nursing staff received training. Residents Affected - Few Record review of in-services titled Transferring Safety dated from 12/2/2024 to 5/15/2025 included all nursing staff. Record review of the facility's policy titled, Liftin Machine, Using a Mechanical, dated 2001 was documented Purpose, The Purpose of this procedure is to establish the general principles of safe lifting using mechanical lifting device. General Guidelines, 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. 2. Mechanical lifts nay be used for the floor: b. transferring a resident from bed to chair, e. toileting or bathing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676498 If continuation sheet Page 4 of 4