Health inspection·December 12, 2025

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. 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 have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. The facility failed to provide a policy regarding use and storage of foods brought to residents by family and other visitors and failed to explain safe food handling practices to Volunteer D, who brought hot food items to the facility on [DATE]. This deficient practice could place residents at risk for foodborne illness.The findings included: Residents Affected - Some Observation on 12/09/2025 at 11:50 PM revealed a table at the end of A Hall with three trays of hot food; one tray had white and wild rice with pieces of chicken covered with cheese, one tray had small pieces of cooked ham and one tray had a vegetable medley of broccoli, carrots and cauliflower. There was no portable heat source or other means of maintaining food temperature present, and no temperature measuring devices or a temperature log visible. During an interview on 12/09/2025 at 12:15 PM with Volunteer D, she stated she was a Sister (nun), and she prepared food in her apartment and brought it to the facility for several of the Sisters (nuns) who were residents at the facility to celebrate Resident #58's birthday. She brought in food on a monthly basis to celebrate special events. When asked if she took the temperature of the food, Volunteer D stated her oven was at 350 degrees. Volunteer D stated she had not been provided with a policy regarding use and storage of food brought to residents by family and other visitors and the facility had not educated her on safe food handling practices, but she purchased the food from a reliable source and washed her hands. During an interview on 12/09/2025 at 12:20 PM, the facility's consultant RD stated the facility failed to ensure safe food handling practices were used when food was brought from outside the facility for residents by family and other visitors. During interviews on 12/09/2025 at 12:55 PM with the facility's staff RD, DON, and Administrator, the facility's staff RD stated she had not provided Volunteer D with a copy of the facility's policy regarding use and storage of food brought to residents from outside the facility. She stated she was unaware Volunteer D had brought in food and did so on a regular basis. The Administrator stated she was unaware Volunteer D fed residents food from outside the facility. The DON stated he did not believe Volunteer D brought in food on a regular basis but did so on special occasions, such as birthday parties. He had not provided a copy of the policy to Volunteer D or ensured safe food handling practices were used. Record review of the facility's policy #C218 revised 1/25, Use and Storage of Food Brought to Residents from the Outside revealed, Policy: Food brought in by family or other visitors is permitted, provided care is taken to ensure food is handled properly for safe and sanitary storage, and consumption .A method will be developed to educate family members and other visitors on safe food handling and storage practices during preparation and transport. Residents and/or family/visitors are informed about the policy of food brought into the community upon admission and provided education on safe food handling practices. All outside foods brought in for residents are verified by Nursing/designee to ensure the resident has no allergies or sensitivities and the food is appropriate for the resident's diet prescription. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676498 If continuation sheet Page 2 of 6 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 12/12/2025 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 0813 Level of Harm - Minimal harm or potential for actual harm Food Storage: The outside food must be stored in an appropriate container, labeled with the resident's name and room number, the date the food was brought to the resident, and the use-by date. Reheating: prepared food: reheat in a microwave on the resident/nursing unit or neighborhood. Foods are reheated to 165 degrees F for at least 15 seconds before being served. Residents Affected - Some Residents on Restrictive or Modified Diets: If the foods brought in from the outside do not comply with the residents' diet order, the resident and/or family is informed and the risks versus benefits of the diet order are explained. The resident has the right to the food items if there are no immediate safety concerns as noted by nursing (i.e. regular texture foods on a pureed diet.) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676498 If continuation sheet Page 3 of 6 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 12/12/2025 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 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for one of two refuse containers (the recycling bin) and one of one grease containers on the loading dock. 1. The facility failed to ensure the waste in the recycling bin was placed inside the bin to allow the top lid to close. 2. The facility failed to ensure the grease container was free of grease, grime and food particles outside the container and on the ground in front of the container. These deficient practices could place residents at risk for illness from exposure to germs and diseases carried by vermin and rodents.The findings included: 1. Observation on 12/11/2025 at 11:15 AM on the back dock of the facility revealed one bin used for trash and one bin used for recycled waste. The bin used for recycled waste was propped open by two cardboard tubes encased in plastic. The gap between the lid and the bin exceeded 12 on left side of the lid and 6 on the right side of the lid. Further observation revealed the RD attempted to kick the tubes so they would fit inside the bin and to allow the lid to close, and was unable to move the tubes.During an interview on 12/11/2025 at 11:16 AM, the RD stated the top lid of the recycling bin should have been closed to prevent pests and other undesirable contaminants from entering the container.2. Observation on 12/11/2025 at 11:17 AM revealed an outdoor grease container to the right of the recycling bin on the back dock of the facility. The grease container had a thick layer of grease and grime, and there were food particles stuck on the grease that extended the length of the container. There was also a puddle of grease on the ground in front of the container approximately 12 in length and 6 in width that was covered with dried leaves and debris.During an interview on 12/11/2025 at 11:25 AM, the RD stated the outdoor grease container was maintained by the contracted company every three months.Record review of Manifest of Hauled Liquid Waste provided by the facility revealed it stated Grease/Grit/Mid traps require pumping every 90-days or sooner. Record review of the facility's policy #F011, Solid Waste Disposal, revised 01/23, revealed, Grease is removed according to procedures established with the facility's/community's Environmental Services Department. Grease containers are cleaned on a monthly basis or as needed by contractor providing services. Procedures: Keep lids closed on all outside trash receptacles.Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 5-501.113 Covering Receptacles. Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: (B) With tight-fitting lids or doors if kept outside the food establishment. 5-501.116 Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated. 5-403.12 Other Liquid Waste and Rainwater. Liquid food wastes and rainwater can provide a source of bacterial contamination and support populations of pests. Proper storage and disposal of wastes and drainage of rainwater eliminate these conditions. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676498 If continuation sheet Page 4 of 6 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 12/12/2025 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 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 disease and infection for 1 of 5 residents (Resident #4) reviewed for infection control, in that:The facility failed to ensure enhanced barrier precautions was used by the staff for Resident #4 who had a wound. These deficient practices could place residents at-risk for infection due to improper care practices.The findings were: Record review of Resident #4's face sheet, dated 12/09/2025, revealed an admission date of 12/17/2015, and a readmission date of 12/06/2021. Resident #4 had diagnoses which included: Dementia (decline in cognitive abilities), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Hypertension (High blood pressure), Schizophrenia (mental disorder characterized by abnormal thought processes and an unstable mood), Malignant neoplasm (Cancer). Record review of Resident #4's Significant Change in Status MDS, dated [DATE], revealed the resident had a BIMS score of 02, which indicated severe cognitive impairment. Resident #4 was indicated to always be incontinent of bowel and bladder and required total care for her activities of daily living. Record review of Resident #4's care plan, dated 11/24/2025, revealed a problem of has stage 3 pressure ulcer of the sacrum r/t Immobility, and an intervention of Administer treatments as ordered and monitor for effectiveness. Record review of Resident #4's physician orders revealed an order dated 12/05/2025 for WOUND CARE SACRUM - Cleanse with woundcleanser and pat dry, cover with hydrocolloid dressing. every evening shifts every Mon, Wed, Fri for wound care. Observation on 12/09/2025 at 11:45 a.m. revealed there was no sign indicating Resident #4 was on Enhanced Barrier Precaution seen outside of Resident #4's room. Further observation revealed there was no personal protective equipment seen inside or outside the door of Resident #4's room. Observation on 12/09/2025 at 1:36 p.m. revealed 2 CNAs were seen entering the room to do a mechanical lift transfer with Resident #4. The CNAs were not wearing a protective gown when they entered the room. During an interview with CNA A on 12/09/2025 at 1:40 p.m., she was able to verbalize what was enhanced barrier precaution and was able to state what kind of resident needed to be on enhanced barrier precaution. She stated a resident with a wound must be on enhanced barrier precaution. She stated Resident #4 had a wound on her buttocks and should have been on enhanced barrier precaution. CNA A stated she had entered the room and provided care for the resident without wearing a gown because she did not know at the time the resident should be on enhanced barrier precaution because there was no sign on the door. CNA A stated the nurse was in charge of starting the enhanced barrier precaution and should put the signage on the door. She stated they received infection control training at least once a year and had received training on enhanced barrier precaution. During an interview with LVN B on 12/09/2025 at 1:46 p.m., LVN B stated she knew Resident #4 but was not the charge nurse for her. After reviewing the orders for the resident, she stated that the resident had a wound but there was no order for enhanced barrier precaution. LVN B stated the ADON rounded with them every week for resident with wounds. During an interview with ADON C on 12/09/2025 at 1:50 p.m., ADON C stated she did rounds for skin breakdown and wounds with the nurses. ADON C stated that Resident #4 had a wound. ADON C stated residents with wound must be on enhanced barrier precaution and she was in charge of starting the enhanced barrier precaution order and put the signage and protective equipment in place. She forgot to place Resident #4 on enhanced barrier precaution and stated it was placing the resident and the staff at risk for infection. During an interview with the DON on 12/09/2025 at 1:54 p.m., the DON stated that a resident with a Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676498 If continuation sheet Page 5 of 6 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 12/12/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete wound should be on enhanced barrier precaution to protect the resident as well as the staff from MDRO organisms, The staff has been trained about Enhanced barrier precaution. Record review of the facility's policy, titled Enhanced Barrier Precaution , dated December 2024, revealed Enhanced barrier precautions apply when: [ .] a resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained. Event ID: Facility ID: 676498 If continuation sheet Page 6 of 6