Inspection·June 8, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #1 required 0 staff member assistance for walking. Resident #1 required one staff member assist for dressing and showers. Section J for fall history since admission revealed yes for falls indicating Resident #1 had no injury from previous a fall. Record review of Resident #1's care plan dated 7/6/2022 with revision on 8/3/2022 and target date of 7/11/2023 revealed, Focus: risk for falls. Goal: resident will be free of falls. Interventions: Assist resident with ambulation and transfers. Determine residents' ability to transfer. Evaluate fall risk on admission and as needed. Record review of Resident #1's Progress Note authored by LVN A on 6/2/2023 at 10:50 p.m. revealed Note Text: Upon initial round noted resident lying on the floor at the foot of the bed in front of restroom door. Resident was lying on her left side, with large amount of blood on floor, bleeding from her head, noted a large hematoma(bruising) to left side of head with laceration approx. 4cms(centimeters) in length. Noted change in LOC (level of consciousness) resident was awake but not responding verbally. Resident was stopped from attempting to get herself up. Attempting to keep resident still due to unknown injuries. Placed call to 911. EMS arrived, picked resident up off floor and placed on stretcher. Stated they would probably take her to [ local] hospital. During an interview on 6/8/2023 at 11:11 a.m. LVN A stated during her initial rounds at the beginning of her shift, she found Resident #1 laying on the floor in her room. Lvn A stated this was an unwitnessed fall. She further revealed the resident was not able to tell her what happened. She stated the resident did not use any assistive devices and did not call for assistance. Needs were anticipated by staff for her care. LVN A stated, I saw a lot of blood around her head on the floor beside her. LVN A further revealed Resident #1 was trying to get up by herself, but I encouraged her not to while I was attempting to assess her. LVN A revealed she found a hematoma(bruising) on the left side of her head behind the ear and there was a laceration on top of the hematoma. LVN A stated Resident #1 had a lot of hair and that made it difficult to see if there were any more injuries to her head. LVN A stated when she assessed Resident #1's eyes and level of consciousness she felt she was not her usual self and was not responding verbally. LVN A stated 911 was called and they arrived soon and tool her to the hospital. LVN A revealed she checked the room for fall risks such as a wet floor or debris on the floor and there was none. She further revealed she notified the Director of nursing and the Administrator via phone text around 2:00 a.m. on 6/3/2023. LVN A stated the facility protocol is to notify the DON and the Administrator of falls. During an interview on 6/8/2023 at 1:40 p.m. the facility DON stated she was contacted by the evening nurse (LVN A) around 2:00 am on 6/2/2023 after Resident #1 had been found in her room on the floor. She stated the LVN told her the resident had blood on the floor but could not tell if she had more than one injury on her head. She stated the LVN informed her that the resident had a small laceration with a hematoma on the left side of her head. When asked if she considered the injury a serious injury, the DON stated she did not of enough information from the LVN at the time to determine if it was. The DON stated she was in the process of still investigating the injury. She further revealed that the incident was not witnessed and the Resident could not tell anyone what had happened. She further revealed LVN A had called 911 and the ambulance came to pick up the resident and took her to the hospital. The DON further revealed she had requested medical records from the hospital on 6/ 5/2023 in the morning to see if the resident had injuries that should be reported to HHS. She stated in the afternoon of 6/5/2023 she decided to submit a self-report to HHS as the resident had head a head injury. She stated she did not report it within 2 hours because she had lack of information to indicate if it was a serious injury to the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745040 If continuation sheet Page 2 of 3 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 745040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Sarah Roberts French Home 1315 Texas Ave San Antonio, TX 78201 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a telephone interview on 6/8/2023 at 2:30 p.m. the facility Administrator stated, we , meaning the DON and the administrator should report to the state a fall with injury within 2 hours of it happening. We follow the state guidelines of abuse or neglect regarding reporting. Record review of HHS computerized program for tracking facility self-reports revealed the Director of Nursing submitted a self-report on 6/5/2023, 3 days post fall. Record review of the facility's document(undated) titled: Reporting instructions: Abuse, Neglect, Exploitation, Misappropriation of resident property and Other Incidents that a nursing facility must report to HHSC. Vendor #004373; 1. All abuse allegations or an allegation that results in serious bodily injury MUST be reported immediately to the Abuse Coordinator and the Director of Nursing. These allegations must be reported to the state within 2 hours, so time is critical. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745040 If continuation sheet Page 3 of 3