Inspection·September 1, 2023

F 0839 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few having trouble identifying the generic name of the medications. Once CNA A pulled the meds, she delivered them to the correct resident. Then CNA A was pulled from the med cart by administration. Interview on [DATE] at 12:05 PM with the Program Director she stated, at the time of the incident, the med aide was going on leave, the DON at the time, decided that CNA A would perform the med pass. I noticed that CNA A was passing medications slowly. She was asking questions when she needed help, CNA A appeared calm. At around noon, I assisted with medication pass. It was verified that the 5 rights of medication administration were followed. There was no harm to any of the residents. Later that day the Administrator and DON decided that CNA A would no longer administer medications. She stated that CNA A had told us that she had been a med aide. CNA A informed me that she had wanted to apply for the 2-10 med tech position. After administration discovered that her permit was expired, she was removed immediately from the med tech role. She had stated that RELIAS is a training platform. In the RELIAS platform, it is optional to enter your license information. Interview on [DATE] at 12:32 PM with the Human Resources Executive she stated CNA A was hired as a CNA. CNA A had informed HR that she had med aid experience, but she was hired as a CNA. She stated that the day of the incident, she believe the DON at the time, had made the decision to have CNA A work as the med aide. The medical records nurse informed the administrator that CNA A was taking a long time to finish passing medications. Then the Administrator inquired with HR as to why CNA A was struggling with med pass. HR informed the administrator that CNA A was hired as a CNA but had mentioned that she had med aide experience. At that time HR pulled CNA A's file and checked her CNA license and then looked into her MA permit and discovered it was expired. Then CNA A was immediately removed off the med pass. CNA A had worked at the facility through an agency and then was later hired directly through the facility. After the incident, steps were put into place to prevent any future occurrences, such as, checking with HR prior to having staff perform other duties. HR verified that all licensed staff had been current, and it was performed that same day. Interview [DATE] at 1:05 PM with the Administrator she stated, the DON had made the schedule and made the decision to have CNA A work as the med aid that day. Regarding RELIAS, the employee can input their own profile and information. She stopped from working as a MA but stayed and continued working as a CNA. Interview on [DATE] @ 10:37 AM with previous DON she stated, she was out of the facility due to COVID exposure so the decision to use CNA A as the med aid would have come from the PD. She stated, she had been out with COVID from about [DATE] until [DATE]. She stated her last at the facility was [DATE]. She stated that at the time of the incident, she was informed during the morning meeting that CNA A was running behind administering medications. She then instructed other nurses to help CNA A. CNA A was pulled from the floor after discovering her med aid permit was expired. She inquired into HR as to why CNA A med aid permit was also not checked since it is normally standard practice to check all permits or licenses that potential employees held. She stated that as far as she knew, none of the residents were harmed because CNA A was going so slow to pass the meds that she had another nurse with her to help her during that time. She stated did notify the doctor of the incident. Record review indicates the facility conducted and in-service, untitled on [DATE], with nursing management team that anytime there is staff position change, such as CNA to MA, that the staff permit and/or license must be verified prior to the position change to ensure that the staff has the training and license/permit to practice in that position. 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 09/01/2023 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interview the facility failed to maintain essential patient care equipment in safe operating condition for the facility's mechanical lift for 1(South Hall mechanical Lift) of 4 mechanical lifts reviewed for essential equipment. Residents Affected - Few The facility failed to restore and repair the mechanical lift's remote mechanism located on the south hall. This failure could place residents at risk who required use of a mechanical lift that is not in operable condition by increasing the risk of injury to residents. Findings included: In an observation on 8/29/2023 at 1:50 PM, - revealed the mechanical lift had loose wires at the remote connection, making the mechanical lift inoperable. Record review of mechanical lifts service record revealed that all mechanical lifts had been serviced and calibrated on 7/24/2023. Records indicated, The scales are now in good calibration and working order. We performed inspection on the listed patient lifts. (The mechanical lift in question was part of the inspection.) In an interview on 8/29/2023 at 12:19 PM with CNA C stated, that the mechanical lift on the south hall had malfunctioned by being unable to raise or lower the resident, twice on the same day on the evening of 8/7/2023 with two different residents. She stated that she had changed the battery and the mechanical lift began functioning but then stopped working when they were raising the mechanical lift to use on the second resident. She stated she then quit using that mechanical lift. In an interview on 8/29/2023 at 1:45 PM with CNA D, he stated, that the malfunctioning mechanical lift was not being used and had been removed from the hall and sent to the maintenance department. He stated that the other three mechanical lifts in the facility were functioning properly. Observation on 8/29/2023 at 1:48 PM revealed the transfer of a resident from wheelchair to bed using a different mechanical lift with two staff assistance and the mechanical lift operating properly with no harm or discomfort to the resident. In an interview with the Administrator on 08/29/2023 at 11:42 AM she stated the mechanical lifts were functioning, and that the CNA's were probably not inserting the batteries correctly. She stated, The mechanical lifts were serviced the week prior, and the service company stated that the staff were probably jamming the batteries into the mechanical lift and messing up the pins that connect the battery and mechanical lift. She stated she had informed the CNA's that there are other mechanical lifts that can be used and are functional. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745040 If continuation sheet Page 3 of 3