Inspection·October 13, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm resident having an OOH-DNR without the facility's knowledge was that the resident may receive CPR against their wishes. Record review of the facility's policy, revised [DATE], revealed, It is the policy of this facility that a resident's choice about advance directives will be recognized and respected. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745040 If continuation sheet Page 2 of 11 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 10/13/2023 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 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a comprehensive assessment after a significant change for 1 (Resident #12) of 13 residents reviewed for assessments, in that: Residents Affected - Few The resident enrolled in hospice services on 06/24/2023 and as of 10/13/2023, a comprehensive assessment following a significant change had not been completed. This failure could place residents at risk of caregivers with inaccurate and/or out of date information. The findings were: Record review of Resident #12's face sheet, dated 10/13/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: acute kidney failure, essential (primary) hypertension, and unspecified dementia. Further review revealed, Advanced Directive: Full Code. Record review of Resident #12's quarterly MDS, dated [DATE], revealed a BIMS score of 01 which indicated severe cognitive deficit. Further review revealed the resident was noted as receiving hospice services. Record review of Resident #12's care plan, revised 02/10/2023, revealed Plan for long term care residence in facility, to make this facility their home. Record review of Resident #12's order summary, dated 10/13/2023, revealed an order dated 07/07/2023, Admit to [facility] long term care with [hospice provider] effective 06/24/2023 . Further review revealed an order dated 07/07/2023, Call [hospice provider] at [phone number] prior to any lab/xray and with any changes in condition, transfer or death . Record review of Resident #12's clinical record revealed a significant change MDS assessment had not been performed. During an interview with the Program Director on 10/13/2023 at 10:48 a.m., the Program Director confirmed that a significant change MDS assessment had not been performed following the resident's admission to hospice service and confirmed the assessment should have been conducted. The Program Director stated that the MDS and care plan duties were performed by an outside provider of contracted services and a new provider was in place since the time that the missing assessment should have been completed. The Program Director stated she did not believe the missing assessment placed the resident at risk of potential harm. Record review of the facility policy, Care Plans, Comprehensive Person-Centered, dated December 2016, revealed A Comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, functional needs is developed and implemented for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745040 If continuation sheet Page 3 of 11 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 10/13/2023 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 7 Residents (Resident #9) whose MDS records were reviewed for accuracy. Residents Affected - Few Resident #14's Quarterly MDS assessment dated [DATE] incorrectly documented the resident was rarely/never understood and did not complete a BIMS (brief interview for mental status). This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #14's face sheet, dated 10/13/2023 revealed Resident #14 was admitted to the facility on [DATE] with diagnoses that included: anemia (a lack of red blood cells or dysfunctional red blood cells in the body. This leads to reduced oxygen flow to the body's organs), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), essential (primary) hypertension (high blood pressure), type 2 diabetes mellitus with unspecified complications (A chronic condition that affects the way the body processes blood sugar), unspecified glaucoma (the nerve connecting the eye to the brain is damaged, usually due to high eye pressure), allergic rhinitis (runny nose) , gastroesophageal reflux disease without esophagitis (heart burn), unspecified systolic (congestive) heart failure, unspecified atrial fibrillation (An irregular, often rapid heart rate that commonly causes poor blood flow), age-related osteoporosis with current pathological fracture, left femur, initial encounter for fracture (broken bone due to brittle bones), Constipation, depression, hyperlipidemia (high lipids). Record review of Resident #14's Quarterly MDS, dated [DATE], revealed under section for cognitive patterns the BIMS should not be conducted due to Resident #14 rarely/never understood and to skip the BIMS assessment. During an interview on 10/12/23 at 12:56 p.m. Resident #14 was in her room, in bed, watching TV, and eating lunch. The Resident asked this surveyor to return after she completed her meal to answer questions. The Resident #14 spoke clearly, and this surveyor was able to understand everything she said. During an observation on 10/13/23 at 11:57 a.m. Resident #14 was administered an insulin injection by LVN A. The Resident stated her insulin she received that morning was administered in her right arm. LVN A confirmed this statement and asked where the Resident would like the current injection. The resident was able to recall the site of the morning insulin administration correctly. During an interview on 10/13/23 at 2:08 p.m. MDS D stated he started to help or complete MDS assessments for the facility in 08/2023. MDS D stated Resident #14 was scheduled to have her next MDS completed on 10/18/23. MDS D stated he would come in person and interview the resident at that time. MDS D stated he reviewed the MDS from 07/18/23 and he was unsure of why they marked the resident as not understood because the resident was interview able. MDS D stated the previous person responsible was a company that worked remotely, and they most likely completed the MDS outside the facility, and never attempted to interview or assess the resident in person. MDS D stated the quarterly MDS was not an accurate reflection of the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745040 If continuation sheet Page 4 of 11 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 10/13/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During interview on 10/13/2023 at 3:00 p.m. the Program Director RN stated they follow the RAI for how to complete an MDS. Record review of the CMS MDS 3.0 Manual dated October 2023 revealed in part, .The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. The MDS 3.0 is part of that assessment process and is required by CMS . Event ID: Facility ID: 745040 If continuation sheet Page 5 of 11 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 10/13/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #45) reviewed for incontinence/perineal care, in that: CNA E did not provide complete catheter care to Resident #45. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #45's face sheet, dated 10/13/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), dependence on renal dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to), and diabetes mellitus (a chronic, long-lasting health condition that affects how your body turns food into energy). Record review of Resident #45's most recent quarterly MDS assessment, dated 8/31/23 revealed the intact cognition for daily decision-making skills and had an indwelling catheter (A catheter which is inserted into the bladder, via the urethra and remains in situ to drain urine). Record review of Resident #45's comprehensive care plan, review date 02/07/23 revealed the resident had indwelling catheter with interventions that included: Position catheter bag and tubing below the level of the bladder and away from entrance room door, Monitor/record/report to Medical Doctor for signs and symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. Observation on 10/12/23 at 10:35 a.m., CNA B was present to assist with catheter care and stood on the side of the resident's bed. CNA E performed catheter care on Resident # 45. CNA E used a basin of soapy water, a clean wipe, and cleansed halfway down the catheter tube (about 4-6 inches past where the catheter exited the resident). CNA E repeated the steps cleaning halfway down the catheter tube up to the catheter bag with plain water and a wipe. CNA never cleaned the tube from the meatus (opening of the female urethra to the outside) and up to about 4-6 inches. CNA E never provided peri care during the observation. CNA E stated she was done with the catheter care and would remove the pad from under the resident and place a new clean brief on the resident. This surveyor then asked CNA E to open the labia majora (the larger outer folds of the vulva [vulva-the global term that describes all the structures that make the female external genitalia]) folds on the resident to reveal how long/far the catheter tube was and observed the tube that was outside the resident which was not cleaned. CNA E put on new clean gloves and opened the labia majora folds and revealed about 4 inches of the catheter tube which had a white residue on it. CNA E then gripped the catheter tube from the meatus and wrapped 4 finger around the tube and stated she measures about 4 inches from the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745040 If continuation sheet Page 6 of 11 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 10/13/2023 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 0690 with her hands and then cleaned the catheter tube after the 4 inch area. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/13/23 at 1:58 p.m. CNA B stated he was the supervisor for the nurse aides. CNA B stated staff should clean the catheter tube 4 inches away from where it exits the resident, so they do not go inside the resident. CNA B then stated the whole catheter tube that was outside the resident's body should be cleaned. CNA B peri care was normally done prior to catheter care but Resident #45 had just come from a shower. CNA B stated staff should clean the whole catheter tube, so the resident does not get a UTI. CNA B stated to his knowledge the resident had not had issues with UTIs. Residents Affected - Few During an interview on 10/13/23 at 2:09 p.m. CNA E stated she learned in school to hold the tube 3-4 inches away from where it exits the resident and then start cleaning. CNA E stated she cannot clean inside the resident and only the nurses can touch the first 3-4 inches of where the catheter exits the residents body. CNA E stated she did not complete peri care on Resident #45 because she had just showered the resident. CNA stated the white residue on the catheter tube and in the folds of the vulva was cream a nurse had applied to the resident after her shower and before catheter care. CNA E stated the 3-4 inches of tube she did not clean were outside the resident and the resident could get an infection if the whole catheter outside the resident was not cleaned. During an interview on 10/13/23 at 2:25 p.m. The Program Director RN stated staff should clean the entire catheter tube outside the resident's body and infection can happen if staff did not clean the entire tube. Records review of the facility's policy titled Catheter Care, Urinary, dated 08/22, stated Purpose: the purpose of this procedure is to prevent urinary catheter associated complications, including urinary tract infections .Steps in the Procedure Routine Perineal Hygiene .11. With the non-dominate hand separate the labia of the female resident . maintain the position of this hand throughout the procedure. 12. Assess the urethral meatus 13. for a female resident: a. use a washcloth with warm water and soap (or clean bathing wipes) to cleanse around the meatus. B. change the position of the washcloth (or wipe) and cleanse around the urethral meatus .c. With a clean wash cloth (or wipe), rinse using the above technique .15. Use a clean washcloth with warm water and soap (or bathing wipes) to cleanse and rinse the catheter from insertion site to approximately 4 inches outward. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745040 If continuation sheet Page 7 of 11 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 10/13/2023 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the facility staff and hospice staff, and failed to maintain required hospice forms and documentation for 2 (Resident #12 and Resident #13) of 2 residents reviewed for hospice coordination of care, in that: The facility did not designate a member of the interdisciplinary team to act as liaison with the companies providing hospice services within the facility; the facility failed to procure current certification of terminal illness. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: 1. Record review of Resident #12's face sheet, dated 10/13/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: acute kidney failure, essential (primary) hypertension, and unspecified dementia. Further review revealed, Advanced Directive: Full Code. Record review of Resident #12's quarterly MDS, dated [DATE], revealed a BIMS score of 01 which indicated severe cognitive deficit. Record review of Resident #12's care plan, revised 02/10/2023, revealed the care plan did not mention the resident's enrollment with hospice services. Record review of Resident #12's order summary, dated 10/13/2023, revealed an order dated 07/07/2023, Admit to [facility] long term care with [hospice provider] effective 06/24/2023 . Further review revealed an order dated 07/07/2023, Call [hospice provider] at [phone number] prior to any lab/xray and with any changes in condition, transfer or death . Record review of Resident #12's facility clinical record as of 10/13/2023, revealed no Certification of Terminal Illness was included within the record. During an interview with the Program Director on 10/13/2023 at 10:48 a.m., the Program Director stated the facility did not currently have a hospice liaison to assist with communication and coordination of care between the hospice and the facility. The Program Director also confirmed Resident #12 clinical record did not include a Certification of Terminal Illness. The Program Director stated the potential harm of not having a designated hospice liaison would be inadequate care of facility residents receiving services from outside hospice providers due to lack of communication and/or coordination. 2. Record review of Resident #13's face sheet dated 10/13/2023 revealed a 77- year- old female who initially admitted on [DATE] with diagnoses that included but not limited Alzheimer's disease with early onset, type 1 diabetes, and major depressive disorder. The face sheet also noted the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745040 If continuation sheet Page 8 of 11 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 10/13/2023 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 0849 was on hospice services. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #13's physician order summary, dated 10/13/23, revealed an order for Admit to hospice for primary dx: senile degeneration of the brain with an order date of 03/20/22 and no end date. Residents Affected - Some Record review of Resident #13's quarterly MDS, dated [DATE], revealed she was severely impaired for cognition and received hospice care. Record review of Resident #13's care plan, revised on 06/28/23, revealed she was admitted to hospice services on 03/19/22. Record review of document titled Certification of Terminal Illness, dated 03/2022, revealed a physician signature certifying the resident had a terminal illness and was dated 03/19/22. During an interview on 10/13/23 at 2:06 p.m. the Program Director RN confirmed Certification of Terminal Illness dated 03/19/2022 was out of date and should be current. Record review of the facility policy, Hospice Program, revised July 2017, revealed, .to coordinate care provided to the resident by our facility staff and the hospice staff .d. Obtaining the following information from the hospice: (1) The most recent hospice plan of care specific to each resident; (2) Hospice election forms; (3) Physician certification and recertification of the terminal illness specific to each resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745040 If continuation sheet Page 9 of 11 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 10/13/2023 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 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 of 2 residents (Resident #13) reviewed for infection control practices, in that: Residents Affected - Few CNA C and CNA E did not utilize appropriate hand hygiene during incontinent/catheter care to Resident #34. These failures could place residents who required incontinent/catheter care at risk for infection or a decline in health. The findings included: Record review of Resident #13's face sheet dated 10/13/2023 revealed a 77- year- old female who initially admitted on [DATE] with diagnoses that included but not limited Alzheimer's disease with early onset, type 1 diabetes, overactive bladder, legal blindness and major depressive disorder. The face sheet also noted the resident was on hospice services. Record review of Resident #13's quarterly MDS, dated [DATE], revealed she was severely impaired for cognition and was always incontinent of bladder and bowel. Record review of Resident #13's care plan, revised on 03/30/23, revealed the resident had bowel and mixed bladder incontinence overactive bladder with interventions to use disposable briefs, check as required for incontinence, wash rinse, and dry perineum, and change clothing PRN after incontinence episodes. During an observation on 10/11/23 at 1:32 p.m. CNA C and CNA E transferred Resident #34 with a lift to her bed. CNA C and CNA E then provided incontinent care. Resident #13 had a bowel movement. CNA E handed CNA C a pair of gloves. CNA C put on gloves without sanitizing her hands, CNA E then opened the residents brief and wipes the resident from front to back 3 times changing the wipe each time. CNA C then removed the dirty brief and discarded it. CNA E then removed her gloves did not sanitize her hands, reached in her pocket, removed nothing, CNA E handed CNA C another pair of gloves and CNA C put them on. CNA E removed her gloves and put on new gloves without sanitizing her hands. CNA C and CNA E positioned the resident and secured a new brief on the resident. CNA C then went to the bathroom and stated she was going to wash her hands. During an interview on 10/11/23 at 1:49 p.m. CNA C and CNA E stated they cleaned their hands before they transferred the resident from her wheelchair and put her in her bed. CNA C and CNA E stated they did not perform hand hygiene between gloves changes while providing peri care. CNA C stated she did not have any hand sanitizer on her. CNA C stated she washed her hands after she done providing incontinent care to Resident #13. CNA C and CNA E stated they should have sanitized their hands between glove changes for prevention of infection. During an interview on 10/13/23 at 2:29 p.m. the Program Director RN stated staff should be sanitizing their hands between gloves changes to prevent infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745040 If continuation sheet Page 10 of 11 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 10/13/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the facility's policy titled Handwashing/Hand Hygiene, dated 08/2019, stated policy statement the facility considers hand hygiene the primary means to prevent the spread of infection .1. all personnel shall be trained and regularly and serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections .7. use an alcohol based hand rub containing at least 62% alcohol; Or, alternatively, soap (antimicrobial or non antimicrobial) and water for the following situations .h. Before moving from a contaminated body site to a clean body site during resident care .m. after removing gloves . Applying and Removing Gloves 1. perform hand hygiene before applying non sterile gloves. 2. When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff. Event ID: Facility ID: 745040 If continuation sheet Page 11 of 11