Inspection·May 29, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #1 complained of severe pain to the neck and upper shoulders. On 12/27/24 Hospice provided a new order for X-rays. On 12/28/24 Hospice reported X-ray results to the facility: distal coccyx/geal irregularities are visualized, likely an acute fracture. The allegation of Resident Neglect was reported to HHSC on 12/30/24. Observation and interview on 5/29/25 at 11:02 AM revealed Resident #1 was lying in bed with ¼ side rails up on both sides of the bed. Resident #1 engaged in conversation and presented as alert and oriented with some confusion and forgetfulness. Resident #1 stated she was doing well, and staff was very attentive. Resident #1 stated she did not remember the details of the fall during December of 2024. She stated she was receiving therapy, was doing much better and was very happy with rehabilitation services. Resident #1 did not express any concerns related to abuse or neglect Interview on 5/29/25 at 11:20 AM with the ADM revealed she did not work at the facility at the time of Resident #1's incident and did not know why the incident was not reported sooner. She stated staff who worked at the time no longer worked at the facility and did not have the staffs contact information. The ADM stated she understood an incident involving a major injury should be reported within 2 hours and it was not reported until 2 days after X-ray results showed a fracture. Interview with the DON and Administrator on 5/29/25 at 6:00 PM revealed the ADM stated not reporting incidents with a major injury could place the residents at risk for further abuse. 2. Review of Resident #2's face sheet, undated. revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Epileptic Seizures, Anxiety Disorder, Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side and left non-dominant side. Review of Resident #2's quarterly MDS, dated [DATE], revealed her BIMS score was 3 of 15, reflective of severe cognitive impairment. Resident #2 required partial to moderate assistance for most ADL's. Review of Resident #2's Provider Investigation Report, dated 1/13/25, revealed on 1/10/25 Resident #2 fell in the bathroom and hit the back of her head on the wall. It was an unassisted transfer. Resident #2 complained of right hip pain and pain to the back of head. Blood was noted on the bathroom wall and on the bathroom door. Resident #2 was sent out to a local hospital and returned to the facility on 1/12/25 with five staples on the back of her head. Further review of the Provider Investigation Report revealed Resident #2 had a history of unassisted transfers, not asking for help and falling. Review of a hospital X-Ray report for Resident #2, dated 1/11/25, revealed negative findings for a right hip fracture. Observation and interview with Resident #2 on 5/29/25 at 1:40 PM revealed she was propelling herself down the hall into the common area. Noted right arm, flaccid (limp), and had limited use of it. Resident #2 stated she did not remember falling or receiving staples on the back of her head. Resident #2 presented as alert, oriented to self and confused. When asked how she was doing she stated, fine. Interview with the DON and ADM on 5/29/25 at 6:00 PM revealed they did not work at the time of Resident #2's incident, dated 1/10/25, and did not know why it was not reported at the required timeframe. The ADM stated the incident should have been reported within 2 hours but was not reported until (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745040 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 745040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/29/2025 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 1/12/25. She stated not reporting incidents with a major injury could place the residents at risk for further abuse. 3. Review of Resident #3's face sheet, undated, revealed she was admitted to the facility on [DATE] with diagnosis of Multiple Sclerosis (according to MedLine it affects your brain and spinal cord). Residents Affected - Some Review of Resident #3's quarterly MDS, dated [DATE], revealed her BIMS score was 13 of 15, reflective of minimal cognitive impairment. Review of Resident #3's Provider Investigation Report, dated 4/24/25, revealed Resident #3 alleged that Resident #4 hit on the side of her face during the nighttime. Resident #3 made the allegation of abuse to a staff on 4/20/25. Upon an assessment there were no noted injuries. Upon interview Resident #4 denied the allegation. Further review of the Provider Investigation Report revealed Resident #3 and Resident #4 were roommates at the time of the incident. The facility reported the allegation of abuse to HHSC on 4/22/25. Review of the facility roster, dated 5/29/25, revealed Resident #4 was no longer a resident at the facility. Observation and interview on 5/29/25 at 1:30 PM with Resident #3 revealed she was sitting in a wheelchair by the front window in the common area. Resident #3 engaged in conversation and stated Resident #4 hit her and pointed to her left shoulder. She stated it hurt when Resident #4 hit her. Resident #3 stated staff moved her to another room, and she was ok with the move. She stated she felt safe, she was good about the care she received and she did not express any concerns related to abuse and neglect. Interview with the DON and ADM on 5/29/25 at 6:00 PM revealed they were not sure the incident between Resident #3 and Resident #4 actually took place but decided to report it anyway. The ADM stated she was responsible for reporting allegations of abuse and neglect to HHSC. The DON stated she did not believe it was reportable within 2 hours because it did not result in a major injury. Upon reviewing the facility's policy the ADM stated because it was an allegation of abuse it should have been reported within 2 hours. She stated Resident #4 was discharged to another facility and was no longer a risk to Resident #3. The ADM stated it was important that all allegations of abuse were reported to ensure the safety of the residents and to prevent further abuse. Review of the facility policy, revised February 10, 2020, read The [facility] enforces that our residents have the right to be free from abuse, neglect, exploitation, misappropriation of property, corporal punishment, involuntary seclusion, and free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. (abuse) TYPES OF INCIDENTS TO REPORT: Abuse, Neglect, Exploitation, Death due to unusual circumstances, A Missing Resident, Misappropriation, Drug Theft, Suspicious injuries of unknown source, Fire, Emergency situations that pose a threat to resident health and safety. Timeframe's for each incident type: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745040 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 745040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/29/2025 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 Abuse of any kind (with or without serious bodily injury); OR neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, WHEN to report the above types of incidents: IMMEDIATELY, BUT NOT LATER THAN TWO HOURS AFTER INCIDENT OCCURS OR IS SUSPECTED. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745040 If continuation sheet Page 4 of 4