Inspection·June 7, 2024

F 0656 Record review of the facility's policy titled Care Plan-Resident dated 12/2017 revealed staff must develop a comprehensive care plan to meet the needs of the resident with measurable and time limited goals. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455804 If continuation sheet Page 2 of 9 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 455804 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northgate Health and Rehabilitation Center 5757 N Knoll San Antonio, TX 78240 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services for 1 of 1 dietary manager reviewed for qualified dietary staff. The facility failed to employ a certified dietary manager as required. This failure could place residents who consumed food prepared by staff in the kitchen at increased risk of food borne illness and not receiving adequate nutrition. The findings were: Record Review of the Employee Service List, undated, revealed the Dietary Manager with an initial hire date of 06/17/21. During an interview with the Human Resources Director on 06/06/24 at 10:00a.m., she stated she was not aware the Dietary Director had to have completed a certified Dietary manager course. She stated she along with the Administrator would have been responsible for ensuring the department heads met their certification requirements. During an interview on 06/6/24 at 10:15a.m., the Dietary Manager revealed she had not taken the Dietary Manager Certification course and was unaware she needed to complete this course. She stated her current role as a Dietary Manager, which began in 01/24, was the only Dietary Manager position she had held. She stated all of her previous positions working in kitchens, had been working in the capacity of a cook. During an interview on 06/6/24 at 1:00p.m., the Administrator stated he was not aware the Dietary Director had to have completed a dietary manager certification course. He stated completion of a certification course would help the Dietary Manager to better run the kitchen. Record review of the facility's employee handbook dated 81/21 stated on page 27 all professionally registered, licensed, and certified staff are required to maintain current licensure, registration and/or certification. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455804 If continuation sheet Page 3 of 9 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 455804 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northgate Health and Rehabilitation Center 5757 N Knoll San Antonio, TX 78240 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: Residents Affected - Some 1. A plastic bag of cheese in the refrigerator was not labeled or dated. 2. A plastic bag of beets in the refrigerator was not labeled or dated. 3-A one gallon plastic container of pudding was not labeled or dated 4. The temperature gauge on the dish machine in the dish room was not working as the temperature reading would not advance on the gauge. 5. Snacks in the Nourishment Rooms were not labeled or dated. These deficient practices could place residents who received meals and snacks from the kitchen at risk for food borne illness from improper infection control, from a lack of food label date monitoring, from a lack of equipment maintenance, and improper sanitation in the kitchen area. The findings included: Observation on 06/04/24 from 9:10 am to 9:40 am, during the kitchen tour with the Dietary Manager revealed the following: a. There was a plastic bag of cheese in the refrigerator that was not labeled or dated. b. There was a plastic bag of beets in the refrigerator that was not labeled or dated. c. There was a one- gallon plastic container of pudding that was not labeled or dated. d. The temperature gauge on the dish machine in the dish room was not working. During an interview with the Dietary Manager on 06/04/24 at 9:45 am, she stated the food in the refrigerators must be dated and labeled to determine the food expiration date. She stated the temperature gauge on the dish machine in the dish room had not been working for about one month. The Dietary Manager stated she had informed the Maintenance Director along with the dish machine service representative of the problem. She stated dietary staff had to use a manual thermometer to check for proper cleaning temperature and having a working temperature gauge on the dish machine was important for sanitation purposes. The Dietary Manager stated a working temperature gauge would be installed on 06/04/24. During an interview with the DON on 06/06/24 at 12:40 pm, issues mentioned during the resident meeting were discussed. One of the issues was residents do not consistently get snacks, especially at night. The DON stated snacks are given on a first come first served basis and if a resident has a doctor's order for a snack, then the resident's name is placed on the snack. The DON then showed surveyor a small refrigerator in the nourishment room where facility snacks and personal resident snacks (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455804 If continuation sheet Page 4 of 9 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 455804 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northgate Health and Rehabilitation Center 5757 N Knoll San Antonio, TX 78240 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 0812 Level of Harm - Minimal harm or potential for actual harm are kept. A tray on the counter in this room revealed a few items that may have been snacks such as cookies but they were not labeled or dated and did not have a resident's name on them. The DON stated these were the snacks that were available but they should have been given to or at least offered to residents unless they were the ones that were just left over. The DON stated she would ensure that snacks were being offered to residents especially at night. Residents Affected - Some On 06/06/24 at 1:30 pm an interview with Dietary Manager revealed snacks are taken to the nourishment rooms at 10:00 am, 2:00 pm and 8:00 pm. The Dietary Manager stated nursing was then responsible to hand out the snacks. During an interview with the Administrator on 06/06/24 at 4:45 pm, he stated having the food labeled and dated was important to determine the food expiration time period. He stated having a working temperature gauge on the dish machine was important for sanitation purposes. During an interview and observation on 06/07/24 at 11:02 am with the Housekeeping Supervisor, the nourishment rooms were discussed along with the lack of cleaning of the refrigerators. The freezer part of the refrigerator in the Nourishment Room on the 100-200 Halls had been observed with a a large build-up of ice and there was a white melted spot of some substance in the bottom of the freezer. There were also spilled liquids on several shelves of the refrigerator part of the device. The Nourishment Room on the 300-400 Halls was observed during this interview and a large full size refrigerator was observed in that room. A tray of snacks were noted on the top shelf of the refrigerator but they were not dated or labeled. The Housekeeping Supervisor stated she had heard that snacks had been delivered about an hour ago so assumed this was the tray that was delivered. The Housekeeping Supervisor stated she and the housekeepers were responsible for keeping the Nourishment Rooms and the refrigerators clean. During an interview with the Dietary Manager on 06/07/24 at 11:30 am, the snack delivery system was discussed and she was asked to view the snacks in the refrigerator in the 300-400 Hall Nourishment Room. The snacks were noted to contain a couple of bowls of pudding, crackers, baggies of cookies, and a couple of baggies of cereal. None of the items were dated or labeled with the name of the item. The Dietary Manager stated when they brought in new snacks, any snacks left over from the previous distribution were taken out and discarded. When asked how anyone would know when these snacks were brought out, she stated she needed to put a date and time they were brought out on each snack so someone would know if it was safe to eat. Record review of the facility's policy on Food Storage, policy number 03.003 dated 2018 revealed food in refrigerators is to be dated and labeled in containers that are approved for food storage. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (A) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Record review of facility's policy on General Kitchen Safety Guidelines, policy number 05.001 dated 2018 revealed all equipment is to be kept in working order and malfunctions reported to the Maintenance Department. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455804 If continuation sheet Page 5 of 9 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 455804 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northgate Health and Rehabilitation Center 5757 N Knoll San Antonio, TX 78240 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 0812 Record review of facility's Maintenance Log Book for the months of April and May 2024 revealed no work order for repair of the dish machine temperature gauge. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455804 If continuation sheet Page 6 of 9 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 455804 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northgate Health and Rehabilitation Center 5757 N Knoll San Antonio, TX 78240 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for environmental concerns. The facility failed to secure a resident's bathroom ceiling fan, replace a resident's bedroom light, fix a resident's window blinds, repair a penetration in a resident's bedroom wall, replace a hallway ceiling panel cover, repair water discoloration marks around a hallway ceiling vent, fix a section of resident hallway floor molding, and replace the light bulbs in a hallway ceiling light unit. This deficient practice could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe. The findings included: During an observation on 06/4/24 from 10:20 a.m. to 11:10 a.m. revealed the following the following: 1. Resident room [ROOM NUMBER] had a bathroom ceiling fan which measured approximately 1 foot in diameter which was disconnected from the ceiling on one side. 2. Resident room [ROOM NUMBER] had a broken circular light fixture which measured approximately 5 inches in diameter located on the wall above the bed headboard. 3. Resident room [ROOM NUMBER] had 4 broken window shade vents. 4. Resident room [ROOM NUMBER] had a round penetration which measured approximately 4 inches in diameter located on the bedroom wall adjacent to the bathroom. 5-Resident corridor hall 100 corridor had a missing ceiling panel which measured approximately 4x2 feet located in front of room [ROOM NUMBER]. 6. Resident corridor hall 100 had a ceiling fan which measured approximately 1 foot by 6 inches located in front of room [ROOM NUMBER] that had signs of visible water penetration around the perimeter. 7. Resident corridor hall had missing floor molding which measured approximately 2 feet by 4 inches located in front of room [ROOM NUMBER]. 8-Resident corridor hall had a ceiling light which measured approximately 2x3 feet located in front of room [ROOM NUMBER] which had non-working light bulbs. During an interview with the Administrator on 6/4/24 at 10:20a.m., he stated that the Maintenance Director had self- terminated his position on 6/4/24, The Administrator stated that any broken light fixtures could negatively impact resident safety. He stated that all of the other observed building concerns could negatively impact resident satisfaction and would be addressed immediately for repair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455804 If continuation sheet Page 7 of 9 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 455804 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northgate Health and Rehabilitation Center 5757 N Knoll San Antonio, TX 78240 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with the Administrator on 6/5/24 at 9:00a.m., he stated that there was not a facility policy on preventative maintenance but the Maintenance Director had maintained a work order communication log for pending and completed work projects on the resident units. Record review of facility's Maintenance Log Book for the months of February, March, April and May 2024 revealed no work orders for repair of resident bathroom ceiling fans, resident bedroom lights, resident window blinds, resident room penetrations, missing ceiling panels on the resident hall corridors, water damage on the ceiling panel in the resident corridors, missing resident hallway floor molding, or broken ceiling light bulbs in resident hall corridors. Record review of the facility's Maintenance Director's job description date 4/12/19 revealed the Maintenance Director was responsible for ensuring that the facility and equipment were properly maintained for patient/resident comfort and convenience. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455804 If continuation sheet Page 8 of 9 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 455804 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northgate Health and Rehabilitation Center 5757 N Knoll San Antonio, TX 78240 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to maintain an effective pest control program for 1 of 1 facility in that: Residents Affected - Some 1. Numerous gnats were observed in a resident room on the 200 hall. 2. Numerous flies were observed on the 200 hall. 3. Observed a cockroach in the conference room This deficient practice could place residents at risk of residing in an environment with pests. The findings were: 1. Observation on 06/04/2024 at 9:34 a.m. revealed the presence of numerous flies on the 200 hall. 2. Observation on 06/04/2024 at 9:39 a.m. revealed the presence of gnats in and around residents' room in the 200 hall. 3. Observation on 06/05/2024 at 3:21 pm revealed the presence of a cockroach in the conference room. Records review revealed that the pest control company had been to the facility twice in May 2024 to treat for ants and insects. During an Interview on 06/06/2024 at 1:14 pm with the Administrator stated the maintenance person for the facility quit on 06/04/2024. He stated the facility should not have pests. He stated the facility does have a contract with a pest control company and the company services the facility at least once a month or sooner as needed. He stated it was the maintenance persons responsibility to maintain their pest control program. He stated the facility was utilizing the maintenance supervisor from a sister facility to resume pest control. He also said that he had ordered four blue lights for pest control and that he would have the interim maintenance personnel install them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455804 If continuation sheet Page 9 of 9