Inspection·December 2, 2025

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5/10/2024, a licensed Physical Therapist (PT) and Qualified Rehabilitation Professional (QRP) conducted a comprehensive wheelchair assessment for (Resident #1). As part of this comprehensive wheelchair assessment, the patient's current weight is obtained from medical records and actual anatomical physical measurements of his body were taken. These measurements are used to ensure proper fit of the recommended equipment. See attached written and signed assessment including relevant measurements on page 7.2. Please provide specific details about the power chair (Resident #1) received on June 2024, including but not limited to its weight limit.(Resident #1) received his customized power wheelchair on 6/24/2024. The weight rating for this chair is 550lbs. He received the following equipment: Manufacturer: (name).Model: (name) HD3 Pwr Wchair item # ATHD3-3VHD-MP, Serial number: 2406152434012 (Resident #1)See attached Manufacturer build sheet/chair specifications that specifies weight rating on line 4. This information can also be found on the manufacturer's website for the model chair in question both on theorder form and in the owners manual.3. What type, if any, service, maintenance, or warranty came with the power wheelchair June 21, 2024 and how was this information communicated to (Resident #1) Please provide supportive documentation.(Resident #1) was provided with the owners manual at the time of delivery which detailed warranty specifications for the provided equipment. See attached United States Limited Warranty available on (manufacturer's)website and as part of the owners manual. Please note that physical damages due to impacts, abuse, misuse, accident, negligence or improper operation of the equipment are exclusions stated in the warranty details. Additionally, see attached signed delivery confirmation acknowledging receipt of the warranty information and attached manufacturer's warranty document. 4. Has (Resident #1) or anyone representing (Resident #1) contacted (name) Rehab Technologies about the status of his current power chair? If yes, please describe steps the steps taken to assistwith this matter. Please provide supportive documentation. (Resident #1) has reached out multiple times regarding both battery replacement and repairs to his caster assembly. He had previously had both warranty and non-warranty repairs completed to his chair. A noncovered warranty repair was completed on 9/16/24 for a front caster and caster fork as well as an additional cup holder. These repairs were made but not covered under the manufacturer's warranty. The patient was informed he or his facility account would be responsible for the charges for these repairs prior to the commencement and ordering of the parts as they were deemed to have been created by a collision with an object (additionally cup holders are not considered medically necessary in nature). The balance due for these repairs was never paid by either the patient or the facility and the patient remains on account hold due to non-payment. A second repair was completed on 12/10/2024 which included a replacement tilt actuator, mechanicallimit switch and various accessories related to the repair. These repairs were completed and covered under the (manufacturer's) warranty and in part the repairs were conducted with the assistance of (manufacturer) local representative. (Resident #1) again reached out on 7/29/2025 requesting new batteries. A subsequent call indicated that there was another issue with the chair possibly related to a bent rear caster fork and caster needing replacement, however we have not been out to diagnose the issue as the chair is now out of warranty and (Resident #1's) account is on credit hold due to non-payment of previously agreed to services that were provided but never paid. We did take the proactive step to provide the current nursing facility with the back due amounts owed as well as a verbal price quotation for replacement batteries. We are unable to provide a written price quote to the facility until past due balances have been satisfied. It is notable that while the CPWC was paid for under (Resident #1's insurance) plan, under Texas Medicaid policy provisions as stated in the NF CPWC policy in Section 11100 of the (insurance provider) Handbook that there is no benefit to cover repairs while the patient resides in a skilled nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455804 If continuation sheet Page 2 of 7 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 12/02/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility and that such repairs are the responsibility of the facility. Beginning in 2025, our company has a policy that we will not begin non warranty repairs or order required parts to commence the repair for SNF patient's PWC equipment unless the repairs are paid in full by the facility prior the parts being ordered. To date we have received no communication from the facility indicating that they are willing to provide payment for the requested batteries and caster repairs. 5. Was the incident previously identified and reviewed internally? If so, were any changes implemented as a result of this review? Extensive review of the account has been conducted and documented. Our finding maintain that we are in compliance with Texas Medicaid policy regarding repairs to CPWC's in skilled nursing facilities.Observation and Interview on 10/24/25 at 11:15 AM with Resident #1 revealed he was sitting in a MWC and noted it was a tight fit. Resident #1 stated he received a MWC while at a previous nursing facility. About a week or so after he received the wheelchair, one of the front casters broke and the wheelchair vendor replaced it. He stated after he arrived at the current nursing facility, a few months later, the rear right caster had bent inward due to his weight. He stated he did not use his wheelchair as much because he was afraid it would break off altogether and was worried if it did he would fall. Resident #1 stated the facility did not have a mechanical lift that would hold his weight and the facility would have to call the fire department to get him off the floor. Resident #1 stated the previous DOR was in contact with the vendor who provided the MWC and tried to get the vendor to replace the back wheel. He stated the vendor would not make the repairs because they were not allowed on premises because of a conflict with the previous owners. He stated another company bought out the nursing facility and the new company used a different vendor. Resident #1 stated the new vendor would not work on his MWC because it did not belong to them and progress came to a halt. He stated the new facility DOR, B was trying to work with him, but he could not move forward with anything because the facility used a different vendor. He stated he talked with the ADM and other administrative staff about the back wheel because it was bent and was worried that it would completely break off. He stated he called the company, the maker of the wheelchair and a representative came out and told him the wheelchair was too small and did not suit his weight. Resident #1 stated the representative told him the weight capacity of the wheelchair was 450 pounds. He stated he had exhausted all avenues and could not get the NF to help him. Resident #1 stated a representative from the original vendor who provided the MWC came to the NF out of the blue and replaced the back wheel, but it did not rotate full circle and would get stuck when making turns. Resident #1 stated he needed help because the NF refused to help him. Interview on 10/24/25 at 12:00 PM with the BOM revealed she submitted a letter for authorization on 12/20/24 to Resident #1's insurance for DME for Resident #1 when he was moving out into the community but was denied because he remained in the NF. The BOM stated an insurance representative provided her with a letter on 1/22/25 stating the facility was responsible for any DME while Resident #1 remained in the NF. She stated she provided the ADM a copy of the letter and had not received any further instructions about moving forward with getting Resident #1 DME including a MWC. Interview on 10/24/25 at 12:06 PM with DOR B revealed he had worked at the facility since 7/28/25. He stated Resident #1 was not currently on caseload but on 8/20/25 he met with Resident #1 about the back wheel and was added to case load for OT for with the primary goal of coordinating with a DME company to either repair or replace his existing PWC. The DOR B stated when he saw the back wheel, it was bent inward and did not know how it was still intact. DOR B stated he immediately reported the issue to the ADM because it was a safety concern and learned the DON and ADON were already aware of the issue. He stated if the back wheel broke while Resident #1 was using it, he could fall and could sustain injuries because of his weight. The DOR B stated he was instructed to call (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455804 If continuation sheet Page 3 of 7 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 12/02/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the facility vendor and make arrangements for the vendor to make repairs. DOR B stated the facility vendor would not make repairs because it was not their wheelchair. DOR B stated he contacted the vendor who provided the MWC and they told him they would not make repairs because Resident #1 had a past due balance from when they made repairs to the front caster. DOR B stated he hit a roadblock and had not received further instruction from the ADM about what else could be done. DOR B stated in the meantime, the vendor who provided the MWC came out unexpectedly and replaced the back wheel. He stated he reached out to the vendor and the representative told him he had extra parts and replaced the back wheel. He stated he did not know what exact repairs were made or if Resident #1 was still having problems with the back wheel/caster. DOR B stated Resident #1 was not on caseload and did not know the representative was coming out to the facility. He stated he did not obtain an invoice. He stated because Resident #1 was not on caseload it would have been up to nursing to obtain an invoice for record keeping. DOR B further stated nursing staff had not referred Resident #1 for a wheelchair evaluation to determine if his current MWC was suitable to meet his needs. Interview on 10/24/25 at 2:45 PM with Resident #1's insurance case manager revealed the vendor who provided the MWC would not service the wheelchair because Resident #1 had an outstanding balance and the wheel that needed replacing was not under warranty. She stated the vendor told her the weight capacity for the MWC was 600 pounds. The case manager stated because Resident #1 was a resident of the facility, the facility was responsible for making current repairs. Interview on 10/24/25 at 2:58 PM with (vendor) Assistive Technician Professional (ATP) stated initially there was a problem with the front caster and was not under warranty because it was considered damaged. He stated Resident #1 drove over a curb and put excess weight on it. The ATP stated it was repaired and Resident #1 had an outstanding balance for the repairs completed at the time. He stated Resident #1 reported his wheelchair required additional repairs (rear right wheel/caster) while at the current facility. The Assistive Technician Professional stated the vendor would not service it because he had an outstanding balance and the wheel/caster was no longer under warranty. He stated all parts other than the wheelchair frame itself were under warranty for a year. He stated the MWC was over a year old. The ATP stated no one from the facility had called to discuss a plan to move forward with making repairs. He also stated the weight capacity rating for the wheelchair was 550 pounds. Interview on 10/24/25 at 3:10 PM with the managing ATP for the MWC vendor revealed the wheelchair's weight capacity was 550 pounds and it was appropriate for Resident #1 when they initially ordered it. He stated Resident #1 weighed 495 pounds at the time while at his previous placement. He stated the wheelchair frame was under a lifetime warranty (5 years) and components were under a 1- year warranty. The managing ATP stated Resident #1 ran over a curb and damaged the front caster. He stated the Resident #1 had an outstanding balance of 336.62 and he emailed the facility that they would be responsible for payment of any parts. The managing ATP stated in talking to the DOR B, he understood the facility was not willing to pay the balance or for other needed repairs. He stated the new owners of the facility used a different wheelchair vendor but stated they could probably wave the outstanding balance if the facility was willing to work with them on a new chair since Resident #1's weight exceeded the weight capacity rating of 550 pounds. Interview on 10/24/25 at 3:49 PM with the DON revealed she did not have knowledge of Resident #1's MWC's weight capacity rating being 550 pounds. She stated they had a meeting about two weeks ago with Resident #1, a family member, his insurance case manager and the vendor of the MWC and discussed the rear wheel/caster which needed replacing. She stated the vendor reported Resident #1 had an outstanding balance and would not make the repairs unless it was paid. The DON stated she saw the back wheel and stated it was a safety hazard. She stated had the back wheel broken off and Resident #1 had fallen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455804 If continuation sheet Page 4 of 7 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 12/02/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete they did not have a mechanical lift which would hold Resident #1's weight and would have to call the fire department to help Resident #1 off the floor. The DON stated she learned the vendor came by after their meeting and replaced the wheel and believed the issue had been addressed. She stated the vendor did not mention the weight capacity rating being 550 pounds. The DON stated she did not ask either and had not asked Resident #1 for documentation or an owner's manual to determine the MWC's specifications although she stated it would be important for the facility to know to ensure that the MWC suited Resident #1's needs. The DON stated if Resident #1 was over the MWC weight capacity then it could pose a safety hazard for Resident #1. The DON stated she had not referred Resident #1 for rehabilitation service for a MWC evaluation because she did not know there was a problem with the size of the MWC. Interview on 10/26/25 at 4:05 PM with DOR B revealed he called the facility wheelchair vendor and understood the weight capacity for Resident #1's MWC was between 450 pounds to 600 pounds. He stated he never asked the vendor who provided Resident #1 with the MWC of the weight capacity, but Resident #1 told him it was 450 pounds. DOR B stated Resident #1 reported the vendor came most recently and replaced the back wheel/caster that was about to fall off. He stated he did not know what exact repairs were made because he was not at the facility. He stated Resident #1 was not on caseload otherwise he would have been a part of the visit. He stated he thought Resident #1's family member paid the outstanding balance and that's why the vendor came out because the facility did not authorize any repairs. DOR B stated nursing staff should have been available during the visit. DOR B stated he did not know the specifications of the wheelchair and had not asked Resident #1 for documentation or a manual. Interview on 10/26/25 at 4:51 PM with the ADM revealed she had been in her position for 14 months. She stated Resident #1 told her the vendor who provided the MWC did not measure him right and he wanted another MWC. The ADM stated she was aware that Resident #1's rear wheel/caster was damaged and needed replacing. She stated DOR B was in contact with the facility vendor and they would not make repairs because it was not their wheelchair. The ADM stated at one point Resident #1 replaced a front wheel by using parts from a manual wheelchair. She stated she did not know if Resident #1 replaced the rear wheel/caster himself. The ADM stated she did not know the weight capacity rating for Resident #1's wheelchair was 550 pounds and did not know his weight. The ADM stated she had not talked with Resident #1. She stated she did not remember the BOM providing her with a letter from Resident #1's insurance case manager stating the facility was responsible for providing Resident #1 with equipment. The ADM stated she did not know what the outcome would be if the rear wheel/caster was not replaced or what the outcome would be if Resident #1 weight exceeded the MWA weight capacity. The ADM stated she would have to talk to DOR B and the DON to discuss the current status. Review of a facility policy, Therapy Policy and Procedures, Therapy Screening, updated 5/21/25, read in relevant part The purpose of this policy is to define the process for performing therapy screens by physical therapist, physical therapist assistants, occupational therapist, occupational therapist assistants, and speech language pathologist. The goal of screening is to identify patients who may benefit from therapy services, ensure timely and appropriate intervention and guide the development of individualized care plans. Procedure, Screening A brief non-diagnostic process conducted by qualified therapy professionals to assess a patient's potential for therapy services, based on the clinical observations, patient reports and available medical information. 1. Initiation of Screen: Screens may be initiated based on the following. Referral from the interdisciplinary care team, including physicians, nurses, and other healthcare providers. 2. Screening Guidelines (Physical Therapy) (PT), Physical Therapy Assistant (PTA): Screenings will focus on assessing mobility, gait, balance, strength, and functional independence. Event ID: Facility ID: 455804 If continuation sheet Page 5 of 7 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 12/02/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure:each resident received adequate supervision and assistive devices to prevent accidents for 1 of 2 Residents (Resident #2) whose records were reviewed. Nursing staff failed to ensure Resident #2's bed was in the lowest position and staff provided Resident #2 with adequate supervision. This violation could place residents at risk for experiencing avoidable falls. The findings were:Review of Resident #2's face sheet, dated 10/26/25, revealed she was admitted to the facility on [DATE] with diagnoses including neurocognitive disorder with Lewy bodies (a progressive neurocognitive disorder characterized by the accumulation of Lewy bodies in the brain, leading to cognitive decline, movement issues, and various other symptoms), psychotic disorder with delusions due to known physiological condition (a psychotic disorder characterized by the presence of delusions that arise as a direct consequence of a known physiological condition), generalized anxiety disorder (when you worry a lot and have a hard time controlling) and dementia in other diseases classified elsewhere severe with other behavioral disturbance (a condition where Dementia is associated with other underlying conditions, characterized by significant cognitive decline and severe behavioral disturbances). Review of Resident #2's quarterly MDS assessment, dated 9/28/25, revealed her BIMS score was 0 of 15 reflective of severe cognitive impairment; she had behaviors not directed at others such as hitting and scratching self and she was dependent on staff for most ADL's including chair/bed-to-chair transfer. Further review revealed Resident #2 had not had any falls since the prior assessment. Review of Resident #2's Care Plan, revised on 7/23/25, revealed Resident #2 had a history of falling related to Lewy Body Dementia and one of the approaches included keep bed in lowest position with brakes locked and observe frequently and place in supervised area when out of bed. Review of the facility incident/accident log from July to October 2025 revealed Resident #2 had not had any falls during this time period. Observation and attempted interview on 10/26/25 at 12:25 PM with Resident #2 revealed she was lying in bed with the head of bed at about 30 degrees. Further observation revealed the bed was positioned about 3 1/2 feet off the floor. There was a mat next to the bed closest to the door. Resident #2 was moving and wiggling around in bed, turning from side to side, kicking her feet and reaching for the blankets which were on the floor. Attempted interview with Resident #2 revealed she was non-verbal. She would make eye contact but did not answer any questions. Observation on 10/26/25 at 12:30 PM revealed LVN A walking away from the nurse's station. Further observation revealed there were no other staff in sight. Observation and interview on 10/26/25 at 12:50 PM revealed CNA D walking up 100 hall picking up lunch trays. Surveyor intervened and called CNA D over for fear Resident #2 would fall. CNA D stated she transferred Resident #2 into bed after lunch about 15 to 20 minutes ago (12:30 PM). CNA D stated, it was her fault, she forgot to lower the bed to the lowest position. CNA D stated Resident #2 was a fall risk, she had falls in the past but had not had any falls most recently. CNA D stated Resident #2 was alert to self with confusion, but she did not follow directives. CNA D stated Resident #2 would also get out of bed without asking for assistance. She stated she should have lowered the bed so that Resident #2 did not fall and get hurt. Interview on 10/26/25 at 4:06 PM with the DON revealed Resident #2 was a fall risk. She stated Resident #2 had fallen before due to confusion and she was very impulsive. The DON stated if Resident #2 was in bed, the bed should be in the lowest position because Resident #2 would get out of bed without assistance. The DON stated Resident #2 would try to walk and could fall because she was very unsteady. Review of facility policy, Falls and Fall Risk Managing revised March 2018, read in relevant part Based on previous evaluations and current data, the staff will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455804 If continuation sheet Page 6 of 7 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 12/02/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Fall Risk Factors: 1. Environmental factors that contribute to the risk of falls include: c. incorrect bed height or width. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455804 If continuation sheet Page 7 of 7