Inspection·June 4, 2023

F 0585 Level of Harm - Minimal harm or potential for actual harm #258 included, continue Lantus [long-acting insulin that works evenly for 24 hours in the body regulating blood glucose]. Record review of Resident #258's Order Summary Report, active as of 6/02/2023, revealed physician orders for: Residents Affected - Few Insulin Regular Human Injection Solution Pen-injector 100 unit/ML inject 40 unit subcutaneously before meals with a start date of 5/09/2023; Lantus SoloStar solution Pen-Injector 100 unit/ML (Insulin glargine) inject 65 unit subcutaneously one time a day with a start date of 5/10/2023. Record review of Resident #258's Medication Administration Record for the month of May 2023, revealed blank spaces for medication administration of Insulin SoloStar (Insulin glargine) on 5/04/2023 at 8:00 PM, 5/05/2023 at 9:00 AM and 8:00 PM, 5/06/2023 at 9:00 AM and 8:00 PM, 5/07/2023 at 9:00 AM and 8:00 PM, 5/08/2023 at 9:00 AM; blank spaces for medication administration of Insulin Regular Human Injection on 5/12/2023 at 11:30 AM. Record review of May 2023 Grievance Log revealed, indicated 8 chronologically documented entries between 5/01/2023 and 5/24/2023. This log did not include an entry for the allegation of missed dosing of insulin dated 5/15/2023. Review of the associated binder for the Grievance Log did not include the 5/15/2023 allegation of missed dosing of insulin. In an interview on 6/3/2023 at 5:34 PM, the ADMN stated the facility has blank Complaint/Grievance Reports posted in a multitude of prominent locations throughout the facility for residents, visitors and staff. The ADMN stated she is the Official Grievance Officer for the facility and was responsible to logging grievances and complaints on the Grievance Log and including the documentation in the associated binder. The ADMN stated grievances and complaints should be logged on the Grievance Log and the original, top copy of the carbon copy form should be placed in the associated binder. Additional documentation would be added as the investigation or resolution progressed. The ADMN stated only in the last few months had she taken over responsibility for the Grievance resolution process. The ADMN stated that before she took over the responsibility, each department head would process and maintain associated records of complaints regarding their particular domain. The ADMN stated the new process is for all Complaint/Grievance Reports to come to her for discussion and distribution in the daily morning meeting. The ADMN stated this has been the process for the past few months. The ADMN stated that if a form or allegation went directly to the associated department, she may not receive the Complaint/Grievance Report and thus be unable to track and process it appropriately. The ADMN stated that all department heads have been advised to bring any allegations, complaints or the paper Report form to the daily morning meeting for discussion. The ADMN stated she did not have a tracking system in place for any outstanding Complaint/Grievance Reports at this time. The ADMN stated, going forward she would take an inventory of how many blank Complaint/Grievance Report forms were currently posted throughout the facility and begin a tracking effort in order to gauge if Complaint/Grievance Reports were missing and need to be tracked down. The ADMN stated this particular Complaint/Grievance Report did not come to her to be included in the Grievance Log or Binder by mistake. Record review of the undated Grievance Policy and Procedure did not include steps to maintain evidence demonstrating the responses and results of all grievances for a period of no less than 3 years from the issuance of the grievance decision, that include date the grievance was received, a summary statement of the grievance, steps taken to investigate the grievance, a summary of pertinent findings or conclusions, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken, and the date the written decision was issued. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675690 If continuation sheet Page 2 of 18 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 675690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Estates Rehabilitation Center 130 Spencer LN 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 Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving neglect were reported not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to the State Survey Agency in accordance with State law through established procedures for 1 (Resident #258) of 15 residents reviewed for abuse. An allegation of neglect was not reported to the State Survey Agency within 24 hours of being made by Resident #258. This failure could place the residents at risk of abuse and neglect allegations being uninvestigated. Findings included: Record review of Resident #258's admission record, dated 6/02/2023, revealed an admission date of 3/07/2022 with the diagnoses which included diabetes mellitus II. Record review of Resident #258's discharge MDS assessment, dated 5/23/2023, revealed Resident #258 was a [AGE] year-old female who needed medical support for diabetes. Record review of Resident #258's care plan, dated 6/02/2023, reflected no focus areas or interventions related to medical diagnosis of diabetes were included. Record review of physician progress note dated 5/17/2023 revealed Assessment and Plan for Resident #258 included, continue Lantus. Record review of Resident #258's Order Summary Report, active as of 6/02/2023, revealed physician orders for: Insulin Regular Human Injection Solution Pen-injector 100 unit/ML inject 40 unit subcutaneously before meals with a start date of 5/09/2023; Lantus SoloStar solution Pen-Injector 100 unit/ML (Insulin Glargine) inject 65 unit subcutaneously one time a day with a start date of 5/10/2023. Record review of Resident #258's Medication Administration Record for the month of May 2023, revealed blank spaces for medication administration of Insulin SoloStar (Insulin glargine) on 5/04/2023 at 8:00 PM, 5/05/2023 at 9:00 AM and 8:00 PM, 5/06/2023 at 9:00 AM and 8:00 PM, 5/07/2023 at 9:00 AM and 8:00 PM, 5/08/2023 at 9:00 AM; blank spaces for medication administration of Insulin Regular Human Injection on 5/12/2023 at 11:30 AM. Record review of the Pharmacy Monthly Review, dated 5/24/2023-5/25/2023, revealed Quality Assurance Comments, 1.) Internal report noted a few missed administrations. Recommend working on keeping these to a minimum. Record review of the facility System: Medication Administration Action Plan form dated 5/19/2023, revealed Problem: Insulin orders were changed to Alert MAR and doses were missed; Goal: No further (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675690 If continuation sheet Page 3 of 18 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 675690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Estates Rehabilitation Center 130 Spencer LN 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 Residents Affected - Few missed doses; Success criteria: No further missed doses signed by the Pharmacist and the DON. Additionally, this packet included Complaint/Grievance Report dated 5/15/2023 from Resident #258, regarding missed dosing of insulin; Action plan included steps to return insulins from High Alert Injectables tab in the electronic medication system to previous administration screen. Included in this packet was a form entitled, Medication error report dated 5/16/2023, detailing a missed dose on 5/12/2023 for Resident #258. In an interview on 6/3/2023 at 5:34 PM, the ADMN stated she had not called in an allegation of neglect to the State Survey Agency in relation to the Grievance/Complaint Report related to a missed dosing of insulin. Record review of the Risk Management: Abuse, Neglect, Exploitation, Mistreatment of Resident or Misappropriation of Resident Property, Review date August 2020, revealed a definition of Neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Further instructions revealed the ADMN, the DON and Risk Manager are ultimately responsible for: reporting, investigation, and trending. Facility leadership will identify situation in which abuse, neglect .may be more likely to occur. An immediate report will be filed .for alleged violations involving abuse, neglect .but not later than 2 hours after the allegation is made if the allegation involve abuses or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .to State Survey Agency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675690 If continuation sheet Page 4 of 18 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 675690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Estates Rehabilitation Center 130 Spencer LN 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the comprehensive assessment of a resident, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 12 out of 16 residents (Residents #2, #3, #7, #11, #12, #16, #21, #23, #34, #107, #257, and Resident #258) reviewed for diabetic care in that; Residents Affected - Some 1. The facility failed to administer injectable insulin for Residents #2, #3, #7, #11, #12, #16, #21, #23, #34, #257, and Resident #258, sporadically from 04/14/2023 to 05/13/2023, due to an update in the electronic medication system. 2. The facility failed to identify and assess for harm, report to the PCP, report to the Residents and/or their Representatives all residents who did not receive their insulin due to the systemic update in the electronic medication administration record. 3. The facility failed to in-service all staff, to include, temporary agency staff, for the update to the electronic medication administration record. 4. The facility failed to implement blood sugar monitoring / checks for levels of blood sugar for Resident # 107 who was diagnosed as diabetic. These failures placed residents at risk for harm, to include death, by declined health status due to abnormal blood sugar levels. An Immediate Jeopardy (IJ) situation was identified on 06/02/2023. While the IJ was removed on 06/03/2023, the facility remained out of compliance at a severity level of potential for actual harm that was not Immediate Jeopardy and a scope of isolated. The findings included: Failures 1 through 2: Resident #2 A record review of Resident #2's admission record, dated 06/02/2023, revealed an admission date of 10/15/2020 with diagnoses which included diabetes mellitus II [a group of diseases that result in too much sugar in the blood (high blood glucose)]. Further review revealed Resident #2 resided on 200-hall. A record review of Resident #2's quarterly MDS, dated [DATE], revealed Resident #2 was a 70-yr-old female who needed medical support for diabetes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675690 If continuation sheet Page 5 of 18 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 675690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Estates Rehabilitation Center 130 Spencer LN 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some A record review of Resident #2's care plan, dated 06/02/2023, revealed, I have diabetes mellitus .intervention: diabetes medication as ordered by doctor. Resident #2 April 2023 A record review of Resident #2's April 2023 PCP order summary revealed the PCP ordered for Resident #2 to receive insulin glargine 100 units/ml, inject 44 units subcutaneous every morning and at bed time for DM; insulin glargine 100 units/ml inject 47 units subcutaneously every morning and bedtime for DM; insulin aspart 100 units/ml, inject as per sliding scale: if 200-249 = 2 units; 250-299 = 4 units; 300-349 = 6 units; 350-399 = 8 units; if greater than 400 give 10 units and notify MD. Subcutaneously before meals and at bedtime [insulin aspart = a short-acting, manmade version of human insulin] . A record review of Resident #2's April 2023 medication administration record revealed blank spaces for medication administration of insulin glargine 100 units/ml, inject 44 units subcutaneous every morning and at bedtime for DM on 04/17/2023 at 08:00 PM; 04/20/2023 at 07:00 AM and 04/21/2023 at 07:00 AM; on 04/22/2023 and on 04/23/2023 at 07:00 AM and 08:00 PM A record review of Resident #2's April 2023 medication administration record revealed blank spaces for medication administration of insulin glargine 100 units/ml, inject 47 units subcutaneous every morning and at bedtime for DM on 04/30/2023 at 08:00 PM. A record review of Resident #2's April 2023 medication administration record revealed blank spaces for medication administration of insulin aspart 100 units/ml, inject as per sliding scale: if 200-249 = 2 units; 250-299 = 4 units; 300-349 = 6 units; 350-399 = 8 units; if greater than 400 give 10 units and notify MD. Subcutaneously before meals and at bedtime, on 04/17/2023 at 04:00 PM and 08:00 PM; 04/19/2023 at 11:00 AM; on 04/20/2023 at 07:00 AM, 11:00 AM, and 04:00 PM; on 04/21/2023 at 07:00 AM and at 11:00 AM; on 04/22 and 04/23/2023 at 07:00 AM, 11:00 AM, 04:00 PM, and at 08:00 PM; and again on 04/30/2023 at 04:00 PM and 08:00 PM. A record review of the facility's schedule revealed on 04/17/2023, agency nurse LVN BB worked the 06:00 AM 02:30 PM shift on 200-hall. A record review of the facility's schedule revealed on 04/17/2023, agency nurse LVN Z worked the 02:30 to 10:30 PM shift on 200-hall. A record review of the facility's schedule revealed on 04/20/2023 LVN H worked the 06:30 AM to 02:30 PM shift and on 04/21/2023 agency LVN O worked the 06:30 AM to 02:30 PM shift on 200-hall. A record review of the facility's schedule revealed on 04/21/2023, on 4/22/2023, and on 04/30/2023 LVN B worked the 06:30 AM to 10:30 PM shift During an interview on 06/03/2023 at 09:40 AM, LVN B stated he was the weekend nurse for the 200-hall. LVN CB stated he recalled during the period of mid-April and mid-May 2023, there was a problem with the electronic medication administration record in that the injectable medications, insulins, were not on the residents MAR. LVN B stated he thought to himself the medications were discontinued and may have not administered some. I did not know the medications were on another tab. LVN B stated he figured it out with reports from other nurses and believes the record will demonstrated he gave the insulins for the residents on 200-hall on weekends [#2, #3, #7, and #34]. LVN B stated he had not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675690 If continuation sheet Page 6 of 18 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 675690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Estates Rehabilitation Center 130 Spencer LN 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 0684 received a training for the incident when the injectable medications were missing from the nurses MAR. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 06/03/2023 at 06:29 PM LVN H stated he was the full-time nurse on the 200-hall days during April - May 2023. LVN H stated he was not informed the injectable medications were removed from the nurse MAR, where he was accustomed to view injectable medications scheduled for residents, to the Alerts tab in the resident's electronic medication record. LVN H stated he may not have administered insulins if he did not know they were scheduled. LVN H stated he might have given some insulins and stated he may have failed to document the administrations. LVN H stated If it is not documented it was not done when asked what the professional standard was for nursing duties. Residents Affected - Some During an interview on 06/03/2023 at 07:38 PM LVN O stated she was an agency nurse and worked temporarily for the facility on 100 and 200-halls. LVN O stated she had worked for the facility during April May 2023. LVN O stated she administered medications and treatments that were on the nurse MAR and had not received any training to alert her to review the Alerts tab for residents scheduled injectable medications. LVN O stated she may have missed some resident's injectable medications if the medications were not visible on the nurse's MAR. LVN O stated If it is not documented it was not done when asked what the professional standard was for nursing duties. Resident #2 May 2023 A record review of Resident #2's May 2023 PCP order summary revealed the PCP ordered for Resident #2 to receive insulin glargine 100 units/ml inject 47 units subcutaneously every morning and bedtime for DM; insulin glargine 100 unit/ml inject 50 units subcutaneously every morning and at bedtime for DM; and insulin aspart 100 units/ml, inject as per sliding scale: if 200-249 = 2 units; 250-299 = 4 units; 300-349 = 6 units; 350-399 = 8 units; if greater than 400 give 10 units and notify MD. Subcutaneously before meals and at bedtime. A record review of Resident #2's May 2023 medication administration record revealed blank spaces for medication administration of insulin glargine 100 units/ml inject 47 units subcutaneously every morning and bedtime for DM, on: 05/01/2023 at 08:00 PM and 05/05/2023 at 08:00 PM. A record review of the facility's schedule revealed agency nurse LVN Y worked the 02:30 PM to 10:30 PM shift on 05/01/2023 and Facility nurse LVN E worked the 02:30 PM to 10:30 PM shift on 05/05/2023. A record review of Resident #2's May 2023 medication administration record revealed blank spaces for medication administration of insulin glargine 100 unit/ml inject 50 units subcutaneously every morning and at bedtime for DM on 05/06/2023, 05/08/2023, 05/09/2023, and 05/13/2023 all at 08:00 PM, both on 200-hall. A record review of the facility's schedule revealed facility nurse LVN B worked the 06:30 AM to 10:30 PM shift on 05/06/2023 and 05/13/2023 and LVN E worked the 02:30 PM to 10:30 PM shift on 05/05/2023, both on 200-hall. A record review of Resident #2's May 2023 medication administration record revealed blank spaces for medication administration of insulin aspart 100 units/ml, inject as per sliding scale: if 200-249 = 2 units; 250-299 = 4 units; 300-349 = 6 units; 350-399 = 8 units; if greater than 400 give 10 units and notify MD. Subcutaneously before meals and at bedtime on 05/01/2023 at 04:00 PM and at 08:00 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675690 If continuation sheet Page 7 of 18 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 675690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Estates Rehabilitation Center 130 Spencer LN 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 0684 Level of Harm - Immediate jeopardy to resident health or safety PM; 05/05/2023 at 04:00 PM and at 08:00 PM; 05/06/2023 at 08:00 PM; 05/08/2023 and 05/09/2023 at 04:00 PM and at 08:00 PM; 05/13/2023 at 08:00 PM; 05/15/2023 at 11:00 AM and 05/16/2023 at 11:00 AM. A record review of the facility's schedule revealed on 05/01/2023 and on 05/05/2023, agency nurse, LVN Y worked the 02:30 PM to 10:30 PM shift and facility nurse LVN A worked the 06:30 AM to 02:30 PM shift on 200-hall. Residents Affected - Some A record review of the facility's schedule revealed on 05/06/2023, and on 05/13/2023 facility LVN B worked the shift from 06:30 AM to 10:30 PM. A record review of the facility's schedule revealed on 05/08/2023, 05/09/2023, 05/15/2023, and 05/16/2023 LVN A worked the 06:30 AM to 02:30 PM shift and LVN E worked the 02:30 PM to 10:30 PM shift. During an interview on 06/03/2023 at 08:47 PM LVN E stated she had worked during the Month of May 2023 as a charge nurse on 200-hall and had not administered some of the residents insulins due to the insulins were moved off of the nurses MAR and onto a tab called the Alert Tab. LVN E stated she had not received training on the Alert Tab and was not aware the residents insulin orders were moved to the Alert Tab. I could not see them .so, I did not know they were scheduled for administration. LVN E stated If it is not documented it was not done when asked what the professional standard was for nursing duties. Resident #3 A record review of Resident #3's admission record, dated 06/02/2023, revealed an admission date of 10/15/2020 with diagnoses which included diabetes mellitus II [a group of diseases that result in too much sugar in the blood (high blood glucose)]. Further review revealed Resident #3 resided on 200-hall. A record review of Resident #3's MDS annual assessment, dated 04/06/2023, revealed Resident #3 was an [AGE] year-old female with diabetes and a BIMS score of 10 out of 15, indicating moderate impairment of mental cognition. A record review of Resident #3's care plan, dated 06/02/2023, revealed, I have diabetes mellitus which requires daily monitoring .interventions: diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. A record review of Resident #3's April 2023 Physician Order Summary revealed, Resident #3 was to receive insulin glargine 100 unit/ml inject 30 units subcutaneously one time a day at 08:00 AM for DM and insulin glargine 100 unit/ml inject 50 units subcutaneously one time a day 09:00 PM for DM. A record review of Resident #3's April 2023 medication administration record revealed blank spaces for medication administration of insulin glargine 100 unit/ml inject 30 units subcutaneously one time a day at 08:00 AM for DM and insulin glargine 100 unit/ml inject 50 units subcutaneously one time a day 09:00 PM for DM, on 04/17/2023 at 09:00 PM, on 04/20-21/2022 at 08:00 AM; on 04/22-04/23 at 08:00 AM and at 09:00 PM. A record review of Resident #3's May 2023 medication administration record revealed blank spaces for medication administration of insulin glargine 100 unit/ml inject 30 units subcutaneously one time a day at 08:00 AM for DM and insulin glargine 100 unit/ml inject 30 units subcutaneously one time a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675690 If continuation sheet Page 8 of 18 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 675690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Estates Rehabilitation Center 130 Spencer LN 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 0684 day 09:00 PM for DM, on 05/06/2023, 05/13/2023, and on 05/14/2023 at 08:00 AM. Level of Harm - Immediate jeopardy to resident health or safety A record review of Resident #3's May 2023 medication administration record revealed blank spaces for medication administration of insulin glargine 100 unit/ml inject 50 units subcutaneously one time a day at 09:00 PM for DM and insulin glargine 100 unit/ml inject 50 units subcutaneously one time a day 09:00 PM for DM, on 05/01/2023 and on 05/05 - 05/10/2023 at 09:00 PM. Residents Affected - Some During an interview on 06/01/2023 at 12:27 PM Resident #3 stated she had not received her insulin several times, I can't remember what days, but it was in May [2023]. Resident #3 stated she reported she had not received her insulin to a female temporary agency nurse. Resident #3 stated the nurse replied, you don't get insulin. Resident #3 stated she experienced the lack of insulin several times but could not recall dates and times other than May 2023. Resident stated she experienced chills, trembling, and anxiety when she did not receive her insulin. During an interview on 06/02/2023 at 12:33 PM LVN A stated she was the facility's nurse for the 200-hall and worked the 06:30 AM to 02:30 PM shift Monday through Friday. LVN A stated she was made aware, by the DON, somewhere around the Middle of May 2023 that there was an additional tab to click on, the Alert tab in the medication administration record, to administer the injectable insulin. LVN A stated the 200-hall utilized temporary agency nurses for the 02:30 PM to 10:30 PM shift. LVN A stated she knew her residents who received insulin, but agency nurses may not if they did not get a good report. LVN A stated she provided good reports to the agency nurses. LVN A stated, If it is not documented it was not done when asked what the professional standard was for documenting nursing duties. Resident #7 A record review of Resident #7's admission record, dated 06/02/2023, revealed an admission date of 12/13/2020 with diagnoses which included diabetes mellitus. A record review of Resident #7's annual MDS, dated [DATE], revealed Resident #7 was a [AGE] year-old female admitted with diabetes and was assessed with an 11 out of 15 BIMS score, which indicated a moderate cognitive impairment. A record review of Resident #7's care plan, dated 06/02/2023 revealed, I have diabetes mellitus .diabetes medication as ordered by physician. A record review of Resident #7's May 2023 physician's order summary revealed Resident #7 was to receive insulin glargine 100 unit/ml inject 10 units subcutaneous at bedtime, 08:00 PM, for DM 2; dulaglutide 1.5 mg/0.5ml inject 1.5mg subcutaneously one time a day every 7 days for type II DM; and insulin aspart 100 units/ml inject per sliding scale if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6units; 301 - 350 = 8 units; 351 - 400 = 10 units if over 400, notify MD., subcutaneously before meals and at bedtime for type II diabetes mellitus. A record review of Resident #7's May 2023 medication administration record revealed blank spaces for medication administration of insulin glargine 100 unit/ml inject 10 units subcutaneous at bedtime, 08:00 PM, for DM 2 on 05/17/2023; 05/22 - 05/23/2023; and on 05/29 - 05/30/2023. A record review of Resident #7's May 2023 medication administration record revealed blank spaces for medication administration of dulaglutide 1.5 mg/0.5ml inject 1.5mg subcutaneously one time a day (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675690 If continuation sheet Page 9 of 18 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 675690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Estates Rehabilitation Center 130 Spencer LN 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 0684 every 7 days for type II DM, on 05/17/2023. Level of Harm - Immediate jeopardy to resident health or safety A record review of Resident #7's May 2023 medication administration record revealed blank spaces for medication administration of insulin aspart 100 units/ml inject per sliding scale if 151 - 200 = 2 units; 201 250 = 4 units; 251 - 300 = 6units; 301 - 350 = 8 units; 351 - 400 = 10 units if over 400, notify MD., subcutaneously before meals and at bedtime for type II diabetes mellitus, on 05/17/2023 at 11:00 AM, 04:00 PM, and at 08:00 PM, on 05/19-05/21/2023 at 07:00 AM and at 11:00 AM; on 05/22 - 05/23/2023 at 07:00 AM, 11:00 AM, 04:00 PM, and at 08:00 PM, and on 05/29 - 05/30/2023 at 04:00 PM and 08:00 PM. Residents Affected - Some Resident #11 Record review of Resident #11's face sheet, dated 06/02/2023, reflected Resident #11 was an [AGE] year-old male admitted on [DATE] with diagnosis including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis), and dementia. Record review of Resident #11's MDS assessment, dated 05/11/2023, reflected a BIMS of 11, indicating moderately impaired cognitive status. Record review of Resident #11's Physician's Orders, dated 06/02/2023, reflected an order for NovoLog Solution 100 unit/ml 3 units subcutaneously two times a day every Monday, Wednesday, and Friday for hypoglycemia dialysis days. Resident #11's Physician's Orders also reflected an order for NovoLog Solution 100 unit/ml 3 units subcutaneously with meals every Tuesday, Thursday, Saturday, and Sunday for hyperglycemia. Record review of Resident #11's April 2023 and May 2023 Medical Administration Record, dated 06/02/2023, revealed blanks in the medical administration record for NovoLog Solution 100 unit/ml. There was no record of NovoLog administration on the following dates and times: 04/14/2023 at 11:30 AM; 04/20/2023 at 11:30 AM; 04/21/2023 at 12:00 PM; 05/1/2023 at 12:00 PM and 06:00 PM; 05/2/2023 at 07:30 AM, 11:30 AM, and 05:00 PM; 05/4/2023 at 07:30 AM, 11:30 AM, and 05:00 PM; 05/11/2023 at 07:30 AM and 11:30 AM; 05/12/2023 at 12:00 PM and 06:00 PM. Observation on 06/02/2023 at 9:00 AM, Resident #11 was observed in their bedroom with the lights off resting. Resident #11 stated they did not want to be disturbed and was not available for interview. Resident #12 Record review of Resident #12's admission record, dated 6/02/2023, revealed an admission date of 06/07/2016 with the diagnoses which included diabetes mellitus II. Record review of Resident #12's annual MDS assessment, dated 4/02/2023, revealed Resident #12 was a [AGE] year-old female who needed medical support for diabetes that included Insulin injections. Record review of Resident #12's care plan, dated 6/02/2023, revealed, I have diabetes mellitus . intervention: diabetes medication as ordered by doctor. Record review of physician progress note dated 5/15/2023 revealed Assessment and Plan for Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675690 If continuation sheet Page 10 of 18 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 675690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Estates Rehabilitation Center 130 Spencer LN 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some #12 included, Diabetes Mellitus Type 2 with peripheral Neuropathy, continue Levemir [Trulicity], AC Humalog [Insulin Lispro]. Record review of Resident #12's Order Summary Report, active as of 6/02/2023, revealed physician orders for: Humalog Kwik-Pen Solution Pen-Injector 100 Unit/ML (Insulin Lispro) Inject 8 unit subcutaneously before meals with a start date of 2/23/2018; Trulicity solution pen-injector 0.75 mg/ml (dulaglutide) inject 0.75mg subcutaneously at bedtime every Friday for type 2 diabetes with a start date of 7/23/2021. Record review of Resident #12's Medication Administration Record for the month of May 2023, revealed blank spaces for medication administration of Trulicity on 5/12/2023; blank spaces for medication administration of Humalog Kwik-Pen (Lispro) at 11:00 AM on 5/01/2023, 11:00 AM on 5/11/2023, 11:00 AM on 5/12/2023, and 4:00 PM on 5/12/2023. Resident #16 Record review of Resident #16's face sheet, dated 6/1/2023, reflected Resident #16 was a [AGE] year-old female admitted on [DATE] with diagnosis including chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). Record review of Resident #16's MDS assessment, dated 3/8/2023, reflected a BIMS of 15, indicating intact cognitive status. Record review of Resident #16's Physician's Orders, dated 6/1/2023, reflected an order for NovoLog Flex pen Subcutaneous Solution Pen-Injector 100 unit/ml injected on a sliding scale based on the resident's blood sugar level. The order reflected that this should be injected subcutaneously before meals and at bedtime for the Resident #16's type 2 diabetes mellitus. Record review of Resident #16's April 2023 and May 2023 Medical Administration Record, dated 06/01/2023, revealed blanks in the medical administration record for NovoLog Solution 100 unit/ml. There was no record of blood sugar checks or NovoLog administration on the following dates and times: 04/14/2023 at 09:00 PM; 04/20/2023 at 11:00 AM; 04/21/2023 at 11:00 AM; 04/23/2023 at 11:00 AM; 05/1/2023 at 11:00 AM; 05/11/2023 at 8:00 AM and 11:00 AM; 05/12/2023 at 11:00 AM, 04:00 PM and 09:00 PM. In an interview on 6/2/2023 at 8:40 AM, Resident #16 stated she does not recall staff not providing her medication to her at any time. In an interview on 6/2/2023 at 7:27 PM, LVN G stated she worked on 4/14/2023, 5/11/2023, and 5/12/2023, and that she could not recall any residents not being provided insulin as ordered. In an interview on 6/2/2023 at 4:36 PM, LVN M stated she worked on 4/23/2023 the MAR tells them if they are diabetic or need insulin. LVN M then stated the system changed, but she were not sure why there would be any holes in the MAR even if the system changed. LVN M stated she could not recall any residents not being provided insulin as ordered. In an interview on 6/2/2023 at 9:21 AM, the DON stated Resident #16 occasionally said she did not need insulin as she did not have diabetes. When asked why there was missing documentation on the MAR, the DON stated they had changed the way insulin was documented in their EMR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675690 If continuation sheet Page 11 of 18 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 675690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Estates Rehabilitation Center 130 Spencer LN 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 0684 Resident #21 Level of Harm - Immediate jeopardy to resident health or safety A record review of Resident #21's quarterly MDS, dated [DATE], revealed Resident #21 was a [AGE] year-old female admitted [DATE] who needed medical support for diabetes that included Insulin injections. Residents Affected - Some A record review of Resident #21's care plan, dated 06/02/2023, revealed, I have diabetes mellitus .intervention: diabetes medication as ordered by doctor. Record review of physician progress note dated 04/26/2023 revealed Assessment and Plan for Resident #21 to included, Diabetic neuropathy, DM2 [Diabetes Mellitus Type 2], continue .SSI [sliding scale Insulin]. Record review of Resident #21's Order Summary Report, active as of 6/02/2023, revealed physician orders for: Humalog Kwik-Pen Subcutaneous solution pen-injector 100 unit/ml (Insulin Lispro) Inject as per sliding scale subcutaneously before meals and at bedtime, Insulin Glargine subcutaneous solution pen-injector 100 unit/ml, inject 10 unit subcutaneously at bedtime. Record review of Resident #21's Medication Administration Record for the month of May 2023, revealed blank spaces for medication administration of Insulin Glargine on 5/12/2023 at bedtime; blank spaces for medication administration of Humalog Kwik-Pen on 05/01/2023 at 11:00 AM, on 05/11/2023 at 8:00 AM, on 05/11/2023 at 11:00 AM, on 05/12/2023 at 11:00 AM, on 05/12/2023 at 04:00 PM, and on 05/12/2023 at 09:00 PM. Resident #23 Record review of Resident #23's MDS assessment, dated 05/06/2023, reflected a BIMS of 14, reflecting an intact cognitive status. Record review of Resident #23's Physician's Orders, dated 06/02/2023, reflected an order for Humulin Kwik Pen Suspension Pen-injector 100 unit/ml two times daily, and Novo-Fine two times daily for type 2 diabetes mellitus. Record review of Resident #23's May 2023 Medical Administration Record, dated 6/2/2023, revealed blanks in the medical administration record for Humulin Kwik Pen Suspension Pen-injector 100 unit/ml. There was no record of Humulin administration on 05/12/2023 at 07:00 PM. Record review of Resident #23's May 2023 Medical Administration Record, dated 06/02/2023, revealed blanks in the medical administration record for Novo-Fine Miscellaneous 30G X 8 MM (Insulin Pen Needle) on 05/12/2023 at 07:00 PM. In an interview on 6/2/2023 at 8:50 AM, Resident #23 stated he could not recall receiving any of his medications, including insulin. In an interview on 6/2/2023 at 7:27 PM, LVN G stated she worked on 5/12/2023, and she could not recall any residents not being provided insulin as ordered. Resident #34 A record review of Resident #34's admission record, dated 06/02/2023 revealed an admission date of 12/31/2022 with diagnoses which included diabetes mellitus II. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675690 If continuation sheet Page 12 of 18 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 675690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Estates Rehabilitation Center 130 Spencer LN 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 0684 Level of Harm - Immediate jeopardy to resident health or safety A record review of Resident #34's quarterly MDS assessment, dated 04/12/2023 revealed Resident #34 was a [AGE] year-old male who was assessed with diabetes and a BIMS score of 06 of 15 possible, which indicated severe mental cognition impairment. A record review of Resident #34's care plan dated 06/02/2023, revealed, I have diabetes mellitus . interventions; observe document report two doctor as needed signs and symptoms of hypoglycemia. Residents Affected - Some A record review of Resident #34's April 2023 physician's order summary revealed Resident #34 was to receive insulin detemir 100 units/ml inject 12 units subcutaneously in the morning [07:00 AM], for type II diabetes; insulin detemir 100 units/ml inject 5 units subcutaneously in the evening [05:00 PM], for type II diabetes; and insulin aspart 100 units/ml inject per sliding scale if 200 - 249 = 2 units; 250 - 299 = 4 units; 300 - 349 = 6 units; 350 - 400 = 8 units; 401 - 999 = 10 units if over 400, notify MD., subcutaneously before meals and at bedtime for type II diabetes mellitus. A record review of Resident #34's May 2023 medication administration record revealed blank spaces for medication administration of insulin detemir 100 units/ml inject 12 units subcutaneously in the morning [07:00 AM], for type II diabetes on 05/20 - 05/23/2023. A record review of Resident #34's April 2023 medication administration record revealed blank spaces for medication administration of insulin detemir 100 units/ml inject 5 units subcutaneously in the evening, 05:00 PM on 04/17/2023, 04/20/2023, 04/22 - 04/23/2023, and on 04/29 - 04/30/2023. A record review of Resident #34's April 2023 medication administration record revealed blank spaces for medication administration of insulin aspart 100 units/ml inject per sliding scale if 200 - 249 = 2 units; 250 299 = 4 units; 300 - 349 = 6 units; 350 - 400 = 8 units; 401 - 999 = 10 units if over 400, notify MD., subcutaneously before meals and at bedtime for type II diabetes mellitus on 04/17/2023 at 11:30 AM, 04:30 PM, and 08:30 PM; on 04/19/2023 at 11:30 AM; on 04/20 - 04/21/2023 at 07:00 AM and at 11:30 AM; on 04/22 - 04/23/2023 at 07:00 AM, 11:30 AM, 04:30 PM, and 08:00 PM; 04/24/2023 at 08:00 PM; and on 04/29 - 04/30/2023 at 04:30 PM and 08:00 PM. Resident #257 Record review of Resident #257's admission record, dated 06/02/2023, revealed an admission date of 5/01/2023 with the diagnoses which included diabetes mellitus II. Record review of Resident #257's admission MDS assessment, dated 05/10/2023, revealed Resident #257 was an [AGE] year-old male who needed medical support for diabetes that included Insulin injections. Record review of Resident #257's care plan, dated 6/02/2023, revealed, I have diabetes mellitus . intervention: diabetes medication as ordered by doctor. Record review of Resident #257's physician progress note dated 5/24/2023 revealed Assessment and Plan, Diabetes Mellitus Type 2, continue Lantus, Trulicity [Insulin Lispro]. Record review of Resident #257's Order Summary Report, active as of 06/02/2023, revealed physician orders for: Humalog Kwik-Pen solution (Insulin Lispro) Inject as per sliding scale .subcutaneously before meals and at bedtime with a start date of 05/01/2023; Insulin glargine subcutaneous solution inject 15 units subcutaneously at bedtime with a start date of 05/01/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675690 If continuation sheet Page 13 of 18 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 675690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Estates Rehabilitation Center 130 Spencer LN 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #257's Medication Administration Record for the month of May 2023, revealed blank spaces for medication administration of Insulin glargine on 05/12/2023 at bedtime; blank spaces for medication administration of Humalog Kwik-Pen (Lispro) at 11:00 AM on 05/11/2023, 11:00 AM on 05/12/2023, 04:00 PM on 05/12/2023 and on 05/12/2023 at 08:00 PM. Resident #258 Residents Affected - Some Record review of Resident #258's admission record, dated 06/02/2023, revealed an admission date of 03/07/2022 with the diagnoses which included diabetes mellitus II. Record review of Resident #258's discharge MDS assessment, dated 05/23/2023, revealed Resident #258 was a [AGE] year-old female who needed medical support for diabetes. Record review of Resident #258's care plan, dated 06/02/2023, no focus areas or interventions related to medical diagnosis of diabetes were included. Record review of physician progress note dated 05/17/2023 revealed Assessment and Plan for Resident #258 included, continue Lantus. Record review of Resident #258's Order Summary Report, active as of 06/02/2023, revealed physician orders for: insulin Regular Human Injection Solution Pen-injector 100 unit/ml inject 40 unit subcutaneously before meals with a start date of 5/09/2023; Lantus solo-star solution pen-injector 100 unit/ml (insulin glargine) inject 65 unit subcutaneously one time a day with a start date of 5/10/2023. Record review of Resident #258's Medication Administration Record for the month of May 2023, revealed blank spaces for medication administration of Insulin solo-star (insulin glargine) on 05/04/2023 at 08:00 PM, 05/05/2023 at 09:00 AM and 08:00 PM, 05/06/2023 at 09:00 AM and 08:00 PM, 05/07/2023 at 09:00 AM and 08:00 PM, 05/08/2023 at 09:00 AM; blank spaces for medication administration of Insulin Regular Human Injection on 05/12/2023 at 11:30 AM. A record review of the facility's grievance for Resident #258, dated 05/15/2023, revealed, Resident #258 made a grievance to the BOM, alleging she had not received her insulin, Resident believes she may have missed a dose of insulin the other day. During an interview on 06/01/2023 at 4:00 PM the DON stated there were holes in the MAR due to the electronic medication administration record received an update where all the injectable medications were moved to a separate tab. The DON stated some staff were unaware of the separate tab and other staff knew residents received injectable insulin and knew to provide the medication. The DON stated the facility investigated system failure and coordinated with the software developer and moved the injectable medications back to the tab where staff were used to access the medication. In an interview on 06/03/2023 at 05:19 PM, the DON stated she did not remember when in April or early May 2023 the high alert injectable medications moved to the alternative tab in the electronic medication system. The DON stated she did not recall why that change occurred. Failure #4 Fail to monitor blood sugar levels. Resident #107 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675690 If continuation sheet Page 14 of 18 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 675690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Estates Rehabilitation Center 130 Spencer LN 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of Resident #107's Face Sheet dated 06/03/2023, revealed Resident #107 was a [AGE] year-old female admitted on [DATE]. Diagnosis information included Type 2 diabetes mellitus without complications with an onset date of 05/24/2023. Record review of Resident #107's comprehensive MDS assessment dated [DATE], revealed Resident #107's primary medical condition category for admission was medically complex conditions related to acute posthemorrhagic anemia [condition that develops when you lose a large amount of blood quickly; tissue and organ damage could be permanent and fatal]. Other active diagnoses included d[TRUNCATED] Event ID: Facility ID: 675690 If continuation sheet Page 15 of 18 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 675690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Estates Rehabilitation Center 130 Spencer LN 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 0756 Level of Harm - Minimal harm or potential for actual harm Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review the facility failed to ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist, in that: Residents Affected - Few There were no monthly medication reviews documented for the months of March 2023 and April 2023. This deficient practice could place residents at risk from harm related to unnecessary medications or dosages, could place them at risk for adverse consequences related to medication therapy, and impact residents' ability to achieve or maintain their highest practicable level of physical, mental, and psychosocial well-being. The findings were: Record review of the facility's Monthly Medication Regimen [MMR] review revealed there was no documentation for the months of March 2023, and April 2023. The binder included only a gradual dose reduction communication email for the month of April 2023. In an interview on 06/02/2023 at 4:18 PM, the DON stated she was sure the meeting for both March 2023 and April 2023 was held in a timely manner and any actionable items were followed through on. The DON stated she did not have any copy of the documentation for either of those months. The DON stated she had started only recently in her role as DON before the first missing month of MMRs and could not find the packets of associated paperwork. The DON stated the pharmacist reviews all residents' medication and makes recommendations which are then passed on the physician and/or nursing for actionable items. The DON stated she did not know what harm could occur to a resident by not having the documentation for those months. The DON stated she did not believe any resident was harmed by the missing MMRs for March and April 2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675690 If continuation sheet Page 16 of 18 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 675690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Estates Rehabilitation Center 130 Spencer LN 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 0760 Ensure that residents are free from significant medication errors. 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 ensure residents are free of any significant medication errors, for 1 of 6 residents (Resident #7) reviewed for medication administration, in that: Residents Affected - Few The facility failed to administer medications as prescribed for Resident #7. This failure could place residents at risk for not receiving therapeutic effects of their medications to include a diminished health status. The findings included: A record review of Resident #7's admission record, dated 06/02/2023, revealed an admission date of 12/13/2020 with diagnoses which included diabetes mellitus. A record review of Resident #7's annual MDS, dated [DATE], revealed Resident #7 was a [AGE] year-old female admitted with diabetes and was assessed with an 11 out of 15 BIMS score, which indicated a moderate cognitive impairment. A record review of Resident #7's care plan, dated 06/02/2023 revealed, I have diabetes mellitus .diabetes medication as ordered by physician. A record review of Resident #7's May 2023 physician's order summary revealed Resident #7 was to receive insulin aspart 100 units/ml inject per sliding scale if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units if over 400, notify MD., subcutaneously before meals and at bedtime for type II diabetes mellitus. During an observation and interview on 06/01/2023 at 08:39 AM revealed LVN AA on the 200-hall with the 200-hall medication cart and prepared to administer medications for Resident #7. LVN AA stated he was awaiting Residents returning from their breakfast meal so he could administer their insulin medications. Continued observation revealed Resident #7 ambulated in her wheelchair to her room on the 200-hall and LVN AA prepared 2 units of insulin aspart 100 units/ml, and injected the medication subcutaneously, for Resident #7. LVN AA stated the medication was scheduled for 07:00 AM prior to Resident #7's breakfast. LVN AA stated he was an agency nurse and was scheduled to arrive for his work shift 06/01/2023 at 06:30 AM. LVN AA stated he arrived at 06:30 AM and spent 35-45 minutes receiving a report from the previous shift nurse, receiving a user ID and password for the EMAR, prior to providing Resident care at 07:05 07:15 AM. LVN AA stated some residents, including Resident #7, had already gone to breakfast by 08:00 AM without receiving their insulin as ordered. LVN AA stated he had not reported the potential late medication of insulin to his immediate supervisor the ADON and/or DON. LVN AA stated he believed they knew due to the work shift he was assigned and the time of the shift, I could have been scheduled earlier to provide more time for orientation on the floor prior to Resident care. LVN AA stated he would report the late medication administration for Resident #7 to the PCP, the ADON, and the DON. LVN AA stated late administration of insulin for diabetic residents may place residents at risk for ineffective therapeutic effects of their diabetic medications and a decline in their health status. During an interview on 06/01/2023 at 08:40 AM Resident #7 stated she had eaten breakfast earlier in the morning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675690 If continuation sheet Page 17 of 18 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 675690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Estates Rehabilitation Center 130 Spencer LN 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 06/01/2023 at 4:00 PM the DON stated LVN AA had not reported a potential for late insulin administration for any residents prior to administering late insulin medication for Resident #7. The DON stated LVN AA was scheduled for the 06:30 AM to 02:30 PM work shift on 200-hall on 06/01/2023. The DON stated she had prepared a user ID and a password for LVN AA and provided the user ID and password by 07:00-07:10 AM on 06/01/2023. The DON stated she expected for all nurses to give a report if they are not able to administer medications as prescribed prior to administration of medications. The DON stated Resident #7 was scheduled to receive insulin prior to the breakfast meal. The DON stated the insulin was not administered per the PCP order and had a potential for a slight adverse reaction of hyperglycemia. A record review of The National Library of Medicine's website, accessed 06/13/2023, https://medlineplus.gov/druginfo/meds/a605013.html , revealed, How should this medicine be used? Insulin aspart comes as a solution and a suspension to inject subcutaneously (under the skin). Insulin aspart solution (NovoLog) is usually injected 5-10 minutes before eating a meal. If you are using insulin aspart suspension (NovoLog Mix 70/30) to treat type 1 diabetes, it is usually injected within 15 minutes before a meal. If you are using insulin aspart suspension to treat type 2 diabetes, it is usually injected within 15 minutes before or after a meal. Insulin aspart solution is usually injected at the start of a meal or within 20 minutes after starting a meal. Your doctor will tell you how many times you should inject insulin aspart each day. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Use insulin aspart exactly as directed. Do not use more or less of it or use it more often than prescribed by your doctor. A record review of the facility's Medication Errors policy, dated December 2022, revealed, Policy Statement: . a medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with physicians' orders, manufacturers specifications, or accepted professional standards and principles of the professionals' providing services. examples of medication errors include: . wrong time . failure to follow manufacturer's instructions and or accepted professional standards . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675690 If continuation sheet Page 18 of 18