Health inspection·April 26, 2024

F 0635 Level of Harm - Minimal harm or potential for actual harm Observation on 04/24/2024 at 2:15 PM of Resident #253 revealed she was lying in bed in her room. She had oxygen infusing via nasal cannula at 2.5 l/min. In an interview on 04/24/2024 at 2:20 PM with Resident #253, she stated she was on oxygen therapy when she was admitted to the facility. Residents Affected - Few Interview on 04/26/2024 at 2:32 PM with LVN C, who was Resident #253's nurse revealed she did not realize Resident #253 did not have an oxygen order and she stated the resident was on oxygen therapy since admission. She stated oxygen was treated like a medication and required a physician's order. She stated the wrong rate could result in respiratory compromise. Interview on 04/26/2024 at 2:50 PM with the DON revealed the oxygen orders for Resident #253 were missed. He stated there were four nurses who collaborated with Resident #253 since her admission and no one questioned her rate or missed orders. He stated the resident was monitored but could have had respiratory distress because of too little or too much oxygen. He stated he did not have a policy or procedure on oxygen administration. Record review of the National Library of Medicine, Chapter 11.1. at https://www.ncbi.nlm.nih.gov/ Oxygen Therapy Introduction reflected Oxygen is considered a medication and, therefore, requires a prescription and continuous monitoring by the nurse to ensure its safe and effective use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676216 If continuation sheet Page 2 of 14 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 676216 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Remington Transitional Care of San Antonio 5423 Hamilton Wolfe Rd San Antonio, TX 78229 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality for 3 (Residents #25, #104 and #253) of 24 residents reviewed for baseline care plans. 1. Resident #25's baseline care plan dated 04/04/2024 did not reflect he received antibiotic therapy at dialysis. 2. Resident #104's baseline care plan dated 04/18/2024 did not reflect she received an antipsychotic medication. 3. Resident #253's baseline care plan dated 04/22/2024 did not reflect she was on oxygen therapy. This deficient practice could affect residents admitted to the facility and result in missed or inadequate care. The findings included: 1. Record review of Resident #25's face sheet dated 4/24/2024 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: septicemia (the body's extreme reaction to an untreated infection that causes the body to attack body organs that could lead to organ failure and then death); metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood); and ESRD (End Stage Renal Disease). Record review of Resident #25's MDS dated [DATE] revealed the resident had a BIMS score of 15. Under section O for Special Treatments, Procedures, and Programs, Group Other subgroup H1, revealed IV medications not checked, and subgroup H4, antibiotics was not checked. Record review of Resident #25's baseline care plan dated 4/5/2024 revealed dialysis with days was not care planned under medical conditions it was checked no and IV antibiotic Ceftazidime was not care planned which was to be administered at dialysis on scheduled dialysis days. Additional orders for dialysis days were to remove pressure dressing from shunt site 4 hours after dialysis was not care planned. During an interview on 2/26/2024 at 3:14 PM the DON stated it is important to assess a resident for accuracy of the care plan to establish point of care, and to ensure it is followed by staff. 2. Record review of Resident #104's face sheet dated 4/24/2024 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: pneumonia (an infection in your lungs caused by bacteria, viruses or fungi), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities. Record review of Resident #104's MDS dated [DATE] revealed it was incomplete due to the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676216 If continuation sheet Page 3 of 14 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 676216 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Remington Transitional Care of San Antonio 5423 Hamilton Wolfe Rd San Antonio, TX 78229 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some recent admission and did not contain BIMS or medication information. In Section I - Active Diagnoses, Psychiatric/Mood Disorder, the diagnoses Anxiety Disorder and Depression (other than bipolar) were checked. Record review of Resident #104's Order Summary Report Active Orders as of 04/18/2024 revealed the resident had an order for: Sertraline HCL Oral Capsule 200 mg (Sertraline HCL), give one tablet by mouth one time a day for depression. The order date was 04/18/2024 with a start date of 04/19/2024. Record review of Resident #104's baseline care plan dated 04/18/2024 revealed under C. Orders, 2. Medications Ordered there was no check mark in the box next to 2b. Psychotropic Medications. During an interview on 04/24/2024 at 1:29 PM with the DON he stated the psychotropic medication Sertraline was not checked off on the resident's baseline care plan and should have been. The DON further stated they try to scrub the care plans as best as possible but sometimes things get missed, and it was important the baseline care plan indicated the medications the resident was receiving so all staff members will know to monitor for side effects. During an interview on 04/26/2024 at 2:55 PM with ADON A she stated one of the supervisors initiated Resident #104's Baseline care plan but she signed off on it, and they both missed indicating the resident was taking a psychotropic medication. 3. Record review of Resident #253's electronic face sheet dated 04/24/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: pneumonia (infection in your lungs caused by bacteria, viruses, or fungi), acute respiratory failure with hypoxia (a condition where there is not enough oxygen in the body tissues) and emphysema (type of lung disease that causes breathlessness). Record review of Resident #253's hospital Discharge summary dated [DATE] reflected Plan: Oxygen supplementation as nasal cannula, titrate to keep saturation of oxygen above 90%. Record review of Resident #253's baseline care plan dated 04/24/2024 did not reflect she was on oxygen therapy. Record review of Resident #253's Active Orders as of: 04/24/2024 reflected no orders for oxygen therapy. Resident #253 was not at the facility long enough for an MDS assessment. Record review of Resident #253's Daily Skilled Note dated 04/22/24, her admission notes, reflected Oxygen via Nasal Cannula. Record review of Resident #253's oxygen saturations dated 4/22/2024 and 04/23/2024 reflected she had saturations taken while she had oxygen therapy via nasal cannula. Observation on 04/23/2024 at 09:53 AM of Resident #253 revealed she was lying in bed in her room. She had oxygen infusing via nasal cannula. Her oxygen concentrator delivered 2.5 l/min. Observation on 04/24/2024 at 2:15 PM of Resident #253 revealed she was lying in bed in her room. She had oxygen infusing via nasal cannula at 2.5 l/min. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676216 If continuation sheet Page 4 of 14 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 676216 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Remington Transitional Care of San Antonio 5423 Hamilton Wolfe Rd San Antonio, TX 78229 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 04/24/2024 at 2:20 PM with Resident #253, she stated she was on oxygen therapy when she was admitted to the facility. Interview on 04/26/2024 at 2:32 PM with LVN C, who was Resident #253's nurse revealed she did not realize Resident #253 did not have an oxygen order and she stated the resident was on oxygen therapy since admission. She said it was important to have the initial baseline care plan because it communicated the residents needs and without her oxygen she could be in respiratory distress. Interview on 04/26/2024 at 2:40 PM with ADON A revealed she reviewed the residents' baseline care plans and did not realize the oxygen therapy was missed. She stated it was important to have the resident's oxygen in her base line care plan to communicate her care needs. She stated Resident #253 could have respiratory issues without her oxygen. Interview on 04/26/2024 at 2:50 PM with the DON revealed the oxygen orders for Resident #253 were missed, and her baseline care plan needed to have her oxygen addressed. He stated there were four nurses who collaborated with Resident #253 since her admission and no one questioned her rate or missed orders. He stated the resident was monitored but could have had respiratory distress because of too little or too much oxygen. Record review of the facility policy and procedure revised date 10/5/23 titled Baseline Care Plan reflected The facility will develop and implement a baseline care plan for each resident that includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676216 If continuation sheet Page 5 of 14 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 676216 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Remington Transitional Care of San Antonio 5423 Hamilton Wolfe Rd San Antonio, TX 78229 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #3) of 24 residents reviewed for care plans. Resident #3's anticoagulant therapy was not address in her comprehensive care plan dated 04/24/2024. This deficient practice could affect residents who required specific care, services and interventions and could result in missed care or harm. The findings included: Record review of Resident #3's electronic face sheet dated 04/23/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: metabolic encephalopathy (a chemical imbalance in the blood which causes a problem in the brain), diabetes mellitus (the body's inability to produce or respond to the hormone insulin is impaired resulting in abnormal metabolism of carbohydrates and elevated levels of blood sugar), rhabdomyolysis (a serious medical condition that can be fatal or result in permanent disability, proteins and electrolytes are released into the blood by damaged muscle tissue) and atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the artery walls, narrowing or blocking blood flow). Record review of Resident #3's admission MDS assessment dated [DATE] reflected she scored a 12/15 on her BIMS which signified she was cognitively intact. Record review of Resident #3's Active Orders as of: 04/23/2024 reflected Heparin Sodium Solution 5000 unit/ml, inject 5000 units subcutaneously every 12 hours for clotting prevention., active date 04/08/2024. Record review of Resident #3's comprehensive care plan revised dated 04/24/2024 did not reflect the resident was on heparin therapy which is an anticoagulant. Record review of Resident #3's MAR dated 04/23/2024 reflected she received Heparin Sodium Solution 5000 unit/ml every 12 hours. Interview on 04/24/2024 at 2:00 PM with Resident #3, she stated she received the Heparin shots twice a day, a week after she was admitted . Interview on 04/26/2024 at 2:40 PM with ADON A revealed she was part of the care planning team and stated Resident #3's Heparin should have been care planned after it was ordered on 04/08/2024. She stated it was a blood thinner or anticoagulant and needed monitoring. She stated a resident could bleed out if it was not managed correctly. Interview on 04/26/2024 at 2:50 PM with the DON revealed Resident #3's Heparin needed to be care planned because it was a blood thinner and could cause serious problems for a resident who required it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676216 If continuation sheet Page 6 of 14 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 676216 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Remington Transitional Care of San Antonio 5423 Hamilton Wolfe Rd San Antonio, TX 78229 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 0656 such as bleeding and clotting if they needed the medication and did not get an accurate amount. Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy and procedure titled Comprehensive Care Plans, dated 10/24/2022 reflected It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the resident's comprehensive assessment. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676216 If continuation sheet Page 7 of 14 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 676216 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Remington Transitional Care of San Antonio 5423 Hamilton Wolfe Rd San Antonio, TX 78229 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals, and preferences for 1 (Resident #253) of 4 residents reviewed for oxygen therapy. Residents Affected - Few The facility failed to get oxygen orders from the physician for Resident #3, who was admitted on [DATE] and did not until 04/26/2024. This deficient practice affects residents admitted on oxygen therapy and could result in respiratory distress. The findings included: Record review of Resident #253's electronic face sheet dated 04/24/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: pneumonia (infection in your lungs caused by bacteria, viruses, or fungi), acute respiratory failure with hypoxia (a condition where there is not enough oxygen in the body tissues) and emphysema (type of lung disease that causes breathlessness). Record review of Resident #253's baseline care plan dated 04/24/2024 did not reflect she was on oxygen therapy. Record review of Resident #253's Active Orders as of: 04/24/2024 reflected no orders for oxygen therapy. Resident #253 was not at the facility long enough for an MDS assessment. Record review of Resident #253's hospital Discharge summary dated [DATE] reflected Plan: Oxygen supplementation as nasal cannula, titrate to keep saturation of oxygen above 90%. Record review of Resident #253's Daily Skilled Note dated 04/22/24, her admission notes, reflected Oxygen via Nasal Cannula. Record review of Resident #253's oxygen saturations dated 4/22/2024 and 04/23/2024 reflected she had saturations taken while she had oxygen therapy via nasal cannula. Observation on 04/23/2024 at 09:53 AM of Resident #253 revealed she was lying in bed in her room. She had oxygen infusing via nasal cannula. Her oxygen concentrator delivered 2.5 l/min. Observation on 04/24/2024 at 2:15 PM of Resident #253 revealed she was lying in bed in her room. She had oxygen infusing via nasal cannula at 2.5 l/min. In an interview on 04/24/2024 at 2:20 PM with Resident #253, she stated she was on oxygen therapy when she was admitted to the facility. Interview on 04/26/2024 at 2:32 PM with LVN C, who was Resident #253's nurse revealed she did not realize Resident #253 did not have an oxygen order and she stated the resident was on oxygen therapy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676216 If continuation sheet Page 8 of 14 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 676216 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Remington Transitional Care of San Antonio 5423 Hamilton Wolfe Rd San Antonio, TX 78229 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few since admission. She stated oxygen was treated like a medication and required a physician's order. She stated the wrong rate could result in respiratory compromise. Interview on 04/26/2024 at 2:50 PM with the DON revealed the oxygen orders for Resident #253 were missed. He stated there were four nurses who collaborated with Resident #253 since her admission and no one questioned her rate or missed orders. He stated the resident was monitored but could have had respiratory distress because of too little or too much oxygen. He stated he did not have a policy or procedure on oxygen administration. Record review of the National Library of Medicine, Chapter 11.1. at https://www.ncbi.nlm.nih.gov/ Oxygen Therapy Introduction reflected Oxygen is considered a medication and, therefore, requires a prescription and continuous monitoring by the nurse to ensure its safe and effective use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676216 If continuation sheet Page 9 of 14 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 676216 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Remington Transitional Care of San Antonio 5423 Hamilton Wolfe Rd San Antonio, TX 78229 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 skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for one of one facility, in that: The Food Service Supervisor (FSS) did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. The findings included: Record review of the staff roster provided by the facility, undated, revealed the hire date for the FSS was 09/01/2019. Record review of the FSS' certification documentation revealed a certificate stating the FSS successfully completed the Texas Food Safety Manager Certification Examination, effective 10/11/2023, expiration date 5 years from the effective date. Record review of facility employee files revealed the facility's RD was contracted and not a full-time employee of the facility. During an interview on 04/23/2024 at 10:50 AM, the FSS stated he was hired by the facility as a cook in 2019 and assumed the position of FSS in 09/2023. The FSS further stated upon assuming the FSS position, he completed a Texas Food Manager's Certification program, received a certificate, and believed this certification met the requirements for the position. During an interview on 04/23/2024 at 1:33 PM with the Administrator she stated she knew the Texas Food Manager's Certification was not a national certification and was not the appropriate certification for the position of FSS. The Administrator further stated she paid for the FSS to take the National Food Manager Certification exam; however, the FSS completed the Texas Food Manager Certification Exam in error. During an interview on 04/26/2024 at 11:45 AM the administrator stated the FSS demonstrated knowledge deficits and would benefit from additional training and possible mentoring from an existing FSS. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 2-102.12 Certified Food Protection Manager. (A) The PERSON IN CHARGE shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM. 2-102.20 Food Protection Manager Certification. (B) A FOOD ESTABLISHMENT that has a PERSON IN CHARGE that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for FOOD Protection-recognized accrediting agency as conforming to the Conference for FOOD Protection Standard for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with §2-102.12. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676216 If continuation sheet Page 10 of 14 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 676216 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Remington Transitional Care of San Antonio 5423 Hamilton Wolfe Rd San Antonio, TX 78229 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 0803 Level of Harm - Potential for minimal harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interviews, and record review, the facility failed to follow menus for 1 of 1 resident meals (lunch meal on 04/25/2024) reviewed for menus in that: Residents Affected - Many The facility failed to follow the menu for residents on regular and modified diets for the lunch meal on 04/25/2024. This failure could place residents who consume food prepared by the facility kitchen at risk of not having their nutritional needs met and/or weight loss. The findings included: Record review of the daily menu posted outside the kitchen on 04/25/2024 at 11:28 AM revealed the lunch meal scheduled for that day was: Baked pork chop, buttered corn, cauliflower w/red potatoes. There was no sign indicating a deviation from the menu and there was no weekly menu posted in any location in the facility. Record review of the menu posted in the kitchen for dietary staff on 04/25/2024 at 11:30 AM revealed the lunch meal scheduled for that day, which was Day 18, Week 3 of the five-week Spring/Summer Menu, was: Baked pork chop, buttered corn, cauliflower w/red potatoes, wheat bread. The menu for all modified diets also included a pork chop, buttered corn and cauliflower (in pureed form for pureed diets). The facility provided a document signed by the consultant registered dietitian (RD) indicating the RD had evaluated the Spring/Summer 2024 for nutritional adequacy in April 2024. Observation on 04/25/2024 at 11:35 AM of the steam table assembled with food ready to be plated for the lunch meal revealed there was no cauliflower on the steam table. There was a half-pan with cooked carrots. During an interview on 04/25/2024 at 11:36 AM with the FSS he stated he knew cauliflower was on the menu for that day's lunch meal and he had ordered this item from the food supplier; however, it did not arrive with the food shipment so carrots were substituted. He knew he could easily procure items that did not arrive on schedule from local approved food sources. He logged the substitution in the Menu Substitution Log. The FSS further stated this substitution was not posted for the residents, there was no weekly menu posted, and he did not discuss this substitution with the consultant RD. During an interview on 04/25/2024 at 11:40 AM with the facility's Dietetic Technician Registered (DTR) she stated she approved all the substitutions and the facility's policy included a list of appropriate substitutions when a food item was not available. The DTR further stated she had not discussed any of the substitutions with the consultant RD. Record review of the Menu Substitution Log provided by the facility revealed an extensive history of menu substitutions going back to October 2023 and beyond. Of 58 food items substituted, the consultant RD's initials were next to 3 items replaced in January, 2 items in February and 2 items in April of 2024. There also appeared to be several occasions where an entire lunch meal was swapped with another day. During an interview with the facility Administrator on 04/26/2024 at 11:00 AM she stated she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676216 If continuation sheet Page 11 of 14 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 676216 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Remington Transitional Care of San Antonio 5423 Hamilton Wolfe Rd San Antonio, TX 78229 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 0803 Level of Harm - Potential for minimal harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete unaware the FSS was making frequent substitutions to the menu, substitutions should only be made in case of an emergency and should be reviewed with the consultant RD. Record review of the facility policy, Menu Substitutions, policy number 01.007, revised 06/01/2019, revealed: Policy: The facility believes that a well-balanced menu, planned in advance and served as posted, is important to the well-being of its residents. The menus will be served as planned except for emergency situations when a food item is unavailable. Procedure: 1. The menu will be served as written unless an emergency situation arises. 5. The consultant RD/DTR will review the Menu Substitution Approval form with the dietitian on each visit to determine trends in substitutions and accuracy of substitutions so that the appropriate training can be provided if needed. 6. The dietitian will initial off the Menu Substitution Form after review. Event ID: Facility ID: 676216 If continuation sheet Page 12 of 14 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 676216 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Remington Transitional Care of San Antonio 5423 Hamilton Wolfe Rd San Antonio, TX 78229 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 Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, 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 reviewed for kitchen sanitation. 1. There were two cases of vegetables and one case of beef patties open with their interior bags open in the walk-in freezer. 2. The tabletop can opener blade, bar, and base were covered in sticky black and brown grime. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 04/23/2024 at 10:52 AM in the walk-in freezer revealed three open cases of food: One 30-lb. case of mixed vegetables, one 30-lb. case of cut green beans, and one 10 lb. case of beef fritters. All three open cases had interior plastic bags that were also open, exposing the food to the ambient air in the freezer and subjecting the food to potential contaminants, freezer burn and a decrease in quality. During an interview on 04/23/2024 at 10:55 AM with the FSS he stated the three cases of food were open and their interior bags were open and should not have been. The FSS further stated the cooks storing the cases in the freezer are responsible for ensuring the food was properly sealed to maintain freshness. 2. Observation on 04/25/2024 at 10:39 AM in the kitchen revealed the tabletop can opener was covered with sticky grime that was black and brown in color. The grime covered the blade, the plastic insert inside the base, and also surrounded the part of the base that was affixed to the table with screws. During an interview on 04/25/2024 at 10:40 AM with the FSS he stated that the can opener blade and entire base was covered in grime and in need of cleaning and sanitizing. The FSS stated the cooks were responsible for keeping the can opener clean and free of debris and failing to do so could result in cross contamination and foodborne illness. The FSS further stated he trained the dietary staff on a monthly basis. Record review of the facility policy, Food Storage, 03.003, revised 06/01/2019, revealed: Procedure: 3. Freezers: e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated. Record review of the facility policy Can Opener, 04.009, approved 10/01/2018, revealed: The facility will maintain can openers free of food particles and dirt to minimize the risk of food hazards. Can openers will be cleaned after each use. Procedure: 1. Hand held or table top: a. Remove can opener shank from base. b. Wash shank in sink with warm water and detergent or in the dishwasher. c. Give close attention to the blade and moving parts. d. Rinse in clean, hot water. e. Sanitize with approved sanitizer. Follow manufacturer's instructions for immersion times. f. Air dry. g. Wash base of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676216 If continuation sheet Page 13 of 14 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 676216 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Remington Transitional Care of San Antonio 5423 Hamilton Wolfe Rd San Antonio, TX 78229 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 Residents Affected - Some can opener with clean cloth soaked in warm water and detergent, removing all food particles and dirt. h. Rinse with clean cloth soaked in clear hot water. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 3-302 Preventing food and ingredient contamination. 3-302.11 Packaged and Unpackaged Food Separation, Packaging, and Segregation. (A) Food shall be protected from cross contamination by: (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings. (6) Protecting food containers that are received packaged together in a case or overwrap from cuts when the case or overwrap is opened. 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676216 If continuation sheet Page 14 of 14