Inspection·January 19, 2024

F 0567 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 1/19/2024 at 12:21 p.m., Resident #4 stated she had difficulties withdrawing money from her account because when the administrator goes to the bank, all of the residents try to get money and the amount of money in the petty cash account would be gone immediately. During an interview on 1/19/2024 at 12:25 p.m., Resident #5 stated the facility does not carry enough money to meet the resident's needs and they never know when the administrator was going to go to the bank. Resident #5 revealed she was aware that part of the problems with accessing her money was due to the facility having recently changed the bank account for the facility-managed trust fund. During an interview on 1/19/2024 at 5:10 p.m., Resident #5 stated she was impacted by not having access to her money by not being able to purchase personal items and snack items for her room. During an interview on 1/19/2024 at 5:13 p.m., Resident #4 stated that due to her inability to go shop for herself, she would typically ask friends visiting her to purchase items on her behalf. Resident #4 stated she was unable to do that during the time the facility was having the banking error because she could not reimburse her friends for the expense. Resident #4 revealed the banking error also impacted her ability to give money to her boyfriend for his birthday. Record review of the BOM's email to the facility corporate Cash/Treasury Team, dated 12/13/2023 revealed I have tried twice now to have my ED go to [bank name] to cash petty cash checks printed from [account name] for our resident petty cash. He has been denied because he is not an authorized signer and was also told that our account was not set up for cashing, only for deposits. I need to know what we need to do to get this fixed ASAP. Our residents are really upset that we are out of petty cash. Record review of the BOM's email from the facility corporate Cash/Treasury Team, dated 12/22/2023 revealed The accounts 'deposit only' has been lifted so you should not have any more problems going forward. Record review of a facility report titled Check Listing Report, dated 1/17/2024 and noted for input date range of 10/19/2023 to 1/17/2024. The following checks were noted under Description/Memo as Resident Petty Cash or the Administrator's name, and noted as Void: 11/29/23, 12/04/23, two for 12/11/23, and three for 12/12/23. Record review of a facility policy titled Accounts Receivable Policy and Procedure Resident Trust Fund last revised 3/1/2023 revealed: The Resident Trust Fund (RTF) policy and procedure establishes guidelines to manage and monitor resident's funds in a uniform process that allows residents the appropriate access to their funds while ensuring protection of resident funds in accordance with state and federal regulatory requirements. The policy further stated, 1. Resident will have convenient access to their funds held in the trust account and 2. The amount held in the Resident Trust Petty cash box at the facility will be sufficient to meet the daily needs of the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676331 If continuation sheet Page 2 of 16 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 676331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as described in the plan of care for 1 of 3 staff (RN A) reviewed for nursing competencies, in that: The facility failed to assess medication competencies for RN A prior to 1/06/2024 when RN A failed to follow physician orders for holding insulin glargine for a blood sugar less than 100. This failure could place residents at risk for not having medications accurately dispensed, not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions. The findings included: Record review of RN A's Nursing Competency Skills Checklist dated 2/11/2023 and signed off by the DON revealed RN A was marked as competent to perform testing blood glucose, patient assessment, administering subcutaneous injections. Medication administration was not part of the competencies assessed. Record review of Resident #1's face sheet dated 1/11/2024 revealed an admission date of 12/27/2023 with diagnoses which included: type 2 diabetes mellitus with hyperglycemia (elevated blood glucose levels), acute kidney failure and hypertension (high blood pressure). The face sheet indicated Resident #1 was discharged on 1/06/2024 to a local hospital. Record review of Resident #1's baseline care plan dated 1/02/2024 revealed the resident had diabetes mellitus with goals to be free from signs and symptoms of hypoglycemia (blood glucose levels that fall below normal) and would not have a re-hospitalization within 30 days with no medication or insulin interventions. Record review of Resident #1's medical record for a comprehensive MDS assessment revealed it had not been completed due to new admission status. Record review of Resident #1's insulin glargine orders dated 12/28/2023 revealed an order for insulin glargine subcutaneous (injection under the skin) solution 100 u/ml, inject 25 units subcutaneously two times a day related to type 2 diabetes mellitus with hyperglycemia, hold if blood sugar less than 100. Record review of Resident #1's January 2024 MAR revealed orders for insulin glargine 100 u/ml, inject 20 units subcutaneously two times a day related to diabetes mellitus, hold if blood sugar less than 100. On -1/06/2024, Resident #1 had a documented BS of 77, insulin was documented as given (instead of held) by RN A. Record review of Resident #1's SBAR documentation dated 1/06/2024 at 10:00 a.m. by the RN Weekend Supervisor revealed Resident #1 had a change of condition of decrease in level of consciousness and was unresponsive. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676331 If continuation sheet Page 3 of 16 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 676331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 1/12/2024 at 10:08 a.m., RN A stated she confused two of Resident #1's orders and gave insulin glargine when Resident #1 had a blood sugar of 77 and did not hold the medication. RN A stated she realized her mistake after Resident #1 was found unresponsive with a blood sugar level that read low. RN A stated low meant the machine could not register a number and the number was lower than the machine could read. RN A stated Resident #1 was taken to the hospital with a low blood glucose reading and unresponsiveness by EMS after the facility called 911. During an interview on 1/12/2024 at 12:15 p.m., the DON stated RN A had a medication error with Resident #1's insulin. The DON stated she had a completed a 1:1 training with RN A over the phone and initiated competencies reviews for licensed staff. She stated on 1/06/2024 RN A had completed an in-service training and insulin administration/glucose monitoring skills check off. During an interview on 1/18/2024 at 3:51 p.m., the DON stated the skills competency check off list did not include a medication competency. The DON stated these skill competencies were given during the hiring process for a new nurse and yearly. The DON stated the ADON's were assigned to complete the medication competencies which were separate from the general competencies. The DON stated she was unable to locate the medication competencies for RN A. The DON stated it was important to assess medication competency skills to ensure the nurses have the correct skills for accuracy of administration and to understand the concepts of medication administration. During an interview on 1/18/2024 at 1/18/2024 at 4:48 p.m., the DON stated after reviewing the facility policy for competencies she knew in her mind the medication competencies were completed for RN A. The DON stated she did not know what was done for competencies for RN A when she was hired because they were unable to locate her hire competency skills and she was not the DON at the time. The DON stated she had trusted both her ADONs to get the competencies done but they just had not been able to find the files. The DON stated the pharmacist also came to the facility and completed random audits and watched random nurses give medication pass. The DON stated she did not know if a pharmacist had observed RN A because the pharmacist did not give her the records. The DON stated the pharmacist records were given to ADON M who was terminated for an undisclosed reason. During an interview on 1/18/2024 at 4:51 p.m., ADON L stated he assisted with nurse competencies upon hire and yearly. He stated medication administration was part of the competency, but he had never completed one. ADON L stated it was ADON M's responsibility to complete the medication administration competencies. ADON L stated the medication competencies were kept in a binder, but they had been unable to locate RN A's medication competencies. During an interview on 1/19/2024 at 9:05 a.m., the HR Director stated ADON M was terminated for poor job performance (date unknown). Attempted interview on 1/19/2024 at 9:18 a.m. with ADON M (who had been terminated). Left a voicemail and a text message. No call backs were received prior to exit. Record review of a facility policy titled Nursing Staff Competency last revised 12/2023 revealed: Definition: Competency (by CMS)- measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. B. Competency in skills and techniques necessary to care for residents' needs include but not limited to: .medication administration .7. Each nursing staff member shall complete an annual competency assessment and additional competency assessments as needed based on the resident population needs in accordance with facility assessment . 10. Records of each staff development program shall be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676331 If continuation sheet Page 4 of 16 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 676331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224 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 0726 maintained. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676331 If continuation sheet Page 5 of 16 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 676331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224 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 - Immediate jeopardy to resident health or safety Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 3 of 16 residents (Resident # 1, #2, and #3) reviewed for significant medication errors, in that; Residents Affected - Few The facility failed to ensure Resident #1 insulin glargine (a long-acting insulin used to treat high blood sugar from diabetes) was held and not administered for a blood sugar level less than 100 per physician orders which resulted in the resident becoming unresponsive and requiring hospitalization in the ICU. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 1/12/2024 at 3:49 p.m. The IJ template was provided to the facility on 1/12/24 at 3:59 p.m. While the IJ was removed on 1/13/24 the facility remained out of compliance at a level of actual harm with a scope identified as isolated until interventions were put in place to ensure staff members were in compliance with following physician orders for insulin administration. The facility failed to ensure Resident #2's medication; insulin glargine was held for a blood sugar level less than 100 per physician order. The facility failed to ensure Resident #3's medication; insulin glargine was held for a blood sugar level less than 100 per physician order. This failure could place residents at risk for a drop in blood sugar levels, a decline in health, unresponsiveness, hospitalization and/or death. The findings included: Record review of Form 3613-a Provider Investigative Report dated 1/06/2024 revealed the DON self-reported an allegation of neglect when Resident #1's family member alleged negligence after Resident #1 was administered insulin glargine 20u (when her) blood sugar was 77. The report indicated insulin glargine 20 u was administered when Resident #1's blood sugar was 77 with orders that stated not to administer if less than 100. The resident was nonresponsive to verbal stimuli/sternal rub, but vital signs were present. The resident was transferred to a local ER. The investigative findings were confirmed and the document was signed by the DON on 1/12/2024. Record review of Resident #1's face sheet dated 1/11/2024 revealed an admission date of 12/27/2023 with diagnoses which included: type 2 diabetes mellitus with hyperglycemia (blood sugar levels that are elevated and above normal), acute kidney failure and hypertension (high blood pressure). The face sheet indicated Resident #1 was discharged on 1/06/2024 to a local hospital. Record review of Resident #1's baseline care plan dated 1/02/2024 revealed the resident had diabetes mellitus with goals to be free from signs and symptoms of hypoglycemia (blood sugar levels that are below normal) and would not have a re-hospitalization within 30 days with no medication or insulin interventions. Record review of Resident #1's medical record for a comprehensive MDS assessment revealed it had not been completed due to new admission status. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676331 If continuation sheet Page 6 of 16 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 676331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224 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 - Immediate jeopardy to resident health or safety Record review of Resident #1's insulin glargine orders dated 12/28/2023 revealed an order for insulin glargine subcutaneous (injection under the skin) solution 100 u/ml, inject 25 units subcutaneously two times a day related to type 2 diabetes mellitus with hyperglycemia, hold if blood sugar less than 100. Record review of Resident #1's January 2024 MAR revealed orders for insulin glargine 100 u/ml, inject 20 units subcutaneously two times a day related to diabetes mellitus, hold if blood sugar less than 100. On Residents Affected - Few -1/06/2024, Resident #1 had a documented BS of 77, insulin was documented as given (instead of held) by RN A. Record review of Resident #1's SBAR documentation dated 1/06/2024 at 10:00 a.m. by the RN Weekend Supervisor revealed Resident #1, who was full code status, had a change of condition of decrease in level of consciousness and was unresponsive. Record review of Resident #1's progress notes dated 1/06/2024 at 12:45 p.m., as documented by RN A revealed: .0700 (7:00 a.m.) I started my morning accuchecks (blood glucose monitoring). Resident (#1) was awake, alert. I asked resident how she was and she stated she was doing fine. I checked her blood sugar, and it was 77. At that time, I administered 20 units of Lantus (insulin glargine) as per MD orders. I mistakenly saw parameters to hold insulin if BS < 70 when the actual order said to hold if BS was < 100 .At 0900 (9:00 a.m. I went to resident's room to check her incision sight (sic) .at this time I noted resident (Resident #1) was nonresponsive to verbal (communication/stimulation) or sternal rub. I immediately checked her vitals .blood sugar machine read lo (sic). At 0910 (9:10 am), I gave resident (Resident #1) glucose oral gel as per MD orders. I stayed with resident and had another nurse call 911. EMS called at 0920 (9:20 a.m.). EMS arrived at 0925 (9:25 a.m.) and transported (Resident #1) to (local hospital) at 0930 (9:30 a.m.). At 0945 (9:45 a.m.), I called the hospital and gave report (to a hospital staff member) and informed her at that time that I had mistakenly given her 20 units of Lantus (insulin glargine). At 1130 (11:30 a.m.), I called to check on Resident #1 and was told she was intubated (required a tube in her airway and mechanical ventilation) but stable and her sugars were up and down .I notified NP C of transfer and medication error, DON and family member . Record review of Resident #1's hospital records dated 1/06/2024 revealed Resident #1 was brought to the emergency department with altered mental status by EMS, after she found unresponsive at the nursing home facility and was given glycogen (medication used to raise blood sugar levels) (at the nursing home). The resident was hypotensive 80/45 (low blood pressure) and hypoglycemic (low blood glucose). EMS checked her blood glucose, and it was also low. She was given D10 (water with 10% sugar via IV) by the paramedic staff and in route her blood sugar improved to 300, however the patient's mental status did not improve. Medical Decision Making: This patient arrived completely unresponsive. Even correcting her glucose with D50 (50% glucose solution via IV), she remained unresponsive. We made the pretty rapid decision to intubate her in order to protect her airway. Normal CT findings (of her brain). Her blood sugar continued to drop despite 2 A (2 doses) of D 50. I think her mental status is due to the hypoglycemia. At this point we will need to admit her to the ICU for further ventilator management. She does not appear to have acute sepsis and her white blood cell count is normal. I am not going to start her on any antibiotics at this point .Her procalcitonin was within normal limits (high levels of procalcitonin indicate sepsis or bacterial infection). Impression/Plan: 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676331 If continuation sheet Page 7 of 16 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 676331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Altered mental status 2. Acute respiratory failure 3. Acute metabolic encephalopathy due to hypoglycemia (alteration in level of consciousness and global brain function as a result of acute metabolic functions) 4. Acute hypokalemia (low potassium levels) (a documented side effect of insulin administration in medical literature). Record review Resident #1's medication administration time audit for 1/06/2024 revealed insulin glargine 100 u/ml was documented as given on 1/06/2024 at 7:02 a.m. by RN A, which was slightly more than 2 hours before Resident #1 was found unresponsive. During an interview on 1/12/2024 at 8:30 a.m., Resident #1's family member stated Resident #1 was in a local hospital ICU. She stated Resident #1 was found unresponsive and the nursing facility told her they found Resident #1 with a blood sugar of 75. The family member stated 75 was low for Resident #1. The family member stated the nurses should have treated Resident #1 with a sugar pill and they should have made sure she ate and retook her blood sugar level to ensure it improved. She stated she did not understand what happened and had questions that were unanswered. The family member stated Resident #1 was treated at the hospital for low blood sugar, e-coli infection, and flu. During an observation/interview on 1/12/2024 at 8:55 a.m., Resident #1 was observed seated in a chair beside a hospital bed in the ICU. She was alert, oriented x 4 (cognitively intact) and talkative. Resident #1 stated she had a history of low blood sugar levels that had previously led to hospitalization. She stated she could feel when her blood sugar was low and would take a glucose tablet. Resident #1 stated she had not been feeling ill prior to this current hospitalization. She stated she had a runny nose a few days before but was already recovering and had never felt bad. Resident #1 stated on 1/06/2024 she does not remember the day at all. She stated she had no memory of the evening before either. She stated she woke up in the hospital with a sore throat and was told by the hospital she was found unresponsive with a low blood sugar and had to have a tube in her throat. Resident #1 stated the nursing home told her family member they made a medication error, but she had not spoken to anyone from the nursing home facility. Resident #1 stated she was hopeful to be discharged from the hospital soon but did not want to return to the nursing home. During an interview on 1/12/2024 at 9:17 a.m., an RN from the local hospital ICU stated Resident #1's diagnosis was hypoglycemia (low blood glucose). She stated Resident #1 had been intubated and, in the ICU, but was now downgraded, was no longer ICU status and was waiting transfer to a regular hospital room. The RN stated Resident #1 came to the hospital with extremely low blood sugar and altered mental status that required intubation. The RN stated during the course of her hospital stay she was also diagnosed with a UTI and the flu. During an interview on 1/12/2024 at 10:08 a.m., RN A stated she was not familiar with Resident #1 because she only worked on the weekends. She stated she had a routine that she completed when she worked. She stated at 6:15 a.m. she checked on Resident #1 at the start of her shift and noted the resident opened her eyes. RN A stated Resident #1 was her first accucheck (blood glucose monitoring) of the day. RN A stated on the MAR she saw a blood glucose monitor order and a Lantus (insulin glargine) order. She stated she thought the blood glucose monitoring order which had a hold if less than 70 order in it meant to hold Lantus (insulin glargine) if less than 70. RN A stated Resident #1's BS was 77 so she gave the insulin and did not hold the medication. RN A stated she confused the two orders. She stated Resident #1 was a little bit awake at 7:00 a.m. when she administered insulin glargine. RN A stated she knew Resident #1 was a little bit awake because she held her finger out and showed her (RN A) what site she wanted her to use before falling back to sleep. RN A stated she went back into the room at 8:30 a.m. and Resident #1 was asleep but woke up. RN A stated a little after 9:00 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676331 If continuation sheet Page 8 of 16 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 676331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224 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 - Immediate jeopardy to resident health or safety Residents Affected - Few a.m. she went into Resident #1's room to check on her surgical incision and found the resident unresponsive. RN A stated she took Resident #1's vitals, which were normal and took a BS reading. RN A stated the BS reading said low. She stated low meant the machine could not register a number and the number was lower than the machine was able to read. RN A stated she gave Resident #1 glucagon gel in her mouth, but because she was unresponsive, she was unable to keep the gel in her mouth. RN A stated she knew she needed to get Resident #1 some sugar, so she gave the resident a glucagon injection in her left arm. RN A stated she asked LVN K to call 911. RN A stated EMS arrived shortly after, and they also checked Resident #1's blood sugar and also got a low reading. She stated EMS took Resident #1 from the facility immediately. RN A stated she determined unresponsiveness because Resident #1 had a different look, she did not open her eyes, did not respond to her name or to touch and when she did a sternal rub there was no response. RN A stated Resident #1's breathing was fine, in fact Resident #1 was snoring a little but otherwise had normal respiration and she had no change in her temperature or other vitals. RN A stated Resident #1 had not complained of feeling ill and other staff had told her it was normal for Resident #1 to sleep in a little. RN A stated at 7:30 a.m. she had put Resident #1's breakfast tray in the room but never checked to see if the resident had eaten. RN A stated she assumed she had eaten. RN A stated she realized she made a medication error when Resident #1's BS read low. RN A stated she went and looked at her actual chart, re-read the order and saw her mistake. RN A stated she then notified the DON and told her she read the order wrong. RN A stated the DON then told her she needed to document what happened in Resident #1's medical record, call the hospital, and tell them what she did. RN A stated she did call the hospital and then Resident #1's NP C. RN A stated NP C stated okay 77 is low, but it is long-acting, not sure why it would drop the sugar so fast: RN A stated she then notified Resident #1's family member. She stated she told the family member she found the resident unresponsive and sent her out (to the hospital). RN A stated the family member came to the facility upset and said she (RN A) was neglectful. RN A stated the Weekend Supervisor had her read the policy on insulin education and read parameters and they had her sign the document. RN A stated she had not yet been called in for her 1:1 education although she had been told it would be done. RN A stated she had training on the 5 Rights of Medication Administration which included the right dose, right patient, right timing and she could not remember the last right. She stated she was trained to read all information on the MAR. She stated the MAR for Resident #1 had more information, but she did not click on it. She stated she should have clicked on it and she should have read the parameters. RN A stated she had never seen parameters in Lantus (insulin glargine) before. She stated since Lantus was a long-acting medicine it was give it and done (meaning she gave the medication without the need for further action). She stated with a short acting insulin she had to make sure the resident ate. RN A stated every facility has their own parameters for low sugar levels. She stated typically normal was 70-110. She stated 70 or lower would be considered critical low. RN A stated she was not concerned about a BS of 77 because she knew Resident #1 was going to eat. RN A stated her mistake was not reading the whole order and confusing two orders. During an observation/interview on 1/12/2024 at 11:50 a.m., LVN N demonstrated on the nurses computerized medical record and medication administration records on the computer how an order for insulin glargine appeared. LVN N clicked on a resident name for medication administration which pulled up the medication insulin glargine. LVN N hovered her curser over the medication name and a short but incomplete order was visible (snip-it of information). Once she clicked on the medication insulin glargine a new screen popped up with the home page which indicated the entire physician order including parameters for holding the medication for blood sugar less than 100. LVN N was then able to navigate from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676331 If continuation sheet Page 9 of 16 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 676331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224 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 - Immediate jeopardy to resident health or safety Residents Affected - Few physician order page to additional tabs that allowed her to document administration. LVN N stated there were several screens to choose from when administering insulin glargine after clicking on the medication name. She stated the first screen that auto populated was the physician order screen with dosage instructions and parameters. She stated she could then click on an additional screen to document actual administration. She stated the snip-it of information might not be complete but once the button was actually pushed the entire order with parameters was visible. LVN N stated she had taken care of Resident #1 in the past (date unknown) and had held insulin glargine for a blood sugar less than 100. LVN N stated to her the order was not confusing. During an interview on 1/12/2024 at 12:15 p.m., the DON stated RN A had a medication error with Resident #1's insulin. The DON stated as a result of the medication error involving Resident #1, the facility had completed an incident report, conducted an audit on insulin to ensure each resident had the right orders and parameters, completed a 1:1 training over the phone with RN A and initiated competencies reviews for licensed staff. The DON stated an in-service training for licensed staff and medication aides had been started on 1/06/2024. The DON said 11 of 42 staff had not completed the in-service training and only 14 of 32 licensed staff had completed skills competencies check offs. During an interview on 1/12/2024 at 2:33 p.m., the DON stated her expectations for medication administration were for staff to follow physician orders, to hold the medication if it was below physician prescribed parameters and to notify the physician of a change of condition. During an interview on 1/12/2024 at 3:49 p.m., the Administrator stated the facility had documentation that the medication error made by RN A was not the facility's fault from the NP (unknown name). The Administrator stated he was unable to locate the document and asked the DON to give the surveyor the document. The DON responded by saying there was no document, only a text conversation between herself and the NP (unknown name). A copy of the text communication was requested but was not received prior to exit. During an interview on 1/12/2024 at 4:10 p.m., the Medical Director stated she was not Resident #1's physician. She stated she had not reviewed Resident #1's medical record and did not have full access to the records. She stated she was told Resident #1's diagnosis at the hospital was metabolic encephalopathy without hypoglycemia by staff (unknown names). The Medical Director stated she thought the findings would be that Resident #1 was septic and her blood sugar was fluctuating from sepsis. The Medical Director, when replying to a question about what staff should do in response to resident illness and fluctuating blood sugars stated staff should call (the physician) to clarify an order if it was below parameters. The Medical Director stated, obviously there was a medication error but the nurse went to monitor the resident as she should have and sent the resident out (to the hospital) as she should have. The Medical Director stated the insulin was long acting and should not have bottomed her (Resident #1) out (caused a rapid decrease in blood sugar) like a short acting . The Medical Director stated she was told there was only a 1-hour window from the time the insulin was administered and her hypoglycemic event. The Medical Director stated she felt like the nurse did what she was supposed to do by getting the resident to the hospital. During an interview on 1/13/2024 at 3:10 p.m., the Weekend Supervisor stated on 1/06/2024, LVN L came and got her for an emergency and stated RN A needed her. The Weekend Supervisor stated she went to Resident #1's room and found the resident unresponsive. She stated they had already tried a sternal rub to wake her up and had tried to raise her blood sugar. The Weekend Supervisor stated they retook Resident #1's BS and it read low, so they called 911. The Weekend Supervisor stated EMS arrived and also took a BS reading but she was not able to see what it read. She stated low meant the blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676331 If continuation sheet Page 10 of 16 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 676331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224 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 - Immediate jeopardy to resident health or safety Residents Affected - Few sugar was too low for the machine to pick up a number. The Weekend Supervisor stated right after Resident #1 left for the hospital, RN A came up to her and said she thought she made a mistake by giving insulin when she was not supposed to. The Weekend Supervisor stated RN A stated she read the order wrong. The Weekend Supervisor stated they completed a risk management/medication error/incident report and RN A called the hospital and informed them she gave the insulin. The Weekend Supervisor stated RN A also notified the RP for Resident #1 and was given a 1:1 in-service by the DON. The Weekend Supervisor stated the DON told her she was to complete blood sugars and insulin for RN A for the rest of the weekend and was told RN A could not give any insulins. The Weekend Supervisor stated RN A was compliant and she (the Weekend Supervisor) completed insulin administration on RN A's residents over the weekend. She stated she did review Resident #1's medical record after the incident and agreed there was a medication error. The Weekend Supervisor stated her job duties did not included auditing or monitoring medical records for accuracy of medication administration. She stated she did not follow up on medication orders because it was not part of her job duties. During an interview on 1/13/2024 at 5:12 p.m., the ADON stated his job duties included medication and medical record audits. He stated he reviews new admissions and ensures medication parameters are in place. He stated he was supposed to review insulin administration by auditing records daily by order listing and review medications. He stated he looked to ensure all residents got all medications. He stated he had not noticed any medication errors prior to the incident with Resident #1 on 1/06/2024. He stated he was not in the facility on that day and had no knowledge of the event. He stated education including medication rights and the right to refuse medications was important to prevent medication errors. He stated he also gave in-service training to staff as part of his job duties but had not given any in-services on medication until 1/06/2024. He stated he reports his finding daily to the DON. During an interview on 1/13/2024 at 6:07 p.m., the DON stated during morning meetings she and the ADON were responsible for running e-mar (electronic medication administration record) reports and reviewing for medication accuracy. The DON stated the ADON should have been reviewing that insulin parameters were followed. The DON stated RN A should have followed Resident #1's physician orders for insulin parameters. The DON stated if the medication was not held when the BS was less than parameters, the RN should notify the physician and the documentation should have clear indicators on why the medication was not held based on the physician order. The DON stated the nurse who administered the medication was responsible for the accuracy of medication administration. The DON stated the ADON and DON were responsible for supervising the nurses. The DON stated when she reviewed reports for medication administration, she was checking for daily medication administration and ensuring new orders were inputted correctly into the computer. The DON stated she thought the medication error occurred because of education. She stated RN A was and old school nurse who was taught that insulin was not held unless blood sugar was less than 70. The DON stated she did not believe RN A intentionally gave the medication (incorrectly). The DON stated she thinks RN A became comfortable and the facility needs to make sure they (nurses) review orders for changes. The DON stated accurate insulin administration was important because the resident could have changes in blood glucose or have an underlying diagnosis which could affect how the body handles insulin. She stated they could result in either hypoglycemia (low blood glucose) or hyperglycemia (high blood glucose) and could lead to unresponsiveness, becoming comatose, and result in a change of condition and/or hospitalization. During an interview on 1/13/2024 at 6:43 p.m., the Administrator stated the DON was responsible for ensuring accuracy of medication administration and reports to him. He stated if the DON found a deficiency, she should report to him so they could collaborate on the best course of action. The Administrator stated he was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676331 If continuation sheet Page 11 of 16 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 676331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224 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 - Immediate jeopardy to resident health or safety Residents Affected - Few notified of the medication error late in the morning (1/06/2024) by the DON. He stated he collaborated with the Corporate RN to get a second opinion to ensure they followed guidelines for reporting because Resident #1 went to the hospital. The Administrator stated he ensured in-service training was started. He stated he monitored staff by holding daily meetings with managers, reviewing 24-hour reports, making room rounds and also attending in-depth clinical meetings. He stated they then take action if needed. He stated they address each hallway as reported by the Charge Nurses and PCC documentation, The Administrator stated he thought the medication error occurred because RN A was rushed. He stated he had not solidified a root cause analysis of the event. He stated he thought she was probably rushing and did not take her time. The Administrator stated there were two orders, both with holds for Resident #1 and he thought RN A looked at one order and not the other. The Administrator stated he did not have a policy on management of diabetes. He stated the facility followed physician orders. Attempted interview on 1/12/2024 at 2:15 p.m. with NP C. Left a message with live physician answering service requesting a call back from NP C and the on-call NP, NP J. On 1/12/2024 at 3:49 p.m., the Administrator was informed of surveyor attempt to reach NP C and NP J. The Administrator stated he would have the NP call this surveyor. No call backs were received. Record review of a Counseling/Disciplinary Notice for RN A dated 1/06/2024 revealed RN A was given counseling. Staff member (RN A) failed to correctly read and administer the insulin dosage according to the physician order which resulted in change of condition. The facility corrective action was listed as, Failure to follow the policies and procedures could result in further disciplinary action. The document was signed by the DON on 1/06/2024. RN A wrote I take full responsibility for my mistake and have learned a very valuable lesson for my mistake. RN A also signed the document on 1/06/2024. Record review of RN A Nursing Competency Skills Checklist dated 2/11/2023 and signed off by the DON revealed RN A was marked as competent to perform testing blood glucose, patient assessment, administering subcutaneous injections. Medication administration was not part of the competencies assessed. Record review of a job description for Registered Nurse signed by RN A on 11/18/2022 listed her Essential Job Functions/Drug Administration Functions as prepare and administer medications as ordered by the physician. Record review of a website describing diabetes and the effects of long-acting insulin (such as insulin glargine) as it appeared on 1/19/2024 https://www.healthline.com/health/type-2diabetes/basal-insulin/how-long-for-insulin-to-work#insulin-types revealed: Because every person is different, the way your body responds to insulin may not be the same as someone else's. The type of insulin you take, and many factors can influence how rapidly insulin works in your body and how long it stays. In general, long-acting insulin (insulin glargine) take effect within 2 hours, has no peak level and lasts up to 24 hours. One possible side effect of long-acting insulin (insulin glargine) is low blood sugar (hypoglycemia). Researchers have pointed out that the behavior of insulin after administration may vary. Several factors can influence the absorption of insulin including site of administration, concentration of insulin, frequency of injection site use, and physical factors such as exercise .massaging the injection site .heat exposure. Record review of a drug reference website as it appeared on 1/19/2024 https://www.drugs.com/sfx/insulin-glargine-side-effects.html revealed under the section titled For Healthcare Professionals: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676331 If continuation sheet Page 12 of 16 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 676331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Serious Side Effects: metabolic: very common (affecting 10% or more) hypoglycemia. Insulin glargine should not be used if you are having an episode of hypoglycemia or low blood sugar. Record review of insulin glargine side effects as it appeared on 1/19/2024 https://www.lantus.com/how-to-use/insulin-glargine-u100/?utm_source=bing&utm_medium=cpc&utm_campaign=Lantus+-+ revealed: The most common side effecting of insulin, including Lantus (brand name for insulin glargine) is low blood sugar (hypoglycemia), which may be serious and life threatening. Other side effects may include .low potassium levels (hypokalemia). Contraindications: Lantus (insulin glargine) is contraindicated during episodes of hypoglycemia .Monitor blood glucose in all patients treated with insulin. Modify insulin regimen only under medical supervision. As with all insulins, Lantus (insulin glargine) use can lead to life-threatening hypokalemia. Record review of a facility policy titled Care and Treatment-Insulin Administration undated revealed: Procedures: 5. Verify medication/dose to order in computer. Record review of a facility policy titled Medication Administration (undated) revealed: It is the policy of this facility that medications shall be administered as prescribed by the attending physician. Procedures: 2. Medications must be administered in accordance with the written orders of the attending physician. The Administrator was notified of an IJ on 1/12/2024 at 3:49 p.m. and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 1/12/2024 at 8:02 p.m. and included the following: Immediate Action 1. Medical Director notified of Immediate Jeopardy on 1/12/2024 at 4:33 p.m. 2. Resident #1 no longer in the facility. Resident #1 was discharged to the hospital on 1/06/2024 at 9:30 p.m. 3. Pharmacist was notified on 1/12/2024 at 5:35 p.m. of medication error and facility receiving an IJ for pharmaceutical services. 4. 100% Audit was completed on 1/06/2024 by DON for all residents who require insulin administration and have parameters to ensure all parameters are being followed. 5. In-service began on 1/06/2024 for licensed nurses and CMA's. The importance of reporting medication errors, possible adverse effects to medication errors, review of medication rights and overview of insulin different types and outcomes by 1/12/2024. Abuse and Neglect in-service was started on 1/12/2024 and will be completed by 8:00 am on 1/13/2024. Any employee not in facility will receive in-service via phone, any employee who had not received in-service will not be allowed to work until in-service had been received. 6. A 1:1 in-service was conducted with nurse who administered insulin on 1/06/2024. 7. Insulin administration skill check off for all nurses was started on 1/07/2024 and will be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676331 If continuation sheet Page 13 of 16 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 676331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224 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 - Immediate jeopardy to resident health or safety Residents Affected - Few completed at 100% by 8:00 a.m. on 1/13/2024. Any employee who had not been checked off will not be allowed to work. A log will be created for employees who have not received competencies or in-service and will be highlighted. Once received a copy of this log will also be given to the staffing coordinator to ensure no one is placed on schedule prior to training starting 1/12/2024. 8. An off cycle QAPI (meeting) was conducted on 1/12/2024 with the Medical Director, IDT team, clinical resource to review the IJ POR. Identification of others: All residents who have insulin orders with parameters have the potential to be affected by this alleged deficient practice. Systemic Change to prevent re-occurrence: 1. The clinical resource or DON/ADON will verify blood glucose level documentation daily to include the weekend via remote for weekend monitoring to ensure glucose parameters are being followed. This will start on 1/12/2024 at 8:00 pm. Daily review of all insulin parameters will be reviewed in the clinical meeting by the DON/ADON/Administrator. 2. New Admissions with insulin orders with parameters will be reviewed by nurse managers to ensure orders are being followed 1/12/2024. Monitoring to ensure ongoing compliance: 1. DON will share summary of Plan of Removal activity with managers an[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676331 If continuation sheet Page 14 of 16 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 676331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 residents (Resident # 7) reviewed for accuracy of medical records in that: The facility failed to ensure RN A's signature matched her job title and nursing license. This deficient practice could affect residents whose records are maintained by the facility and could place improper identification of staff and role in the resident medical records. The findings included: Record review of the Texas Board of Nursing website at https://www.bon.texas.gov revealed: RN A's nursing license for registered nurse (RN was current with an expiration date of [DATE]. RN A's nursing license for LVN/LPN was delinquent and had expired on [DATE]. Record review of Resident #1's face sheet dated [DATE] revealed an admission date of [DATE] with diagnoses which included: type 2 diabetes mellitus with hyperglycemia (elevated blood glucose levels) , acute kidney failure and hypertension (high blood pressure). The face sheet indicated Resident #1 was discharged on [DATE] to a local hospital. Record review of Resident #1's electronic medical record progress notes including a resident change of condition revealed multiple documentation entries on [DATE] that were electronically signed by RN A as LPN-Licensed Practical Nurse (LPN is a title given to nurses in 48 of 50 states with the exception of California and Texas which use the title LVN) instead of RN (registered nurse) to match her licensing title. During an interview on [DATE] at 3:07 p.m., the DON stated she was not aware RN A's signature on Resident #1's medical record was signed as an LPN instead of RN. The DON stated as long as she had known RN A, she had been a RN. The DON stated she was not certain but believed the HR Director was responsible for changing the way the computer electronically assigned titles for documentation. The DON stated it was important that the medical record reflected the nurse's accurate job title. During an interview on [DATE] at 3:10 p.m., RN A stated she originally began working in the nursing facility as an LVN. She stated when she completed school and became a RN, she notified Human Resources and gave them a copy of her new RN license. RN A stated she was unaware that her documents were signed as LPN. During an interview on [DATE] at 7:22 p.m., the HR Director stated the HR department was responsible for changing status or titles in their records called Workday but did not know who was responsible for ensuring those records were correct in PCC. The HR Director stated she did not have access to PCC, only a program called Workday which synchronized data into PCC. The HR Director stated RN A's information in Workday was listed correctly as RN. She stated she does not know why the information did not synch or how to correct the issue. The HR Director stated no one had informed her (prior to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676331 If continuation sheet Page 15 of 16 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 676331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hunters Pond Rehabilitation and Healthcare 9903 Hunters Pond San Antonio, TX 78224 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 0842 surveyor intervention) that RN A's title in the medical records was inaccurate. Level of Harm - Minimal harm or potential for actual harm Record review of a facility policy titled Charting and Documentation (undated) revealed: The resident's clinical record is a concise account of treatment care, response to care, signs, and symptoms and progress of the resident's condition. The policy did not address how a staff were to sign the medical records. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676331 If continuation sheet Page 16 of 16