Health inspection·February 9, 2024

F 0742 Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's PHQ-9 assessment [an assessment for screening, diagnosing, monitoring, and measuring the severity of depression], dated [DATE] and written by MDS Coordinator D, revealed Resident #1 had a severity score of 8, signifying mild depression. Further record review of this document revealed Resident #1 denied suicidal ideation, but Resident #1 was noted with: - Little interest or pleasure in doing things, with a symptom frequency of 7-11 days. Residents Affected - Few - Trouble falling asleep or staying asleep, or sleeping too much, with a symptom frequency of 12-14 days. - Feeling tired or having little energy, with a symptom frequency of 12-14 days. Further record review of this document revealed a score of 15-19 was Moderately Severe Depression. Record review of Resident #1's Social Services assessment, dated [DATE] and written by Community Liaison Staff C, revealed Resident #1 did not have any psychosocial needs. Record review of Resident #1's inventory sheet, dated [DATE], revealed no firearms in Resident #1's inventory. Record review of Resident #1's nursing progress notes, dated from [DATE] to [DATE], revealed no progress note regarding any notification or coordination of psychiatric services. Record review of Resident #1's Physician Progress Note, dated [DATE] at 9:41 a.m. and written by NP H, revealed no documentation of any depression or referral to psychiatric services. There was no documentation of any physician or nurse practitioner notification for psychiatric-related reason prior to Resident #1's suicide on [DATE]. Record review of Resident #1's PHQ-9 assessment, dated [DATE] at 12:36 p.m. and written by Community Liaison Staff C, revealed Resident #1 did not have a PHQ-9 score. Resident #1 denied suicidal ideation but Resident #1 was noted with: - Feeling down, depressed, or hopeless, with a symptom frequency of 12-14 days (nearly every day [over the last 2 weeks].) This was a new finding that was not noted on Resident #1's previous PHQ-9 assessment on [DATE]. - Trouble falling asleep or staying asleep, with a symptom frequency of 7-11 days (half or more of the days [over the last 2 weeks].) - Feeling tired or having little energy, with a symptom frequency of 12-14 days (nearly every day [over the last 2 weeks]). - Poor appetite or overeating, with symptom frequency of 12-14 days (nearly every day [over the last 2 weeks].) This was a new finding that was not noted on Resident #1's previous PHQ-9 assessment on [DATE]. - Feeling bad about yourself, with a symptom frequency of 7-11 days (half or more of the days [over the last 2 weeks]). This was a new finding that was not noted on Resident #1's previous PHQ-9 assessment on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676331 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 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 0742 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few - Trouble concentrating on things, with a symptom frequency of 12-14 days (nearly every day [over the last 2 weeks].) This was a new finding that was not noted on Resident #1's previous PHQ-9 assessment on [DATE]. - Moving or speaking so slowly, with a symptom frequency of 7-11 days (half or more of the days) [over the last 2 weeks]. This was a new finding that was not noted on Resident #1's previous PHQ-9 assessment on [DATE]. Record review of Resident #1's physician orders, obtained on [DATE], revealed no orders for psychiatric services or medications for psychiatric illnesses. Record review of Resident #1's care plan, obtained [DATE], revealed no care plan specifically for psychiatric illnesses such as depression. Record review of an email from this surveyor to the Administrator, dated [DATE], revealed this surveyor requested for the following: Anything and everything related to your [self-reported incident] (even if it's in progress. In-services, photographs, video footage.) During the entrance conference and joint interview on [DATE] at 12:47 p.m., the Administrator stated the facility began their in-services last night, [DATE], and in-serviced staff members on the evening shift (2:00 p.m. - 10:00 p.m.) working on [DATE] and the overnight shift (10:00 p.m. - 6:00 a.m.) working from the evening of [DATE] into the morning of [DATE]. The Administrator stated there was a team of social workers currently in the facility conducting 1:1 interviews with residents. The Director of Nursing stated the facility should be 90% finished with their educational in-services. During this entrance conference, this surveyor requested for everything related to Resident #1's suicide, including educational in-services. During an interview on [DATE] at 2:29 p.m., the DON provided three educational in-services: one educational in-service on social media and resident rights, a second educational in-service on Active Shooter Procedure, and a third educational in-service on Abuse and Neglect. There were no other educational in-services provided to this surveyor prior to the identification of the Immediate Jeopardy on [DATE]. During an interview on [DATE] at 2:35 p.m., LVN B stated he worked with Resident #1 on the evening of [DATE]. LVN B stated Resident #1 went to chemotherapy every day and Resident #1 went to chemotherapy earlier in the morning shift of [DATE] and returned on his shift, which was the afternoon shift. LVN B denied Resident #1 verbalized suicidal ideation. LVN B stated Resident #1 seemed happy that day. LVN B stated, from what I understand, I think [Resident #1] was going into hospice on Wednesday [[DATE]]. I think that was the story but as far as that, I had no knowledge of him being depressed or any of those ideation. LVN B stated, I was doing my last rounds. I was in the room diagonal of the hall. I was flushing the tube-feeding pump [in the other room] and around 8:30 [p.m.] I heard a pop . I walked outside [the room], I looked at [the residents in room [ROOM NUMBER]], I looked if everyone was ok. They were all asleep. I went to [room] 115, which was across [Resident #1's] room, and everyone was asleep. And as soon as I got to [Resident #1's door] I smelled the gunpowder . So I opened up the door and I noticed he had-the gun [a handgun] was in his right hand and it was pointed at him with his thumb on the trigger and a bullet wound in his forehead . And so I stepped out of the room. And I said [to his co-workers] ' you guys aren't allowed to go into that room . I called 911. I got EMS on the scene, 911 on the scene. And I was on the phone with them and I got to explain what happened . I had to stay out there at the front door . They got there within a couple minutes. I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676331 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 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 0742 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few want to say 5 to 6 cop cars got there . They had me sit back in the cop car because they said, 'you can't be around your co-workers. You need to be isolated from there.' They had a CSI guy and I did my statement with them. I explained what happened . [Resident #1] had a visitor who I had never seen before. I've never seen anyone enter that room besides us giving him treatment, changing him, things like that. LVN B stated he never saw the gun Resident #1 used before. During an interview on [DATE] at 8:52 a.m., Representative F (social worker from a local hospital) stated Resident #1 did not have any psychiatric diagnoses or psychiatric services during his hospital stay from [DATE] to [DATE] prior to his admission to the facility on [DATE]. During an interview and record review on [DATE] at 10:15 a.m., video footage of Resident #1's hallway was reviewed with the Administrator. The camera angle was from the very end of the hallway and pointed towards the nurses' station at the center of the building, which was near the facility's main entrance. The entire hallway was in view, but the inside of the residents' room were not in view except for the resident's doors. The video did not include sound. The Administrator stated the video footage's clock was ahead by one hour, therefore the timestamps are one hour ahead of the actual time of events. Record review of video footage of Resident #1's hallway revealed at the video timestamp [DATE] at 15:03 [2:03 p.m.] a visitor visited Resident #1 in his room. At the video timestamp [DATE] at 16:47 [3:47 p.m.], Resident #1's visitor pushed Resident #1 out of Resident #1's room on Resident #1's wheelchair. Resident #1 wore a bulky, dark-colored jacket. Resident #1 and his visitor moved towards the nurses' station at the center of the building and then moved off-camera. At the video timestamp [DATE] at 19:44 [6:44 p.m.], Resident #1 and his visitor returned to Resident #1's room. Resident #1 and his visitor did not have any visible packages or bags with them upon their return. Resident #1 did not reappear on the video footage after this. At the video timestamp [DATE] at 20:34 [7:34 p.m.], Resident #1's visitor left Resident #1's room, moved towards the nurses' station at the center of the building, and then moved off-camera. Resident #1's visitor did not reappear on the video footage after this. At the video timestamp [DATE] at 21:24 [8:24 p.m.], LVN B entered another resident's room across the hall from Resident #1's room. At the video timestamp [DATE] at 21:26 [8:26 p.m.], LVN B exited the other resident's room and looked around the hallway and checked the rooms of other residents. The Administrator stated LVN B must have heard the gunshot at this point. At the video timestamp [DATE] at 21:27 [8:27 p.m.], LVN B entered Resident #1's room. At the video timestamp [DATE] at 21:28 [8:28 p.m.], LVN B exited Resident #1's room with his personal phone in one hand and his other palm on his forehead. LVN B paced in front of Resident #1's room and eventually moved towards the nurses' station, speaking to his co-workers as he walked. At the video timestamp [DATE] at 21:33 [8:33 p.m.], LVN B walked to his nurse cart parked in the middle of the hallway. LVN B's phone was in his hand and he was speaking into his phone. Then LVN B left his nurses cart, moved towards the nurses' station at the center of the facility, and then moved off-camera. LVN B did not reappear on the camera footage after this. At the video timestamp [DATE] at 21:40 [8:40 p.m.], local police officers and EMTs arrive at Resident #1's room. At the video timestamp [DATE] at 21:44 [8:44 p.m.], the EMTs leave. Resident #1's remains were not removed by the EMTs. During an interview on [DATE] at 11:33 a.m., Representative G (psychologist from a local hospital) stated Resident #1 did not have a history of suicidal ideation or mental health history. Representative G stated Resident #1 had never been treated for any sort of mental health condition and never called the suicide crisis hotline. During an interview and record review on [DATE] at 11:47 a.m., MDS Coordinator D stated upon admission she typically performed a PHQ-9 assessment on the resident. MDS Coordinator D stated, PHQ-9 entails depression. I want to say anything over 10 is major depression, 9 and under is moderate, mild. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676331 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 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 0742 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few After that's done and if it's major [depression] we get psych consult involved. I can't remember what [Resident #1's PHQ-9 score] was off-hand. We do that [assessment] and if [the resident] was still here for more than 20 or 30 days, we do another one. MDS Coordinator D stated Resident #1 never verbalized suicidal ideation. MDS Coordinator D stated she did Resident #1's PHQ-9 assessment on [DATE] and she did not remember what Resident #1's PHQ-9 score was (which was an 8), but stated Resident #1 was not somber or sad. MDS Coordinator D stated if the PHQ-9 score was an 8, she did not notify the physician but she would notify the nurse. MDS Coordinator D stated they discussed the PHQ-9 score in the morning meeting. Resident #1's PHQ-9 score, dated [DATE], was reviewed with MDS Coordinator D. MDS Coordinator D stated Resident #1's score on the PHQ-9, dated [DATE], would have been 16. MDS Coordinator D stated Community Liaison Staff C (who performed the PHQ-9 assessment on [DATE]) would have reported her findings to the SW. The MDS Coordinator stated if the resident had major depression, psychiatric services would have been notified. The MDS Coordinator stated she was not aware if there were any referral to psychiatric services due to Resident #1's latest PHQ-9 score on [DATE]. During an interview on [DATE] at 12:09 p.m., Community Liaison Staff C stated she completed Resident #1's PHQ-9 assessment on [DATE]. Community Liaison Staff C stated she conducted the PHQ-9 assessment on Resident #1 because Resident #1 was going to be discharged . Community Liaison Staff C stated, I asked if he lost motivation with activities, [was he] feeling tired, low energy, [was he] sleeping at night, [was he] feeling depression, and his situation. He did answer yes to a lot of those questions, which signified he was depressed. But he did answer no to self-harm . I asked [Resident #1] if he wanted to talk to somebody and he said maybe. Community Liaison Staff C denied Resident #1 verbalized suicidal ideation. Community Liaison Staff C stated she reported Resident #1's assessment findings to the SW after lunch on [DATE]. Community Liaison Staff C could not recall the specific time. Community Liaison Staff C stated the SW stated a referral for psychiatric services would be sent. Community Liaison Staff C stated she was unsure if the SW sent a referral to psychiatric services for Resident #1. During an interview on [DATE] at 12:30 p.m., the SW stated Community Liaison Staff C helped her conduct the PHQ-9 scale and she oversaw Community Liaison Staff C's work. The SW stated Community Liaison Staff C usually spoke to her [the SW] about any findings on the PHQ-9. The SW stated, [the PHQ-9] is basically assessing for depression. If there's symptoms in mood, behavior, any behavioral changes, if they're [the resident is] having little interest in eating or overeating, sleep hygiene, if they don't have focus or memory, if they're having problems concentrating. It has questions about if they feel bad about themselves or if they want to hurt themselves, if they feel better off dead . It ranges between 1-9 is low. Anything over 9 is a higher number. The SW stated if the resident's PHQ-9 score was over 9, she would refer the resident to the facility's psychiatric service. The psychiatric service would then come and evaluate the patient and see if the resident required counseling or medication. The SW stated she visited Resident #1 frequently and denied Resident #1 verbalized any feelings of depression or suicidal ideation. The SW stated Community Liaison Staff C reported Resident #1's PHQ-9 score, dated [DATE], to her on the afternoon of [DATE]. The SW stated, Community Liaison Staff C] stated it was high and I said I was going to call [Resident #1's] case manager (from a local agency) the next morning. When asked if she notified anyone about Resident #1's PHQ-9 score, the SW stated, No. I'm not sure if I attempted to call [Resident #1's case manager] . I just hadn't gotten to it that day. I usually talk to [Resident #1's case manager] in the morning and we were going to discuss his discharge in the morning. In a follow-up interview on [DATE] at 1:25 p.m., when asked how soon she would notify psychiatric services if a resident required psychiatric evaluation the SW stated she did not know and referred this surveyor to the DON. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676331 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 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 0742 Level of Harm - Immediate jeopardy to resident health or safety During an interview on [DATE] at 1:26 p.m., when asked how soon the facility would notify psychiatric services if a resident required psychiatric evaluation, the DON stated the facility would notify psychiatric services immediately if it was an emergent issue such as self harm. The DON stated during the week the facility could contact the on-call psychiatric services within twenty-four hours. The DON stated if the psychiatric services could not see the resident within the same day, the facility would put the resident on a 1:1 observation. Residents Affected - Few During an interview on [DATE] at 1:28 p.m., Resident #1's visitor stated at around 11:00 a.m. on [DATE] Resident #1 texted him [the visitor] that he wanted a tool from his truck. Resident #1's visitor stated, I had an idea . he was probably talking about a gun. He's a gun guy . I got up there right away [at around 3:00 p.m.] and [Resident #1] said he wanted to kill himself. [Resident #1] said, 'I'm done fighting.' [Resident #1] said he could smell his braining burning and he went on to tell me all these things that brought him to his low . So we decided he was going to move to my house on Wednesday [[DATE]] and go to the hospice and not to treatment and just die. Me and him, we talked about the suicide part. I said, 'what are you going to do? Blow your brains out in the [facility]?' We talked about it. We talked about the trauma he's causing innocent people. I said, 'you need to get out of this place. We need fresh air.' And so we left, we signed out. We loaded him in [Resident #1's] truck and the first place we went to was [the visitor's relative's] house . And then we went out to the lake and we sat there and talked about various things . We brought him back to the nursing home and got him in bed . I want to say I left at around 7:49 p.m. Resident #1's visitor stated after Resident #1 was discharged from the hospital to the facility, he drove Resident #1's truck from the hospital and left it at the facility. Resident #1's visitor stated he did not know if Resident #1 had a firearm in his truck and did not check if Resident #1 had a firearm in his vehicle. Resident #1's visitor stated he did not know how Resident #1 obtained the firearm. Resident #1's visitor stated he did not notify the facility or Resident #1's case manager about Resident #1's suicidal ideation. Resident #1's visitor stated, He didn't indicate that he was going to do anything specific to himself. I never heard anything out of his mouth to indicate that he had any depression or mental health issues. And that was the first time I ever heard him talk about wanting to die . If I had any indication he was going to harm himself, I wouldn't tell anybody, but I wouldn't leave him alone. I would have stayed with him. During an interview on [DATE] at 2:42 p.m., NP H stated Resident #1 was admitted to the facility with cancer and was getting outpatient radiation. NP H stated she denied Resident #1 verbalized depression and suicidal ideation to her. NP H stated the PHQ-9 was an assessment for depression. When asked what would be a significant finding on the PHQ-9, NP H stated, I would have to look up the scale and go off what it is. I know it breaks it down for you. NP H stated she did not recall Resident #1's PHQ-9 score. When asked if she would be concerned if Resident #1's PHQ-9 score was an 8, NP H stated, I'd have to pull up the score. NP H stated she did not know Resident #1 had a PHQ-9 score the day he passed away and she would have liked to have been notified of an increase in his PHQ-9 score. NP H stated, normally when something is critical they notify us right away. It would have been within thirty minutes to one hour . I would have asked [Resident #1] more intense questions and then depending on what he would have reported I would have gotten him the needed orders or assistance at that time. During an interview on [DATE] at 4:04 p.m., the DON stated the PHQ-9 assessment was usually completed by the SW, the MDS Coordinators and Community Liaison Staff C. The DON stated the PHQ-9 was an assessment to check a resident's mindset and mental well-being. When asked what would be a significant finding on the PHQ-9, the DON stated, depending on question and how [the resident] answered the question. There's a question on there that says if you're having any suicidal thoughts or if you're (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676331 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 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 0742 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few trying to kill yourself. If you say yes in any form or fashion it would raise a red flag. When asked what was her expectation if a resident had a high PHQ-9 score, the DON stated, I would like to be made aware. I would like to see if they notified psych services, or if they notified the nurse. Or if they did do any interventions . As soon as you identify it, you would call [psychiatric services.] If you go straight to the doctor, the doctor would ask or the NP would ask if it's immediate harm. Or maybe if it's not immediate, they'll say go ahead and refer to psychiatric services. The DON stated she could not recall if Resident #1 had significant findings on his PHQ-9 scores, but she stated she knew Resident #1 did not verbalize suicidal ideation. The DON stated she was not aware of any interventions put in place following Resident #1's first PHQ-9 score on [DATE] or his second PHQ-9 score on [DATE]. The DON stated she did not know if Resident #1's physician was notified of Resident #1's increased PHQ-9 score on [DATE]. When asked what she would have done if she had known Resident #1's PHQ-9 had increased during his PHQ-9 assessment on [DATE], the DON stated, Based on the questions, I would have asked [the SW] to go and talk to him and see his thoughts . and maybe follow-up from there and see what the outcome was. We would have definitely followed up with the intervention that was needed. When asked if the facility had a quality assurance process to ensure physicians were notified if a resident had an increased or significant PHQ-9 score, the DON stated, I would say reviewing the education with the administrative team. The DON stated the facility would also review changes in the clinical morning meeting. When asked what sort of negative effects could occur to the residents if physicians were not notified of an increase in their PHQ-9 score, the DON stated, increased behaviors. Maybe aggressive behaviors as far as lashing at the staff or verbally aggressive to the staff or verbally aggressive to the residents. Something in the nature of a decline. During an interview on [DATE] at 4:33 p.m., the Administrator stated Resident #1's PHQ-9 score doubled and stated the facility's policy stated psychiatric services will be contacted on elevated PHQ-9 scores within 24 hours. The Administrator stated, the plan with [Resident #1] was to get services for him as quickly as possible or get someone down here and we didn't have any time. [Resident #1] went out at 4:00 [p.m.] When would we have someone come in? Now if we knew he was in danger and he said, 'I'm going to kill myself,' then yes. We would get a 1:1, keep him in his room, get rid of sharp objects. We had nothing to say that this [Resident #1's suicide] was going to happen . The Administrator stated the policy stated psychiatric services will see the resident within 24 to 72 hours. During an interview on [DATE] at 6:53 p.m., Physician E stated she was the Medical Director of the facility. Physician E stated usually the social worker will conduct the PHQ-9 assessment upon admission and frequently. We do have psych services if they [the resident] triggered for BIMS or something. They can refer to behavioral health services. When asked what interventions would she expect if a resident had mild depression, Physician E stated, I would try to engage if there's an immediate risk. I feel if there's an issue that needs no immediate intervention I would prescribe a mild anti-depressant and call psychiatric services. Physician E stated she would expect some interventions if the resident had a PHQ-9 score indicating mild depression and stated the interventions would depend on the situation because sometimes the resident would refuse treatments. Physician E stated on [DATE] at around 9:30 p.m. or 10:00 p.m. (after Resident #1's suicide) she was notified by the Administrator that Resident #1 had moderate depression but denied self-harm. Physician E stated the Administrator also informed her of Resident #1's increased PHQ-9 score. Physician E stated she did not know if Resident #1 had any interventions for his depression. During an interview on [DATE] at 9:23 a.m., the Administrator stated the facility educated their staff members on the PHQ-9 and interventions of the PHQ-9 on [DATE]. The Administrator stated this education was done because of Resident #1's high PHQ-9 score (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676331 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 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 0742 Level of Harm - Immediate jeopardy to resident health or safety dated on [DATE]. The Administrator stated he didn't know this surveyor was asking for any education on the PHQ-9 and he thought when the surveyor asked for all educational in-services that this surveyor was asking for large educational in-service. In a follow-up interview on [DATE] at 1:07 p.m., LVN B stated he did not know what a PHQ-9 assessment was and he was not made aware Resident #1's PHQ-9 score was high the day he committed suicide. Residents Affected - Few In a follow-up interview on [DATE] at 11:21 a.m., when asked what should have been done when Resident #1 had a PHQ-9 score of 8 on [DATE], considering his new cancer diagnosis and his lack of mental illness history, the SW stated, I could have asked him if he wanted me to refer him to counseling services. I could have coordinated with [the local hospital] if he wanted. I would have just let him know what his score was and ask him if he needed any services or needed to talk to anybody. Record review of the facility's staff roster revealed the facility had 141 staff members. Record review of the facility's educational in-services titled, Social Media - Resident Rights, do not give out information, re-direct to ED/DON, dated [DATE] and provided to this surveyor on [DATE], revealed a total of 131 staff signatures or documentation of verbal education on the educational in-service. However, upon further inspection there were 5 staff members who were noted twice. This brought the actual total number to 126 of 141 (89%) staff members who were educated on how to handle social media and resident rights. Record review of the facility's educational in-service titled, Active Shooter Procedure, dated [DATE] and provided to this surveyor on [DATE], revealed a total of 143 staff signatures or documentation of verbal education on the educational in-service. However, upon further inspection there were 8 staff members who were noted at least twice. This brought the actual total number to 134 of 141 (95%) staff members who were educated on the facility's Active Shooter Procedure. Record review of the facility's educational in-service titled, Abuse & Neglect, dated [DATE] and provided to this surveyor on [DATE], revealed a total of 140 staff signatures or documentation of verbal education on the educational in-service. However, upon further inspection there were 6 staff members who were noted at least twice. This brought the actual total number to 133 of 141 (94%) staff members who were educated on the facility's abuse and neglect policy. Record review of the facility's electronic health record revealed 48 residents did not have a PHQ-9 assessment completed as part of this facility's action plan following Resident #1's suicide until after this surveyor entered the facility on [DATE] at 12:47 p.m. Two of these residents did not have their PHQ-9 assessments completed until after surveyor intervention on [DATE] at 10:57 a.m. Record review of a facility policy titled, Behavior Management, dated 7/2007, revealed, The physician and psychiatric services will be contacted if a resident presents with an elevated PHQ-9 score and or signs and symptoms of behavioral changes. Psychiatric services will perform an assessment within 24-72 hours of notification. There was no verbiage regarding how quickly the facility should contact psychiatric services. Record review of a facility policy titled, Behavior Management and the use of medications, dated 7/2007, revealed: Social Services will make the appropriate referral if needed following agreement from the resident and/or responsible party. There was no verbiage regarding how quickly the facility should contact psychiatric services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676331 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 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 0742 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of a facility policy titled, Change of Condition Reporting, dated 5/2007, revealed the following: Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. The Administrator was notified of an IJ on [DATE] at 5:31 p.m. and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal accepted on [DATE] and included the following: Immediate Action - Medical Director notified of Immediate Jeopardy on [DATE]. - Resident RP . was notified of incident on [DATE]. - Resident #1 expired. - PHQ9 will be completed on all residents to identify residents with potential depression scores that may require psychosocial treatment to be completed on [DATE]. - Psych services on site on [DATE] and [DATE] to assist with identified issues from PHQ9 assessment. - Inservice on PHQ9 completion and comparing score from current to prior to identify any potential needed intervention, notification to MD and Policy on PHQ9 started on [DATE] and completed on [DATE]. Inservice given by MDS resource. - The following in-services were conducted Abuse and neglect, Resident Rights, Active shooter and Behaviors Management. Started on [DATE] and completed on [DATE]. Any employee not receiving inservices will not be allowed to work their shift until inservices have been received. Inservices will be in person or via phone. - Residents safe surveys were completed on [DATE]. - Staff interviews conducted on [DATE] thru [DATE]. - Off Cycle QAPI completed on [DATE]. Identification of Others Affected All residents have the potential to be affected by this alleged deficient practice. &q[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676331 If continuation sheet Page 9 of 9