Golden Estates Rehabilitation Center
Golden Estates Rehabilitation Center in San Antonio, TX — inspection on August 15, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Observation on 08/12/2025 at 12:05 PM revealed Resident #2's lips were sunken inside her mouth, indicating a possible lack of dentition (missing teeth).
During an interview on 08/14/2025 at 12:02 PM, the Administrator stated Resident #2 had some upper teeth but no lower teeth.
She had dentures but sometimes did not use them.
The resident's admission MDS was coded incorrectly.
She did not know why and deferred to the MDS coordinator.
During an interview on 08/14/2025 at 12:15 PM, the MDS LVN stated he knew the resident was missing teeth but was confused when completing the MDS, since there was no problem with her denture (it was not broken or loosely fitting).
The MDS LVN understood that an MDS coded incorrectly could potentially lead to inaccurate resident care.
The MDS LVN stated the facility used the RAI manual as their policy for coding resident assessments Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
675690 08/15/2025
Golden Estates Rehabilitation Center 130 Spencer LN San Antonio, TX 78201
Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals
(station 1 and station 2) observed, in that: The medication aide cart for station 2 contained 4 loose medication pills.
The medication aide cart for station 1 contained 1 loose medication pill.
These deficient practices could place residents who receive medications at risk for not receiving the intended therapeutic effects of medications.
The findings included: The findings were: Observation on 8/14/2025 at 11:32 a.m. of the medication aide cart for station 2 revealed there were 4 loose medication pills inside one of the drawers.
During an interview with LVN F on 8/14/2025 at 11:34 a.m., LVN F confirmed there were 4 loose medication pills inside a drawer of the medication aide cart for station 2.
Observation on 8/14/2025 at 11:42 a.m. of the medication aide cart for station 1 revealed there was 1 loose medication pill inside one of the drawers.
During an interview with LVN G on 8/14/2025 at 11:44 a.m., LVN G confirmed there was 1 loose medication pill inside a drawer of the medication aide cart for station 1.
During an interview with the ADON on 8/14/2025 at 12:25 p.m., he stated medication carts should be checked by the medication aides and nurses and that pharmacy came about once a week to check the carts too. He stated any loose pills should be identified and disposed of properly.
During an interview with the Administrator on 8/15/2025 at 9:07 a.m., she stated medication carts should be checked daily, and carts were also reviewed by the ADON. If there were any loose pills, they were destroyed.
Record review of the facility policy titled Storage of Medications, dated 12/2024, revealed, Policy Statement: Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received.
The nursing staff shall be responsible for maintaining medication storage.
675690 08/15/2025
Golden Estates Rehabilitation Center 130 Spencer LN San Antonio, TX 78201
Observation on 08/12/2025 at 10:18 AM in the reach-in cooler revealed a cardboard case of breakfast sausage.
The case was open and the bag inside the case was open, exposing the sausage to the ambient air in the cooler.
During an interview on 08/12/2025 at 10:20 AM, the DM stated both the containers of cheese and breakfast sausage were opened and should have been sealed, as their exposure to air could contribute to the food going bad.
All staff storing food in the cooler were responsible for ensuring food was properly sealed.
Record review of facility policy Food Safety and Sanitation, Diet and Nutrition Manual 2023, revealed: Policy: All local, state, and federal standards and regulations will be followed to assure a safe and sanitary food and nutrition services department. 4.
Food Storage. a.
Stored food is handled to prevent contamination and growth of pathogenic organisms.
All time and temperature control for safety (TCS) foods (including leftovers) . should be labeled. covered and dated when stored.
Record review of the Food Code, U.S.
Public Health Service, U.S. FDA, 2022 U.S.
Department of H&HS, revealed 3-302 Preventing food and ingredient contamination. 302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (1) Except as specified in (1)(d) below or when combined as ingredients, separating raw animal FOODS during storage, preparation, holding, and display from: (b) Arranging each type of FOOD in EQUIPMENT so that cross contamination of one type with another is prevented, and (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings.
675690 08/15/2025
Golden Estates Rehabilitation Center 130 Spencer LN San Antonio, TX 78201
During an interview with the Regional Nurse on 08/14/2025 at 1:40 pm, the Regional Nurse confirmed the beauty shop contained potentially unsafe items and should have been locked to protect residents, staff, and the public from encountering such items.
Record review of the facility policy, Storage Areas Maintenance, revised December 2009, revealed, Maintenance storage areas shall be maintained in a clean and safe manner.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.