Golden Estates Rehabilitation Center

F 0641

Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 8 residents (Resident #2) whose assessments were reviewed. he facility failed to accurately document Resident #2's dental status on the resident's admission assessment dated [DATE REDACTED]. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings were:Record

review of resident #2's face sheet dated 08/12/2025 revealed the resident was an [AGE] year-old female admitted to the facility on [DATE REDACTED] with diagnoses including hypertensive heart disease without heart failure, unspecified dementia without behavioral disturbance, major depressive disorder, and legal blindness.

Record review of Resident #2's comprehensive care plan, revised 07/24/2025, revealed the resident was on

a No Added Salt diet, Minced and Moist texture, thin liquid consistency, served in a divided plate. There was no focus area indicating the resident's dental status. Record review of Resident #2's quarterly MDS assessment dated [DATE REDACTED] revealed in Section C - Cognitive Patterns a BIMS score of 11/15, indicating the resident had moderately impaired cognition. Record review of Resident #2's admission MDS assessment dated [DATE REDACTED] revealed in Section L - Oral/Dental Status there was no check mark next to, B. No natural teeth or tooth fragments (edentulous) or D. Obvious or likely cavity or broken natural teeth, indicating there were no deficiencies with the resident's dental status. 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

Residents Affected - Few

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 REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Estates Rehabilitation Center

130 Spencer LN San Antonio, TX 78201

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles, 2 of 3 medication carts (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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Estates Rehabilitation Center

130 Spencer LN San Antonio, TX 78201

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in 1 of 1 kitchen in accordance with professional standards for food service safety.The facility failed to ensure a container of shredded cheese and a case of breakfast sausage were properly sealed in the reach-in cooler.These failures could place residents at risk for foodborne illness.The findings were:Observation on 08/12/2025 at 10:18 AM in the reach-in cooler revealed an opaque hard plastic container filled halfway with shredded cheese. The container was covered with a plastic lid. One corner of

the lid was not sealed onto the container, exposing the cheese to the ambient air in the cooler. 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Estates Rehabilitation Center

130 Spencer LN San Antonio, TX 78201

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and

the public.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 of 1 facility beauty shop, in that: The facility beauty shop contained potentially unsafe items and was unlocked. This deficient practice could result in residents, staff, and/or the public encountering potentially unsafe items. The findings were:

Observation on 08/14/2025 at 1:35 pm revealed the facility beauty shop, located on the 100 hall, was unlocked and no staff were in the room. Further observation revealed the beauty shop contained a container of bleach wipes labeled hazardous, keep out of reach of children, four tubes of hair color labeled avoid contact with eyes and skin and keep out of reach of children, and a package of plastic razors. 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.

Event ID:

Facility ID:

If continuation sheet