Golden Estates Rehabilitation Center

F 0552 Level of Harm - Minimal harm or potential for actual harm

because, we want them to know what condition we are treating and what side effects to look out for.Record

review of the facility's policy titled, Antipsychotic or Neuroleptic Medication Use (revised December 2024), revealed a policy statement that included, Written or verbal consent witnessed by two staff members must be given by resident if able or resident representative PRIOR TO starting any antipsychotic medication.

Residents Affected - Few

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

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

11/21/2025

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 0641

complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment.

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:

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

11/21/2025

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 0732

Post nurse staffing information every day.

Level of Harm - Potential for minimal harm

Based on observation, interview, and record review, the facility failed to post the daily nursing staffing formation that included the facility name, the current date, the total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: registered nurses, licensed practical nurses, certified nurse aides and resident census in a prominent place readily accessible to residents, staff, and visitors for (11/19/2025 and 11/20/2025) in that:The facility failed to post the daily staffing posting information on 11/19/2025 and 11/20/2025.This failure could place residents and visitors at risk of not being able to review the facility's daily staffing hours. The findings included:During an observation on 11/20/2025 at 9:47 a.m. and 10:46 a.m., a daily staffing poster was observed on a bulletin board in the front lobby that was titled, Daily Care Report and was dated 11/18/2025. Record review of the staffing schedule, dated 11/19/2025, revealed the facility had 14 CNAs, 2 MAs, 1 DON, 1 ADON, 1 MDS Nurse, 1 Treatment Nurse and 6 LVN/RNs scheduled throughout the day.

Record review of the staffing schedule, dated 11/20/2025, revealed the facility had 14 CNAs, 2 MAs, 1 DON, 1ADON, 1 Treatment Nurse, 1 MDS Nurse and 6 LVN/RNs scheduled throughout the day. During an

interview with MA F, 11/21/2025 at 12:55 p.m., MA F stated he was responsible for posting the staffing posters daily in the front lobby. MA F stated if he was not scheduled to work, the DON was responsible for posting the staffing numbers. MA F stated it was important to post the staffing numbers so people would know how many staff were in the facility each day and he had received training in posting the staff numbers daily. During an interview with the Administrator, 11/21/2025 at 12:22 p.m., the Administrator stated MA F was responsible for posting the daily staffing number each morning and stated if MA F was not scheduled to work, the DON was responsible for posting the staffing numbers. The Administrator stated MA F had received training on posting the staffing numbers daily and stated it was important to post the numbers daily, so we know how many staff members are in the building and so families can read it as well. During an

interview with the DON, 11/21/2025 at 1:17 p.m., the DON stated MA F or herself were responsible for posting the daily staffing numbers and stated, I was supposed to do it yesterday and I did not do it. The DON stated the staffing posters were to be posted in the morning each day, and it was important, because

it is a regulation to post the staffing ratios.

Residents Affected - Many

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

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

11/21/2025

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

medication. RN D stated she was not aware of Resident #6's responsible party's request to be notified prior to administration of the medication and stated the order should have included instructions to notify the responsible party prior to administration. RN D stated she would have notified Resident #6's responsible party prior to administering Alprazolam if the order included those instructions. During an interview with Hospice RN, 11/21/2025 at 10:09 a.m., Hospice RN stated she completed Resident #6's respite admission to the facility on [DATE REDACTED], and Resident #6 was scheduled to be on respite services for 5 days before returning home with the responsible party. Hospice RN stated she provided the facility with written orders that included the Alprazolam .5 mg prn and stated she wrote in the orders for Resident #6's responsible party to be notified prior to medication administration. The Hospice RN stated the facility should have included the responsible party notification in Resident #6's MAR so any nurses administering Alprazolam would be aware that the responsible party was to be notified prior to administration of the medication. The Hospice RN stated she discussed the order and notification with the nurse who completed Resident #6's admission. During an interview with LVN J, 11/21/2025 at 11:23 a.m., LVN J stated she completed the admission paperwork for Resident #6 on 09/13/2025. LVN J stated the Hospice RN reviewed Resident #6's orders with LVN J and discussed Alprazolam order and the order for Resident #6's responsible party to be notified prior to administering the medication. LVN J stated she documented the order in Resident #6's progress notes but did not add the information into Resident #6's physician orders. LVN J stated she should have included the order for responsible party notification on Resident #6's MAR and stated, I'm not good about adding extra things in the orders. LVN J stated it was important to transcribe orders accurately into

the clinical record, so the orders are followed accurately. During an interview with the DON, 11/21/2025 at 1:17 p.m., the DON stated when hospice wrote orders for a resident, the orders would be transcribed into a resident's physician orders for administration. The DON stated nurses received training on entering orders into the EMR system. The DON stated if a hospice order said to notify a resident's responsible party prior to administration, that order should have been included in the order for the medication, so the administering nurse was aware of the order for notification. The DON stated it was important for the clinical record and orders to be accurate, because the physician approved the order and the hospice nurse wrote the orders, and it should be accurate.

Event ID:

Facility ID:

If continuation sheet