Health inspection·August 3, 2025

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few checked her code status and began CPR. During an observation on 8/225 at 1:08 p.m. the facility had an AED by the nurses' station which contained pads with an expiration date of [DATE]. The AED green light indicator, indicated it was in working order. There was a crash cart with various supplies including an Ambu bag (manual resuscitator is a handheld medical device used to provide positive pressure ventilation to patients who are not breathing). During an interview on [DATE] at 12:44 p.m. EMS F stated they were dispatched to a call for Resident #1 at 11:24 p.m. Upon arrival to the facility at 11:26 p.m. the patient was the only person in the room at 11:30 p.m., no care was being provided, and it did not appear that any care had been provided prior to their arrival. Resident #1 was found pulseless and apneic (not breathing). EMS F stated staff told them the resident was full code and did not have a DNR. EMS F stated there were no signs of lividity (bluish-purple discoloration of the skin that occurs after death) or rigor mortis. (stiffening of the body after death) EMS F stated they moved the resident from the bed to the floor and began CPR. EMS F stated the resident was found to be in asystole (absence of electrical activity in the heart). EMS F stated a medical director was contacted and advised to cease efforts and the time of death was 11:52 p.m. During an interview on [DATE] at 3:58 p.m. LVN D stated she was called to the 2nd floor of the building by CNA A and CNA B to check on Resident #1 because she was not breathing and could not find LVN C to help. LVN D stated she went to Resident #1's room, she found her not breathing, pulseless, and began CPR in the resident's bed while holding the phone with her cheek calling 911 and performing compressions. LVN D stated she instructed CNA B to go find the LVN C and CNA A to go find RT E. LVN D stated CNA A returned with RT E. LVN D stated she asked the aide and RT if the resident was full code, and both told her they did not know. LVN D stated RT E started to bag Resident #1 and CNA A took over compression while she left to go look up the resident's code status on the computer. LVN D stated she never returned to the room because EMS showed up while she was at the computer. LVN D stated she never instructed staff to obtain the AED but did ask for the crash cart however it was never obtained. LVN D stated she was CPR certified, and her certification was current. During an interview on [DATE] at 3:25 p.m. CNA A stated she and CNA B went to Resident #1's room to provide incontinent care during her rounds. CNA A stated she was unsure of the exact time this occured. CNA A stated she found the resident with her eyes closed and not responding. She stated they checked Resident #1's pulse and they could not find one. CNA A stated her and CNA B left the resident's room and started looking for LVN C, were not able to find her, and went down to the first floor and got LVN D to help instead. CNA A stated they returned to the Resident #1's room and LVN D started CPR. CNA A stated at some point the maintenance director came into the resident room and stated the resident was a DNR, and showed everyone a text from the ADON stating she was a DNR. CNA A stated the nurse then left the room to check the patient chart for code status and she took over compressions. CNA A stated she called 911 at 11:23 p.m. but was advised by the dispatcher that the nurse had already called, and EMS was in route to the nursing home, and she could hang up. CNA A stated she took over compressions then. CNA A stated RT E came into the room to take over and CNA A left to check the patient's chart for code status. CNA A stated she was CPR certified, and her certification was current. During an interview on [DATE] at 6:07 p.m. RT E stated she was called from the hallway to help with CPR for Resident #1. RT E stated she started bagging Resident #1 when the maintenance director came to the room and stated Resident #1 was DNR. RT E stated she put the resident back on her vent to respect her wishes in case she was DNR and returned to her computer to check the residents code status. RT E stated EMS arrived while she was at her computer, and she went into the room with EMS to assist with CPR. RT E stated she was CPR certified, and her certification was current. During an interview on [DATE] at 7:06 p.m. the DON stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455450 If continuation sheet Page 2 of 7 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 455450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meridian Care Monte Vista 616 W Russell Pl San Antonio, TX 78212 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few she was informed on a group text that staff called 911 for Resident #1 on the night of [DATE]. The DON stated the primary way staff check a residents' code status is on the EHR. If the resident is full code they should initiate CPR. The DON stated anyone who is CPR certified can initiate CPR and call for help, have other staff obtain the AED and crash cart. The DON stated LVN D did leave the room to obtain the code status but other staff continued CPR to her knowledge. The DON stated she did not know if staff attempted to obtain the AED or crash cart. The DON stated you can do CPR in the resident bed but it is not ideal. The DON stated delayed or stopped CPR could cause prolonged oxygen deprivation to the brain leading to loss of brain activity. The DON stated she would expect staff to continue CPR until EMS arrived. During an interview on [DATE] at 7:27 p.m. the Administrator stated he was notified the resident had passed [DATE]. The administrator stated as far as he knew staff responded appropriately to the resident and there was nothing to report to the state. The Administrator stated when they looked at everything it looked like it was done correctly. Record review of the facility's policy titled Emergency Procedure Cardiopulmonary Resuscitation, dated 2018, stated 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless:a. it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; orb. there are obvious signs of irreversible death (e.g., rigor mortis).7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 9:11 p.m. The Administrator was notified and provided with the IJ template. The following Plan of Removal (POR) was accepted on [DATE] at 1:44 p.m. and indicated the following: The facility respectfully submits this plan of removal to abate the allegations of immediate jeopardy identified on [DATE]. Plan submitted on [DATE] at 1:20pm. Facility failed to provide timely emergency services and professional standards for CPR. - The facility failed to initiate CPR on Resident #1 who was found unresponsive on [DATE] around 11pm, not breathing, and with no pulse. On [DATE], around 11pm, Resident #1 was found unresponsive, not breathing, and with no pulse by CNA A and CNA B. CNAs A and B left Resident #1's room to locate the Charge Nurse for help. CNA A is CPR certified and did not initiate CPR on Resident #1 who was a full code. When LVN D arrived moments later, CPR was initiated. Staff did not obtain either the AED or crash cart. CPR remained in effect for several minutes until the time that staff reports they were notified by the ADON (who has remote access for PointClickCare log-in) that Resident #1 was a DNR. At this time, they stopped CPR and exited room. EMS arrived moments later and re-initiated CPR. Residents with the potential to be affected by the alleged deficient practice:On [DATE], The Facility completed an audit of Resident code status. Eighteen (18) Residents were confirmed as DNR and thirty-seven (37) Residents were confirmed as full code. Red dot visual aide for all DNR Residents was audited and confirmed accurate. DNR Binder with OOH DNRs was audited and found accurate. Staff in-servicing of all Charge Nurses and Respiratory Therapists was immediately initiated regarding how to confirm/verify code status prior to initiating CPR; location of code status is confirmed by using PointClickCare; where to find the DNR binder at nurses' station with copies of OOH DNRs, and to utilize the red dot visual reminder on Resident's door for DNR Residents. Resident identified to have been affected by the alleged deficient practice:Resident #1, who was a full code, was identified as having been affected by the alleged deficient practice. Systemic Measures: Training Topics for timely emergency services and professional standards for CPR will be added to new-hire orientation: The Facility immediately added the training for providing timely emergency services and professional standards for CPR to all new hire education. (See training topics (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455450 If continuation sheet Page 3 of 7 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 455450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meridian Care Monte Vista 616 W Russell Pl San Antonio, TX 78212 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few below.) Mock Codes: The Facility immediately implemented a mock code program in which random monthly mock codes will be called on all 3 shifts to ensure appropriate and timely response occurs from all staff. The first mock code was conducted by the DON on [DATE] on the 10p-6a shift. Code Status Audits: The Facility's DON and/or Designee will perform daily code status audits to ensure the OOH DNR is in the DNR binder and the red dot visual reminder is on the Resident's nameplate. The audit will be completed by pulling the Order Listing Report daily from PCC for review of any new/changed code status orders. If any new/changed orders exist, the DON and/or Designee will then ensure that any needed OOH DNRs are confirmed in the binder, and that any needed Red Dot visual aides are in place on the Resident's nameplate. Training: Will be completed by [DATE] as follows:a. Re-initiate staff in-servicing on CPR/code status to include the additional topics of any CPR certified staff member initiating CPR (if you are CPR certified and the Resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR); non-CPR certified staff member action (if you are not CPR certified, you must call 911 and follow the 911 operator's instruction until a CPR certified staff member arrives); Charge Nurse and/or Designee will be responsible for confirming any unclear code status; ensuring AED is placed on Resident during all codes; ensuring crash cart is brought to Resident's room during all codes; and to continue all CPR efforts until you have been relieved of this duty by EMS. All Facility staff will be included the aforementioned in-servicing. Inservice sign in sheet will be cross referenced with employee roster. Quality Assurance Performance Improvement: On [DATE], the Quality Assessment and Assurance Committee members to include the Medical Director, Administrator, and Director of Nursing, and the Regional Director of Clinical Services met to review and approve this plan. The Administrator and/or Designee will review any new-hire packets weekly for 3 months to ensure training on timely emergency services and professional standards for CPR has been completed. The Administrator and/or Designee will review the random monthly mock code sign-in sheets to ensure it is being completed at least monthly on all 3 shifts on a weekly basis for 3 months. The Administrator and/or Designee will review the code status audits weekly for 3 months. The results of the Administrator and/or Designee reviews will be presented to the Quality Assessment and Assurance Committee for review of trends and/or negative findings and further recommendations during the scheduled meetings for 3 months. The committee will make recommendations for further education as warranted and develop further performance improvement plans as necessary. Plan of Removal Verification[DATE] On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ after verifying their POR had been initiated and/or completed by: On [DATE] at 1:49 p.m. residents #1-#18 rooms were verified to have red dots next to their names. Record review on [DATE] of the 100 hall and 200 hall DNR binders contained DNRs for 18 residents and were available in the nurses station. Record review of order audit report, dated [DATE], revealed a list of all current residents' code status orders. Record review of order audit report, dated [DATE], revealed a list of 18 residents who's order for code status was DNR. Record review of a facility document titled DNR Audits-monitoring frequency-weekly x3 months, no date, revealed a log with a start date on the log of [DATE]-[DATE] for tracking completion of weekly DNR audits. Record review of facility document titled Timely Emergency Services and Professional Standards for CPR, no dated, stated scare providers for our Residents, we need to ensure that we always provide timely emergency services and professional standards for CPR. Key points to ensure this is achieved are: If you are CPR certified and the Resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. Non-CPR certified staff members must call 911 and follow the 911 operator's instruction until a CPR certified staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455450 If continuation sheet Page 4 of 7 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 455450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meridian Care Monte Vista 616 W Russell Pl San Antonio, TX 78212 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few member arrives. The Charge Nurse and/or Designee will be responsible for confirming any unclear code status. To determine a Resident's code status, you can look in the Resident's chart/orders in PCC or you can refer to the visual red dot aide. If you see a red dot on the resident's nameplate by the door it indicates the Resident is a DNR. Any Resident with a red dot on his/her nameplate is a DN R. If you are a CNA, you can also find the Resident's CPR status on the Resident's tab in the POC. To be able to perform effective compressions, you must either place the backboard from the crash cart under the Resident OR move the Resident to the floor. In any code situation, the crash cart and AED must be brought to the room and utilized. The AED should be placed on the Resident as soon as possible as it will guide the CPR process from that point forward. Once the CPR process is initiated, it cannot be stopped for any reason until EMS arrives and completely takes over. Record review of a log titled New Hire Training Emergency Services and Professional Standards for CPR, no date, monitor frequency- weekly x3 months, with a start date of [DATE] through [DATE]. During an interview on [DATE] at 6:34 p.m. the DON stated new hire orientation is given by HR, that would be included in the nursing portion of new hire orientation. The DON stated nursing management participated in new hire orientation. The DON stated orientation was usually on a set date of the week and management all had a time slot to present training material. The DON stated nurses have extra training they had to completed and the emergency training would be implemented for new hires. During an interview on [DATE] at 4:38 p.m. the ADON G stated they had a mock code the night of [DATE] and that morning. ADON G stated that morning she went into the room and put my call light to see how long staff would take. She was unresponsive by holding a sign that said she was unresponsive, full code, and laid in a patient bed. The ADON stated staff eventually figured out it was a mock code, grabbed the crash cart and AED, simulated compressions and calling 911. Record review of a document with Mock Code written at the top, and no date, showed on [DATE] 5 staff signatures that participated in the mock code. Another date of [DATE] showed 7 staff signatures participated in the mock code. Record review of a document titled Mock Code, no date, revealed a check list of questions asking if mock codes were conducted on all 3 shifts at least monthly? If not was this immediately corrected? And admin/designee signature and date. The start date was [DATE]. During an interview on [DATE] at 6:34 p.m. the DON stated herself and ADON G had done the mock codes on [DATE] during the night shift and on [DATE] during the morning shift. The DON stated they had a person pretending to be unconscious in an empty room, they pulled the call light, waited for someone to respond, and had a sign on that said I am not breathing. The DON stated then staff realized what was going on, they had them go through the steps and pretend to call 911, get the AED, get the crash cart, and get other staff. They had done the mock codes on both floor the 1st and the 2nd floor. The staff upstairs had done better probably due to most of the emergency codes they actually had were upstairs because it was where the vent unit was and they are used to emergency code situations. The DON stated the downstairs staff had parts of the code were easier for some and parts needed to be refreshed on. The DON stated they went through the scenario more than once and introduced new scenarios each time. During an interview on [DATE] at 4:40 p.m. ADON G stated she had assisted with chart audits. The ADON stated they have an order listing report which pulled all the resident orders from whatever time range they set. The ADON stated they would check the report daily. The ADON stated chart audits were a team effort between the ADONs and DON. The DON would check the current DNR binders to ensure they were up to date and located at the nurse's station. Record review of in-service, dated 8/1, reviewed topics of: advance directives-you must always verify code status on your residents prior to initiating/ not initiating CPR, look in PCC profile DNR/ full code this is priority, visual reminder with the red dot on the door of DNR patients, code book of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455450 If continuation sheet Page 5 of 7 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 455450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meridian Care Monte Vista 616 W Russell Pl San Antonio, TX 78212 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few nurses station with copies of OOH DNR. The in-service was signed by 54 direct care staff between [DATE]-[DATE] Record review of in-service, dated 8/2 and 8/3, reviewed topics of: CPR code status-who is there I code states in PCC, these are your active current physician orders. Residents who are DNR will have (red dot) on the name plate on their door and copy of OOH DNR in binder at nurses station. Once decision is made to initiate CPR and code status these verified, CPR certified staff will initiate CPR (chest compressions) and call for help. Either place patient on the floor or utilize backboard for effective CPR. Crash cart and AED brought to room and placed AED on patient following directions of ADD. Once CPR is initiated it is never stopped until EMS arrives and assumes care of patient fully taking over CPR/ ALS. If you are CPR certified and the resident DNR status is unclear CPR will be initiated until it is determined that there is a DNR on a physicians order not to administer CPR. If you are not CPR certified, you must call 911 and follow the 911 operator instructions until the CPR certified staff member arrives. The in-service was signed by 54 staff in person. Record review of a current employee list 2025 by department revealed there were 89 staff at the facility. 82 were in service in person or by phone. One staff was active duty and not available, 2 staff phones were disconnected, 3 did not answer, and 1 was on FLMA. Record review of in-service titled AED and Crash Cart, dated [DATE], revealed anytime you are performing CPR on a resident, you must ensure the AED and crash cart are obtained. The AED should be placed on the resident as soon as possible and the crash cart must be available. LVN D was in-service via phone by RN H. LVN D verbalized understanding of the above. 18 staff (CNA A, ADON G, LVN I, LVN J, RT K, LVN L, RT M, DOR N, DA O, FDS P, HR, MS, AD, HK Q, HKS, CNA R, COOK S, DA T, CAN U, and CNA V) were interviewed to include direct care staff, non-direct care staff, day shift, and night shift staff were on [DATE] between 3:26 p.m. and 5:24 p.m. All staff verbalized understanding the in-service training over CPR, code status, and emergency response. CPR certified staff were able to verbalize appropriate emergency response actions and non CPR certified staff were able to verbalize appropriate emergency response actions. All staff verbalized understanding of the code status systems. During an interview on [DATE] at 6:34 p.m. the DON stated she gave the in-service on [DATE], [DATE], and [DATE]. The DON stated she went over how to find resident code status that it is in the patient's profile in PCC. The DON stated she trained staff to ensure they gave effective CPR compressions on a hard surface with the back board or on the floor, utilized the AED and crash cart, the importance of initiating 911 for advanced life support, initiating CPR immediately, and not stopping till EMS comes in and takes over. The DON stated she trained on the red dot system; the red dot was a visual reminder of resident with DNR code status, and orders for DNR. The DON stated she was the one who places the dot by residents' names on the door, after she verified there is a valid DNR, and signed order. Record review of a log titled Quality Assessment and Assurance Committee, dated [DATE], revealed the DON, Medical Director, Administrator, and Regional nurse attended a meeting reviewing the POR for this IJ. During an interview on [DATE] at 7:03 p.m. Administrator stated they had a QA meeting on [DATE] where they went over the dos and Don'ts of a DNR or full code, if residents had the red dot you would not resuscitate, they would get help if you are not DNR code status, if there was not red dot net to the resident's name they can assume they were full code, and if non clinical staff of course they would not start CPR, they would call for help. The Administrator stated once staff arrived with a crash cart if you are not clinical you could step out or be on stand by for assistance. During an interview on [DATE] at 6:34 p.m. the DON stated they went over CPR if the code status was unknown, they would initiate CPR until they were confirmed DNR or until EMS arrived. Record review of a log titled New Hire Training Emergency Services and Professional Standards for CPR, no date, revealed a log to monitor frequency- weekly x3 months, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455450 If continuation sheet Page 6 of 7 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 455450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meridian Care Monte Vista 616 W Russell Pl San Antonio, TX 78212 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete with a start date of [DATE] through [DATE]. Record review of a document titled Mock Code, no date, revealed a check list asking if mock codes were conducted on all 3 shifts at least monthly? If not was this immediately corrected? And admin/designee signature and date. The start date was [DATE]. During an interview on [DATE] at 6:34 p.m. the DON stated they would complete the mock code and fill out the forms. Herself and the ADONs will perform the mock code or nursing management. Record review of a facility document titled DNR Audits-monitoring frequency-weekly x3 months revealed a log with a start date on the log of [DATE]-[DATE] to monitor if DNR audits were completed weekly for 3 months. During an interview on [DATE] at 7:03 p.m. Administrator stated he was going to oversee the binder with the logs, the DON and ADON were going to be doing the code status, and logs were for him to fill out based on the information they gave him. The Administrator stated he would say yes or no to them filling out the log and completing the task. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 7:19 p.m. While the IJ was removed on [DATE] at 7:19 p.m., the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of their plan of removal. Event ID: Facility ID: 455450 If continuation sheet Page 7 of 7