Health inspection·August 30, 2024

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that the resident's needs and choices for how he spends time outside the facility, were not supported and accommodated, including making transportation arrangements, for 1 of 8 resident (Resident #54) whose care was reviewed, in that: Resident #54's requested help with transportation for a non-medical appointment to explore benefits he may qualify for due to his diagnoses of blindness, including help with medical appointments. This deficient practice could place residents with the ability to make choices at risk of having their rights violated, diminished quality of life and unmet needs. The findings were: Record Review of Resident #54's admission Record, dated 08/28/24, reflected a [AGE] year-old male admitted [DATE] with diagnoses to include blindness in one eye, low vision in the other eye, and glaucoma (group of eye conditions that damage the optic nerve) in right eye. Record Review of Resident #54's quarterly MDS assessment, dated 06/26/24, reflected Resident #54 had a BIMS score of 15 out of 15, indicating intact cognition. Record Review of Resident #54's care plan, dated 08/26/24, reflected, [Resident #54] is dependent on staff for meeting emotional, intellectual, physical, and social needs, dated 03/16/23. Record Review of Resident #54's doctor's orders, dated 08/26/24, reflected May go out on pass with meds, dated 11/22/23. Record Review of the Facility Assessment, dated 08/02/24, reflected they had a transportation van as a physical resource for the facility. During an interview on 08/26/24 at 09:04 AM, Resident #54 revealed a [non-profit organization] set him up with the blind division of [organization #2] to explore more benefits Resident #54 could qualify for due to his diagnosis of blindness, to include medical benefits. Resident #54 revealed he missed about 3 appointments with [organization #2] because the facility would cancel or not set up his transportation accommodations due to this appointment not being considered a medical appointment. During an interview on 08/28/24 at 10:08 AM, Receptionist N revealed the facility only made transportation arrangements for medical or health appointments. She further revealed they did not make any Page 1 of 20 455742 455742 08/30/2024 The Lev at San Antonio 7703 Briaridge Drive San Antonio, TX 78230

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few other transportation arrangements. She further revealed some residents used [transportation company] for themselves. She further revealed the facility had a transportation van but the facility was not using it. During an interview on 08/28/24 at 10:35 AM, the Administrator revealed they did not use the facility's transportation van because it was titled in another state. They did, however, coordinate with [transportation companies]. She further revealed they would accommodate transportation for other appointments and the residents would schedule appointments through the receptionist. During an interview on 08/28/24 at 02:20 PM, the BOM revealed the facility only scheduled residents to attend medical appointments through [transportation companies]. She revealed the facility can make transportation arrangements for residents to pay for. She revealed Resident #54 wanted transportation to [organization #2] because he wanted to work in the community . She revealed they didn't offer transportation for this. During an interview on 08/28/24 at 02:34 PM, confidential staff member revealed she was told she could not make any transportation arrangements for Resident #54. When the confidential staff member was told she couldn't make transportation arrangements for Resident #54, she was not asked why Resident #54 needed transportation for others to decide if he needed transportation for health or not . The confidential staff member stated this appointment seemed necessary for Resident #54 to attend as it would benefit his quality of life and health. She further revealed she was not aware if the facility tried to only schedule transportation with Resident #54 and have Resident #54 pay for it. During an interview on 08/30/24 at 03:08PM, staff member from [organization #2] revealed she had to visit the facility because Resident #54 was not able to attend appointments with her. She revealed Resident #54 said he could not go to the appointments because it was not a medical appointment, however, she revealed their organization helps with medical appointments like helping Resident #54 see an eye specialist. She further revealed the facility told her they couldn't help Resident #54 with transportation because Resident #54's insurance would not cover his transportation to this appointment. She further revealed this was concerning to her but she knew that insurance was complicated. Record Review of Statement of Resident Rights in the residents' admission agreement, undated, reflected The facility must encourage and assist you to fully exercise your rights .You have the right to: 1. All care necessary for you to have the highest possible level of health; 4. Be treated with courtesy, consideration, and respect . 455742 Page 2 of 20 455742 08/30/2024 The Lev at San Antonio 7703 Briaridge Drive San Antonio, TX 78230

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure residents' rights to voice grievances to the facility or other agencies or entities that heard grievances without discrimination or reprisal and without fear of discrimination or reprisal for 1 of 8 residents (Resident #16) reviewed for grievances: 1. The facility failed to ensure Licensed Vocational Nurse A (LVN A) initiated a grievance report on behalf of Resident #16's grievance on 08/23/2024. 2. The facility failed to ensure Medication Aide O (MA O) and the ADON initiated a grievance report on behalf of Resident #16's grievance on 08/25/2024. This failure could place residents at risk by denying their right to make and have grievances heard and contributed to ill feelings of not being heard and unresolved issues. The findings included: 1. Resident #16 A record review of Resident #16's admission record dated 08/27/2024 revealed an admission date of 05/26/2024 with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD, a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitations), anxiety, and mood disorder. A record review of Resident #16's admission MDS assessment, dated 06/29/2024, revealed Resident #16 was a [AGE] year-old female admitted for long term care and was assessed with a BIMS score of 12 out of a possible 15 which indicated no cognitive impairment. A record review of Resident #16's care plan dated 08/28/2024, revealed, Resident #16 is dependent on staff for meeting emotional, intellectual, physical, and social needs . All staff to converse with resident while providing care . Resident #16 has a potential communication problem r/t bilateral tinnitus (ringing in the ears) . COMMUNICATION: Allow adequate time to respond, repeat as necessary, Do not CNA rush , Request clarification from the resident to ensure understanding, Face when speaking, make eye contact, Turn off TV/radio to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed A record review of Resident #16's physicians' orders revealed the Medical Director gave an order on August 9th, 2024, for Resident #16 to be seen by an oncology physician. A record review of the facility's grievance binder for the period of January 2024 through August 455742 Page 3 of 20 455742 08/30/2024 The Lev at San Antonio 7703 Briaridge Drive San Antonio, TX 78230

F 0585 25, 2024, revealed no grievances for Resident #16. Level of Harm - Minimal harm or potential for actual harm During an interview on 08/25/2024 at 12:00 PM Resident #16 stated she was diagnosed on [DATE]th, 2024, with kidney cancer. Resident #16 stated her physician had ordered for her to see a cancer specialist and she has not received any information on an appointment. Resident #16 stated she had asked many staff for details of an appointment to see the specialist without success, no one will give me an answer. Resident #16 stated she recently told LVN A early this morning, (LVN A) works overnight and last night / early this morning, I told her I was upset no one would tell me when my appointment with the cancer specialist is, can you look into this? Residents Affected - Few During an interview and observation on 8/25/24 at 12:10 PM revealed MA O entered the room to administer medications to Resident #16. Resident #16 stated to MA O she had a complaint and would like to have information on her cancer specialist appointment. MA O was observed to leave Resident #16's room. MA O stated to the surveyor Resident #16 had just now made a complaint regarding her cancer specialist appointment. MA O stated she would report the complaint to the nurse. During an interview on 08/27/24 at 05:13 PM the ADON stated in the afternoon of 08/25/2024 MA O asked her to research an oncology appointment on behalf of Resident #16. The ADON stated MA O did not report Resident #16 had a complaint. The ADON stated if she had she would have had MA O generate a grievance report and would have followed the investigation of the report. During an interview on 08/30/24 at 01:10 PM, LVN A stated she was Resident #16's nurse on the 08/23/2024 from 10:00 PM to 8/24/2024 at 06:00 AM. LVN A stated, during the shift, Resident #16 reported to her that she was concerned no one had given her any information regarding an oncology appointment she needed. LVN A stated she had not generated a grievance regarding Resident #16's concerns for information regarding the oncology appointment. LVN A stated Resident #16 was not complaining but rather just had a concern. LVN A stated an example of a complaint would include more emotions and or Pain. LVN A stated she had relayed the concern to the hospice RN but had not reported the concern to the ADON and or the DON. A record review of Resident #16's medical record revealed a note dated 08/23/2024 at 02:31 AM authored by LVN A, . relayed to Hospice nurse, Resident #16 wanting to be seen by oncology During an interview on 08/29/24 at 05:40 PM the DON stated the expectation for all staff who heard a complaint were to report the complaint on a grievance form and report the grievance to a supervisor and or the administrator or herself (the DON). The DON stated the risk for harm to residents was varied and at a minimum could lead to unresolved needs and or concerns. A record review of the facility's undated Resident and Family Grievances policy revealed, . A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC facility stay. The facility will not prohibit or in any way discourage a resident from communicating with external entities including federal and state surveyors or other federal or state health department employees . Grievances may be voiced in the following forums: Verbal complaint to a staff member or Grievance Official . The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. Take any immediate actions needed to prevent further potential violations of any resident's 455742 Page 4 of 20 455742 08/30/2024 The Lev at San Antonio 7703 Briaridge Drive San Antonio, TX 78230

F 0585 Level of Harm - Minimal harm or potential for actual harm right. Report any allegations involving neglect, abuse, injuries of unknown source, and or misappropriation of resident property immediately to the administrator and follow procedures for those allegations. Forward the grievance form to the grievance official as soon as practicable. The grievance official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form Residents Affected - Few 455742 Page 5 of 20 455742 08/30/2024 The Lev at San Antonio 7703 Briaridge Drive San Antonio, TX 78230

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice that would meet the resident's physical needs for 2 of 6 (Residents #22 and #5) residents reviewed for quality of care, in that: Residents Affected - Some 1. The facility failed to ensure Resident #22 had a follow-up appointment with a GI doctor within 4-6 weeks from 05/25/24 for a esophageal stent removal, as recommended. Resident #22 did not have an appointment until 10 weeks later where the stent had migrated into the stomach causing an unanticipated need for removal of the stent from the stomach. 2. The facility failed to ensure Resident #5 had a follow-up appointment with a cardiologist in 4 weeks from January 25th. Resident #5 did not see a cardiologist until her 07/17/24 hospitalization for heart health issues. An Immediate Jeopardy (IJ) situation was identified on 08/29/24. The IJ template was provided to the facility on [DATE] at 02:58 PM. While the IJ was removed on 08/30/24, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm, due to the facility's continuation of in-servicing and monitoring the Plan or Removal. This failure could place residents at risk for delay in needed treatment and diminished quality of care. The findings included: 1. Record Review of Resident #22's admission Record, dated 08/28/24, reflected a [AGE] year-old male initially admitted [DATE] with diagnoses to include esophageal obstruction (a blockage or narrowing of the esophagus, the tube that connects the mouth to the stomach), severe protein-calorie malnutrition, surgical aftercare following surgery on the digestive system, dysphagia (difficulty swallowing), gastric ulcer, (open sores on the inner lining of the stomach and the upper part of the small intestine) and gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). Record Review of Resident #22's quarterly MDS assessment, dated 07/23/24, reflected Resident #22 had a BIMS score of 13 out of 15, indicating intact cognition. It further revealed Resident #22 had a feeding tube while a resident. Record Review of Resident #22's care plan, dated 08/28/24, reflected, [Resident #22] requires tube feeding r/t Weight Loss, esophageal obstruction, Severe protein calorie malnutrition., initiated 06/28/24, with an intervention, Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated., initiated 06/28/24. 455742 Page 6 of 20 455742 08/30/2024 The Lev at San Antonio 7703 Briaridge Drive San Antonio, TX 78230

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #22's hospital discharge records for 05/18/24-05/25/24, dated 05/25/24, reflected patient was evaluated by gastroenterology due to recommendations per speech therapist secondary to high risk for aspiration due to esophageal stricture Patient with PEG placement with esophageal stent and patient has been cleared to discharge with instructions to have this esophageal stent removed in 6 weeks. And FOLLOW UP: [gastroenterologist] and GI will [coordinate] GI f/u with [GI doctor] to schedule EGD for esophageal stent removal in 4-6 wks. Residents Affected - Some Record Review of Nurses Note, dated 05/26/24 at 02:32 AM and authored by LVN A, reflected Pt [Resident #22] is a readmit arrived at 4pm . Follow up with GI in 4 weeks to remove stent Record Review of Resident #22's hospital documents, dated 08/07/24, reflected reason for visit with the GI doctor was foreign body removal dysphagia. It further reflected the procedure as follows The stent had migrated into the stomach causing an unanticipated need for removal of the stent from the stomach. This removal caused some significant traumatic dilation of the esophagus at the level of the stricture and the stricture was widely patent at the end of the procedure. During an interview on 08/28/24 at 03:05 PM, LVN A was not able to provide specific details about Resident #22 being readmitted in May. She stated she did not recall who needed to make Resident #22's GI appointment, the facility or the GI doctor. During an interview on 08/28/24 at 03:27 PM, the DON revealed if a follow-up doctor's appointment was needed to be made in 4 to 6 weeks and the deadline was approaching, the facility would intervene and make this appointment to include finding a different doctor in the same specialty to have a resident seen in the time frame recommended from hospital discharge paperwork. The DON revealed LVN A could have created a doctor's order for a GI follow up appointment in 4 to 6 weeks from re-admission. She further revealed LVN B, who was to follow a clinical admission checklist to include reading the entirety of residents' hospital discharge paperwork that would allow for necessary doctor's appointments to be made timely. The DON revealed she oversaw these processes and should have caught that a follow up for the GI doctor was needed to be made for Resident #22 in a timely manner. She further revealed the receptionist was making medical appointments; however, the nursing staff were now [after survey investigations] going to start making medical appointments for residents as the nursing staff understood the urgency of making medical appointments. 2. Record Review of Resident #5's admission Record, dated 08/29/24, reflected an [AGE] year-old female initially admitted [DATE] and re-admitted [DATE] with diagnoses to include hypertension (high blood pressure), hypercholesterolemia (excess of cholesterol in the bloodstream), atrial fibrillation (a type of irregular heartbeat), and myocardial infarction (heart attack). Record Review of Resident #5's quarterly MDS assessment, dated 08/09/24, reflected Resident #5 had a BIMS score of 12 out of 15, indicating moderate cognitive impairment. Record Review of Resident #5's hospital discharge paperwork, dated 07/27/24, reflected admission date 07/17/24 for dysarthria (slurred speech)/NSTEMI (type of heart attack) with discharge instructions to follow-up with [Cardiologist] within 1-2 weeks, which would be 08/03/24-08/10/24. Record Review of Resident #5's hospital records, dated 08/20/24, with admission date 08/18/24 reflected resident had diagnoses to include stable angina (type of chest pain that happens when your 455742 Page 7 of 20 455742 08/30/2024 The Lev at San Antonio 7703 Briaridge Drive San Antonio, TX 78230

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some heart muscle needs more oxygen), severe pulmonary HTN (high blood pressure in your pulmonary arteries), CAD (coronary heart disease) status post stents, hypertensive urgency (urgency with elevated blood pressure), and CHF (congestive heart failure). Record Review of Medical Practitioner Note, dated 07/29/24 at 04:44 PM reflected, was originally admitted to [hospital] for NSTEMI . Her hospital stay was complicated with new onset afib, and acute ischemic stroke with transient dysarthria (a type of stroke) which was then resolved . is now admitted here for continuation of medical care and comprehensive (sp) rehabilitation Record Review of Resident #5's doctor's orders, dated 08/27/24, reflected no cardiologist appointment noted. During an interview on 08/28/24 at 06:30 PM, the Facility MD, the facility's Medical Director he stated Resident #22 should have been seen sooner and that geriatric residents were vulnerable. He said residents should be seen by the specialist as requested by the specialist. During an interview on 08/29/24 at 08:56 AM, the medical office specialist at Resident #5's cardiology clinic revealed Resident #5's cardiologist saw Resident #5 on January 25th, 2024 and needed a 4 week follow up appointment. He revealed in the January 25th appointment Resident #5 had acute CHF and needed to come back for her follow up appointment with the cardiologist to see where everything is at with Resident #5's CHF and if her cariologist saw anything alarming, they would have addressed any concerns quickly. He revealed Resident #5 had an appointment February 13th, 2024 but it appeared to be cancelled. He further revealed the nursing facility needed to call back and get this appointment rescheduled. He revealed the nursing facility had not called to make an appointment with Resident #5's cardiologist until 08/05/24. During an interview on 08/29/24 at 11:45 AM, the DON revealed Resident #5 had an appointment on January 25th, 2024 and they did not have paperwork uploaded in Resident #5's medical records to show if there were any follow up appointments needed to be made because the staff member who oversaw medical records did not upload this paperwork appropriately. The DON verbally confirmed after Resident #5's January 25th cardiologist appointment, Resident #5 did not get seen by a cardiologist until her 07/27/24 hospitalization. The DON revealed it was important for the paperwork to be uploaded and pertinent medical appointments to be scheduled to provide necessary care for the health of the residents. During an interview on 08/29/24 at 12:21 PM, the DON and ADON revealed it was important for residents to have doctor's appointments scheduled appropriately so doctors could give appropriate care to their residents. Left voicemail for cardiologist on 08/30/24 at 02:17 PM with no call back. Attempted to interview Resident #5 3 times on 08/30/24. She was not available . Record Review of the facility's policy, undated, Provision of Quality Care, reflected Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. An IJ was identified on 08/29/2024. The IJ template was provided to the Administrator and the DON on 08/29/2024 at 02:58 PM and a POR was requested. 455742 Page 8 of 20 455742 08/30/2024 The Lev at San Antonio 7703 Briaridge Drive San Antonio, TX 78230

F 0684 The following Plan of Removal submitted by the facility was accepted on 08/30/2024 at 05:58 PM: Level of Harm - Immediate jeopardy to resident health or safety POR Verification Residents Affected - Some SURVEY TYPE: Annual Survey FACILITY: [Facility ID] ABATEMENT PLAN: F684 Quality of Care 8/29/24 This abatement plan is submitted to meet the applicable OBRA regulations. It is not to be construed as an admission of the truth of the factual allegations of the survey or the Department's theories of violation. Plan to remove immediate jeopardy Resident #22 was assessed by licensed nurse on 8/29/24, no adverse reactions noted. Resident #5 was assessed by licensed nurse on 8/29/24, no adverse reactions noted. On 8/29/24, licensed nurses physically present were educated in person regarding the community process for scheduling consults and medical appointments. Training conducted by DON and/or ADON. On 8/29/24 licensed nursing staff not physically present, to include those that are PRN and on leave, were contacted by the Administrator, ADON and/or DON via phone and provided education regarding the communities process on scheduling consults and medical appointments. Above mentioned training will be completed on 8/29/24, all licensed staff will be required to have training on community process of resident appointments before assuming resident care responsibilities. Process: New Residents: Licensed nurse, ADON and/or DON will review documentation from the hospital to confirm appointments are scheduled in the timeframe requested. Current Residents: Upon return from appointments Licensed nurse, ADON and/or DON will review documentation from resident appointments to confirm appointments are scheduled in the timeframe requested if follow up is documented. Once documentation mentioned above is received after resident returns from appointment or resident admits to the community it will be reviewed the Licensed Nurse, ADON or DON and will enter an order immediately upon notification/review into Point Click Care that will include the appointment details per the documentation received from the hospital and/or the appointment. Example: Consult needed for Dr. ABC in 4-6 weeks. DON and/or ADON will review orders the following business day and ensure that appointments are made per the recommendations of the physician. 455742 Page 9 of 20 455742 08/30/2024 The Lev at San Antonio 7703 Briaridge Drive San Antonio, TX 78230

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some DON, ADON or Licensed Nurse will enter progress note after appointment is confirmed to ensure staff have the details for the appointment, this will be an ongoing process. If doctor/clinic is unable to coordinate in the specified timeframe DON, ADON or Licensed Nurse will work with the resident/family and physician to locate a different provider that can accommodate their needs if physician deems necessary. If an appointment is made outside of the timeframe requested by the physician the DON, ADON or Licensed Nurse will enter a progress note explaining the reason for the delay and confirm attending physician. The DON, ADON, MDS Coordinator or other designee will review re-admission paperwork as a secondary review from admitting nurse to ensure that residents care is followed up. Concerns found will be immediately reported to administrator and re-education provided. When the community is notified of a cancelled appointment, they will follow the process and enter a new order into PCC, stating that appointment was cancelled and needs to be rescheduled. This will alert DON or ADON when orders are reviewed the following business day. Appointments will be maintained in a calendar book to be located at nurses' station for appointment tracking. DON, ADON or other designee will be responsible for ensuring calendar is up to date and will be reviewed no less than three times a week. This new process will be effective immediately, 8/29/24, for current residents and any new residents. All residents that have appointments or consults outside the community have the potential to be affected by this alleged deficient practice. The process outlined above was reviewed by the Director of Nursing, Nursing Home Administrator and Medical Director during an Ad Hoc QAPI meeting on 8/29/24. The medical director was involved with the review and the plan of removal. All licensed staff will be required to have training on community process of resident appointments before assuming resident care responsibilities, to include new hires. The Administrator will be responsible for monitoring the above actions for compliance which will be an ongoing process. The Administrator will be responsible for oversight to ensure the process is being completed and will complete an audit no less than one time per month and a report of findings will be reported to the facility's QAPI committee no less than one time per month for six months. The Administrator will ensure the plan is completed in full by 8/29/24. POR verification was as follows: A record review of resident #22's medical record revealed LVN C assessed on 08/30/2024 resident #22 without injuries. During an interview on 08/30/2024 at 12:39 pm LVN C stated she assessed Resident #22 without injuries. A record review of resident #5's medical record revealed LVN C assessed resident #5 without injuries. 455742 Page 10 of 20 455742 08/30/2024 The Lev at San Antonio 7703 Briaridge Drive San Antonio, TX 78230

F 0684 During an interview on 08/30/2024 at 12:39 pm LVN C stated she assessed Resident #5 without injuries. Level of Harm - Immediate jeopardy to resident health or safety A record review of the facility's in-service Medical Appointments dated 08/29/2024 revealed, New Residents: Licensed nurse, ADON and/or DON will review documentation from the hospital to confirm appointments are scheduled in the timeframe requested. Residents Affected - Some Current Residents: Licensed nurse, ADON and/or DON will review documentation from resident appointments to confirm appointments are scheduled in the timeframe requested if follow up is documented. Once documentation mentioned above is reviewed the Licensed Nurse, ADON or DON will enter an order into Point Click Care that will include the appointment details per the documentation received from the hospital and/or the appointment. Example: Consult needed for Dr. ABC in 4-6 weeks. DON and/or ADON will review orders the following business day and ensure that appointments are made per the recommendations of the physician. DON, ADON or Licensed Nurse will enter progress note after appointment is confirmed to ensure staff have the details for the appointment. If doctor/clinic is unable to coordinate in the specified timeframe DON, ADON or Licensed Nurse will work with the resident/family and physician to locate a different provider that can accommodate their needs if physician deems necessary. If appointment is made outside of the timeframe requested by the physician the DON, ADON or Licensed Nurse will enter a progress note explaining the reason for the delay and confirm attending physician. further review revealed the following nurses received the training on 08/29/2024: o DON o ADON o LVN A o LVN D o 455742 Page 11 of 20 455742 08/30/2024 The Lev at San Antonio 7703 Briaridge Drive San Antonio, TX 78230

F 0684 LVN K Level of Harm - Immediate jeopardy to resident health or safety o Residents Affected - Some o LVN H LVN C o LVN L o LVN J o LVN E o LVN F o LVN G o RN M o RN I During an interview on 08/30/2024 at 01:36 PM the DON stated she was trained by the corporate RN and she provided in-service training for all the nursing staff. The DON stated the training covered reviewing residents' discharge / doctors' recommendations paperwork and communicating the recommendations to the medical director for orders to support the residents needs for follow up appointments and or preprocedural orders. On 8/29/24 licensed nursing staff not physically present, to include those that are PRN and on leave, were contacted by the Administrator, ADON and/or DON via phone and provided education regarding the communities process on scheduling consults and medical appointments. Above mentioned training will be completed on 8/29/24, all licensed staff will be required to have 455742 Page 12 of 20 455742 08/30/2024 The Lev at San Antonio 7703 Briaridge Drive San Antonio, TX 78230

F 0684 training on community process of resident appointments before assuming resident care responsibilities. Level of Harm - Immediate jeopardy to resident health or safety 14 of 14 licensed nursing staff were interviewed. The breakdown is as follows: Residents Affected - Some Shift 2 PM-10 PM (2 of 2 licensed nursing staff interviewed) Shift 6 AM- 2 PM (5 of 5 licensed nursing staff interviewed, including 1 DON and 1 ADON) Shift 10 PM-6 AM (3 of 3 licensed nursing staff interviewed) Weekend shift (4 of 4 licensed nursing staff interviewed) Shift 6 AM- 2 PM (5 of 5 licensed nursing staff interviewed, including 1 DON and 1 ADON) During an interview on 08/30/24 at 12:37 PM, LVN D revealed she was in-serviced to review all documents when residents returned from clinics, doctor appointments, and / or hospital visits for follow up appointments and new orders. LVN D stated she would SBAR the Medical Director for an order for the follow-up visits and document in the residents' chart. During an interview on 08/30/24 at 12:38 PM, LVN F revealed she received an in-service on 08/29/2024 which covered expectations for nurses to review all residents' documents when a resident was admitted and / or returned from a doctor's visit. LVN F stated if the documents revealed any recommendations like a follow up visit, she would ask the doctor for an order for the appointment and document the appointment in the resident's chart and document the appointment in the calendar appointment book at the nurse's station. During an interview on 08/30/24 at 12:39 PM, LVN C revealed she received in-service training on 08/29/2024 which covered reviewing return from clinic hospital documents for follow up appointments. LVN C stated she would document new orders for follow up appointments in the resident's chart and the calendar appointment book at the nurse's station. During a combined interview on 08/30/24 at 01:26 PM, the DON and the ADON stated they were in-serviced by the corporate RN to review residents' discharge/doctors' recommendations paperwork and create appointments in a timely manner, as recommended. Shift 2 PM-10 PM (2 of 2 licensed nursing staff interviewed) During an interview on 08/30/24 at 02:19 PM, LVN J revealed he received training on 08/29/2024 for reviewing documents when residents return from appointments and or clinics. LVN J stated he would review the documents for any follow-up appointments and if there were he would document the order in the resident's chart and in the appointment book. During an interview on 08/30/24 at 03:46 PM, RN M stated he received training on 08/29/2024 which covered reviewing all documents from residents' doctors' appointments and if the resident needed a follow up appointment, he would document a new doctors order for the follow up appointment in the resident's chart and the appointment book. Shift 10 PM-6 AM (3 of 3 licensed nursing staff interviewed) 455742 Page 13 of 20 455742 08/30/2024 The Lev at San Antonio 7703 Briaridge Drive San Antonio, TX 78230

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During an interview on 08/30/24 at 01:10 PM, RN I revealed he received training on 08/29/2024 which covered documenting and supporting residents with their needs with follow-up appointments and or future procedures. RN I stated he would do so by reviewing the documents upon the residents return from the doctor's visit / hospitalization and writing orders and utilizing the appointment book. During an interview on 08/30/24 at 02:57 PM, LVN K revealed she received training on 08/29/2024 which covered reviewing documents after residents were admitted and / or returned from clinic appointments. LVN K stated she would make a doctor's order for follow-up appointments and / or procedures and document the details in the appointment book at the nurse's station. During an interview on 08/30/24 at 03:19 PM, LVN L revealed she was trained on making medical appointments for residents in a timely manner. She further revealed the nursing staff have doctor's orders and a calendar to follow to prepare residents for their appointments. Weekend shift (4 of 4 licensed nursing staff interviewed) During an interview on 08/30/24 at 12:20 PM, LVN E and LVN H revealed they had received training for reviewing and documenting any needed follow up appointments and / or procedures after residents returned from appointments or were admitted . LVN E and LVN H stated they would document the follow-up appointments as orders in the resident's record and document the appointments in the appointment book / calendar at the nurse's station. During an interview on 08/30/24 at 01:10 PM, LVN A revealed she was in-serviced on 08/29/2024 which covered a system to document follow-up appointments and / or procedures by reviewing all documents returned to the facility after an admission and / or a doctor's visit. During an interview on 08/30/24 at 01:27 PM, LVN G revealed she received in-service training on 08/29/2024 which re-enforced residents' documents after a clinic or admission were reviewed for follow-up appointments. LVN G stated she would document the follow-up appointment in the resident's chart and the appointment book. During an interview on 08/30/24 at 03:35 PM, the ADON revealed there were 2 new admissions since 08/29/24, and they did not have any instructions to have any medical appointments scheduled. The ADON presented a calendar book to show how the nursing staff has already used the calendar book at 1 of 1 nurse's station to write down all residents' medical appointments. Record review of 1 of 2 new admissions revealed no medical appointments were needed to be scheduled. Record Review of Resident #5's medical record revealed she was re-admitted [DATE] after a hospitalization from 08/18/24 to 08/28/24. Record Review of Resident #5's Nurses Note, dated 08/29/24 at 09:01 AM and authored by the DON, reflected Resident #5 went to a cardiology appointment at 10:30 AM on 08/29/24. Record Review of Nurses note, dated 08/29/24 at 02:24 PM and authored by LVN D, reflected a 3 month follow up appointment was scheduled for 11/19/24 at 11:00 AM for Resident #5. Record Review of Resident #5's doctor's orders, dated 08/30/24, reflected, 3 month follow up 455742 Page 14 of 20 455742 08/30/2024 The Lev at San Antonio 7703 Briaridge Drive San Antonio, TX 78230

F 0684 [appointment] on Tuesday 11/19/24 @1100 [cardiologist], receptionist to schedule transportation Level of Harm - Immediate jeopardy to resident health or safety Observation and record review on 08/30/24 at 03:35 PM at 1 of 1 nurse's station revealed a calendar book with medical appointments. Record review of this calendar book revealed medical appointments have been added for the residents. Residents Affected - Some During an interview on 08/30/24 at 04:05 PM, the administrator revealed they had a QAPI meeting with the DON, ADON, and the doctor to discuss this plan of removal. An Immediate Jeopardy (IJ) situation was identified on 08/29/24. The IJ template was provided to the facility on [DATE] at 02:58 PM. While the IJ was removed on 08/30/24, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm, due to the facility's continuation of in-servicing and monitoring the Plan or Removal. 455742 Page 15 of 20 455742 08/30/2024 The Lev at San Antonio 7703 Briaridge Drive San Antonio, TX 78230

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation, in that: 1. The facility failed to ensure cases of cookies, shortening, and coffee filters were stored off the floor in the dry storage room. 2. The facility failed to ensure disposable condiment cups of salsa and butter were covered in the reach in cooler. 3. The facility failed to ensure a pan of cake, a bag of sliced turkey breast, a container of whipped topping and a bag of boiled eggs were covered/sealed and labeled with a use-by date in the walk-in cooler. 4. The facility failed to ensure two bags of food, contents unknown, were properly sealed and labeled with a use-by date in the walk-in freezer. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 08/25/2024 at 10:48 AM revealed two 9 lb. cases of bulk cookies, one case stacked on top of the other; one 35-lb. case of liquid shortening; and one case of 500-count coffee and tea filters on the floor of the dry storage room. During an interview on 08/25/2024 at 10:49 AM, DA O stated she had come into work that morning and the cases were on the floor. During an interview on 08/25/2024 at 1:05 PM, the DM stated the cases of food and filters were not on the floor of the dry storage room when she departed the kitchen two days prior, and they should not be on the floor to prevent potential contamination from rodents and debris. 2. Observation on 08/25/2024 at 11:10 AM in the reach in cooler revealed 8 small disposable condiment cups of salsa and one small commercial container of margarine on a plastic tray without lids or plastic wrap covering them. During an interview on 08/25/2024 at 1:05 PM, the DM stated the containers of salsa and margarine were missing lids and/or a plastic wrap covering them, and they should have been covered to prevent potential cross contamination. 3. Observation on 08/25/2024 at 11:12 AM in the walk-in cooler revealed: a. One sheet pan of yellow cake with white frosting, approximately ¼ cake remaining in the pan, on a rack along the back of the cooler. There was no plastic wrap covering the cake and no label indicating the date prepared or a use-by date. 455742 Page 16 of 20 455742 08/30/2024 The Lev at San Antonio 7703 Briaridge Drive San Antonio, TX 78230

F 0812 Level of Harm - Minimal harm or potential for actual harm b. One opened 2 lbs. bag of sliced turkey breast inside an opened zip-locked bag. There was no label indicating an opened or a use-by date. c. One 16-oz. opened container of whipped topping. There was approximately ¾ topping remaining in the container. There was no label indicating an opened or a use-by date. Residents Affected - Some d. One large zip-locked bag containing nine boiled eggs. The bag was opened and there was no label indicating the date opened or a use-by date. During an interview on 08/25/2024 at 1:07 PM, the DM stated all food stored in the cooler should have been properly covered and/or sealed with a label indicating the date prepared and use-by date. It was the responsibility of all staff members who stored food in the cooler to cover, seal and label food to ensure freshness and prevent cross contamination. Staff members were trained upon hire by her and all staff had current food handlers' certification. 4. Observation on 08/25/2024 at 11:17 AM in the walk-in freezer revealed two clear plastic bags of food, both containing individual beige-colored items, sealed with a knot. The first bag was on a rack on the left side of the freezer and the second bag was on a rack along the back of the freezer. There was no label indicating the name of the food, the date stored or a use-by date. During an interview on 08/25/2024 at 1:10 PM, the DM stated the first bag contained biscuits and the second bag contained chocolate chip cookies. Both bags should have been stored in zip locked bags and labeled with the name of the item, the date stored, and a use-by date, and the dietary aide or cook who returned the unused portions to the freezer was responsible for labeling and dating the bags. Record review of facility policy 03.003, Food Storage, Revised 06/01/2019, revealed: 1. Dry storage rooms: h. Store all items at least 6 above the floor and with adequate clearance between goods and ceiling to protect from pipes and other contamination. 2. Refrigerators. d. Date, label and tightly seal all refrigerated foods using clean, non-absorbent, covered containers approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. 3. Freezers. e. Store foods in moisture-proof wrap or containers that are labeled and dated. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022 U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (A) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the 455742 Page 17 of 20 455742 08/30/2024 The Lev at San Antonio 7703 Briaridge Drive San Antonio, TX 78230

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. 455742 Page 18 of 20 455742 08/30/2024 The Lev at San Antonio 7703 Briaridge Drive San Antonio, TX 78230

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to develop policies and procedures to ensure that before offering the influenza immunization, each resident or the resident's representative received education regarding the benefits and potential side effects of the immunization and each resident was offered an influenza immunization during October 1 through March 31 annually, for 3 of 70 residents (Resident #10, #22, and #28) reviewed for the influenza vaccine offered. Residents Affected - Some The facility failed to provide education to Residents #10, #22, and #28 regarding the benefits and potential side effects of the influenza immunization. The facility failed to offer an influenza immunization to Residents #10, #22, and #28, during October 1, 2023, through March 31, 2024. These deficient practices could place residents at risk for harm, by contracting and spreading influenza. The findings included: Resident #10: A record review of Resident #10's admission record dated 08/25/2024 revealed an admission date of 10/19/2021 with diagnoses which included dementia (a general decline in cognitive abilities that affects a person's ability to perform everyday activities. This typically involves problems with memory, thinking, behavior, and motor control), personal history of covid-19 (a contagious virus), and type II diabetes (a chronic disease characterized by high blood sugar levels). A record review of Resident #10s annual MDS assessment dated [DATE] revealed Resident #10 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 00 out of a possible 15 which indicated severe impaired cognition. A record review of Resident #10's physicians orders dated 08/25/2024 revealed no order for Resident #10 to receive the influenza vaccine yearly. A record review of Resident #10's immunization record dated 08/25/2024 revealed no influenza vaccine was offered and or declined. Resident #22 A record review of Resident #22's admission record dated 08/28/2024 revealed an admission date of 01/29/2024 with diagnoses which included adult failure to thrive, chronic kidney disease with need for dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally), and type II diabetes (a chronic disease characterized by high blood sugar levels). A record review of Resident #22's quarterly MDS assessment dated [DATE] revealed Resident #22 was an [AGE] year-old male admitted for long term care and assessed with a BIMS score of 13 out of a possible 15 which indicated intact cognition. 455742 Page 19 of 20 455742 08/30/2024 The Lev at San Antonio 7703 Briaridge Drive San Antonio, TX 78230

F 0883 Level of Harm - Minimal harm or potential for actual harm A record review of Resident #22's physicians orders dated 08/25/2024 revealed an order for Resident #22 to receive the influenza vaccine yearly. A record review of Resident #22's immunization record dated 08/25/2024 revealed no influenza vaccine was offered and or declined. Residents Affected - Some Resident #28 A record review of Resident #28's admission record dated 08/28/2024 revealed an admission date of 01/20/2024 with diagnoses which included chronic kidney disease with need for dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally), and type II diabetes (a chronic disease characterized by high blood sugar levels). A record review of Resident #28's quarterly MDS assessment dated [DATE] revealed Resident #28 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 13 out of a possible 15 which indicated intact cognition. A record review of Resident #28's physicians orders dated 08/25/2024 revealed an order for Resident #22 to receive the influenza vaccine yearly. A record review of Resident #28's immunization record dated 08/25/2024 revealed no influenza vaccine was offered and or declined. During an interview on 08/27/24 at 05:13 PM the ADON stated residents #10, #22, and #28 were not offered education on the benefits and potential side effects of the influenza immunization and the facility did not offer an influenza immunization to Residents #10, #22, and #28, during October 1, 2023, through March 31, 2024. The ADON stated the risk for harm to the residents was potential exposure to the influenza virus and infection by the virus. During an interview on 08/29/24 at 04:15 PM the DON stated the facility's policy was to offer all residents the influenza immunization annually from October 1 through March 31. The DON stated some how residents #10, #22, and #28 were not offered the influenza virus. The DON stated the risk for harm to the residents was potential exposure to the influenza virus and infection by the virus. A record review of the facility's undated Influenza Vaccination policy revealed, It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents, staff members, and volunteer workers annual immunization against influenza . Influenza vaccinations will be routinely offered annually from October 1st, through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during this time period, or refuses to receive the vaccine. Additionally, influenza vaccinations will be offered to residents upon availability of the seasonal vaccine until influenza is no longer circulating in the facility's geographic area. Following assessment for potential medical contraindications, influenza vaccinations may be administered in accordance with physician-approved standing orders. Prior to the administration of the influenza vaccine, the person receiving the immunization, or his/her legal representative, will be provided with a copy of CDC's current vaccine information statement relative to the influenza vaccination. The vaccine information statements (VIS) will, as appropriate, be supplemented with visual presentations or oral explanations to assist vaccine recipients in understanding the benefits and potential side effects of the influenza vaccine 455742 Page 20 of 20