Health inspection·April 3, 2025

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to document a resident's discharge to ensure that appropriate information is communicated to the receiving health care provider for 1 or 6 residents (resident #1) reviewed for transfer or discharge. The facility failed to ensure that: 1.Resident #1 did have a documented discharge order written by the resident's physician for the resident's discharge from the facility. 2. Resident #1 did have a documented discharge summary written by the resident's physician or nurse for the resident's discharge from the facility. This deficient practice could affect resident's planned discharge destination by contributing to a discharge from the facility that was not properly documented. The findings included: Record review of Resident #1's face sheet, dated 04/01/25, revealed a [AGE] year-old resident initially admitted on [DATE] with diagnoses including autistic disorder (a neuro-developmental disorder of repetitive patterns of behavior), trisomy 21-mosaicism (a genetic condition in which there is a mixture of two types of cells-Down's syndrome), and type 2 diabetes with hyperglycemia (a condition in which the body does not produce enough insulin). Record review of Resident #1's re-admission MDS assessment dated [DATE] reflected that Resident #1 had a BIMS of 14, indicating intact cognition. Record review of Resident #1's initial care-plan dated 9/30/24 revealed Resident #1 was dependent on staff for meeting her emotional, intellectual, physical, and social needs. Record review of Resident's #1's progress notes dated 4/1/25 revealed Resident #1 was discharged on 12/6/24 with the following notation: Resident left in good spirits via gurney with EMT, all belongings were taken with resident. Record review of Resident #1's electronic medical record on 4/1/25 revealed that there was not a physician order for the discharge on [DATE] or a completed discharge summary pertaining to the discharge. (continued on next page) 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 Page 1 of 4 Event ID: 455742 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 455742 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lev at San Antonio 7703 Briaridge Drive San Antonio, TX 78230 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)