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. Page 1 of 4 455742 455742 04/03/2025 The Lev at San Antonio 7703 Briaridge Drive San Antonio, TX 78230

F 0622 Level of Harm - Minimal harm or potential for actual harm During an interview with the Assistant Director of Nurses (ADON) on 4/1/25 at 12:25 p.m., she stated that Resident #1 did not have a physician's order for discharge on [DATE]. The ADON stated that a discharge summary pertaining to Resident #1's discharge had not been completed by Resident #1's physician or by the nursing staff. The ADON stated she was aware of the documentation requirements for a physician order for discharge and for the completion of a discharge summary. Residents Affected - Few During an interview with the MDS Nurse on 4/1/25 at 1:00p.m., she stated that a physician's order for discharge for Resident #1 on 12/6/24 was not completed. The MDS Nurse stated that she was not aware of a discharge summary completed by the resident's physician or nurse for Resident #1's discharge on [DATE]. During an interview with the Administrator on 4/2/25 at 2:50pm stated the facility would be completing in-service for nursing staff on obtaining physician orders for discharge and for the completion of the discharge summaries. Record review of the facility policy and procedure titled Discharge Summary and Plan of Care dated 2021 reflected Upon discharge of a resident a discharge summary will be provided to the receiving care provider. The Discharge Summary should include; an overview of the resident's stay, and a final summary of the resident's status at the time of discharge. 455742 Page 2 of 4 455742 04/03/2025 The Lev at San Antonio 7703 Briaridge Drive San Antonio, TX 78230

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide notification of a resident's discharge to ensure that appropriate information is communicated to the Office of the State Long-Term Care Ombudsman for 1 or 6 residents (Resident #1) reviewed for transfer or discharge. The facility failed to ensure that: 1. Resident #1's discharge notification was sent to the Office of the State Long-Term Care Ombudsman. This deficient practice could affect resident's safe discharge planning by missed notification to the proper authorities. 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 social worker progress notes dated 4/1/25 revealed that Resident #1 had requested alternate nursing facility placement during the month of 10/24 and was agreeable with the social worker's search for alternate nursing facility placement. During an interview with the facility's Ombudsman on 4/1/25 at 1:45pm she stated that she had not received written notification of Resident #1's discharge to another nursing facility on 12/6/24. During an interview with the facility's admission Director on 4/3/25 at 9:05 a.m , she stated that Resident #1 was her own responsible party (RP) and had signed her own admission documents to the facility. During an interview with the facility's Social Worker on 4/3/25 at 9:15am she stated that she was responsible for sending the Ombudsman's office the discharge notification information and that Resident #1 had been discharged to another nursing facility on 12/6/24. The Social Worker stated that at the time of the resident's discharge she was unaware of the notification requirement. During an interview with the Administrator on 4/3/25 at 10:15am she stated that the local Ombudsman had not been notified of Resident #1's discharge on [DATE]. The Administrator stated that the notification was important to meet the proper resident discharge requirement. 455742 Page 3 of 4 455742 04/03/2025 The Lev at San Antonio 7703 Briaridge Drive San Antonio, TX 78230

F 0623 Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy and procedure titled Discharge Summary and Plan of Care dated 2021 reflected, The Discharge Summary should include: A final summary of the resident's status at the time of discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative. Residents Affected - Few 455742 Page 4 of 4