Health inspection·September 15, 2023

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess each resident quarterly (every 3 months) using the Minimum Data Set form specified by the state and approved by CMS for 1 of 36 residents (Resident #10) reviewed reviewed for quarterly assessments, in that: Residents Affected - Few Resident #10's Quarterly MDS Assessment was not completed within 92 days of the previous quarterly assessment. This failure could place residents at-risk of not having their assessments completed timely. The findings were: Record review of Resident #10's face sheet, with a report date of 09/15/2022, reflected Resident #10 was admitted on [DATE] with diagnoses that included: muscle atrophy of left shoulder (breakdown of muscle in the left shoulder), dementia (A group of thinking and social symptoms that interferes with daily functioning), and pulmonary hypertension (A type of high blood pressure that affects arteries in the lungs and in the heart.) Record review of Resident #10's last MDS assessment revealed it was completed on 05/10/2023. The proceeding MDS assessment was due dated 8/10/2023, however it was completed on 09/03/2023. Interview on 09/14/2023 at 1:33 PM, the MDS Coordinator stated Resident #10's MDS, dated [DATE], was the last MDS completed for Resident #10. The MDS Coordinator stated Resident #10 should have this last assessment completed on or before 08/10/2023. The MDS Coordinator stated the MDS assessment was completed on 09/03/2023 due to a late response and inability to complete the assessment on time. The MDS Coordinator stated the risk associated with a late MDS assessment was that a resident could have a change of condition go unnoticed or unrecorded. recent MDS assessment for Resident #10. The ADM stated it is his expectation that MDS assessments be completed within their required timeframes according to the RAI Manual. The ADM stated the risk associated with not completing the MDS assessments timely would be that residents may have changes that would not be noticed or recorded. Record review of the RAI (Resident Assessment Instrument) Manual OBRA Assessment Summary, dated 10/2019, reflected, The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. Page 1 of 9 676312 676312 09/15/2023 Legend Oaks Healthcare and Rehabilitation - West S 222 Bertetti Dr San Antonio, TX 78227

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to refer a resident with newly evident or possible serious mental disorder for a PASRR Level II resident review upon a significant change of condition for 1 of 2 Residents (Resident #59) reviewed for PASRR (Preadmission Screening and Resident Review Services). The MDS Coordinator failed to refer Resident #59 for a resident review after being diagnosed with major depression, recurrent (04/02/21), major depressive disorder, recurrent, severe with psychotic symptoms (12/29/21) and schizoaffective disorder, (03/18/22). This deficient practice could place residents at risk of not receiving the needed PASRR services. The findings were: Review of Resident #59's Face Sheet dated 09/14/21 revealed Resident #59 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior), major depressive disorder, recurrent, severe with psychotic symptoms (a common, chronic, treatable mood disorder that typically follows a remitting and relapsing course of depressive episodes), frontal lobe and executive function deficit following CVA a cognitive dysfunction resulting in a reduced ability to initiate, control and monitor targeted behavior), chronic kidney disease, stage 3 (your kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of your blood), major depressive disorder, recurrent (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life ). Review of Resident #59's Annual MDS dated [DATE] revealed in Section A (Identification Information), A1500 (Preadmission Screening and Resident Review (PASRR), Is the resident currently considered by state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition? The area has documented 0. No. Further review revealed Resident #59 had a BIMS of 05 indicating severe cognitive impact, Mood was 10 indicating the resident feels down, depressed or hopeless, poor appetite or overeating, feeling bad about herself, trouble concentrating and or behaviors the resident according to the documentation revealed no behaviors. Review of Resident #59's older Annual MDS dated [DATE] revealed in Section A, A1500 has documented the same 0. No. Review of Resident #59's PASRR Level I Screening, completed on 11/04/20, by the hospital. Section C PASRR Screen questions C0100 asks is there evidence or an indicator this individual has Mental Illness? The answer was 0 (0. No). The PASRR Level I Screening. was correct until a change in condition revealed a diagnoses for major depression, recurrent on 04/02/21. Review of Resident #59's Comprehensive Care Plan dated 11/28/20 to 08/10/23 had documented for Potential to demonstrate verbally abusive behaviors due to schizoaffective disorder with date initiated on 11/28/20 and last revision on 08/22/23. Further review of the Comprehensive Care Plan revealed a care plan initiated on 03/14/22 and last revision was 05/11/23 which addresses Resident #59's diagnosis major depressive disorder with delusions and to administer medications as ordered (Risperidone). 676312 Page 2 of 9 676312 09/15/2023 Legend Oaks Healthcare and Rehabilitation - West S 222 Bertetti Dr San Antonio, TX 78227

F 0644 Monitor/document for side effects and effectiveness initiated 03/13/22. Level of Harm - Minimal harm or potential for actual harm Review of Resident #59's Physician's Orders dated 09/14/23 revealed the resident was taking Risperidone 1mg tab give 1 po bid for schizoaffective disorder (started 04/28/23), and also taking Remeron 15mg tab give 0.5mg (7.5mg) po at bedtime (started 1/09/23) for Depression and Doxepin Hcl cap 100mg give 1 cap po at bedtime (started 06/18/23) for major depression. Residents Affected - Few Interview on 09/15/23 at 1:25 p.m. with the MDS Coordinator revealed a PASRR Level I on 11/05/20 and the PASRR was negative. When the MDS Coordinator was asked to review Resident #59's diagnoses, she stated a new PASRR Level I positive for MI should have been done and then a referral on over to PASRR services to review to see if Resident #59 really needed any services. No, I did not realize it and Resident #59 was receiving psych services, which if Resident #59 had been referred on over could have not only received psych services but, possibly other benefits. Interview on 09/15/23 at 1:50 p.m. with the DON revealed she was not aware of Resident #59's PASRR and not aware the resident might have qualified for more services if Resident #59 had been referred over. The DON stated, since she has not been seen by PASRR she could be missing out on services she qualifies for. Interview on 09/15/23 at 2:00 p.m. with the Administrator revealed he does not deal with PASRR. The Administrator stated no, I was not aware Resident #59 was not possibly provided with services Resident #59 could have benefited from. Review of the facility PASRR Policy and Procedure dated 11/2016 with revision 01/22 stated in part: The facility will designate an individual to follow up on ALL residents have received PASRR Level I screening. If facility serves a resident with a positive PASRR Level 1 screening, the facility MUST have obtained A PASRR Level II evaluation from the Local Authority or have documented attempts to follow up with the Local Authority to obtain the PASRR Level II evaluation. 676312 Page 3 of 9 676312 09/15/2023 Legend Oaks Healthcare and Rehabilitation - West S 222 Bertetti Dr San Antonio, TX 78227

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure they transmitted a PASSR evaluation on newly admitted resident for 1 of 4 residents (Resident #69) reviewed for PASRR screenings. Residents Affected - Few The facility failed to ensure that the initial PASRR screening (Level 1 Screening) was transmitted to the Local Mental Health Authority: This failure could place the residents at risk of not receiving specialized and/or habilitative services as need to meet their needs. Findings included: Record review of the clinical record for Resident #69 revealed he was a [AGE] year old male admitted on [DATE] with the diagnosis that included but not limited to the following: Major Depressive Disorder, recurrent, unspecified (feelings of low or depressed mood and/or decreased interest in pleasurable activities for prolonged and persistent time period), anxiety disorder (excessive anxiety and worry for more days than not maybe uncontrollable and for no specific rationale), post-traumatic stress disorder (may experience feelings of isolation, irritability and/or guilt, may have problems with sleep, difficulty concentrating , may have nightmares and find concentrating difficult). Record review of Resident #69's MDS dated [DATE] revealed a BIMS of 12 indicating the resident had mildly impaired cognition. Record review of Resident #69's care plan, dated 12/15/2023, revealed in part: Resident #69 will show decreased episodes of symptoms of depression and is at risk for re-traumatization r/t history of trauma Post-traumatic stress disorder. Record review of Resident #69's chart revealed there was not a prescreening for PASRR eligibility in the electronic health record, prior to the admission (PL-1, form utilized to determine whether an individual could possibly have a diagnosis which could make them eligible for additional services in relation to a mental health or intellectual and developmental disability). Interview on 09/14/2023 at 2:43 p.m. the DOA stated, the Admissions department was responsible for obtaining the PASSR level 1 (PL-1) screenings from the referring entity for all admitted residents. The DOA stated, Resident #69 did have a positive PL-1 but it must have been overlooked by the previous DOA, therefore Resident #69 did not have a screening by the Local Authority after admission as he should have, to determine whether he would qualify for services. Interview with MDS on 09/14/2023 at 2:48 p.m., MDS stated it appeared Resident #69's positive PL-1 was sent with Resident #69 at the time of admission but was not entered by the facility as it should have been. Therefore Resident #69 was not screened for service eligibility by the Local Authority as the resident should have been. Further stating, The admission Coordinator that was responsible for making sure those are sent to me is no longer employed by the facility. Those are important because of the services residents may get. Interview with on 09/14/2023 at 4:00 p.m., the Administrator stated the PASSR for Resident #69 was overlooked a few years ago and it should have been entered but it was not. The Administrator further 676312 Page 4 of 9 676312 09/15/2023 Legend Oaks Healthcare and Rehabilitation - West S 222 Bertetti Dr San Antonio, TX 78227

F 0645 stated he did not know why it was not completed, but the resident is getting other mental health services. Level of Harm - Minimal harm or potential for actual harm Record review of the facility PASRR policy and procedure document, dated 11.2016, with a revised date of 1.2022, provided prior to exit revealed: The facility will designate an individual to follow up on all residents have received a PASRR Level 1 screening. A. Coordinate with the local Intellectual/Developmental Disability and/or Local Mental Health Authority (Local Authority to ensure a PASRR Level II Evaluation is conducted when an individual's PASRR Level 1 screening indicates the individual may have an ID, DD or MI). Residents Affected - Few 676312 Page 5 of 9 676312 09/15/2023 Legend Oaks Healthcare and Rehabilitation - West S 222 Bertetti Dr San Antonio, TX 78227

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 32 residents (Resident # 5) reviewed for accidents and hazards. The facility failed to ensure Resident #5 did not have four disposable razors in the room. The failure could place residents at risk of harm or injury and contribute to avoidable accidents. The findings were: Record review of Resident #5's Face Sheet dated 09/14/2023, revealed an admission date of 12/05/2022 and readmission date of 09/11/2022 with diagnoses which included but not limited to the following: after care following joint replacement surgery, presence of left artificial knee joint, muscle wasting and atrophy(the wasting or thinning of muscle mass), not elsewhere classified, multiple sites, pain in the left knee, (the resident had a left knee replacement and required assistance to complete daily tasks for himself); unspecified dementia, mild with other behavioral disturbance (dementia is a term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life), depression (feeling of sadness or loneliness) , essential hypertension (high blood pressure), and presence of a cardiac pacemaker (has a cardiac pace maker). Record review of Resident #5's Quarterly MDS dated [DATE] revealed the resident had a BIMS of 14 which indicated the resident was cognitively intact. Record review of Resident # 5's Care Plan with a print date of 09/15/2023 revealed the resident had impaired immunity related to a life threatening illness and was at risk for contracting infections due to impaired immune status, keep the environment clean and people with infection away. During an observation and interview on 09/12/2023 at 4:35 p.m. Resident #5 said the 4 disposable razors on his side table were razors he used to shave himself. During an observation and interview on 09/14/2023 at 1:41 p.m , while looking at the 4 personal disposable razors, Resident #5 stated I keep them on that table and I shave myself, staff gives them to me. When asked if he would be able to get to the razors to prevent anyone resident from taking them from his room if needed, he replied, no I would not. During an interview on 9/14/2023 at 2:01 p.m., CNA B said, sometimes Resident #5 will let us take the razors and sometimes he will not. CNA B explained the razors should not be left in the room and should be disposed of in a special container made for used razors to prevent anyone from getting hurt and to make sure there was no cross contamination. During an interview and observation with the DON on 09/15/2023 at 3:35 p.m., the DON said Resident #5 curses at staff and will throw things when he is upset. The razors are not in his care plan and they are a risk, anyone could go in the room and cut themselves. During an interview and observation with the Administrator, the Administrator stated the razors 676312 Page 6 of 9 676312 09/15/2023 Legend Oaks Healthcare and Rehabilitation - West S 222 Bertetti Dr San Antonio, TX 78227

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few should not be in Resident #5's room. Resident #5 is very noncompliant with services at time. They should not be in the room, there is an infectious disease issue with them being there. They should be disposed of properly. The Administrator went on to explain Resident #5 has a history of aggressive behaviors when he does not get what he wants and it makes it difficult for staff. Policy Provided by the facility prior to exit Subject: Accident Intervention, with the revised date of 05/2007, revealed the following: it is the policy of this facility that the resident environment remains free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents. 676312 Page 7 of 9 676312 09/15/2023 Legend Oaks Healthcare and Rehabilitation - West S 222 Bertetti Dr San Antonio, TX 78227

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 2 of 2 nourishment rooms reviewed for dietary sanitation in that: The facility failed to maintain the cleanliness of the ice maker found within the nourishment rooms. These failures could place residents at risk for foodborne illnesses such as norovirus. The findings included: Observation on 9/14/2023 at 1:39 PM, revealed Nourishment room [ROOM NUMBER] located by halls 100-400 to have contained an ice maker with white, grey, and black mass accumulation in and around the ice dispensing components. Observation on 9/14/2023 at 1:50 PM, revealed Nourishment room [ROOM NUMBER] located by halls 500-800 to have contained an ice maker with white, grey, and black mass accumulation in and around the ice dispensing components. Interview and observation on 9/14/2023 at 1:55 PM, the DM stated the Dietary Department shared the responsibility of the cleanliness of the ice makers with the Maintenance Department. The DM stated routine inspections and deep cleanings were only completed by the Maintenance Department. The DM stated the Dietary Department had begun a cleaning schedule for the main ice maker located in the kitchen but had not began a routine cleaning schedule for the ice makers within the nourishment rooms due to the DM not believing the nourishment rooms required them. The DM stated the white, grey, and black masses looked like calcium or hard water buildup. The DM stated the risk associated with an unclean ice maker can result in poor taste and unclean ice consumption by residents. Interview and observation on 9/14/2023 at 2:05 PM, the Maintenance Supervisor stated her routine for cleaning the nourishment room ice makers was every three months. The MS stated she was responsible for cleaning the machines. The MS stated the white, grey, and black masses looked like calcium or hard water buildup. The MS stated that the cleaning frequency was quarterly, but if this level of uncleanliness was observed then a monthly schedule should have been enacted. Interview on 9/14/2023 at 5:24 PM, the ADM stated he was not aware of the level of cleanliness of the ice makers in the nourishment rooms. The ADM stated that it was his expectation that ice makers intended for resident use be cleaned on a frequent basis in order to prevent potential contamination spreading to residents. Record review of document titled, Ice Machine Maintenance Log, undated, reflected the last cleaning was on 8/12/2023. A policy specific to ice machine cleanliness was not provided upon exit. Record review of US FDA Food Code, dated 2022, revealed Surfaces of utensils and equipment 676312 Page 8 of 9 676312 09/15/2023 Legend Oaks Healthcare and Rehabilitation - West S 222 Bertetti Dr San Antonio, TX 78227

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few contacting food that is not time/temperature control for safety food such as . ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. Some equipment manufacturers and industry associations, e.g., within the tea industry, develop guidelines for regular cleaning and sanitizing of equipment . and 3-304.11 Food Contact with Equipment and Utensils. FOOD shall only contact surfaces of: (A) EQUIPMENT and UTENSILS that are cleaned as specified under Part 4-6 of this Code and SANITIZED as specified under Part 4-7 of this Code; P (B) Single-service and single-use articles. 676312 Page 9 of 9