Health inspection·July 31, 2025

F 0641 Ensure each resident receives an accurate assessment. 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 the resident Minimum Data Set (MDS) assessment accurately reflected the resident's status for 2 (Resident #48 and Resident #84) of 5 residents reviewed for accuracy of assessments. 1.The facility failed to ensure Resident #48 was coded on his annual MDS assessment dated [DATE] as receiving an antipsychotic medication. 2.The facility failed to ensure Resident #84 was coded on his quarterly MDS assessment dated [DATE] as receiving an antipsychotic medication. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: 1.Review of Resident #48's admission sheet with an original admission date of 8/31/24 and a re-admission date of 7/16/25, showed a [AGE] year-old male resident with diagnoses including Dementia, Depression, Anxiety, Post Traumatic Stress Disorder, Cholecystitis (inflammation of the gallbladder, often caused by gallstones), Parkinson's Disease (a movement disorder of the nervous system), and Hypertension (high blood pressure). Review of Resident #48's order summary included an order for Nuplazid (Pimavanserin) 34 MG dated 8/30/24, with directions to give 34 MG one time a day for hallucinations. Nuplazid is an atypical antipsychotic indicated for the treatment of hallucinations and delusions associated with Parkinson's disease psychosis. Review of Resident #48's annual MDS assessment dated [DATE] documented the resident with a BIMS of 11, indicating moderate cognitive impairment. Further review of the assessment showed in Section N Medications, N0415. High-Risk Drug Classes: Use and Indication 1. Is taking Check if the resident is taking any medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days A. Antipsychotic, a blank box under the Is taking column for antipsychotic medication. Review of Resident #48's care plan with a revision date of 9/2/24, documented the resident is on antipsychotic medication use r/t hallucinations with interventions/tasks including Document episodes of behavior; Document non-pharmacological interventions; Pimavanserin as ordered per Medical Doctor (MD); and Quarterly Abnormal Involuntary Movement Scale (AIMS) assessment to be completed. 2.Review of Resident #84's admission sheet with an original admission date of 1/17/23 and a re-admission date of 10/3/23, showed a [AGE] year-old male with diagnoses including Type 2 Diabetes Mellitus, Hypertension, Anxiety, Bipolar Disorder, and Benign Prostatic Hyperplasia (enlarged prostate). Review of Resident #84's order summary included an order for Latuda (Lurasidone) 40 MG dated 4/10/25, with directions to give 1 tablet by mouth one time a day for Bipolar. Latuda is an atypical antipsychotic indicated for the treatment of schizophrenia and bipolar depression. Review of Resident #84's quarterly MDS assessment dated [DATE] documented the resident with a BIMS of 14, indicating intact cognition. Further review of the assessment showed in Section N - Medications, N0415. High-Risk Drug Classes: Use and Indication 1. Is taking Check if the resident is taking any medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days A. Antipsychotic, a blank box under the Is taking column for antipsychotic medication. Review of Resident #84's care plan with a revision date of 5/20/24, documented the resident receives Lurasidone Psychotropic medication r/t Bipolar disorder with interventions/tasks including Administer medications (Latuda) as ordered. Monitor/document for side effects and effectiveness. During an interview with the MDS Coordinator on 7/30/25 at 2:24 PM, the MDS Coordinator stated she opens the MDS assessment in the scheduled time frame and the interdisciplinary team reviews the medical record and completes their portion of the assessment. The MDS Coordinator stated when the assessment was complete, a registered nurse with Resource Utilization Group (RUG) training will sign the assessment. The MDS Coordinator stated after the assessment has been signed, she Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676325 If continuation sheet Page 2 of 5 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 676325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeside Nursing and Rehabilitation Center 8707 Lakeside Parkway San Antonio, TX 78245 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete will lock and transmit it. The MDS Coordinator stated it was important for the MDS to be accurate, because they use the assessment for quality measures, to perform the care of the patient, and to revise the care plan. During an interview with the DON on 7/30/25 at 4:00 PM, the DON stated her expectation for the MDS assessments is that they are accurate, and if they are inaccurate, her expectation was that they be fixed. During an interview with the DON on 7/31/25 at 9:08 AM, the DON stated they use the Resident Assessment Instrument (RAI) Manual as a reference for the MDS assessments. Review of the RAI Manual (Resident Assessment Instrument) dated October 2024, documented in section N0450: Antipsychotic Medication Review Coding Tips and Special Populations, Any medication that has a pharmacological classification or therapeutic category of antipsychotic medication must be recorded in this section, regardless of why the medication is being used.Review of the facility policy titled Resident Assessment, undated, documented It is the policy of this facility to complete a comprehensive assessment of the resident's needs which are based on the State's specific Resident Assessment Instrument (RAI) and the facility's interdepartmental assessment forms. Event ID: Facility ID: 676325 If continuation sheet Page 3 of 5 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 676325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeside Nursing and Rehabilitation Center 8707 Lakeside Parkway San Antonio, TX 78245 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews 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. 1. 1 container of an orange juice cup was sitting on top of a box of orange juice and was partially opened. 2. A box of graham cracker tart shells was open and the individual shells were not covered. 3. A box of vanilla ice cream cups was open, not dated and contained cups that had opened and spilled out into the cardboard box. 4. A box of strawberries in the freezer was open and the plastic wrap around the strawberries was torn, exposing the strawberries to the air. 5. An individually wrapped glazed donut was in a plastic baggie with smeared marks at the top where the Date and Contents line was located. 6. An undated and unlabeled bag of red juice was located under the juice dispenser and was not connected to the dispenser. 7. The facility failed to store a mop in the proper position in the utility closet. These deficient practices could place residents who received meals and snacks from the kitchen at risk for food borne illness. The findings were: 1. Observation on 07/28/25 at 9:12 am in the kitchen revealed a small container of orange juice sitting on top of a cardboard box of orange juice that had the cardboard lid partially opened and juice had leaked out onto the side of the container. 2. Observation on 07/28/25 at 9:12 am in the kitchen revealed a box of graham cracker crust tart shells that was open, not dated and exposed to the air.3. Observation on 07/28/25 at 9:12 am in the kitchen freezer revealed a box of vanilla ice cream cups that was open, not dated and contained cups that had opened and spilled out into the cardboard box. This appeared to indicate that at some point the containers were not kept frozen and melted so that the contents spilled out. 4. Observation on 07/28/25 at 9:12 am in the kitchen, revealed a box of strawberries in the freezer that was open and the plastic wrap around the strawberries was torn, exposing the strawberries to the air.5. Observation on 07/28/25 at 9:12 am in the kitchen, revealed a baggie of an individually wrapped glazed donut with illegible ink smears on the label part of the bag for date and contents.6. Observation on 07/28/25 at 9:12 am in the kitchen, revealed an undated and unlabeled open bag of red juice located under the juice dispenser laying on a shelf that was not connected to the dispenser. A kitchen employee grabbed the container off the shelf when she noted surveyor was looking at it and said she was going to take it to the trash. 7. Observation of the utility closet in the kitchen on 07/29/25 at 10:00 am revealed a mop stored head-side down in the drain compartment of a mop- bucket. The mop was not in use at the time of the observation. The Dietary Manager was asked if that is where the mop is usually stored he said, ‘No, it should be hung up. He then proceeded to try and hang the handle of the mop on a wall mounted mop and broom holder. The holder would not hold the handle so he just took the mop head off, put it in a plastic bag and had one of his employees take it to the laundry. On 07/31/25 at 1:00 pm, a follow-up observation of the closet revealed a mop with the mop head up leaning against the wall of the closet. When asked if this was the proper way to store the mop, the Dietary Manager stated that it should probably be stored with mop head down which was also incorrect. Record review of an undated Policy/Procedure for Dietary Services revealed It is the policy of this facility that the facility shall have an organized food service, appropriately planning, equipped, and staffed to prepare and serve the number of meals created in the kitchen. Under the Procedures, #7 stated All cleaning equipment must be stored in designated area when not in use. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 6-501.16 Drying Mops. After use, mops shall be placed in a position that allows them to air-dry without soiling walls, equipment, or supplies. Event ID: Facility ID: 676325 If continuation sheet Page 4 of 5 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 676325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeside Nursing and Rehabilitation Center 8707 Lakeside Parkway San Antonio, TX 78245 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 6 residents (Resident #86) reviewed for infection control, in that: While providing colostomy care for Resident #86, LVN C failed to use proper infection control. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #86's face sheet, dated 07/30/2025, revealed an admission date of 02/05/2025, and a readmission date of 05/01/2025, with diagnoses which included: Dementia (decline in cognitive abilities), Type 2 diabetes mellitus(high level of sugar in the blood),Dysphagia (Difficulty swallowing), Depression (mood disorder that causes a persistent feeling of sadness and loss of interest), Hypothyroidism (under active thyroid), Hypertension (high blood pressure), Ileostomy status(opening in the abdominal wall allowing for elimination of feces). Record review of Resident #86's Significant Change MDS, dated [DATE], revealed the resident had a BIMS score of 15 indicating no cognitive impairment. Resident #86 required total assistance with her ADLs, was always incontinent of bladder and, had a ostomy. Review of Resident #86's care plan, dated 02/06/2025, revealed a problem of Has an alteration in gastro-intestinal status r/t Diverticulitis withperforation and Ileostomy status. and an intervention of Provide ileostomy care and change bag as needed. Observation on 07/30/2025 at 12:05 p.m. revealed while providing Ileostomy (opening in the abdomen allowing waste to exit the body) care for Resident #86, LVN C, use sanitizer between change of gloves after removing the collection bag and after cleaning the stoma, however LVN C did not sanitize between her fingers. During an interview with LVN C, on 07/30/2025 at 12:25 p.m., she stated she did not realize she did not correctly sanitize her hands but confirmed she should sanitize between her fingers to prevent cross contamination and put the resident at risk for infection. She confirmed receiving infection control training within the year. During an interview with the DON on 07/30/2025 at 3:55 p.m., she stated staff had to sanitize between their fingers while sanitizing to prevent risk of infection for the residents. She confirmed training was provided for the staff at least annually and their skills were check at least annually Review of facility policy, titled Hand Hygiene, dated 10/2022, revealed Using alcohol-based hand rubs. Apply generous amount of product to palm of hands and rub hands together. Cover all surfaces of hands and fingers until hands are dry. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676325 If continuation sheet Page 5 of 5