Inspection·July 14, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm the morning of 7/8/23. CNA D stated around 1 or 2 in the morning he was assisting CNA E in helping Resident #1 to the bathroom. CNA D stated they noticed a bad odor coming from the bandages of Resident #1's feet and that was when he and CNA E noticed the maggot between Resident #1's left toes. CNA D stated, like 3 baby little small worms. The smallest worms. CNA D stated he notified LVN C of the maggots on Resident #1 and LVN C notified the Treatment Nurse. CNA D stated LVN C took pictures of the maggots. Residents Affected - Few During an interview on 7/13/23 at 8:57 a.m., when asked if something happened to her on the weekend of 7/8/23, Resident #1 stated, They said it was little bugs. But it wasn't a bug. It was just a little something. Something they saw over in the corner of the bed . Ain't no maggots on my legs. They saw it. I didn't see it. It was a little . it was probably a piece of something. A fabric or something. During an interview on 7/13/23 at 2:22 p.m., the Treatment Nurse stated, I got a call in at 3:00 a.m. on 7/8/23, a Saturday morning. I was called to come in and address a patient with a wound that supposedly a maggot was on a drape in her bed . I went to [Resident #1's room]. I observed the patient laying in bed and with the chuck underneath her and pointed out that there was white crawling on it (the chuck), and I said, 'yeah, okay.' .It was just laying on the chuck. It was a half centimeter long and it was white. The Treatment Nurse confirmed it was a maggot and stated she informed the DON of what she found. The Treatment Nurse stated, I found nothing, just one laying on the chuck. There was nothing on her body. During an interview on 7/13/23 at 2:47 p.m., the DON stated, My night shift nurse called telling me that there was bugs on the bed and [Resident #1] had-I don't know if it [the bug] was on top of the dressing or on the side . I told my administrator so he can get housekeeping to come and clean the room. I had the nurses remove whatever was there. And that's pretty much it. When asked what insects the nurses thought were in Resident #1's room, the DON stated, Maggots. When asked if the nurses actually found any, the DON stated, I believe so, but it wasn't inside or underneath [Resident #1's] dressing. When asked if the nurses sent her a picture of the insects, the DON stated, No. Not on the patient. When asked if the nurses were able to confirm if the insect was a maggot, the DON stated, I'm not sure if it was confirmed. I don't know how we'd-I didn't specifically see it, so I wouldn't know. During an interview on 7/14/23 at 5:29 a.m., CNA E stated she worked the evening of 7/7/23 into the morning of 7/8/23. CNA E stated she responded to Resident #1's call light and assisted Resident #1 to the bathroom. CNA E stated she noticed Resident #1's right bandage was soaked and reported the issue to LVN C. CNA E stated about 20 minutes after she reported the issue to LVN C, LVN C went into Resident #1's room and told CNA E she found maggots between Resident #1's left toes. When asked if she saw the maggots, CNA E stated, Yes, they were little. I can't tell you how many. I just opened the toes and she [LVN C] put the light on it and they were in there moving. During a follow-up interview and a record review on 7/14/23 at 5:55 a.m., LVN C stated the Treatment Nurse had to know about the maggots because the Treatment Nurse had to use her [the Treatment Nurse's own] two fingers to push the maggots out from between Resident #1's left toes. At this point, LVN C disclosed two photographs to this surveyor. LVN C stated she took the photographs on the morning of 7/8/23 because she wanted to show the insects to the DON. LVN C stated the first picture had the Treatment Nurse's orange-painted fingernail tip pointing at 2 maggots curled together on white linen. LVN C stated the second picture was her own finger pointing at a maggot inside an inverted glove (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676281 If continuation sheet Page 2 of 16 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 676281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westover Hills Rehabilitation and Healthcare 9922 State Hwy. 151 San Antonio, TX 78251 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 7/13/23 at 7:01 p.m., LVN C stated she worked overnight from Friday, 7/7/23, to Saturday morning, 7/8/23. LVN C stated Resident #1 had a bandage on her left lower leg that stopped just below the toe knuckles, leaving the toes to wiggle free, and the toes were where the maggots were found. LVN C stated, The CNAs alerted me that she was having a lot of weeping on her legs. And her left foot was itching. So they addressed the right leg, when I went to look at her left leg, she said her toes itched. So I looked between her toes and between, I want to say it was between the 3rd and 4th digit on her left toe, she had some little bugs between them. So I called the DON, the DON called [the Treatment Nurse] and [the Treatment Nurse] came up to look at her toes. We looked at her toes. There was little wormy maggot-looking things. I'm not an expert on entomology [the study of insects] so I don't know. [The Treatment Nurse] cleaned it out. She re-wrapped the legs. I'm not exactly sure what she put on the leg. But the skin was intact between the toes. LVN C stated she took 2 pictures of the maggots and sent them to the DON on 7/8/23 between 3:00 a.m. - 4:30 a.m. When asked if she notified anyone, LVN C stated, No. I was told to have [the Treatment Nurse] take care of everything. She did the notes and assessments and everything. When asked if she notified the physician, LVN C stated, No. I was told to have [the Treatment Nurse] take care of everything, so I turned it over to [the Treatment Nurse.] During a follow-up interview on 7/14/23 at 9:48 a.m., when asked if she notified Resident #3's physician of the maggots, the Treatment Nurse stated, No, not at 3:15 in the morning. I don't know if the nurse did, but I did not. The reason I didn't was because there was nothing on her skin. There was no change in condition. During an interview on 7/14/23 at 4:33 p.m., when asked why it was important to notify a physician or a nurse practitioner promptly, ADON A stated, to ensure treatment is carried out as soon as possible rather than after a length of time. The sooner we could get the condition treated, the better. When asked what sort of quality assurance the facility had to ensure physicians and other mid-level providers (such as Nurse Practitioners) are notified, ADON A stated, as soon as the change of condition occurs, it's part of the process. During an interview on 7/14/23 at 10:19 a.m., NP F stated neither she nor the on-call primary care provider were notified of an incident involving Resident #1 on the weekend of 7/8/23. NP F stated she spoke to the on-call provider and that was how she (NP F) was aware the facility did not report anything to their services on the weekend of 7/8/23. NP F stated, [Resident #1] had a history of lymphedema [swelling in the arm or leg caused by blockage in the lymphatic system, which is a part of the immune and circulatory symptoms.] . We're doing wraps for her [legs] and doing diuresis [treatment to help the body dispose of extra fluid] for the swelling. And wound care, as well. NP F stated she rounded on Resident #1 on Monday (7/10/23) and Wednesday (7/12/23.) When asked if she was aware that maggots were found on Resident #1's left foot, NP F stated, No. It was today that you wanted my contact information. And it was regarding this supposed situation. But it sort of sounded like no one knows what really happened. When asked what would she do if she had been notified of maggots on a resident, NP F stated, If she had dressings on her foot, we would change them. We would clean the wound. I would also probably change her room if possible, possibly change the room, period. Change her gown, change everything we can change, all the linens. When asked if there would be any changes to her treatment if there were maggots, NP F stated, The wraps are optional, I could remove those. When asked what sort of issues happen to Resident #1 if maggots were on her foot, NP F stated, You do have a chance for infection. Further inflammation and worsening things. During a follow-up interview on 7/14/23 at 4:19 p.m., when asked if she would want to be notified if maggots were found on a resident, NP F stated, Yes, generally. I'm notified about anything or any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676281 If continuation sheet Page 3 of 16 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 676281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westover Hills Rehabilitation and Healthcare 9922 State Hwy. 151 San Antonio, TX 78251 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few change. When asked if she would want to be notified if maggots were found in a resident room, NP F stated, I'm not against it. I get notified about a lot of-of pretty much everything. During an interview on 7/14/23 at 4:39 p.m., the Medical Director stated she was not familiar with Resident #1 and she was not notified of an incident involving possible maggots on Resident #1. When asked if she would want to be notified if maggots were found on a resident, the Medical Director stated, If they were on the resident, yes. When asked if she wanted to be notified if possible maggots were found in the resident's room (but not necessarily on the resident), the Medical Director stated, If it's not affecting the patient, it's not necessary to notify me. Record review of facility policy titled, Notification, Physician or Responsible party, dated 8/2007, revealed the following: The Nurse Supervisor will notify the resident's attending physician when: B. There is a significant change in the resident's physical, mental, or psychosocial status; C. there is a need to alter the resident's treatment significantly[.] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676281 If continuation sheet Page 4 of 16 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 676281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westover Hills Rehabilitation and Healthcare 9922 State Hwy. 151 San Antonio, TX 78251 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement written policies that prevent neglect for 1 of 7 residents (Residents #3) reviewed for neglect, in that: Residents Affected - Few The nursing staff did not adequately and clearly communicate to the Administrator that maggots were found between Resident #1's left toes. The Treatment Nurse and DON stated there were no maggots on Resident #1's skin when, in fact, maggots were found between Resident #1's left toes. Photographs of the maggots were taken by an LVN C and shared with the DON, but the DON did not share them with the Administrator. This deficient practice could place residents at risk for not having their allegations of abuse and neglect investigated timely and place the residents at risk for abuse and neglect. The findings were: Record review of Resident #1's face sheet, dated 7/13/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of cerebral infarction [a disruption in the brain's blood flow], paroxysmal atrial fibrillation [a rapid, erratic heart rate begins suddenly and then stops on its own within 7 days], End Stage Renal Disease, and other symptoms and signs involving cognitive functions following cerebral infarction. Record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 had a BIMS score of 8, signifying moderate cognitive impairment. Record review of Resident #1's Skin Evaluation, dated 7/8/23 and written by the Treatment Nurse, revealed no documentation of any insects and no documentation that the Administrator was notified. Record review of Resident #1's nursing progress notes from 6/1/23 to 7/13/23, revealed no progress notes documenting the Administrator was notified. Record review of a photograph, provided on 7/14/23, revealed two small, whitish, worm-like maggots on a white linen. An orange fingernail was seen pointing at the two maggots. Record review of a second photograph, provided on 7/14/23, revealed a finger pointing at an inverted glove, which had an indiscernible black spot inside the glove. Record review of a facility policy titled, Abuse Prevention, dated 11/28/2016, revealed the following: All Personnel, residents, visitors, etc. are encouraged to report incidents and grievances without the fear of retribution . All identified events are reported to the Administrator/Designee immediately and will be thoroughly investigated. During an interview on 7/13/23 at 8:57 a.m., when asked if something happened to her on the weekend of 7/8/23, Resident #1 stated, They said it was little bugs. But it wasn't a bug. It was just a little something. Something they saw over in the corner of the bed . Ain't no maggots on my legs. They saw it. I didn't see it. It was a little . it was probably a piece of something. A fabric or something. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676281 If continuation sheet Page 5 of 16 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 676281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westover Hills Rehabilitation and Healthcare 9922 State Hwy. 151 San Antonio, TX 78251 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 7/13/23 at 2:22 p.m., the Treatment Nurse stated, I got a call in at 3:00 a.m. on 7/8/23, a Saturday morning. I was called to come in and address a patient with a wound that supposedly a maggot was on a drape in her bed . I went to [Resident #1's room]. I observed the patient laying in bed and with the chuck underneath her and pointed out that there was white crawling on it and I said, 'yeah, okay.' .It was just laying on the chuck. It was a half centimeter long and it was white. The Treatment Nurse stated she performed the skin assessment with CNA D. The Treatment Nurse stated, I found nothing, just one laying on the chuck. There was nothing on her body. The Treatment Nurse confirmed it was a maggot and stated she informed the DON of what she found. The Treatment Nurse stated she was not sure if the Administrator was informed. During an interview on 7/13/23 at 2:47 p.m., the DON stated, My night shift nurse called telling me that there was bugs on the bed and [Resident #1] had-I don't know if it [the bug] was on top of the dressing or on the side . I told my administrator so he can get housekeeping to come and clean the room. I had the nurses remove whatever was there. And that's pretty much it. When asked what insects the nurses thought were in the resident's room, the DON stated, Maggots. When asked if the nurses actually found any, the DON stated, I believe so, but it wasn't inside or underneath [Resident #1's] dressing. When asked if the nurses sent her a picture of the insects, the DON stated, No. Not on the patient. When asked if the nurses were able to confirm if the insect was a maggot, the DON stated, I'm not sure if it was confirmed. I don't know how we'd-I didn't specifically see it, so I wouldn't know. During an interview on 7/13/23 at 4:39 p.m., CNA D stated he worked from the evening of 7/7/23 to the morning of 7/8/23. CNA D stated around 1 or 2 in the morning he was assisting CNA E in helping Resident #1 to the bathroom. CNA D stated they noticed a bad odor coming from the bandages of Resident #1's feet and that was when he and CNA E noticed the maggot between Resident #1's left toes. CNA D stated, like 3 baby little small worms. The smallest worms. CNA D stated he notified LVN C of the maggots on Resident #1 and LVN C notified the Treatment Nurse. CNA D stated LVN C took pictures of the maggots. During an interview on 7/13/23 at 7:01 p.m., LVN C stated she worked overnight from Friday, 7/7/23, to Saturday morning, 7/8/23. LVN C stated Resident #1 had a bandage on her left lower leg that stopped just below the toe knuckles, leaving the toes to wiggle free, and the toes were where the maggots were found. LVN C stated, The CNAs alerted me that she was having a lot of weeping on her legs. And her left foot was itching. So they addressed the right leg, when I went to look at her left leg, she said her toes itched. So I looked between her toes and between, I want to say it was between the 3rd and 4th digit on her left toe, she had some little bugs between them. So I called the DON, the DON called [the Treatment Nurse] and [the Treatment Nurse] came up to look at her toes. We looked at her toes. There was little wormy maggot-looking things. I'm not an expert on entomology [the study of insects] so I don't know. [The Treatment Nurse] cleaned it [the maggots] out. She re-wrapped the legs. I'm not exactly sure what she put on the leg. But the skin was intact between the toes. LVN C stated she took 2 pictures of the maggots and sent them to the DON on 7/8/23 between 3:00 a.m. - 4:30 a.m. When asked if she notified anyone, LVN C stated, No. I was told to have [the Treatment Nurse] take care of everything. She did the notes and assessments and everything. LVN C stated she did not know if the Administrator was notified. During an interview on 7/14/23 at 5:29 a.m., CNA E stated she worked the evening of 7/7/23 into the morning of 7/8/23. CNA E stated she responded to Resident #1's call light and assisted Resident #1 to the bathroom. CNA E stated she noticed Resident #1's right bandage was soaked and reported the issue to LVN C. CNA E stated about 20 minutes after she reported the issue to LVN C, LVN C went into (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676281 If continuation sheet Page 6 of 16 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 676281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westover Hills Rehabilitation and Healthcare 9922 State Hwy. 151 San Antonio, TX 78251 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #1's room and told CNA E she found maggots between Resident #1's left toes. When asked if she saw the maggots, CNA E stated, Yes, they were little. I can't tell you how many. I just opened the toes and she [LVN C] put the light on it and they were in there moving. During a follow-up interview and a record review on 7/14/23 at 5:55 a.m., LVN C stated the Treatment Nurse had to know about the maggots because the Treatment Nurse had to use her [the Treatment Nurse's own] two fingers to push the maggots out from between Resident #1's left toes. At this point, LVN C disclosed two photographs to this surveyor. LVN C stated she took the photographs on the morning of 7/8/23 because she wanted to show the insects to the DON. LVN C stated the first picture had the Treatment Nurse's orange-painted fingernail tip pointing at 2 maggots curled together on white linen. LVN C stated the second picture was her own finger pointing at a maggot inside an inverted glove. During an observation and interview on 7/14/23 at 9:48 a.m., when asked if she took any pictures of the maggots, the Treatment Nurse stated, I can't recall if I took a picture or if I had my camera or phone with me. When asked if anyone else took a picture of the maggots, the Treatment Nurse stated, I can't recall if anyone else took a picture. I'm being honest, I can't remember. The Treatment Nurse stated she did not notice anything on Resident #1's left or right toes. At this point, the Treatment Nurse's nails were observed to be painted the same shade as the fingernail in one of LVN C's photographs. The Treatment Nurse stated her nails had been painted in that color for about 5 weeks. During an interview on 7/14/23 at 11:30 a.m., when asked what he would consider a sign or symptom of neglect, the Administrator stated, For neglect, I just look for stuff out of the norm, through visual or communication. When asked if he would consider maggots on a resident as neglect, the Administrator stated, I think if they were in the wounds-actual wounds-I'd have a huge issue with it. If it's neglect, I'd have to look at it, I wouldn't know. I would have to look at that. Now if I walked in and saw an open wound with a maggot, yeah, I've had an issue and that's definitely a reportable . I would report in that case. There would be a big problem at that point. It would mean the wound care system had broken down, the nurses wouldn't be doing their assessments. When asked about what happened with Resident #1 on the weekend of 7/8/23, the Administrator stated, I was told that day [7/8/23], probably about 8:30 in the morning, [the DON] rang me up and told me what happened. I made sure to clean the room and I said, 'if it was a maggot, did anyone keep it?' I wanted to verify it . [The DON] said [the Treatment Nurse] had gone in at 3 in the morning to check in and all that stuff and [the Treatment Nurse] found-I don't know who found it, a nurse or something-but [the Treatment Nurse] said there was none on [Resident #1's] skin. Everything checked out and everything was fine. The Administrator stated he did not know if pictures were taken during the incident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676281 If continuation sheet Page 7 of 16 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 676281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westover Hills Rehabilitation and Healthcare 9922 State Hwy. 151 San Antonio, TX 78251 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law through established procedures for 1 of 7 residents (Residents #1) reviewed for abuse and neglect, in that: The facility failed to report to the State Survey Agency that maggots were found on Resident #1 on 7/8/23. This deficient practice could place residents at risk for not having allegations of abuse or neglect reported to the State Agency to ensure that allegations are fully investigated. The findings were: Record review of Resident #1's face sheet, dated 7/13/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of cerebral infarction [a disruption in the brain's blood flow], paroxysmal atrial fibrillation [a rapid, erratic heart rate begins suddenly and then stops on its own within 7 days], End Stage Renal Disease, and other symptoms and signs involving cognitive functions following cerebral infarction. Record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 had a BIMS score of 8, signifying moderate cognitive impairment. Record review of a photograph, provided on 7/14/23, revealed two small, whitish, worm-like maggots on a white linen. An orange fingernail was seen pointing at the two maggots. Record review of a second photograph, provided on 7/14/23, revealed a finger pointing at an inverted glove, which had an indiscernible black spot inside the glove. Record review of the facility's TULIP account, reviewed on 7/12/23 at 3:30 p.m., revealed no self-reported incidents involving Resident #1 and maggots. During an interview on 7/13/23 at 8:57 a.m., when asked if something happened to her on the weekend of 7/8/23, Resident #1 stated, They said it was little bugs. But it wasn't a bug. It was just a little something. Something they saw over in the corner of the bed . Ain't no maggots on my legs. They saw it. I didn't see it. It was a little . it was probably a piece of something. A fabric or something. During an interview on 7/13/23 at 2:22 p.m., the Treatment Nurse stated, I got a call in at 3:00 a.m. on 7/8/23, a Saturday morning. I was called to come in and address a patient with a wound that supposedly a maggot was on a drape in her bed . I went to [Resident #1's room]. I observed the patient laying in bed and with the chuck underneath her and pointed out that there was white crawling on it and I said, 'yeah, okay.' .It was just laying on the chuck. It was a half centimeter long and it was white. The Treatment Nurse stated she performed the skin assessment with CNA D. The Treatment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676281 If continuation sheet Page 8 of 16 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 676281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westover Hills Rehabilitation and Healthcare 9922 State Hwy. 151 San Antonio, TX 78251 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Nurse stated, I found nothing, just one laying on the chuck. There was nothing on her body. The Treatment Nurse confirmed it was a maggot and stated she informed the DON of what she found. During an interview on 7/13/23 at 2:47 p.m., the DON stated, My night shift nurse called telling me that there was bugs on the bed and [Resident #1] had-I don't know if it [the bug] was on top of the dressing or on the side . I told my administrator so he can get housekeeping to come and clean the room. I had the nurses remove whatever was there. And that's pretty much it. When asked what insects the nurses thought were in the resident's room, the DON stated, Maggots. When asked if the nurses actually found any, the DON stated, I believe so, but it wasn't inside or underneath [Resident #1's] dressing. When asked if the nurses sent her a picture of the insects, the DON stated, No. Not on the patient. When asked if the nurses were able to confirm if the insect was a maggot, the DON stated, I'm not sure if it was confirmed. I don't know how we'd-I didn't specifically see it, so I wouldn't know. When asked if this facility considered reporting this incident to the State, the DON stated, Yes, I did. That's why I sent to [the Treatment Nurse] there. When asked to explain why there was no self-reported incident in TULIP, the DON replied, Because there was no wound and there was nothing in the wound. During an interview on 7/13/23 at 4:39 p.m., CNA D stated he worked from the evening of 7/7/23 to the morning of 7/8/23. CNA D stated around 1 or 2 in the morning he was assisting CNA E in helping Resident #1 to the bathroom. CNA D stated they noticed a bad odor coming from the bandages of Resident #1's feet and that was when he and CNA E noticed the maggot between Resident #1's left toes. CNA D stated, like 3 baby little small worms. The smallest worms. During an interview on 7/13/23 at 7:01 p.m., LVN C stated she worked overnight from Friday, 7/7/23, to Saturday morning, 7/8/23. LVN C stated Resident #1 had a bandage on her left lower leg that stopped just below the toe knuckles, leaving the toes to wiggle free, and the toes were where the maggots were found. LVN C stated, The CNAs alerted me that she was having a lot of weeping on her legs. And her left foot was itching. So they addressed the right leg, when I went to look at her left leg, she said her toes itched. So I looked between her toes and between, I want to say it was between the 3rd and 4th digit on her left toe, she had some little bugs between them. So I called the DON, the DON called [the Treatment Nurse] and [the Treatment Nurse] came up to look at her toes. We looked at her toes. There was little wormy maggot-looking things. I'm not an expert on entomology [the study of insects] so I don't know. [The Treatment Nurse] cleaned it out. She re-wrapped the legs. I'm not exactly sure what she put on the leg. But the skin was intact between the toes. LVN C stated she took 2 pictures of the maggots and sent them to the DON on 7/8/23 between 3:00 a.m. - 4:30 a.m. When asked if she notified anyone, LVN C stated, No. I was told to have [the Treatment Nurse] take care of everything. She did the notes and assessments and everything. LVN C stated she did not know if the Administrator was notified. During an interview on 7/14/23 at 5:29 a.m., CNA E stated she worked the evening of 7/7/23 into the morning of 7/8/23. CNA E stated she responded to Resident #1's call light and assisted Resident #1 to the bathroom. CNA E stated she noticed Resident #1's right bandage was soaked and reported the issue to LVN C. CNA E stated about 20 minutes after she reported the issue to LVN C, LVN C went into Resident #1's room and told CNA E she found maggots between Resident #1's left toes. When asked if she saw the maggots, CNA E stated, Yes, they were little. I can't tell you how many. I just opened the toes and she [LVN C] put the light on it and they were in there moving. During a follow-up interview and a record review on 7/14/23 at 5:55 a.m., LVN C stated the Treatment Nurse had to know about the maggots because the Treatment Nurse had to use her [the Treatment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676281 If continuation sheet Page 9 of 16 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 676281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westover Hills Rehabilitation and Healthcare 9922 State Hwy. 151 San Antonio, TX 78251 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 0609 Level of Harm - Minimal harm or potential for actual harm Nurse's own] two fingers to push the maggots out from between Resident #1's left toes. At this point, LVN C disclosed two photographs to this surveyor. LVN C stated she took the photographs on the morning of 7/8/23 because she wanted to show the insects to the DON. LVN C stated the first picture had the Treatment Nurse's orange-painted fingernail tip pointing at 2 maggots curled together on white linen. LVN C stated the second picture was her own finger pointing at a maggot inside an inverted glove. Residents Affected - Few During an interview on 7/14/23 at 11:30 a.m., when asked what he would consider a sign of symptom of neglect, the Administrator stated, For neglect, I just look for stuff out of the norm, through visual or communication. When asked if he would consider maggots on a resident as neglect, the Administrator stated, I think if they were in the wounds-actual wounds-I'd have a huge issue with it. If it's neglect, I'd have to look at it, I wouldn't know. I would have to look at that. Now if I walked in and saw an open wound with a maggot, yeah, I've had an issue and that's definitely a reportable . I would report in that case. When asked about what happened with Resident #1 on the weekend of 7/8/23, the Administrator stated, I was told that day [7/8/23], probably about 8:30 in the morning, [the DON] rang me up and told me what happened. I made sure to clean the room and I said, 'if it was a maggot, did anyone keep it?' I wanted to verify it . [The DON] said [the Treatment Nurse] had gone in at 3 in the morning to check in and all that stuff and [the Treatment Nurse] found-I don't know who found it, a nurse or something-but [the Treatment Nurse] said there was none on [Resident #1's] skin everything checked out and everything was fine. The Administrator stated he did not know if pictures were taken during the incident. Record review of a facility policy titled, Abuse Prevention, dated 11/28/2016, revealed the following: All alleged violations will be reported via phone or in writing within 24 hours to the State Licensing Agency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676281 If continuation sheet Page 10 of 16 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 676281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westover Hills Rehabilitation and Healthcare 9922 State Hwy. 151 San Antonio, TX 78251 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 7 residents (Resident #3) reviewed for accuracy of medical records in that: The Treatment Nurse did not accurately document that maggots were found on Resident #1 on 7/8/23. This deficient practice could affect Residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings were: Record review of Resident #1's face sheet, dated 7/13/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of cerebral infarction [a disruption in the brain's blood flow], paroxysmal atrial fibrillation [a rapid, erratic heart rate begins suddenly and then stops on its own within 7 days], End Stage Renal Disease, and other symptoms and signs involving cognitive functions following cerebral infarction. Record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 had a BIMS score of 8, signifying moderate cognitive impairment. Record review of Resident #1's Skin Evaluation, dated 7/8/23 and written by the Treatment Nurse, revealed no documentation of any insects. Record review of a photograph, provided on 7/14/23, revealed two small, whitish, worm-like maggots on a white linen. An orange fingernail was seen pointing at the two maggots. Record review of a second photograph, provided on 7/14/23, revealed a finger pointing at an inverted glove, which had an indiscernible black spot inside the glove. During an interview on 7/13/23 at 8:57 a.m., when asked if something happened to her on the weekend of 7/8/23, Resident #1 stated, They said it was little bugs. But it wasn't a bug. It was just a little something. Something they saw over in the corner of the bed . Ain't no maggots on my legs. They saw it. I didn't see it. It was a little . it was probably a piece of something. A fabric or something. During an interview on 7/13/23 at 2:22 p.m., the Treatment Nurse stated, I got a call in at 3:00 a.m. on 7/8/23, a Saturday morning. I was called to come in and address a patient with a wound that supposedly a maggot was on a drape in her bed . I went to [Resident #1's room]. I observed the patient laying in bed and with the chuck underneath her and pointed out that there was white crawling on it and I said, 'yeah, okay.' .It was just laying on the chuck. It was a half centimeter long and it was white. The Treatment Nurse stated she performed the skin assessment with CNA D. The Treatment Nurse stated, I found nothing, just one laying on the chuck. There was nothing on her body. The Treatment Nurse confirmed it was a maggot and stated she informed the DON of what she found. During an interview on 7/13/23 at 2:47 p.m., the DON stated, My night shift nurse called telling me (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676281 If continuation sheet Page 11 of 16 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 676281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westover Hills Rehabilitation and Healthcare 9922 State Hwy. 151 San Antonio, TX 78251 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that there was bugs on the bed and [Resident #1] had-I don't know if it [the bug] was on top of the dressing or on the side . When asked what insects the nurses thought were in the resident's room, the DON stated, Maggots. When asked if the nurses actually found any, the DON stated, I believe so, but it wasn't inside or underneath [Resident #1's] dressing. When asked if the nurses sent her a picture of the insects, the DON stated, No. Not on the patient. When asked if the nurses were able to confirm if the insect was a maggot, the DON stated, I'm not sure if it was confirmed. I don't know how we'd-I didn't specifically see it, so I wouldn't know. During an interview on 7/13/23 at 4:39 p.m., CNA D stated he worked from the evening of 7/7/23 to the morning of 7/8/23. CNA D stated around 1 or 2 in the morning he was assisting CNA E in helping Resident #1 to the bathroom. CNA D stated they noticed a bad odor coming from the bandages of Resident #1's feet and that was when he and CNA E noticed the maggot between Resident #1's left toes. CNA D stated, like 3 baby little small worms. The smallest worms. CNA D stated LVN C took pictures of the maggots. CNA D stated he notified LVN C of the maggots on Resident #1 and LVN C notified the Treatment Nurse. During an interview on 7/13/23 at 7:01 p.m., LVN C stated she worked overnight from Friday, 7/7/23, to Saturday morning, 7/8/23. LVN C stated Resident #1 had a bandage on her left lower leg that stopped just below the toe knuckles, leaving the toes to wiggle free, and the toes were where the maggots were found. LVN C stated, The CNAs alerted me that she was having a lot of weeping on her legs. And her left foot was itching. So they addressed the right leg, when I went to look at her left leg, she said her toes itched. So I looked between her toes and between, I want to say it was between the 3rd and 4th digit on her left toe, she had some little bugs between them. So I called the DON, the DON called [the Treatment Nurse] and [the Treatment Nurse] came up to look at her toes. We looked at her toes. There was little wormy maggot-looking things. I'm not an expert on entomology [the study of insects] so I don't know. [The Treatment Nurse] cleaned it out. She re-wrapped the legs. I'm not exactly sure what she put on the leg. But the skin was intact between the toes. LVN C stated she took 2 pictures of the maggots and sent them to the DON on 7/8/23 between 3:00 a.m. - 4:30 a.m. When asked if she notified anyone, LVN C stated, No. I was told to have [the Treatment Nurse] take care of everything. She did the notes and assessments and everything. LVN C stated she did not know if the Administrator was notified. During an interview on 7/14/23 at 5:29 a.m., CNA E stated she worked the evening of 7/7/23 into the morning of 7/8/23. CNA E stated she responded to Resident #1's call light and assisted Resident #1 to the bathroom. CNA E stated she noticed Resident #1's right bandage was soaked and reported the issue to LVN C. CNA E stated about 20 minutes after she reported the issue to LVN C, LVN C went into Resident #1's room and told CNA E she found maggots between Resident #1's left toes. When asked if she saw the maggots, CNA E stated, Yes, they were little. I can't tell you how many. I just opened the toes and she [LVN C] put the light on it and they were in there moving. During a follow-up interview and a record review on 7/14/23 at 5:55 a.m., LVN C stated she did not know where the documentation of the maggots on Resident #1 was. LVN C stated she didn't document on the maggots because she was instructed by the DON to allow the Treatment Nurse to handle the situation. At this point, a record review of Resident #1's Skin Evaluation, dated 7/8/23 and written by the Treatment Nurse, was reviewed and LVN C confirmed there was no documentation of the maggots. LVN C stated the Treatment Nurse had to know about the maggots because the Treatment Nurse had to use her [the Treatment Nurse's own] two fingers to push the maggots out from between Resident #1's left toes. At this point, LVN C disclosed two photographs to this surveyor. LVN C stated she took the photographs on the morning of 7/8/23 because she wanted to show the insects to the DON. LVN C stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676281 If continuation sheet Page 12 of 16 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 676281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westover Hills Rehabilitation and Healthcare 9922 State Hwy. 151 San Antonio, TX 78251 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few first picture had the Treatment Nurse's orange-painted fingernail tip pointing at 2 maggots curled together on white linen. LVN C stated the second picture was her own finger pointing at a maggot inside an inverted glove. During an observation and interview on 7/14/23 at 9:48 a.m., when asked if she took any pictures of the maggots, the Treatment Nurse stated, I can't recall if I took a picture or if I had my camera or phone with me. When asked if anyone else took a picture of the maggots, the Treatment Nurse stated, I can't recall if anyone else took a picture. I'm being honest, I can't remember. The Treatment Nurse stated she did not notice anything on Resident #1's left or right toes. When asked to explain why this surveyor could not find documentation on the insects found on Resident #1, the Treatment Nurse stated, You won't, because it wasn't on her skin, so you won't find documentation about it. I only documented what I saw on the skin assessment. So I cleansed the wounds and rewrapped them and to be honest we put new linen on her bed. At this point, the Treatment Nurse's nails were observed to be painted the same shade as the fingernail in one of LVN C's photographs. The Treatment Nurse stated her nails had been painted in that color for about 5 weeks. During an interview on 7/14/23 at 4:33 p.m., when asked if the facility had a process in place to ensure staff documented things accurately, ADON A stated, Typically they're [the staff] are aware of what to document and me and [NAME] come in and make sure things are documented in place, whether it's antibiotics, falls, psych stuff, change in condition. We go and follow-up with them [the staff] to make sure it's put into place. When asked how would she know what sort of events or incidents to look for, ADON A stated, They'll typically let me or ADON B know. But the big stuff goes through [the DON.] If we feel that [the DON] needs to know, we'll tell her. Between the 3 of us, we keep up with it. When asked what sort of negative effects could occur to the resident if documentation was not accurate, ADON A stated, A lot of things could fall through the cracks, their [the residents'] condition could worsen, things could really get bad. They could get hospitalized . Record review of a facility policy titled, Documentation, dated 05/2007, revealed the following: The resident's clinical record is a concise account of treatment, care, response to care, signs, symptoms and progress of the resident's condition . IMPORTANCE AND USE OF THE RECORD . 2. To the institution it reflects the quality of care given to the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676281 If continuation sheet Page 13 of 16 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 676281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westover Hills Rehabilitation and Healthcare 9922 State Hwy. 151 San Antonio, TX 78251 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 7 residents (Resident #1) reviewed for environment in that: On 7/8/23, Resident #1 had maggots between her left toes. This deficient practice could affect the safety of residents, staff, and the public. The findings were: Record review of Resident #1's face sheet, dated 7/13/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of cerebral infarction [a disruption in the brain's blood flow], paroxysmal atrial fibrillation [a rapid, erratic heart rate begins suddenly and then stops on its own within 7 days], End Stage Renal Disease, and other symptoms and signs involving cognitive functions following cerebral infarction. Record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 had a BIMS score of 8, signifying moderate cognitive impairment. Record review of a photograph, provided on 7/14/23, revealed two small, whitish, worm-like maggots on a white linen. An orange fingernail was seen pointing at the two maggots. Record review of a second photograph, provided on 7/14/23, revealed a finger pointing at an inverted glove, which had an indiscernible black spot inside the glove. During an interview on 7/13/23 at 8:57 a.m., when asked if something happened to her on the weekend of 7/8/23, Resident #1 stated, They said it was little bugs. But it wasn't a bug. It was just a little something. Something they saw over in the corner of the bed . Ain't no maggots on my legs. They saw it. I didn't see it. It was a little . it was probably a piece of something. A fabric or something. During an interview on 7/13/23 at 2:22 p.m., the Treatment Nurse stated, I got a call in at 3:00 a.m. on 7/8/23, a Saturday morning. I was called to come in and address a patient with a wound that supposedly a maggot was on a drape in her bed . I went to [Resident #1's room]. I observed the patient laying in bed and with the chuck underneath her and pointed out that there was white crawling on it and I said, 'yeah, okay.' .It was just laying on the chuck. It was a half centimeter long and it was white. The Treatment Nurse stated she performed the skin assessment with CNA D. The Treatment Nurse stated, I found nothing, just one laying on the chuck. There was nothing on her body. The Treatment Nurse confirmed it was a maggot. During an interview on 7/13/23 at 2:47 p.m., the DON stated, My night shift nurse called telling me that there was bugs on the bed and [Resident #1] had-I don't know if it [the bug] was on top of the dressing or on the side . I told my administrator so he can get housekeeping to come and clean the room. I had the nurses remove whatever was there. And that's pretty much it. When asked what insects the nurses thought were in the resident's room, the DON stated, Maggots. When asked if the nurses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676281 If continuation sheet Page 14 of 16 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 676281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westover Hills Rehabilitation and Healthcare 9922 State Hwy. 151 San Antonio, TX 78251 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few actually found any, the DON stated, I believe so, but it wasn't inside or underneath [Resident #1's] dressing. When asked if the nurses sent her a picture of the insects, the DON stated, No. Not on the patient. When asked if the nurses were able to confirm if the insect was a maggot, the DON stated, I'm not sure if it was confirmed. I don't know how we'd-I didn't specifically see it, so I wouldn't know. During an interview on 7/13/23 at 3:35 p.m., the Maintenance Director stated he had no issues with the pest control company. The Maintenance Director stated when the pest control company visited before the pest control company checked outside, then came inside to inspect the facility. The Maintenance Director stated he never saw maggots in the facility but he heard they found some maggots in Resident #1's room and he [the Maintenance Director] was advised to check for flies. The Maintenance Director stated he called the pest control company today to address the issue. During an interview on 7/13/23 at 4:39 p.m., CNA D stated he worked from the evening of 7/7/23 to the morning of 7/8/23. CNA D stated around 1 or 2 in the morning he was assisting CNA E in helping Resident #1 to the bathroom. CNA D stated they noticed a bad odor coming from the bandages of Resident #1's feet and that was when he and CNA E noticed the maggot between Resident #1's left toes. CNA D stated, like 3 baby little small worms. The smallest worms. CNA D stated LVN C took pictures of the maggots. During an interview on 7/13/23 at 7:01 p.m., LVN C stated she worked overnight from Friday, 7/7/23, to Saturday morning, 7/8/23. LVN C stated Resident #1 had a bandage on her left lower leg that stopped just below the toe knuckles, leaving the toes to wiggle free, and the toes were where the maggots were found. LVN C stated, The CNAs alerted me that she was having a lot of weeping on her legs. And her left foot was itching. So they addressed the right leg, when I went to look at her left leg, she said her toes itched. So I looked between her toes and between, I want to say it was between the 3rd and 4th digit on her left toe, she had some little bugs between them. So I called the DON, the DON called [the Treatment Nurse] and [the Treatment Nurse] came up to look at her toes. We looked at her toes. There was little wormy maggot-looking things. I'm not an expert on entomology [the study of insects] so I don't know. [The Treatment Nurse] cleaned it out. She re-wrapped the legs. I'm not exactly sure what she put on the leg. But the skin was intact between the toes. LVN C stated she took 2 pictures of the maggots and sent them to the DON on 7/8/23 between 3:00 a.m. - 4:30 a.m. When asked if she notified anyone, LVN C stated, No. I was told to have [the Treatment Nurse] take care of everything. She did the notes and assessments and everything. During an interview on 7/14/23 at 5:29 a.m., CNA E stated she worked the evening of 7/7/23 into the morning of 7/8/23. CNA E stated she responded to Resident #1's call light and assisted Resident #1 to the bathroom. CNA E stated she noticed Resident #1's right bandage was soaked and reported the issue to LVN C. CNA E stated about 20 minutes after she reported the issue to LVN C, LVN C went into Resident #1's room and told CNA E she found maggots between Resident #1's left toes. When asked if she saw the maggots, CNA E stated, Yes, they were little. I can't tell you how many. I just opened the toes and she [LVN C] put the light on it and they were in there moving. During a follow-up interview and a record review on 7/14/23 at 5:55 a.m., LVN C stated the Treatment Nurse had to know about the maggots because the Treatment Nurse had to use her [the Treatment Nurse's own] two fingers to push the maggots out from between Resident #1's left toes. At this point, LVN C disclosed two photographs to this surveyor. LVN C stated she took the photographs on the morning of 7/8/23 because she wanted to show the insects to the DON. LVN C stated the first picture had the Treatment Nurse's orange-painted fingernail tip pointing at 2 maggots curled together on white (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676281 If continuation sheet Page 15 of 16 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 676281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westover Hills Rehabilitation and Healthcare 9922 State Hwy. 151 San Antonio, TX 78251 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 0921 linen. LVN C stated the second picture was her own finger pointing at a maggot inside an inverted glove. Level of Harm - Minimal harm or potential for actual harm Record review of a facility policy titled, Maintains Effective Pest control Program, not dated, revealed the following: Maintain an effective pest control program so that the facility is free of pests and rodents . An effective pest control program is defined as measures to eradicated and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitos, flies, mice, and rats.) Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676281 If continuation sheet Page 16 of 16