Inspection·July 15, 2024

F 0684 at the edges and was stiff feeling, not like a IV dressing should feel. Level of Harm - Minimal harm or potential for actual harm During an interview on 7/15/2024 at 9:10 am LVN A stated he was the charge nurse for Resident #1 on 7/4/2024. He further stated he had documented in the EMR he had changed the IV dressing on Resident #1. He stated he documented first and then was going to change the IV dressing but got busy and did not go back and change the dressing. He stated the IV dressings are changed every 7 days and as needed. He further revealed it is important that the dressing be changed to prevent infection. Residents Affected - Some Record review of Resident #2's electronic medical record face sheet dated 7/15/2024 revealed an [AGE] year old male with an admission date of 7/2/2024.His diagnoses included sepsis due to enterococcus (bacterial infection that can spread to body and cause serious illnesses.), MRSA(,Infections caused by specific bacteria that are resistant to commonly used antibiotics) hypertension(high blood pressure), atrial fibrillation(irregular heart rate), cardiac pacemaker(device iimplanted in body to help heart beat correctly), and heart failure(when heart cannot pump blood as should). Record review of Resident #2's MDS assessment dated [DATE] revealed in section C a BIMS score of 15 which indicted he was cognitively intact. Record review of Resident #2's physician orders on 7/11/2024 reflected an order for PICC(IV which is inserted in body to accept fluids) line dressing change every 7 days. Record review of Resident #2's ETAR dated 7/1/2024-7/31/2024 revealed documentation on 7/14/2024 LVN B changed the PICC line dressing. Unable to contact LVN B after 2 attempts (7/12/2024 at 10:40 am, and 7/15/2024 at 9:46 am) for an interview during investigation period. During an observation and interview on 7/15/2024 at 9:30 am Resident #2 stated he had a right arm IV for his antibiotics. Observed clear dressing over insertion site to right upper arm with a date of 6/28/24. During an observation and interview on 7/15/2024 at 9:31 am Treatment nurse observed with surveyor dressing to Resident #2's right arm with date of 6/28/2024. Treatment nurse stated IV dressings are changed every 7 days. She further stated Resident #2's IV dressing should have been changed 7 days after 6/28/2024 which would have been 7/5/2024 and then again on 7/12/2024.The IV dressing was intact. During an observation and interview on 7/15/2024 at 9:35 am LVN A stated he was Resident #2's nurse Monday thru Friday on the day shift. He further stated IV dressings should be changed every 7 days and as needed. He confirmed by observation that Resident #2's IV dressing had a date of 6/28/2024 on it and the date should have reflected a closer date to 7/15/2024. He stated he did not know why the dressing to the IV site had not been changed as ordered but that it was very important to have a clean IV dressing to help prevent infection to the resident. During an interview on 7/15/2024 at 10:00 am facility ADON stated she did not know why the dressings to the IV site's of Resident #1 and Resident #2 had not been changed as ordered but it was very important to have a clean IV dressing to help prevent infection to the residents. She further stated there was not a particular policy on the time frame for changing IV dressings and the nurses followed physician orders. She further stated Resident #2 had a PICC line on admission and he should have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676281 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 676281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete had an order on admission to change IV drsg every 7 days. But no one noticed until 7/11/24.She said she did not know why this was not done. When asked who checks the new orders. She stated we all do meaning adons x3. During an interview on 7/15/2024 at 10:30 am facility Administrator stated the nurses should have looked at the IV dressings on the residents (#1 and #2) and noticed the dates. Since they are to be changed every 7 days then they should have been changed every 7 days. Event ID: Facility ID: 676281 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 676281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2024 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 on each resident that were accurate and complete in accordance with accepted professional standards and practices for 2 03 3 residents (Resident #1 and #2) in that: LVN A and LVN B failed to demonstrate competency in skills by failing to correctly document and perform IV dressing changes on Resident #1 and Resident #2. This failure has potential to affect residents by placing them at an increased and unnecessary risk of pain and exposure to communicable diseases and infection. Findings include: Record review of Resident #1's electronic medical record face sheet dated 7/12/2024 revealed a [AGE] year-old male with an initial admission date of 5/31/2024 and a readmission date of 6/26/2024. His diagnoses included cytomegaloviral disease (CMV is related to the viruses that cause chickenpox, herpes simplex and mononucleosis (complications for healthy adults include problems with the digestive system, liver, brain and nervous system.), Diabetes Mellitus 2, acute kidney failure (A condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days. Symptoms include legs swelling and fatigue), hypertension, gastrointestinal hemorrhage (bleeding in the stomach), and anemia (low blood). Record review of Resident #1's MDS assessment dated [DATE] revealed in section C, a BIMS score of 10 which indicted he was moderately cognitively impaired. Record review of Resident #1's physician orders on 6/26/2024 reflected an order for Midline care to left upper arm change dressings, change each lumen injection caps with each dressing change every day shift every 7 days and prn. Record review of Resident #1's ETAR dated 7/1/2024-7/31/2024 revealed documentation on 7/4/2024 by LVN A as having changed midline dressing to left arm of Resident #1. Record review of Resident #2's electronic medical record face sheet dated 7/15/2024 revealed an [AGE] year old male with an admission date of 7/2/2024. His diagnoses included sepsis due to enterococcus, MRSA, hypertension,atrial fibrillation, cardiac pacemaker, and heart failure. Record review of Resident #2's MDS assessment dated [DATE] revealed in section C a BIMS score of 15 which indicted he was cognitively intact. Record review of Resident #2's physician orders on 7/11/2024 reflected an order for a PICC line dressing change every 7 days . Record review of Resident #2's ETAR dated 7/1/2024-7/31/2024 revealed documentation on 7/14/2024 of LVN B changing PICC line dressing. Unable to contact LVN B after 2 attempts (7/12/2024 at 10:40 am, and 7/15/2024 at 9:46 am) for an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676281 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 676281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2024 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 interview during investigation period. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 7/15/2024 at 9:30 am Resident #2 stated he had a right arm IV for his antibiotics. Observed clear dressing over insertion site to right upper arm with a date of 6/28/24. Residents Affected - Few During an observation and interview on 7/15/2024 at 9:31 am Treatment nurse observed with surveyor dressing to Resident #2's right arm with date of 6/28/2024. Treatment nurse stated IV dressings are changed every 7 days. She further stated Resident #2's IV dressing should have been changed 7 days after 6/28/2024 which would have been 7/5/2024 and then again on 7/12/2024. During an observation and interview on 7/15/2024 at 9:35 am LVN A stated he was Resident #2's nurse Monday thru Friday on the day shift. He further stated IV dressings should be changed every 7 days and as needed. He confirmed by observation that Resident #2's IV dressing had a date of 6/28/2024 on it and the date should have reflected a closer date to 7/15/2024. He stated he did not know why the dressing to the IV site had not been changed as ordered but that it was very important to have a clean IV dressing to help prevent infection to the resident. During an interview on 7/15/2024 at 10:00 am facility ADON stated she did not know why the dressings to the IV site's of Resident #1 and Resident #2 had not been changed as ordered but it was very important to have a clean IV dressing to help prevent infection to the residents. She further stated there was not a particular policy on the time frame for, and the nurses followed physician orders. Record review on 7/15/2024 of competencies and training for LVN A dated 10/18/2023 included certificate of completion in Intravenous Therapy which included dressing changes for IV sites. Intravenous Therapy competencies and training specifically included Midline IVs and PICC lines. Record review on 7/15/2024 of competencies and training for LVN B dated 10/18/2023 included certificate of completion in Intravenous Therapy which included dressing changes for IV sites.Intravenous Therapy competencies and training specifically include Midline IVs and PICC lines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676281 If continuation sheet Page 5 of 5