Inspection·December 11, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview on 12/06/2023 at 2:12 PM, CNA L revealed that Resident #10's call light was not within reach and should be within reach. During an interview on 12/06/2023 at 2:19 PM, RN I revealed that all staff should be aware of having call lights within reach of the residents. RN I further revealed that care plans should be followed by everyone. RN I confirmed that family has requested that Resident #10's night stand edges be padded for resident's safety. During an interview on 12/11/2023 at 10:21 AM, CNA J revealed that Resident #10 needed to be monitored frequently as she would crawl out of bed, leaned forward in bed, etc. CNA J reported reading care plans to know how to care for her residents. CNA J reported that for Resident #10 she needed to make sure that her call light was within reach and fall mats were on both sides of the bed to prevent falls. During an interview on 12/11/2023 at 11:26 AM, the Administrator reported that staff did rounds several times a day to ensure that call lights are within reach of the resident and were working. During an interview on 12/11/2023 at 11:33 AM, the DON reported that every shift call lights should be checked that they were within reach of the resident and were working. During an interview on 12/11/2023 at 11:39 AM, the Housekeeping Supervisor revealed that call lights were supposed to be within reach of the resident and falls mats were supposed to be placed next to the residents' bed when applicable. (There was an attempt to interview a housekeeper, however, they refused to be interviewed) Record review of the facility's policy, titled Answering the Call Light, revised March 2021, revealed When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 2 of 8 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 676328 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Las Colinas of Westover 9738 Westover Hills Blvd 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement a comprehensive person centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 16 residents (Resident #8 and Resident #10) reviewed for care plans in that: 1. Resident #8's comprehensive care plan did not address the residents past medical history of Diabetes Mellitus 2. (Type 2 diabetes is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel. That sugar also is called glucose. This long-term condition results in too much sugar circulating in the blood. Eventually, high blood sugar levels can lead to disorders of the circulatory, nervous, and immune systems.) 2. Resident #10's comprehensive care plan's interventions were not implemented regarding the focus of Resident #10 being at risk for falls, including making sure that call light was within reach and fall mats were in place on 12/05/2023 and 12/06/2023. This failure could affect residents at the facility who require a care plan and place them at risk for not receiving the appropriate care and services needed to maintain optimal health. The findings were: 1. Record review of Resident #8's face sheet, undated revealed a 87 year female with initial admission date of with readmission of , with diagnoses to include Type 2 diabetes mellitus, atrial fibrillation(is a heart condition that makes your heartbeat irregular and fast, sometimes causing palpitations or fluttering sensations.), dementia(is not a single disease, but a term for a range of conditions that affect the brain's ability to think, remember, and function normally.), hypothyroidism(is a common disorder that affects your thyroid gland, a butterfly-shaped organ in your neck that regulates your metabolism.),hypertension(High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache), congestive heart disease(A progressive heart disease that affects pumping action of the heart muscles. This causes fatigue, shortness of breath.),and peripheral vascular disease(a slow and progressive circulation disorder. Narrowing, blockage, or spasms in a blood vessel can cause PVD. PVD may affect any blood vessel outside of the heart including the arteries, veins, or lymphatic vessels.) Record review of Resident #8's MDS(Minimum Data Set) is part of a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes.), dated 10/28/2023 revealed a BIMS(Brief Interview for Mental Status),(The total BIMS score ranges between zero to fifteen points and is categorized into three cognitive groups: Intact, Moderate, and Severe.) score of 8 , which indicated cognitively impaired. Section I for active diagnosis Diabetes Mellitus 2 which was indicated in physician admission note and progress notes. Record review of Resident #8's Care plan dated 8/28/23 with revision date 10/28/23 revealed no documentation of Diabetes Mellitus 2 which was indicated in physician admission note and progress notes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 3 of 8 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 676328 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Las Colinas of Westover 9738 Westover Hills Blvd 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #8's physician notes written by primary physician, on 10/9/2023 revealed Diabetes Mellitus due to hyperglycemia, active diagnosis. During an interview on 12/6/2023 at 1:24 pm, the Care plan coordinator revealed she was responsible for making sure a comprehensive care plan was met for each resident. She further revealed Resident #8 did not have Diabetes Mellitus 2 documented in her care plan. She stated this could lead to inconsistent care. During an interview on 12/6/2023 at 1:45 pm, the DON confirmed the care plan coordinator was responsible for developing the comprehensive care plan for each resident . She further confirmed Resident #8 did not have a care plan which reflected Resident #8's medical history of Diabetes Mellitus 2 documented in her electronic medical record. She further revealed this could lead to inconsistent care for the resident. 2. Record review of Resident #10's admission Record dated 12/05/2023 reflected a resident initially admitted to the facility on [DATE] and readmitted [DATE] with diagnosis including: generalized muscle weakness, other abnormalities of gait (a person's manner of walking) and mobility, repeated falls, age-related cognitive decline, and personal history of traumatic fracture. Record review of Resident #10's quarterly MDS, dated [DATE], revealed a BIMS score of 1/15, reflected severe cognitive impairment. The MDS revealed that Resident #10 needed one-person physical assist with bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS further revealed that the resident has had 2 or more falls with no injury since prior assessment. Record Review of Resident #10's care plan revealed Resident #10 was at risk for falls with interventions of Provide resident with fall mats next to bed and Keep call light within reach and Remind resident to use call light for assistance. During an observation on 12/05/2023 at 3:04 PM, the fall mat that was supposed to be present on the right-hand side of Resident #10 was not present and call light was not within reach of the resident. The call light was against the wall, underneath where the call light cable plugged into the wall. During an observation and interview on 12/05/2023 at 3:08 PM, RN I revealed that Resident #10 should have fall mats on both sides of her bed. RN I revealed that the fall mat on the resident's right-hand side was not present. RN I also confirmed Resident #10's call light was not within reach and should be within reach. RN I put the resident's right hand side fall mat back but left the call light not within reach as CNA G was going to come to Resident #10's room. RN I revealed that the nursing staff followed residents' care plans for resident care. During an observation and interview on 12/05/2023 at 3:15 PM, CNA G revealed Resident #10's call light was not within reach of the resident. CNA G picked up the call light and placed it within reach of the resident. During an interview on 12/05/2023 at 3:58 PM, RN I revealed that housekeeping may have taken the fall mats away from the side of Resident #10's bed to clean and did not put it back. RN I confirmed that Resident #10 would grab snacks from the drawers in her night stand and may have fallen and hit the edges of the night stand. During an observation and interview on 12/06/2023 at 2:12 PM, CNA L revealed that the fall mat on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 4 of 8 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 676328 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Las Colinas of Westover 9738 Westover Hills Blvd 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 0656 Level of Harm - Minimal harm or potential for actual harm the resident's right-hand side was not present and Resident #10's call light was not within reach of the resident and should be within reach. During an interview on 12/06/2023 at 2:19 PM, RN I revealed that all staff should be aware of having call lights within reach of the residents. RN I further revealed that care plans should be followed by everyone. Residents Affected - Some During an interview on 12/11/2023 at 10:21 AM, CNA J revealed that Resident #10 needed to be monitored frequently as she would crawl out of bed, leaned forward in bed, etc. CNA J revealed that there should be padding on the nightstand edges as this could hurt the resident. CNA J further revealed that she has bumped into the edge of a nightstand and it hurt CNA J. CNA J reported reading care plans to know how to care for her residents. CNA J reported that for Resident #10 she needed to make sure that her call light was within reach and fall mats were on both sides of the bed to prevent falls. Record review of the facility policy and procedure, titled Care Planning- Interdisciplinary Team, dated 2001 with revision date of September 2013 ; Policy statement: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. Policy interpretation, 1. A comprehensive care plan for each resident is developed within 7 days of completion of the resident assessment (MDS). Record review of facility's policy Care Plans, Comprehensive Person-Centered, revised December 2016, revealed a Policy statement of A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: receive the services and/or items included in the plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 5 of 8 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 676328 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Las Colinas of Westover 9738 Westover Hills Blvd 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 16 residents (Resident #10), reviewed for care plan revisions, in that: The facility failed to ensure that Resident #10's care plan included an intervention, that was requested by Resident #10's Responsible Party (RP) to prevent further injury with falls. This deficient practice could place residents at risk for lack of coordination of services. The finding included: Record review of Resident #10's admission Record dated 12/05/2023 reflected a resident initially admitted to the facility on [DATE] and readmitted [DATE] with diagnosis including: generalized muscle weakness, other abnormalities of gait (a person's manner of walking) and mobility, repeated falls, age-related cognitive decline, and personal history of traumatic fracture. Record review of Resident #10's quarterly MDS, dated [DATE], revealed a BIMS score of 1/15, reflected severe cognitive impairment. The MDS revealed that Resident #10 needed one-person physical assist with bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS further revealed that the resident has had 2 or more falls with no injury since prior quarterly assessment. Record Review of Resident #10's care plan, printed 12/5/2023, revealed Resident #10 was at risk for falls with interventions after each documented fall. There was not an intervention that included padding sharp edges of the resident's nightstand and [NAME]. Resident #10's care plan, printed 12/11/2023 revealed an intervention of sharp edges on nightstand and [NAME] to be padded, initiated 12/08/2023 by the DON. During observations on 12/05/2023 at 3:04 PM and 12/06/2023 at 2:19 PM, there was no padding to cover the sharp edges of the resident's nightstand and [NAME]. During an interview on 12/05/2023 at 3:58 PM, RN I revealed that Resident #10 would grab snacks from the drawers in her night stand that is to the right of her bed. RN I further revealed that Resident #10 had a minor injury from an unwitnessed fall that could have been caused by the resident's head hitting the edge of the night stand. During an interview on 12/05/2023 at 4:18 PM, Resident #10's responsible party (RP) revealed that resident falls frequently, having to have stitches and even surgery for a fractured right hip. The RP brought up that the resident bumped herself on the drawer of he nightstand when she got snacks. The RP requested padding to be on the edges of the nightstand about 3 months ago to prevent further injury. During an interview on 12/06/2023 at 2:19 PM, RN I revealed that family has requested that Resident #10's nightstand edges be padded for resident's safety. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 6 of 8 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 676328 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Las Colinas of Westover 9738 Westover Hills Blvd 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/06/2023 at 2:26 PM, the Maintenance Director revealed that for about 3 months, the nursing staff requests to have padding on Resident #10's nightstand to prevent injury for when the resident falls, as this was requested by the family. The Maintenance Director reports that this probably should be documented in the care plan so that nursing staff knows to contact him to replace the padding as needed. When asked to replace the padding on the nightstand for Resident #10, the Maintenance Director could put on more padding right away. The Maintenance Director reported that the padding was currently not on the nightstand, and he was in process of padding the resident's night stand and [NAME]. During an interview on 12/08/2023 at 10:06 AM, the Social Worker revealed that the family asked for padding on the nightstand. The SW reported that this request by Resident #10's family was to prevent more injury if the resident bumps into the nightstand during a fall. The SW further revealed that this should be care planned because the nursing staff used the residents' care plan to provide care to the residents. During an interview on 12/11/2023 at 10:21 AM, CNA J revealed that Resident #10 needed to be monitored frequently as she would crawl out of bed, leaned forward in bed, etc. CNA J revealed that there should be padding on the nightstand edges as this could hurt the resident. CNA J further revealed that she has bumped into the edge of a nightstand, and it hurt CNA J. CNA J reported reading care plans to know how to care for her residents. During an interview on 12/11/2023 at 11:33 AM, the DON revealed that it should be care planned that padding should be on the edges of the nightstand, but the DON was only told last week about the family requesting the nightstand edges being padded. The DON further revealed that this intervention was important to prevent injury. The DON reported that she care planned on falls and skin impairment. The DON reported that they would be working on improving communication so that the care plans were updated accordingly. Record review showed that the DON updated the care plan on 12/08/023 to add the intervention: Sharp edges on nightstand and [NAME] to be padded. With the focus of The resident is at risk for falls During an interview on 12/11/2023 at 12:02 PM, the MDS nurse K revealed that care plans were important for staff to reference for resident continuity of care. MDS nurse K revealed that any nurse was able to update care plans and when family told nursing staff to add padding to nightstand edges that someone could have added that as an intervention to prevent injuries. The MDS nurse K further revealed that communication could be improved in order to keep care plans updated accordingly. Record review of facility's policy Care Planning-Interdisciplinary Team, revised September 2013, revealed The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Record review of facility's policy Care Plans, Comprehensive Person-Centered, revised December 2016, revealed a Policy statement of A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. and the following: 8. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 7 of 8 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 676328 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Las Colinas of Westover 9738 Westover Hills Blvd 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 0657 Level of Harm - Minimal harm or potential for actual harm 10. The comprehensive, person-centered care plan will: Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. Residents Affected - Few 13. Assessments of the residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 8 of 8