Health inspection·December 23, 2023

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of Resident #1's assessments for 12/15/23 did not reveal LVN A reassessed resident or progress note regarding family members concerns. Record review of Resident #1's vital signs taken on 12/15/23 documented at 3:55 p.m., revealed normal vital signs, no further vital signs noted reflecting nursing assessment. Record review of Resident #1's assessment for 12/15/23 documented on 12/15/23 at 3:55 p.m., revealed a normal assessment. Record review of Resident #1's progress note for 12/15/23 revealed the catheter showed urine in the drainage bag was clear and draining via gravity. Recoard review of Resident #1's Treatment Administrator Record for 12/15/23 day shift documentation revealed the catheter was flushed. Record review of [Name of Hospital] records for Resident #1, provided by family member, revealed an admission date of 12/15/2023 and he was admitted for [ Septic Shock ] a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection and [intubation] procedure that's used when you can't breathe on your own. In an interview with LVN A on 12/22/23 at 10:45 a.m., stated she was the assigned nurse for Resident #1 on 12/15/23, 6:00 a.m. - 2:00 p.m., and took vital signs of Resident # 1 at the start of her shift on 12/15/23 at 7:15 a.m. LVN A stated she did not repeat vital signs as she did not see a change in condition, or reason to reassess Resident # 1. LVN A was asked why her assessment of Resident # 1 was started on 12/15/23 at 3:55 p.m., after her shift was over and why the assessment did not include a change of condition, abnormal vital signs or conversation had with family member. LVN A responded that she documented what she saw in the morning around 7:15 a.m., and she replied she did not do a second set of vital signs as Resident # 1 was stable on her shift and did not have a change of condition. In an interview with the DON on 12/22/23 at 10:45 a.m., the DON stated the family member of Resident #1 notified her of a change of condition on 12/15/23 at 2:04 p.m. at that time was when she looked up vital signs on the electronic medical record and no vital signs for Resident # 1 were listed at that time. The DON stated she ordered RN B to take vital signs. They were respirations - 32, Oxygen - 78% and Blood pressure of 74/45. This was when the family called 911 and Resident #1 was sent to the hospital via ambulance. The DON stated that it was her expectation that licensed nurses follow policy and procedure to notify physician of any change and document accurate vital signs. In an interview with RN B on 12/22/23 at 11:30 am she stated that she was the evening nurse for Resident # 1 on 12/15/23 from 2:00 p.m. - 10:00 p.m., shift, she recalled in the nursing report from LVN A on 12/15/23 she was told that family of Resident # 1 wanted him sent to the hospital for a change of condition. RN B stated that after the report, she went to do rounds on her residents. When the DON asked her to do a set of vital signs on Resident # 1, she recalled vital signs were abnormal, and family member was asking for them and writing them down. RN B was asked why there was no change of the condition assessment completed or nursing notes on her shift. RN B stated, it all happened so fast that day her only thought was to send the resident out as he did not look like himself and probably forgot. RN B stated Resident #1 was sent via ambulance to the hospital and family member called 911 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 2 of 11 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 12/23/2023 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few In an interview with the family member of Resident #1 on 12/22/23 at 3:15 p.m. revealed she came to LVN A various times on 12/15/23 starting at 12:00 p.m., 12:20 p.m. and 1:00 p.m. with concerns that Resident #1 was more confused, and the resident's catheter was clogged. Resident #1's family member stated not once did LVN A take vital signs of a Resident #1. The family member recalled LVN A telling her that Resident #1 was, fine and not to worry. In an interview with Resident #1's physician on 12/22/23 at 3:30 p.m., he stated that he assessed Resident #1 on 12/14/23 and did not have any concerns at that time. However, it was his expectation that licensed nurses contact him on any change of condition on any of his residents. In an interview with CNA A on 12/22/23 at 3:45 p.m., she stated she was the assigned CNA on 12/15/23 for the day shift (6:00 a.m. - 2:00 p.m.). She recalled speaking to LVN A on one occasion that day at 11:20 a.m. and telling LVN A that Resident #1 was not eating his lunch and not himself. Record review of Facility policy title Acute Condition Changes, dated 2001 , revised March 2018 revealed The Nursing staff will contact the physician based on urgency of the situation, The Physician should request information to clarify the situation for example vital signs and physical findings . This was determined to be an Immediate Jeopardy (IJ) on 12/22/2023 at 4:25 p.m. The Administrator was notified at 4:35 p.m. The Administrator was provided with an IJ template on 12/22/23 at 4:35 p.m. The following Plan of Removal (POR) was submitted by the facility on 12/22/2023 at 7:47 p.m. The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the issues: Regional Director of Operations re-educated the Administrator on ensuring residents were receiving necessary and accurate follow through with change of condition, notification, and implementation on 12/22/2023. Regional Nurse Consultant for the facility reinforced and re-educated the Director of Nursing on identification, assessment, and notification of change in condition to be maintained consistently following facility policies and monitored for effective and successful outcomes on 12/22/2023. Licensed facility personnel to perform audit of all resident charts to include identification, assessment, outcome, and communication for the past 14 days to assess for proper implementation of change in condition policy with interventions performed accordingly by 12/23/2023. The DON/designee to have completion of change in condition to include identification, assessment, and notification competencies on all licensed nursing personnel by 12/23/2023. Re-education of all licensed staff members began per the DON/ADON and/or designees on abuse/neglect, change in condition to include identification, assessment, documentation, notification, and outcome of resident status per facility policies. Integrity checks by educators began 12/22/2023 and to continue to completion 12/23/2023 with posttest as noted below in interventions and monitoring. Interventions and Monitoring Plan to Ensure Compliance Quickly: The Director of Nursing/Designee educated all licensed nursing staff on abuse/neglect, change in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 3 of 11 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 12/23/2023 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 0580 Level of Harm - Immediate jeopardy to resident health or safety condition to include identification, assessment, documentation, notification, and outcome of resident status including discharge procedures and documentation. Initiated: 12/22/2023 Completion: 12/23/2023 Reeducation to be completed by 12/23/2023 with licensed nurses regarding change of condition, immediate notification, and responsible party integration in care to include notification and follow through with findings. Initiated: 12/22/2023 Completion: 12/23/2023 Residents Affected - Few All resident changes in conditions were to be reported to the Director of Nursing/designee to ensure monitoring all acute change of condition documentation and notification of physician and responsible party with appropriate interventions and actions daily. Initiated: 12/22/2023 Completion: 12/23/2023 Immediate action to notify the physician and receive new orders on any residents identified through audit findings for potential change in condition with appropriate documentation at such time of notification. Initiated: 12/22/2023 Completion: 12/23/2023 100% of the licensed staff that were currently scheduled performed return demonstration of understanding will be noted by post competency check for each person educated with a written post-test administered by the Director of Nursing, the Assistant Director of Nursing, and/or designee for all the nursing staff receiving training on change in condition and appropriate documentation and notification. Staff that are not scheduled or on leave from the facility will perform return demonstration of understanding and will be noted by post competency check for each person educated with a written post-test administered by Director of Nursing, Assistant Director of Nursing, and/or designee before starting their next shift. This facility does not employ the use of agency personnel. Initiated: 12/22/2023 Completion: 12/23/2023. The facility DON/ADON will act as monitoring liaison to coordinate completion of audits and communication of any issues in weekly clinical at risk (CAR) meetings which include the Administrator and interdisciplinary team for continuum of care to be documented through signed attendance sheet. Initiated: 12/22/2023 Completed: 12/23/2023 The policy and procedure for abuse/neglect and change in condition were reviewed by the Regional [NAME] President of Operations and the Regional Nurse Consultant with no changes to policies to be implemented. Continue to follow policies as implemented and monitor compliance as noted above. Initiated: 12/22/2023 Completed: 12/23/2023 The QAPI Team, led by the Administrator, will meet weekly for 3 weeks to discuss that coordination and completion of all education, assessments, and interventions are utilized to ensure that appropriate change of condition procedures and protocol are followed and maintained per current facility policies. The Medical Director was notified of Immediate Jeopardy and QAPI meetings on 12/22/2023 and will be part of the QAPI intervention meetings. Abuse/neglect and change of condition protocols and policies to be added to the QAPI monthly for 3 months following the initial 3 weeks to monitor program progress. Verification: Interview with the Regional [NAME] President of Operations and Regional Nurse Consultant on 12/23/23 at 2:30 p.m. They stated they have reviewed the change of condition and the Abuse/Neglect policy, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 4 of 11 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 12/23/2023 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 0580 and no changes will be implemented. Level of Harm - Immediate jeopardy to resident health or safety Interview with Administrator on 12/23/23 at 12:10 p.m., the Administrator stated the Regional Director of Operations re-educated him on ensuring residents were receiving necessary and accurate follow through with change of condition, notification, and implementation. Verified, via records review signed by the Administrator on 12/22/23 where he acknowledged re-education by the Regional Director of Operations on ensuring residents were receiving necessary and accurate follow through with change of condition, notification, and implementation. Residents Affected - Few Interview with the DON on 12/23/23 at 12:30 p.m., the DON stated she was re-educated by the Regional Nurse Consultant on identification, assessment, and notification of change in condition to be maintained consistently following facility policies and monitored for effective and successful outcomes. Verified, via records review signed by the DON on 12/22/23, where she acknowledges re-education by the Regional Nurse Consultant identification, assessment, and notification of change in condition to be maintained consistently following facility policies and monitored for effective and successful outcomes, Record review of 56 residents' charts, of which 56 charts revealed compliance. Interviews with the DON and ADON revealed the ADON was immediately trained on 12/22/23 in the change of condition procedures to ensure they were able to train other staff. Verified via inservice titled Change of Condition. and post-test for Change of Condition reflecting all licensed nurses employed by facility. Interviewed 3 day shift licensed Nurses, 3 evening shift licensed nurses and 2 night shift licensed nurses all stated they had received recent in-service regarding change of condition identification, assessment, and notification competencies. Interviews with the DON and ADON revealed the ADON was immediately trained on 12/22/23 in the abuse/neglect procedures to ensure they were able to train other staff. Verified inservice titled Abuse/neglect. reflecting all staff employed by facility. Interviewed 3 day shift licensed Nurses, 2 CNA's, 3 evening shift licensed nurses, 3 CNA's and 2 night shift licensed nurses , 1 CNA , night shift; all stated they had received recent in-service regarding change of condition identification, assessment, and notification competencies. Interview with the DON,on 12/23 /23 at 2:00 p.m., the DON was asked , what was the facility's monitoring or oversight process for ensuring residents were assessed timely upon being informed of concerns for a change of condition. She responded her plan was for this to be a continuous quality measure; she planned to utilize the 72-hour report in point-click care to identify any changes of condition and have the ADON ensure proper steps were completed. Interview with the Clinical Regional Nurse on 12/23/2023 at 1:45 p.m. revealed all staff training began on 12/22/2023. Employees who have not worked since the incident have been in-serviced via phone however all will be trained in person on a one-to-one basis by the DON/designee before they are allowed to work their next shift. Of the employees in-serviced via telephone currently; 13 were nursing/direct care staff, 2 were therapy/activities staff, 1 was administrative/office staff, and 4 were ancillary staff. Interviews with 11 employees were conducted on 12/23/2023 by state surveyor, all were able to verbalize an understanding of neglect and change of condition and stated they were provided handouts to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 5 of 11 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 12/23/2023 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete reference as needed. Of the employees interviewed all shifts were covered, including: (3) 6 am - 2 pm, (2) 2 pm - 10 pm, (2) 10 pm - 6 pm, (1) 6 am - 6 pm (12-hour shift), (1) 6 am - 10 pm (doubles), (5) 8 am - 5 pm/8 pm (office staff). The Administrator was informed the Immediate Jeopardy was removed on 12/23/2023 at 5:54 p.m. The facility remained out of compliance at a severity level of actual harm that was not an Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Event ID: Facility ID: 676328 If continuation sheet Page 6 of 11 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 12/23/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 1 residents (Resident #1) reviewed quality of care in that: Residents Affected - Few The facility failed to immediately assess Resident #1 or notify the physician when a change of condition was voiced by Resident #1's family member. On 12/22/2023 at 4:31 p.m., an Immediate Jeopardy (IJ) was Identified. While the IJ was removed on 12/23/2023, the facility remained out of compliance at a severity of actual harm but with potential for more than minimal harm and with a scope isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk for not receiving the appropriate care and treatment. Findings included: Record review of Resident #1's face sheet, dated 12/22/23, revealed a male resident with an admission date of 12/7/23 and diagnosis that included [Shortness of Breath] the frightening sensation of being unable to breathe normally or feeling suffocated, [Bladder Cancer] rare form of cancer that starts in the lining of your bladder, and [Severe Protein Calorie Malnutrition] significant muscle wasting, and loss of subcutaneous fat. Record review of Resident #1's admission MDS assessment, dated 12/13/2023, revealed no BIMS score as the Cognitive assessment was not completed with the resident. Further review revealed a staff assessment for mental status had been completed that revealed short-term and long-term memory problems. Memory/Recall ability indicated resident is unable to recall the current season, the location of their own room, staff names and faces, that the resident in a nursing home and noted resident's cognitive skills to be severely impaired. No behavior issues, such as refusal of care, were identified on the MDS. Further review revealed under section H that Resident # 1 was noted to have an indwelling catheter. Record review of Resident # 1's care plan dated 12/13/23 revealed a focus area for an indwelling catheter with interventions to flush and assess each shift. Record review of Resident #1's assessments for 12/15/23 did not reveal LVN A reassessed resident or progress note regarding family members concerns. Record review of Resident #1's vital signs taken on 12/15/23 documented at 3:55 p.m., revealed normal vital signs, no further vital signs noted reflecting nursing assessment. Record review of Resident #1's assessment for 12/15/23 documented on 12/15/23 at 3:55 p.m., revealed a normal assessment. Record review of Resident #1's progress note for 12/15/23 revealed the catheter showed urine in the drainage bag was clear and draining via gravity. Recoard review of Resident #1's Treatment Administrator Record for 12/15/23 day shift documentation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 7 of 11 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 12/23/2023 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 0684 revealed the catheter was flushed. Level of Harm - Immediate jeopardy to resident health or safety Record review of [Name of Hospital] records for Resident #1, provided by family member, revealed an admission date of 12/15/2023 and he was admitted for [ Septic Shock ] a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection and [intubation] procedure that's used when you can't breathe on your own. Residents Affected - Few In an interview with LVN A on 12/22/23 at 10:45 a.m., stated she was the assigned nurse for Resident #1 on 12/15/23, 6:00 a.m. - 2:00 p.m., and took vital signs of Resident # 1 at the start of her shift on 12/15/23 at 7:15 a.m. LVN A stated she did not repeat vital signs as she did not see a change in condition, or reason to reassess Resident # 1. LVN A was asked why her assessment of Resident # 1 was started on 12/15/23 at 3:55 p.m., after her shift was over and why the assessment did not include a change of condition, abnormal vital signs or conversation had with family member. LVN A responded that she documented what she saw in the morning around 7:15 a.m., and she replied she did not do a second set of vital signs as Resident # 1 was stable on her shift and did not have a change of condition. In an interview with the DON on 12/22/23 at 10:45 a.m., the DON stated the family member of Resident #1 notified her of a change of condition on 12/15/23 at 2:04 p.m. at that time was when she looked up vital signs on the electronic medical record and no vital signs for Resident # 1 were listed at that time. The DON stated she ordered RN B to take vital signs. They were respirations - 32, Oxygen - 78% and Blood pressure of 74/45. This was when the family called 911 and Resident #1 was sent to the hospital via ambulance. The DON stated that it was her expectation that licensed nurses follow policy and procedure to notify physician of any change and document accurate vital signs. In an interview with RN B on 12/22/23 at 11:30 am she stated that she was the evening nurse for Resident # 1 on 12/15/23 from 2:00 p.m. - 10:00 p.m., shift, she recalled in the nursing report from LVN A on 12/15/23 she was told that family of Resident # 1 wanted him sent to the hospital for a change of condition. RN B stated that after the report, she went to do rounds on her residents. When the DON asked her to do a set of vital signs on Resident # 1, she recalled vital signs were abnormal, and family member was asking for them and writing them down. RN B was asked why there was no change of the condition assessment completed or nursing notes on her shift. RN B stated, it all happened so fast that day her only thought was to send the resident out as he did not look like himself and probably forgot. RN B stated Resident #1 was sent via ambulance to the hospital and family member called 911 In an interview with the family member of Resident #1 on 12/22/23 at 3:15 p.m. revealed she came to LVN A various times on 12/15/23 starting at 12:00 p.m., 12:20 p.m. and 1:00 p.m. with concerns that Resident #1 was more confused, and the resident's catheter was clogged. Resident #1's family member stated not once did LVN A take vital signs of a Resident #1. The family member recalled LVN A telling her that Resident #1 was, fine and not to worry. In an interview with Resident #1's physician on 12/22/23 at 3:30 p.m., he stated that he assessed Resident #1 on 12/14/23 and did not have any concerns at that time. However, it was his expectation that licensed nurses contact him on any change of condition on any of his residents. In an interview with CNA A on 12/22/23 at 3:45 p.m., she stated she was the assigned CNA on 12/15/23 for the day shift (6:00 a.m. - 2:00 p.m.). She recalled speaking to LVN A on one occasion that day at 11:20 a.m. and telling LVN A that Resident #1 was not eating his lunch and not himself. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 8 of 11 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 12/23/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Record review of Facility policy title Acute Condition Changes, dated 2001 , revised March 2018 revealed The Nursing staff will contact the physician based on urgency of the situation, The Physician should request information to clarify the situation for example vital signs and physical findings . This was determined to be an Immediate Jeopardy (IJ) on 12/22/2023 at 4:25 p.m. The Administrator was notified at 4:35 p.m. The Administrator was provided with an IJ template on 12/22/23 at 4:35 p.m. Residents Affected - Few The following Plan of Removal (POR) was submitted by the facility on 12/22/2023 at 7:47 p.m. The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the issues: Regional Director of Operations re-educated the Administrator on ensuring residents were receiving necessary and accurate follow through with change of condition, notification, and implementation on 12/22/2023. Regional Nurse Consultant for the facility reinforced and re-educated the Director of Nursing on identification, assessment, and notification of change in condition to be maintained consistently following facility policies and monitored for effective and successful outcomes on 12/22/2023. Licensed facility personnel to perform audit of all resident charts to include identification, assessment, outcome, and communication for the past 14 days to assess for proper implementation of change in condition policy with interventions performed accordingly by 12/23/2023. The DON/designee to have completion of change in condition to include identification, assessment, and notification competencies on all licensed nursing personnel by 12/23/2023. Re-education of all licensed staff members began per the DON/ADON and/or designees on abuse/neglect, change in condition to include identification, assessment, documentation, notification, and outcome of resident status per facility policies. Integrity checks by educators began 12/22/2023 and to continue to completion 12/23/2023 with posttest as noted below in interventions and monitoring. Interventions and Monitoring Plan to Ensure Compliance Quickly: The Director of Nursing/Designee educated all licensed nursing staff on abuse/neglect, change in condition to include identification, assessment, documentation, notification, and outcome of resident status including discharge procedures and documentation. Initiated: 12/22/2023 Completion: 12/23/2023 Reeducation to be completed by 12/23/2023 with licensed nurses regarding change of condition, immediate notification, and responsible party integration in care to include notification and follow through with findings. Initiated: 12/22/2023 Completion: 12/23/2023 All resident changes in conditions were to be reported to the Director of Nursing/designee to ensure monitoring all acute change of condition documentation and notification of physician and responsible party with appropriate interventions and actions daily. Initiated: 12/22/2023 Completion: 12/23/2023 Immediate action to notify the physician and receive new orders on any residents identified through (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 9 of 11 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 12/23/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few audit findings for potential change in condition with appropriate documentation at such time of notification. Initiated: 12/22/2023 Completion: 12/23/2023 100% of the licensed staff that were currently scheduled performed return demonstration of understanding will be noted by post competency check for each person educated with a written post-test administered by the Director of Nursing, the Assistant Director of Nursing, and/or designee for all the nursing staff receiving training on change in condition and appropriate documentation and notification. Staff that are not scheduled or on leave from the facility will perform return demonstration of understanding and will be noted by post competency check for each person educated with a written post-test administered by Director of Nursing, Assistant Director of Nursing, and/or designee before starting their next shift. This facility does not employ the use of agency personnel. Initiated: 12/22/2023 Completion: 12/23/2023. The facility DON/ADON will act as monitoring liaison to coordinate completion of audits and communication of any issues in weekly clinical at risk (CAR) meetings which include the Administrator and interdisciplinary team for continuum of care to be documented through signed attendance sheet. Initiated: 12/22/2023 Completed: 12/23/2023 The policy and procedure for abuse/neglect and change in condition were reviewed by the Regional [NAME] President of Operations and the Regional Nurse Consultant with no changes to policies to be implemented. Continue to follow policies as implemented and monitor compliance as noted above. Initiated: 12/22/2023 Completed: 12/23/2023 The QAPI Team, led by the Administrator, will meet weekly for 3 weeks to discuss that coordination and completion of all education, assessments, and interventions are utilized to ensure that appropriate change of condition procedures and protocol are followed and maintained per current facility policies. The Medical Director was notified of Immediate Jeopardy and QAPI meetings on 12/22/2023 and will be part of the QAPI intervention meetings. Abuse/neglect and change of condition protocols and policies to be added to the QAPI monthly for 3 months following the initial 3 weeks to monitor program progress. Verification: Interview with the Regional [NAME] President of Operations and Regional Nurse Consultant on 12/23/23 at 2:30 p.m. They stated they have reviewed the change of condition and the Abuse/Neglect policy, and no changes will be implemented. Interview with Administrator on 12/23/23 at 12:10 p.m., the Administrator stated the Regional Director of Operations re-educated him on ensuring residents were receiving necessary and accurate follow through with change of condition, notification, and implementation. Verified, via records review signed by the Administrator on 12/22/23 where he acknowledged re-education by the Regional Director of Operations on ensuring residents were receiving necessary and accurate follow through with change of condition, notification, and implementation. Interview with the DON on 12/23/23 at 12:30 p.m., the DON stated she was re-educated by the Regional Nurse Consultant on identification, assessment, and notification of change in condition to be maintained consistently following facility policies and monitored for effective and successful outcomes. Verified, via records review signed by the DON on 12/22/23, where she acknowledges re-education by the Regional Nurse Consultant identification, assessment, and notification of change in condition to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 10 of 11 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 12/23/2023 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 0684 be maintained consistently following facility policies and monitored for effective and successful outcomes, Level of Harm - Immediate jeopardy to resident health or safety Record review of 56 residents' charts, of which 56 charts revealed compliance. Residents Affected - Few Interviews with the DON and ADON revealed the ADON was immediately trained on 12/22/23 in the change of condition procedures to ensure they were able to train other staff. Verified via inservice titled Change of Condition. and post-test for Change of Condition reflecting all licensed nurses employed by facility. Interviewed 3 day shift licensed Nurses, 3 evening shift licensed nurses and 2 night shift licensed nurses all stated they had received recent in-service regarding change of condition identification, assessment, and notification competencies. Interviews with the DON and ADON revealed the ADON was immediately trained on 12/22/23 in the abuse/neglect procedures to ensure they were able to train other staff. Verified inservice titled Abuse/neglect. reflecting all staff employed by facility. Interviewed 3 day shift licensed Nurses, 2 CNA's, 3 evening shift licensed nurses, 3 CNA's and 2 night shift licensed nurses , 1 CNA , night shift; all stated they had received recent in-service regarding change of condition identification, assessment, and notification competencies. Interview with the DON,on 12/23 /23 at 2:00 p.m., the DON was asked , what was the facility's monitoring or oversight process for ensuring residents were assessed timely upon being informed of concerns for a change of condition. She responded her plan was for this to be a continuous quality measure; she planned to utilize the 72-hour report in point-click care to identify any changes of condition and have the ADON ensure proper steps were completed. Interview with the Clinical Regional Nurse on 12/23/2023 at 1:45 p.m. revealed all staff training began on 12/22/2023. Employees who have not worked since the incident have been in-serviced via phone however all will be trained in person on a one-to-one basis by the DON/designee before they are allowed to work their next shift. Of the employees in-serviced via telephone currently; 13 were nursing/direct care staff, 2 were therapy/activities staff, 1 was administrative/office staff, and 4 were ancillary staff. Interviews with 11 employees were conducted on 12/23/2023 by state surveyor, all were able to verbalize an understanding of neglect and change of condition and stated they were provided handouts to reference as needed. Of the employees interviewed all shifts were covered, including: (3) 6 am - 2 pm, (2) 2 pm - 10 pm, (2) 10 pm - 6 pm, (1) 6 am - 6 pm (12-hour shift), (1) 6 am - 10 pm (doubles), (5) 8 am - 5 pm/8 pm (office staff). The Administrator was informed the Immediate Jeopardy was removed on 12/23/2023 at 5:54 p.m. The facility remained out of compliance at a severity level of actual harm that was not an Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 11 of 11