Inspection·August 6, 2024

F 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few all the signs of drug overdose. The hospital RN stated he was blue and had 3 breaths per minute (agonal breaths). She stated he received Narcan and tested positive for Methadone overdose. She stated after he received the Narcan, he woke up but needed another dose of Narcan. She stated she Resident #1 eventually admitted to ICU and he woke up again. During an interview on 8/4/2024 at 6:30 PM, the DON stated Resident #1 could have received the Methadone because someone pre-pulled the medication that caused a medication error because they did not remember what pills belonged to which resident. She stated medications are to be pulled using the 5 rights of medication administration. The individual administering the medication checks the label 3 times the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication to the resident. During an interview 8/5/2024 at 4:35 PM, the Pharmacist that was contracted with the facility stated the effects of methadone overdose was confusion, disorientation, fatigue, and sleepiness. She stated the dosage that would cause an overdose would depend on the dosage and depend on how fast they metabolized it. Record Review of the facility's policy titled Administering Medications dated April 2019 stated in part; Medications are administered in a safe and timely manner, and as prescribed. (9). The individual administering medications verifies the resident's identity before giving the resident medication. Methods of identifying the resident include checking identification band, photograph attached to medical record, and if necessary, verify resident identification with other facility personnel.(10). The individual administering the medication checks the label 3 times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. On on 8/4/2024 at 7:02 PM, an Immediate Jeopardy (IJ) was identified. The Administrator and the DON were notified. The Administrator and the DON was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. The POR was accepted on 8/5/2024 and verification began on 8/6/2024: IJ Component: F 755 Pharmaceutical Services Facility failed to ensure resident was receiving the appropriate medication. Immediate Actions: 1. DON/designee reviewed all resident narcotic administration records to ensure residents are receiving the correct medication as ordered by the physician. All counts were correct. Initiated on 8/4/2024. Completed 8/5/2024 2. DON/designee moved all scheduled and PRN narcotic medications from the certified medication aide cart to the licensed nurse medication cart-this will be permanent. Only Licensed Nurses will be administering routine ordered and PRN ordered narcotics. The CMA's will not have access or keys to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 2 of 18 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 08/06/2024 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 0755 Nurses medication carts. Initiated on 8/4/2024. Completed 8/4/2024 Level of Harm - Immediate jeopardy to resident health or safety Facility Plan to ensure compliance: Residents Affected - Few DON/designee to re-educate licensed nurses and certified medication aides in the process of medication administration with an emphasis of verifying the resident's identity before giving the resident his/her medications and adverse consequences of medication errors. The Regional Nurse Consultant and [NAME] President of Operations provided in-service to DON and administrator on 8/4/2024. Staff that are on leave from the facility, as well as newly hired staff in the future will be given medication administration education by the same individuals noted above before starting their next shift. This facility does not employ the use of agency personnel. Initiated on 8/4/2024. Completed 8/5/2024. 1. 2. DON/designee to educate licensed nurses that all narcotics given will require 2 licensed nurses to initial administration to ensure administration of medication to the correct resident. The Regional Nurse Consultant and [NAME] President of Operations provided in-service to DON and administrator on 8/4/2024. Staff that are on leave from the facility, as well as newly hired staff will be given medication administration education by the same individuals noted above before starting their next shift. This facility does not employ the use of agency personnel. This training will be on an ongoing basis for all new hires. Initiated on 8/4/2024. Completed 8/5/2024. 3. The Medical Director was notified by the Administrator on 8/4/2024 at 7:20 pm on the immediate jeopardy citation. 4. An Ad-hoc QAPI meeting was held on 8/4/2024 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. Monitoring 1. DON/designee will perform medication administration observations on the licensed nurses and certified medication aides twice a week beginning 8/4/2024 and ongoing to ensure medications are administered to the correct resident. A medication observation tool will be used to document compliance with the medication administration beginning 8/4/2024 for 60 days. The pharmacy consultant will perform medication observation monthly during her routine monthly visit on an ongoing basis. 2. The above will be reviewed in the monthly facility QAPI meeting for no less than 60 days or until the Administrator determines substantial compliance has been achieved and maintained. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 3 of 18 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 08/06/2024 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 0755 Monitoring of the Plan of Removal from 8/6/2024 to 8/6/2024 included the following: Level of Harm - Immediate jeopardy to resident health or safety Interviews with 27 out of 28 were done with 27 nurses and 2 Medication Aides were done (one terminated). 4 nurses for day and evening; 5 nurses for day shift; 7 nurses and 1 Medication Aide for evening; 4 nurses for all shifts (PRN); 4 nurses for overnight; and 3 RN Managers. The one nurse that was PRN (as needed) would receive the in-service before she can start her shift. All that received the in-service stated the carts were audited and the narcotics were only on the nurses' carts, not to be administered by Medication Aides any longer. They were in-serviced on medication rights of administration: right resident, right time, right dose, and right route and right documentation. Residents Affected - Few During an interview on 8/6/2024 at 9:38 AM LVN A who worked day shift stated she had been a nurse 5 years. She stated she had in-service on passing medication. She stated she was told that they had to have another person to witness narcotics being passed for at least 60 days. She stated they would be checked weekly on medication passed and it was done yesterday. She stated Med Aides no longer have access to narcotics and only nurses would administer as needed narcotics and scheduled narcotics. She stated they went over the 5 rights of administering medication; nursing assessment and when medication should be held and call doctor to inform of reason of holding medication and document. She stated before passing medication they did a count of the narcotics with the previous shift nurse or Med Aide. She stated if there was an error with the narcotics, she would not take the keys and immediately inform the DON. She stated she would take vitals on her residents when needed before administering her medications. She stated pre-pulling medications could cause confusion and it would be better to do the medications one resident at a time. During an interview on 8/6/2024 at 9:50 AM LVN U who worked day shift stated he had in-service on narcotics administration that now needed 2 signatures as a witness. He stated he did not pre-pull medication, take vitals, assessment for pain and makes sure he does the 5 rights order, patient, time, dose, and medication. He stated that there was no Med Aide on the unit he worked and was not aware there would be random medication observations. During an interview on 8/6/2024 at 9:58 AM LVN C who worked day shift stated she had the in-service on nurses passed narcotics for scheduled and as needed and 2 nurses had to sign off on the narcotics. She stated DON audited her narcotics on her cart and moved all narcotics to her cart. She stated she did not pre-pull her medications because it would be easy to make a mistake with administering medication. She stated she did one resident at a time, even if it was over the counter medications. She stated that administering someone the wrong medication may have an allergic reaction. She stated she would check MAR, resident, blood pressure and document, check name of medication, dose, frequency, time and day using 5 rights of medication administration. She stated when there had been times, she found medications on the cart that had been pre-pulled she would notify the ADON and they would discard the medications. During an interview on 8/6/2024 at 10:16 AM Med Aide A1 stated she had the in-service on medication pass. She stated she was taught the 5 rights of medication pass and taking vitals. She stated she was told to pass medication one resident at a time. She stated it was important not to pre-pull medication because a mistake could happen, giving the wrong medication to a resident. She stated she pre-pulled today and was terminated. She stated the last time she gave Resident #1 was Friday at 10 or 11 in the morning. She stated she would have to buy him a cupcake or a soda for him to take his medications. She stated he would agree to take it after an hour or so without buying him anything. She stated she had not seen anyone else pre-pull medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 4 of 18 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 08/06/2024 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 0755 Level of Harm - Immediate jeopardy to resident health or safety During an interview on 8/6/2024 at 10:41 AM LVN D who worked day shift stated she had in-service on medication pass. She stated she was informed not to pre-pull, medication rights. She stated only the nurses would pass out medication with 2 nurses' signatures. She stated pre-pulling medication could cause a medication error. She stated her cart was audited by the DON and all the narcotic sheets and keys were now on her cart and not the Med Aide's cart. She stated she had not seen anyone pre-pull medications but if she had seen it, she would report it to the DON. Residents Affected - Few During an interview on 8/6/2024 at 10:53 AM LVN E who worked day shift new hired nurse and had been a nurse since 2004. She stated she had an in-service on Monday. She stated she was off on the weekend and the training was about the rights of the resident with medication pass. She stated she always kept the rights on her. She stated she did not pre-pull because it could cause confusion and med pass error. She stated it should be done one resident at a time. She stated she had not seen anyone pre- pulling medication but if she had seen it, she would inform them of the issues with doing that and then notify the DON. She stated only the nurses passed the narcotics with 2 signatures each time a narcotic was pulled. She stated she did not know how long the 2-signature process would last. During an interview on 8/6/2024 at 11:48 AM LVN G who worked overnight shift stated the in-service was about medication pass and narcotics. He stated it was about the 6 rights, counting and documentation: not giving unprescribed medications. He stated only nurses were to administer narcotics. He stated he had not seen anyone pre-pull medication. He stated pre-pull medication can be a safety hazard, it would be loose medication in the cart. He stated pre-pulled medication could cause a medication error. He stated 2 nurses were to sign out narcotics. During an interview on 8/6/2024 at 12:20 PM LVN K who worked evening shift stated she had been at the facility for 4 days. She was called to the DON's office to discuss medication administration with the 5 rights and another nurse to sign off for narcotics. She stated only the nurses were allowed to pass narcotics. She stated she was in the Memory Care Unit and she did not have a MA. She stated pre-pulling medications can cause medication error and she would only do one resident at a time. She stated she was unaware if the cart was audited because yesterday was her first day working alone. She stated there was no issue with the narcotic count and when she ended her shift, she and the other nurse both signed out. She stated if there was an issue with the narcotic count, she would not accept the keys and inform the DON. She stated if she saw if someone pre-pulled medication, she would inform a supervisor. During an interview on 8/6/2024 at 12:35 PM RN Weekend Supervisor (P) she stated that 2 nurses were to sign off on narcotics. She stated as the supervisor to enforce the new policy, she would do a medication pass audit/in-service because she only worked on the weekend. She stated she would be more adamant about checking carts for pre-pulled medications on each shift. Most times there were shift changes but most of them worked doubles. During an interview on 8/6/2024 at 12:44 PM LVN W who worked day and evening shifts stated she had the in-service Sunday about medication pass, and verifying with the 5 rights of medication pass. She stated she would not pre-pull medication because it could cause medication error and she only does one medication at time. She stated she had not seen anyone pre-pull medication. She stated she would report it to a supervisor. She stated the narcotics were the only one to give out narcotics and the process is for 2 nurses to verify and sign. She stated she would not give medications to a resident that was drowsy. She would take vitals, check medications given previously, and call the doctor. During an interview on 8/6/2024 at 12:57 PM LVN L who worked day and evening shifts stated she had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 5 of 18 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 08/06/2024 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the in-service and were told Med Aides were not allowed to pass the narcotics and 2 nurses were to verify and sign out narcotics. She stated she noticed that all of the narcotics and the keys were on her cart. She stated pre-pulling medications were not allowed and medications were not allowed to be administered before the scheduled time. She stated pre-pulling medication could cause medication error. She stated she used the 6 rights of the residents to pass her medication. She stated she had not seen anyone pre-pulled medication and if she had seen it, she would notify the supervisor. She stated she would not allow the medication to be passed and immediately call a supervisor. She stated if she observed someone drowsy, she would take vitals and call the doctor to get an order to hold a medication that may cause drowsiness she would also notify a supervisor. She states she only worked on the weekends. During an interview on 8/6/2024 at 1:05 PM RN X who worked evening shift stated she had an in-service on Sunday about medication pass and the 5 rights of medication pass. She stated the narcotics were not to be administered by Medication Aides and all the narcotics were moved to her cart with the keys given to her. She stated 2 nurses now need to verify and sign for narcotic administration. She stated she did not pre pull her medications because it could cause medication error- giving the wrong medication to a resident, confusing medications. If she saw someone drowsy, she would take vitals and call the physician to hold the medication, or any other orders given. She stated if she saw someone had pre pulled medication she would notify the supervisor. During an interview on 8/6/2024 at 1:40 PM LVN O who worked day and evening shifts worked on the weekends. He stated he had the in-service on the 5 rights of medication administration and was also observed doing a medication pass. He stated all the narcotics were on the nurses' carts and no longer on the Med Aide's carts. He stated he was informed that the narcotics were to be signed by 2 nurses for verification. He stated medications should not be pre pulled because the medication could be given to the wrong resident. He stated he was newly hired at the facility and had not seen anyone pre pull medication. If he were to see it, he would notify the supervisor. He stated he had been observed by the DON doing medication pass. During an interview on 8/6/2024 at 1:49 PM LVN I who worked overnight shift stated she had an in-service this morning about medication administration and the 5 rights. She stated 2 nurses needed to confirm and sign for narcotics. She stated the med aides would not be passing narcotics any longer. She stated she had not seen any pre pulled medications. She stated she would ask about the medication if it was left in the cart and she would call the supervisor. She stated pre pulled medications could result in a medication error. During an interview on 8/6/2024 at 2:00 PM LVN H who worked overnight shift stated he had received the in-services about drug administration and the 5 rights. He stated he did not pre-pull medication because it could result in a medication error. He stated he had not seen any pre pulled medications in the cart and if he had seen it, he would report it to the DON. He stated 2 nurses needed to verify and sign off for the administration of narcotics. He was informed that med aides would not be allowed to pass narcotics. He stated if he saw someone very drowsy, he would take a set of vitals, notify the doctor, and hold the medication until he spoke with the doctor. During an interview on 8/6/2024 at 2:06 PM LVN N who worked as needed and weekends stated she had the in-service and was informed only nurses would administer narcotics, all the narcotics were removed from the med aides' carts, and 2 nurses would be needed to administer the narcotics to verify and sign. She stated it was important to not pre pull medications because it would be easy to make a medication error giving the medication to the wrong resident. She stated they also discussed the 5 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 6 of 18 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 08/06/2024 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few rights of medication administration. She stated if she saw pre pulled medication on the cart, she would report it to the DON or ADON. During an interview on 8/6/2024 at 2:07 PM LVN M who worked evening shift stated she had the in-service yesterday and was told the nurses would administer the narcotic. She stated she was told to use the 5 rights to administer medications. She stated that 2 nurses needed to sign out narcotics to verify the correct medication was administered. She stated all the narcotics and the books with the sheets were put into the nurses' carts. She stated it was important not to pre pull medications because it could cause a medication error- by forgetting who the medication belonged to. She stated she had not seen medication pre pulled on a cart. She stated she would question who or what the medication was for, she would discard it and inform the supervisor. She stated if she saw a resident groggy, she would do an assessment, take vitals, notify the supervisor, notify the physician, and hold the medication until further orders from the doctor. During an interview on 8/6/2024 at 2:16 PM Med Aide B1 who worked evening shift stated she had the in service about medication process using 5 rights and not to pre pull medications. She stated narcotics were removed from her cart and would be administer by the nurses only to prevent too many people handling the narcotics. She stated it was important not to pre pull medication to prevent medication error. She stated she had not seen anyone pre pulling medications. She stated if she had seen it, she would report it to the charge nurse and if nothing was done about it, she would report it to the DON. She stated there had been times that Resident #2 had been very drowsy and she reported it the nurse and she did not give the medication to him. During an interview on 8/6/2024 at 2:29 PM RN R who worked evening shift stated she had the in-service of medication administration and the 5 rights of medication administration. She stated there would need to be 2 nurses to sign for a delivery of a narcotic and to administer to a resident. She stated it was important not to pre pull to prevent medication error- wrong time, wrong med, wrong resident. She stated she had seen medication pre pulled medication and she informed the person that did it not to do it and she told the ADON about it. She stated if she saw that a resident was very drowsy, she would do an assessment with a set of vitals, hold the medication, notify the doctor, the DON, family, and wait for further orders from the doctor. During an interview on 8/6/2024 at 2:49PM RN J worked all shifts stated she had the in service yesterday. She stated they discussed 5 rights of medication administration. 2 nurses were needed to administer narcotics. She stated the carts were audited and is aware Med Aides were no longer able to pass narcotics. She stated she had not seen anyone pre pull medications. She stated pre pulled medications could cause medication error. She stated if she had seen someone who pre pulled, she would stop the administration first and notify a supervisor immediately. During an interview on 8/6/2024 at 2:58 PM RN V who worked evening shift stated she had the in-service on medication administration on the 7 rights of administration. She stated that narcotics required 2 nurses to verify and sign. She stated pre pulled medications-ask the resident first if it was needed before pulling a narcotic. She stated pre pulled medications could result in medication error that could have dangerous results. She stated Med Aides were no longer allowed to administer narcotics. She stated she had not seen anyone pre pull medications and she had only been employed with the facility for 2 months. She stated if she saw someone pre pulled medications, she would inquire to the person who had done it, she stated it would be best to report it to the supervisor. She stated if she saw someone groggy, she would not administer a narcotic and do an assessment with vitals, report it to the doctor, the supervisor, and the family await further instructions from the doctor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 7 of 18 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 08/06/2024 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview on 8/6/2024 at 3:06 PM LVN Y who worked overnight shift stated she had the in-service this morning about resident 7 rights of medication administration. She stated she was informed that 2 nurses would need to sign out narcotics to verify. She stated the cart and narcotic book was audited. She stated she was informed that the Med Aides were not allowed to pass narcotics. She stated she had not seen anyone pre pull medications, and pre pulled med errors could cause a medication error. She stated she would do an assessment with vital signs, hold the medication, and notify the doctor. She stated if she would see someone with pre pulled medications, she would advise them to discard the medications and assist them if needed. She stated if the person were to do it more than once, she would then go to the DON. During an interview on 8/6/2024 at 3:21 PM LVN T who worked overnight shift stated she had the inservice about medication administration that now required 2 nurses to sign for verification. She stated that medications should not be pre pulled and use the 7 rights of medication administration. She stated it was important not to pre pull to prevent medication error. She stated she had not seen anyone pre pull medications, but had she seen it, she would inform the person not to do that and then report. She stated if she saw someone drowsy, she would not administer a narcotic because it could mask another problem. She stated she would call the supervisor, the doctor, and the family and wait for further orders from the doctor. During an observation on 8/6/2024 at 3:50 PM, the medication carts on the 100-hall unit had all the narcotics on the nurses' carts and no narcotics on the Medication Aide's cart. Observed LVN F on 100 hall passed medication and LVN F verified a narcotic he pulled with RN V. During an interview on 8/6/2024 at 10:10 AM, the DON stated she did not want staff to know she would do random medication observations because she wanted to ensure they were doing the medication pass per facility policy. She stated she did an in-service with Med Aide A1 that morning and she was informed not to pre-pull medication. She stated she allowed her to prepare for medication pass and decided to do a random observation with her. She stated she found that the Med Aide A1 was about to enter a residents' room with 2 cups of medication- one cup for each resident. The Med Aide was terminated. During an interview on 8/6/2024 at 1:40 PM LVN O who worked day and evening shifts worked on the weekends. He stated he had the in-service on the 5 rights of medication administration and was also observed doing a medication pass. He stated all the narcotics were on the nurses' carts and no longer on the Med Aide's carts. He stated he was informed that the narcotics were to be signed by 2 nurses for verification. He stated medications should not be pre pulled because the medication could be given to the wrong resident. He stated he was newly hired at the facility and had not seen anyone pre pull medication. If he were to see it, he would notify the supervisor. He stated he had been observed by the DON doing medication pass. Record review of QAPI signature page dated 8/4/2024 revealed the Medical Director gave verbal approval over the phone and email due to being on vacation. The Administrator stated the Medical Director also received a scanned copy of the signed IJ template. During an interview on 8/6/2024 at 6:56 PM LVN S stated he had in-service on medication right of medication administration. He stated he was told not to pre pull medication because it could cause a medication error. He stated he had not seen anyone pre pull medication. He stated if he saw anyone pre pull medication he would advise them not to administer medication that way and inform the DON. He stated that 2 nurses were to sign off on any narcotic to be given. He stated he would not give (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 8 of 18 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 08/06/2024 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 0755 narcotics to anyone who would be drowsy, but instead hold it and call the doctor and notify the supervisor. Level of Harm - Immediate jeopardy to resident health or safety Observation on 8/6/2024 at 7:03 PM revealed LVN F removed a Norco for Resident #3 and LVN M verified and signed off with LVN F before medication was administered. There were no pre pulled pills in the top drawer of the cart. He administered the medication to the resident using the 5 rights of medication administration. Residents Affected - Few Observation on 8/6/2024 at 7:08 PM revealed Med Aide B1 administered to Resident #3 -Cymbalta 20 mg, Atorvastatin 40mg, and Trazadone 50 mg using the 5 rights of medication administration. There were no pre pulled pills in the top drawer. An IJ was identified on 8/4/2024. The IJ template was presented to the facility on 8/4/2024 at 7:02 PM. While the IJ was removed on 8/6/2024 at 8:03 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm due to the facilities need to continue to monitor the effectiveness of their plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 9 of 18 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 08/06/2024 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Immediate jeopardy to resident health or safety Based on interviews, and record reviews,the facility failed to ensure residents are free of any significant medication error for 1 of 2 residents (Resident #1). Residents Affected - Few The facility failed to prevent Resident #1 from having a methadone overdose due to receiving incorrect medications. An IJ was identified on 8/4/2024. The IJ template was presented to the facility on 8/4/2024 at 7:02PM. While the IJ was removed on 8/6/2024 at 8:03PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm due to the facilities need to continue to monitor the effectiveness of their plan. This deficient practice could place residents at risk of receiving incorrect medications resulting in hospitalization or death. The findings included: Record review of Resident #1's eMAR (electronic Medication Administration Record) revealed an admission date of 3/30/2023 with diagnoses that included: coronary artery disease, heart failure, Parkinson's, and dementia with behaviors. Resident #1 had a BIMS score of 3. Record review of Resident #1's physician orders and MARS revealed no order for Methadone. Record reviews of facility physician orders revealed the only resident in the facility receiving Methadone was Resident #2, who resided across the hall from Resident #1. Record review Resident #2's eMar revealed LVN F (4:00PM); Med Aide B1 (10:00PM), and Med Aide A1 (10:00AM) administered Methadone to resident on 8/2/2024. During an interview on 8/4/2024 at 12:28 PM, LVN A stated Resident #1 on 8/3/2024 at 2:53PM was becoming less active and falling asleep and not his normal behavior. LVN A stated she took his vitals and his O2 saturation was low at 87%-91%. She stated she gave him oxygen and put him back to bed, called the NP, and got the order to send him to the hospital. During an interview on 8/4/2024 1:10 PM, the RN at a local hospital stated Resident #1 displayed all the signs of drug overdose. The hospital RN stated he was blue and had 3 breaths per minute (agonal breaths). She stated he received Narcan and tested positive for Methadone overdose. She stated after he received the Narcan, he woke up but needed another dose of Narcan. She stated she Resident #1 eventually admitted to ICU and he woke up again. During an interview on 8/4/2024 at 6:30 PM, the DON stated Resident #1 could have received the Methadone because someone pre-pulled the medication that caused a medication error because they did not remember what pills belonged to which resident. She stated medications are to be pulled using the 5 rights of medication administration. The individual administering the medication checks the label 3 times the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication to the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 10 of 18 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 08/06/2024 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview 8/5/2024 at 4:35 PM, the Pharmacist that was contracted with the facility stated the effects of methadone overdose was confusion, disorientation, fatigue, and sleepiness. She stated the dosage that would cause an overdose would depend on the dosage and depend on how fast they metabolized it. Record Review of the facility's policy titled Administering Medications dated April 2019 stated in part; Medications are administered in a safe and timely manner, and as prescribed. (9). The individual administering medications verifies the resident's identity before giving the resident medication. Methods of identifying the resident include checking identification band, photograph attached to medical record, and if necessary, verify resident identification with other facility personnel.(10). The individual administering the medication checks the label 3 times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. On on 8/4/2024 at 7:02PM, an Immediate Jeopardy (IJ) was identified. The Administrator and the DON were notified. The Administrator and the DON was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. The POR was accepted on 8/5/2024 and verification began on 8/6/2024: IJ Component: F 755 Pharmaceutical Services Facility failed to ensure resident was receiving the appropriate medication. Immediate Actions: 1. DON/designee reviewed all resident narcotic administration records to ensure residents are receiving the correct medication as ordered by the physician. All counts were correct. Initiated on 8/4/2024. Completed 8/5/2024 2. DON/designee moved all scheduled and PRN narcotic medications from the certified medication aide cart to the licensed nurse medication cart-this will be permanent. Only Licensed Nurses will be administering routine ordered and PRN ordered narcotics. The CMA's will not have access or keys to the Nurses medication carts. Initiated on 8/4/2024. Completed 8/4/2024 Facility Plan to ensure compliance: 1. DON/designee to re-educate licensed nurses and certified medication aides in the process of medication administration with an emphasis of verifying the resident's identity before giving the resident his/her medications and adverse consequences of medication errors. The Regional Nurse Consultant and [NAME] President of Operations provided in-service to DON and administrator on 8/4/2024. Staff that are on leave from the facility, as well as newly hired staff in the future will be given medication administration education by the same individuals noted above before starting their next shift. This (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 11 of 18 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 08/06/2024 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 0760 facility does not employ the use of agency personnel. Initiated on 8/4/2024. Completed 8/5/2024. Level of Harm - Immediate jeopardy to resident health or safety 2. Residents Affected - Few DON/designee to educate licensed nurses that all narcotics given will require 2 licensed nurses to initial administration to ensure administration of medication to the correct resident. The Regional Nurse Consultant and [NAME] President of Operations provided in-service to DON and administrator on 8/4/2024. Staff that are on leave from the facility, as well as newly hired staff will be given medication administration education by the same individuals noted above before starting their next shift. This facility does not employ the use of agency personnel. This training will be on an ongoing basis for all new hires. Initiated on 8/4/2024. Completed 8/5/2024. 3. The Medical Director was notified by the Administrator on 8/4/2024 at 7:20 pm on the immediate jeopardy citation. 4. An Ad-hoc QAPI meeting was held on 8/4/2024 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. Monitoring 1. DON/designee will perform medication administration observations on the licensed nurses and certified medication aides twice a week beginning 8/4/2024 and ongoing to ensure medications are administered to the correct resident. A medication observation tool will be used to document compliance with the medication administration beginning 8/4/2024 for 60 days. The pharmacy consultant will perform medication observation monthly during her routine monthly visit on an ongoing basis. 2. The above will be reviewed in the monthly facility QAPI meeting for no less than 60 days or until the Administrator determines substantial compliance has been achieved and maintained. Monitoring of the Plan of Removal from 8/6/2024 to 8/6/2024 included the following: Interviews with 27 out of 28 were done with 27 nurses and 2 Medication Aides were done (one terminated). 4 nurses for day and evening; 5 nurses for day shift; 7 nurses and 1 Medication Aide for evening; 4 nurses for all shifts (PRN); 4 nurses for overnight; and 3 RN Managers. The one nurse that was PRN (as needed) would receive the in-service before she can start her shift. All that received the in-service stated the carts were audited and the narcotics were only on the nurses' carts, not to be administered by Medication Aides any longer. They were in-serviced on medication rights of administration: right resident, right time, right dose, and right route and right documentation. During an interview on 8/6/2024 at 9:38 AM LVN A who worked day shift stated she had been a nurse 5 years. She stated she had in-service on passing medication. She stated she was told that they had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 12 of 18 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 08/06/2024 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to have another person to witness narcotics being passed for at least 60 days. She stated they would be checked weekly on medication passed and it was done yesterday. She stated Med Aides no longer have access to narcotics and only nurses would administer as needed narcotics and scheduled narcotics. She stated they went over the 5 rights of administering medication; nursing assessment and when medication should be held and call doctor to inform of reason of holding medication and document. She stated before passing medication they did a count of the narcotics with the previous shift nurse or Med Aide. She stated if there was an error with the narcotics, she would not take the keys and immediately inform the DON. She stated she would take vitals on her residents when needed before administering her medications. She stated pre-pulling medications could cause confusion and it would be better to do the medications one resident at a time. During an interview on 8/6/2024 at 9:50 AM LVN U who worked day shift stated he had in-service on narcotics administration that now needed 2 signatures as a witness. He stated he did not pre-pull medication, take vitals, assessment for pain and makes sure he does the 5 rights order, patient, time, dose, and medication. He stated that there was no Med Aide on the unit he worked and was not aware there would be random medication observations. During an interview on 8/6/2024 at 9:58 AM LVN C who worked day shift stated she had the in-service on nurses passed narcotics for scheduled and as needed and 2 nurses had to sign off on the narcotics. She stated DON audited her narcotics on her cart and moved all narcotics to her cart. She stated she did not pre-pull her medications because it would be easy to make a mistake with administering medication. She stated she did one resident at a time, even if it was over the counter medications. She stated that administering someone the wrong medication may have an allergic reaction. She stated she would check MAR, resident, blood pressure and document, check name of medication, dose, frequency, time and day using 5 rights of medication administration. She stated when there had been times, she found medications on the cart that had been pre-pulled she would notify the ADON and they would discard the medications. During an interview on 8/6/2024 at 10:16 AM Med Aide A1 stated she had the in-service on medication pass. She stated she was taught the 5 rights of medication pass and taking vitals. She stated she was told to pass medication one resident at a time. She stated it was important not to pre-pull medication because a mistake could happen, giving the wrong medication to a resident. She stated she pre-pulled today and was terminated. She stated the last time she gave Resident #1 was Friday at 10 or 11 in the morning. She stated she would have to buy him a cupcake or a soda for him to take his medications. She stated he would agree to take it after an hour or so without buying him anything. She stated she had not seen anyone else pre-pull medications. During an interview on 8/6/2024 at 10:41 AM LVN D who worked day shift stated she had in-service on medication pass. She stated she was informed not to pre-pull, medication rights. She stated only the nurses would pass out medication with 2 nurses' signatures. She stated pre-pulling medication could cause a medication error. She stated her cart was audited by the DON and all the narcotic sheets and keys were now on her cart and not the Med Aide's cart. She stated she had not seen anyone pre-pull medications but if she had seen it, she would report it to the DON. During an interview on 8/6/2024 at 10:53 AM LVN E who worked day shift new hired nurse and had been a nurse since 2004. She stated she had an in-service on Monday. She stated she was off on the weekend and the training was about the rights of the resident with medication pass. She stated she always kept the rights on her. She stated she did not pre-pull because it could cause confusion and med pass error. She stated it should be done one resident at a time. She stated she had not seen anyone (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 13 of 18 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 08/06/2024 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few pre- pulling medication but if she had seen it, she would inform them of the issues with doing that and then notify the DON. She stated only the nurses passed the narcotics with 2 signatures each time a narcotic was pulled. She stated she did not know how long the 2-signature process would last. During an interview on 8/6/2024 at 11:48 AM LVN G who worked overnight shift stated the in-service was about medication pass and narcotics. He stated it was about the 6 rights, counting and documentation: not giving unprescribed medications. He stated only nurses were to administer narcotics. He stated he had not seen anyone pre-pull medication. He stated pre-pull medication can be a safety hazard, it would be loose medication in the cart. He stated pre-pulled medication could cause a medication error. He stated 2 nurses were to sign out narcotics. During an interview on 8/6/2024 at 12:20 PM LVN K who worked evening shift stated she had been at the facility for 4 days. She was called to the DON's office to discuss medication administration with the 5 rights and another nurse to sign off for narcotics. She stated only the nurses were allowed to pass narcotics. She stated she was in the Memory Care Unit and she did not have a MA. She stated pre-pulling medications can cause medication error and she would only do one resident at a time. She stated she was unaware if the cart was audited because yesterday was her first day working alone. She stated there was no issue with the narcotic count and when she ended her shift, she and the other nurse both signed out. She stated if there was an issue with the narcotic count, she would not accept the keys and inform the DON. She stated if she saw if someone pre-pulled medication, she would inform a supervisor. During an interview on 8/6/2024 at 12:35 PM RN Weekend Supervisor (P) she stated that 2 nurses were to sign off on narcotics. She stated as the supervisor to enforce the new policy, she would do a medication pass audit/in-service because she only worked on the weekend. She stated she would be more adamant about checking carts for pre-pulled medications on each shift. Most times there were shift changes but most of them worked doubles. During an interview on 8/6/2024 at 12:44 PM LVN W who worked day and evening shifts stated she had the in-service Sunday about medication pass, and verifying with the 5 rights of medication pass. She stated she would not pre-pull medication because it could cause medication error and she only does one medication at time. She stated she had not seen anyone pre-pull medication. She stated she would report it to a supervisor. She stated the narcotics were the only one to give out narcotics and the process is for 2 nurses to verify and sign. She stated she would not give medications to a resident that was drowsy. She would take vitals, check medications given previously, and call the doctor. During an interview on 8/6/2024 at 12:57 PM LVN L who worked day and evening shifts stated she had the in-service and were told Med Aides were not allowed to pass the narcotics and 2 nurses were to verify and sign out narcotics. She stated she noticed that all of the narcotics and the keys were on her cart. She stated pre-pulling medications were not allowed and medications were not allowed to be administered before the scheduled time. She stated pre-pulling medication could cause medication error. She stated she used the 6 rights of the residents to pass her medication. She stated she had not seen anyone pre-pulled medication and if she had seen it, she would notify the supervisor. She stated she would not allow the medication to be passed and immediately call a supervisor. She stated if she observed someone drowsy, she would take vitals and call the doctor to get an order to hold a medication that may cause drowsiness she would also notify a supervisor. She states she only worked on the weekends. During an interview on 8/6/2024 at 1:05 PM RN X who worked evening shift stated she had an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 14 of 18 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 08/06/2024 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few in-service on Sunday about medication pass and the 5 rights of medication pass. She stated the narcotics were not to be administered by Medication Aides and all the narcotics were moved to her cart with the keys given to her. She stated 2 nurses now need to verify and sign for narcotic administration. She stated she did not pre pull her medications because it could cause medication error- giving the wrong medication to a resident, confusing medications. If she saw someone drowsy, she would take vitals and call the physician to hold the medication, or any other orders given. She stated if she saw someone had pre pulled medication she would notify the supervisor. During an interview on 8/6/2024 at 1:40 PM LVN O who worked day and evening shifts worked on the weekends. He stated he had the in-service on the 5 rights of medication administration and was also observed doing a medication pass. He stated all the narcotics were on the nurses' carts and no longer on the Med Aide's carts. He stated he was informed that the narcotics were to be signed by 2 nurses for verification. He stated medications should not be pre pulled because the medication could be given to the wrong resident. He stated he was newly hired at the facility and had not seen anyone pre pull medication. If he were to see it, he would notify the supervisor. He stated he had been observed by the DON doing medication pass. During an interview on 8/6/2024 at 1:49 PM LVN I who worked overnight shift stated she had an in-service this morning about medication administration and the 5 rights. She stated 2 nurses needed to confirm and sign for narcotics. She stated the med aides would not be passing narcotics any longer. She stated she had not seen any pre pulled medications. She stated she would ask about the medication if it was left in the cart and she would call the supervisor. She stated pre pulled medications could result in a medication error. During an interview on 8/6/2024 at 2:00 PM LVN H who worked overnight shift stated he had received the in-services about drug administration and the 5 rights. He stated he did not pre-pull medication because it could result in a medication error. He stated he had not seen any pre pulled medications in the cart and if he had seen it, he would report it to the DON. He stated 2 nurses needed to verify and sign off for the administration of narcotics. He was informed that med aides would not be allowed to pass narcotics. He stated if he saw someone very drowsy, he would take a set of vitals, notify the doctor, and hold the medication until he spoke with the doctor. During an interview on 8/6/2024 at 2:06 PM LVN N who worked as needed and weekends stated she had the in-service and was informed only nurses would administer narcotics, all the narcotics were removed from the med aides' carts, and 2 nurses would be needed to administer the narcotics to verify and sign. She stated it was important to not pre pull medications because it would be easy to make a medication error giving the medication to the wrong resident. She stated they also discussed the 5 rights of medication administration. She stated if she saw pre pulled medication on the cart, she would report it to the DON or ADON. During an interview on 8/6/2024 at 2:07 PM LVN M who worked evening shift stated she had the in-service yesterday and was told the nurses would administer the narcotic. She stated she was told to use the 5 rights to administer medications. She stated that 2 nurses needed to sign out narcotics to verify the correct medication was administered. She stated all the narcotics and the books with the sheets were put into the nurses' carts. She stated it was important not to pre pull medications because it could cause a medication error- by forgetting who the medication belonged to. She stated she had not seen medication pre pulled on a cart. She stated she would question who or what the medication was for, she would discard it and inform the supervisor. She stated if she saw a resident groggy, she would do an assessment, take vitals, notify the supervisor, notify the physician, and hold the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 15 of 18 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 08/06/2024 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 0760 medication until further orders from the doctor. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 8/6/2024 at 2:16 PM Med Aide B1 who worked evening shift stated she had the in service about medication process using 5 rights and not to pre pull medications. She stated narcotics were removed from her cart and would be administer by the nurses only to prevent too many people handling the narcotics. She stated it was important not to pre pull medication to prevent medication error. She stated she had not seen anyone pre pulling medications. She stated if she had seen it, she would report it to the charge nurse and if nothing was done about it, she would report it to the DON. She stated there had been times that Resident #2 had been very drowsy and she reported it the nurse and she did not give the medication to him. Residents Affected - Few During an interview on 8/6/2024 at 2:29 PM RN R who worked evening shift stated she had the in-service of medication administration and the 5 rights of medication administration. She stated there would need to be 2 nurses to sign for a delivery of a narcotic and to administer to a resident. She stated it was important not to pre pull to prevent medication error- wrong time, wrong med, wrong resident. She stated she had seen medication pre pulled medication and she informed the person that did it not to do it and she told the ADON about it. She stated if she saw that a resident was very drowsy, she would do an assessment with a set of vitals, hold the medication, notify the doctor, the DON, family, and wait for further orders from the doctor. During an interview on 8/6/2024 at 2:49PM RN J worked all shifts stated she had the in service yesterday. She stated they discussed 5 rights of medication administration. 2 nurses were needed to administer narcotics. She stated the carts were audited and is aware Med Aides were no longer able to pass narcotics. She stated she had not seen anyone pre pull medications. She stated pre pulled medications could cause medication error. She stated if she had seen someone who pre pulled, she would stop the administration first and notify a supervisor immediately. During an interview on 8/6/2024 at 2:58 PM RN V who worked evening shift stated she had the in-service on medication administration on the 7 rights of administration. She stated that narcotics required 2 nurses to verify and sign. She stated pre pulled medications-ask the resident first if it was needed before pulling a narcotic. She stated pre pulled medications could result in medication error that could have dangerous results. She stated Med Aides were no longer allowed to administer narcotics. She stated she had not seen anyone pre pull medications and she had only been employed with the facility for 2 months. She stated if she saw someone pre pulled medications, she would inquire to the person who had done it, she stated it would be best to report it to the supervisor. She stated if she saw someone groggy, she would not administer a narcotic and do an assessment with vitals, report it to the doctor, the supervisor, and the family await further instructions from the doctor. During an interview on 8/6/2024 at 3:06 PM LVN Y who worked overnight shift stated she had the in-service this morning about resident 7 rights of medication administration. She stated she was informed that 2 nurses would need to sign out narcotics to verify. She stated the cart and narcotic book was audited. She stated she was informed that the Med Aides were not allowed to pass narcotics. She stated she had not seen anyone pre pull medications, and pre pulled med errors could cause a medication error. She stated she would do an assessment with vital signs, hold the medication, and notify the doctor. She stated if she would see someone with pre pulled medications, she would advise them to discard the medications and assist them if needed. She stated if the person were to do it more than once, she would then go to the DON. During an interview on 8/6/2024 at 3:21 PM LVN T who worked overnight shift stated she had the in(continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 16 of 18 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 08/06/2024 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few service about medication administration that now required 2 nurses to sign for verification. She stated that medications should not be pre pulled and use the 7 rights of medication administration. She stated it was important not to pre pull to prevent medication error. She stated she had not seen anyone pre pull medications, but had she seen it, she would inform the person not to do that and then report. She stated if she saw someone drowsy, she would not administer a narcotic because it could mask another problem. She stated she would call the supervisor, the doctor, and the family and wait for further orders from the doctor. During an observation on 8/6/2024 at 3:50 PM, the medication carts on the 100-hall unit had all the narcotics on the nurses' carts and no narcotics on the Medication Aide's cart. Observed LVN F on 100 hall passed medication and LVN F verified a narcotic he pulled with RN V. During an interview on 8/6/2024 at 10:10 AM, the DON stated she did not want staff to know she would do random medication observations because she wanted to ensure they were doing the medication pass per facility policy. She stated she did an in-service with Med Aide A1 that morning and she was informed not to pre-pull medication. She stated she allowed her to prepare for medication pass and decided to do a random observation with her. She stated she found that the Med Aide A1 was about to enter a residents' room with 2 cups of medication- one cup for each resident. The Med Aide was terminated. During an interview on 8/6/2024 at 1:40 PM LVN O who worked day and evening shifts worked on the weekends. He stated he had the in-service on the 5 rights of medication administration and was also observed doing a medication pass. He stated all the narcotics were on the nurses' carts and no longer on the Med Aide's carts. He stated he was informed that the narcotics were to be signed by 2 nurses for verification. He stated medications should not be pre pulled because the medication could be given to the wrong resident. He stated he was newly hired at the facility and had not seen anyone pre pull medication. If he were to see it, he would notify the supervisor. He stated he had been observed by the DON doing medication pass. Record review of QAPI signature page dated 8/4/2024 revealed the Medical Director gave verbal approval over the phone and email due to being on vacation. The Administrator stated the Medical Director also received a scanned copy of the signed IJ template. During an interview on 8/6/2024 at 6:56 PM LVN S stated he had in-service on medication right of medication administration. He stated he was told not to pre pull medication because it could cause a medication error. He stated he had not seen anyone pre pull medication. He stated if he saw anyone pre pull medication he would advise them not to administer medication that way and inform the DON. He stated that 2 nurses were to sign off on any narcotic to be given. He stated he would not give narcotics to anyone who would be drowsy, but instead hold it and call the doctor and notify the supervisor. Observation on 8/6/2024 at 7:03 PM revealed LVN F removed a Norco for Resident #3 and LVN M verified and signed off with LVN F before medication was administered. There were no pre pulled pills in the top drawer of the cart. He administered the medication to the resident using the 5 rights of medication administration. Observation on 8/6/2024 at 7:08 PM revealed Med Aide B1 administered to Resident #3 -Cymbalta 20mg, Atorvastatin 40mg, and Trazadone 50mg using the 5 rights of medication administration. There were no pre pulled pills in the top drawer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 17 of 18 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 08/06/2024 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 0760 An IJ was identified on 8/4/2024. The IJ template was presented to the facility on 8/4/2024 at 7:02PM. Level of Harm - Immediate jeopardy to resident health or safety While the IJ was removed on 8/6/2024 at 8:03PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm due to the facilities need to continue to monitor the effectiveness of their plan. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676328 If continuation sheet Page 18 of 18