Health inspection·July 5, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few but still sharp enough to break the skin . The ADM stated he did not know how long Resident #29's closet and personal items had been like that. During a phone interview with a family member of Resident #29 on 06/28/23 at 4:36 pm, Resident #29 had lived at the facility for 5 years. She stated she had not looked in Resident #29's closet before her last visit on 06/26/23. She stated she did so because she noticed Resident #29 had on the same shirt, and she was wondering what was going on because he had many shirts. She stated the shirts and pants in his closet felt damp, and other clothing items were in a pile, in the corner of the closet, on the bottom with food crumbs on them. She stated Resident #29's shoes were covered in mold, and Resident #29 had been coughing . She stated she believed the dampness and mold in Resident #29's closet may have been causing his cough. She stated Resident #29 had not been wearing shoes for she did not know how long, because he had some sores on his feet and his shoes were uncomfortable for him to wear. She stated she did not report her findings to anyone because she was concerned that Resident #29 would be retaliated against. She stated she had no grounds for her concern of retaliation, she just wanted to be sure. Record review of the facility policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021, 5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455608 If continuation sheet Page 2 of 4 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 455608 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hacienda Oaks at Beeville 4713 Business 181 N Beeville, TX 78102 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and observation, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (Resident #1), reviewed for care plans in that: The facility failed to implement a comprehensive person-centered care plan for Resident #1(R#1) in that: -fingernails should be short and filed -Sheepskin to arm rest, handles, metal joints on the wheelchair to prevent injury. These deficient practices could place residents in the facility at risk of not being provided with the necessary care or services and implementing personalized plans developed to address their specific needs. The Findings include: 1)Record review of the admission record dated 07/5/23 for R#1 revealed R#1 was admitted to the facility initially on 12/17/2017 and a readmission date of 02/11/20, was an [AGE] year-old female. R#1's diagnosis included Emphysema (lung condition that causes shortness of breath), Parkinson's (degenerative disorder of the central nervous system that mainly affects the motor system), Epilepsy (seizure disorder), Left femur fracture, Fatigue fracture of lumbar region vertebra (fracture of the bones on lower back), Osteoporosis (brittle weak bones), Dysphagia (unable to comprehend or unable to formulate language because of damage to specific part of brain regions), Lack of coordination, and History of falls. Record review of Resident #1's care plan dated 05/22/23 indicated R#1 had Potential for alteration of skin integrity related to PVD/PAD (peripheral vein and artery disease) of bilateral legs, feet, and lower legs become discolored, cool to touch when dependent at times. R#1 was constantly bumping arms, legs against the wheelchair, door frame or running up against the wall in wheelchair. Interventions include, keep fingernails short and filed, and Sheepskin to arm rests, handles, metal joints o the wheelchair to prevent injury. Record review of Resident # 39's quarterly MDS assessment dated [DATE] indicated R#1 was cognitively impaired and wheelchair bound, required extensive assistance with bed mobility, and transfers. Limited assistance with personal hygiene, toilet use, eating, and dressing. Observation on 7/5/2023 at 12:55pm of R#1 in dining room. R#1 was in wheelchair at table and just finished eating lunch. R#1 noted with no sheep skin to any part of wheelchair. R#1 appeared calm, with pale skin. R#1 noted with fingernails at medium length approximately 0.5 centimeter to 1 centimeter over grown beyond fingertip and fingernails did not appear to be cut nor filed short as stated in care plan. Interview with ADON on 7/5/23 at 1:30pm, stated R#1's fingernails should be short and filed down to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455608 If continuation sheet Page 3 of 4 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 455608 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hacienda Oaks at Beeville 4713 Business 181 N Beeville, TX 78102 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm prevent injury. ADON stated that R#1's fingernails are medium to long in length. ADON stated R#1 is resistive to care and usually the Activities Director helps with cutting resident's fingernails. ADON stated R#1 being resistive to care is not care planned at this time and did not state why it was not care planned. ADON stated, some adverse effects of R#1's fingernails not being short and filed as care planned are, R#1 could scratch, cut, scrape, and possibly injure herself. Residents Affected - Few ADON stated that R#1 does not have sheepskin over wheelchair as care planned because R#1 was in a new wheelchair and thinks it is no longer necessary to have the sheep skin placed as current care plan states. ADON stated, care plan will be updated to reflect the changes. ADON stated, according to care plan, resident should have sheepskin over arm rest and the other places as stated in care plan. R#1 could get skin tears, cuts, and possible bruising. ADON stated, MDS Coordinator, is responsible for updating care plans and effective tomorrow (7/6/2023), Regional RN will be coming in to oversee care plans but currently, ADON and DON oversee care plans and implementations. Interview with MDS Coordinator on 7/5/23 at 2:23pm revealed care plans began upon admission, quarterly, and updated as needed. MDS Coordinator stated, at first the LVN's create the care plan and the next day I enter it into the system and check for any flags. MDS Coordinator stated, LVN'S do not always put what they need to (on care plans). Falls and skin tears are added and revised every morning. DON and ADON are going to start helping with care plans. MDS Coordinator stated, if care plans were not updated, mistakes on the care plan can alter a resident's well-being and care. DON was unavailable for interview regarding care plans. Review of Care Planning Policy dated 3/2018 states: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. 8. The comprehensive, person-centered care plan will; a. Include measurable objectives and timeframes b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455608 If continuation sheet Page 4 of 4