Health inspection·June 5, 2025

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents were free from neglect for 1 (Resident #1) of 5 residents reviewed for abuse/neglect, in that: The facility failed to ensure Resident #1, who required 2 or more staff per her care plan was provided with the appropriate number of staff while in the shower chair. As a result, the resident had a fall when she was left unattended and sustained a broken toe. This failure could place residents at risk of emotional distress, fear, decreased quality of life, and further neglect. Findings included: Record review of Resident #1's admission record revealed she was an [AGE] year-old female with an admission date of 01/13/21. Diagnoses included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), stroke, type 2 diabetes mellitus, epilepsy (seizure disorder), and hypertension (high blood pressure). Record review of Resident #1's Quarterly MDS on 01/03/25 revealed: -A BIMS of 03 which indicated severe cognitive impairment. -Shower/bathe: Dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity Or, the assistance of 2 or more helpers is required for the resident to complete the activity). -TRANSFER: The resident is dependent on (2) staff for transferring Dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity Or, the assistance of 2 or more helpers is required for the resident to complete the activity). Record review of Resident #1's Care Plan dated 01/03/2025, revealed: FOCUS: -Resident #1 has an ADL self-care performance deficit r/t Confusion, Dementia, Impaired balance, seizure disorder, CVA with left hemiplegia (paralysis affecting only one side of the body) Date Initiated: 01/14/2021 Page 1 of 16 455621 455621 06/05/2025 Valley Grande Manor 1212 S Bridge Weslaco, TX 78596

F 0600 Level of Harm - Actual harm GOALS: -Will be clean/dry, well groomed, appropriately dressed and well nourished on a daily basis through next review. Date Initiated: 01/14/2021 Target Date: 02/03/2025 o The resident will maintain current level of function in (ADLs) through the review date. Date Initiated: 01/14/2021 Residents Affected - Few INTERVENTIONS/TASKS: -Functional Limitation in Range of Motion -Upper extremity (Impairment on one side) -Lower extremity (Impairment on one side) Date Initiated: 10/20/2023 CNA RN LVN -GG (Section on MDS) Shower bathe: 2 personal Hygiene: 2 Date Initiated: 01/08/2024 Revision on: 05/10/2024 CNA -Tub/shower transfer: Dependent 01 RN LVN Date Initiated: 10/20/2023 Revision on: 08/13/2024 -The resident requires the use of Geri Chair when OOB Date Initiated: 04/28/2021 RN LVN CNA -BATHING/SHOWERING: The resident is dependent by (1) staff with (Bathing) (QOD) and as necessary. Date Initiated: 01/22/2021 Revision on: 12/20/2022 CNA RN -TRANSFER: The resident is dependent on (2) staff for transferring Date Initiated: 01/14/2021 Revision on: 10/20/2023 CNA RN Initiated: 01/14/2021 Revision on: 04/26/2024 CNA RN FOCUS: Resident #1 is at risk for falls r/t poor safety awareness d/t dementia Date Initiated: 01/14/2021 GOALS: - The resident will not sustain serious injury through the review date. Date Initiated: 01/14/2021 Target Date: 07/29/2025 INTERVENTIONS/TASKS: - Monitor closely during care rounds to ensure safety. Date Initiated: 01/14/2021 Revision on: 01/14/2021 Record review of x-rays taken on 02/05/25 of right foot and results on 02/05/25 revealed: -IMPRESSION: Acute fractures of the great toe at the base and the P1 segment and first metatarsal at the base (first bone just behind the big toe. The thickest and strongest of the bones in the toe). -IMPRESSION: Acute fractures of the great toe at the base and the P1 segment and first metatarsal at the base (first bone just behind the big toe. The thickest and strongest of the bones in the toe). Record review of Resident #1's Progress Note on 02/05/25 at 10:42 am written by LVN B revealed, SN was called into Resident #1's room to inform of fall. SN questioned Resident #1 on how she fell. Resident #1 was unable to provide an answer and only repeating No se (I do not know). SN assessed Resident #1. Resident #1 had a laceration to top lip and discoloration to right foot. Resident #1 complained of pain to (right) foot, PRN analgesic was administered. Record review of Progress Note on 02/06/25 at 05:11 am written by LVN H revealed, LVN H noticed Resident #1 tossing and turning. LVN H asked Resident #1 if she had any pain. Resident #1 said, Si, me 455621 Page 2 of 16 455621 06/05/2025 Valley Grande Manor 1212 S Bridge Weslaco, TX 78596

F 0600 duele mi pie (Yes, my foot has pain). LVN H administered PRN acetaminophen 650mg as ordered. Level of Harm - Actual harm Record review on 02/06/25 Physician's order for Tramadol 50mg tablet Give 50mg tablet by mouth every 4 hours for pain for 14 days. Residents Affected - Few Record review of Progress Note on 02/06/25 at 09:07 am written by LVN B revealed, new order for PRN tramadol 50mg x 14 days and referral to orthopedics (branch of medicine dealing with the correction of deformities of bones or muscles). Record review of Progress Note on 02/06/25 at 03:03 pm MD/NP Progress Note written by PA I revealed Subjective: Fall, sustained right great toe fracture Patient seen today at bedside alert, complaining of right great toe pain. Right great toe fracture: pain medication, supportive care, consider ortho consult. In an interview on 06/04/25 at 01:35 pm CNA A stated she was with Resident #1 the day she fell back in February (2025) and broke her toe. CNA A stated she had Resident #1 in the shower chair and was going to transfer her to her bed. She said she turned her back on the resident for just a second to get the mechanical lift and Resident #1 threw herself forward and fell out of the shower chair. CNA A stated she was the only CNA with Resident #1 even though she was a 2-person assist and the mechanical lift was always a 2-person assist. CNA A stated when 1 person had done a 2 person assist, accidents could happen, and the resident could fall. CNA A stated when Resident #1 fell, she was in-serviced by LVN B on not leaving the resident alone, the mechanical lift, 1- or 2-person assist, not rushing, and being careful. CNA A stated she received an in-service on A/N last month. She said about the A/N in-service, If you don't give the resident anything they ask for, talk to them bad, not change them, it is neglect. CNA A stated she reports A/N to the person in the front but did not know their name. CNA A did not know the name of the abuse coordinator. There was no documentation of the in-service CNA A stated she received from LVN B. In an interview on 06/04/25 at 03:23 pm LVN C stated the nurse was responsible for CNA supervision on whether they are using the correct 1- or 2-person assist. LVN C stated the resident or staff could be injured if only one person was helping a resident who was a 2-person assist. In an interview on 06/04/25 at 03:38 pm CNA D stated she would not do a 2-person assist by herself. She said she would wait for her partner. CNA D stated she would not endanger her resident or herself. In an interview on 06/05/25 at 09:04 am the Administrator stated the facility did not do any in-servicing after Resident #1's fall (02/05/25) because it was a witnessed fall. He said in the case of Abuse or Neglect, they would in-service. The Administrator provided in-service documentation dated 01/31/25 for Abuse & Neglect. In an interview on 06/05/25 at 09:32 am the DON stated she was not at the facility when the fall occurred with Resident #1 (02/05/25). She said she had read over the notes and the notes showed CNA A had brought Resident #1 back from her shower, who was a 1-person assist for showers, and was waiting on her partner to transfer Resident #1 back to bed. The DON said the fall was not reported because it was a witnessed fall. 455621 Page 3 of 16 455621 06/05/2025 Valley Grande Manor 1212 S Bridge Weslaco, TX 78596

F 0600 In an interview on 06/05/25 at 12:45 pm CNA A stated back at that time (February 2025), they were short on staff so several times she had to do a 2-person assist by herself. Level of Harm - Actual harm Residents Affected - Few Record review of the facility's Abuse, Neglect and Exploitation policy (PL 2024-14) dated 08/29/24 reflected: Type of Incident Do report: -An incident that results in serious bodily injury and that involves any of the following: -neglect When to report: Immediately, but not later than two hours after the incident occurs or is suspected. Neglect: HHSC rules define neglect as, the failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. CMS defines neglect as, the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. To determine whether neglect may have occurred, a NF must decide if an injury, emotional harm, pain, or death of a resident was due to the NF's failure to provide goods or services to a resident. Example of neglect: A resident, per his care plan, requires a two-person transfer from his bed to a chair. Only one staff member assists the resident in transferring him from his bed to a chair and the resident falls, resulting in extensive bruising to his thigh that was determined to be a serious injury. Record review of the facility's Resident Safety policy, 2001 Med Pass, Inc. Revised July 2017 reflected: Policy Statement Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 455621 Page 4 of 16 455621 06/05/2025 Valley Grande Manor 1212 S Bridge Weslaco, TX 78596

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 1 of 5 residents (Resident#1) reviewed for abuse and neglect, in that: Residents Affected - Few The facility failed to implement their Abuse Neglect Exploitation (ANE) policy when the facility failed to ensure Resident #1, who required 2 or more staff per her care plan was provided with the appropriate number of staff while in the shower chair. As a result, the resident had a fall when she was left unattended and sustained a broken toe. This failure could place residents at risk of abuse and neglect. The findings included: Record review of Resident #1's admission record revealed she was an [AGE] year-old female with an admission date of 01/13/21. Diagnoses included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), stroke, type 2 diabetes mellitus, epilepsy (seizure disorder), and hypertension (high blood pressure). Record review of Resident #1's Quarterly MDS on 01/03/25 revealed: -A BIMS of 03 which indicated severe cognitive impairment. -Shower/bathe: Dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity Or, the assistance of 2 or more helpers is required for the resident to complete the activity). -TRANSFER: The resident is dependent on (2) staff for transferring Dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity Or, the assistance of 2 or more helpers is required for the resident to complete the activity). Record review of Resident #1's Care Plan dated 01/03/2025, revealed: FOCUS: -Resident #1 has an ADL self-care performance deficit r/t Confusion, Dementia, Impaired balance, seizure disorder, CVA with left hemiplegia (paralysis affecting only one side of the body) Date Initiated: 01/14/2021 GOALS: -Will be clean/dry, well groomed, appropriately dressed and well nourished on a daily basis through next review. Date Initiated: 01/14/2021 Target Date: 02/03/2025 o The resident will maintain current level of function in (ADLs) through the review date. Date Initiated: 01/14/2021 INTERVENTIONS/TASKS: -Functional Limitation in Range of Motion -Upper extremity (Impairment on one side) -Lower extremity (Impairment on one side) Date Initiated: 10/20/2023 CNA RN LVN 455621 Page 5 of 16 455621 06/05/2025 Valley Grande Manor 1212 S Bridge Weslaco, TX 78596

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -GG (Section on MDS) Shower bathe: 2 personal Hygiene: 2 Date Initiated: 01/08/2024 Revision on: 05/10/2024 CNA -Tub/shower transfer: Dependent 01 RN LVN Date Initiated: 10/20/2023 Revision on: 08/13/2024 -The resident requires the use of Geri Chair when OOB Date Initiated: 04/28/2021 RN LVN CNA -BATHING/SHOWERING: The resident is dependent by (1) staff with (Bathing) (QOD) and as necessary. Date Initiated: 01/22/2021 Revision on: 12/20/2022 CNA RN -TRANSFER: The resident is dependent on (2) staff for transferring Date Initiated: 01/14/2021 Revision on: 10/20/2023 CNA RN Initiated: 01/14/2021 Revision on: 04/26/2024 CNA RN FOCUS: Resident #1 is at risk for falls r/t poor safety awareness d/t dementia Date Initiated: 01/14/2021 GOALS: - The resident will not sustain serious injury through the review date. Date Initiated: 01/14/2021 Target Date: 07/29/2025 INTERVENTIONS/TASKS: - Monitor closely during care rounds to ensure safety. Date Initiated: 01/14/2021 Revision on: 01/14/2021 Record review of x-rays taken on 02/05/25 of right foot and results on 02/05/25 revealed: -IMPRESSION: Acute fractures of the great toe at the base and the P1 segment and first metatarsal at the base (first bone just behind the big toe. The thickest and strongest of the bones in the toe). -IMPRESSION: Acute fractures of the great toe at the base and the P1 segment and first metatarsal at the base (first bone just behind the big toe. The thickest and strongest of the bones in the toe). Record review of Resident #1's Progress Note on 02/05/25 at 10:42 am written by LVN B revealed, SN was called into Resident #1's room to inform of fall. SN questioned Resident #1 on how she fell. Resident #1 was unable to provide an answer and only repeating No se (I do not know). SN assessed Resident #1. Resident #1 had a laceration to top lip and discoloration to right foot. Resident #1 complained of pain to (right) foot, PRN analgesic was administered. Record review of Progress Note on 02/06/25 at 05:11 am written by LVN H revealed, LVN H noticed Resident #1 tossing and turning. LVN H asked Resident #1 if she had any pain. Resident #1 said, Si, me duele mi pie (Yes, my foot has pain). LVN H administered PRN acetaminophen 650mg as ordered. Record review on 02/06/25 Physician's order for Tramadol 50mg tablet Give 50mg tablet by mouth every 4 hours for pain for 14 days. Record review of Progress Note on 02/06/25 at 09:07 am written by LVN B revealed, new order for PRN tramadol 50mg x 14 days and referral to orthopedics (branch of medicine dealing with the correction of deformities of bones or muscles). 455621 Page 6 of 16 455621 06/05/2025 Valley Grande Manor 1212 S Bridge Weslaco, TX 78596

F 0607 Record review of Progress Note on 02/06/25 at 03:03 pm MD/NP Progress Note written by PA I revealed Subjective: Fall, sustained right great toe fracture Level of Harm - Minimal harm or potential for actual harm Patient seen today at bedside alert, complaining of right great toe pain. Residents Affected - Few Right great toe fracture: pain medication, supportive care, consider ortho consult. In an interview on 06/04/25 at 01:35 pm CNA A stated she was with Resident #1 the day she fell back in February (2025) and broke her toe. CNA A stated she had Resident #1 in the shower chair and was going to transfer her to her bed. She said she turned her back on the resident for just a second to get the mechanical lift and Resident #1 threw herself forward and fell out of the shower chair. CNA A stated she was the only CNA with Resident #1 even though she was a 2-person assist and the mechanical lift was always a 2-person assist. CNA A stated when 1 person had done a 2 person assist, accidents could happen, and the resident could fall. CNA A stated when Resident #1 fell, she was in-serviced by LVN B on not leaving the resident alone, the mechanical lift, 1- or 2-person assist, not rushing, and being careful. CNA A stated she received an in-service on A/N last month. She said about the A/N in-service, If you don't give the resident anything they ask for, talk to them bad, not change them, it is neglect. CNA A stated she reports A/N to the person in the front but did not know their name. CNA A did not know the name of the abuse coordinator. There was no documentation of the in-service CNA A stated she received from LVN B. In an interview on 06/04/25 at 03:23 pm LVN C stated the nurse was responsible for CNA supervision on whether they are using the correct 1- or 2-person assist. LVN C stated the resident or staff could be injured if only one person was helping a resident who was a 2-person assist. In an interview on 06/04/25 at 03:38 pm CNA D stated she would not do a 2-person assist by herself. She said she would wait for her partner. CNA D stated she would not endanger her resident or herself. In an interview on 06/05/25 at 09:04 am the Administrator stated the facility did not do any in-servicing after Resident #1's fall (02/05/25) because it was a witnessed fall. He said in the case of Abuse or Neglect, they would in-service. The Administrator provided in-service documentation dated 01/31/25 for Abuse & Neglect. In an interview on 06/05/25 at 09:32 am the DON stated she was not at the facility when the fall occurred with Resident #1 (02/05/25). She said she had read over the notes and the notes showed CNA A had brought Resident #1 back from her shower, who was a 1-person assist for showers, and was waiting on her partner to transfer Resident #1 back to bed. The DON said the fall was not reported because it was a witnessed fall. In an interview on 06/05/25 at 12:45 pm CNA A stated back at that time (February 2025), they were short on staff so several times she had to do a 2-person assist by herself. Record review of the facility's Abuse, Neglect and Exploitation policy (PL 2024-14) dated 08/29/24 reflected: Type of Incident Do report: 455621 Page 7 of 16 455621 06/05/2025 Valley Grande Manor 1212 S Bridge Weslaco, TX 78596

F 0607 -An incident that results in serious bodily injury and that involves any of the following: -neglect Level of Harm - Minimal harm or potential for actual harm When to report: Immediately, but not later than two hours after the incident occurs or is suspected. Residents Affected - Few Neglect: HHSC rules define neglect as, the failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. CMS defines neglect as, the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. To determine whether neglect may have occurred, a NF must decide if an injury, emotional harm, pain, or death of a resident was due to the NF's failure to provide goods or services to a resident. Example of neglect: A resident, per his care plan, requires a two-person transfer from his bed to a chair. Only one staff member assists the resident in transferring him from his bed to a chair and the resident falls, resulting in extensive bruising to his thigh that was determined to be a serious injury. Record review of the facility's Resident Safety policy, 2001 Med Pass, Inc. Revised July 2017 reflected: Policy Statement Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 455621 Page 8 of 16 455621 06/05/2025 Valley Grande Manor 1212 S Bridge Weslaco, TX 78596

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving neglect, were reported immediately to the State Survey Agency, not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 of 5 residents (Resident #1) reviewed for abuse/neglect. The facility failed to report Resident #1's fall with injury on 02/05/25, where Resident #1 sustained a fractured right great toe. State Survey Agency was not notified of the fall with injury within 2 hours. The incident occurred on 02/05/25 at 10:42 am and was not reported. The facility failed to report Resident #1's FM's allegation of resident neglect related to the Resident #1's fall with injury on 02/05/25, where Resident #1 sustained a fractured right great toe. FM alleged resident neglect. The incident occurred on 02/05/25 at 10:43 am and was not reported. These failures could place all residents at increased risk for potential abuse due to not having allegations reported as required. The findings included: Record review of Resident #1's admission record revealed she was an [AGE] year-old female with an admission date of 01/13/21. Diagnoses included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), stroke, type 2 diabetes mellitus, epilepsy (seizure disorder), and hypertension (high blood pressure). Record review of Resident #1's Quarterly MDS on 01/03/25 revealed: -A BIMS of 03 which indicated severe cognitive impairment. -Shower/bathe: Dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity Or, the assistance of 2 or more helpers is required for the resident to complete the activity). -TRANSFER: The resident is dependent on (2) staff for transferring Dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity Or, the assistance of 2 or more helpers is required for the resident to complete the activity). Record review of Resident #1's Care Plan dated 01/03/2025, revealed: FOCUS: o Resident #1 has an ADL self-care performance deficit r/t Confusion, Dementia, Impaired balance, seizure disorder, CVA with left hemiplegia (paralysis affecting only one side of the body) Date Initiated: 01/14/2021 GOALS: o Will be clean/dry, well groomed, appropriately dressed and well nourished on a daily basis through next review. Date Initiated: 01/14/2021 Target Date: 02/03/2025 o The resident will maintain current level of function in (ADLs) through the review date. Date Initiated: 01/14/2021 455621 Page 9 of 16 455621 06/05/2025 Valley Grande Manor 1212 S Bridge Weslaco, TX 78596

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few INTERVENTIONS/TASKS: o Functional Limitation in Range of Motion -Upper extremity (Impairment on one side) -Lower extremity (Impairment on one side) Date Initiated: 10/20/2023 CNA RN LVN o GG (Section on MDS) Shower bathe: 2 personal Hygiene: 2 Date Initiated: 01/08/2024 Revision on: 05/10/2024 CNA o Tub/shower transfer: Dependent 01 RN LVN Date Initiated: 10/20/2023 Revision on: 08/13/2024 o The resident requires the use of Geri Chair when OOB Date Initiated: 04/28/2021 RN LVN CNA o BATHING/SHOWERING: The resident is dependent by (1) staff with (Bathing) (QOD) and as necessary. Date Initiated: 01/22/2021 Revision on: 12/20/2022 CNA RN o TRANSFER: The resident is dependent on (2) staff for transferring Date Initiated: 01/14/2021 Revision on: 10/20/2023 CNA RN o TRANSFER: The Revision on: 04/26/2024 CNA RN FOCUS: Resident #1 is at risk for falls r/t poor safety awareness d/t dementia Date Initiated: 01/14/2021 GOALS: o The resident will not sustain serious injury through the review date. Date Initiated: 01/14/2021 Target Date: 07/29/2025 INTERVENTIONS/TASKS: o Monitor closely during care rounds to ensure safety. Date Initiated: 01/14/2021 Revision on: 01/14/2021 Record review of x-rays taken the day of the fall on 02/05/25 right foot x-ray with results on 02/05/25 revealed: -IMPRESSION: Acute fractures of the great toe at the base and the P1 segment and first metatarsal at the base (first bone just behind the big toe. The thickest and strongest of the bones in the toe). Record review of Resident #1's Progress Note on 02/05/25 at 10:42 am written by LVN B revealed, SN was called into Resident #1's room to inform of fall. SN questioned Resident #1 on how she fell. Resident #1 was unable to provide an answer and only repeating No se (I do not know). SN assessed Resident #1. Resident #1 had a laceration to top lip and discoloration to right foot. Resident #1 complained of pain to (right) foot, PRN analgesic was administered. Record review of Resident #1's Progress Note on 02/05/25 at 10:43 am written by LVN B revealed, LVN B received a call from Resident #1's FM. LVN B informed FM of fall resident had. FM became upset and stated, This is neglect. FM stated accidents were unacceptable and should not be happening when patients are under 24hr care of a facility. LVN B offered to transfer FM to ADON to further discuss his concerns. FM declined and stated No, this needs to go further. I am going to be calling the state today. Record review of Progress Note on 02/06/25 at 05:11 am written by LVN H revealed, LVN H noticed Resident #1 tossing and turning. LVN H asked Resident #1 if she had any pain. Resident #1 said, Si, me duele mi pie (Yes, my foot has pain). LVN H administered PRN acetaminophen 650mg as ordered. Record review on 02/06/25 Physician's order for Tramadol 50mg tablet Give 50mg tablet by mouth every 4 hours for pain for 14 days. Record review of Progress Note on 02/06/25 at 09:07 am written by LVN B revealed, new order for PRN tramadol 50mg x 14 days and referral to ortho. 455621 Page 10 of 16 455621 06/05/2025 Valley Grande Manor 1212 S Bridge Weslaco, TX 78596

F 0609 Record review of Progress Note on 02/06/25 at 03:03 pm MD/NP Progress Note written by PA I revealed Subjective: Fall, sustained right great toe fracture Level of Harm - Minimal harm or potential for actual harm Patient seen today at bedside alert, complaining of right great toe pain. Residents Affected - Few Right great toe fracture: pain medication, supportive care, consider ortho consult. Record review of Progress Note on 02/06/25 at 05:04 pm written by DON revealed, the DON and the Administrator placed a call to FM to give him an update from incident yesterday. FM was given an explanation of how witnessed fall occurred, reassured him that resident was not unattended during incident. FM voiced understanding and stated facility was not neglectful but needed to be more careful to avoid another accident. In an interview on 06/03/25 at 11:42 am FM stated he had nothing more to add concerning his mother's fall and that what could the surveyor do about it. He said, It was done and nobody could do anything to change it. In an interview on 06/04/25 at 01:35 pm CNA A stated she was with Resident #1 the day she fell back in February (2025) and broke her toe. CNA A stated she had Resident #1 in the shower chair and was transferring her to her bed. She said she turned her back on the resident for just a second to get the mechanical lift and Resident #1 threw herself forward and fell out of the shower chair. CNA A stated she was the only CNA with Resident #1 even though she was a 2-person assist and the mechanical lift was always a 2-person assist. CNA A stated if she did not know a resident, she would see if the resident was heavy. She said if a resident was heavy, the CNA would let the nurse know so that resident could be a 2-person assist. CNA A stated when 1 person had done a 2 person assist, accidents could happen, and the resident could fall. CNA A stated when Resident #1 fell, she was in-serviced by LVN B on not leaving the resident alone, the Hoyer Lift, 1- or 2-person assist, not rushing, and being careful. A phone interview on 06/04/25 at 3:55 pm was attempted with LVN B. The surveyor was unable to leave a message. In an interview on 06/05/25 at 09:04 am the Administrator stated Resident #1's FM had originally claimed neglect, but he recanted the allegation the next day and said for them to be more careful. He did not report the allegation of neglect due to the FM had recanted the allegation. The Administrator stated the CNA was not doing a transfer when the resident fell. In an interview on 06/05/25 at 09:32 am the DON stated she was not at the facility when the fall occurred with Resident #1 (02/05/25). She said she had read over the notes, and they said CNA A was bringing Resident #1 back from her shower, who was a 1-person assist for showers, and waiting on her partner to transfer Resident #1 back to bed. She said it was not reported because it was a witnessed fall. In an interview on 06/05/25 at 12:40 pm The DON stated if a family member or a resident alleged abuse or neglect, she would right away tell the Administrator and start the investigation. The DON stated that it would be a reportable and they would have to report it in less than two hours. In an interview on 06/05/25 at 12:45 pm CNA A stated Resident #1 was a 2-person assist for transfers because the mechanical lift was used. CNA A stated back at that time (February 2025), they were 455621 Page 11 of 16 455621 06/05/2025 Valley Grande Manor 1212 S Bridge Weslaco, TX 78596

F 0609 Level of Harm - Minimal harm or potential for actual harm short on staff so several times she would do a 2-person assist by herself. She said it was better now and she did not have to do that anymore. Record review of the facility's Abuse, Neglect and Exploitation policy (PL 2024-14) dated 08/29/24 reflected: Residents Affected - Few Type of Incident Do Report: -An incident that results in serious bodily injury and that involves and of the following: -Neglect When to report: Immediately, but not later than two hours after the incident occurs or is suspected. Do report: -An incident that does not results in serious bodily injury but that involves any of the following: -Neglect When to report: Immediately, but not later than 24 hours after the incident occurs or is suspected. Neglect: HHSC rules define neglect as, the failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. CMS defines neglect as, the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. To determine whether neglect may have occurred, a NF must decide if an injury, emotional harm, pain, or death of a resident was due to the NF's failure to provide goods or services to a resident. Example of neglect: A resident, per his care plan, requires a two-person transfer from his bed to a chair. Only one staff member assists the resident in transferring him from his bed to a chair and the resident falls, resulting in extensive bruising to his thigh that was determined to be a serious injury. 3.0 Background / History 455621 Page 12 of 16 455621 06/05/2025 Valley Grande Manor 1212 S Bridge Weslaco, TX 78596

F 0609 Level of Harm - Minimal harm or potential for actual harm State and federal law requires an owner or employee of a NF that has cause to believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect, or exploitation (ANE) caused by another person to report the abuse, neglect, or exploitation. NFs must report all suspected or alleged incidents involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sourse and misappropriation of resident property. Residents Affected - Few 455621 Page 13 of 16 455621 06/05/2025 Valley Grande Manor 1212 S Bridge Weslaco, TX 78596

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Residents #1) reviewed for care plans. 1.The facility failed to implement the care plan to ensure Resident #1's was a 2 person assist for shower/bath. 2. The facility failed to implement the care plan to ensure Resident #1's was a 2 person assist for transferring. These failures could place residents at risk of not receiving the necessary care and services. Findings include: Record review of Resident #1's admission record revealed she was an [AGE] year-old female with an admission date of 01/13/21. Diagnoses included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), stroke, type 2 diabetes mellitus, epilepsy (seizure disorder), and hypertension (high blood pressure). Record review of Resident #1's Quarterly MDS on 01/03/25 revealed: -A BIMS of 03 which indicated severe cognitive impairment. -Shower/bathe: Dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity Or, the assistance of 2 or more helpers is required for the resident to complete the activity). -TRANSFER: The resident is dependent on (2) staff for transferring Dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity Or, the assistance of 2 or more helpers is required for the resident to complete the activity). Record review of Resident #1's Care Plan dated 01/03/2025, revealed: FOCUS: -Resident #1 has an ADL self-care performance deficit r/t Confusion, Dementia, Impaired balance, seizure disorder, CVA with left hemiplegia (paralysis affecting only one side of the body) Date Initiated: 01/14/2021 GOALS: -Will be clean/dry, well groomed, appropriately dressed and well nourished on a daily basis through next review. Date Initiated: 01/14/2021 Target Date: 02/03/2025 o The resident will maintain current level of function in (ADLs) through the review date. Date Initiated: 01/14/2021 INTERVENTIONS/TASKS: 455621 Page 14 of 16 455621 06/05/2025 Valley Grande Manor 1212 S Bridge Weslaco, TX 78596

F 0656 -Functional Limitation in Range of Motion -Upper extremity (Impairment on one side) -Lower extremity (Impairment on one side) Date Initiated: 10/20/2023 CNA RN LVN Level of Harm - Actual harm Residents Affected - Few -GG (Section on MDS) Shower bathe: 2 personal Hygiene: 2 Date Initiated: 01/08/2024 Revision on: 05/10/2024 CNA -Tub/shower transfer: Dependent 01 RN LVN Date Initiated: 10/20/2023 Revision on: 08/13/2024 -The resident requires the use of Geri Chair when OOB Date Initiated: 04/28/2021 RN LVN CNA -BATHING/SHOWERING: The resident is dependent by (1) staff with (Bathing) (QOD) and as necessary. Date Initiated: 01/22/2021 Revision on: 12/20/2022 CNA RN -TRANSFER: The resident is dependent on (2) staff for transferring Date Initiated: 01/14/2021 Revision on: 10/20/2023 CNA RN 01/14/2021 Revision on: 04/26/2024 CNA RN. FOCUS: Resident #1 is at risk for falls r/t poor safety awareness d/t dementia Date Initiated: 01/14/2021 GOALS: - The resident will not sustain serious injury through the review date. Date Initiated: 01/14/2021 Target Date: 07/29/2025 INTERVENTIONS/TASKS: - Monitor closely during care rounds to ensure safety. Date Initiated: 01/14/2021 Revision on: 01/14/2021. Record review of Resident #1's Progress Note on 02/05/25 at 10:42 am written by LVN B revealed, SN was called into Resident #1's room to inform of fall. SN questioned Resident #1 on how she fell. Resident #1 was unable to provide an answer and only repeating No se (I do not know). SN assessed Resident #1. Resident #1 had a laceration to top lip and discoloration to right foot. Resident #1 complained of pain to (right) foot, PRN analgesic was administered. Record review of x-rays taken on 02/05/25 of right foot and results on 02/05/25 revealed: -IMPRESSION: Acute fractures of the great toe at the base and the P1 segment and first metatarsal at the base (first bone just behind the big toe. The thickest and strongest of the bones in the toe). In an interview on 06/04/25 at 01:35 pm CNA A stated she was with Resident #1 the day she fell back in February (2025) and broke her toe. CNA A stated she had Resident #1 in the shower chair and was going to transfer her to her bed. She said she turned her back on the resident for just a second to get the mechanical lift and Resident #1 threw herself forward and fell out of the shower chair. CNA A stated she was the only CNA with Resident #1 even though she was a 2-person assist and the mechanical lift was always a 2-person assist. CNA A stated when 1 person had done a 2 person assist, accidents could happen, and the resident could fall. CNA A stated when Resident #1 fell, she was in-serviced by LVN B on not leaving the resident alone, the mechanical lift, 1- or 2-person assist, not rushing, and being careful. There was no documentation of the in-service CNA A stated she received from LVN B. 455621 Page 15 of 16 455621 06/05/2025 Valley Grande Manor 1212 S Bridge Weslaco, TX 78596

F 0656 Level of Harm - Actual harm Residents Affected - Few In an interview on 06/04/25 at 03:23 pm LVN C stated the nurse was responsible for CNA supervision on whether they are using the correct 1- or 2-person assist. LVN C stated the resident or staff could be injured if only one person was helping a resident who was a 2-person assist. In an interview on 06/04/25 at 03:38 pm CNA D stated she would not do a 2-person assist by herself. She said she would wait for her partner. CNA D stated she would not endanger her resident or herself. In an interview on 06/05/25 at 09:32 am the DON stated she was not at the facility when the fall occurred with Resident #1 (02/05/25). She said she had read over the notes and the notes showed CNA A had brought Resident #1 back from her shower, who was a 1-person assist for showers, and was waiting on her partner to transfer Resident #1 back to bed. In an interview on 06/05/25 at 12:45 pm CNA A stated on the day Resident #1 fell (02/05/25), she had given her a shower by herself. CNA A stated back at that time (February 2025), they were short on staff so several times she had to do a 2-person assist by herself. No Care Plan policy was obtained. 455621 Page 16 of 16