Health inspection·December 30, 2023

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3ml , one vial via mask every four hours for cough/congestion was administered on 10:00 am with O2 at 92, respiratory rate at 17, and pulse at 60 by LVN A. Interview on [DATE] at 2:02 pm with LVN A revealed Resident # 1 had orders for medication nebulizer treatments. LVN said on [DATE] at approximately 10:07 am, he took Resident #1's vitals which included placing a pulse oximeter (to monitor a person's blood oxygen saturation) on resident's finger to check his oxygen saturation. LVN A said he also checked the lung sounds using a stethoscope and respiratory rate.) LVN A said Resident #1's oxygen was 92%, pulse was 60 and respiratory rate was 17. LVN A stated then applied the medication nebulizer treatment by placing the nebulizer mask on Resident# 1's mouth and nose. LVN A said the nebulizer treatment would take about 10 to 15 minutes to complete. LVN A said he stepped out of Resident #1's room and headed to the nurse's station because he could not document in the EMARs, the readings for oxygen, pulse rate and respiratory rate because he was not getting internet in the room or hallway. LVN A said he went and stood by nurse's station at approximately 10:15 am. LVN A said at approximately 10:20 or 10:25 am, Resident #1's FM D came out of Resident #1's room that was halfway down the hall from the nurse's station, appearing distressed voicing the Resident #1 was not responding. LVN A said while he had been standing at the nurse's station, LVN B had walked to the nurse's station and was standing inside the nurse's station and heard FM D voicing Resident #1 was not responding. LVN A said he walked to Resident #1's room, assessed Resident #1 by checking his pulse, and oxygen saturation and got no readings on both vitals. LVN A said Resident #1 code status was DNR in his clinical record. FM C who was the resident's RP, voiced to him to do anything to help Resident #1 who was not breathing. LVN A said FM D came into to the resident's room and told LVN A to do anything to help Resident #1. LVN A said he then asked FM C if she wanted to revoke the code status to Full Code and FM C said she did. Interview on [DATE] at 2:21 pm with LVN B revealed on [DATE] at approximately 10:15 am she walked into the nurse's station and saw LVN A standing by his med cart next to the nurse's station. LVN B said at about 10:20 am she saw Resident #1's FM C and FM D walk by the nurse's station, greeted her and proceeded to walk down Resident #1's hall. LVN B said about a minute or two later, she saw FM D come out of Resident #1's room, appearing distressed and voicing out loud that Resident #1 was not responding to her calling his name. FM D voiced to call 911 or do something to help Resident #1. LVN B said she saw LVN A walk into Resident #1's room and LVN B went to Resident #1's clinical record to verify the code status. LVN B said she saw that Resident #1 was a DNR. LVN B said she walked into Resident #1's room and heard FM C to revoke the code status to full code. LVN B said she assessed the resident and began to provide CPR to Resident #1. LVN B said LVN A went outside the room to call 911 and to nurse's station to begin paperwork for the Emergency staff. LVN B said she continued performing CPR on Resident #1 until EMS arrived and they took over performing CPR on the resident. EMS took Resident #1 on a stretcher to the hospital, and he had not responded as they left the facility. LVN B said Resident #1 was pronounced dead at the ER. Interview on [DATE] at 2:27 pm with the DON revealed Resident #1 was admitted to the facility on [DATE] from another nursing home. On [DATE], Resident #1 was transferred to the hospital with the diagnosis of sepsis. Resident #1 was transferred back to the facility on [DATE]. On [DATE], Resident #1 was transferred to the hospital by doctor orders for diagnosis of hypoxia (low oxygen in the blood). Resident was re-admitted to the facility from the hospital on [DATE] with diagnosis of pneumonia and sepsis and orders for antibiotics for pneumonia. The DON said she was notified on [DATE] on the change of condition for Resident #1. Interview on [DATE] at 10:39 am with LVN A revealed he did check Resident #1's oxygen levels, pulse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 2 of 6 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 455761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Nursing & Rehabilitation Center 1013 S Bryan Rd Mission, TX 78572 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few rate and respiratory rate before he applied the nebulizer treatment. LVN A said he wrote the readings on a piece of paper so he could enter the Resident #1's electronic record at the nurse's station. LVN A said he did not enter the vitals in the electronic clinical chart until 5:02 pm in the afternoon because he got very busy after Resident #1 left to the hospital. LVN B said the vitals were taken before and after the nebulizer treatment to assess if the nebulizer treatment was effective and to monitor for the heart rate because the medication administered in the nebulizer treatment might raise the heart rate. LVN A said he did not stay in the resident's room during the nebulizer treatment to monitor or assess the treatment. LVN A said he should have stayed to monitor to see if the resident experienced a rise in the heart rate or to ensure the nebulizer mask did not fall off his face. Interview on [DATE] at 1:38 pm with the DON revealed LVN A should have stayed with Resident #1 through the entire process of administering the medication via nebulizer mask, according to their policy and protocol. The DON said staff were in-serviced after the incident and LVN A was given a disciplinary action warning for not providing respiratory care when he did not follow the facility nursing protocols that indicated staff needed to stay with the resident during the medication nebulizer administration. Interview on [DATE] at 2:45 pm with Resident #1's physician revealed Resident #1 had been in the hospital ICU for a long time while he was intubated (insertion of a tube into the body to keep the airway open.) The physician said Resident #1's prognosis had been very poor when he was transferred back to the facility on [DATE]. The physician said Resident #1 would not have lived very long. Resident #1's physician said in his medical opinion, the staff leaving Resident #1 alone with his medication treatment of the Ipratropium-Albuterol Solution via a nebulizer mask could not have caused any injury, harm, or death to Resident #1. Record review of the facility policy titled Administering Medications through a small volume (handheld) Nebulizer dated [DATE] reflected The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Steps in the Procedure; Remain with the resident for the treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 3 of 6 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 455761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Nursing & Rehabilitation Center 1013 S Bryan Rd Mission, TX 78572 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to maintain clinical records on each resident that were complete and accurate, for one Resident (R#1), of five residents reviewed for clinical records, in that. The facility failed to ensure LVN E documented the results of vital sign assessments accurately in Resident #1's clinical records. This failure could place residents at risk for not receiving proper care and treatments. The findings included: Record review of Resident #1's admission record, dated 12/28/23, reflected he was a [AGE] year-old male with an admission date of 12/16/23 with diagnoses which included dementia (decline in cognitive abilities), chronic obstructive pulmonary disease with acute exacerbation (progressive lung disease and airflow limitation), contracture (shortening of muscles, tendons, skin causing joints to shorten), gastrostomy status (artificial external opening into stomach for nutritional support), and aphasia (damage to the language areas of the brain.) Record review of Resident #1 Physician Order Summary of all orders, dated 12/20/23, reflected there was an order for oxygen administration at .2 liters per minutes via nasal cannula if O2 below 92% room air, as needed for SOB, start date 12/16/23. Including an order for Ipratropium-Albuterol Solution 0.05-2.5 (3) mg/3ml vial via mask every 4 hours for cough/congestion, start date 12/16/23. Record review of Resident #1's baseline care plan dated 12/16/2023, reflected under pulmonary disease/URI to check lung sounds, clear, O2 per nasal cannula at 2 lpm. Record review of the MARs dated 12/01/23-12/31/23 for Resident #1 reflected: -Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3ml , one vial via mask every four hours for cough/congestion was administered on 2:00 am with O2 at 96, respiratory rate at 20, and pulse at 72 by LVN G. -Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3ml , one vial via mask every four hours for cough/congestion was administered on 6:00 am with O2 at 96, respiratory rate at 20, and pulse at 74 by LVN G. -Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3ml , one vial via mask every four hours for cough/congestion was administered on 10:00 am with O2 at 92, respiratory rate at 17, and pulse at 60 by LVN A. -Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3ml , one vial via mask every four hours for cough/congestion was administered on 10:00 pm with respiratory rate at 18, and pulse at 63 by LVN E. No record of the O2 was recorded. Interview on 12/28/23 at 2:02 pm with LVN A revealed Resident # had orders for medication nebulizer treatments. LVN said on 12/20/23 at approximately 10:07 am he took Resident #1's vitals which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 4 of 6 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 455761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Nursing & Rehabilitation Center 1013 S Bryan Rd Mission, TX 78572 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few included placing a pulse oximeter (to monitor a person's blood oxygen saturation) on resident's finger to check his oxygen saturation. LVN A said he also checked the lung sounds using a stethoscope and respiratory rate.) LVN A said oxygen was 92%, pulse was 60 and respiratory rate was 17. LVN A then applied the medication nebulizer treatment by placing the nebulizer mask on Resident# 1's mouth and nose. LVN A said the nebulizer treatment would take about 10 to 15 minutes to complete. LVN A said he stepped out of Resident #1's room and headed to the nurse's station because he could not document in the EMARs, the readings for oxygen, pulse rate and respiratory rate because he was not getting internet in the room or hallway. Interview on 12/29/23 at 10:39 am with LVN A revealed he did check Resident #1's oxygen levels, pulse rate and respiratory rate before he applied the nebulizer treatment. LVN A said he wrote the readings on a piece of paper so he could enter the Resident #1's electronic record at the nurse's station. LVN A said he did not enter the vitals in the electronic clinical chart until 5:02 pm in the afternoon because he got very busy after Resident #1 left to the hospital. LVN A said he should have entered the readings on Resident #1's clinical record as soon as possible within time necessary to provide the information to staff providing care to the resident. Interview on 12/29/23 at 11:09 with the DON revealed LVN A did not record the vitals for Resident #1 when he took the reading on 12/20/23 at 10:07 am until later in the day at 5:02 pm. Staff are required to document information on clinical records in a timely manner, such as two hours later. If an entry is made after 24 hours, a data entry error must be documented. The vitals taken by LVN A on 12/20/23 at 10:07 am were not recorded until 12/20/23 at 5:02 pm as indicated on the EMAR the time the record was entered. Interview on 12/29/23 at 11:09 am with the DON revealed she had reviewed Resident #1's EMARs on 12/28/23. The DON said she found that LVN E had inaccurately recorded on Resident #1's EMARs on 12/20/23 at 10:00 pm when she entered the vital reading for his pulse and respiratory rate. Resident #1 had been transferred to the hospital on [DATE] at about 10:30 am, when he was found unresponsive. The DON said she tried to contact LVN E by telephone to ask her about the error but was unable to contact LVN E. The DON said she entered a note into Resident #1's progress notes to indicate error documentation as a late entry on 12/28/23. The DON said LVN E had gotten confused but should have informed her or someone about the inaccurate documentation on Resident #1 right away. The DON stated it was very important to document accurate information on resident's clinical charts because the misinformation could affect the care the residents should be receiving. The DON every staff member was responsible for ensuring all information recorded was accurate. Interview on 12/30/23 at 9:20 am with LVN E via telephone revealed she had worked on 12/20/23 during the evening shift as she worked PRN. She took a resident's (unnamed) vitals and recorded on a piece of paper to later record in the EMARS for that resident. After entering the vitals, she had taken from another resident and proceeded to enter Resident #1's EMARS on 12/20/23 at around 10:00 am. She immediately realized she was on the wrong resident's EMARs (Resident #1's). She stopped entering the vitals on Resident #1's EMARs and closed his record and started recording on the correct resident's EMAR. LVN E said she did not inform the DON about her mistake on recording on the wrong residents EMARs. LVN E said failure to correctly document on every resident's record could cause misinformation for the resident. Interview on 12/30/23 at 11:40 am with RN F revealed after providing any type of medication or treatment the EMARs should be documented in the resident's clinical record right after the administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 5 of 6 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 455761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Nursing & Rehabilitation Center 1013 S Bryan Rd Mission, TX 78572 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 0842 Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy titled Charting and Documentation dated July 2017 reflected All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Accurate medical records should be maintained by this facility. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 6 of 6