Health inspection·December 15, 2023

F 0641 restroom for toileting. Level of Harm - Minimal harm or potential for actual harm Interview on 12/14/2023 at 1:32 p.m. with LVN E who was charge nurse on Resident #40's unit, she stated that Resident #40 was always incontinent of bladder and received total care. Residents Affected - Few Interview on 12/15/2023 at 12:00 p.m. with MDS G, she stated that Resident #40 could have been on therapy and being taken to the toilet during the 5 day look back. She stated CNA F was working and could verify the accuracy of the MDS. Interview on 12/15/2023 at 12:15 p.m. with CNA F who documented continent for Resident #40 on 9/23/2023 at 4:30 p.m., she stated that Resident #40 was able to tell her she was wet and that is why she coded continent, but she did not take her to the toilet. Interview on 12/15/2023 at 12:20 p.m. with the DON, he stated the MDS coding for Resident #40 was inaccurate and CNA F needed to be trained on what incontinent and continent was for the ADL sheet. He stated an audit needed to be completed on the MDS's where CNA F was working in order to correct other inaccurate MDS's. He stated that it was important to have accurate assessments because they affected the plan of care which showed what care was needed for a resident. He stated that he reviewed the MDS's for accuracy. Interview on 12/15/2023 at 12:25 p.m. the DON stated that the facility used the RAI manual as a reference and policy. Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated October 2019, revealed, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident ' s medical record, physician, and family, guardian, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident ' s actual status was during that observation period) by the IDT completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455869 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 455869 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Guadalupe Valley Nursing and Rehabilitation Center 1210 Eastwood Dr Seguin, TX 78155 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to provide food prepared in a form designed to meet individual needs for 1 (Resident #85) of 12 residents observed during dining observations in that: Resident #85 was served a regular consistency diet when he was ordered a pureed. This failure could affect residents with eating and swallowing disorders and result in choking. The findings included: Record review of Resident #85's electronic face sheet dated December 12, 2023 reflected he was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (a feeling of fear, dread, and uneasiness) and dysphagia (difficulty swallowing foods or liquids, arising from the throat and esophagus, ranging from mild difficulty to complete and painful blockage). Record review of Resident #85's annual MDS assessment with an ARD of 09/15/2023 reflected he was not a candidate for the BIMS which signified he was severely cognitively impaired. Further review reflected he required set up assistance with meals and he was on a mechanically altered diet. Record review of Resident #85's comprehensive care plan revised date 11/03/2022 reflected under Problem . has an ADL self-care performance deficit r/t dementia .Interventions .EATING .resident is able to eat meals with set up assistance and supervision .date initiated 09/15/2023. Further review reflected Problem .has potential nutritional problem r/t dementia .Interventions .regular diet, pureed texture, regular liquids consistency for aspiration precautions .revised date: 06/15/2023. Record review of Resident #85's Active Orders as of : 12/12/2023 .Regular diet Pureed texture, Regular Liquids consistency, fortified foods with every meal and house shakes bid with lunch supper Phone Active 06/20/2023. Observation on 12/12/2023 at 1:45 p.m. of Resident #85 in the dining room, he was eating a whole wheat roll with butter on it. Review of his meal ticket lying on the table reflected Regular diet Pureed Texture. Resident #85 had chopped meat, spinach, noodles and a wheat roll with butter on his tray in a regular consistency, and sliced whole strawberries with whip cream on top for dessert. Interview on 12/12/2023 at 1:50 p.m. with RN A who was in the dining room passing out trays, she stated that she and others were checking the trays, and she did not know how the pureed diet for Resident #85 was missed. She stated it was important to check the trays for the appropriate form of food because a resident could choke and aspirate. Interview on 12/13/2023 at 4:37 p.m. with RD B, she stated there was a breakdown in communication and passing out trays to residents on 12/12/2023 at lunchtime. She stated the kitchen staff and nursing staff need to be checking the meal tickets. She stated that Resident #85 could choke or aspirate on the wrong food texture due to his dysphagia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455869 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 455869 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Guadalupe Valley Nursing and Rehabilitation Center 1210 Eastwood Dr Seguin, TX 78155 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 12/15/2023 at 12:30 p.m. with the DON, he stated nursing staff needed to check meal tickets in the dining room to ensure the accurate food form and diet was provided to the appropriate resident. He stated he wasn't sure, but the staff might have mixed up the trays somehow. He stated nursing staff were trained to identify residents and their diets when passing out trays and assisting them with meals. Review of the facility policy and procedure titled Meal Service and dated October 1, 2018, reflected Placement, color and texture of foods will meet residents' needs, including vision problems and swallowing difficulties. Event ID: Facility ID: 455869 If continuation sheet Page 4 of 4