Health inspection·December 10, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few comprehensive care plan with initiated date 7/24/25 and revision date 8/20/25 reflected the resident had a potential/actual impairment to skin integrity related to incontinence and impaired mobility with a goal for the resident not to have complications related to gluteal fold peeling and interventions that included assistance with turning and positioning, avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, diet as ordered, pressure reduction mattress, and use of a draw sheet or lifting device to move the resident. Record review of Resident #1's Skin and Wound Evaluation document completed by the Wound Care Nurse on 7/31/25 and electronically signed on 8/1/25 revealed the resident had no new wounds.Record review of Resident #1's Skin and Wound Evaluation document completed by the Wound Care Nurse on 8/6/25 and electronically signed on 8/6/25 revealed the resident had a Stage 2 pressure wound to the sacrum, staged by the Wound Care Nurse. Resident #1's Skin and Wound Evaluation document revealed on the Additional Care Section, None was checked, and the Notifications section: Practitioner Notified, Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) were left blank.Record review of Resident #1's Skin and Wound Evaluation document completed by the Wound Care Nurse on 8/13/25 and electronically signed on 8/13/25 revealed the resident had a Stage 2 pressure wound to the sacrum staged by the Wound Care Nurse. Resident #1's Skin and Wound Evaluation document revealed on the Additional Care section, the resident had a moisture barrier and positioning wedge, and the Notifications: Practitioner Notified, Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) were left blank.During an interview on 10/8/25 at 1:41 p.m., the Wound Care Nurse stated Resident #1 had cancer and believed the resident had developed a Stage 2 pressure wound to the sacrum or coccyx. The Wound Care Nurse initially stated she could not recall when she had notified the physician or if she had told the physician at all. The Wound Care Nurse stated, Resident #1 had an irritation to the area, but it was not like a Stage 3 wound whereas a Stage 3 wound was more open and a better chance for an infection. The Wound Care Nurse stated, had the resident developed a Stage 3 pressure wound, then she would have reported it to the physician or the NP who in turn would have referred the resident to the NP Wound Nurse. The Wound Care Nurse then stated she recalled a notification to the physician but didn't document it and could not remember how the physician had responded. The Wound Care Nurse stated when Resident #1's wound to the buttock was identified as a Stage 2 pressure ulcer, it would have been considered a change of condition, and the physician should have been notified which would have prompted a referral to the NP Wound Nurse. A telephone interview with Resident #1's physician was attempted on 10/8/27 at 2:07 p.m., and the State Surveyor was re-directed to contact the physician at a facility where he was holding clinic.A telephone interview with Resident #1's physician was attempted on 10/8/27 at 2:52 p.m., and a message was left requesting a call back.During an interview on 10/8/25 at 4:29 p.m., the DON stated, when Resident #1 was identified with a Stage 2 pressure ulcer, the physician should have been notified.During an interview on 10/9/25 at 8:29 a.m., the NP Wound Nurse stated she made rounds at the facility to look at wounds every Thursday. The NP Wound Nurse stated, if she needed to look at a resident who had wounds, she would have been notified by the Wound Care Nurse. The NP Wound Nurse stated, she had never seen or had Resident #1 referred to her and did not recall his name. The NP Wound Nurse stated, if Resident #1 had been identified with a Stage 2 pressure wound, the resident should have been referred to her. During a telephone conversation on 10/9/25 at 9:06 a.m., the GVN called on behalf of Resident #1's physician and stated she could not find documentation by the physician on notification from the facility regarding a change of condition to Resident #1.During an interview on 10/9/25 at 9:46 a.m. LVN D stated, as part of his duties, he would provide wound care treatments to the residents. LVN D stated, he did not recall doing wound care on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455869 If continuation sheet Page 2 of 23 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 12/10/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Resident #1. LVN D stated, when providing wound care, and if the wound were to change in appearance, he would consider it a change of condition and would notify the Wound Care Nurse, the physician, and the DON. LVN D stated, notification would have been made within the hour, the same day.During an interview on 10/9/25 at 10:13 a.m., RN E stated, as part of her duties, she would provide skin assessments on the residents and if she noted a skin integrity issue she would have reported it to the Wound Care Nurse and the physician.During an interview on 10/9/25 at 10:26 a.m., LVN F stated, as part of her duties, she would provide wound care treatments to the residents. LVN F stated, for residents who developed skin integrity issues she would complete a Change of Condition form, notify the Wound Care Nurse, and see what the next treatment would be. LVN F stated, for wounds, the first course of action would be to tell the Wound Care Nurse and notification should be made within a couple of hours.During an interview on 10/9/25 at 10:49 a.m., RN A stated she could not recall if Resident #1 ever had a wound and didn't do anything other than cream. RN A stated, as part of her duties, she would provide wound care treatments to the residents. RN A stated, as soon as a resident was noted with a change in condition, for a wound, the resident would have been referred to the Wound Care Nurse first, then the physician, and the resident's family.Record review of the facility document titled Notification of Changes, dated 10/24/22 revealed in part, .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.Definitions.Clinical Complications: Examples - Development of stage 2 pressure injury.Compliance Guidelines.The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Event ID: Facility ID: 455869 If continuation sheet Page 3 of 23 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 12/10/2025 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 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 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 includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans:The facility failed to develop a person-centered care plan with interventions that addressed Resident #1's pressure wound, refusals for offloading and repositioning and wound care treatments.This failure could place residents at risk of not having their needs and preferences met.The findings included:Record review of Resident #1's face sheet dated 10/7/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged on 8/18/25 with diagnoses that included sepsis (condition in which the body's response to infection causes widespread inflammation, leading to tissue damage, organ failure, or death), secondary malignant neoplasm of right lung (cancer has metastasized/spread and it not the original primary cancer), malignant neoplasm of kidney (cancerous tumor that starts at the kidney), acute cystitis without hematuria (a sudden inflammation or infection of the bladder that does not involve blood in the urine), heart failure, severe protein-calorie malnutrition (serious form of undernutrition), dysphagia, oropharyngeal phase (difficulty swallowing that occurs during the first part of swallowing, when food or liquid moves from the mouth through the throat and into the esophagus), muscle wasting and atrophy (the wasting away or decrease in size of a body part, tissue, or organ), weakness, need for assistance with personal care, pain in the right and left hip, hypokalemia (low level of potassium in the blood), and hypertension (high blood pressure).Record review of Resident #1's admission MDS assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making skills, required partial/moderate assistance with mobility/transfers, had an indwelling urinary catheter, was always incontinent of bowel, and was at risk of developing pressure ulcers/injuries.Record review of Resident #1's discharge MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills, required partial/moderate assistance with mobility/transfers, was always incontinent of bowel and bladder, and had one unhealed Stage 2 pressure ulcer (a partial-thickness loss of skin involving the epidermis and/or dermis indicating the damage does not extend through the full thickness of the skin or underlying muscle).Record review of Resident #1's Order Summary Report for active orders as of 7/23/25, and dated 10/7/25 revealed the following:- Mattress: Pressure Reduction for skin protection every shift related to sepsis with order date 7/23/25 and no stop dateRecord review of Resident #1's Order Summary Report for active orders as of 8/1/25 and dated 10/8/25 revealed the following:- Mattress: Pressure Reduction for skin protection every shift related to sepsis with order date 7/23/25 and no stop date- Apply zinc base cream to the buttock area, every shift for Blanchable redness to bilateral buttocks with order date 7/25/25 and no stop dateRecord review of Resident #1's comprehensive care plan with initiated date 7/24/25 and revision date 8/20/25 reflected the resident had a potential/actual impairment to skin integrity related to incontinence and impaired mobility with a goal for the resident not to have complications related to gluteal fold peeling and interventions that included assistance with turning and positioning, avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, diet as ordered, pressure reduction mattress, and use of a draw sheet or lifting device to move the resident.Record review of Resident #1's Skin and Wound Evaluation document completed by the Wound Care Nurse on 7/31/25 and electronically signed on 8/1/25 revealed the resident had no new wounds.Record review of Resident #1's Skin and Wound Evaluation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455869 If continuation sheet Page 4 of 23 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 12/10/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few document completed by the Wound Care Nurse on 8/6/25 and electronically signed on 8/6/25 revealed the resident had a Stage 2 pressure wound to the sacrum.Record review of Resident #1's Skin and Wound Evaluation document completed by the Wound Care Nurse on 8/13/25 and electronically signed on 8/13/25 revealed the resident had a Stage 2 pressure wound to the sacrum and reflected the Patient noncompliant with turn and repositioning, poor food intake.During an interview on 10/8/25 at 1:41 p.m., the Wound Care Nurse stated Resident #1 had cancer and believed the resident had developed a Stage 2 pressure wound to the sacrum or coccyx. The Wound Care Nurse stated the resident was pleasant and would not resist care, but he did have one or two refusals for wound care.During an interview on 10/8/25 at 4:29 p.m., the DON stated he believed Resident #1 had cancer, possibly prostate cancer, and had metastasized to the upper body. The DON stated he did not recall Resident #1 having had a pressure wound, but with him (Resident #1) not wanting to be turned, not wanting to be moved, a wound would not surprise me.During an interview on 10/9/25 at 10:26 a.m., LVN F stated she did not really participate in care plan revisions. LVN F stated the care plan was important because it helped to prevent further issues and to improve the patient's life and for the staff to know what to do in any given situation. LVN F stated, for a resident who had chronic refusals, notification should be made to the DON, ADON, and the family and probably should be care planned to show the staff what to do for refusals.During an interview on 10/9/25 at 10:49 a.m., RN A stated she recalled Resident #1 and remembered the resident was very ill, and very easy to care for. RN A stated she had participated in developing a baseline care plan but was not involved in revising a care plan. RN A stated the care plan was important because it showed the staff how to care for a resident, and how to address their personal needs.During an interview on 10/9/25 at 1:59 p.m., the MDS Coordinator stated almost everybody modified/updated the care plan. The MDS Coordinator stated that for an acute problem, the ADON and the charge nurse could add an acute problem to the care plan. The MDS Coordinator stated she and the other MDS Coordinator were responsible for updating the comprehensive care plan after the quarterly or comprehensive assessments had been completed. The MDS Coordinator stated if the comprehensive care plan addressed wounds, then the ADON or the Wound Care Nurse were responsible for revising the comprehensive care plan. The MDS Coordinator stated the comprehensive care plan was important because it helped staff to know how to provide a resident with specific care.During an interview on 10/9/25 at 2:19 p.m., the ADON stated she recalled Resident #1, and she was responsible for updating or revising the comprehensive care plan if the resident had developed an infection but did not care plan wounds. The ADON stated the Wound Care Nurse would probably care plan wounds. The ADON stated she only recalled the resident was unable to get up. The ADON stated the comprehensive care plan was important because it helped tell the staff What is going on with the resident.Record review of the facility document titled Care Plan Revisions Upon Status Change, dated 10/24/22 revealed in part, .The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change.The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change.Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable.The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options.The team meeting discussion will be documented in the nursing progress notes.The care plan will be updated with the new or modified interventions.Staff involved in the care of the resident will report resident response to new or modified interventions.Care plans will be modified as needed by the MDS Coordinator or other designated staff member.The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455869 If continuation sheet Page 5 of 23 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 12/10/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm resident's care.The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455869 If continuation sheet Page 6 of 23 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 12/10/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident's environment remains as free of accident hazards as is possible, for 1 of 1 resident (Resident #2), in the facility reviewed for accidents, in that:The facility failed to ensure Resident # 2 did not have disposable razors in his room.This failure could place residents at risk of injury and contribute to avoidable accidents and a decline in health.The findings include:Record review of Resident #2's face sheet dated 10/07/2025 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included diabetes, other sequelae following unspecified cerebrovascular disease (lingering affects due to a disruption in blood flow to the brain), major depressive disorder, anxiety disorder, chronic pain syndrome, gastro-esophageal reflux disease (frequent acid reflux), and long term us of insulin.Record review of Resident #2's MDS dated [DATE] documented a BIMS of 14 out of 15 indicating independent decision making and recorded the needed use of supervision or touching assistance with personal hygiene.Record review of Resident #2's care plan provided on 10/07/2025 recorded a focus area for the following: Resident # 2 has an ADL self-care performance deficit r/t weakness, malnutrition, initiated on 03/22/2023, with interventions including PERSONAL HYGIENE: The resident requires set up assistance to limited assist by 1 staff with personal hygiene and oral care initiated on 03/22/2023.Record review of Resident # 2's care plan provided on 10/07/2025 did not address Resident # 2's ability to keep razors in his room. During an observation on 10/07/2025 at 9:36 a.m., in Resident #2's room there was three disposable razors beside the sink. During an interview on 10/08/2025 at 8:51 a.m., Resident #2 stated he shaved himself and staff have not helped him. Resident #2 stated the staff provide the razor and typically take it back when Resident #2 is finished shaving. Resident #2 stated he prefers to shave himself. During an observation on 10/08/2025 at 8:54 a.m., in Resident #2's room was three disposable razors beside the sink. During an interview on 10/08/2025 at 8:55 a.m., CNA B stated Resident #2 mostly does his hygiene and personal care for himself. CNA B stated Resident #2 showers himself but with shaving staff assist. When asked if Resident #2 can have disposable razors in his room CNA B stated they were not sure if Resident #2 was allowed to have disposable razors in their room but would assume no. When asked if any directive or information had been given regarding residents having disposable razors in their room CNA B stated they have not been told anything about disposable razors being in residents rooms at the facility. When asked where disposable razors come from CNA B stated they get them from the supply closet. When asked what the danger would be for a resident to have disposable razors in their room CNA B stated the resident could hurt themselves, residents could fight, and another resident could potentially hurt themselves. During an interview on 10/08/2025 at 9:06 a.m., LVN C stated Resident #2 required assist times one, and he was a brittle diabetic. When asked about Resident #2's activities of daily living LVN C stated that staff is preferred to supervise Resident #2 during showers and staff shaved him. When asked about the process for shaving Resident #2, LVN C stated nurses get the disposable razors and shaving cream from the locked supply closet and shave Resident #2 at the sink. When asked if Resident #2 can have disposable razors in their room LVN C stated residents are not allowed to have disposable razors in their room due to the possibility of the disposable razor being used as a weapon, or to hurt themselves, or a dementia patient could get ahold of it. When shown where the disposable razors was located in Resident #2's room, LVN C confirmed Resident #2 had three blue disposable razors on the side of the sink and removed them from Resident #2's room.During an interview on 10/08/2025 at 4:30 p.m., the DON stated regarding residents who request to shave two things can happen the first being if the resident has (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455869 If continuation sheet Page 7 of 23 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 12/10/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete a high enough BIMS score greater than 12 the resident can shave themselves if the resident has BIMS lower than 12 then a CNA or nurse would assist. The DON stated razors are kept in the supply closet which only staff have access to. When asked if Resident #2 can have a disposable razor in their room the DON stated if he could it would have to be documented in Resident #2's care plane. After reviewing Resident #2's care plan the DON stated nothing was found regarding disposable razors or shaving on Resident #2's care plan.During an interview on 10/09/2025 at 8:12 a.m., the Administrator stated that depending on residents BIMS they are technically allowed to have razors in their room but that it needs to be care planned. When asked if Resident #2 could have disposable razors in their room the Administrator stated to their understanding it had not been care planned. When asked about the danger of Resident #2 having had a disposable razor in their room the Administrator stated they want to be able to keep track of things and that it could lead to improper use.At time of exit on 10/09/2025 at 3:32 p.m., the Administrator stated the facility did not have a policy for the above deficiency. Event ID: Facility ID: 455869 If continuation sheet Page 8 of 23 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 12/10/2025 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 1 of 1 nurse (Wound Care Nurse) reviewed for competent nursing care.The facility failed to ensure the Wound Care Nurse was aware of notification of changes to the RN Unit Manager or designee per facility policy when she identified Resident #1 with a Stage 2 pressure ulcer.These deficient practices affect residents who depend on nursing care and could place residents at risk for injury, infection and a decline in health. The findings included:Record review of Resident #1's face sheet dated 10/7/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged on 8/18/25 with diagnoses that included sepsis (condition in which the body's response to infection causes widespread inflammation, leading to tissue damage, organ failure, or death), secondary malignant neoplasm of right lung (cancer has metastasized/spread and it not the original primary cancer), malignant neoplasm of kidney (cancerous tumor that starts at the kidney), acute cystitis without hematuria (a sudden inflammation or infection of the bladder that does not involve blood in the urine), heart failure, severe protein-calorie malnutrition (serious form of undernutrition), dysphagia, oropharyngeal phase (difficulty swallowing that occurs during the first part of swallowing, when food or liquid moves from the mouth through the throat and into the esophagus), muscle wasting and atrophy (the wasting away or decrease in size of a body part, tissue, or organ), weakness, need for assistance with personal care, pain in the right and left hip, hypokalemia (low level of potassium in the blood), and hypertension (high blood pressure).Record review of Resident #1's admission MDS assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making skills, required partial/moderate assistance with mobility/transfers, had an indwelling urinary catheter, was always incontinent of bowel, and was at risk of developing pressure ulcers/injuries.Record review of Resident #1's discharge MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills, required partial/moderate assistance with mobility/transfers, was always incontinent of bowel and bladder, and had one unhealed Stage 2 pressure ulcer (a partial-thickness loss of skin involving the epidermis and/or dermis indicating the damage does not extend through the full thickness of the skin or underlying muscle).Record review of Resident #1's Order Summary Report for active orders as of 7/23/25, and dated 10/7/25 revealed the following:- Mattress: Pressure Reduction for skin protection every shift related to sepsis with order date 7/23/25 and no stop dateRecord review of Resident #1's Order Summary Report for active orders as of 8/1/25 and dated 10/8/25 revealed the following:- Mattress: Pressure Reduction for skin protection every shift related to sepsis with order date 7/23/25 and no stop date- Apply zinc base cream to the buttock area, every shift for Blanchable redness to bilateral buttocks with order date 7/25/25 and no stop dateRecord review of Resident #1's comprehensive care plan with initiated date 7/24/25 and revision date 8/20/25 reflected the resident had a potential/actual impairment to skin integrity related to incontinence and impaired mobility with a goal for the resident not to have complications related to gluteal fold peeling and interventions that included assistance with turning and positioning, avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, diet as ordered, pressure reduction mattress, and use of a draw sheet or lifting device to move the resident.Record review of Resident #1's Skin and Wound Evaluation document completed by the Wound Care Nurse (LVN) on 7/31/25 and electronically signed on 8/1/25 revealed the resident had no new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455869 If continuation sheet Page 9 of 23 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 12/10/2025 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wounds.Record review of Resident #1's Skin and Wound Evaluation document completed by the Wound Care Nurse (LVN) on 8/6/25 and electronically signed on 8/6/25 revealed the resident had a Stage 2 pressure wound to the sacrum, staged by the Wound Care Nurse (LVN). Resident #1's Skin and Wound Evaluation document revealed on the Additional Care Section, None was checked, and the Notifications section: Practitioner Notified, Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) were left blank.Record review of Resident #1's Skin and Wound Evaluation document completed by the Wound Care Nurse (LVN) on 8/13/25 and electronically signed on 8/13/25 revealed the resident had a Stage 2 pressure wound to the sacrum staged by the Wound Care Nurse (LVN). Resident #1's Skin and Wound Evaluation document revealed on the Additional Care section, the resident had a moisture barrier and positioning wedge, and the Notifications: Practitioner Notified, Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) were left blank.During an interview on 10/8/25 at 1:41 p.m., the Wound Care Nurse (LVN) stated Resident #1 had cancer and believed the resident had developed a Stage 2 pressure wound to the sacrum or coccyx. The Wound Care Nurse (LVN) initially stated she could not recall when she had notified the physician or if she had told the physician at all. The Wound Care Nurse (LVN) stated, Resident #1 had an irritation to the area, but it was not like a Stage 3 wound whereas a Stage 3 wound was more open and a better chance for an infection. The Wound Care Nurse (LVN) stated, had the resident developed a Stage 3 pressure wound, then she would have reported it to the physician or the NP who in turn would have referred the resident to the NP Wound Nurse. The Wound Care Nurse then stated she recalled a notification to the physician but didn't document it and could not remember how the physician had responded. The Wound Care Nurse (LVN) stated when Resident #1's wound to the buttock was identified as a Stage 2 pressure ulcer, it would have been considered a change of condition, and the physician should have been notified which would have prompted a referral to the NP Wound Nurse.A telephone interview with Resident #1's physician was attempted on 10/8/27 at 2:07 p.m., and the State Surveyor was re-directed to contact the physician at a facility where he was holding clinic.A telephone interview with Resident #1's physician was attempted on 10/8/27 at 2:52 p.m., and a message was left requesting a call back.During an interview on 10/9/25 at 8:14 a.m., the DON stated, the Wound Care Nurse (LVN) completed Wound Care Certification on 10/10/22, and stated the facility adhered to the Wound Care Nurse's documented training regarding the staging of pressure wounds. The DON stated there was no facility policy on a nurse being able to stage a wound, as that would be determined by the training received for Wound Care Certification.During a follow up interview on 10/9/25 at 8:24 a.m., the Wound Care Nurse (LVN) stated she could not recall if she had received training on staging a wound as part of her certification.During an interview and record review on 10/9/25 at 8:29 a.m., the NP Wound Nurse stated she made rounds at the facility to look at wounds every Thursday. The NP Wound Nurse stated, if she needed to look at a resident who had wounds, she would have been notified by the Wound Care Nurse. The NP Wound Nurse stated, she had never seen or had Resident #1 referred to her and did not recall his name. The NP Wound Nurse stated, if Resident #1 had been identified with a Stage 2 pressure wound, the resident should have been referred to her. The NP Wound Nurse reviewed Resident #1's wound photos and stated, absolutely he (Resident #1) should have been referred to me. The NP Wound Nurse stated, Resident #1 did not have a Stage 2 pressure ulcer, but had a moisture associated lesion and the Wound Care Nurse should not be staging wounds because that was not within her scope of practice as staging a wound was giving a diagnosis. The NP Wound Nurse stated, a lot of nurses don't know that that is diagnosing, and we're not doctors.During a follow up interview on 10/9/25 at 8:52 a.m., the Wound Care Nurse (LVN) stated she reviewed the class legend for the Wound Care Certification and stated, as part of her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455869 If continuation sheet Page 10 of 23 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 12/10/2025 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete training, she was shown how to stage a wound.During a telephone conversation on 10/9/25 at 9:06 a.m., the GVN called on behalf of Resident #1's physician and stated she could not find documentation by the physician on notification from the facility regarding a change of condition to Resident #1.Record review of the Wound Care Nurse's (LVN) Wound Care Nurse certification revealed the course was completed in October 2022 and was valid for 4 years after course completion.Record review of the Wound Care Nurse Certification booklet, dated 2022, and provided by the Wound Care Nurse revealed in part, under Course Objectives,.Classification of wounds: Identification and Management. Scope of Practice - Role of Wound Care Nurse: Assessment, Documentation, Infection Control, Consultation and Monitoring.Scope of Practice - Licensed nurses. Registered Nurse (RN)/Licensed Practical Nurse (LPN), Licensed Vocational Nurse (LVN).Wound care nurse activities require clinical supervision/delegation of a medical provider.Licensed nurse working as a certified wound care nurse shall perform his/her duties per the prescribing medical provider orders with a focus on patient safety, and function within the parameters of the legal scope of practice and in accordance with the federal state, and local laws; rules and regulations; and policies, procedures and guidelines of the employing health care institution or practice setting.Record review of the facility document titled, Pressure Injury Prevention and Management dated 8/15/22 revealed in part, .This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries.The facility shall establish and utilize a systemic approach for pressure injury prevention and management.Licensed nurses will conduct a pressure injury risk assessment, on all residents upon admission/re-admission, or whenever the resident's condition changes significantly.Monitoring.The RN Unit Manager, or designee, will review all relevant documentation regarding skin assessment, pressure injury risks, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record.The attending physician will be notified of.The presence of a new pressure injury upon identification. Event ID: Facility ID: 455869 If continuation sheet Page 11 of 23 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 12/10/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to determine that drug records were in order and that an account of all controlled substances was maintained and periodically reconciled for 8 of 17 residents (Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, and Resident #11) and 4 of 6 medication carts (MC #1, MC #2, MC #4 and MC #6) reviewed for pharmaceutical services. 1. The facility failed to ensure discontinued/expired medications were removed from the medication carts on (4) occasions.2. The facility failed to ensure the administration and count of controlled substances were reconciled on (3) occasions.3. The facility failed to ensure counts of controlled medications were completed/signed for on (28) occasions. These deficient practices could put residents at risk for diversion and reduced effectiveness of medications. Findings included: 1. Record review of Resident #4's admission Record, dated 9/26/25, revealed the resident was re-admitted on [DATE] with diagnoses which included: History of Malignant Neoplasm of Breast (uncontrollable cell growth that destroy body tissue), Dementia (group of thinking and social symptoms that interferes with daily functioning), Congestive Heart Failure (condition in which the heart can't pump blood well enough to meet the body's needs), Anxiety (feeling of dread, fear, or uneasiness) and Spondylosis (degeneration of the bones and discs of the spine).Record review of Resident #4's Order Summary, dated 2/24/25, revealed: LORazepam Oral Tablet 0.5MG (Lorazepam) *Controlled Drug* Give 1 tablet by mouth every 12 hours as needed for anxiety.for 14 days. Record review of Resident #4's Individual Resident's Controlled Substance Record revealed LORAZEPAM 0.5 MG TABLET TAKE ONE TABLET BY MOUTH EVERY 12 HOURS AS NEEDED FOR 14 DAYS. Further review of this record revealed the last administration of Lorazepam was on 3/6/25. Observation of controlled substance reconciliation on 9/24/25, beginning at 11:48 pm, revealed a blister pack with tablets labeled LORAZEPAM 0.5 MG Tablet for Resident #4. Further observation revealed AS NEEDED FOR 14 DAYS . During an interview on 9/24/25 at 11:50 pm, LVN A said when a medication was ordered for a specific number of days, the medication was discontinued after the number of days it was ordered for, removed from the cart and given to the DON. Record review of Resident #6's admission Record, dated 9/26/25, revealed the resident was re-admitted on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down), Pain in Shoulders. Record review of Resident #6's Order Summary, dated 9/26/25, revealed: TraMADol HCl Tablet 50 MG Give 1 tablet by mouth three times a day for pain.Order Date 06/26/2024. Observation of controlled substance reconciliation on 9/24/25, beginning at 11:48 pm, revealed a blister pack with tablets labeled TRAMADOL 50 MG take 1 tablet by mouth 4 times a day PRN for pain, 1 of 2 expiration date 6/22/25, for Resident #6. Further observation revealed a second blister pack with tablets labeled TRAMADOL 50 MG take 1 tablet by mouth 4 times a day PRN for pain, 2 of 2 expiration date 6/22/25, for Resident #6. Record review of Resident #6's September MAR, dated 9/26/25, revealed Tramadol 50 mg PRN was not administered. Record review of Resident #11's admission Record, dated 9/26/26, revealed the resident was admitted on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning).Record review of Resident #11's Order Summary, dated 9/26/25, revealed: Lorazepam oral concentrate 2 mg/mL, give 0.25 mL by mouth every 4 hours PRN.Observation of controlled substance reconciliation on 9/25/25, beginning at 2:09 pm, revealed a bottle labeled Lorazepam Oral Concentrate 2 MG/ML with an expiration date of 3/31/26; however, the box had a use by date of 8/2/25. Record review of Resident #11's September MAR, dated 9/26/25, revealed Lorazepam oral concentrate 2 mg/mL was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455869 If continuation sheet Page 12 of 23 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 12/10/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some administered. 2. Record review of Resident #5's admission Record, dated 9/25/25, revealed the resident was re-admitted on [DATE] with diagnoses which included: Atherosclerosis of Arteries of Bilateral Legs (The build-up of fats, cholesterol, and other substances in and on the artery walls), Pain in Right Foot, and Non-pressure Chronic Ulcer (wound that does not heal within 6 weeks) of Right Foot. Record review of Resident #5's quarterly MDS assessment, dated 9/9/25, revealed the resident had a BIMS score of 15 (suggesting intact cognition). Record review of Resident #5's Order Summary, dated 9/25/25, revealed: HYDROcodone-Acetaminophen Oral Tablet 7.5-300 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for Pain.Order Date 02/24/2025. Observation, on 9/25/25, of medication administration with LVN G, beginning at 11:42 am, revealed: Resident #5's blister pack of Hydrocodone-APAP 7.5-300 mg, 1 tablet orally q6 hours PRN, contained 6 tablets prior to administration. Record review of Resident #5's Individual Controlled Substance Record for Hydrocode-APAP 7.5-300 mg (pain medication) 1 tablet orally q6 hours PRN, last entry revealed: Name of person administering - LVN A, date - 9/24/25, time - 5:50 am, amount on hand - 8, amount given - 1, amount remaining - 7. Record review of Resident #5's September MAR, dated 9/25/25, revealed: Resident #5's pain level was 6 and Hydrocode-APAP 7.5-300 mg (pain medication) 1 tablet orally q6 hours PRN for pain was administered by LVN A on 9/25/25 at 5:40 am. Record review of Resident #7's admission Record, dated 9/26/25, revealed the resident was re-admitted on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning) and Down Syndrome (a genetic disorder causing developmental/intellectual delays).Record review of Resident #7's Physician Order, dated 9/24/25 at 7:14 pm, revealed: ALPRAZolam Oral Tablet 0.5 MG (Alprazolam) Give 0.5 mg by mouth one time only.Confirmed By: [LVN A] Printed Date: Sep 24, 2025, 19:56:42 [7:46 pm] . Observation, on 9/24/25, of medication administration and count reconciliation of controlled substances, beginning at 11:48 pm, revealed: Resident #7's blister pack of Alprazolam 0.5 mg, take one tablet by mouth q12 hours PRN, contained 25 tablets.Record review of Resident #7's Individual Controlled Substance Record for Alprazolam 0.5 mg, take one tablet by mouth q12 hours PRN, last entry revealed: Name of person administering illegible, Date - 9/12/25, time - 12:00 pm, amount given - 1, amount remaining - 26.Record review of Resident #7's September MAR, dated 9/26/25, revealed: Alprazolam Give 0.5 mg by mouth one time only was administered by LVN A on 9/24/25 at 7:30 pm. During an interview on 9/24/25 at 11:50 pm, LVN A said he had just received an order for Resident #7's alprazolam on 9/24/25. LVN A said he administered the alprazolam at around 9:00 pm. LVN A said the expectation was to sign out controlled substances immediately after administering the medication but he needed to document the resident's behavior and why the medication was ordered.Record review of Resident #8's admission Record, dated 9/26/25, revealed the resident was admitted on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Generalized Anxiety Disorder (severe and ongoing that is ongoing and interferes with daily activities) and History of Falling.Record review of Resident #8's quarterly MDS assessment, dated 9/8/25, revealed the resident's cognitive skills for daily decision making was moderately impaired. Record review of Resident #8's Order Summary, dated 9/26/25, revealed: Lorazepam Oral Concentrate 2 MG/ML (Lorazepam) Give 0.5 ml by mouth every 2 hours as needed for agitation/anxiety for 365 Days.Order Date 08/20/2025. Observation, on 9/25/25, of count reconciliation of controlled substances with LVN G, beginning at 1:56 pm, revealed: Resident #8's bottle of lorazepam 2 mg/mL, give 0.5 mL q4 hours PRN, contained 16 mLs of liquid medication. Record review of Resident #8's Individual Controlled Substance Record Lorazepam 2 mg/mL, take 0.5 mL (1 mg) by mouth q4 hours PRN for anxiety, last entry revealed: Name of person administering - RN C, Date - 9/14/25, time - 10:00 pm, amount given - 0.5, amount remaining (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455869 If continuation sheet Page 13 of 23 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 12/10/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 17.5. Record review of Resident #8's September MAR, dated 9/26/25, revealed: Lorazepam 2 mg/mL give 0.5 mLs by mouth q2 hours PRN for agitation/anxiety for 365 days was administered by RN C on 9/14/25 at 11:35 am. During an interview on 9/25/25 at 12:13 pm, LVN G said the facility's policy for controlled substance discrepancies was to identify the missing medication and let the DON know that the count was off as soon as it was identified. LVN G further stated nurses were responsible for ensuring there were no discrepancies with controlled substance counts. LVN G said he did not count the controlled substances in his medication cart at the beginning of his shift on 9/25/25 because he was overwhelmed with shift report, forgot and just started working. LVN G further stated it was his responsibility to count controlled substances with the previous shift to ensure the counts were correct because they were controlled substances and staff want the correct count 100% of the time for accountability. LVN G said it was important to avoid discrepancies to avoid double dosing a resident and causing possible adverse reactions. 3. Record review of Resident #9's Individual Controlled Substance Record for Acetaminophen-Codeine #3 (pain medication) 1 tablet orally q12 hours scheduled and 1 tablet q4 hours PRN revealed: Name of person administering CMA E, date - 9/21/25, time - 5:00 pm, amount given - 1, amount remaining 16. Further review of this record revealed an R (refused) Destroyed and signatures of CMA E and CMA F. During an interview on 9/26/25 at 6:00 pm, CMA E said R meant the resident refused a medication. CMA E said Resident #9 refused Acetaminophen-Codeine #3 on 9/21/25 because he was nauseated. CMA E said she took the dose to the nurse and explained the resident refused the dose. CMA E further stated the nurse, she was pretty sure it was LVN I, saw her put the dose of Acetaminophen-Codeine #3 into the receptacle. CMA E said only one nurse's signature was required when wasting with another CMA. CMA E said the nurse must have forgotten to sign the record after the dose was wasted. CMA E further stated she did not know why it was important for there to be 2 nurses present to waste a dose of a controlled substance. Record review of Resident #10's Individual Controlled Substance Record for Lorazepam (anxiety medication) 0.5 mg take one tablet orally q8 hours PRN revealed: Name of person administering - LVN C, date - 6/9/25, time - 7:45 pm, amount given - 1, amount remaining 24. Further review of this record revealed wasted and one signature which was illegible. During an interview on 9/26/25 at 6:17 pm, LVN C said staff were expected to count controlled substances at the beginning and the end of the shift. LVN C further stated staff were expected to sign outgoing or oncoming controlled substance record, saying the count was right. LVN C said every time a controlled substance count was completed, both staff had to sign the Controlled Drugs Count Record immediately after. LVN C said the signatures were important for accountability, adding that the staff signature was like the staff's word, saying yes, the controlled substances were counted. LVN C further stated she did not think there was ever a time that she had not signed the Controlled Drugs Count Record after a count. Record review of Resident #11's Individual Narcotic Record, Lorazepam Concentrate 2 mg/mL Give 0.25 mL orally q4 hours PRN, revealed it did not contain the name of the person delivering/receiving the medication, date the medication was delivered/received, or time the medication was received.Record review, on 9/24/25, of the Controlled Drugs Count Record September 2025, MC #1, revealed the following shifts had missing signatures: 9/1/25 (2 pm - 10 pm shift) 9/3/25 (10 pm - 6 am shift) 9/4/25 (10 pm - 6 am shift) 9/4/25 (2 pm - 10 pm shift) 9/6/25 (2 pm - 10 pm shift) 9/8/25 (10 pm - 6 am shift) 9/11/25 (2 pm - 10 pm shift) 9/12/25 (2 pm - 10 pm shift) 9/17/25 (10 pm - 6 am shift) 9/18/25 (10 pm 6 am shift) 9/19/25 (10 pm - 6 am shift) 9/20/25 (10 pm - 6 am shift) 9/21/25 (2 pm - 10 am shift) 9/22/25 (10 pm - 6 am shift) 9/24/25 (10 pm - 6 am shift) Record review on, 9/24/25, of the Controlled Drugs Count Record September 2025 for, MC #2, revealed the following shifts had missing signatures: 9/4/25 (10 pm - 6 am shift) 9/5/25 (2 pm - 10 pm shift) 9/5/25 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455869 If continuation sheet Page 14 of 23 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 12/10/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (10 pm - 6 am shift) 9/6/25 (2 pm - 10 pm shift) 9/6/25 (10 pm - 6 am shift) 9/12/25 (10 pm - 6 am shift) 9/15/25 (10 pm - 6 am shift) 9/16/25 (10 pm - 6 am shift) Record review on, 9/24/25, of the Controlled Drugs Count Record September 2025 for, MC #4, revealed the following shifts had missing signatures: 9/1/25 (6 pm - 6 am shift) 9/14/25 (6 am - 6 pm shift) 9/20/25 (6 pm - 6 am shift) 9/25/25 (6 am - 6 pm shift) Record review on, 9/25/25, of the Controlled Drugs Count Record September 2025 for, MC #6, revealed the following shifts had missing signatures: 9/1/25 (6 pm - 6 am shift) 9/1/25 (6 am - 6 pm shift) 9/2/25 (6 am - 6 pm shift) 9/4/25 (6 am - 6 pm shift) Record review on, 9/25/25, of the Controlled Drugs Count Record September 2025, MC #4, revealed the document was not signed on 9/25/25. During an interview on 9/24/25 at 11:50 pm, LVN A said staff were expected to count controlled substances before every administration and document the amount before and after administration. LVN A further stated he counted controlled substances when he arrived for his shift and before he left. LVN A said he did not check for expiration dates during the controlled substance reconciliation. LVN A further stated he only made sure that the count was accurate. LVN A said he did not remove medications that needed to be removed form the medication carts. LVN A said expired medications should not be administered because the efficacy may be reduced, it may not be the correct dose or affect the resident in another way. During an interview on 9/26/25 at 1:54 PM, the PharmD said he was not sure what the facility policy was for counting controlled substances, but the facility was provided with a Controlled Drugs Count Record for each resident and the facility staff signed for doses every time one was administered, keeping a running count. The PharmD further stated he was not sure if this was the facility's policy. The PharmD said it was important to maintain an accurate count of controlled substances to help prevent diversion. The Pharm D said when a liquid medication has been opened, the facility should use the expiration date on the label unless the bottle/box said a shorter date. During an interview on 9/26/25 at 4:48 pm, ADON A said controlled substances were wasted (disposal of unused dose) by nurses or CMA. ADON A further stated she did not know what the facility policy said regarding wasting controlled substances. ADON A said when a medication was discontinued it was removed from the cart and given to the DON. ADON A further stated discontinued medications should not be in the cart because it might be administered without an active order. ADON A said the staff completing the controlled substance counts should be looking out for medications that were expired or discontinued. ADON A said the ADONs pulled orders every Monday morning for their assigned halls and review the orders for any discontinued medications. ADON A further stated that a prudent nurse would also check for expired or discontinued medications. During an interview on 9/26/25 at 5:35 pm, ADON B said when medications were expired/discontinued, they were pulled from the cart and given to the DON. ADON B said she did not audit medication carts for expired/discontinued medications. ADON B said the pharmacists completed audits of the medication carts monthly. ADON B further stated the CMAs and nurses were responsible for keeping track of expired/discontinued medications. ADON B said she was not aware there were expired/discontinued medications in the medication carts. ADON B said it was important to remove expired/discontinued medications from the carts because they would not want the residents to take that medication because they may experience side effects from the medication, or the efficacy of the medication may decrease. ADON B said staff counting controlled substances at the beginning of the shift, end of the shift, and when working a split shift, any time the cart changes hands. ADON B said staff were expected to sign the Controlled Drugs Count Record once they were done counting the controlled substances. ADON B said the staff with the carts were responsible for ensuring for counting the controlled substances and signing the Controlled Drugs Count Record. ADON B said it was important to count the controlled substances and sign the Controlled Drugs Count Record (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455869 If continuation sheet Page 15 of 23 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 12/10/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some afterward to ensure the count was correct and there were not any missing doses. ADON B said if there was a discrepancy in the count, staff were expected to notify the DON. ADON B said when controlled substances were delivered by the pharmacy, two nurses needed to verify the amount received was correct. ADON B further stated was the amount was verified the Controlled Drugs Count Record was signed and dated by the delivery person and one nurse. ADON B said this was important because there could be a discrepancy and staff needed to ensure all the medications were accounted for. ADON B said controlled substances should be wasted by two nurses. During an interview on 9/26/25 at 5:55 pm, LVN B said staff were required to count controlled substances at the beginning of the shift before administering medications and at shift change. LVN B further stated 9/4/25 might have been a shift that she picked, but did not remember if she worked. LVN B said it was important to count controlled substances because staff needed to make sure that when they took control of the medication cart, all controlled substances were accounted for because they were narcotics and controlled. During an interview on 9/26/25 at 7:36 pm, LVN D said she always counted the controlled substance on her cart. LVN D further stated she might have forgotten to sign the Controlled Drugs Count Record for MC #6 on 9/1/25 for the 6 am - 6 pm shift. LVN D said it was important to sign the Controlled Drugs Count Record because staff were acknowledging what was in the cart and were responsible for the contents during their shift. Call was attempted to interview LVN G on 9/26/25 at 8:02 pm with no success, a voicemail was left. Call was attempted to interview LVN D on 9/26/25 at 8:08 pm with no success, a voicemail was left. Call was attempted to interview LVN H on 9/26/25 at 8:06 pm with no success, a voicemail was left. Call was attempted to interview LVN I on 9/26/25 at 8:05 pm with no success, a voicemail was left. Call was attempted to interview RN C on 9/26/25 at 8:04 pm with no success, a voicemail was left. Call was attempted to interview LVN A on 9/26/25 at 7:52 pm with no success, a voicemail was left. During an interview on 9/26/25 at 7:54 pm, LVN J said she did not remember counting the controlled substances on 9/1/25, 9/2/25, and 9/4/25 for MC #6. LVN J further stated she had the cart for part of the shifts and staff usually did not count until the end of the shift, not when the cart was changing hands during a split shift. LVN J said she had not been told that controlled substances had to be counted during split shifts, only during the 6 am - 6 pm and 6 pm - 6 am shifts. LVN J further stated that she knew the controlled substance count was correct by the signature on the resident's record. LVN J said that when a 12-hour shift was split between staff, medications were administered using the same cart. Record review of facility's policy Controlled Substance Destruction, dated 10/1/19, read: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations. Procedure .2. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It is destroyed in the presence of two licensed nurses, and the disposal is documented on theaccountability record/book on the line representing that dose.3. All controlled substances remaining in the facility after a resident has been discharged , or the order is discontinued, are disposed of . Record review of facility's policy Documentation of Controlled Substances, dated 10/1/19, read: .Controlled Substances Record documentation will be maintained accurately. 5. An up-to-date index is kept as part of each Controlled Substances Record. Each individual resident's page lists the resident's name, physician, prescription number, date, name and strength of the drug, directions for use, amount of drug and the name of the pharmacy from which the drug was obtained. 7. Two Licensed Nurses or Medical Aides or combination thereof, are responsible to complete a count of all controlled substances at the change of shift or any time that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455869 If continuation sheet Page 16 of 23 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 12/10/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete the narcotic keys are surrendered from one nurse to another. 8. The LICENSED NURSE or MEDICAL AIDE on the shift reporting for duty counts all medication with the LICENSED NURSE or MEDICAL AIDE going off duty. The nurse coming on duty should be overseeing both the Controlled Substances Record and each sealed unit dose card. Each card should be checked back and front for tampering and quality control. Refrigerated controlled medications must be inspected as well. The LICENSED NURSE or MEDICAL AIDE on both shifts will count and sign the Controlled Substances Record in each other's presence. If there is a discrepancy in the count, DO NOT SIGN the record. Report the discrepancy to the Supervisor or the Director of Nursing immediately .Record review of facility's policy Medication Administration, dated 10/24/22, read: .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. If medication is a controlled substance, sign narcotic book. Event ID: Facility ID: 455869 If continuation sheet Page 17 of 23 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 12/10/2025 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the medication error rate was not five percent or greater for 1 of 5 residents (Resident #12). The facility had a medication error rate of 45% based on 5 errors out of 11 opportunities. LVN D failed to administer medications as ordered to Resident #12 by administering Gabapentin (for neuropathy), Cyclobenzaprine (for pain), Colace (for constipation), Carboxymethylcellulose Sodium ophthalmic gel (dry eyes), and Rosuvastatin (for high cholesterol) 2 hours and 12 minutes before the scheduled time. This failure could place residents at risk of not receiving the desired therapeutic effect of their medications. Findings included: Record review of Resident #12's admission Record, dated 9/26/25, revealed the resident was re-admitted on [DATE] with diagnoses which included: Dry Eye Syndrome, Constipation, Hemiparesis (weakness or an inability to move one side of the body), Hemiplegia (paralysis or weakness to one side of the body) and Hyperlipidemia (elevated cholesterol). Record review of Resident #12's Order Summary Report, dated 9/26/25, revealed: Gabapentin oral tablet 100 mg, give 1 tablet by mouth two times a day; Cyclobenzaprine oral tablet 10 mg, give 1 tablet by mouth two times a day; Colace capsule 100 mg, give 100 mg by mouth two times a day; Rosuvastatin oral tablet, give 1 tablet by mouth at bedtime; Carboxymethylcellulose Sodium ophthalmic gel 1%, instill 1 drop in both eyes two times a day. Observation and interview on 9/25/25 at 3:38 pm, revealed LVN D administered: Gabapentin oral tablet 100 mg, give 1 tablet by mouth two times a day; Cyclobenzaprine oral tablet 10 mg, give 1 tablet by mouth two times a day; Colace capsule 100 mg, give 100 mg by mouth two times a day; Rosuvastatin oral tablet, give 1 tablet by mouth at bedtime; Carboxymethylcellulose Sodium ophthalmic gel 1%, instill 1 drop in both eyes two times a day to Resident #12. LVN D said the medications were not due yet but was going to administer them. LVN D further stated that some residents liked their medications administered at a specific time. LVN D said she had not read the bottle of eye drops and had not realized it was not the correct dose. During an interview on 9/26/25 at 10:32 am, Resident #12 said she did not know what medications she received, when she received it or how many drops LVN D put in her eyes on 9/25/25. During an interview on 9/26/25 at 5:35 pm, ADON B said medications ordered to be administered BID where to be administered at 6 am - 10 am and 6 pm - 10 pm, unless specified in the order. ADON B further stated HS medications were to be administered between 6 pm - 10 pm. ADON B said staff should not administer medications over 2 hours before the specified time because, depending on the medication, it could affect the efficacy of the medication. Record review of the facility's policy Medication Administration revised 10/24/22, read: .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice.11. Compare medication source.to verify resident name, medication name, form, dose, route, and time.b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician.Medication timing. BID 9 am, 9 pm HS 9pm. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455869 If continuation sheet Page 18 of 23 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 12/10/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 residents (Resident #11) reviewed for medication labeling. The facility failed to ensure medications were correctly labeled. These deficient practices could place residents at risk of medication misuse and drug diversion. Findings included: Record review of Resident #11's admission Record, dated 9/26/25, revealed the resident was admitted on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #11's Order Summary Report, dated 9/26/25, revealed: Lorazepam oral concentrate 2mg/mL by mouth every 4 hours PRN. Observation on 9/25/25 at 2:15 pm revealed Resident #11's Lorazepam was in the refrigerator, stored in a plastic baggie. Further observation revealed the baggie contained a box with a label that was partially illegible. Further observation revealed the medication bottle inside the box had a manufacturer label on it, but did not have a label with the resident or prescription information. LVN G said staff knew who the medication was prescribed to because the name was on the box. During an interview on 9/25/25 at 2:17 pm, the DON said the pharmacy said they were unable to send replacement medication labels to the facility. The DON further stated the pharmacy said that they needed to have the medication in hand to properly relabel them. The DON said the facility was unable to send medications back to the pharmacy for labeling because residents would be without their medications. During an interview on 9/26/25 at 1:54 PM, the PharmD said he was not sure what the facility's procedure was but was sure the facility could handwrite labels for medication bottles/syringes. The PharmD further stated that typically the pharmacy labels the bottles/syringes as well, but the facility was supposed to call the pharmacy to let them know if a medication needs labeling so that the medication could be picked up from the facility and labeled. The PharmD said it was important for bottles/syringes be labeled so the staff knew what resident to administer the medication to. Record review of the facility's policy, Pharmacy Provider Requirements dated 10/1/19, read: .4. The provider pharmacy agrees to perform the following pharmaceutical services, including but not limited to.E. Labeling all medications dispensed. Event ID: Facility ID: 455869 If continuation sheet Page 19 of 23 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 12/10/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 medical records, in accordance with accepted professional standards and practices, that are complete; and accurately documented for 1 of 2 residents (Resident #1) reviewed for medical records:The facility failed to document wound care dressing changes on the Treatment Administration Record (TAR) for Resident #1 on 8/2/25, 8/3/25, 8/5/25, 8/8/25, 8/13/25, 8/14/25, and 8/16/25.These failures could place residents at risk for missed treatments and care which could result in the deterioration of the wound and/or development of an infection.The findings included:Record review of Resident #1's face sheet dated 10/7/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged on 8/18/25 with diagnoses that included sepsis (condition in which the body's response to infection causes widespread inflammation, leading to tissue damage, organ failure, or death), secondary malignant neoplasm of right lung (cancer has metastasized/spread and it not the original primary cancer), malignant neoplasm of kidney (cancerous tumor that starts at the kidney), acute cystitis without hematuria (a sudden inflammation or infection of the bladder that does not involve blood in the urine), heart failure, severe protein-calorie malnutrition (serious form of undernutrition), dysphagia, oropharyngeal phase (difficulty swallowing that occurs during the first part of swallowing, when food or liquid moves from the mouth through the throat and into the esophagus), muscle wasting and atrophy (the wasting away or decrease in size of a body part, tissue, or organ), weakness, need for assistance with personal care, pain in the right and left hip, hypokalemia (low level of potassium in the blood), and hypertension (high blood pressure).Record review of Resident #1's admission MDS assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making skills, required partial/moderate assistance with mobility/transfers, had an indwelling urinary catheter, was always incontinent of bowel, and was at risk of developing pressure ulcers/injuries.Record review of Resident #1's discharge MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills, required partial/moderate assistance with mobility/transfers, was always incontinent of bowel and bladder, and had one unhealed Stage 2 pressure ulcer (a partial-thickness loss of skin involving the epidermis and/or dermis indicating the damage does not extend through the full thickness of the skin or underlying muscle).Record review of Resident #1's Order Summary Report for active orders as of 8/1/25 and dated 10/8/25 revealed the following:- Apply zinc base cream to the buttock area, every shift for Blanchable redness to bilateral buttocks with order date 7/25/25 and no stop dateRecord review of Resident #1's TAR for August 2025 revealed the following:- Apply zinc base cream to the buttock area every shift (twice daily) for Blanchable redness to bilateral buttocks with start date 7/25/25. The TAR was missing documentation on the following days:8/2/25, Saturday day shift8/3/25 Sunday night shift8/5/25 Tuesday day shift8/8/25 Friday night shift8/13/25 Wednesday night shift8/14/25 Thursday day shift8/16/25 Saturday day shiftRecord review of Resident #1's comprehensive care plan with initiated date 7/24/25 and revision date 8/20/25 reflected the resident had a potential/actual impairment to skin integrity related to incontinence and impaired mobility with a goal for the resident not to have complications related to gluteal fold peeling and interventions that included assistance with turning and positioning, avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, diet as ordered, pressure reduction mattress, and use of a draw sheet or lifting device to move the resident. Record review of Resident #1's Skin and Wound Evaluation document completed by the Wound Care Nurse (LVN) on 7/31/25 and electronically signed on 8/1/25 revealed the resident had no new wounds.Record review of Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455869 If continuation sheet Page 20 of 23 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 12/10/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #1's Skin and Wound Evaluation document completed by the Wound Care Nurse (LVN) on 8/6/25 and electronically signed on 8/6/25 revealed the resident had a Stage 2 pressure wound to the sacrum, staged by the Wound Care Nurse. Resident #1's Skin and Wound Evaluation document revealed on the Additional Care Section, None was checked, and the Notifications section: Practitioner Notified, Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) were left blank.Record review of Resident #1's Skin and Wound Evaluation document completed by the Wound Care Nurse (LVN) on 8/13/25 and electronically signed on 8/13/25 revealed the resident had a Stage 2 pressure wound to the sacrum staged by the Wound Care Nurse. Resident #1's Skin and Wound Evaluation document revealed on the Additional Care section, the resident had a moisture barrier and positioning wedge, and the Notifications: Practitioner Notified, Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) were left blank.During an interview on 10/8/25 at 9:45 a.m., LVN G stated the facility had a Wound Care Nurse (LVN), but when she was not on schedule, then the floor nurses were responsible for doing wound care. LVN G stated it was not acceptable to have missing documentation on a MAR/TAR because then there would be a question about whether wound care was done or not done. LVN G stated the electronic MAR/TAR allowed for the nurse to document if a resident refused treatment or whatever.During an interview on 10/8/25 at 1:41 p.m., the Wound Care Nurse stated, after reviewing Resident #1's August 2025 TAR revealed, missing documentation on the TAR meant the treatment was not done. The Wound Care Nurse (LVN) stated she worked Monday through Friday and sometimes on the weekends. The Wound Care Nurse stated the floor nurses were responsible for doing wound care on the residents when she was not on schedule. The Wound Care Nurse stated if the residents did not receive scheduled wound care, the residents could get worse. The Wound Care Nurse stated she could not account for the missing documentation on the TAR.During an interview on 10/8/25 at 4:29 p.m., the DON stated, if there was documentation missing from the MAR/TAR it would look like it wasn't done; you could assume that is what happened. The DON stated the MAR/TAR were reviewed at morning meetings with the IDT and the review of the 24-hour report would show any missing documentation or a lapse in documentation. The DON stated that the IDT audited those records.During an interview on 10/9/25 at 9:46 a.m., LVN D stated the facility had a Wound Care Nurse (LVN) on staff but when she was off, the floor nurses were responsible for doing wound care. LVN D stated, if there was missing documentation on the MAR/TAR then it could be assumed that the medication or treatment wasn't done. LVN D stated, if scheduled treatments were not done it could affect the resident in a negative way such as delaying the wound getting better. LVN D stated he did not recall Resident #1.During an interview on 10/9/25 at 10:26 a.m., LVN F stated she had done wound care on the residents and if a resident didn't get a treatment, it would still have to be documented in the TAR. LVN F stated, if the TAR had missing documentation, she would assume the treatment was not done. LVN F stated she admitted ly had forgotten to document when she had done a treatment, but would go back and write a late note, sometimes. LVN F stated she did not recall Resident #1.During an interview on 10/9/25 at 10:49 a.m., RN A stated she had done wound care on the residents when she worked on the weekends. RN A stated she could not recall if Resident #1 had a wound and recalled applying a cream. RN A stated missing documentation on the TAR could mean the treatment was not done or the resident went to the hospital. RN A stated, even if the resident went to the hospital, I think you would use the code ‘6' for hospital. RN A stated, if a resident was not getting scheduled wound care the wound could get worse.Record review of the facility document titled Documentation in Medical Record dated 10/24/22 revealed in part, .Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455869 If continuation sheet Page 21 of 23 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 12/10/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete and timely documentation.Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.Principals of documentation include, but are not limited to.Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.Sign each entry with name and credentials of the person making the entry.When documentation occurs after the fact, outside acceptable time limits, the entry shall be clearly indicated as ‘late entry'. Event ID: Facility ID: 455869 If continuation sheet Page 22 of 23 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 12/10/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Residents #12) reviewed for infection control. The facility failed to ensure LVN D followed proper infection control practices during medication administration on 9/26/25. This deficient practice could place residents at risk for exposure to pathogens causing infection resulting in diminished quality of life. Findings included: Record review of Resident #12's admission Record, dated 9/26/25, revealed the resident was re-admitted on [DATE] with diagnoses which included: Dry Eye Syndrome, Constipation, Hemiparesis (weakness or an inability to move one side of the body), Hemiplegia (paralysis or weakness to one side of the body) and Hyperlipidemia (elevated cholesterol). Record review of Resident #12's Order Summary, dated 9/26/25, revealed: Gabapentin Oral Tablet 100 MG (Gabapentin) Give 1 tablet by mouth two times a day. Observation of medication administration for Resident #12 on 9/26/25 beginning at 3:48 pm revealed LVN D had a capsule lying on a piece of paper on top of the medication cart. Further observation revealed LVN D picked up the capsule with her bare hand and placed it into the medication cup. LVN D said it was a Gabapentin capsule and she had placed it there because she thought Resident #12 required her medications to be crushed. During interview on 9/26/25 at 4:17 pm, LVN D said she had put the Gabapentin aside because it was a capsule and could not be crushed. LVN D further stated she did not have a reason for placing the capsule on top of the paper on the medication cart instead of in a medication cup. LVN D said this could put the resident at risk for infection, adding that medications should be handled in a clean manner, for example: not putting medications on top of the cart and performing hand hygiene. During interview on 9/26/25 at 5:35 pm, ADON B said placing a medication capsule on top of a paper on the medication cart was not acceptable due to cross contamination. ADON B further stated medications should go from the blister pack or bottle straight to a medication cup. ADON B said not following this procedure could cause infection. Record review of the facility's policy Medication Administration revised 10/24/22, read: .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.13. Remove medication from source, taking care not to touch medication with bare hand. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455869 If continuation sheet Page 23 of 23