Health inspection·August 24, 2022

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 observation, interviews and record review the facility failed to develop and implement comprehensive care plan to meet the medical and nursing needs for 2 of 10 residents reviewed for care plans (Resident # 66 and Resident #75). - The facility failed to ensure Resident #75's Comprehensive Care Plan was developed in a personalized manner to address refusal of diet recommendation. - The facility failed to ensure Resident # 66's Comprehensive Care Plan was developed to address physical needs for devices to prevent wounds or other skin concerns. -The facility failed to ensure Resident #66 was provided bunny boot to left foot at all times as tolerated as ordered by his physician. This failure could place residents at risk for not having their individualized needs met in a timely manner and communicated with providers and could result in an injury, pressure ulcer and a decline in physical well-being and in quality of life. Findings included: Review of Resident #75's face sheet dated 08/24/2022 revealed Resident #75 was an [AGE] year-old female admitted to the facility 08/17/2017 with a diagnoses of pneumonia, dysphagia (trouble swallowing), urinary tract infection and vascular dementia (loss of cognitive functioning that interferes with a person's daily life and activities). Review of Resident #75's MDS Significant Change assessment dated [DATE] revealed Resident #75 was admitted to hospice care which resulted in the significant change assessment . Resident #75 had a BIMS score of zero to indicate severely impaired cognition. Resident #75 received a mechanically altered diet and did not receive a therapeutic diet. Review of Resident #75's Care Plan dated 08/01/2022 revealed Resident #75's care plan was not updated to include an Informed Refusal of Diet Recommendation for Resident #75 to have a mechanical soft diet order instead of the recommended pureed diet order. Review of Resident #75's Physician orders dated 08/09/2022 revealed Resident #75 was ordered a regular diet, pureed texture with nectar thick liquids. Review of Resident #75's Nursing Progress Note dated 08/03/2022 revealed Change of condition care plan meeting held with social services, activities, dietary manager, MDS nurse, DON and administrator in attendance; resident and Family Member A on conference phone call; no participation by resident or hospice this date; resident w/ recent admission to hospice; requires extensive to total assistance with all aspects of ADL's; resident admitted hospice related to diagnosis of cerebrovascular disease, vascular dementia, dysphagia, aspiration pneumonia; comfort medications in place; resident with recent diet change as per family wishes as resident disliked pureed diet; FamilyMember A signed waiver understanding potential risks to change of diet to mechanical soft; Family member A and Family (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455908 If continuation sheet Page 2 of 11 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 455908 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Schulenburg Regency Nursing Center 111 College St Schulenburg, TX 78956 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 member B both stated they hoped resident would eat better but understand possible risk of aspiration w/diet change; resident current weight is 133.4 pounds and stable at present. In an interview on 08/23/2022 at 2:00 PM, the DON stated Resident #75 had aspiration pneumonia at the end of June 2022 and was hospitalized . She said when Resident #75 returned to the facility the physician ordered a pureed diet to decrease the risk of further aspiration pneumonia or other complications from dysphagia. She said Resident #75 did not like the pureed foods and Resident #75's RP brought it to their attention. She said Resident #75's RP said that for Resident #75's quality of life they wanted Resident #75 to have a regular diet or mechanical soft diet. She said she spoke with them regarding a waiver to allow the upgraded diet and that they were aware of the risks for Resident #75. She said Resident #75's RP agreed to signing the Informed Refusal of Diet Recommendation and they held a care plan meeting to discuss the diet changes and Resident #75 going on hospice care. She said after the waiver was signed on 08/09/2022 and the diet order was changed, Resident #75's care plan was not updated. She said Resident #75's care plan was updated with the hospice care information, but not the diet order information. In an interview on 08/23/2022 at 11:20 AM, MDS LVN G stated Resident #75's care plan should have been updated with the new diet order of mechanical soft and that the Informed Refusal of Diet Recommendations Waiver was in place with the risks noted on her care plan. She said it could result in Resident #75 not receiving appropriate and safe care if her care plan was inaccurate. Review of Resident # 66's face sheet dated 08/24/2022 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] and 07/19/2022 with a diagnoses type 2 diabetes mellitus with diabetic neuropathy, unspecified (high blood sugar can injure nerves throughout the body. Most often damages nerves in the legs and feet), type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene (a blood vessel disease caused by high blood sugar levels), cutaneous abscess of left lower limb ( a localized collection of pus in the skin and may occur on any skin surface), cellulitis of right and left lower limb ( potentially serious bacterial skin infection. The affected skin is swollen and inflamed and is typically painful and warm to the touch), local infection of the skin and subcutaneous tissue , unspecified ( bacterial or fungal that enters any break in the skin and can invade the subcutaneous tissue) and localized edema ( your small blood vessels leak fluid into nearby tissues). Review of Resident #66's MDS admission assessment dated [DATE] reflected resident had a BIMS score of 11 which indicated resident cognition was mildly impaired. Resident #66 was assessed to require extensive assistance with one-person physical assist with bed mobility, transfers, dressing and personal hygiene. He required extensive assistance with two persons assist with toileting. Resident #66 was also assessed to have limited range of motion in lower extremity on both sides. Resident was at risk for developing pressure ulcers/injuries. Resident required a pressure reducing device for chair. Review of Resident #66's MDS Significant Change assessment dated [DATE] reflected resident had a BIMS score of 13 indicated his cognition was intact. Resident #66 required assistance with ADL's. Resident was also assessed at risk of developing ulcers/injuries and had an unhealed pressure ulcer/injury which was unstageable. He was assessed to require a pressure ulcer reducing device for bed. Review of Resident #66's Comprehensive Care Plan dated 8/11/2022 reflected Resident #66's bunny boot to left foot at all times as tolerated every day and night shift and offloading cushion to float bilateral heels while in bed every day and night shift related to pressure-induced deep tissue damage (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455908 If continuation sheet Page 3 of 11 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 455908 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Schulenburg Regency Nursing Center 111 College St Schulenburg, TX 78956 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 of left heel was not care planned. Level of Harm - Minimal harm or potential for actual harm Review of Resident #66's Physician Orders dated 07/19/2022 reflected bunny boot to left foot at all times as tolerated every day and night shift related to pressure-induced deep tissue damage to left heel. Offloading cushion to float bilateral heels while in bed every day and night shift related to pressure induced deep tissue damage to left heel. Residents Affected - Few Review of Resident #66's Wound- Weekly Observation Tool dated 07/08/2022, 7/15/2022 and 7/22/2022 reflected special equipment offloading cushion and bunny boot to left heel at all times as tolerated. The physician was notified of skin status by Treatment Nurse-LVN on each wound-weekly observation tool. The wound to resident's left heel was acquired on 07/05/2022 and resolved on 07/22/2022. Review of Resident #66's Nurses Notes from 07/23/2022 thru 08/24/2022 reflected a fluid filled blister to his left heel. Resident #66 frequently had edema to his left lower leg. Nurse's notes did not reflect documentation about an offloading cushion or a bunny boot to left heel. Observation and interview on 08/22/2022 at 3:46 PM revealed Resident #66 was in his room sitting in his recliner with his feet propped on the footrest of the recliner. Resident #66 stated he had pain in his knees and legs. He stated he was wearing house socks due to his feet were swollen and he was unable to wear his shoes. He stated he did have a sore on his left heel, but it was no longer there. He stated he currently had a blister on his left heel and pulled his sock down to show surveyor the fluid filled blister . He stated he was supposed to be wearing some type of boot, but he didn't know if the doctor had taken it away from him. He also stated the boot helped when he was sitting in his recliner. Observation on 08/22/2022 at 4:15 PM, Resident #66 was sitting in his recliner asleep. He was not wearing his bunny boot to his left foot and his left foot had edema. Observation on 08/23/2022 at 8:17 AM, Resident #66 was sitting in his room eating breakfast. His left foot had edema. He was not wearing bunny boot to his left foot. Observation and Interview on 08/23/2022 at 12:33 PM revealed Resident #66 was sitting in his room in the recliner. He did not have his shoes on or his bunny boot to left foot. He had nonskid house socks. Resident stated his legs and feet was hurting and he needed to prop his feet up to help with the swelling. He stated his shoes fit perfect except when his feet swell. He stated he must be careful about his heel because he had a blister. (he pointed to the left heel and showed the blister). Resident stated he didn't want to get any wounds to his legs, feet or anywhere if he could prevent it. Observation and Interview on 08/24/2022 at 11:45 AM revealed Resident #66 was sitting in wheelchair in his room. Resident had his shoes on, and he stated he had been to therapy. He also stated his legs and feet was hurting him and he was waiting on staff to assist him to his recliner. He stated he was going to take his shoes off and put on some socks. He stated no one had placed a bunny boot on his left foot in a very long time. He stated he wore it a few times when he had a wound on his left heel but did not wear it all the time. He also stated he was taking medication for his swollen feet. He stated he did not know the exact days staff looked at his heel. In an interview on 08/25/2022 at 9:30 AM, LVN A stated the offloading cushion and the bunny boot to Resident #66's left foot was required to be care planned. She stated the staff would not know if a resident needed a device if it wasn't on the care plan. She stated the interventions on the care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455908 If continuation sheet Page 4 of 11 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 455908 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Schulenburg Regency Nursing Center 111 College St Schulenburg, TX 78956 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 plan was transferred to electronic medical records for the staff to know what type of personalized care each resident needed. She stated any type of device most definitely needed to be care planned. She stated the cushion and the bunny boot was to prevent skin breakdown or any other skin issues. She also stated it was the Treatment Nurse, DON and MDS nurses' responsibility to monitor the care plans. In an interview on 08/25/2022 at 10:00 AM, MDS LVN B stated if there was a physician order for a bunny boot to left heel and an offloading cushion for a resident to use daily, these devices were required to be care planned. She stated any type of interventions related to skin concerns/ wounds were the Treatment Nurses responsibility to document those concerns on the care plan. She also stated care plans were developed for the staff to know what type of care and interventions each resident needed. She stated the CNA's had access to electronic medical record and these devices would be in the ADL section for the CNA's to know what type of intervention each resident would need to help with their physical condition. She also stated it was the Treatment Nurse responsibility to monitor any care plans related to skin concerns. She also stated the nurses was documenting in the nurses notes of new fluid filled blister on his left heel. In an interview on 08/25/2022 at 11:45 AM, CNA C stated Resident # 66 had not been wearing a heel boot to his left heel. She stated she didn't know he needed to be wearing a heel boot. She stated she was not aware of a cushion he needed in bed. She stated Resident #66 wasn't in bed during the day. She also stated if a resident needed any type of devices such as: alarms for bed/wheelchair, cushions, or heel boots, it would be in the electronic medical record under ADL. She stated no staff informed her verbally or in writing that Resident #66 required a heel boot. She stated the charge nurse would inform the staff if there were any changes with residents' care. She stated if any resident refused a device, she would report it to the nurse working on that hall. She stated she did not see any type of devices located under the ADL tab for Resident #66. She also stated if Resident #66's feet became swollen, he preferred to sit in his recliner with his feet propped up. She stated he preferred to wear non-skid socks when his feet were swollen. In an interview on 08/24/2022 at 12:00 PM, CNA D stated she was assigned to care for Resident #66 sometimes. She stated if anyone had heel protectors, alarms, cushions, or any type of device it would be located under the ADL tab in the electronic medical record. She stated she had not noticed Resident #66 wearing a heel boot. She also stated Resident #66 feet did swell sometimes. She stated she didn't give care to Resident #66 very often and didn't know his routine. She further stated if a resident refused to wear a device staff would inform the nurse on the 400 hall. She stated any devices or any type of care a Resident needed would be under the ADL tab in the electronic medical record. She stated she didn't know he was to have a bunny boot. In an interview on 08/24/2022 at 12:45 PM, LVN E stated if any resident required any type of special device it would be in the electronic medical record for the CNA's to know what type of device / care to give each Resident. She stated she would need to review the electronic medical record to determine if Resident #66 needed bunny boot or cushion. She also stated Resident #66 did have a wound on his left heel approximately 3 weeks, but it was healed. She stated a bunny heel protector could possibly prevent further skin breakdown. She stated Resident #66 did have a blister on his left heel at this time and the bunny heel protector could benefit him from having another wound. She also stated he was high risk for skin breakdown on his legs and feet. She stated the CNA's never reported to her of Resident #66 refusing to wear the bunny heel protector. She also stated the Treatment Nurse F did not verbally inform her or give her any information in writing concerning Resident #66 needing a heel protector or offloading cushion (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455908 If continuation sheet Page 5 of 11 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 455908 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Schulenburg Regency Nursing Center 111 College St Schulenburg, TX 78956 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 In an interview and record review on 08/24/2022 at 1:05 PM, the DON stated the bunny boot and uploading cushion for Resident #66 was a preventive measure to prevent any wounds or skin breakdowns. She reviewed the physician order and care plan during the interview and stated the cushion and heel protector was expected to be care planned. She also stated the care plan was implemented for the staff to know what type of care to give each resident. She stated if it wasn't on the care plan the information would not be on the electronic medical record for the staff to know what type of devices,/ care Resident #66 needed. She also stated if Resident #66 was not wearing left heel bunny boot or using the cushion there was a potential the wound could reopen or develop other skin concerns. She stated it was Treatment Nurse F's responsibility to care plan interventions for wounds, skin concerns or any devices needed to prevent skin breakdown She also stated it was the Tx Nurse F responsibility to monitor these type of care plans. In an interview on 08/25/2022 at 1:15 PM, Treatment Nurse F stated Resident #66's offloading cushion and bunny boot documented on the physician order most definitely needed to be care planned. She stated the care plan was where the staff received information of what type of care/ interventions the residents needed to prevent skin breakdown or to help hear any type of skin concerns. She also stated Resident #66 needed to be wearing the bunny boot as tolerated. She stated his feet had edema sometimes and this was when resident preferred to sit in his recliner with his feet elevated. She stated Resident #66 did have a blister to his left heel. She also stated a bunny boot would be more beneficial to Resident #66 than him wearing his shoes especially when his feet had edema. She stated if Resident #66 did refuse the bunny boot the staff would report it to her, or the nurse would document it in the nurse's notes. She also stated any type of interventions on the care plan would be transferred over to the ADL in the electronic medical record for the staff to know what type of devices Resident #66 required. She stated if these were not on the care plan it wouldn't be in the ADL electronic medical record for the staff to know to use these devices. She stated she would print a copy of the ADL's in the electronic medical record and bring it to the conference room to review with surveyor. Records of CNA's ADL and the MARS was requested from the treatment nurse on 08/24/2022 and these records were not provided at time of the exit. Review of Facility's Policy on Care Plans, Comprehensive Person -Centered revised March 2022 reflected A. The interdisciplinary team in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 1. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes. b. Describes the services that are to be furnished attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. c. Reflects currently recognized standards of practice for problem areas and conditions. 2. Care plan interventions are chosen only after data gathering, proper sequencing of events, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455908 If continuation sheet Page 6 of 11 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 455908 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Schulenburg Regency Nursing Center 111 College St Schulenburg, TX 78956 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 Careful consideration of the relationship between the resident's problem areas and their Level of Harm - Minimal harm or potential for actual harm causes, and relevant clinical decision making. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455908 If continuation sheet Page 7 of 11 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 455908 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Schulenburg Regency Nursing Center 111 College St Schulenburg, TX 78956 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 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for 1 of 3 residents (Resident #19) reviewed for discharge planning. Residents Affected - Few The facility failed to provide discharge planning for Resident #19 that focused on the resident's discharge goals and notify Resident #19 of the discharge goal. This failure could place residents at risk of not receiving care and services to meet their needs upon discharge. Findings included: Review of Resident #19's dated 08/24/2022 revealed Resident #19 was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included a history of a stroke causing partial paralysis, Type II Diabetes, major depressive disorder, anxiety disorder and high blood pressure. Review of Resident #19's quarterly MDS assessment dated [DATE] revealed Resident #19 had a BIMS score of eight to indicate moderately impaired cognition. For questions regarding Resident #19's discharge plan the question of overall goal established during assessment process was not answered. For the question, is active discharge planning already occurring for the resident to return to the community? the answer was no. Review of Resident #19's admission MDS assessment dated [DATE] revealed Resident #19's overall goal established during assessment process was unknown or uncertain for discharge plans. For the question, is active discharge planning already occurring for the resident to return to the community? the answer was no. For the question, does the resident want to be asked about return to the community on all assessments the answer was yes. Review of Resident #19's Care Plan dated 06/17/2022 revealed Resident #19 did not have a discharge plan in his care plan with goals and interventions defined. In an interview on 08/22/2022 at 11:00 AM, Resident #19 stated he wanted to go home, and his doctor said he could go home, but he did not know if he was going to be allowed to go home. He stated his family member and family lived with him prior to his admission to the facility and it was his family member's decision as his POA if he was able to go home . He asked the facility in the past when he would get to go home, and they did not have an answer for him. He said nothing was wrong with the facility, he just wanted to go home. In an interview on 08/23/2022 at 2:41 PM, the SW stated she had spoken with Resident #19's RP and the discharge plan for Resident #19 was for him to remain in the facility . She said Resident #19's family member had not had the conversation with Resident #19 about remaining in the facility permanently at this time. She said they did not want to upset Resident #19. She stated the plan had been back and forth for a while about whether Resident #19 would be able to return home. She said Resident #19's RP did not feel he could provide the needed care and supervision Resident #19 required due to multiple falls. She said Resident #19 did ask frequently about going home, but in the past month had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455908 If continuation sheet Page 8 of 11 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 455908 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Schulenburg Regency Nursing Center 111 College St Schulenburg, TX 78956 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 0660 Level of Harm - Minimal harm or potential for actual harm not asked as much. She said the plan when he was admitted was for him to go home, but the plan changed. She said she thought the discharge plan was in his care plan and she also specified it in her last quarterly note. She said she was responsible for discharge planning at the facility and for establishing discharge goals with residents and responsible parties. She said the MDS Nurses would add the plans to the care plan based on what was decided. Residents Affected - Few In an interview on 08/24/2022 at 10:45 AM, CNA H said Resident #19 would ask about his discharge plans frequently and they would direct him to the social worker or the DON. She said in the last few weeks he had not asked as much. She said Resident #19's RP told them they could not care for him at home. She said Resident #19's RP did not want to have to tell Resident #19 that he was not coming home. In an interview on 08/24/2022 at 11:20 AM, MDS LVN G stated Resident #19's care plan should be updated with his established discharge plan, but because the plan had not been confirmed for so long it was not added to the care plan. She said when Resident #19 was first admitted Resident #19's plan was to return home. She said Resident #19's RP made the decision that Resident #19 required more care than he could provide, and Resident #19 was safest at the facility. She stated she was not sure if anyone had the conversation with Resident #19 about the permanent plan. In an interview on 08/24/2022 at 11:30 AM, MDS LVN B stated the social worker was in charge of discharge planning and the MDS nurses would update the care plan. She said the original plan for Resident #19 was to return home, but Resident #19's RP did not feel he could take care of Resident #19 and the permanent plan became for Resident #19 to remain in the facility. She said Resident #19 required increased supervision due to multiple falls. She said Resident #19's care plan should have been updated with the permanent plan and Resident #19 should have been notified of the permanent plan. In an interview on 08/24/2022 at 11:55 AM, the DON stated the long-term plan for Resident #19 was for him to remain at the facility as decided by Resident #19's RP. She stated Resident #19's care plan should have been updated with the care plan and Resident #19 should have had a care plan meeting to discuss the decision. She stated the social worker was in charge of the discharge planning process. Review of Resident #19's Social Services Quarterly Note dated 06/14/2022 revealed Resident #19 was noted to have no plans on discharge. Review of Resident #19 admission Social Services Quarterly Note dated 03/14/2022 revealed Resident #19's discharge plan was uncertain. Review of Discharge Summary and Plan Policy dated December 2016 revealed Residents will be asked about their interest in returning to the community. If the resident indicates an interest in returning to the community, he or she will be referred to local agencies and support services. If it is determined that returning to the community is not feasible, it will be documented why this is the case and who made the determination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455908 If continuation sheet Page 9 of 11 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 455908 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Schulenburg Regency Nursing Center 111 College St Schulenburg, TX 78956 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents medical record included documentation that indicates the resident either received the influenza and pneumococcal immunizations or did not receive the immunizations due to medical contraindications or refusal for 1 of 5 residents (Resident #76) reviewed for immunizations. Residents Affected - Few Resident #76's medical record contained no evidence of the influenza or pneumococcal immunizations being administered. This failure could place residents at risk for contracting a viral disease that could spread through the facility and cause respiratory complications, and potential adverse health outcomes. Findings included: Review of Resident #76's admission Record printed 08/24/2022 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, cerebral infarction (stroke), communication deficit, anemia (lack of healthy red blood cells), major depressive disorder, and anxiety. Review of Resident #76's admission MDS assessment dated [DATE] reflected the influenza vaccine was not given in the facility. The MDS also reflected the pneumococcal vaccination was not up to date. The reason the pneumococcal vaccine was not received was marked as not offered. The MDS reflected a BIMS assessment was not completed because the resident is rarely or never understood. The MDS reflected the resident had impaired long- and short-term memory impairment. Review of Resident #76's Pneumococcal Vaccination and Influenza Vaccination Consent forms revealed both forms had been signed by the responsible party on 01/19/2022 and gave the facility permission to administer both vaccines. Review of Resident #76's immunization record in the electronic medical record revealed no evidence of influenza or pneumococcal vaccine administration. During an interview on 08/24/2022 at 9:06 AM with the IP, she stated she could not find any documentation or other paperwork regarding Resident #76's immunizations. The IP stated, I think we missed it. During an interview on 08/24/2022 at 10:27 AM with the IP and DON, the DON stated the immunizations may not have been given at the time because the resident was having some behaviors and the responsible party wanted the behaviors to resolve first. The DON stated the facility had not documented any reason for not giving the immunizations. During and attempted interview on 08/24/2022 at 11:35 AM with Resident #76, she mumbled something unintelligible when asked if she had ever had a pneumococcal vaccine. When asked if she had taken flu shots every year she responded, probably then did not engage in any other interactions. During an interview on 08/24/22 at 11:55 AM with Resident #76's Responsible Party, she stated she remembered giving consent for both the influenza and pneumococcal vaccines. She stated she was a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455908 If continuation sheet Page 10 of 11 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 455908 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Schulenburg Regency Nursing Center 111 College St Schulenburg, TX 78956 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few registered nurse, and she was familiar with the immunizations. She could not recall if the resident had received the immunizations. She stated there was no reason she could recall that she would not have wanted the vaccines given. During an interview on 08/24/2022 at 12:56 PM with Resident #76's Responsible Party, she stated she thought about it some more and had to call back. She stated the resident had recently been in acute care and inpatient rehabilitation and she must have had the immunizations at one of those facilities and that would be why this facility did not give the immunizations. She denied having any paperwork regarding immunization status from the previous facilities. During an interview on 08/24/2022 at 1:20 PM with the DON, she stated the IP was responsible for monitoring and tracking immunizations. She stated the immunizations were not given to Resident #76 because she had the immunizations before. When asked why earlier she said the immunizations were not given because of behaviors, she stated the behavior should not stop a resident form getting immunizations. She stated she had not looked at prior facility documents nor called the previous facility for immunization records for Resident #76. She stated she thought the Responsible Party had reached out to the previous facility for the immunization records. She stated it did not meet her expectations that facility had not documented whether the immunizations had been administered. She stated and adverse outcome of not documenting resident immunization status could be an outbreak of infections. During an interview on 08/24/2022 at 1:34 PM with the ADMIN, he stated it does not meet his expectations the immunization status of a resident is not documented. He stated not administering immunizations could lead to people getting sick and spreading infection. Review of the Pneumococcal Vaccine policy revised March 2022, reflected in part, 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) day of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Assessments of pneumococcal vaccination status are conducted within five (5) working days of the resident's admission in not conducted prior to admission. Review of the Influenza Vaccine policy revised March 2022, reflected in part, 1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to resident and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized. 5. For those who receive the vaccine, the date of the vaccination, lot number, expiration date, person administering, and the site of the vaccination will be documented in the resident's/employee's medical record. 6. A resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455908 If continuation sheet Page 11 of 11