Health inspection·October 26, 2023

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #6's Nurse Medication Administration Record dated October 2023 reflected an entry Catheter: ensure catheter is draining properly to bedside, privacy bag in place and leg strap in place. Entry was signed every shift as Yes. Observation on 10/26/23 at 9:54 AM revealed Resident #6 lying in bed while CNA B, CNA C, and CNA D performed catheter care. Resident #6 was observed with an indwelling urinary catheter draining to a bag on the side of the bed. There was no leg strap or other stabilizing device in place. When CNA C and CNA D turned Resident #6 to her left side, it caused tension on the catheter tubing. They stopped turning the resident and adjusted the position of the drain bag then continued with the procedure. Review of Resident #30's Face Sheet dated 10/26/203 reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Cystitis (Infection or inflammation of the urinary bladder or any part of the urinary system caused by a type of bacteria called Escherichia coli (E. coli). This results in urge to urinate, blood in urine and burning while urinating.), Obstructive and reflux uropathy (Is a term that refers to conditions that affects the urinary tract due to blockage or backward flow of urine) and Alzheimer's Disease (A type of brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition.). Review of Resident #30's Annual MDS dated [DATE] reflected Resident #30 was assessed to have a BIMS assessment not conducted indicating Resident #30 had severe cognitive impairment. Resident #30 was assessed to require extensive to dependent assist for ADLs. Resident #30 was further assessed to have an indwelling catheter. Review of Resident #30's Comprehensive Care Plan reflected a problem with the start date of 08/30/2022 and revised on 09/13/2023 The resident has indwelling catheter related to diagnoses of neuromuscular dysfunction of bladder with increased risk of urinary tract infections . Interventions included .ensure catheter is draining properly to bedside with privacy bag and leg strap in place. Review of Resident #30's Consolidated Physician's Orders reflected an order dated 09/12/2022 CATHETER: Ensure Catheter is draining property to Prescriber bedside privacy bag and leg strap is in place. Review of Resident #30's TAR and MARs dated October 2023 reflected no entry for checking Resident #30's leg strap for his catheter. Observation on 10/25/23 at 2:49 PM revealed Resident #30 lying in bed while CNA A and CNA B performed catheter care and incontinent care. Resident #30 was observed with an indwelling urinary catheter but no leg strap or other stabilizing device in place. During an interview on 10/26/23 at 9:56 AM with CNA B, she stated they used catheter stabilization devices on some people adding, It all depends. She stated sometimes the devices got wet so she would let the nurse know. During an interview on 10/26/23 at 10:41 with LVN E, she stated they had two types of stabilization devices; one has adhesive on the back and the other was a leg strap. LVN E reached into the nurses' cart and retrieved a stabilization device with the adhesive on the back and stated she preferred that type as is stayed in place better. She stated the CNAs let her know if a device needs to be replaced. She stated if a resident with a catheter did not have a stabilization device in place, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455908 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455908 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 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 0690 catheter could get pulled out which could be painful. Level of Harm - Minimal harm or potential for actual harm In an interview on 10/26/23 at 10:49 AM with RN F, she stated they do use stabilizing devices for residents with indwelling catheters. She stated there was a device that sticks on the leg, kind of like a bandage that has a clamp where you would put the tubing. RN F stated, Lots of times we just use the clamp that comes on the catheter bag. She described the clamp on the drain bag tubing that is usually attached to the sheet or bed. She stated without a stabilization device, residents were at risk of having the catheter pulled on, pulled out, and pain. Residents Affected - Few In an interview on 10/26/23 with the DON, she stated they used a couple different stabilizing devices including the ones that stick to the leg. She stated it is her expectation that all resident with a catheter will have a stabilizing device. She stated without the device, the catheter could get caught on something or pulled out. She stated it did not meet her expectations that two residents with catheters had been observed without a stabilization device. A policy for indwelling catheters was requested. Review of the facility's policy Catheter care, Urinary dated August 2022 reflected The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections .Steps in the Procedure . 16. Secure catheter with catheter securement device FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455908 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455908 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 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 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review, the facility failed to follow guidelines for mandatory electronic submission of staffing information based on payroll data in a uniform format. The facility failed to submit direct care staffing information on the schedule specified by CMS (Centers for Medicare and Medicaid Services), but no less frequently than quarterly for 1 of 3 quarters reviewed for payroll data information (Quarter 3 2023). The facility failed to submit PBJ staffing information to CMS for the 3rd quarter (April 1 - June 30) of fiscal year 2023. This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings included: Review of the facility's undated Civil Rights Survey Report (Form 3761) indicated the following: 7 RNs 24 LVNs 42 Direct Care Staff 14 Dietary 22 Housekeeping & Laundry 12 All Others Record review of the CMS PBJ Staffing Data Report (payroll-based staffing), CASPER Report (Certification and Survey Provider Enhanced Report) 1705 D FY Quarter 3 2023 (April 1 - June 30), dated 10/18/2023, indicated the following entry: Metric Failed to Submit Data for the Quarter, Result Triggered Definition Triggered = No Data Submitted for Quarter. In an interview on 10/26/2023 at 9:54 AM, the DON was asked who in the facility was responsible for quarterly PBJ reporting. The DON stated that the BOM was responsible for reporting to CMS. The DON stated that she knew they also had a payroll consultant that assisted with preparation. The DON stated that she knew that the PBJ information is provided to CMS to ensure adequate staffing and is very specific to RN coverage requirements. In an interview on 10/26/2023 at 10:00 AM, the BOM stated that PBJ reporting was the responsibility of her office during the 3rd quarter of fiscal year 2023. The BOM stated that she had an ABOM that was responsible for the quarterly submission of the report but stated that assurance of submission was her responsibility. The BOM stated that the PBJ report was to be submitted to CMS quarterly and was due within 45 days of the final day in the quarter. The BOM stated that the PBJ report contains staffing hours for nurses, agency, dietary consult, and pharmacy. The BOM stated that the PBJ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455908 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455908 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 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 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many reporting was important because it goes towards their star rating and CMS uses the report to ensure staffing ratios. The BOM was questioned about how failure to submit the PBJ report could affect residents and she stated she could only think of the star rating. The BOM stated that they utilized a consultant who puts together the information and provides it back to the facility, which then is provided electronically to CMS. The BOM was notified that they failed to electronically file their 3rd quarter PBJ. The BOM stated that she knew the ABOM had been working on it. The BOM was asked if the ABOM still worked for the facility, and she stated she did not. The BOM stated that the ABOM was a part time employee who they terminated for not coming into work and mistakes with payroll. The BOM was requested to provide employment dates for the ABOM, which were later provided as December 6, 2022, through July 11, 2023. The BOM was asked if she would be able to provide email correspondence from the consultant for the 3rd quarter or the PBJ report that may have been prepared by the ABOM but not submitted. The BOM stated that she did not have an email from the consultant and that it likely would have been sent to the ABOM. The BOM stated that she would check to see if she could locate information the ABOM completed but stated that she would likely be unable to do so. In an interview on 10/26/2023 at 10:44 AM, the Administrator stated the PBJ reporting was important because it helps to determine and ensure that necessary staffing ratios were met by the facility. The Administrator stated that he knew it was a requirement of CMS to report their PBJ information quarterly and knew that their failure to do so lowered their star rating. The Administrator stated that while it was not his direct responsibility, he failed to ensure that the PBJ was reported for the 3rd quarter. In an interview on 10/26/2023 at 12:20 AM, the BOM stated that she was not able to retrieve any email information from the ABOM's account due to it being inaccessible. The BOM further stated that she was not able to recover or locate a prepared 3rd quarter PBJ report. Review of facility Reporting Direct Care Staffing Information (Payroll-Based Journal) policy with a revised date of August 2022 indicated: Policy Statement: Direct care staffing information is reported electronically to CMS through the Payroll-Based Journal system. Policy Interpretation and Implementation: 1. Complete and accurate direct care staffing information is reported electronically to CMS through the Payroll-Based Journal (PBJ) system in a uniform format specified by CMS. 8. Technical specifications for uploading data directly from a payroll or time and attendance system will be accessed through: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-S 9. Direct care staffing information is submitted on the schedule specified by CMS, but no less frequently than quarterly. 10. Staffing information is collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. Dates are as follows: Fiscal Quarter Date Range (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455908 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455908 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 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 0851 Submission Deadline Level of Harm - Minimal harm or potential for actual harm 1 October 1 - December 31 Residents Affected - Many February 14 2 January 1 - March 31 May 15 3 April 1 - June 30 August 14 4 July 1 - September 30 November 14 References: OBRA Regulatory Reference Numbers - 483.70(q) Mandatory submission of staffing information based on payroll data in a uniform format. Survey Tag Number - F851 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455908 If continuation sheet Page 6 of 6