Health inspection·November 14, 2024

F 0839 -Quarterly BIMS evaluation on [DATE] Level of Harm - Minimal harm or potential for actual harm -Quarterly PHQ9 on [DATE] -Quarterly Mini nutritional assessment screening on [DATE] Residents Affected - Some -Quarterly social services quarterly note on [DATE] Review of Resident #1's comprehensive care plan, closed [DATE], reflected charge nurses, which were RNs, were required to assess Resident #1's skin weekly for breaks in skin integrity and changes in usual appearance and follow up with physician with concerns. RNs were also required to monitor/document/report PRN any signs/symptoms of dehydration, UTI, any changes in cognitive function, changes in ADLs, and any possible causes of incontinence and malnutrition and perform risk evaluations and scheduled clinical evaluations per facility's protocol. Review of Resident #2's admission record, dated [DATE], reflected an [AGE] year old female who was readmitted to the facility on [DATE] and had diagnoses including myopathy (diseases that affect skeletal muscles), major depressive disorder, primary osteoarthritis in the left shoulder (a type of arthritis that occurs in joints over time without a known cause), unspecified dementia, unspecified depression, unspecified anxiety disorder, memory deficit following cerebral infarction (a medical condition that occurs when blood flow to the brain is disrupted, leading to brain cell death), other speech and language deficits following unspecified cerebrovascular disease, generalized muscle weakness, overactive bladder, other abnormalities of gait and mobility, cognitive communication deficit, need for assistance with personal care, history of falling and other fatigue. Review of Resident #2's assessments log, dated [DATE], reflected the ADON provided the following assessments to Resident #2: -Quarterly social service quarterly note on [DATE] -Quarterly bowel and bladder program screener on [DATE] -Elopement evaluation on [DATE] -Quarterly BIMS evaluation on [DATE] -Quarterly social service quarterly note on [DATE] -Quarterly PHQ9 on [DATE] -ADL only evaluation on [DATE] Review of Resident #2's comprehensive care plan, dated [DATE], reflected RNs were required to monitor/document for signs/symptoms of UTI, any possible causes of incontinence, changes in ADL status and abilities, change in mental status, changes in cognitive function, immobility, depression, and immobility, and perform scheduled clinical evaluations per facility's protocol. Review of Resident #3's admission record, dated [DATE], reflected a [AGE] year old female who was readmitted to the facility on [DATE] and had diagnoses including urinary tract infection, unspecified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455908 If continuation sheet Page 2 of 9 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 11/14/2024 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 0839 Level of Harm - Minimal harm or potential for actual harm protein-calorie malnutrition, dehydration, unspecified altered mental status, cognitive communication deficit, other lack of coordination, other abnormalities of gait and mobility, and generalized muscle weakness. Review of Resident #3's assessments log, dated [DATE], reflected the ADON provided the following assessments to Resident #3: Residents Affected - Some -Quarterly social services note on [DATE] -Quarterly PHQ9 on [DATE] -Quarterly BIMS evaluation on [DATE] Review of Resident #3's comprehensive care plan, dated [DATE], reflected RNs were required to perform clinical evaluations per facility's protocol and monitor/document/report PRN any changes in status, any potential for improvement, reasons for self-care deficit, expected course, and declines in function, confounding communication problems, and UTI. Review of Resident #4's admission record, dated [DATE], reflected an [AGE] year old female who was readmitted to the facility on [DATE] and had diagnoses including metabolic encephalopathy (a brain disorder that occurs when an underlying condition causes a chemical imbalance in the blood that affects the brain), unspecified anxiety disorder, dehydration, unspecified depression, unspecified altered mental status, restlessness and agitation, unspecified dementia, other recurrent depressive disorders, unspecified Alzheimer's disease, other chronic pain, unspecified low back pain, repeated falls, need for assistance with personal care, and history of falling. Review of Resident #4's assessments, dated [DATE], reflected the ADON provided the following assessments to Resident #4: -Quarterly social services note on [DATE] -Quarterly BIMS evaluation on [DATE] -Quarterly PHQ9 on [DATE] -Bowel and bladder program screener on [DATE] -ADL only evaluation on [DATE] Review of Resident #4's comprehensive care plan, dated [DATE], reflected RNs were required to monitor/document/report to MD PRN signs and symptoms of UTI, any changes, any potential for improvement, reasons for self-care deficit, expected course and declines in ADL function, any possible causes of incontinence, change in mental status, agitation, complications related to constipation, changes in cognitive function, abnormalities for urinary output, dehydration, and perform scheduled clinical evaluations per facility's protocol. Review of Resident #5's admission record, dated [DATE], reflected an [AGE] year old female who was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455908 If continuation sheet Page 3 of 9 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 11/14/2024 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 0839 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some readmitted to the facility on [DATE] and had diagnoses including unspecified ataxia (a neurological sign that indicates a loss of muscle coordination and control), cognitive communication deficit, need for assistance with personal care, unspecified depression, generalized muscle weakness, other specified disorders of muscle, other abnormalities of gait and mobility, and other lack of coordination. Review of Resident #5's assessments, dated [DATE], reflected the ADON provided the following assessments to Resident #5: -admission social services history and initial assessment on [DATE] Review of Resident #5's comprehensive care plan, dated [DATE], reflected RNs were required to evaluate Resident #5's desire to return to the community and perform clinical admission evaluation. Review of Resident #6's admission record, dated [DATE], reflected a [AGE] year old female who was admitted to the facility on [DATE] and had diagnoses including unspecified candidiasis (a fungal infection caused by an overgrowth of the Candida yeast), other abnormalities of gait and mobility, history of falling, unspecified chronic fatigue, cognitive communication deficit, generalized muscle weakness, and need for assistance with personal care. Review of Resident #6's assessments, dated [DATE], reflected the ADON provided the following assessments to Resident #6: -Quarterly social services note on [DATE] Review of Resident #6's comprehensive care plan, dated [DATE], reflected RNs were required to perform scheduled clinical evaluations per facility's protocol and monitor/document/report PRN any changes in ability to communicate, potential contributing factors for communication problems and potential for improvement, physical/ nonverbal indicators of discomfort or distress and confounding communication problems such as decline in cognitive status and mood. Review of Resident #7's admission record, dated [DATE], reflected an [AGE] year old male who was readmitted to the facility on [DATE] and had diagnoses including unspecified anxiety disorder, major depressive disorder that was recurrently severe without psychotic features, cognitive communication deficit, vascular dementia (a condition that occurs when blood flow to the brain is disrupted, causing changes in memory, thinking, and behavior), generalized muscle weakness, unspecified abnormalities of gait and mobility, and unspecified lack of coordination. Review of Resident #7's assessments, dated [DATE], reflected the ADON provided the following assessments to Resident #7: -Quarterly social services note on [DATE] and [DATE] Review of Resident #7's comprehensive care plan, dated [DATE], reflected RNs were required to perform clinical evaluations per facility's protocol and monitor/document/report PRN any changes any potential for improvement, reasons for self-care deficit, expected course and declines in function, changes in cognitive function, confounding communication problems such as decline in cognitive status and mood, ability to communicate, potential contributing factors for communication problems, potential for improvement, ability to express and comprehend language, memory, reasoning ability, and problem (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455908 If continuation sheet Page 4 of 9 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 11/14/2024 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 0839 solving ability and ability to attend. Level of Harm - Minimal harm or potential for actual harm Review of Resident #8's admission record, dated [DATE], reflected an [AGE] year old female who was readmitted to the facility on [DATE], admitted on [DATE], and had diagnoses including unspecified fracture of shaft of right arm, insomnia, need for assistance with personal care, unspecified altered mental status, history of falling, restlessness and agitation, age-related cognitive decline, generalized muscle weakness, other abnormalities of gait and mobility, cognitive communication deficit, unspecified depression, unspecified anxiety disorder, and unspecified Alzheimer's disease. Residents Affected - Some Review of Resident #8's assessments, dated [DATE], reflected the ADON provided the following assessments to Resident #8: -Quarterly social services note on [DATE] and [DATE] -Preadmission memory screening form on [DATE] Review of Resident #8's comprehensive care plan, dated [DATE], reflected RNs were required to monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course and declines in function, any changes in cognitive function, signs/symptoms of non-verbal pain, confounding problems such as decline in cognitive status, mood and decline in ADL, physical/ nonverbal indicators of discomfort or distress, ability to express and comprehend language, memory, reasoning ability and problem solving ability and ability to attend, changes in ability to communicate, potential contributing factors for communication problems and potential for improvement, change in mental status, and signs/symptoms of UTI. Review of the Texas Board of Nursing Primary Source License Verification Database, dated [DATE], reflected the ADON's license was originally issued on [DATE] and currently issued on [DATE]. Review of the ADON's personnel file, dated [DATE], reflected the ADON was hired as the ADON position on [DATE]. Review of the ADON's personnel change form information change, undated, reflected the ADON changed from the ADON to the DON effective [DATE]. During an interview on [DATE] at 10:35 AM, CNA A stated she worked at the facility from February 2024 through [DATE]. CNA A stated she observed the ADON provide direct care to residents. CNA A stated she recalled the ADON performing perineal care on a resident two months ago . CNA A couldn't recall who the resident was that the ADON performed perineal care on. During an interview on [DATE] at 12:02 PM, the WCN stated the current DON used to be the ADON. During an interview on [DATE] at 12:07 PM, the Wound Care MD stated the DON used to be the ADON and rounded with him. The Wound Care MD stated he couldn't recall when the ADON last rounded with him. During a confidential interview on [DATE] at 12:15 PM, the CE stated they were working at the facility when the DON used to be the ADON. The CE stated the ADON worked the floor and provided direct care to residents, performed resident COVID-19 tests and signed off and charted resident assessments and medication administrations during the day shift and night shift . The CE stated the ADON also (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455908 If continuation sheet Page 5 of 9 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 11/14/2024 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 0839 Level of Harm - Minimal harm or potential for actual harm signed the staff schedules stored at the nursing station as RN daily and presented herself as an RN during the time her license was delinquent from [DATE] through [DATE] . The CE stated the ADON promoted to DON on [DATE] according to a social media post in which the facility presented the ADON as having a BSN RN on [DATE]. The CE stated there were nursing staff who observed the ADON working the floor and providing direct care to residents . Residents Affected - Some During an interview on [DATE] at 12:52 PM, the MD stated he visited the facility once a week. The MD stated the ADON rounded with him. The MD stated he observed the ADON reposition residents and unwrap residents' bandages with him in the past . The MD stated he couldn't recall the last time that the ADON repositioned residents and unwrapped residents' bandages with him. During an interview on [DATE] at 3:41 PM, the ADM stated she was the DON for 4 years until [DATE] when she got her administrator license. The ADM stated LVNs and RNs were responsible for completing residents' assessments, such as elopement and fall risk evaluations. The ADM stated LVNs and RNs must have a current license in order to do those residents' assessments. The ADM stated the current DON used to be the ADON and had a delinquent license for several months . The ADM stated on [DATE], it was discovered that the ADON's license was delinquent . The ADM stated the Texas Board of Nursing reinstated the ADON's license on [DATE]. The ADM stated the ADON didn't perform any nursing duties during the delinquent period. The ADM stated the ADON didn't know her license was delinquent. The ADM stated she knew RNs' licenses renew during RNs' birthday months. The ADM stated the former ADON didn't get the notification when her license was required to renew. The ADM stated in 2024, the Texas Board of Nursing stopped mail notification. The ADM stated she knew that the ADON didn't have a nursing license on [DATE] during the facility's state readiness process. The ADM stated the HR must check annually at minimum to ensure nursing licenses were current. The ADM stated the facility had a payroll system transition period that started in 2023 and messed up the HR's automatic notifications. The ADM stated the HR's backup process during the payroll system transition period was that the HR checked nursing licenses manually. The ADM stated the HR was unaware that the ADON didn't have an active RN license. During an interview on [DATE] at 3:54 PM, the HR stated she couldn't recall when the ADON was hired as the DON, but she believed it was [DATE] or [DATE]. The HR stated she was required to check LVNs and RNs licenses upon hire. The HR stated that six months ago, she was told to start reviewing LVNs and RNs licenses every quarter. The HR stated she couldn't recall when she was told to start reviewing licenses quarterly. The HR stated she forgot to check the LVNs and RNs licenses last quarter. The HR stated she started reviewing licenses again a month ago ([DATE]). The HR stated she was trained to print out all LVNs and RNs licenses and place them in a binder. The HR stated she was under the impression that she was to check only new hire LVNs and RNs licenses. The HR stated the BOM previously worked as the HR until she was hired in [DATE]. The HR stated the BOM trained her to check new hire LVNs and RNs licenses using the EMR/CNA/CMA/Nursing license sites. The HR stated the BOM trained her to input information to ensure LVNs and RNs had their license and to ensure licenses were not expired. The HR stated she misunderstood the BOM's training and thought she was to check LVNs and RNs licenses who were in the process of being hired and when first hired. The HR stated she misunderstood the training that the BOM gave her two months ago. The HR stated she believed she misunderstood the training on [DATE] or [DATE]. During an interview on [DATE] at 4:04 PM, the BOM stated she was trained to check LVNs and RNs licenses to ensure they were current at the time of hire. The BOM stated she would print the LVNs and RNs license status results and place them in the LVNs and RNs files. The BOM stated she didn't know how often she was required to check LVNs and RNs licenses at the time of interview because she wasn't (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455908 If continuation sheet Page 6 of 9 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 11/14/2024 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 0839 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some familiar with the facility's current process. The BOM stated she trained the HR how to check LVNs and RNs licenses and to check licenses at time of hire. The BOM stated the nursing administration taught the HR more on that process than she did. The BOM stated she didn't know who from the nursing administration taught the HR more on the process. During an interview on [DATE] at 5:35 PM, LVN B stated LVNs and RNs perform assessments on residents. LVN B stated LVNs and RNs must have current licenses to perform assessments on residents. LVN B stated he was not sure if residents were at risk if LVNs and RNs performed assessments on them without current licenses. LVN B stated he was not sure if he was notified of his license requiring renewal or expiring soon. During an interview on [DATE] at 5:42 PM, RN C stated she was notified by mail and email from the Texas Board of Nursing as to when her license was due for renewal. RN C stated LVNs and RNs complete assessments on residents. RN C stated LVNs and RNs licenses must be current to perform evaluations on residents. RN C stated LVNs and RNs were not supposed to perform assessments on residents without a current license. RN C stated LVNs and RNs shouldn't even be in the building if they didn't have a current license. During an interview on [DATE] at 6:02 PM, LVN D stated a staff member had to be an LVN or RN to perform assessments on residents. LVN D stated LVNs and RNs must have a current license to perform assessments on residents. LVN D stated she was notified by mail when her license was due for renewal. During an interview on [DATE] at 6:13 PM, the ADON stated she started her DON position on [DATE]. The ADON stated she was previously the ADON and Infection Control Preventionist. The ADON stated her license lapsed. The ADON stated she couldn't recall when her license lapsed . The ADON stated no one would knowingly let their license lapse because it's more expensive to reapply for a license than to renew. The ADON stated she didn't check the status of her RN license. The ADON stated she wasn't monitoring her own license status. The ADON stated she relied on the notification by mail as to when she needed to renew her license. The ADON stated when her RN license lapsed, she found out she no longer received a mail notification. The ADON stated her RN license expired on her birthday month . The ADON stated she knew her license expired on her birthday month because this was the second time she was renewing her license. The ADON stated she didn't think to check her license status and didn't get a notification. The ADON stated her license expired in February 2024 . The ADON stated she used to be notified by mail when her license was due for a renewal. The ADON stated the HR didn't realize she was supposed to be running LVNs and RNs nursing licenses quarterly. The ADON stated she wasn't sure that licenses were supposed to be checked quarterly to verify status. The ADON stated the HR didn't have any oversight to ensure the process of checking license statuses was completed prior to her license incident. The ADON stated the HR notified her that her license was expired. The ADON stated she couldn't recall when the HR notified her that her license was expired. The ADON stated the facility wasn't responsible for notifying her to keep up to date with her license. The ADON stated she expected RNs and LVNs to keep their licenses up to date. The ADON stated the importance of staying up to date with an LVN or RN license was to ensure that education and certification was current. The ADON stated she didn't give direct care a lot to residents. The ADON stated she also couldn't recall if she performed any evaluations or nurse duties during her delinquency license period. The ADON stated she didn't know she performed assessments on residents during her license delinquency period. The ADON stated she didn't know if LVNs and RNs needed a current license to perform evaluations on residents, such as fall risk evaluation. The ADON stated anyone who was more than capable of asking a question and answering questions in a residents' electronic health record evaluation, especially for evaluations related to social service didn't need a current license to do so. The ADON stated if a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455908 If continuation sheet Page 7 of 9 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 11/14/2024 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 0839 Level of Harm - Minimal harm or potential for actual harm staff member could be trained, they could evaluate residents without a LVN and RN license. The ADON stated having anyone complete the evaluation without a current license also depended on questions in the evaluation unless the questions were nursing related. The ADON stated a person just needed to know how to answer yes or no questions in residents' evaluations that ask for a yes or no answer. Residents Affected - Some Review of the facility's job description for charge nurse, undated, reflected, Qualifications: Must have successfully completed state board of registration or licensure and carry a current state license as a registered or licensed vocational nurse. Responsibilities: 6. Make meaningful rounds of all patients utilizing Resident Assessment and Comprehensive Care Plan 7. Insures that the individual Resident Assessment and Comprehensive Care Plan is followed to meet the resident's needs according to generally accepted nursing practices in the State of Texas 8. Assist in writing and updating the Resident Assessment and Comprehensive Care Plan as resident's condition changes, with the help of the Director of Nursing, Activities Director, Dietary Manager, and designated nurse 19. Directs charting on his/her shift and makes regular detailed evaluation of all resident charting at least monthly so chart reflects progress and condition of resident at all times. Is responsible for approving and signing each chart when observations are made 20. Be aware of legal implication if physician's orders are not carried out correctly 22. Know when situation cannot be handled and be willing to ask for help and to know who to ask 23. Abide by policies of facility and ascertain that employees under his/her supervision do the same 25. Insure that all medications and treatments are charted after the fact: by the person administering the medication or completing the treatment on his/her assigned shift. 29. Detect and correct situations that have a high probability of causing accidents or injuries to residents 30. Ensures continuing promotion of the resident's physical and emotional health by assisting him regarding their medical care. Review of the facility's job description for assistant director of nursing, undated, reflected, Qualifications Needed: Must be a graduate of an accredited school of vocational or professional nursing and have a current nursing licensure in the state of Texas. Responsibilities and Duties: Provide nursing care on shift when needed Review of the facility's resident assessments policy and procedure, revised [DATE], reflected, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455908 If continuation sheet Page 8 of 9 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 11/14/2024 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 0839 Level of Harm - Minimal harm or potential for actual harm 7. All members of the care team, including licensed and unlicensed staff members, are asked to participate in the resident assessment process. 9. The results of the assessments are used to develop, review, and revise the resident's comprehensive care plan. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455908 If continuation sheet Page 9 of 9