Health inspection·August 1, 2025

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change for one (Resident #1) of four residents reviewed for notification of changes. The facility failed to notify the NP when Resident #1's diabetic pump malfunctioned in July of 2025. Resident #1's blood sugar readings were sporadically out of range which led her to experience increased dizziness, nausea, and sweatiness. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/25 PM and a template was provided. While the IJ was removed on 08/01/25 at 2:13 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of DKA, dizziness, nausea, and a decreased quality of life. Findings included:Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including type I diabetes, gastroparesis (a condition in which the muscles in the stomach do not move well), chronic kidney disease, and muscle weakness. Review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 15, indicating she was cognitively intact. Section N (Medications) reflected she received insulin injections since admission. Review of Resident #1's admission care plan, dated 06/30/25, reflected there was not a focus regarding her being a diabetic or having an insulin pump. Review of Resident #1's physician order, dated 07/03/25, reflected the following: Dexcom G7 Receiver Device (Continuous Glucose System Receiver) - Apply to bar of upper arm topically one time a day every 10 day(s) for DM management. Review of Resident #1's TAR, July of 2025, reflected the receiver was changed on 07/03/25 and 07/13/25. Review of Resident #1's physician order, dated 07/01/25, reflected the following: Omnipod 5 Libre2 Plus G6 Kit (Insulin Infusion Disposable Pump) - Inject 200 ml subcutaneously one time a day every 3 day(s) for DM management. Review of Resident #1's MAR, July of 2025, reflected insulin was placed in the pump on 07/01/25, 07/04/25, 07/10/25, and 07/14/25. It reflected she refused on 07/07/25. Review of Resident #1's physician order, dated 07/01/25, reflected Glucagon Emergency Kit 1 MG - Inject 1 mg intramuscularly as need for hypoglycemia per protocol if patient is unconscious or unable to swallow. Review of Resident #1's MAR, July of 2025, reflected she was administered the Glucagon three times: 07/08/25 at 4:36 AM - BS: 7407/09/25 at 4:48 PM - BS: 5307/11/25 at 3:49 AM - BS: 65 Review of Resident #1's blood sugar readings in her EMR, from 07/01/25 - 07/15/25, reflected the following days/times her blood sugar was abnormally out of normal the range (normal range is 70 mg/dL -100 mg/dL): 07/01/25 10:43 PM - 42.0 mg/dL07/05/25 6:21 PM - 300.0 mg/dL07/06/25 6:33 AM - 326.0 mg/dL07/09/25 4:49 PM - 52.9 mg/dL07/13/25 8:55 PM - 350.0 mg/dL07/14/25 7:09 AM - 400.0 mg/dL07/14/25 12:09 PM - 399.0 mg/dL Review of Resident #1's physician order, dated 07/15/25, reflected to d/c insulin pump. Review of Resident #1's physician order, dated 07/15/25, reflected HumaLOG KwikPen Subcutaneous Solution Pen-inject 100 UNIT/ML - Inject subcutaneously Page 1 of 11 455917 455917 08/01/2025 Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some before meals for DM. Review of Resident #1's physician order, dated 07/15/25, reflected Lantus Subcutaneous Solution 100 UNIT/ML - Inject 10 unit subcutaneously in the morning for DM - hold if BG is less than 110. During a telephone interview on 07/15/25 at 12:23 PM, Resident #1's NP stated she had been working with the facility for about a week but was familiar with Resident #1. She stated she had a conversation with her that morning (on 07/15/25) and there were concerns that the pump was not functioning the way it should be, so she put in orders to discontinue the pump. She stated she should not have it on her if it was not working. She stated she ordered a sliding scale to better manage her blood sugars. She stated the staff had been informing her of general concerns regarding Resident #1 such as refusing showers and not eating much of her meals, but they had not mentioned irregular blood sugar readings. She stated if she had been, she would have discontinued the pump sooner. She stated if the pump was not working, a negative outcome could be potentially all the negative things with diabetes. She stated there was not a way to check those pumps in these environments. During a telephone interview on 07/15/25 at 12:38 PM, RN A stated she was very familiar with Resident #1. She stated since she had a pump, she would tell the nurses what her blood sugar was, and they would document it. She stated her biggest concern was that the nurses did not know what the pump was set at, so they did not know how much insulin she was getting. She stated Resident #1 had also not been eating much and that was a problem as well. She stated she did relay to the NP that she was not eating but not about the irregular blood sugar readings. She stated a few days prior in the morning (could not remember date), her blood sugar was 400 and she realized the pump was off. She stated there had been a time when her blood sugar was in the 60's and she realized it was not working and changed it out. She stated the day prior, 07/14/25, she had never seen Resident #1 with so much anger. She stated she was mad her pump was off and was not getting the insulin she needed. She stated she notified the NP who said she was going to put her on a sliding scale. She stated insulin pumps were rare in nursing facilities because they are hard to regulate. She stated Resident #1 had a history of being nauseous and did not notice an increase when her blood sugars were extremely high or extremely low. During an interview on 07/15/25 at 12:58 PM, Resident #1 stated the NP saw her that morning and discontinued her insulin pump. She stated that was what she requested because she was having a hard time keeping her blood sugar level up. She stated when it would get really high or really low, she would get extremely nauseated, more than normal. She stated she would get sweaty, dizzy, and was miserable. She stated she had difficulty sleeping and the nurses were aware.During an interview on 07/15/25 at 2:00 PM, the DON stated she had been working at the facility for about a month. She stated if Resident #1's blood sugar was in the 300-400 range that would be abnormal for her. She stated if it were her, she would have rechecked her blood sugar in an hour with one of their glucometers because the insulin pumps were not always accurate. She stated she would expect the nurses to follow-up on the blood sugar and notify the NP. She stated if she had known her blood sugar had not been stable, she would have spoken to the NP sooner about getting the pump discontinued and getting her on a sliding scale. She stated with really high or low blood sugar, a negative outcome could be DKA or feeling really hot or dizzy. During an interview on 07/30/25 at 12:52 PM, RN A stated there was a time (could not remember the date) when Resident #1's diabetic pump had been turned off or was not working properly. She stated she was not trained on the pump and had read the instructions inside the monitor's box on how to apply a new one. She stated the monitoring was being done on Resident #1's phone and she would go into her room every morning to the blood sugar readings off her phone so that she could document the numbers. She stated prior to the removal of her pump, there were no parameters of when to notify the NP in the (electronic monitoring system). She stated after it was removed, she was put 455917 Page 2 of 11 455917 08/01/2025 Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some on a sliding scaled and nursing staff were in-serviced to notify the NP if her blood sugar was above 400. During an interview on 07/30/25 at 1:13 PM, RN B stated she started working at the facility about two weeks prior and did not work with Resident #1 when she had the insulin pump. She stated when she was hired, she was in-serviced on rechecking the blood sugar when a reading was too high or too low to ensure the reading was accurate. She stated she the in-service also included when to notify the NP (blood sugar above 400). She stated she could not recall if the in-serviced including applying a sensor or pump. During an interview on 07/30/25 at 1:24 PM, RN C stated she had not worked with Resident #1. She stated a few weeks ago (could not remember the date), the DON present an in-service on insulin pumps and continuous glucose monitoring. She stated if there was a high reading (above 400), they would need to do a finger stick to have a comparison reading and then notify the NP. She stated if a resident was being administered insulin, there needed to be parameters in their chart of when to notify the NP if a reading was out of range. She stated if there were no parameters listed, the nurses needed to reach out the NP to get those parameters. She stated if a resident's blood sugar was too high or too low, they could experience increased confusion, drowsiness, and dizziness. During an interview on 07/30/25 at 1:33 PM, the DON stated the glucose monitoring devices/pumps were pretty self-explanatory and had directions in the box. She stated the staff had to read the device instructions to be able to apply it. She stated she was not at the facility at the time that it had to be applied to Resident #1 after it was found nonfunctional, so she did not check or verify that the new one was functioning. She stated she conducted an in-service to nurses on 07/15/25 on what to do if blood sugars were out of range on a Dexcom or Libre and they were required to re-check with a finger stick. She stated there was no in-service conducted on the application of the device itself (when Resident #1 was admitted ). She stated it was her expectation that there be parameters in residents' charts for glucose readings especially if there were fluctuating high and low numbers like she (Resident #1) did. She stated that was her expectation and felt like my nurses all knew that. She stated residents could experience out of parameter symptoms such as being hot or cold, clammy, thirsty, dizziness, and as nurses, we knew to look for those symptoms as they were very educated and taught that in nursing school. She stated there were no diabetic pumps currently in the facility and those devices were not seen much in nursing facilities. She stated if another resident was admitted with one, she would ensure parameters were in place and ensure glucose levels were checked manually AC and HS and that the NP was involved. She stated she would conduct in-services regularly on parameters, monitoring, and what to do if out of range. Review of the facility's undated Change in a Resident's Condition or Status Policy, reflected the following: Our facility shall promptly notify the reside, his or her Attending Physician, and representative of any changes in the resident's medical/mental condition and/or status.The ADM and DON were notified on 07/30/25 at 2:14 PM that an IJ had been identified and an IJ template was provided.The following POR was approved on 07/31/25 at 3:50 PM: IMMEDIATE CORRECTIVE ACTIONS FOR REMOVAL OF IMMEDIATE JEPOARDY:On July 30,2025 at approximately 3:00 pm the following actions were initiated upon facility identification of concern. Action: Resident # 1 was assessed to ensure that the resident was not suffering from ongoing negative effects. Prior Glucose Dexcom Receiver Devise (Continuous Glucose System Receiver) was discontinued, and new orders were put in place for monitoring on 7.15.25. There are no Director of Nursing Action: Director of Nursing was educated on Notification of Changes and Change of Services Action: All Nurses were educated on Notification of Changes. Nursing should also complete Change of Condition in system as well as 455917 Page 3 of 11 455917 08/01/2025 Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some notify physician and Director of Nursing. Certified Medication Aides and Certified Nursing Aides were also This was initiated and completed on 7/30/2025. The Director of Nursing/designee will utilize staff roster to track those who have received education and to determine those who still require it. Anyone not able to be reached by phone or in person, agency and new nurses will be educated prior to the start of their next shift. Responsible: Director of Nursing IDENTIFICATION OF OTHER AFFECTED: All residents with diabetes have the potential to be affected by the alleged deficient practice. Action: Review of 22 residents who have diabetes diagnoses for proper orders and hypo/hyper glycemic protocols in place and care planned. Three were sent to MD to review and see if any orders wanted to be changed. One change to a sliding scale, one added accucheck schedule. The third one we are requesting labs. Nurse will inform physician when admissions occur and go over any devices to ensure proper monitoring and orders are in place.Start Date: MEASURES: Action: ADHOC QAPI was performed for blood glucose monitoring and how to proceed with equipment failure. To perform in service and training to nurses. All residents with accuchecks will be audited Director of Nursing Action: All residents that with diabetes were audited to ensure checks were occurring and that hypo/hyper glycemic protocols were in placed and care planned. Start Date: 7/30/2025Completion Date: 7/30/2025Responsible: Director of Nursing TRACKING AND MONITORING: Action: Change of Condition will be monitored by running 24 hour report and order listing report. This will be completed daily for a week, then biweekly for 2 weeks, then monthly for 2 months. This will be kept on a log.Start Date: admissions will be reviewed by Director of Nursing/Designee to ensure physician is aware of any devices and that proper orders are in place. This review will take place daily for 2 weeks, then biweekly for 2 weeks, then monthly for 2 months. Any noncompliance will be communicated to nurse responsible and counseled Party: Director of Nursing/DesigneeAction: Implemented interventions immediately if notifications have not been made to the provider of any suspected change in condition. Documentation of notifications made to resident/representative and physician will be noted in the resident's electronic medical record to include alert charting for change in condition if warranted. Staff responsible for the deficient practice will be Director of Nursing/DesigneePlease accept this letter as our plan of removal for determination of the alleged Immediate Jeopardy issued 7/31/2025. The Surveyor monitored the POR from 07/31/25 - 08/01/25 as followed: During interviews on 08/01/25 from 11:54 AM - 1:05 PM with staff from all shifts - RN A, RN B, RN D, MA E, MA F, CNA G, and CNA H all stated they had been in-serviced before their shifts by the DON. The CNAs and MAs stated they closely monitored the residents for any changes in condition or changes from their baselines. The CNAs and MAs stated they would notify their nurse immediately of any changes and would document in their documenting system. The RNs stated they were in-serviced on changes in condition and notifying the NP/MD immediately. The RNs stated if a residents BS readings were not within parameters it was important for the NP/MD to be informed and for a change of condition form to be completed in their charts. During an interview on 08/01/25 at 1:30 PM, the DON stated Resident #1 remained on long-acting insulin. She stated Resident #1 had type I diabetes and her pancreas did not work, so in her case her blood sugar would remain and, go up and down, and will always have to be closely monitored. She stated she and the ADM were in-serviced by 455917 Page 4 of 11 455917 08/01/2025 Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some their corporate nurse before providing education to the staff on notification on changes in condition. She stated any time a resident's blood sugar was outside of the parameters, the physician needed to be notified. During an interview on 08/01/25 at 1:38 PM, the ADM stated she and the DON were in-serviced by their DCS on notification of changes in condition before the staff were in-serviced. She stated 94% of the nursing staff had been in-serviced, and none could work the floor until they were.Review of Resident #1's physician order, dated 07/22/25, reflected record blood sugar AC/HS (before meals and at bedtime for monitoring). Review of Resident #1's physician order, dated 07/35/25, reflected HumaLOG Injection Solution - 100 UNIT/ML - Inject subcutaneously before meals for DM. Review of Resident #1's physician order, dated 08/01/25 reflected Insulin Glargine Subcutaneous Solution - 100 UNIT/ML - Infect 14 units subcutaneously in the morning for DM1. Hold if less than 110. Review of the facility's ADHOC meeting agenda, dated 07/30/25, reflected the ADM, DON, MDSC, DOR, and MD were in attendance. Review of an in-service, dated 07/30/25 and conducted by the DCS, reflected the ADM and DON were in-serviced on NP notification of changes with a key point: A malfunctioning diabetic pump and/or elevated blood glucose levels require immediate attention and notification to MD and nurse management. Provider and representative notification must be timely and clearly documented. Documentation should include date/time of change identification, communication, provider response, and new orders. Review of their monitoring audit tool for review the 24-hour report for any changes in condition, on 08/01/25, reflected three different residents had been sampled on 07/30/25 and 08/01/25. It reflected if there was a change in condition in 24 hours, order listing report reviewed, notifications completed, and corrective actions taken if change in condition was identified. Four residents were idented with a change of condition and corrective actions were taken and verified. Review of an in-service dated 07/30/25 - 08/01/25 and conducted by the DON, reflected all nursing staff were notified on of their Notification of Changes/Change in Condition Policy. The CNAs and MAs were expected to notify the nurses of any change and nurses were expected to complete a change of condition form and to notify the NP and DON.The ADM and DON were notified on 08/01/25 at 2:13 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. 455917 Page 5 of 11 455917 08/01/2025 Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of four residents reviewed for quality of care. The facility failed to: Notify Resident #1's NP when her diabetic insulin pump malfunctioned in July of 2025. - Ensure nursing staff were trained on Resident #1's insulin pump.- Ensure nursing staff were aware of how much insulin Resident #1 was receiving and not relying on her for blood sugar readings.- Ensure there were parameters in place on when to notify Resident #1's NP when her readings were abnormal.These failures resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/25 at 2:14 PM and a template was provided. While the IJ was removed on 08/01/25 at 2:13 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of DKA, dizziness, nausea, and a decreased quality of life, and death. Findings included:Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including type I diabetes, gastroparesis (a condition in which the muscles in the stomach do not move well), chronic kidney disease, and muscle weakness. Review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 15, indicating she was cognitively intact. Section N (Medications) reflected she received insulin injections since admission. Review of Resident #1's admission care plan, dated 06/30/25, reflected there was not a focus regarding her being a diabetic or having an insulin pump. Review of Resident #1's physician order, dated 07/03/25, reflected the following: Dexcom G7 Receiver Device (Continuous Glucose System Receiver) - Apply to bar of upper arm topically one time a day every 10 day(s) for DM management. Review of Resident #1's TAR, July of 2025, reflected the receiver was changed on 07/03/25 and 07/13/25. Review of Resident #1's physician order, dated 07/01/25, reflected the following: Omnipod 5 Libre2 Plus G6 Kit (Insulin Infusion Disposable Pump) - Inject 200 ml subcutaneously one time a day every 3 day(s) for DM management. Review of Resident #1's MAR, July of 2025, reflected insulin was placed in the pump on 07/01/25, 07/04/25, 07/10/25, and 07/14/25. It reflected she refused on 07/07/25. Review of Resident #1's physician order, dated 07/01/25, reflected Glucagon Emergency Kit 1 MG - Inject 1 mg intramuscularly as need for hypoglycemia per protocol if patient is unconscious or unable to swallow. Review of Resident #1's MAR, July of 2025, reflected she was administered the Glucagon three times: *07/08/25 at 4:36 AM - BS: 74*07/09/25 at 4:48 PM - BS: 53*07/11/25 at 3:49 AM - BS: 65 Review of Resident #1's blood sugar readings in her EMR, from 07/01/25 - 07/15/25, reflected the following days/times her blood sugar was abnormally out of normal the range (normal range is 70 mg/dL -100 mg/dL): *07/01/25 10:43 PM - 42.0 mg/dL*07/05/25 6:21 PM - 300.0 mg/dL*07/06/25 6:33 AM - 326.0 mg/dL*07/09/25 4:49 PM - 52.9 mg/dL*07/13/25 8:55 PM - 350.0 mg/dL*07/14/25 7:09 AM - 400.0 mg/dL*07/14/25 12:09 PM - 399.0 mg/dL Review of Resident #1's physician order, dated 07/15/25, reflected to d/c insulin pump. Review of Resident #1's physician order, dated 07/15/25, reflected HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML - Inject subcutaneously before meals for DM. Review of Resident #1's physician order, dated 07/15/25, reflected Lantus Subcutaneous Solution 100 UNIT/ML - Inject 10 unit subcutaneously in the morning for DM - hold if BG is less than 110. During a telephone interview on 07/15/25 at 12:23 PM, Resident #1's NP stated she had been working with the facility for about a week but was familiar with Resident #1. She stated she had a conversation with her that morning (on 07/15/25) and there were concerns the pump was not functioning the way it should be, so she put in orders to Residents Affected - Some 455917 Page 6 of 11 455917 08/01/2025 Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some discontinue the pump. She stated she should not have it on her if it was not working. She stated she ordered a sliding scale to better manage her blood sugars. She stated the staff had been informing her of general concerns regarding Resident #1 such as refusing showers and not eating much of her meals, but they had not mentioned irregular blood sugar readings. She stated if she had been, she would have discontinued the pump sooner. She stated if the pump was not working, a negative outcome could be potentially all the negative things with diabetes. She stated there was not a way to check those pumps in these environments. During a telephone interview on 07/15/25 at 12:38 PM, RN A stated she was very familiar with Resident #1. She stated since she had a pump, she would tell the nurses what her blood sugar was, and they would document it. She stated her biggest concern was that the nurses did not know what the pump was set at, so they did not know how much insulin she was getting. She stated Resident #1 had also not been eating much and that was a problem as well. She stated she did relay to the NP that she was not eating but not about the irregular blood sugar readings. She stated a few days prior in the morning (could not remember date), her blood sugar was 400 and she realized the pump was off. She stated there had been a time when her blood sugar was in the 60's and she realized it was not working and changed it out. She stated the day prior, 07/14/25, she had never seen Resident #1 with so much anger. She stated she was mad her pump was off and was not getting the insulin she needed. She stated she notified the NP who said she was going to put her on a sliding scale. She stated insulin pumps were rare in nursing facilities because they are hard to regulate. She stated Resident #1 had a history of being nauseous and did not notice an increase when her blood sugars were extremely high or extremely low. During an interview on 07/15/25 at 12:58 PM, Resident #1 stated the NP saw her that morning and discontinued her insulin pump. She stated that was what she requested because she was having a hard time keeping her blood sugar level up. She stated when it would get really high or really low, she would get extremely nauseated, more than normal. She stated she would get sweaty, dizzy, and was miserable. She stated she had difficulty sleeping and the nurses were aware. During an interview on 07/15/25 at 2:00 PM, the DON stated she had been working at the facility for about a month. She stated if Resident #1's blood sugar was in the 300-400 range that would be abnormal for her. She stated if it were her, she would have rechecked her blood sugar in an hour with one of their glucometers because the insulin pumps were not always accurate. She stated she would expect the nurses to follow-up on the blood sugar and notify the NP. She stated if she had known her blood sugar had not been stable, she would have spoken to the NP sooner about getting the pump discontinued and getting her on a sliding scale. She stated with really high or low blood sugar, a negative outcome could be DKA or feeling really hot or dizzy. During an interview on 07/30/25 at 12:52 PM, RN A stated there was a time (could not remember the date) when Resident #1's diabetic pump had been turned off or was not working properly. She stated she was not trained on the pump and had read the instructions inside the monitor's box on how to apply a new one. She stated the monitoring was being done on Resident #1's phone and she would go into her room every morning to the blood sugar readings off her phone so that she could document the numbers. She stated prior to the removal of her pump, there were no parameters of when to notify the NP in the (electronic monitoring system). She stated after it was removed, she was put on a sliding scaled and nursing staff were in-serviced to notify the NP if her blood sugar was above 400. During an interview on 07/30/25 at 1:13 PM, RN B stated she started working at the facility about two weeks prior and did not work with Resident #1 when she had the insulin pump. She stated when she was hired, she was in-serviced on rechecking the blood sugar when a reading was too high or too low to ensure the reading was accurate. She stated she the in-service also included when to notify the NP (blood sugar above 400). She stated she could not 455917 Page 7 of 11 455917 08/01/2025 Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some recall if the in-serviced including applying a sensor or pump. During an interview on 07/30/25 at 1:24 PM, RN C stated she had not worked with Resident #1. She stated a few weeks ago (could not remember the date), the DON present an in-service on insulin pumps and continuous glucose monitoring. She stated if there was a high reading (above 400), they would need to do a finger stick to have a comparison reading and then notify the NP. She stated if a resident was being administered insulin, there needed to be parameters in their chart of when to notify the NP if a reading was out of range. She stated if there were no parameters listed, the nurses needed to reach out the NP to get those parameters. She stated if a resident's blood sugar was too high or too low, they could experience increased confusion, drowsiness, and dizziness. During an interview on 07/30/25 at 1:33 PM, the DON stated the glucose monitoring devices/pumps were pretty self-explanatory and had directions in the box. She stated the staff had to read the device instructions to be able to apply it. She stated she was not at the facility at the time that it had to be applied to Resident #1 after it was found nonfunctional, so she did not check or verify that the new one was functioning. She stated she conducted an in-service to nurses on 07/15/25 on what to do if blood sugars were out of range on a Dexcom or Libre and they were required to re-check with a finger stick. She stated there was no in-service conducted on the application of the device itself (when Resident #1 was admitted ). She stated it was her expectation that there be parameters in residents' charts for glucose readings especially if there were fluctuating high and low numbers like she (Resident #1) did. She stated that was her expectation and felt like my nurses all knew that. She stated residents could experience out of parameter symptoms such as being hot or cold, clammy, thirsty, dizziness, and as nurses, we knew to look for those symptoms as they were very educated and taught that in nursing school. She stated there were no diabetic pumps currently in the facility and those devices were not seen much in nursing facilities. She stated if another resident was admitted with one, she would ensure parameters were in place and ensure glucose levels were checked manually AC and HS and that the NP was involved. She stated she would conduct in-services regularly on parameters, monitoring, and what to do if out of range. Review of the facility's undated Change in a Resident's Condition or Status Policy, reflected the following: Our facility shall promptly notify the reside, his or her Attending Physician, and representative of any changes in the resident's medical/mental condition and/or status. Review of the facility's Blood Glucose Monitoring Policy, revised 05/13/25, reflected the following: For residents who have continuous glucose monitoring systems, blood glucose via glucometer for verification of results will be done as per physician order. Review of the facility's Insulin Pump Use Policy, dated 05/16/25, reflected the following: It is the policy of this facility to allow access to administration of insulin via insulin pump in order to meet the needs of residents requiring the use of insulin and to prevent adverse effects on a resident's condition.1. Insulin pump settings will be in accordance with physician's orders. Depending on the pump, settings may include: insulin correction factor, carbohydrate to insulin ratio, basal and bolus settings, maximum bolus limits, glucose goals, correction above what glucose value, target ranges, duration of insulin action, temporary basal and activity settings and pump software updates.2. A hypoglycemia management plan will be documented and followed per physician's orders.The ADM and DON were notified on 07/30/25 at 2:14 PM that an IJ had been identified and an IJ template was provided.The following POR was approved on 07/31/25 at 3:50 PM: IMMEDIATE CORRECTIVE ACTIONS FOR REMOVAL OF IMMEDIATE JEPOARDY:On July 30,2025 at approximately 3:00 pm the following actions were initiated upon facility identification of concern. Action: Resident # 1 was assessed to ensure that the resident was not suffering from ongoing negative effects. Prior Glucose Dexcom Receiver Devise (Continuous Glucose System Receiver) was discontinued, and new orders were put in place 455917 Page 8 of 11 455917 08/01/2025 Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some for monitoring on 7.15.25. There are no other pumps in the facility at this time.Start Date: educated on Insulin Pumps, Continuous Glucose Monitors and expectations when monitoring glucose and to check manually with glucometer if readings on a device are out of normal range.Start Date: educated on Insulin Pumps, Continuous Glucose Monitors and expectations when monitoring glucose and to check manually with glucometer if readings on a device are out of normal range.Start Date: Nursing/designee will utilize staff roster to track those who have received education and to determine those who still require it. Anyone not able to be reached by phone or in person, agency and new hires will be educated prior to the start of their next shift. Responsible: Director of Nursing IDENTIFICATION OF OTHER AFFECTED: All residents with diabetes have the potential to be affected by this alleged deficient practice.Action: Review of 22 residents who have diabetes diagnoses for proper orders and hypo/hyper glycemic protocols in place and care planned. Three were sent to MD to review and see if any orders wanted to be changed. One changed to a sliding scale, one added accucheck schedule. The third one we are requesting labs today. Nurse will inform physician when admissions occur and go over any devices to 7/31/2025Responsible: Director of Nursing SYSTEMIC CHANGES AND/OR MEASURES: Action: ADHOC QAPI was performed for blood glucose monitoring and how to proceed with equipment failure. To perform in service and training to nurses. All residents with accuchecks will be audited to ensure appropriate orders residents with diabetes were audited to ensure checks were occurring and that hypo/hyper glycemic Director of Nursing TRACKING AND MONITORING: Action: Audits will be conducted on blood sugar monitoring daily for a week, biweekly for 2 weeks and then monthly for 2 months. This will be tracked on a Action: Any new admissions will be reviewed by Director of Nursing/Designee to ensure physician is aware of any devices and that proper orders are in place. This review will take place daily for 2 weeks, then biweekly for 2 weeks, then monthly for 2 months. Any noncompliance will be communicated to nurse responsible and counseled accordingly. This will be tracked on a log. Start Date: 7/30/2025Completion Date: 7/31/2025. Responsible Party: Director of Nursing/DesigneeThe Surveyor monitored the POR from 07/31/25 - 08/01/25 as followed: During interviews on 08/01/25 from 11:54 AM - 1:05 PM with staff from all shifts - RN A, RN B, RN D, MA E, MA F, CNA G, and CNA H all stated they had been in-serviced before their shifts by the DON. The CNAs and MAs stated they closely monitored the residents for any changes in condition or changes from their baselines. The CNAs and MAs stated they would notify their nurse immediately of any changes and would document in their documenting system. The RNs stated they were in-serviced on changes in condition and notifying the NP/MD immediately. The RNs stated if a residents BS readings were not within parameters it was important for the NP/MD to be informed and for a change of condition form to be completed in their charts. The nurses stated if a resident was on an insulin pump and their sugar level was too high or too low (out of parameters), they were to recheck it with glucometer to ensure accuracy. The nurses stated if they believed an insulin pump was malfunctioning, they would notify the DON and NP/MD immediately. The nurses stated any resident that was administered insulin should have parameters in place on when to notify the NP/MD. The nurses stated signs and symptoms of blood sugar being outside of parameters could be nausea, dizziness, 455917 Page 9 of 11 455917 08/01/2025 Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some lethargy, or being unable to swallow. During an interview on 08/01/25 at 1:30 PM, the DON stated Resident #1 remained on long-acting insulin. She stated Resident #1 had type I diabetes and her pancreas did not work, so in her case her blood sugar would remain and, go up and down, and will always have to be closely monitored. She stated she and the ADM were in-serviced by their corporate nurse before providing education to the staff on notification on changes in condition, glucose monitoring, and insulin pumps. She stated any time a resident's blood sugar was outside of the parameters, the physician needed to be notified. During an interview on 08/01/25 at 1:38 PM, the ADM stated she and the DON were in-serviced by their DCS on notification of changes in condition, glucose monitoring, and insulin pumps before the staff were in-serviced. She stated 94% of the nursing staff had been in-serviced, and none could work the floor until they were. Review of Resident #1's physician order, dated 07/22/25, reflected record blood sugar AC/HS (before meals and at bedtime for monitoring). Review of Resident #1's physician order, dated 07/35/25, reflected HumaLOG Injection Solution - 100 UNIT/ML - Inject subcutaneously before meals for DM. Review of Resident #1's physician order, dated 08/01/25 reflected Insulin Glargine Subcutaneous Solution - 100 UNIT/ML - Inject 14 units subcutaneously in the morning for DM1. Hold if less than 110. Review of five sampled residents' charts that required insulin, on 08/01/25, reflected their care plans had diabetic interventions and there were ordered parameters for their blood sugar levels. Review of the facility's ADHOC meeting agenda, dated 07/30/25, reflected the ADM, DON, MDSC, DOR, and MD were in attendance. Review of an in-service, dated 07/30/25 and conducted by the DCS, reflected the ADM and DON were in-serviced on two key points: A malfunctioning diabetic pump and/or elevated blood glucose levels require immediate attention and notification to MD and nurse management. Provider and representative notification must be timely and clearly documented. Documentation should include date/time of change identification, communication, provider response, and new orders. Timely recognition and management of changes in condition, including care and management of diabetic pumps, and blood glucose readings. Clinical assessments and documentation must reflect staff recognizing when a blood glucose reading is inconsistent or clinically abnormal. Staff to recognize when to utilize a backup manual finger stick for malfunctioning diabetic pumps. Delay in response or lack of intervention may constitute a deficiency. Review of an audit conducted by the DON, dated 07/30/25 - 07/31/25, reflected all 22 residents who had a diagnosis of diabetes were audited for proper orders and hyper/hypo glycemic protocols in place and care planned. Of the 22 audited residents, three residents' clinicals were sent to the MD to review for a determination if any orders wanted to be changed. One resident was put on a sliding scale, one resident was added to the accucheck schedule, and one received an order for lab work. Review of their monitoring audit tool for review the 24-hour report for any changes in condition, on 08/01/25, reflected three different residents had been sampled on 07/30/25 and 08/01/25. It reflected if there was a change in condition in 24 hours, order listing report reviewed, notifications completed, and corrective actions taken if change in condition was identified. Four residents were idented with a change of condition and corrective actions were taken appropriately and verified. Review of an in-service dated 07/30/25 - 08/01/25 and conducted by the DON, reflected all nursing staff were notified on of their Notification of Changes/Change in Condition Policy. The CNAs and MAs were expected to notify the nurses of any change and nurses were expected to complete a change of condition form and to notify the NP and DON. Review of an in-service dated 07/30/25 - 08/01/25 and conducted by the DON, reflected all nurses were in-serviced on their Continuous Glucose Monitors Policy. Review of an in-service dated 07/30/25 - 08/01/25 and conducted by the DON, reflected all nurses were in-serviced on their Insulin Pump Use Policy.The ADM and DON were notified on 08/01/25 at 2:13 PM that the IJ had been removed. While 455917 Page 10 of 11 455917 08/01/2025 Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676

F 0684 the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 455917 Page 11 of 11