Health inspection·August 16, 2023

F 0760 Record review of Resident #1's MAR showed her blood sugars were not done as ordered on the following dates in August: Level of Harm - Actual harm 08/10/2023 6:28 pm before dinner Residents Affected - Few 08/09/2023 before dinner not done 08/09/2023 8:33 am before breakfast 08/08/2023 5:48 pm before dinner 08/08/2023 11:50 am before lunch 08/06/2023 before breakfast not done 08/05/2023 before bed not done 08/04/2023 7:32 am before breakfast Record review of Resident #1's progress notes revealed on 08/10/23 at 12:47 am Resident #1 was found unresponsive with a blood sugar of 53 and was sent to the emergency room. Further review revealed on 08/11/23 at 4:51 am Resident #1 was found unresponsive with a blood sugar of 43 and was sent to the hospital. Record review of Resident #1's vital signs revealed on 08/10/23 her blood sugar was taken after dinner at 6:28 pm and dinner started at 5:00 pm by ADON and insulin was administered. Further review revealed on 08/09/23 her blood sugar was not taken and insulin was not given for her pre-dinner blood sugar and insulin. In an interview 08/11/23 at 12:30 pm with the ADON she stated that Resident #1 was taken back to hospital Friday (08/11/23) morning after being found unresponsive. She stated the Resident #1 eats lots of junk food and is non-compliant, so it was her fault that her blood sugar was so low. ADON stated Resident #1 was hospitalized on [DATE] and 08/11/23. ADON stated she did check Resident #1's blood sugar on 08/09/23 before dinner, but did not document it. In an interview on 08/14/23 at 3:15 pm with Clinical Resource Nurse she stated that it was the responsibility of everyone to follow physician orders. She further stated that the nurse was responsible for checking blood sugar before meals and before dinner and to report any abnormalities to the DON and physician. She stated that failure to follow the physician orders can cause illness, hospitalization and death. In an interview and observation on 08/14/23 at 8:30 am with Resident #1 , she stated that they gave her insulin without food and that made her sick. She told them not to do that multiple times, but the facility kept giving her insulin without food. She also said that when she went to the hospital the second time (08/11/23), they put the IV in her bone in her shoulder and it still hurt her. Resident #1 stated that she remembered feeling sick before she lost consciousness on both occasions, but she did not realize she had fallen. She said it scared her because she felt so sick. She was rubbing her shoulder while she spoke about them putting an IV in her shoulder; she also became tearful when discussing the hospitalizations and how fearful it made her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 If continuation sheet Page 2 of 3 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 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 0760 Level of Harm - Actual harm In an interview with the MD on 08/14/23 at 8:45 am, he stated that measuring blood sugar after a meal instead of before could lead to an over injection of insulin and low blood sugar. He was informed that Resident #1 was sent to the hospital, but he was not informed that both evenings before she was hospitalized the facility failed to administer her insulin before dinner. Residents Affected - Few Record review of the facility's policy on Hypoglycemia Management, dated November 2020 revealed signs of hypoglycemia could be weakness, tachycardia, headaches, unconsciousness, and coma . administer glucagon, notify provider, monitor vital signs, recheck blood sugar in 15 minutes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 If continuation sheet Page 3 of 3