Health inspection·July 30, 2022

F 0686 In an observation on 7/28/22 at 10:30 a.m. of Resident #32 revealed the resident was in bed asleep. Level of Harm - Minimal harm or potential for actual harm In an observation and interview on 7/28/2022 at 10:31 a.m. with CNA H revealed the resident was wearing socks on his feet but he was not wearing any heal protectors. The CNA reported she was not working when the resident was placed in bed. Residents Affected - Few In an interview on 7/28/2022 at 10:41 a.m. with RN F, after reviewing Resident #32's medical record she reported the resident had an order for heel protectors while in bed. In an observation and interview on 7/28/2022 at 10:42 a.m., after observing Resident #32 in bed, RN F reported there were no heal protectors on the resident's feet as ordered. At that same time the DON came into the room with Podus boots (multipurpose boots designed to use for plantar flexion contracture, decubitus heel and toe ulcers, and hip rotation) and stated to place them on the resident's feet until his heel protectors could be located. The DON reported, yes, he is supposed to have heel protectors while in bed. Review of the facility policy, Pressure Injury Prevention and management, date implemented 6/29/22, revealed, c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have pressure injury present. Basic or routine care interventions could include, but are not limited to: i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675110 If continuation sheet Page 2 of 15 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 675110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cuero Nursing and Rehabilitation Center 1310 E Broadway Cuero, TX 77954 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interviews and record reviews. the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. Residents Affected - Some The facility did not have a registered nurse for a minimum of 8 hours for 6 days from May 1st to July 29th, 2022. This failure could place residents at risk harm by not having a registered nurse to provide clinical assessments and communications with physicians. The findings are: During a record review of the facility's payroll documents for the period May 1st, 2022 to July 29th, 2022 the following dates were noted without a registered nurse on duty for a minimum of 8 Hours; Sunday May 1st, 2022 = no RN Friday May 6th, 2022 = no RN for a minimum of 8 hours. Friday May 20th, 2022 = no RN for a minimum of 8 hours. Saturday May 28th, 2022 = no RN Saturday June 11th, 2022 = no RN for a minimum of 8 hours. Saturday June 25th, 2022 = no RN for a minimum of 8 hours. During an interview on 7/30/2022 at 11:02 AM the DON stated she relieved DON A of duty on 7/7/2022. The DON stated she reviewed the payroll reports for the period 5/1 to 7/30/2022 and recognized the facility failed to have RN coverage for 2 days during the period from 5/1 to 7/30/2022 and did not have RN coverage for a minimum of 8 hours for another 4 days. The DON stated the failure was the responsibility of the previous DON, DON A. the DON stated residents could have been at risk for harm by not having the nursing staff with the experience and education an RN would have to assess residents with a change of condition and intervene with nursing services. During an interview on 7/30/2022 at 11:38 PM the Administrator stated she relieved the previous Administrator, Administrator B, at the beginning of July 2022. The Administrator stated the failure to have RN services for a minimum of 8 hours a day could place residents at risk for harm by not having the clinical assessment services of an RN. The Administrator stated she could not comment as to why the failure occurred but did state the Administrator and DON were directly responsible for the RN coverage schedule. A record review of the facility's Nursing Services - Registered Nurse (RN) policy dated 1/1/2022, revealed, Policy: it is the intent of the facility to comply with Registered Nurse staffing requirements. Policy Requirements and Compliance Guidelines .the facility will utilize the services of a registered nurse for at least 8 consecutive hours per day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675110 If continuation sheet Page 3 of 15 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 675110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cuero Nursing and Rehabilitation Center 1310 E Broadway Cuero, TX 77954 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews the facility failed to ensure a medication error rate below 5% for 2 of 3 residents (Resident #188 and #189) observed and 1 of 1 staff, LVN C, reviewed for medication administration errors. Residents Affected - Few 1. 33 medications opportunities were observed of which 7 were in error, which resulted in a 21% medication error rate (7/33=21.21%). 2. LVN C administered 2 late medications to Resident #188. 3. LVN C administered 5 late medications to Resident #189. These failures could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: 1. A record review of Resident #188's admission record revealed an admission date of 7/25/2022 with diagnoses which included type II diabetes (an impairment in the way the body regulates and uses sugar (glucose) as a fuel) and urinary tract infection. A record review of Resident #188's July 2022 physician order summary, dated 7/27/2022, revealed medications to be administered: cefuroxime axetil (a second-generation oral cephalosporin antibiotic) 500mg, give 1 tablet by mouth two times a day, at 8:00 AM and at 8:00 PM, related to urinary tract infection, and metformin (used together with diet to lower high blood sugar levels in patients with type 2 diabetes) 500mg, give 1 tablet by mouth two times a day, at 8:00 AM and again at 8:00 PM, related to type II diabetes. A record review of Resident #188's July 2022 medication administration record revealed LVN C administered cefuroxime axetil and metformin medications on 7/27/2022 scheduled for 8:00 AM. During an observation on 7/27/2022 at 12:00 PM revealed LVN C prepared, dispensed and administered to Resident #188, 8 medications of which 2 were scheduled for 8:00 AM (1 tablet cefuroxime axetil 500mg and 1 tablet metformin 500mg). During an interview on 7/27/2020 at 12:05 PM, LVN C stated the medication aide who was scheduled to pass medications called in, due to a death in the family. LVN C stated she was assigned to pass medications around 11:40 AM. LVN C stated she was late at passing the 8:00 AM morning medications. LVN C stated she was so distraught she would resign at the end of her shift. LVN C stated Resident #188 received all his medications morning medications hours late of which 2 were scheduled twice a day. LVN stated Resident #188 was at risk for not receiving the effects of his medication as prescribed, his next scheduled doses are at 8PM and there may not be enough time for him to metabolize the meds. 2. A record review of Resident #189's admission record revealed an admission date of 7/22/2022 with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675110 If continuation sheet Page 4 of 15 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 675110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cuero Nursing and Rehabilitation Center 1310 E Broadway Cuero, TX 77954 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few diagnoses which included urinary tract infection, embolism (obstruction of a blood vessel) and thrombosis (blood clot) of left popliteal vein (behind the knee, a major route for venous return from the lower leg), hypertension (high blood pressure), and constipation. A record review of Resident # 189's July 2022 physician's order summary, dated 7/27/2022, revealed medications to be administered: apixaban (used to treat and prevent blood clots) give 5mg by mouth two times a day, at 9:00 AM and at 5:00 PM, for deep vein thrombosis; cipro (used to treat infections caused by bacteria) 250mg give 1 tablet two times a day, at 9:00 AM and at 5:00 PM, for urinary tract infection; metoprolol 25mg (used to lower blood pressure) give 1 tablet by mouth two times a day related to hypertension; miralax 17gm (used to treat constipation), give 1 packet by mouth two times a day, at 9:00 AM and at 5:00 PM, related to constipation; diltiazem 30mg, (used to treat high blood pressure) give 1 tablet by mouth three times a day, at 9:00 AM, 5:00 PM and at 9:00 PM related to hypertension. A record review of Resident #189's July 2022 medication administration record revealed LVN C administered apixaban, cipro, metoprolol, miralax, and diltiazem medications scheduled for 9:00 AM on 7/27/2022. During an observation on 7/27/2022 at 12:15 PM revealed LVN C prepared, dispensed and administered to Resident #189, 7 medications of which 5 were scheduled for 9:00 AM; Apixaban 5mg, 1 tablet; cipro 2mg 1 tablet; metoprolol 25mg 1 tablet; miralax 17gm 1 packet; diltiazem 30mg 1 tablet. During an interview on 7/27/2022 at 9:28 AM LVN C stated she it is what it is I am late passing medications. During an interview on 7/27/2022 at 4:52 PM the DON stated LVN C was alerted earlier that morning (around 8:00 AM) the medication aide would not be in to pass medications. The DON stated LVN C refused help from 2 other nurses and stated, I'll pass my own meds. The DON stated LVN C resigned today 7/27/2022. The DON stated LVN C's refusal for help in providing on time quality care for residents was unacceptable and accepted LVN C's resignation. The DON stated residents were at risk for not receiving their medications therapeutic effects as prescribed. The DON stated the Residents, their representatives, and their physician were given a report. The DON stated a med error incident report and investigation were initiated and the results would be reviewed by the QAPI committee. A record review of the facility's policy Medication Administration, dated 10/1/2019, revealed, The director of nursing services will supervise and direct all nursing personnel who administer medications and or have related functions medications must be administered in accordance with the orders including any required timeframe. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675110 If continuation sheet Page 5 of 15 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 675110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cuero Nursing and Rehabilitation Center 1310 E Broadway Cuero, TX 77954 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record reviews the facility failed to ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date, and failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys, for 2 of 4 medication carts and 1 of 3 Residents (Resident #24) reviewed for medication storage in that: 1. Resident #24's medications were stored without labels, instructions, and or expiration dates. 2. A medication cart containing Resident's medications, was left unsupervised and unlocked. 3. A vial of injectable lidocaine and a medication broncho inhaler were stored in the medication cart with out the packaging as sent from th pharmacy and lacked labels, instructions, and or expiration dates. These failures could place residents at risk for not receiving the therapeutic effects of their medications by not storing all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access. The findings included: 1. A record review of Resident #24's admission record, dated 7/29/2022, revealed an admission date of 5/24/2022 with diagnoses which included vascular dementia (caused when decreased blood flow damages brain tissue), delusional disorder (a mental illness in which a person has delusions, but with no accompanying prominent hallucinations), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A record review of Resident #24's care plan, dated 7/29/2022, revealed, Resident #24 has impaired cognitive function related to a diagnosis of vascular dementia .administer memory enhancing medication as ordered. Assure all medications, laboratory orders, and treatment orders are carried out per doctor's orders daily. A record review of Resident #24's physicians order summary, dated 7/29/2022, revealed medications to be administered, donepezil 5mg give 1 tablet by mouth at bedtime related to vascular dementia; risperidone 0.25mg, give 1 tablet by mouth at bedtime related to delusional disorders; sertraline 25mg, give 0.5 tablet by mouth at bedtime related to major depressive disorder, recurrent mild anxiety disorder. A record review of Resident #24's July medication administration record revealed LVN D recorded, on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675110 If continuation sheet Page 6 of 15 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 675110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cuero Nursing and Rehabilitation Center 1310 E Broadway Cuero, TX 77954 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 7/28/2022 at 9:00 PM, Resident #24 was administered 1 tablet donepezil 5mg 1 tablet; risperidone 0.25mg 1 tablet, and sertraline 25mg ½ tablet. During an observation on 7/29/2022 at 9:26 AM, revealed MA E at the medication cart. MA E opened the 1st drawer of the medication cart and revealed a small clear white pill cup with a name written on the cup. The cup contained 3 pills (1 lite blue round pill, 1 small round orange pill, and 1 half of an oval green pill). During an interview on 7/29/2022 MA E stated the pills were a mystery I don't know whose they are or who put them here . I will show and report them to the DON. MA E stated the pills should not have been in the cart. MA E stated the pills could have been mistaken by a staff member and administered to the wrong Resident. MA E stated she never pre-pours medications. MA E stated pre-pouring refers to preparing and dispensing someone's medications and storing them for a later administration. During an interview on 7/30/3022 at 1:01 PM the DON stated she was given a report of the pre-poured medications discovered in the medication cart by MA E. the DON stated her investigation revealed LVN D had pre-poured the medication on the evening of 7/28/2022 with the intent of administering them to Resident #24 when he was distracted and stored the medications in the cart. The DON stated, LVN D told her, Resident #24 fell and I forgot his medications. The DON stated LVN D did not administer Resident #24's medications on the evening of 7/28/2022 but did document in Resident #24's medication administration record as if he had administered Resident #24's medications. The DON stated this practice was not the facility expectation or training. The DON stated she initiated a medication error incident investigation and would report the incident to the Resident, the Resident's representative, the physician, and the QAPI committee. The DON stated LVN D would receive disciplinary action and re-enforced training for medication administration. The DON stated the failure rested upon LVN D and could have place Resident #24 at risk for not receiving the therapeutic effects of the medications prescribed. 2. During an observation on 7/27/2022 at 11:09 AM revealed RN F left the medication cart, located on 600-hall, unlocked and unattended when RN F entered Residents #9 and #14's room, RN F then exited and entered Resident #31's room, and exited down the hall out of sight, leaving the 600-hall medication cart unattended and unlocked. During an observation on 7/27/2022 from 11:14 to 11:20 AM revealed the medication cart was unattended and unsecured with 3 separate staff passing by the cart. During an observation on 7/27/2022 at 11:22 AM RN F returned to the 600-hall medication cart. During an interview on 7/27/2022 at 11:23 AM RN F stated she did leave the medication cart unattended and unlocked. RN F stated, .I am new to the facility .and I am unfamiliar with the medication cart .I know I should have locked the cart every time I leave it. RN F stated the failure to secure the cart could have resulted in missing and or misappropriated medications. RN F stated the medication cart stored medications, including narcotics, for Residents of 600-hall. During an interview on 7/27/2022 at 4:45 PM the DON stated the facility policy, training, and expectation was for all medication carts to be locked when not attended. The DON stated RN F would receive re-enforced training for medication / medication cart safety. The DON stated residents could have been placed at risk by not having their medications secured, e.g., medications could have gone missing, medications could have been taken by residents for whom the medications were not intended. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675110 If continuation sheet Page 7 of 15 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 675110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cuero Nursing and Rehabilitation Center 1310 E Broadway Cuero, TX 77954 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some DON stated the failure was due to RN F not following professional standards, facility policy and training for medication storage. 3. During an observation on 7/28/2022 at 12:54 PM revealed LVN G attending the medication cart on 500-hall. Further observation revealed LVN G opened the top drawer of the medication cart and revealed 1 clear liquid vial and 1 broncho inhaler. The vial was not in the original pharmacy packaging and not labeled with any resident's name. The broncho inhaler was not in the original pharmacy packaging and not labeled with any resident's name. The vial was labeled as Lidocaine HCL Injection 1% 100mg/10ml, (10mg/ml), for infiltration and nerve block. Not for epidural or caudal use. 10ml multiple dose vial, RX only. The broncho inhaler was labeled as albuterol sulfate inhalation aerosol, 90mcg per actuation, for oral inhalation with enclosed actuator only, 200 metered inhalations, RX only, 8.5 grams net contents. During an interview on 7/28/2022 at 12:56 PM LVN G stated she did not know the origin of the lidocaine vial or the albuterol inhaler. LVN G stated she would report the vial and broncho inhaler to the DON. LVN G stated all medications should be kept in their original pharmacy packaging with the pharmacy label which would indicate the residents name, drug, and instructions. During an interview on 7/29/2022 at 1:10 PM, the DON stated all medications in the facility were received from the pharmacy and were stored in the original pharmacy packaging with the pharmacy label indicating the Resident's name, drug, dosage, and instructions for administration, and expiration date. The Administrator stated the lidocaine vial and broncho inhaler should not have been stored outside of their original pharmacy packaging without labels and were returned to the pharmacy for disposal. The DON stated the practice of storing medications outside of the pharmacy packaging without labels placed residents at risk, e.g., residents could receive unintended medications. The DON stated the failure was due to staff not following standard professional practices and facility policies for medication storage. During an interview on 7/29/2022 at 5:02 PM the Administrator stated she received report that LVN D stored Resident #24's medications in a pill cup, RN F left the 600-hall cart unattended and unlocked, and 2 medications were stored in the 500-hall cart without labels. The Administrator stated the practice could have placed residents at risk for not having their medications secured and was not tolerated. The Administrator stated the incidents would generate incident reports with QAPI follow up and disciplinary actions with re-enforced training for staff. A record review of the facility's Medication Administration policy, dated 10/1/2019, revealed, The facility maintains equipment and supplies necessary for the preparation and administration of medications to residents. The mobile medication cart will be used to facilitate administration of medications to residents. The purpose of the mobile medication system is to ensure appropriate control and surveillance of residents assigned medications. Procedure .medcarts .the medication cart is locked at all times when not use .do not leave the medication cart unlocked or unattended in resident care areas . Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675110 If continuation sheet Page 8 of 15 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 675110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cuero Nursing and Rehabilitation Center 1310 E Broadway Cuero, TX 77954 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 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observations, interviews, and record reviews the facility failed to ensure assessments accurately reflected Resident statuses for 1 of 3 residents (Resident #24) reviewed for accuracy of assessments. Residents Affected - Few LVN D recorded Resident #24's medications as administered when Resident #24 did not receive his medications. This failure could place residents at risk for harm by not accurately reflecting their health status. The findings included: A record review of Resident #24's admission record, dated 7/29/2022, revealed an admission date of 5/24/2022 with diagnoses which included vascular dementia (caused when decreased blood flow damages brain tissue), delusional disorder (a mental illness in which a person has delusions, but with no accompanying prominent hallucinations), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A record review of Resident #24's care plan, dated 7/29/2022, revealed, Resident #24 has impaired cognitive function related to a diagnosis of vascular dementia .administer memory enhancing medication as ordered. Assure all medications, laboratory orders, and treatment orders are carried out per doctor's orders daily. A record review of Resident #24's physicians order summary, dated 7/29/2022, revealed medications to be administered, donepezil 5mg give 1 tablet by mouth at bedtime related to vascular dementia; risperidone 0.25mg, give 1 tablet by mouth at bedtime related to delusional disorders; sertraline 25mg, give 0.5 tablet by mouth at bedtime related to major depressive disorder, recurrent mild anxiety disorder. A record review of Resident #24's July medication administration record revealed LVN D recorded, on 7/28/2022 at 9:00 PM, Resident #24 was administered 1 tablet donepezil 5mg 1 tablet; risperidone 0.25mg 1 tablet, and sertraline 25mg ½ tablet. During an observation on 7/29/2022 at 9:26 AM, revealed MA E at the medication cart. MA E opened the 1st drawer of the medication cart and revealed a small clear white pill cup with a name written on the cup. The cup contained 3 pills (1 lite blue round pill, 1 small round orange pill, and 1 half of an oval green pill). During an interview on 7/29/2022 at 12:30 PM MA E stated the pills were a mystery I don't know whose they are or who put them here . I will show and report them to the DON. MA E stated the pills should not have been in the cart. MA E stated the pills could have been mistaken by a staff member and administered to the wrong Resident. MA E stated she never pre-pours medications. MA E stated pre-pouring refers to preparing and dispensing someone's medications and storing them for a later administration. During an interview on 7/30/3022 at 1:01 PM the DON stated she was given a report of the pre-poured (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675110 If continuation sheet Page 9 of 15 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 675110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cuero Nursing and Rehabilitation Center 1310 E Broadway Cuero, TX 77954 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medications discovered in the medication cart by MA E. The DON stated her investigation revealed LVN D had pre-poured the medication on the evening of 7/28/2022 with the intent of administering medications to Resident #24 when he was distracted and stored the medications in the cart. The DON stated, LVN D claimed, Resident #24 fell and I forgot his medications. The DON stated LVN D did not administer Resident #24's medications on the evening of 7/28/2022 but did document in Resident #24's medication administration record as if he had administered Resident #24's medications. The DON stated this practice is not the facility expectation or training. The DON stated she initiated a medication error incident investigation and would report the incident to the Resident, the Resident's representative, the physician, and the QAPI committee. The DON stated LVN D would receive disciplinary action and re-enforced training for medication administration. The DON stated the failure rested upon LVN D and could have place Resident #24 at risk for not receiving the therapeutic effects of the medications prescribed. A record review of the facility's Medication Administration policy, dated 10/1/2019, revealed, document administered medications as they are passed. Medications not given are logged with an initial and circled in the proper time slot. An explanation is provided on the back of the medication administration record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675110 If continuation sheet Page 10 of 15 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 675110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cuero Nursing and Rehabilitation Center 1310 E Broadway Cuero, TX 77954 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 7 of 7 Residents (Resident's #11, #77, #187, #188, #189, #190, and #192) reviewed for infection control. Residents Affected - Some 1. CNA, I did not don or doff PPE per CDC and facility guidelines., CNA I wore the same N95 FFR in between serving and assisting COVID-19 Residents and non-COVID-19 Residents with their lunch. a. The FSM did not don COVID-19 PPE, other than a N95 FFR, prior to entering Resident #187's presumed COVID-19 room and did not doff the N95 FFR after she exited the residents' room to return to the kitchen. b. All the residents' doors, in the presumed COVID-19 and COVID-19 500-hall, presented open. These failures could place residents at risk for harm by contracting the COVID-19 virus during a pandemic. The findings included: 1. A record review of Resident #11's admission record, dated 7/28/2022, revealed an admission date of 10/30/2022 with diagnoses which included COVID-19, neurogenic bladder(lack of bladder control), and aphasia (damage to one or more of the language areas of the brain). A record review of Resident #11's care plan dated 7/28/2022, revealed, Resident #11 is at high risk for exposure to COVID-19 due to living in close proximity to others and frequent interaction with caregivers and staff. A record review of Resident #192's baseline care plan dated 7/28/2022 revealed an admission date of 7/23/2022 with diagnoses which included COVID-19 and hypertension (high blood pressure). A record review of Resident #192's care plan dated 7/28/2022, revealed, Resident #192 is at high risk for exposure to COVID-19 due to living in close proximity to others and frequent interaction with caregivers and staff. A record review of Resident #77's care Plan dated 7/28/2022, revealed an admission date of 2/25/2021 with diagnoses which included Alzheimer's disease (a progressive neurologic disorder that causes the brain to shrink (atrophy) and brain cells to die), dementia (the loss of cognitive functioning), and osteoporosis (a disease that weakens bones). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675110 If continuation sheet Page 11 of 15 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 675110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cuero Nursing and Rehabilitation Center 1310 E Broadway Cuero, TX 77954 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A record review of Resident #77's care plan dated 7/28/2022, revealed, Resident #77 is at high risk for exposure to COVID-19 due to living in close proximity to others and frequent interaction with caregivers and staff. A record review of Resident #187's baseline care plan dated 7/28/2022 revealed an admission date of 7/19/2022 with diagnoses which included hypertension (high blood pressure) and type II diabetes. A record review of Resident #187's care plan dated 7/28/2022, revealed, Resident #187 is at high risk for exposure to COVID-19 due to living in close proximity to others and frequent interaction with caregivers and staff. A record review of Resident #188's admission record, dated 7/28/2022, revealed an admission date of 7/25/2022 with diagnoses which included chronic pulmonary obstructive disease (a group of diseases that cause airflow blockage and breathing) and dependence on supplemental oxygen. A record review of Resident #188's care plan dated 7/28/2022, revealed, Resident #188 is at high risk for exposure to COVID-19 due to living in close proximity to others and frequent interaction with caregivers and staff. A record review of Resident #189's admission record, dated 7/28/2022, revealed an admission date of 7/22/2022 with diagnoses which included pulmonary fibrosis and dementia. A record review of Resident #189's care plan dated 7/28/2022, revealed, Resident #189 is at high risk for exposure to COVID-19 due to living in close proximity to others and frequent interaction with caregivers and staff. A record review of Resident #190's admission record, dated 7/27/2022, revealed an admission date of 7/25/2022 with diagnoses which included atherosclerotic heart disease (narrowed / blocked arteries) and pulmonary edema (too much fluid in the lungs). A record review of Resident #190's care plan dated 7/27/2022, revealed, Resident #189 is at high risk for exposure to COVID-19 due to living in close proximity to others and frequent interaction with caregivers and staff. b. During an observation on 7/27/2022 at 11:26 AM revealed the facility utilized the 500-hall as their presumed COVID-19 and COVID-19 hall. Observation of the 500-hall revealed Resident doors open , fresh PPE supplies stored in hangers which were hung on the Resident's door . Further observation revealed, no PPE doffing waste receptacles in the hallway and residents on isolation droplet transmission-based precautions had their doors open, to include Resident's in the presumed COVID-19 area, #187, #188, #189, and #190. The residents who resided on the COVID-19 area, Residents #11, and #192 also presented with their doors opened. During a record review on 7/27/22, at 11:35 AM, revealed Resident #187's room with signage that read, Droplet Isolation .See Charge Nurse Before Entering .PPE required for staff / visitors; face shield or goggles, gloves, gown, N95 respirator .Droplet Isolation Donning and Doffing procedure; How to put on (Don) PPE gear; 1. Perform hand hygiene, 2. Put on isolation gown, 3. Put surgical mask over n95 respirator to allow for reuse of N95 respirator, 4. Put on face shield or goggles, 5. Put on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675110 If continuation sheet Page 12 of 15 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 675110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cuero Nursing and Rehabilitation Center 1310 E Broadway Cuero, TX 77954 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 0880 Level of Harm - Minimal harm or potential for actual harm gloves, 6. You may now enter room .How to take off (Doff) PPE gear; 1. Remove gown and peel off your gloves at the same time, only touching the inside of the gloves and gown with your bare hands, 2. You may now exit the room, 3. Perform hand hygiene, 4. Remove face shield / goggles, 5. Remove surgical mask covering n95 respirator, 6. Perform hand hygiene. Further observation revealed Residents #188, #189, #190, #11 and #192 had the exact same signage posted by their room doors. Residents Affected - Some Observation on 7/27/2022 at 11:46 AM revealed CNA I entered the 500-hall with a large stainless steel carriage containing Residents' lunch meals. CNA, I wore an N95 FFR green in color. CNA, I proceeded to deliver lunch trays to residents without donning COVID-19 PPE and without doffing COVID-19 PPE. CNA, I entered Resident #187's room and delivered the lunch tray, did not doff the N95 FFR and continued to deliver lunch trays in the same manner to Residents #188, #189, 190. CNA, I arrived at the COVID-19 area of 500-hall and proceeded to practice hand hygiene, donned gloves, gown, a surgical mask over the N95 FFR, and face shield . CNA, I delivered the lunch meal to COVID-19 positive Resident #Resident #11. CNA, I doffed the PPE in Resident #11's room except for the N95 FFR, which CNA I continued to wear and provided hand hygiene, donned gloves, gown, a surgical mask over the N95 FFR, and face shield. CNA, I delivered the lunch meal to COVID-19 positive Resident #Resident #192. CNA, I doffed the PPE in Resident #192's room except for the N95 FFR, which CNA I continued to wear. At 11:58 AM, CNA I exited the COVID-19 area of 500-hall and recovered the meal cart and proceeded to return the meal cart to the kitchen. a. During an observation on 7/27/2022 at 11:48 AM revealed the FSM in Resident #187's presumed COVID-19 room speaking to Resident #187. The FSM wore a N95 FFR as the sole PPE. The FSM was observed to exit the room and after a small interval of time returned to Resident #187's room and continued to not don or doff any PPE other than the N95 FFR the FSM already wore. During an interview on 7/27/2022 at 12:38 PM the FSM stated she had spoken to Resident #187 earlier today (7/27/2022) concerning Resident #187's dietary preferences. The FSM stated she had not donned or doffed any PPE and was not aware of the COVID-19 PPE precautions for Resident #187. The FSM stated she returned to the kitchen in between visits to Resident #187's presumed COVID-19 room. During an interview on 7/27/2022 at 11:59 AM LVN C stated residents at the beginning of 500-hall, Residents #187, #188, #189, and #190, were being monitored for signs and symptoms of COVID-19 due to their exposure to COVID-19, lack of COVID-19 vaccinations, or unknown COVID-19 vaccination status. LVN C stated residents at the end of the hall were segregated due to their positive COVID-19 status and included 2 residents, Resident #11, and Resident #192. LVN C stated COVID-19 PPE should be used when interacting with the 500-hall residents to include doffing the PPE in the room and continuing with the same N95 FFR. During an interview on 7/27/2022 at 2:08 PM, CNA I stated she was the CNA assigned to 500 and 600halls. CNA, I stated 500-hall was the COVID-19 hall with 2 residents in the back were COVID-19 positive and the others are being watched for COVID-19. CNA, I stated she arrived for work today (7/27/2022) at 6:00 AM and donned a fresh N95 FFR. When asked if it was the same N95 FFR CNA I currently wore, CNA I stated, yes, it is. CNA, I stated she did serve lunch to the residents in the presumed COVID-19 area of the 500-hall, Residents #187, #188, #189, and #190. CNA, I stated she did not don and doff PPE in between serving residents. CNA, I stated, I did sanitize my hands in between each Resident. CNA, I stated she did don COVID-19 PPE when she arrived at the COVID-19 area of 500-hall. CNA, I stated she doffed her PPE in the COVID-19 Residents' rooms, except for her N95 FFR, which she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675110 If continuation sheet Page 13 of 15 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 675110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cuero Nursing and Rehabilitation Center 1310 E Broadway Cuero, TX 77954 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some continued to wear through the day. CNA, I stated she was confused as to the COVID-19 PPE donning and doffing protocol and stated she has had conflicting training by the previous DON A. CNA I stated the signage posted directing staff to don and doff PPE was also confusing, it said to don a surgical mask over the N95 FFR and then to doff the surgical mask over the N95 and to continue to wear the N95. CNA, I stated she did not doff the N95 after serving COVID-19 positive residents and then assisted non-COVID-19 Resident #77 to eat her meal. During an interview on 7/27/2022 at 2:50 PM, the DON stated she was the facility's Infection Preventionist. The DON stated the facility's 500-hall was the facility's designated isolation warm and hot zones where residents who were COVID-19 positive reside at the end of the hall and residents who were being monitored for signs and symptoms of COVID-19 reside in the beginning of the hall. The DON stated Residents #11 and #192 were diagnosed as COVID-19 positive and reside at the end of the hall, segregated from the rest of the hall. The DON stated 4 residents, #187, #188, #189, and #190 reside in the warm zone of 500-hall. The DON stated these residents were at risk for contracting COVID-19 due to either not being vaccinated against COVID-19 and / or being exposed to COVID-19 prior to their admission into the facility. The DON stated the rooms themselves are considered the warm / hot zones and the hallway a cold zone. The DON stated the staff were to follow the CDC's guidance for COVID-19 PPE donning and doffing as posted on flyers in the hallway by the Residents' doors detailing instructions for COVID-19 PPE donning and doffing. The DON stated the staff were instructed to don a new N95 FFR at the beginning of their work day and prior to entering a room under presumed COVID-19 or COVID-19 precautions the staff were to: perform hand hygiene, don a gown, gloves, and a face shield; and prior to exiting the COVID-19 precautions room the staff are to: doff the gown, gloves, perform hand hygiene, exit the room, and in the cold zone immediately perform hand hygiene, doff the face shield, and doff the N95 FFR and DON a fresh N95 FFR prior to continuing work duties. The DON stated this was the procedure for all staff who entered COVID-19 or presumed (warm) COVID-19 rooms. The DON stated the signage would be removed immediately and the entire staff would receive re-enforced training for COVID-19 PPE donning and doffing procedures. The DON stated the failure was upon the previous DON and herself by not communicating the CDC / facility guidelines for COVID-19 PPE donning and doffing procedures. The DON stated the failure could expose residents and staff to the COVID-19 virus and could cause residents and staff to contract the COVID-19 virus during a pandemic. When asked for the facility's COVID-19 infection control prevention policy the DON stated the facility followed the CDC's COVID-19 prevention guidelines. A record review on 7/27/2022 of the CDC's website, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated Feb. 2, 2022. Source control options for HCP include: A NIOSH-approved N95 or equivalent or higher-level respirator OR A respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators (Note: These should not be used instead of a NIOSH-approved respirator when respiratory protection is indicated) OR a well-fitting facemask. When used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged, or hard to breathe through. If they are used during the care of patient for which a NIOSH-approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH-approved N95 or equivalent or higher-level respirator) during the care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675110 If continuation sheet Page 14 of 15 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 675110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cuero Nursing and Rehabilitation Center 1310 E Broadway Cuero, TX 77954 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some of a patient with SARS-CoV-2 infection, facemask during a surgical procedure or during care of a patient on Droplet Precautions, they should be removed and discarded after the patient care encounter and a new one should be donned. 2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection The IPC recommendations described below also apply to patients with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for empiric Transmission-Based Precautions (quarantine) based on close contact with someone with SARS-CoV-2 infection. However, these patients should NOT be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing. Patient Placement Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). The patient should have a dedicated bathroom. Facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with SARS-CoV-2 infection. Dedicated means that HCP are assigned to care only for these patients during their shifts. Only patients with the same respiratory pathogen should be housed in the same room. Limit transport and movement of the patient outside of the room to medically essential purposes. Communicate information about patients with suspected or confirmed SARS-CoV-2 infection to appropriate personnel before transferring them to other departments in the facility (e.g., radiology) and to other healthcare facilities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675110 If continuation sheet Page 15 of 15