Health inspection·September 15, 2023

F 0640 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 09/15/2023 at 11:20 AM with the SSD revealed Resident #74 was discharged to the community with home health and that was his discharge plan since his admission. Interview on 09/15/2023 at 1:47 p.m. with LVN B (Care Management Specialist and MDS Nurse) revealed that she did not know why she coded Resident #74's discharge MDS wrong. She stated she knew he was discharged to the community and she sent CMS a corrected MDS already. She stated it was important to know what his disposition and status was for follow-up care at the time of his discharge. Record review of CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, October 2019 revealed The RAI process has multiple regulatory requirements .the assessment accurately reflects the resident's status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675110 If continuation sheet Page 2 of 13 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 09/15/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 8 residents (Resident #277) reviewed for baseline care plan, in that: The facility failed to ensure Resident #277's baseline care plan included information related to resident's use of oxygen therapy. This failure could place newly admitted residents at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met. The findings were: Record review of Resident #277's face sheet, dated 09/15/2023, revealed an admission date of 09/01/2023 with diagnoses that included: secondary malignant neoplasm (cancerous tumor) of brain, malignant neoplasm (cancerous tumor) of upper lobe, pulmonary hypertension (increased blood pressure in the arteries of the lungs) and chronic obstructive pulmonary disease (progressive lung disease; long term respiratory symptoms and airflow limitation). Record review of Resident #277's admission MDS, dated [DATE], revealed a BIMS score of 15, which indicated the resident's cognition to be intact. Further review in Section O, Special Treatments, Procedures, and Programs, revealed Resident #277 had received Oxygen therapy and Non-Invasive Mechanical Ventilator (BiPaP/CPAP) both while not a resident at the facility and while a resident of the facility within the last 14 days. Record review of Resident #277's baseline care plan, effective date 09/01/2023, revealed no focus area for Resident #277's oxygen therapy needs. Record review of Resident #277's Order Summary Report, Active Orders as of 09/15.2023 revealed an order, Apply O2 at 5LPM via NC continuous. every shift related to MALIGNANT NEOPLASM OF UPPER LOBE, LEFT BRONCHUS OR LUNG, with a start date of 09/01/2023 and a second order, Place CPAP on at HS at bedtime, also with a start date of 09/01/2023. Further review of the active orders revealed an order, assess after administering Nebulizer Treatment two times a day with a start date of 09/05/2023. In an observation and interview with Resident #277 on 09/12/2023 at 1:35 p.m., Resident #277 was observed with O2 at 5 LPM. Resident #277 CPAP was observed lying on the bedside table. Resident #277 revealed the CPAP machine belonged to her, that she used it each night and had used the CPAP prior to moving into the facility. In an interview with LVN F on 09/15/2023 at 1:57 p.m., LVN F confirmed Resident #277's oxygen and CPAP requirements were not addressed in the baseline care plan. LVN F stated she had included Resident #277's respiratory issues in her initial nursing assessment however the baseline care plan did not have a respiratory section to complete. In an interview with the DON on 09/15/2023 at 2:37 p.m., the DON confirmed Resident #277's oxygen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675110 If continuation sheet Page 3 of 13 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 09/15/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete therapy to include oxygen and CPAP use should have been included on her baseline care plan. The DON stated not having oxygen therapy on the care plan could place residents at risk of not receiving continuity of care. Record review of the facility's policy titled, Baseline Care Plan, date implemented 10/22/2022, revealed, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Event ID: Facility ID: 675110 If continuation sheet Page 4 of 13 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 09/15/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to review and revise the comprehensive person-centered care plan for one resident (#11) out of 8 residents reviewed for comprehensive care plans in that: Resident #11's PRN oxygen or her oxygen saturation checks each shift were not reflected on her care plan since she had them ordered on 06/01/2023. This deficient practice could affect residents who are assessed and have care plans and places them at risk for not receiving necessary care. The findings included: Record review of Resident #11's electronic face sheet dated 09/14/2023 revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE]. She had diagnoses which included: Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), rheumatoid arthritis f(an autoimmune inflammatory disease which attacks healthy cells in the body by mistake causing painful swelling and inflammation of joints), delusional disorders (unshakable belief in something that's not true), heart failure (condition that develops when the heart doesn't pump enough blood for the body's needs) and parainfluenza pneumonia (human parainfluenza viruses which cause respiratory infections). Record review of Resident #11's SCSA MDS dated [DATE] reflected she scored a 03/15 on her BIMS which indicated she was severely cognitively impaired. Further review revealed she received oxygen therapy while a resident at the facility. Record review of Resident #11's comprehensive person-centered care plan with a revision date of 07/11/2023 reflected Focus .is at high risk for communicable respiratory infections influenza pneumonia .05/25/2023. Further review revealed no oxygen therapy or oxygen saturation checks each shift was reflected. Record review of Resident #11's Active Orders As of: 09/14/2023 reflected Oxygen at 2 LPM via N/C every 1 hours as needed related to PNEUMONIA, UNSPECIFIED ORGANISM to keep O2 saturations above 94%Active 06/02/2023 . Oxygen Saturation - Check every shift related to PNEUMONIA, UNSPECIFIED ORGANISM To keep O2 SATS above 94% ** See PRN O2 order **Active 06/02/2023. Record review of Resident #11's MAR dated 09/01/2023 to 09/30/2023 reflected she had oxygen saturation checks recorded on each shift and she had not required the PRN oxygen. Observation on 09/12/2023 at 10:40 a.m. of Resident #11 revealed she was sitting up in a tall wheelchair in her room, and there was an oxygen concentrator in her room. Interview on 09/15/2023 at 1:47 p.m. with LVN C, who completed the comprehensive care plan revealed that Resident #1 was on oxygen when she had pneumonia in June and that she still had an as needed order which was not reflected in her care plan. She stated Resident #1 received oxygen saturation checks each shift and it was an important ongoing part of her care. She confirmed that the PRN oxygen and saturation checks needed to be a part of Resident #1's care plan and it was missed. She stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675110 If continuation sheet Page 5 of 13 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 09/15/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that as major changes or orders for a resident have occurred the care plan needed to be revised and her SCSA MDS triggered her use and need for oxygen. Interview on 09/15/2023 at 2:00 p.m. with the DON revealed Resident #11's comprehensive person-centered care plan needed to address her oxygen saturation checks and PRN oxygen because that was an important part of her care and if missed could result in a compromised cardiac or respiratory issue not being addressed. Record review of the facility policy and procedure titled Care Plan Revisions Upon Status Change dated 10/24/202 reflected The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Record review of CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, October 2019 revealed Care Plan Completion .SCSA's .in these cases the care plan will already be in place. Review of the CAA's (Care Area Assessments) when the MDS is complete for these assessment types should raise questions about the need to modify or continue services and result in either the continuance or revision of the existing care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675110 If continuation sheet Page 6 of 13 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 09/15/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals for 3 residents (#15, #41 and #127) out of 6 residents observed for oxygen therapy in that: Residents Affected - Some 1. Resident #15's nasal cannula tubing was lying on her bed and not placed in the plastic bag provided at her bedside when not in use. 2. Resident #41's oxygen nebulizer mask was unbagged when not in use. 3. Resident #127's oxygen nebulizer mask was unbagged when not in use. These deficient practices could affect residents on oxygen and nebulization therapy and place them at risk for respiratory distress. The findings included: 1. Record review of Resident #15's electronic face sheet dated 09/14/2023 reflected she was initially admitted to the facility on [DATE] and readmitted on [DATE]. She had diagnoses which included: dementia, a range of conditions that affect the brain's ability to think, remember and function normally) acute bronchitis (condition when the lining of the bronchial tube which carries air to and from the lungs is inflamed and can cause shortness of breath), hypoxemia (underlying illness that affects blood flow or breathing which leads to low oxygen levels in the blood) and Parkinson's disease (condition that affects the brain and causes problems with movement, balance and coordination). Record review of Resident #15's quarterly MDS assessment with an ARD of 08/31/2023 revealed she scored a 02/15 on her BIMS which indicated she was severely cognitively impaired. Further review reflected she was on oxygen therapy while a resident at the facility. Record review of Resident #15's comprehensive person-centered care plan with a revision date of 09/12/2023 reflected Focus .is at risk for ineffective breathing pattern related to .acute bronchitis .Interventions .oxygen as ordered. Record review of Resident #15's Active Orders As of: 09/14/2023 reflected Oxygen at 2 LPM via nasal cannula every shift for Hypoxemia **May be off for short periods', Active 12/05/2022. Record review of Resident #15's MAR dated 09/01/2023 to 09/30/2023 reflected she received oxygen at 2 LPM via nasal cannula every shift for her hypoxemia. Observation on 09/12/2023 at 10:30 a.m. of Resident #15's room revealed her oxygen nasal cannula tubing was lying on her bed and not placed in the plastic bag by her bedside stand. Observation on 09/14/2023 at 1:30 p.m. of Resident #15 revealed she was lying in bed with her oxygen nasal cannula on and her concentrator was set at 2 LPM. Interview on 09/15/2023 at 08:32 a.m. with CN A D revealed she was the C NA on the hall with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675110 If continuation sheet Page 7 of 13 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 09/15/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #15 on 09/12/2023 and may have set her oxygen nasal cannula tubing on her bed instead of placing it in the plastic bag beside her bed. She stated it was important to place the tubing into a plastic bag to keep any dirt or dust from getting into the tubing which would cause respiratory distress. Interview on 09/15/2023 at 2:00 p.m. with the DON revealed staff are trained to place oxygen tubing and breathing equipment when not in use into the plastic bags to prevent them from getting soiled or damaged which could cause respiratory compromise. Record review of facility policy and procedure titled Oral Inhalation Administration revised date 10/01/19 reflected Store oxygen tubing and mask in plastic bag when not in use. 2. Record review of Resident #41's electronic face sheet, dated 09/13/2023, revealed an initial admission date of 02/27/2023 and re-admission date of 07/06/2023 with diagnoses that included: chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), sepsis (blood poisoning), emphysema (lung condition that causes shortness of breath), and chronic respiratory failure with hypoxia (decreased level of oxygen in all or part of your body) and hypercapnia (CO2 retention, condition of abnormally elevated carbon dioxide levels in the blood). Record review of Resident #41's Quarterly MDS, dated [DATE], revealed a BIMS score of 12, which indicated moderate cognitive impairment. Further review revealed the assessment indicated Resident #41 had received oxygen therapy during the 14-day look back period. Record review of Resident #41's care plan, last review date 09/05/2023, revealed a focus area [Resident #41] is at risk for ineffective breathing pattern related to DX: COPD, CHF, CKD 3b, Chronic Hypoxic & Hypercapnic Respiratory Failure, Cirrhosis, Pleural Effusion, Emphysema, Chronic Dyspnea, & Chronic Pulmonary Edema and a goal for optimal breathing patterns through review date initiated 02/27/2023, with a revision on 07/12/2023 and target date of 10/12/2023. Further review of Resident #41's care plan revealed an intervention Administer routine and PRN nebulizer treatments as ordered/needed. Following surveyor intervention, a record review of Resident #41's care plan revealed [Resident] has been noted removing his nebulizer mask and setting it at his bedside. He will take his oxygen off and throw tubing down, on the bed, bedside table & floor at times, with a revision date of 09/12/2023. Record review of Resident #41's active orders, dated 09/13/2023, revealed an order for Budesonide Inhalation Suspension 0.5 MG/2ML (Budesonide (Inhalation)) 1 vial inhale orally two times day for COPD rinse mouth after use, with a start date of 07/14/2023 and DuoNeb Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 unit inhale orally every 6 hours as needed for COPD related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED with a start date of 07/10/2023. An observation and interview with Resident #41 on 09/12/2023 at 11:44 a.m., revealed Resident #41's nebulizer mask was hanging between the bed and bedside table unbagged. Resident #41 revealed nursing staff perform nebulizer treatments. He stated, I don't fool with it here like I did at home, they come in and do it when it's time. Resident #41 stated he was not aware of a bag for his nebulizer mask. 3. Record review of Resident #127's electronic face sheet, dated 09/13/2023, revealed an admission date of 07/28/2023 with diagnoses that included: aftercare following explantation of hip joint (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675110 If continuation sheet Page 8 of 13 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 09/15/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some prosthesis, polyosteorarthritis (any type of arthritis that involves 5 or more joints simultaneously) and emphysema (lung condition that causes shortness of breath). Record review of Resident #127's admission MDS, dated [DATE], revealed a BIMS score of 12, which indicated moderate cognitive impairment. Further review of the assessment revealed Resident #127 had not received oxygen therapy within the 14-day look back period. Record review of Resident #127's care plan, last review date 08/14/2023, revealed a focus area [Resident] is at risk for ineffective breathing pattern related to DX: Emphysema, CHF, & Allergic Rhinitis with an intervention Administer nebulizer treatments as ordered. Record review of Resident #127's active orders, dated 09/13/2023, revealed an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally every 4 hours as needed for CHF, with a start date of 08/23/2023. An observation and interview with Resident #127 on 09/12/2023 beginning at 1:00 p.m., revealed Resident #127's nebulizer mask resting on top of the bedside table behind his bed was unbagged. Resident #127 stated he had not taken a treatment in a long time and would refuse them because they make me cough so hard I can't breathe. In an observation and interview with the ADON on 09/12/2023 beginning at 1:10 p.m., the ADON stated Resident #41's nebulizer mask should have been bagged. The ADON revealed an uncovered mask could place the resident at risk of a respiratory infection. In an observation and interview with the ADON on 09/12/2023 beginning at 1:17 p.m., the ADON confirmed Resident #127's nebulizer mask should have been bagged. The ADON revealed she felt the resident removed the mask from the plastic bag at times. The ADON further stated that both nursing and CNA staff can ensure the resident's nebulizer masks remain in a plastic bag each time they are in the room. In an interview with the DON on 09/14/2023 at 3:53 p.m., the DON confirmed all respiratory masks should be placed in a plastic bag and dated when not in use to prevent respiratory infections. Record review of the facility's policy titled Medication Administration: Oral Inhalation Administration revised date 10/01/19 revealed Nebulizer - 23. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675110 If continuation sheet Page 9 of 13 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 09/15/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one resident (#58) out of 7 residents reviewed for medication administration in that: CMA E left Resident #58's lactulose (used to treat high ammonia levels in the blood which can lead to loss of brain function for people with liver disease) at his bedside for him to take and she did not observe the resident take the medication. This deficient practice could affect residents with medications and place residents at risk for aspiration or not taking required medications. The findings included: Record review of Resident #58's electronic face sheet dated 09/14/2023 reflected he was initially admitted to the facility on [DATE]. He had diagnoses which included: Alzheimer's disease (type of dementia that damages the brain and affects memory, thinking and behavior), anxiety (common emotion that helps people cope with stress, but sometimes becomes overwhelming and interferes in daily living), and cirrhosis of liver (a degenerative disease of the liver resulting in scarring and liver failure), Record review of Resident #58's quarterly MDS assessment with an ARD of 05/31/2023 revealed he scored a 15/15 on his BIMS which indicated he was cognitively intact. Further review reflected he needed supervision and oversight with his ADL's. Record review of Resident #58's Active Orders As of: 09/14/2023 reflected Lactulose Oral Solution 20 GM/30ML (Lactulose) Give 30 ml by mouth two times a day for elevated ammonia Active 01/12/2023. Record review of Resident #58's MAR dated 09/01/2023 to 09/30/2023 reflected he received Lactulose Oral Solution 20 GM/30ML two times a day for elevated ammonia and was initialed off for his 5:00 p.m. dose on 09/14/2023. Observation on 09/14/2023 at 4:38 p.m. of Resident #58 was sitting on the side of his bed yelling for someone to come in and help him. His medication cup with his Lactulose Oral Solution was tipped over on his bed side stand and dripping down onto his sheet between his legs. When asked by the surveyor who left the medication with him, he stated the aide who entered back into the room. Interview on 09/144/2023 at 5:00 p.m. with CMA E, she stated she left the Resident #58's Lactulose Solution by his bedside as she went to check on his snack. She stated she knew she should not have left the medicine there because he could spill it or choke. She further stated she was trained to watch the resident take medication for safety reasons. Interview on 09/14/2023 at 5:15 p.m. with the DON, she stated CMA E knew better than to leave medication at the bedside. She stated Resident #58 needed supervision and leaving a medication at the bedside could place a resident at risk of choking or spilling their medication which they require for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675110 If continuation sheet Page 10 of 13 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 09/15/2023 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 0755 their disease process. Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy and procedure titled Medication Administration dated 10/24/22 reflected Observe resident's consumption of medication. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675110 If continuation sheet Page 11 of 13 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 09/15/2023 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 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews the facility failed to have medical records that were in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for one resident (#129) of 8 residents reviewed for clinical records in that: The facility was aware that Resident #129's Full Code status was changed to DNR and the physician orders in the clinical record were not updated until 9 days later. This deficient practice could affect residents who desire advanced directives and place them at risk for receiving full code measures when they wanted to have DNR status. The findings included: Record review of Resident #129's electronic face sheet dated [DATE] reflected he was admitted to the facility on [DATE]. He had diagnoses which included: alcoholic cirrhosis of liver with ascites (type of end-stage liver disease caused by years of heavy drinking), anemia (deficiency of healthy red blood cells essential to carry oxygen to all parts of the body and could cause fatigue) and hypertensive heart and kidney disease with heart failure (high blood pressure causes damage to the blood vessels and filters in the kidney, making removal of waste from the body difficult leading to heart failure). Record review of Resident #129's entry tracking record MDS dated [DATE] revealed he was admitted from an acute hospital setting. Record review of Resident #129's Nursing-Initial Baseline/Advanced Care Plan-V2 dated [DATE] reflected he answered the questions himself and he did not have advanced directives and was checked off on code status as full code. Record review of Resident #129's comprehensive person-centered care plan date initiated as [DATE] revealed Focus .is a DNR .Interventions .Ensure signed DNR is in medical record. Record review of Resident #129's Active Orders As of: [DATE] reflected CPR (Full Code) Active [DATE]. Record review of Resident #129's OOH DNR Order dated [DATE] reflected the physician signed the document on [DATE]. Observation on [DATE] at 4:00 p.m. of Resident #129 revealed he was in his room lying on his bed. Interview on [DATE] at 4:03 p.m. with Resident #129 he stated he did not want any life saving measures and wanted DNR status. Interview on [DATE] at 2:00 p.m. with the SSD revealed that Resident #129's DNR paperwork was signed and back on [DATE]. He stated he must have missed not getting it in or communicating the information to the nursing staff so Resident #129's physician orders would be updated to reflect his status (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675110 If continuation sheet Page 12 of 13 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 09/15/2023 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 of DNR and not Full Code. He stated it was important because the resident did not want CPR and if the nurse did not check the right record, he could get CPR. Interview on [DATE] at 2:15 p.m. with the DON, she stated she did not know what happened and why the information took 9 days to be updated once the facility had the paperwork. She stated it was important to know and accommodate the resident's wishes. Record review of the facility policy and procedure titled Communication of Code Status dated [DATE] reflected When an order is written pertaining to a resident's presence or absence of an Advance Directive, the directions will be clearly documented in the physician orders section of the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675110 If continuation sheet Page 13 of 13