Health inspection·July 2, 2024

F 0580 o Level of Harm - Minimal harm or potential for actual harm Resident # 1 was on hemodialysis related to end stage renal disease on Monday, Wednesday and Friday at 11:30 am. Days may vary based on holidays and dialysis center schedule. Goals include intervention should any s/sx of complication from dialysis occurs. Interventions incudes monitor vital signs and notify MD of significant. Residents Affected - Few Record review of Resident #1's progress note dated 6/23/2023 at 12:10 pm, LVN A wrote Resident with BGS of 47, this nurse provided snack and drink to resident and stayed at bedside. Rechecked BGS approximately 10 minutes later and sugar was 157. No hypoglycemic symptoms displayed during this episode. Record review of Resident # 1's Blood Sugar Summary for June 2024 revealed: o 6/23/2024 at 7:53 am blood sugar was 167 mg/dl o 6/23/2024 at 11:47 am blood sugar was 47 mg/dl o 6/23/2024 at 6:28 pm blood sugar was 226 mg/dl o 6/23/2024 at 10:01 pm blood sugar was 122 mg/dl Record review of Resident # 1's reviewed on 5/28/2024 revealed: o Novolog injection solution 100 unit/ml-insulin aspart (an insulin analog indicated to improve glycemic control in patients with diabetes mellitus). Directions: inject 10 unit subcutaneous; start date 6/3/2024. End date: open ended o Give a peanut butter and jelly sandwich. Directions: at bedtime for Diabetes Mellitus; start date 5/1/2024. End date: open ended o Ozempic (0.25 or 0.5 mg/dose) Subcutaneous solution pen injector 2mg/3/ml (Semaglutide). Direction: Inject 0.5 mg subcutaneous; start date 4/29/2024. End date: open ended o (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675361 If continuation sheet Page 2 of 4 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 675361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wharton Nursing and Rehabilitation Center 1220 Sunny Lane Wharton, TX 77488 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Novolog Injection Solution 100 unit/ml (insulin aspart). Directions: Inject as per sliding scale; start date 3/27/2024. End date: open ended o ACCUCHECKS before meals and at bedtime. Directions: before meals and at bedtime; start date 6/22/2023. End date: open ended o Glucan emergency injection kit 1 mg (Glucagon rDNA). Directions: Inject 1 dose intramuscular; start date 6/21/2023. End date: open ended In an interview with Relative # 1 on 6/27/2024 at 10:30 am she stated that Resident # 1 was a diabetic. She stated that on 6/23/2024 Resident # 1's sugar was 47. She stated that no one from the facility contact her about Resident # 1's change of condition. She stated that on 6/24/2024 LVN A told informed her that Resident # 1's sugar was low on 6/23/2024. She stated that LVN A stated that Resident # 1's sugar was 47 and she gave Resident# 1 cookie and juice. She stated that LVN A rechecked Resident # 1's sugar and Resident # 1's sugar was 150. She stated that LVN A did not contact Resident # 1's doctor or Relative # 1 because Resident # 1 did not have any signs of distress and Resident # 1 was talking to her and stated she was okay. She stated LVN A stated that she stayed by Resident # 1's side and she made certain Resident # 1 was not in distress and not having signs of Hypoglycemia. Relative # 1 stated that she spoke with the Administrator about Resident # 1's sugar levels. She stated that the Administrator stated that she did not know that Resident # 1's sugar dropped as LVN did not notify her, Resident # 1's doctor or the DON. Observation of Resident # 1 on 6/27/2024 at 2:20 pm. Resident # 1 was in a wheelchair and Relative # 1 was taking her out for fresh air. Resident # 1 was non-interview able as she had limited verbal skills. In an interview with LVNA on 6/27/2024 at 4:40 pm she stated she checked Resident #1's sugar on 6/23/2024 at 11:30 am and Resident # 1's sugar was 47. She stated that Resident # 1 had a can of sprite and cookies by her bed. She stated that she gave Resident # 1 sprite and cookies. She stated that Resident # 1 was talking to her and did not have any sign of distress. She stated that 10 minutes later she rechecked Resident # 1's sugar and it was 152. She stated she did not consider this a change of condition because Resident # 1 talking and was not altered. She stated Resident # 1's sugar was out of range. LVN A stated that she apologized to Resident # 1's family. LVN A stated that if a resident's sugar was at 47 the resident could go into a coma and lose consciousness. LVN stated that she did not contract Resident # 1's doctor or representative. LVN A stated that she did not contact the DON. LVN A stated that she in-serviced on change of conditions. In an interview on 6/27/2024 at 4:00 pm with the DON she stated she found out about Resident # 1's low blood sugar on 6/26/2024. She stated LVN A told her Resident # 1's blood sugar was 47 and Resident # 1 did not display hypoglycemia. The DON stated LVN A gave Resident # 1 snacks and rechecked Resident # 1's blood sugar and it was 157. She stated she told LVN A that since Resident # 1's blood sugar was below 60 she should have notified the NP and family. She stated that LVN A did not notify the NP and family because when LVN A rechecked Resident # 1's blood sugar it was within normal range. The DON stated that if a resident's blood sugar is low the resident may experience sweating, confusion, and tremors. She stated that LVN A has been in-serviced on change of condition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675361 If continuation sheet Page 3 of 4 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 675361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wharton Nursing and Rehabilitation Center 1220 Sunny Lane Wharton, TX 77488 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 7/2/2024 at 8:20 pm with the ADON she stated that LVN A reported Resident # 1's low blood sugar after the fact. She stated that when she read the 24 hours report she noticed that Resident # 1's blood sugar was low. She stated LVN A checked Resident # 1's blood sugar and it was low. She stated LVN A gave Resident # 1 snack and later rechecked Resident # 1's blood sugar and it was within normal range. The ADON stated that she could not remember the sugar levels for Resident # 1. The ADON stated she expected the nurses to contact the residents Doctor/NP, family and DON. She stated that LVN A should have contacted the resident's doctor and received orders from the doctor. She stated that staff was in-serviced on change of condition on 6/27/2024. Record review of Notification of Changes policy, dated 10/24/2024, revealed: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician: and notifies consistent with his or her authority, the representative when there is a change requiring notification. Circumstances requiring notification include: 2) Significant change in resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a) Life-threatening conditions or b) Clinical complications Record review of In-service training report: Notification of Change, dated 4/6/2024, revealed For all changes of conditions, please call DON and/or Administrator. Texting is not acceptable. Signed by LVN A on 4/8/2024. Record review of In-Service training report: Notification of Change, dated 6/27/2024, revealed When a resident has any change of condition, the physician, or NP, RP, and DON must be notified. This should be documented in PCC on Change of Condition form and a progress note should be completed with any additional information. Signed by LVN A on 6/27/2024. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675361 If continuation sheet Page 4 of 4