Inspection·October 1, 2023

F 0656 non-adhering pad every shift as ordered by a physician. Level of Harm - Minimal harm or potential for actual harm 3. The facility failed to ensure Resident #3 received wound care and treatment as ordered by a physician. Residents Affected - Some -Resident #3's skin tear to her right calf was not cleansed with cleaner and patted dry followed by application of steri strips until resolved as ordered by a physician. -Resident #3's unstageable pressure ulcer to the right heel did not receive application of 4x4 betadine gauze, cover with dry dressing and wrap with kerlix once per day as ordered by a physician. 4. The facility failed to ensure Resident #4 received wound care and treatment as ordered by a physician. -Resident #4's stage 3 chronic ulcer to right heel did not receive wound cleanser, pat dry apply silvasorb and cover with super absorbent dressing once per day as ordered by a physician. These failures affected and could place additional residents at risk for a delay in treatment, hospitalization, loss of limb and/or a significant decline in health. The findings included: 1. Record review of Resident #1's face sheet dated 9/28/2023 revealed she was [AGE] years of age with an admission date of 1/2/2022 and a readmission date of 6/1/2023 with diagnoses which included: Type 2 diabetes mellitus with diabetic neuropathy, end stage renal disease, major depressive disorder, mild cognitive impairment, dysphagia, cognitive communication deficit, urinary tract infection, degenerative disease of nervous system, lack of coordination, morbid obesity, muscle wasting, anemia in chronic kidney disease, fluid overload, anxiety disorder, cerebral infarction, nausea with vomiting, diarrhea. Record review of Resident #1's comprehensive MDS dated [DATE] revealed a BIMS score of 10 indicating moderate impairment. Further review under category, Skin Conditions, revealed Resident #1 was indicated as having zero venous and arterial ulcers, and no other ulcers, wounds and skin problems. Record review of Resident #1's Care Plan, start date 6/1/2023, stated, (Resident #1) has potential impairment to skin integrity r/t incontinence and decreased mobility. (Resident #1) will be free from skin break down through the review date Interventions included, Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heel, s/sx of infection, maceration etc. to MD. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Record review of Resident #1's Care Plan, start date, 8/18/2023, stated, (Resident #1) has DTI to left toe. (Resident #1's) Pressure ulcer will show signs of healing and remain free from infection by/through review date. (Resident #1) will have intact skin, free of redness, blisters or discoloration by/through review date. Interventions included, Administer treatments as ordered and monitor for effectiveness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 2 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 0656 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's Care Plan, start date, 8/18/2023, stated, (Resident #1) has DTI to right great toe. The (Resident #1s) will Pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions included, Administer treatments as ordered and monitor for effectiveness. Residents Affected - Some Record review of Resident #1's Care Plan, start date, 8/18/2023, stated,(Resident #1) has DTI to right heel. (Resident #1's) pressure ulcer will show signs of healing and remain free from infection by/through review date. PHYSICIAN ORDERS Record review of Resident #1's physician's orders, start date, 7/26/2023, stated, DTI to Right heel-monitor daily for changes. Record review of Resident #1's physician's orders, start date, 7/26/2023, stated, DTI - right great toe monitor daily for changes. Record review of Resident #1's physician's orders, start date, 8/30/2023 stated, DTI-right great toe monitor daily for changes. Frequency, one time a day. Record review of Resident #1's physician's orders, start date, 8/30/2023 stated: DTI to Right heel-monitor for changes. Frequency, one time a day. Record review of Resident #1's physician's orders, start date, 8/30/2023 stated: stage 2 to R buttock: cleanse with wound cleanser pat dry apply mediseptic QS. Frequency, every shift. Record review of Resident #1's physician's orders, start date, 8/30/2023 stated: Stage 2 to L buttock: cleanse with wound cleanser, pat dry apply mediseptic QS. Frequency, every shift. Record review of Resident #1's physician's orders, start date, 9/9/2023 stated: Monitor skin tear left upper leg Monitor every shift for signs of infection until heeled. Frequency, every shift. Record review of Resident #1's physician's orders, start date, 9/11/2023 stated: Stage 2 to R gluteal fold cleanse with wound cleanser pat dry apply mediseptic QS. Frequency, every shift. TREATMENT ADMINISTRATION: Record review of Resident #1's TAR September 2023 stated, DTI - right great toe monitor daily for changes one time a day -Start Date 08/01/2023. Further review revealed holes in the TAR the following: 9/5, 9/6, 9/8, 9/13, 9/14, 9/15. Record review of Resident #1's September 2023 TAR stated, TI to Right heel-monitor daily for changes one time a day -Start Date 08/01/2023. Further review revealed holes in the TAR on the following: 9/5, 9/6, 9/8, 9/13, 9/14, 9/15. Record review of Resident #1's September 2023 TAR stated, Monitor skin tear left upper leg Monitor every shift for signs of infection until heeled every shift -Start Date 09/09/2023 Further review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 3 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 0656 revealed holes in the TAR for the following: Level of Harm - Minimal harm or potential for actual harm Shift 6:00 AM - 2:00 PM - 9/13 thru 9/15, 9/18 Shift 2:00 PM - 10:00 PM - 9/9, 9/11 thru 9/15 Residents Affected - Some Shift 10:00 PM - 6:00 AM - 9/9 Record review of Resident #1's September 2023 TAR stated, stage 2 to L buttock: cleanse with wound cleanser, pat dry apply mediseptic QS every shift -Start Date 08/30/2023. Further review revealed holes in the TAR for the following: Shift 6:00 AM - 2:00 PM - 9/4 thru 9/6, 9/8, 9/13 thru 9/15, 9/18 Shift 2:00 PM - 10:00 PM - 9/5-9/9, 9/11 thru 9/18 Shift 10:00 PM - 6:00 AM - 9/9 Record review of Resident #1's September 2023 TAR stated, stage 2 to R buttock: cleanse with wound cleanser pat dry apply mediseptic QS every shift -Start Date 08/30/2023. Further review revealed holes in the TAR for the following: Shift 6:00 AM - 2:00 PM - 9/4 thru 9/6, 9/8, 9/13 thru 9/15, 9/18 Shift 2:00 PM - 10:00 PM - 9/5-9/9, 9/11 thru 9/18 Shift 10:00 PM - 6:00 AM - 9/9 Record review of Resident #1's September 2023 TAR stated, Stage 2 to R gluteal fold cleanse with wound cleanser, pat dry apply mediseptic QS every shift -Start Date 09/11/2023. Further review revealed holes in the TAR for the following: Shift 6:00 AM - 2:00 PM - 9/13, 9/14, 9/15, 9/18 Shift 2:00 PM - 10:00 PM - 9/11 thru 9/18 Shift 10:00 PM - 6:00 AM - 0 missed SKIN ASSESSMENTS Record review of Resident #1's Weekly Skin Evaluation, effective date, 9/14/2023, revealed: What type of wound(s) does patient have? - A. Pressure Ulcer(s). Further review revealed there these were new since last skin assessment. Type of wound was, Right gluteal fold - Stage 2 to R gluteal fold measuring 2cmx4cm. This document was signed by Treatment Nurse, LVN B. Record review of Resident #1's Weekly Pressure Ulcer Evaluation, effective date, 9/14/2023, revealed: date of assessment was 9/11/2023 -Right Great Toe, length 1.5 cm, width 1.5 cm, depth N/A, stage suspected deep tissue injury. Further review revealed the wound developed 8/13/2023 and was, admitted with. This document was signed by Treatment Nurse, LVN B. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 4 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #1's Weekly Pressure Ulcer Evaluation, effective date, 9/14/2023, revealed: date of assessment was 9/11/2023 - Right Heel, length 4cm, width 4.5cm, depth N/A, stage suspected deep tissue injury. Further review revealed the wound developed 8/13/2023 and was, admitted with. This document was signed by Treatment Nurse, LVN B. Record review of Resident #1's Weekly Pressure Ulcer Evaluation, effective date, 9/14/2023, revealed: date of assessment was 9/11/2023 - Right Buttock pressure ulcer, length 5cm, width 6cm, depth .1cm, stage N/A. Further review revealed the wound developed 8/30/2023 and was, in house developed. This document was signed by Treatment Nurse, LVN B. Record review of Resident #1's Weekly Pressure Ulcer Evaluation, effective date, 9/14/2023, revealed: date of assessment was 9/11/2023 - Left Buttock pressure ulcer, length 3.5cm, width 4cm, depth .1cm, stage II. Further review revealed the wound developed 8/30/2023 and was, in house developed. This document was signed by Treatment Nurse, LVN B. Record review of Resident #1's electronic chart for weight measurements revealed: 6/5/2023 - 237 LBS via Mechanical Lift 7/7/2023 - 233.6 LBS via Wheel Chair 8/2/2023 - 214.2 LBS via Standing 9/13/2023 - 192.3 LBS via Lift PROGRESS NOTES Record review of Resident #1's progress note, dated 6/1/2023 - 6:18 PM, stated, Note Text: Received resident via stretcher by Amistad ambulance. (Resident #1) is a [AGE] year-old female with PMH of HTN, DM, CAD, neuropathy, anxiety, depression, seizure, CVAx2, ESRD on HD M, W, F, with Fresenius, morbid obesity. (Resident #1) is A/Ox4, skin intact, respirations even and unlabored, lung sounds clear to all lobes, active BS to all 4 quadrants, abdomen non distend, non-tender. Left upper extremity shunt functioning properly. (Resident #1) unable to ambulate due to extreme weakness. (Resident #1) is able to help with transfer with assistance, incontinent X2. (Resident #1) with no belongings. RP and MD made aware. (Resident #1) voices no concerns at this time. (Resident #1)) orientated to room, call bell and bed remote control. Record review of a typed summary drafted by Resident #1's Hospital Physician, received by email on 9/27/2023, stated: Regarding patient (Resident #1) from (Resident #1) arrived to (a as a transfer from (a on 9/19/2023 for the evaluation and management of altered mental status in the setting of sepsis which was presumed to be caused by an infected sacral decubitus ulcer. Upon my initial evaluation the patient was very lethargic and disoriented and there was a very strong odor. After turning her to the side there was a large unstageable sacral decubital ulcer and other surrounding decubital ulcers of varying stage with some noted purulence. The wounds were also noted in the perineal and groin areas near the skin folds. Photos of the wounds are available in the medical record if needed. Due to low blood pressure/shock (Resident #1) was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 5 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some transferred to the ICU to be placed on pressors to maintain blood pressure. She underwent a CT of the abdomen and pelvis with IV contrast to further assess the wound for surgical planning. Incidentally found on the CT scan was the presence of blood clots in both lungs (bilateral pulmonary embolism). Since clots in the lungs typically originate in the legs we next obtained US dopplers of both legs to assess for any further clots and was found to have blood clots in both legs. An echocardiogram was performed to assess for any strain on the heart caused by the blood clots in the lungs, the study did not indicate any strain to the heart. Since her cardiac function was stable the surgeon and anesthesiologist agreed to proceed with debridement of the sacral wound. The wound was extensively debrided to removed any nonviable tissues which required resecting tissue down to the sacral bones (stage 4 pressure ulcer). I have not seen the wound personally since the surgery was performed but per discussion with (Resident #1's) nurse, the wound is approximately the diameter of a basketball. [sic]Due to the location of the wound, near the anus, there is high risk of stool entering and subsequently causing infection within the wound. For this reason (Resident #1) had to be taken back to the operating room for placement of a colostomy to divert stool away from the wound. Once the wound heels it will be possible to reverse the colostomy. A wound vac is to be placed to assist in wound healing. Due to the extent of the injury, this wound will take significant time and optimal conditions in order to heel. I am unable to provide more specific details on prognosis/outcome. A specialist in wound care may be able to provide more information. (Resident #1) is to remain on blood thinners for at least 3 months for the management of blood clots in the legs and lungs. The wound on (Resident #1's) back/buttock/perineal area is caused by prolonged pressure to the skin and underlying tissue which results in poor blood flow to the affected tissue. These injuries can be made worse or more likely to get infected when patients are incontinent of urine or stool and are not promptly cleaned. In patients who are bed bound or with limited mobility, these injuries can be avoided or made less likely to occur by frequent repositioning to offload pressure on a particular area for prolonged periods of time. Other measures include making sure the skin is regularly cleaned and dried. For patients at risk for developing pressure injuries, the skin should be regularly monitored for signs of injury so that it can be addressed early in the course of the injury. I am unaware of the care that was being provided at the nursing home to address the decubital ulcers or what measures were being implemented to heel or prevent these injuries. (Resident #1) presented to our facility/care at a late stage in the course of this injury process. If this was the first presentation for evaluation of these injuries then it would be an unusually late recognition on the part of the party responsible for her care and would suggest that she was not being adequately monitored or that the injuries were possibly noted but not being adequately tended to. The presence of clots in the legs and lungs also would indicate that she has been very immobile given that immobility is the greatest risk factor for development of these types of blood clots. Interview and attempted observation on 9/22/2023 at 10:51 AM at a hospital ICU (Intensive Care Unit) with Resident #1: Resident #1's Family Member A, revealed Resident #1 had just left for dialysis treatment and would return in approximately 4 hours. During this interview, Family Member A stated the resident had been residing at a nursing facility in for the last 3 months. Family Member A said she used to work at a nursing facility and was familiar with protocol specific to resident care. Family Member A indicated staff at the Nursing Facility were not turning, repositioning, or transferring Resident #1 to her wheelchair on the occasions she would visit the resident. Family Member A further stated the Resident #1 was obese and confused and that facility staff had skipped several of the resident's dialysis appointments and also said staff were not adequately feeding the resident and that she had had a significant weight loss. Additionally, Family (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 6 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Member A said Resident #1 had a severe infection in her brain and large pressure wound to sacral area which required surgical intervention at the hospital. Family Member A said Resident #1's wound, .smelled like a dead animal, and that hospital staff had to make special interventions in Resident #1's ICU room in an attempt to mask the odor. Finally, Family Member A said she had signed a DNR for Resident #1 and indicated Resident #1's medical team informed her there was a good chance Resident #1 would not survive much longer. Additionally, Family Member A said medical imaging revealed blood clots in Resident #1's lungs and lower extremities as well as an infection to her brain. Finally, Family Member A mentioned a representative from the facility had just left and was attempting to determine if Resident #1's family was under the impression the facility was responsible for the Resident #1's deteriorating condition. Family Member A showed this investigator a business card whom she purported was a representative of the facility at which time this investigator took a photograph of the business card. A review of this business card revealed an RN D. Telephone interview 9/22/2023 at 1:11 PM with Resident #1's Hospital Physician revealed, Resident #1 appeared , .extremely unkempt . upon her admission to the hospital and was discovered to have .blood clots in both her legs and lungs . The doctor explained that he would typically see these symptoms in patients that, .had not been moved enough . or, .kept in one place for extended periods of time. The doctor further stated it was obvious Resident #1, .had not been turned enough . and that, . her wounds were pretty extensive, specific to Resident #1's peri area. The doctor further stated Resident #1 was, .septic upon arrival. Interview and record review on 9/26/2023 at 9:55 AM, LVN A was asked to describe Resident #1, and replied that Resident #1 came to the facility for physical therapy, was a dialysis patient, was a diabetic, and was alert and oriented times 4 upon admission. LVN A said the Resident #1 had to go to one time because staff thought she had a stroke. LVN A said when Resident #1 returned to the facility, she became totally dependent on staff for assistance. LVN A said Resident #1 seemed to fail to thrive. LVN A said Resident #1 had a referral for psych services and started to take Zoloft. LVN A also said Resident #1 had to downgrade her diet from regular to puree. When asked if Resident #1 had any wounds, LVN A said that Resident #1 had a stage II to her bottom. When asked why Resident #1 was recently discharged , LVN A said she was not sure. When asked how Resident #1 acquired her wound, LVN A said she was unsure. During a record review at this time, LVN A agreed that multiple wound treatments were missed for Resident #1 during the month of September 2023. When asked why, LVN A indicated she did not know because Resident #1 was not combative and was bedbound so she couldn't run away. LVN A agreed this was a concern and that missed wound treatments could lead to serious infection. When asked again what the breakdown was as to why residents were missing so many treatments, LVN A said there really was no good reason as the treatment nurse would typically administer treatments for wounds and then nursing staff would also divide treatments up if and when the treatment nurse was out of the facility. When asked who the treatment nurse was, the LVN said it was LVN B. Interview and record review on 9/26/2023 at 10:31 AM, Treatment Nurse, LVN B was asked to describe Resident #1, LVN B responded that Resident #1 came to the facility with a DTI to her right heel and tip of her right great toe. LVN B said (Resident #1's) bottom started breaking down, and that the, .area between her brief and her leg started breaking down as well. LVN B said Resident #1 started getting another area on her left gluteal fold, and then she went to dialysis on 9/18/2023 and from there was sent to the hospital for low blood pressure, and said the hospital sent Resident #1 to a hospital with a diagnosis of encephalopathy. When asked what encephalopathy was, LVN B responded that, it was something in the brain where you get confused, and, get an altered mental status. LVN B said Resident #1's wounds to her peri area were acquired at the facility and that the resident was refusing to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 7 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some turned. When asked why the resident was refusing to be turned, LVN B said it was because, (Resident #1) wasn't comfortable. When asked why the hospital in sent Resident #1 to a different hospital in San [NAME], LVN B responded that she was unsure. When asked if Resident #1's wound was getting infected, the LVN responded that, it wasn't looking great but it didn't have a smell or anything. During this interview, LVN B was shown Resident #1's September 2023 TAR, at which time LVN B confirmed that multiple entries for Resident #1's skin treatments were blank and responded that she may have been working the floor those days. LVN B said that she would have to work the floor if someone called in and would have to also attend to wounds simultaneously. When asked if that posed a problem because she was having to do 2 jobs during a shift, LVN B said she would delegate to other nurses to handle the lower category wounds. When asked what could be done to ensure treatments could never be missed, LVN B said a lot of the 2pm-10pm nurses moved to the hospital which had caused a bit of a strain on staffing. When asked if the facility utilized agency staff, LVN B responded that the facility did not. Interview and record review on 9/26/2023 at 11:03 AM, RN C stated she was filling in for the DON as the DON was out of the facility. During this interview, RN C said she was not that familiar with the residents as she currently only worked PRN. RN C said staffing had been short and she was frequently asked to work. RN C was shown September 2023 TARs for Resident #1 and agreed they had missing entries. When asked what that meant, the RN C said it meant the treatments, didn't occur. When asked what the concern was specific to wound treatments, RN C said it was a concern because the missed treatments could cause the wounds to evolve into serious infections which could lead to sepsis and or death. RN C said this facility had difficulty retaining staff because other facilities in the area were paying more and believed staffing was the reason some of these treatments were being missed. RN C said that if the treatment nurse is required to work the floor, other nurses on the shift will be delegated to do wound care. Interview and record review on 9/26/2023 at 2:00 PM, the DON said the facility had the staff they need but had been overlapping their shifts. The DON agreed that if there was a missed entry in the TAR it didn't happen. The DON said Resident #1 was very sick and she said the staff tried to get her family to sign a DNR. The DON said facility staff would fear that when (Resident #1) would go to dialysis, they would send her to the hospital and said that is exactly what happened. The DON said Resident #1 was previously discharged from dialysis because she didn't look right. The DON said Resident #1 was, very young and they were having to spoon feed her. The DON said Resident #1 was much more motivated when she was admitted but started to decline. At this time, the DON was shown Resident #1's September TAR, the DON agreed it was a concern that there were missed wound treatments and that missed wound treatments had the potential to evolve into more serious issues like infections. Interview on 9/26/2023 at 3:09 PM, the Medical Director, said he found out recently that there had been missed treatments relative to wound care and that he was very surprised. When asked who was supposed to be doing wound treatments between his visits, the Medical Director responded, LVN B. When asked if he was noticing the decline in Resident #1 and if he would have given different orders, the Medical Director responded that he was not aware of a decline specific to Resident #1's wounds. The Medical Director said he had only heard that another resident had been sent to the ER and insisted on not coming back to the facility and that the resident alleged she was not being provided care for her wounds. The Medical Director further stated this resident had a wound vac. The Medical Director said Resident #1's name came up a couple of times but he could not recall the reason. The Medical Director said Resident #1 was not eating well and had to have IV fluids once or twice and said DON or charge nurse would typically be the one who contacted him when there was a decline. When asked if the Medical Director would come in more than just monthly if a resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 8 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some experienced a decline, the Medical Director said that he would. The Medical Director said he expected residents would receive nursing care and that he knew skin care was important because a lot of the residents have a lot of vulnerabilities. The Medical Director also stated that staff should be documenting and not missing treatments because the ultimate concern would be that the wounds would get worse. The Medical Director said, A soft tissue wound can lead to infection and lead to hospitalization. The whole idea of being in a nursing home is to avoid hospitalizations. The Medical Director said he was not responsible for training the facility staff. The Medical Director said he was notified and aware of concerns with resident wound care but could not remember the names of the residents for which he had been notified. The Medical Director stated, I probably would have called the DON and asked what was going on with the care the resident was not receiving, when asked what he would have done if he had been notified that a resident did not receive wound care as ordered. The doctor said he, wouldn't like to think there was willful neglect. Finally, the Medical Director stated, there has got to be someone who has to be responsible if the treatment nurse is away so staff have to be more pro-active than reactive. Interview on 9/26/2023 at 4:40 PM, LVN B, when asked about training, said she would get (online training program) training quarterly or if and when an incident of abuse and neglect occurred, and said those trainings, occur frequently. When asked if there were any training the last several weeks, LVN B said there was training for covid, hand washing, abuse and neglect and said that was all. LVN B said that staff were told daily that they need to clear their MARs and TARs, meaning to complete all prompted tasks for their shift. When asked if there had been any trainings specific to Resident #1 since she had been discharged to the hospital, the LVN B said training occurred only when the resident started to decline. When asked when this was, the LVN B said it was after the resident came back from one of her admissions from the hospital. When asked if any trainings occurred in response to the Resident #1's most recent discharge, the LVN B indicated there had been no trainings specific to this incident since Resident #1 discharged on 9/19/2023. When asked if any other nurses were qualified to do wound treatment, LVN B said that LVN A and several other LVNs had become qualified. LVN B said those LVN staff do a rotation with me when they get hired. LVN B said staff typically get evaluated annually. LVN B was asked if she had her wound treatment skills evaluated, she responded, yes, by the DON. LVN B was asked when this evaluation took place and said it was in in March or April 2023 and said the evaluations would occur annually. Interview on 9/26/2023 at 5:07 PM, the DON, stated Resident #1 was sent from dialysis to the hospital. When asked what diagnosis Resident #1 was sent out for the DON responded that she was not sure. The DON said she guessed it was encephalopathy and found out Resident #1 was going to the ER when dialysis called to inform her. When asked if staff had any training since Resident #1 was sent to the hospital relative to encephalopathy or other issues related to the Resident #1's incident the DON responded, no. The DON said Resident #1 was unpredictable and her alert and oriented status would frequently change. The DON said Resident #1 was continent when she arrived to the facility but once she became incontinent, staff noticed Resident #1 had genital warts upon changing her. Interview on 9/27/2023 at 5:02 PM, the DON stated the facility's Medical Director came to the facility monthly and talked to residents, reviewed charts/meds, would look at wounds if staff requested. The DON said she was informed of residents' wound status by reviewing a weekly skin report and would check to see who was progressing or declining and who needs what type of interventions. The DON said staff communications began with the CNAs who would inform their charge nurse of concerns and the charge nurse would put those concerns on the 24-hour report and contact physician to get orders. The DON was made aware by staff that Resident #1's wounds were getting worse. The last time she had seen the resident had been a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 9 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 0656 Level of Harm - Minimal harm or potential for actual harm little while, and she was under the impression the resident's sacral pressure ulcer had evolved into a stage II pressure ulcer. When asked what facility staff could have done differently for this resident, the DON said facility staff should have sent the resident to the hospital more frequently but said the hospital would just send her back and we had to have a van on standby to pick her up, implying the resident was frequently sent to the hospital. (note: Resident #1 was only sent out 3 times in 3 months including most recent visit). Residents Affected - Some Interview on 9/27/2023 at 5:14 PM, the Administrator revealed information obtained during the previous interview with the DON. Additionally, when asked what could have been done differently for Resident #1, the Administrator said, We should have added the resident to patients at risk, and could have sent her to the hospital for slightest decline. Interview on 9/28/2023 at 10:42 AM, the Administrator revealed LVN B did not have Wound Care Certification. Telephone interview on 9/29/2023 at 12:30 PM, the Medical Director said that had he been made aware that Resident #1's wound status had changed, he would have wanted to have found out the last time Resident #1 saw the vascular surgeon, would have wanted to talk FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 10 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the comprehensive assessment of a resident, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 6 residents (Resident #1) reviewed for pressure sores, in that: Residents Affected - Some The facility failed to ensure Resident #1 received wound care and treatment as ordered by a physician. -Resident #1's right great toe was not monitored daily for changes once per day as ordered by a physician. -Resident #1's right heel was not monitored daily for changes once per day as ordered by a physician. -Resident #1's skin tear to the left upper leg was not monitored every shift for signs of infection as ordered by a physician. -Resident #1's pressure ulcer to her left buttock was not cleansed with wound cleaner, patted dry and did not have medseptic QA applied every shift as ordered by a physician. -Resident #1's pressure ulcer to her right buttock was not cleansed with wound cleaner, patted dry and did not have medseptic QA applied every shift as ordered by a physician. -Resident #1's pressure ulcer to her right gluteal fold was not cleansed with wound cleaner, patted dry and did not have medseptic QA applied every shift as ordered by a physician. -Resident #1 had a significant weight from August 2023 to September 2023. Resident #1 was admitted to the hospital with sepsis presumed to be from an infected sacral decubitus ulcer. An IJ was identified on 9/27/2023 at 6:00 p.m., and a template was provided to the facility at this time. While the IJ was removed on 10/1/2023, the facility remained out of compliance at a scope of pattern and a scope of actual harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place additional residents at risk for a delay in treatment, hospitalization, loss of limb and/or a significant decline in heelth. The findings included: Record review of Resident #1's face sheet dated 9/28/2023 revealed she was [AGE] years of age with an admission date of 1/2/2022 and a readmission date of 6/1/2023 with diagnoses which included: Type 2 diabetes mellitus with diabetic neuropathy, end stage renal disease, major depressive disorder, mild cognitive impairment, dysphagia, cognitive communication deficit, urinary tract infection, degenerative disease of nervous system, lack of coordination, morbid obesity, muscle wasting, anemia in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 11 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 0686 chronic kidney disease, fluid overload, anxiety disorder, cerebral infarction, nausea with vomiting, diarrhea. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's comprehensive MDS dated [DATE] revealed a BIMS score of 10 indicating moderate impairment. Further review under category, Skin Conditions, revealed Resident #1 was indicated as having zero venous and arterial ulcers, and no other ulcers, wounds and skin problems. Residents Affected - Some Record review of Resident #1's Care Plan, start date 6/1/2023, stated, (Resident #1) has potential impairment to skin integrity r/t incontinence and decreased mobility. (Resident #1) will be free from skin break down through the review date Interventions included, Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heel, s/sx of infection, maceration etc. to MD. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Record review of Resident #1's Care Plan, start date, 8/18/2023, stated, (Resident #1) has DTI to left toe. (Resident #1's) Pressure ulcer will show signs of healing and remain free from infection by/through review date. (Resident #1) will have intact skin, free of redness, blisters or discoloration by/through review date. Interventions included, Administer treatments as ordered and monitor for effectiveness. Record review of Resident #1's Care Plan, start date, 8/18/2023, stated, (Resident #1) has DTI to right great toe. The (Resident #1s) will Pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions included, Administer treatments as ordered and monitor for effectiveness. Record review of Resident #1's Care Plan, start date, 8/18/2023, stated,(Resident #1) has DTI to right heel. (Resident #1's) pressure ulcer will show signs of healing and remain free from infection by/through review date. PHYSICIAN ORDERS Record review of Resident #1's physician's orders, start date, 7/26/2023, stated, DTI to Right heel-monitor daily for changes. Record review of Resident #1's physician's orders, start date, 7/26/2023, stated, DTI - right great toe monitor daily for changes. Record review of Resident #1's physician's orders, start date, 8/30/2023 stated, DTI-right great toe monitor daily for changes. Frequency, one time a day. Record review of Resident #1's physician's orders, start date, 8/30/2023 stated: DTI to Right heel-monitor for changes. Frequency, one time a day. Record review of Resident #1's physician's orders, start date, 8/30/2023 stated: stage 2 to R buttock: cleanse with wound cleanser pat dry apply mediseptic QS. Frequency, every shift. Record review of Resident #1's physician's orders, start date, 8/30/2023 stated: Stage 2 to L (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 12 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 0686 buttock: cleanse with wound cleanser, pat dry apply mediseptic QS. Frequency, every shift. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's physician's orders, start date, 9/9/2023 stated: Monitor skin tear left upper leg Monitor every shift for signs of infection until heeled. Frequency, every shift. Residents Affected - Some Record review of Resident #1's physician's orders, start date, 9/11/2023 stated: Stage 2 to R gluteal fold cleanse with wound cleanser pat dry apply mediseptic QS. Frequency, every shift. TREATMENT ADMINISTRATION: Record review of Resident #1's TAR September 2023 stated, DTI - right great toe monitor daily for changes one time a day -Start Date 08/01/2023. Further review revealed holes in the TAR the following: 9/5, 9/6, 9/8, 9/13, 9/14, 9/15. Record review of Resident #1's September 2023 TAR stated, TI to Right heel-monitor daily for changes one time a day -Start Date 08/01/2023. Further review revealed holes in the TAR on the following: 9/5, 9/6, 9/8, 9/13, 9/14, 9/15. Record review of Resident #1's September 2023 TAR stated, Monitor skin tear left upper leg Monitor every shift for signs of infection until heeled every shift -Start Date 09/09/2023 Further review revealed holes in the TAR for the following: Shift 6:00 AM - 2:00 PM - 9/13 thru 9/15, 9/18 Shift 2:00 PM - 10:00 PM - 9/9, 9/11 thru 9/15 Shift 10:00 PM - 6:00 AM - 9/9 Record review of Resident #1's September 2023 TAR stated, stage 2 to L buttock: cleanse with wound cleanser, pat dry apply mediseptic QS every shift -Start Date 08/30/2023. Further review revealed holes in the TAR for the following: Shift 6:00 AM - 2:00 PM - 9/4 thru 9/6, 9/8, 9/13 thru 9/15, 9/18 Shift 2:00 PM - 10:00 PM - 9/5-9/9, 9/11 thru 9/18 Shift 10:00 PM - 6:00 AM - 9/9 Record review of Resident #1's September 2023 TAR stated, stage 2 to R buttock: cleanse with wound cleanser pat dry apply mediseptic QS every shift -Start Date 08/30/2023. Further review revealed holes in the TAR for the following: Shift 6:00 AM - 2:00 PM - 9/4 thru 9/6, 9/8, 9/13 thru 9/15, 9/18 Shift 2:00 PM - 10:00 PM - 9/5-9/9, 9/11 thru 9/18 Shift 10:00 PM - 6:00 AM - 9/9 Record review of Resident #1's September 2023 TAR stated, Stage 2 to R gluteal fold cleanse with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 13 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 0686 Level of Harm - Immediate jeopardy to resident health or safety wound cleanser, pat dry apply mediseptic QS every shift -Start Date 09/11/2023. Further review revealed holes in the TAR for the following: Shift 6:00 AM - 2:00 PM - 9/13, 9/14, 9/15, 9/18 Shift 2:00 PM - 10:00 PM - 9/11 thru 9/18 Residents Affected - Some Shift 10:00 PM - 6:00 AM - 0 missed SKIN ASSESSMENTS Record review of Resident #1's Weekly Skin Evaluation, effective date, 9/14/2023, revealed: What type of wound(s) does patient have? - A. Pressure Ulcer(s). Further review revealed there these were new since last skin assessment. Type of wound was, Right gluteal fold - Stage 2 to R gluteal fold measuring 2cmx4cm. This document was signed by Treatment Nurse, LVN B. Record review of Resident #1's Weekly Pressure Ulcer Evaluation, effective date, 9/14/2023, revealed: date of assessment was 9/11/2023 -Right Great Toe, length 1.5 cm, width 1.5 cm, depth N/A, stage suspected deep tissue injury. Further review revealed the wound developed 8/13/2023 and was, admitted with. This document was signed by Treatment Nurse, LVN B. Record review of Resident #1's Weekly Pressure Ulcer Evaluation, effective date, 9/14/2023, revealed: date of assessment was 9/11/2023 - Right Heel, length 4cm, width 4.5cm, depth N/A, stage suspected deep tissue injury. Further review revealed the wound developed 8/13/2023 and was, admitted with. This document was signed by Treatment Nurse, LVN B. Record review of Resident #1's Weekly Pressure Ulcer Evaluation, effective date, 9/14/2023, revealed: date of assessment was 9/11/2023 - Right Buttock pressure ulcer, length 5cm, width 6cm, depth .1cm, stage N/A. Further review revealed the wound developed 8/30/2023 and was, in house developed. This document was signed by Treatment Nurse, LVN B. Record review of Resident #1's Weekly Pressure Ulcer Evaluation, effective date, 9/14/2023, revealed: date of assessment was 9/11/2023 - Left Buttock pressure ulcer, length 3.5cm, width 4cm, depth .1cm, stage II. Further review revealed the wound developed 8/30/2023 and was, in house developed. This document was signed by Treatment Nurse, LVN B. PROGRESS NOTES Record review of Resident #1's progress note, dated 6/1/2023 - 6:18 PM, stated, Note Text: Received resident via stretcher by Amistad ambulance. (Resident #1) is a [AGE] year-old female with PMH of HTN, DM, CAD, neuropathy, anxiety, depression, seizure, CVAx2, ESRD on HD M, W, F, with Fresenius, morbid obesity. (Resident #1) is A/Ox4, skin intact, respirations even and unlabored, lung sounds clear to all lobes, active BS to all 4 quadrants, abdomen non distend, non-tender. Left upper extremity shunt functioning properly. (Resident #1) unable to ambulate due to extreme weakness. (Resident #1) is able to help with transfer with assistance, incontinent X2. (Resident #1) with no belongings. RP and MD made aware. (Resident #1) voices no concerns at this time. (Resident #1)) orientated to room, call bell and bed remote control. Record review of a typed summary drafted by Resident #1's Hospital Physician, received by email on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 14 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 0686 9/27/2023, stated: Level of Harm - Immediate jeopardy to resident health or safety Regarding patient (Resident #1) from (Nursing Facility) Residents Affected - Some (Resident #1) arrived to (Hospital B) as a transfer from (Hospital A) on 9/19/2023 for the evaluation and management of altered mental status in the setting of sepsis which was presumed to be caused by an infected sacral decubitus ulcer. Upon my initial evaluation the patient was very lethargic and disoriented and there was a very strong odor. After turning her to the side there was a large unstageable sacral decubital ulcer and other surrounding decubital ulcers of varying stage with some noted purulence. The wounds were also noted in the perineal and groin areas near the skin folds. Photos of the wounds are available in the medical record if needed. Due to low blood pressure/shock (Resident #1) was transferred to the ICU to be placed on pressors to maintain blood pressure. She underwent a CT of the abdomen and pelvis with IV contrast to further assess the wound for surgical planning. Incidentally found on the CT scan was the presence of blood clots in both lungs (bilateral pulmonary embolism). Since clots in the lungs typically originate in the legs we next obtained US dopplers of both legs to assess for any further clots and was found to have blood clots in both legs. An echocardiogram was performed to assess for any strain on the heart caused by the blood clots in the lungs, the study did not indicate any strain to the heart.Since her cardiac function was stable the surgeon and anesthesiologist agreed to proceed with debridement of the sacral wound. The wound was extensively debrided to removed any nonviable tissues which required resecting tissue down to the sacral bones (stage 4 pressure ulcer). I have not seen the wound personally since the surgery was performed but per discussion with (Resident #1's) nurse, the wound is approximately the diameter of a basketball. [sic]Due to the location of the wound, near the anus, there is high risk of stool entering and subsequently causing infection within the wound. For this reason (Resident #1) had to be taken back to the operating room for placement of a colostomy to divert stool away from the wound. Once the wound heels it will be possible to reverse the colostomy. A wound vac is to be placed to assist in wound healing. Due to the extent of the injury, this wound will take significant time and optimal conditions in order to heel. I am unable to provide more specific details on prognosis/outcome. A specialist in wound care may be able to provide more information.(Resident #1) is to remain on blood thinners for at least 3 months for the management of blood clots in the legs and lungs.The wound on (Resident #1's) back/buttock/perineal area is caused by prolonged pressure to the skin and underlying tissue which results in poor blood flow to the affected tissue. These injuries can be made worse or more likely to get infected when patients are incontinent of urine or stool and are not promptly cleaned. In patients who are bed bound or with limited mobility, these injuries can be avoided or made less likely to occur by frequent repositioning to offload pressure on a particular area for prolonged periods of time. Other measures include making sure the skin is regularly cleaned and dried. For patients at risk for developing pressure injuries, the skin should be regularly monitored for signs of injury so that it can be addressed early in the course of the injury. I am unaware of the care that was being provided at the nursing home to address the decubital ulcers or what measures were being implemented to heel or prevent these injuries. (Resident #1) presented to our facility/care at a late stage in the course of this injury process. If this was the first presentation for evaluation of these injuries then it would be an unusually late recognition on the part of the party responsible for her care and would suggest that she was not being adequately monitored or that the injuries were possibly noted but not being adequately tended to. The presence of clots in the legs and lungs also would indicate that she has been very immobile given that immobility is the greatest risk factor for development of these types of blood clots. Interview and attempted observation on 9/22/2023 at 10:51 AM at a hospital ICU (Intensive Care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 15 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Unit) with Resident #1: Resident #1's Family Member A, revealed Resident #1 had just left for dialysis treatment and would return in approximately 4 hours. During this interview, Family Member A stated the resident had been residing at a nursing facility for the last 3 months. Family Member A said she used to work at a nursing facility and was familiar with protocol specific to resident care. Family Member A indicated staff at the Nursing Facility were not turning, repositioning, or transferring Resident #1 to her wheelchair on the occasions she would visit the resident. Family Member A further stated the Resident #1 was obese and confused and that facility staff had skipped several of the resident's dialysis appointments and also said staff were not adequately feeding the resident and that she had had a significant weight loss. Additionally, Family Member A said Resident #1 had a severe infection in her brain and large pressure wound to sacral area which required surgical intervention at the hospital. Family Member A said Resident #1's wound, .smelled like a dead animal, and that hospital staff had to make special interventions in Resident #1's ICU room in an attempt to mask the odor. Finally, Family Member A said she had signed a DNR for Resident #1 and indicated Resident #1's medical team informed her there was a good chance Resident #1 would not survive much longer. Additionally, Family Member A said medical imaging revealed blood clots in Resident #1's lungs and lower extremities as well as an infection to her brain. Finally, Family Member A mentioned a representative from the facility had just left and was attempting to determine if Resident #1's family was under the impression the facility was responsible for the Resident #1's deteriorating condition. Family Member A showed this investigator a business card whom she purported was a representative of the facility at which time this investigator took a photograph of the business card. A review of this business card revealed an RN D. Telephone interview 9/22/2023 at 1:11 PM with Resident #1's Hospital Physician revealed, Resident #1 appeared , .extremely unkempt . upon her admission to the hospital and was discovered to have .blood clots in both her legs and lungs . The doctor explained that he would typically see these symptoms in patients that, .had not been moved enough . or, .kept in one place for extended periods of time. The doctor further stated it was obvious Resident #1, .had not been turned enough . and that, . her wounds were pretty extensive, specific to Resident #1's peri area. The doctor further stated Resident #1 was, .septic upon arrival. Interview and record review on 9/26/2023 at 9:55 AM, LVN A was asked to describe Resident #1, and replied that Resident #1 came to the facility for physical therapy, was a dialysis patient, was a diabetic, and was alert and oriented times 4 upon admission. LVN A said the Resident #1 had to go to San [NAME] one time because staff thought she had a stroke. LVN A said when Resident #1 returned to the facility, she became totally dependent on staff for assistance. LVN A said Resident #1 seemed to fail to thrive. LVN A said Resident #1 had a referral for psych services and started to take Zoloft. LVN A also said Resident #1 had to downgrade her diet from regular to puree. When asked if Resident #1 had any wounds, LVN A said that Resident #1 had a stage II to her bottom. When asked why Resident #1 was recently discharged , LVN A said she was not sure. When asked how Resident #1 acquired her wound, LVN A said she was unsure. During a record review at this time, LVN A agreed that multiple wound treatments were missed for Resident #1 during the month of September 2023. When asked why, LVN A indicated she did not know because Resident #1 was not combative and was bedbound so she couldn't run away. LVN A agreed this was a concern and that missed wound treatments could lead to serious infection. When asked again what the breakdown was as to why residents were missing so many treatments, LVN A said there really was no good reason as the treatment nurse would typically administer treatments for wounds and then nursing staff would also divide treatments up if and when the treatment nurse was out of the facility. When asked who the treatment nurse was, the LVN said it was LVN B. Interview and record review on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 16 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 9/26/2023 at 10:31 AM, Treatment Nurse, LVN B was asked to describe Resident #1, LVN B responded that Resident #1 came to the facility with a DTI to her right heel and tip of her right great toe. LVN B said (Resident #1's) bottom started breaking down, and that the, .area between her brief and her leg started breaking down as well. LVN B said Resident #1 started getting another area on her left gluteal fold, and then she went to dialysis on 9/18/2023 and from there was sent to the hospital for low blood pressure, and said (Hospital A) sent Resident #1 to a hospital Hospital B with a diagnosis of encephalopathy. When asked what encephalopathy was, LVN B responded that, it was something in the brain where you get confused, and, get an altered mental status. LVN B said Resident #1's wounds to her peri area were acquired at the facility and that the resident was refusing to be turned. When asked why the resident was refusing to be turned, LVN B said it was because, (Resident #1) wasn't comfortable. When asked why the Hosptial A sent Resident #1 to Hospital B, LVN B responded that she was unsure. When asked if Resident #1's wound was getting infected, the LVN responded that, it wasn't looking great but it didn't have a smell or anything. During this interview, LVN B was shown Resident #1's September 2023 TAR, at which time LVN B confirmed that multiple entries for Resident #1's skin treatments were blank and responded that she may have been working the floor those days. LVN B said that she would have to work the floor if someone called in and would have to also attend to wounds simultaneously. When asked if that posed a problem because she was having to do 2 jobs during a shift, LVN B said she would delegate to other nurses to handle the lower category wounds. When asked what could be done to ensure treatments could never be missed, LVN B said a lot of the 2pm-10pm nurses moved to the hospital which had caused a bit of a strain on staffing. When asked if the facility utilized agency staff, LVN B responded that the facility did not. Interview and record review on 9/26/2023 at 11:03 AM, RN C stated she was filling in for the DON as the DON was out of the facility. During this interview, the RN C said she was not that familiar with the residents as she currently only worked PRN. RN C said staffing had been short and she was frequently asked to work. RN C was shown September 2023 TARs for Resident #1 and agreed they had missing entries. When asked what that meant, the RN C said it meant the treatments, didn't occur. When asked what the concern was specific to wound treatments, RN C said it was a concern because the missed treatments could cause the wounds to evolve into serious infections which could lead to sepsis and or death. RN C said this facility had difficulty retaining staff because other facilities in the area were paying more and believed staffing was the reason some of these treatments were being missed. RN C said that if the treatment nurse is required to work the floor, other nurses on the shift will be delegated to do wound care. Interview and record review on 9/26/2023 at 2:00 PM, the DON said the facility had the staff they need but had been overlapping their shifts. The DON agreed that if there was a missed entry in the TAR it didn't happen. The DON said Resident #1 was very sick and she said the staff tried to get her family to sign a DNR. The DON said facility staff would fear that when (Resident #1) would go to dialysis, they would send her to the hospital and said that is exactly what happened. The DON said Resident #1 was previously discharged from dialysis because she didn't look right. The DON said Resident #1 was, very young and they were having to spoon feed her. The DON said Resident #1 was much more motivated when she was admitted but started to decline. At this time, the DON was shown Resident #1's September TAR, the DON agreed it was a concern that there were missed wound treatments and that missed wound treatments had the potential to evolve into more serious issues like infections. Interview on 9/26/2023 at 3:09 PM, the Medical Director, said he found out recently that there had been missed treatments relative to wound care and that he was very surprised. When asked who was supposed to be doing wound treatments between his visits, the Medical Director responded, LVN B. When asked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 17 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some if he was noticing the decline in Resident #1 and if he would have given different orders, the Medical Director responded that he was not aware of a decline specific to Resident #1's wounds. The Medical Director said he had only heard that another resident had been sent to the ER and insisted on not coming back to the facility and that the resident alleged she was not being provided care for her wounds. The Medical Director further stated this resident had a wound vac. The Medical Director said Resident #1's name came up a couple of times but he could not recall the reason. The Medical Director said Resident #1 was not eating well and had to have IV fluids once or twice and said DON or charge nurse would typically be the one who contacted him when there was a decline. When asked if the Medical Director would come in more than just monthly if a resident experienced a decline, the Medical Director said that he would. The Medical Director said he expected residents would receive nursing care and that he knew skin care was important because a lot of the residents have a lot of vulnerabilities. The Medical Director also stated that staff should be documenting and not missing treatments because the ultimate concern would be that the wounds would get worse. The Medical Director said, A soft tissue wound can lead to infection and lead to hospitalization. The whole idea of being in a nursing home is to avoid hospitalizations. The Medical Director said he was not responsible for training the facility staff. The Medical Director said he was notified and aware of concerns with resident wound care but could not remember the names of the residents for which he had been notified. The Medical Director stated, I probably would have called the DON and asked what was going on with the care the resident was not receiving, when asked what he would have done if he had been notified that a resident did not receive wound care as ordered. The doctor said he, wouldn't like to think there was willful neglect. Finally, the Medical Director stated, there has got to be someone who has to be responsible if the treatment nurse is away so staff have to be more pro-active than reactive. Interview on 9/26/2023 at 4:40 PM, LVN B, when asked about training, said she would get relias training quarterly or if and when an incident of abuse and neglect occurred, and said those trainings, occur frequently. When asked if there were any training the last several weeks, LVN B said there was training for covid, hand washing, abuse and neglect and said that was all. LVN B said that staff were told daily that they need to clear their MARs and TARs, meaning to complete all prompted tasks for their shift. When asked if there had been any trainings specific to Resident #1 since she had been discharged to the hospital, the LVN B said training occurred only when the resident started to decline. When asked when this was, the LVN B said it was after the resident came back from one of her admissions from the hospital. When asked if any trainings occurred in response to the Resident #1's most recent discharge, the LVN B indicated there had been no trainings specific to this incident since Resident #1 discharged on 9/19/2023. When asked if any other nurses were qualified to do wound treatment, LVN B said that LVN A and several other LVNs had become qualified. LVN B said those LVN staff do a rotation with me when they get hired. LVN B said staff typically get evaluated annually. LVN B was asked if she had her wound treatment skills evaluated, she responded, yes, by the DON. LVN B was asked when this evaluation took place and said it was in in March or April 2023 and said the evaluations would occur annually. Interview on 9/26/2023 at 5:07 PM, DON, stated Resident #1 was sent from dialysis to the hospital. When asked what diagnosis Resident #1 was sent out for the DON responded that she was not sure. The DON said she guessed it was encephalopathy and found out Resident #1 was going to the ER when dialysis called to inform her. When asked if staff had any training since Resident #1 was sent to the hospital relative to encephalopathy or other issues related to the Resident #1's incident the DON responded, no. The DON said Resident #1 was unpredictable and her alert and oriented status would frequently change. The DON said Resident #1 was continent when she arrived to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 18 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the facility but once she became incontinent, staff noticed Resident #1 had genital warts upon changing her. Interview on 9/27/2023 at 5:02 PM, the DON stated the facility's Medical Director came to the facility monthly and talked to residents, reviewed charts/meds, would look at wounds if staff requested. The DON said she was informed of residents' wound status by reviewing a weekly skin report and would check to see who was progressing or declining and who needs what type of interventions.The DON said staff communications began with the CNAs who would inform their charge nurse of concerns and the charge nurse would put those concerns on the 24-hour report and contact physician to get orders. The DON was made aware by staff Resident #1's wounds were getting worse. The last time she had seen the resident had been a little while, and she was under the impression the resident's sacral pressure ulcer had evolved into a stage II pressure ulcer. When asked what facility staff could have done differently for this resident, the DON said facility staff should have sent the resident to the hospital more frequently but said the hospital would just send her back and we had to have a van on standby to pick her up, implying the resident was frequently sent to the hospital. (note: Resident #1 was only sent out 3 times in 3 months including most recent visit). Interview on 9/27/2023 at 5:14 PM, the Administrator revealed information obtained during the previous interview with the DON. Additionally, when asked what could have been done differently for Resident #1, the Administrator said, We should have added the resident to patients at risk, and could have sent her to the hospital for slightest decline. Interview on 9/28/2023 at 10:42 AM, the Administrator revealed LVN B did not have Wound Care Certification. Telephone interview on 9/29/2023 at 12:30 PM, the Medical Director said that had he been made aware that Resident #1's wound status had changed, he would have wanted to have found out the last time Resident #1 saw the vascular surgeon, would have wanted to talk to the treatment nurse, and would have looked for any signs of infection. Record review of facility policy, Job Description for Treatment Nurse, revised 3/2015, stated, The Treatment Nurse will provide quality of care to prevent and promote healing of alterations in skin integrity of each resident as determined by resident assessments and individual plans of care . 12. Initiate and continue treatments on residents in the facility with skin breakdown and other conditions requiring treatment. 13. Modify and/or change treatments as necessary and notifying physician for approval. 14. Inform the DON and the assessment nurse of resident change of condition. Record review of facility policy, Pressure Injury Prevention and Management, dated 8/15/2022, stated, This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries . The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatmen[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 19 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 - Some 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 interviews, and record reviews, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 3 of 4 residents (Resident #s 2,3,and 4) reviewed for resident records, in that: 1. The facility failed to accurately document Resident #s 2, 3, and 4's September 2023 wound treatments. 2. The facility failed to ensure Resident #3's physician progress notes from July 2023 and September 2023 were in the resident's electronic clinical record. This deficient practice could affect all residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: 1. Resident #2 Record review of Resident #2's a face sheet dated 9/30/2023 revealed Resident #2 was [AGE] years of age and was initially admitted on [DATE]. Resident #2's diagnoses included: type 2 diabetes, severe sepsis with septic shock, encounter for surgical aftercare following surgery on the digestive system, acquired absence of other specified parts of digestive tract, pressure ulcer of right heel stage 2 (onset 6/13/2023), pressure ulcer left heel stage 2 (onset 6/14/2023), pressure ulcer of sacral region stage 3 (onset 6/14/2023), colostomy status (onset 6/13/2023), depression, lack of coordination, muscle weakness, acute kidney failure. Record review of Resident #2's quarterly MDS dated [DATE], stated: Resident #2 had a BIMS score of 15 which indicated cognitive intactness. Further review revealed Resident #2 was totally dependent on staff for transfers and bathing, and required extensive assistance for bed mobility, dressing, toilet use, and limited assistance with bed mobility, and personal hygiene. Additionally, Resident #2 had 2 unstageable pressure injuries and required pressure reducing device for bed, pressure ulcer/injury care, and application of dressings to feet. Record review of Resident #2's Care Plan, printed 10/1/2023, revealed (Resident #2) has a DTI to retrocalcaneal. (Resident #2's) DTI to retrocalcaneal bursa (Achilles area) will show sings of healing and remain free from infection by/through review date. (Revision date: 9/26/2023). Interventions included, Administer medications as ordered. Administer treatments as ordered and monitor effectiveness. Assess/record/monitor wound healing. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length x width x depth), stage . (Resident #2) has a DTI to left heel. (Resident #2's) DTI will show sings of healing and remain free from infection by/through review date. (Revision date: 9/26/2023). Interventions included, Administer medications as ordered. Administer treatments as ordered and monitor effectiveness. Assess/record/monitor wound healing. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length x width x depth), stage . (Resident #2) has impairment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 20 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 - Some to skin integrity d/t has an ostomy. (Resident #2's) will be free of injury /through review date. (Date initiated 5/23/2023, Revision on 6/27/2023). Interventions included, Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heel, s/sx of infection, maceration etc. to MD. Provide ostomy care as ordered monitor for skin break down and or irritation to site. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. PHYSICIAN ORDERS Record review of Resident #2's physician orders, printed 9/30/2023, stated: DTI to retrocalcaneal bursa (Achilles area) apply betadine QD one time a day. (Order date 8/14/2023) DTI to L heel apply betadine 4x4 gauze and wrap with kerlix QD one time a day. (Order date 8/14/2023) TREATMENT ADMINISTRATION Record review of Resident #2's TAR revealed: Record review of Resident #2's TAR September 2023 stated, DTI to L heel apply betadine 4x4 gauze and wrap with kerlix QD one time a day - Start Date 8/15/2023. Further review revealed holes in the TAR for the following: 9/5, 9/6, 9/7, 9/8, and 9/15, and 9/21. Record review of Resident #2's TAR September 2023 stated, DTI retrocalcaneal bursa (achilles area) apply betadine QD one time a day - Start Date 8/15/2023. Further review revealed holes in the TAR for the following: 9/5, 9/6, 9/7, 9/8, and 9/15, and 9/21. Record review of Resident #2's TAR September 2023 stated, Monitor opening on old incision site. No bleeding. Covered with nonadhering pad - Start Date 8/31/2023. Further review revealed holes in the TAR for the following: Shift 6:00 AM - 2:00 PM - 9/5 thru 9/8, 9/15, 9/21 Shift 2:00 PM - 10:00 PM - 9/5 thru 9/9, 9/11 thru 9/15 9/18 thru 9/21, 9/23, 9/26 Shift 10:00 PM - 6:00 AM - 9/9 Interview and record review on 9/26/2023 at 11:03 AM, RN C was shown September 2023 TARs for Resident #2 and agreed they had missing entries. Resident #3 Record review of Resident #3's face sheet dated 9/30/2023 revealed the resident was [AGE] years old and was originally admitted on [DATE]. Resident #3's diagnoses included: Pressure ulcer of left heel, unstageable (onset 1/27/2023), pressure ulcer of right heel, stage 2 (onset 1/27/2023), other reduced mobility (4/25/2023), local infection of the skin and subcutaneous tissue, unspecified (10/3/2022), osteomyelitis (onset 10/3/2022), generalized edema (8/25/2022). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 21 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 - Some Record review of Resident #3's quarterly MDS, dated [DATE], revealed: Resident #3 had a BIMS of 1 indicating severe cognitive impairment, and was indicated as totally dependent on staff for bed mobility, transfer, dressing, eating toilet use, personal hygiene, and bathing. Further review revealed Resident #3 was always incontinent of bowel and bladder. Record review of Resident #3's Care Plan revealed the following: (Resident #3) has MRSA to right heel (date initiated 7/24/2023). (Resident #3) will be free from MRSA infection through review date. Interventions included, Monitor/document/report to MD PRN for s/sx of MRSA infection: Inflammation around wound sites, drainage, lethargy, headache, increased heart rate. Open wounds should be kept covered, rather than open to air . (Resident #3) is at risk for abnormal bruising and bleeding r/t anticoagulants (date initiated 1/28/23). (Resident #3) will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Interventions included, Daily skin inspection. Report abnormalities to the nurse. (Resident #3) has unstageable to right heel (date initiated 2/16/23). (Resident #3's) pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions included, Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length x width x depth) stage. (Resident #3) has stage 3 to left heel (date initiated 7/24/2023). (Resident #3's) pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions included, Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length x width x depth) stage. PHYSICIAN ORDERS Record review of a physician order for Resident #1, revealed: St to right calf cleanse area w/wound cleanser pat dry and apply steri strips until resolved (one time a day every 3 days). - start date: 8/25/2023 Unstageable to right heel apply 4x4 betadine gauze, cover with dry dressing and wrap with kerlix 1 time a day. - start date: 5/11/2023 TREATMENT ADMINISTRATION Record review of Resident #3's TAR September 2023 stated, ST to right alf cleanse area w/wound cleanser pat dry and apply steri strips until resolved once time a day every 3 days. (start date 8/25/2023) . Further review revealed holes in the TAR for the following: 9/6, 9/15, 9/27. Record review of Resident #3's TAR September 2023 stated, Unstageable to right heel apply 4x4 betadine gauze, cover with dry dressing and wrap with keflix. Further review revealed holes in the TAR for the following: 9/5, 9/6, 9/8, 9/15. Record review of Resident #3's TAR September 2023 stated, A&D to ble every shift. (start date 2/19/23). Further review revealed holes in the TAR for the following: Shift 6:00 AM - 95, 9/6, 9/8, 9/15 Shift 2:00 PM - 10:00 PM - 9/5 thru 9/9, 9/11 thru 9/15, 9/19 thru 9/21, 9/23 Shift 10:00 PM - 6:00 AM - 9/9, 9/25 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 22 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 - Some Interview and record review on 9/26/2023 at 9:26 AM, LVN A stated Resident #3 was confused (alert and oriented to person only, had a feeding tube, was on blood thinners, had an ulcer to her left heel, was bed bound, was totally dependent for ADLS, and got in her wheelchair on occasion. LVN A said nursing did offloading heels and the treatment nurse provided care to Resident #3's heels. When asked how residents received wound care when the treatment nurse was out of the facility, LVN A said the charge nurses would address the residents' wounds. During this interview, LVN A was shown Resident #3's September 2023 TAR and confirmed there were missing entries in the TAR for wound care. When asked what the missed entries meant, LVN A responded that the blank spaces in the TAR meant the treatments did not occur. Interview and record review on 9/26/2023 at 11:03 AM, RN C was shown September 2023 TARs for Residents #3 and agreed they had missing entries. When asked what that meant, the RN C said it meant the treatments, didn't occur. Resident #4 Record review of Resident #4's face sheet revealed Resident #4 was [AGE] years of age and originally admitted on [DATE]. Resident #4's diagnoses included: diabetes 2, non-pressure chronic ulcer of other part of right lower leg with unspecified severity, peripheral vascular disease, major depressive disorder, anxiety disorder, other feeding difficulties, other atherosclerosis of native arteries of extremities, bilateral legs, non-pressure ulcer of right heel and midfoot limited to breakdown of skin, non pressure chronic ulcer of left heel and midfoot limited to breakdown of skin. Record review of Resident #4's quarterly MDS dated [DATE] revealed Resident #4 had a BIMS of 14 which indicated cognitive intactness. Further review revealed Resident #4 was totally dependent on staff for bed mobility, transfer, locomotion on/off unit, dressing toilet use, personal hygiene, and bathing. Furthermore, Resident #4 was always incontinent of bowel and bladder. Record review of Resident #4's Care Plan revealed: (Resident #4) has peripheral vascular disease. (Date initiated 3/22/2023). (Resident #4 will remain free of complications related to PVD through review date. Interventions included, Keep skin on extremities well hydrated with lotion in order to prevent dry skin and cracking of the skin. Monitor the extremities for s/sx of injury, infection or ulcers. Monitor/document for excessive edema and encourage resident to elevate legs. (Resident #4) is on anticoagulant medications r/t PVD and hyperlipidemia (Date initiated 3/22/2023). (Resident #4 will be free from discomfort or adverse reactions related to anticoagulant use through review date. Interventions included, Daily skin inspection. Report abnormalities to the nurse. (Resident #4) has stage 3 to right heel. (Date initiated 3/23/2023). (Resident #4's) pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions included, Monitor/document/report PRN and changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length x width x depth), stage. PHYSICIAN ORDERS Record review of a physician order for Resident #4 stated: Cleanse stage 3 right heel with wound cleanser, pat dry, apply SILVASORB and cover with super absorbent dsg QD one time a day for ulcer. - start date: 8/4/2023 TREATMENT ADMINISTRATION (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 23 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 - Some Record review of Resident #4's September 2023 TAR revealed: Cleanse stage 3 right heel with wound cleanser, pat dry apply SILVASORB and cover with super absorbent dsg QD one time a day for ulcer. - start date 8/4/2023. Further review revealed holes in the TAR for the following: 9/6, 9/8, 9/15. Interview and record review on 9/26/2023 at 9:33 AM, LVN A revealed Resident #4 was bed fast, had wounds to her heels, was diabetic, and was almost totally dependent because of her arthritis and stroke so she needed help with her ADLS. LVN A said nursing assisted Resident #4 with accuchecks, offloading heels and the treatment nurse providing care to her heels. When asked what happened if the treatment nurse was out of the facility, she said charge nurses would address the residents' wounds. When asked where these treatments were documented, LVN A said documenting occurred on the TAR. When asked if there was any other location wounds or wound care were documented, LVN A said a progress note would be made if there was a change in condition but that the TAR was the primary source of documentation when a wound treatment occurred. LVN A said that if there was something scheduled in the MAR or TAR that was left blank, it didn't happen. She also said that there were color-coded reminders that were like a check-list that required staff to complete tasks so they can get into the green before the end of their shift. LVN A said that, in July 2023, there was a covid 19 outbreak that caused several staff to be placed off the schedule as well as multiple residents to be put into isolation. LVN A was shown Resident #4's September 2023 TAR and confirmed there were missing entries. This investigator asked if there was a code that should have been used if the resident was not present during a scheduled treatment and LVN A said there was but confirmed the blanks in the TAR indicated the medication treatments did not occur. Interview and record review on 9/26/2023 at 10:20 AM, LVN B. was asked where treatments were documented and she responded that the would occur in the TARs or skilled treatments. When shown Resident #4's September 2023 TAR, the LVN B confirmed missing entries for the resident's skin treatments. LVN B was asked why some residents were missing wound treatments, LVN B responded that she assists the CNAs frequently with continent care and will at times forget to do wound care. When asked if there was a certain priority schedule for the more serious wounds, the LVN B responded that she would make sure to address the most serious wounds first as a priority in the event that some other less serious treatments have to be skipped. LVN B was asked if she does a pass down to oncoming staff if a certain resident misses a treatment and she responded that she would. Interview and record review on 9/26/2023 at 11:03 AM, RN C stated she was filling in for the DON as the DON was out of the facility. During this interview, the RN C said she was not that familiar with the residents as she currently only worked PRN. RN C said staffing had been short and she was frequently asked to work. RN C was shown September 2023 TARs for Resident #4 and agreed they had missing entries. When asked what that meant, the RN C said it meant the treatments, didn't occur. When asked what the concern was specific to wound treatments, RN C said it was a concern because the missed treatments could cause the wounds to evolve into serious infections which could lead to sepsis and or death. RN C said this facility had difficulty retaining staff because other facilities in the area were paying more and believed staffing was the reason some of these treatments were being missed. RN C said that if the treatment nurse is required to work the floor, other nurses on the shift will be delegated to do wound care. 2.Record review of Resident #3's face sheet, dated 09/29/2023, revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebral infarction (stroke), anemia (blood disorder where the blood has decreased ability to carry oxygen due to a lower number of red blood cells), severe protein-calorie malnutrition (inadequate consumption of protein and calories that can lead to muscle loss and weight loss), high blood pressure, dementia (decline in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 24 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 - Some cognitive abilities that impacts a person's ability to perform everyday activities), peripheral vascular disease (systemic disorder of narrowed blood vessels that causes decreased blood flow to the legs and feet), and heart failure. Further review of the face sheet revealed Resident #3's physician was Physician W. Record review of Resident #3's MDS, a Quarterly Assessment, dated 08/03/2023 revealed Resident #3's BIMS (Brief Interview of Mental Status) score was 1 out of 15, indication of severe cognitive impairment. Record review of Resident #3's electronic clinical record under the Progress Notes Section and under the Miscellaneous section revealed the most recent physician progress note was dated 05/18/2023 and no further physician progress notes were in the electronic clinical record. Record review of Resident #3's Physician Progress note dated 05/18/2023, revealed the resident was seen by Physician W. In an interview on 09/29/2023 at 2:53 p.m. the DON stated Physician W was recently in the facility and the most recent progress notes may not have been scanned into Resident #3's clinical record. In an interview on 09/29/2023 at 3:17 p.m., the DON stated she could not find a more recent physician progress note from Physician W in Resident #3's electronic clinical record and would reach out to the physician's office for the progress note. In an interview on 09/29/2023 at 5:03 p.m., the DON handed the surveyor Resident #3's physician progress note completed by Physician W on 09/26/2023, stated she had only asked Physician W for his most recent progress note and was certain Physician W had seen Resident #3 between 05/18/2023 and 09/26/2023 but would ask Physician W about any visits between those dates. Record review of Resident #3's Physician Progress Note dated 09/26/2023 revealed there were no new concerns and was signed by Physician W. In an interview on 09/30/2023 at 2:41 p.m. the DON stated the facility would have the Medical Records Employee go to Physician W's office to obtain his handwritten progress notes and then scan them into the electronic clinical record. The DON stated they encourage Physician W to complete the Physician Progress Notes before he leaves the facility and leave them with the facility but sometimes he was called away before he could finish the notes. The DON stated she was not sure why Resident #3's Physician Progress note for July 2023 was not placed in the resident's electronic clinical record. On 09/30/2023 at 3:10 p.m. the DON handed the surveyor a copy of Resident #3's Physician Progress Note dated 07/30/2023 that was completed by Physician W. In an interview on 09/30/20232 at 4:08 p.m. the DON stated Resident #3's physician (Physician W) provided the Administrator a copy of his Physician Progress Note for Resident #3 dated 07/30/2023. Record review of Resident #3's Physician Progress Note dated 07/30/2023 revealed the physician noted the resident was progressing well, there were no new issues or concerns, and was signed by Physician W. In an interview on 09/30/2023 at 4:47 p.m., the Administrator stated one of the facility's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 25 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 - Some challenges has been that some of the physicians would do paper progress notes instead of electronic progress notes. The Administrator stated when Physician W was in the facility, she would remind him in person to provide the facility with the paper physician progress notes. The Administrator stated the harm of not having the physician's progress notes in the resident's electronic clinical record would be that the facility would not have the most up-to-date information available to reference from the physician's latest assessment. Record review of the Documentation in Medical Record policy, dated 10/24/22, revealed Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Under Policy Explanation and Compliance Guidelines: was 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. 3. Principles of documentation include, but are not limited to: .b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 26 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, 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 infection for 1 of 4 residents (Resident #2) reviewed for infection control Residents Affected - Few LVN B failed to maintain a sterile environment when performing wound care for Resident #2 These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #2's a face sheet dated 9/30/2023 revealed Resident #2 was [AGE] years of age and was initially admitted on [DATE]. Resident #2's diagnoses included: type 2 diabetes, severe sepsis (infection in the blood stream) with septic shock, encounter for surgical aftercare following surgery on the digestive system, acquired absence of other specified parts of digestive tract, pressure ulcer of right heel stage 2 (onset 6/13/2023), pressure ulcer left heel stage 2 (onset 6/14/2023), pressure ulcer of sacral region stage 3 (onset 6/14/2023), colostomy status (onset 6/13/2023), depression, lack of coordination, muscle weakness, acute kidney failure. Record review of Resident #2's quarterly MDS dated [DATE], stated: Resident #2 had a BIMS score of 15 which indicated cognitive intactness. Further review revealed Resident #2 was totally dependent on staff for transfers and bathing, and required extensive assistance for bed mobility, dressing, toilet use, and limited assistance with bed mobility, and personal hygiene. Additionally, Resident #2 had 2 unstageable pressure injuries and required pressure reducing device for bed, pressure ulcer/injury care, and application of dressings to feet. Record review of Resident #2's Care Plan, printed 10/1/2023, revealed (Resident #2) has a DTI to retrocalcaneal. (Resident #2's) DTI to retrocalcaneal bursa (Achilles area) will show signs of healing and remain free from infection by/through review date. (Revision date: 9/26/2023). Interventions included, Administer medications as ordered. Administer treatments as ordered and monitor effectiveness. Assess/record/monitor wound healing. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length x width x depth), stage . (Resident #2) has a DTI to left heel. (Resident #2's) DTI will show signs of healing and remain free from infection by/through review date. (Revision date: 9/26/2023). Interventions included, Administer medications as ordered. Administer treatments as ordered and monitor effectiveness. Assess/record/monitor wound healing. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length x width x depth), stage . (Resident #2) has impairment to skin integrity d/t has an ostomy. (Resident #2's) will be free of injury /through review date. (Date initiated 5/23/2023, Revision on 6/27/2023). Interventions included, Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heel, s/sx of infection, maceration etc. to MD. Provide ostomy care as ordered monitor for skin break down and or irritation to site. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. PHYSICIAN ORDERS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 27 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 Record review of Resident #2's physician orders, printed 9/30/2023, stated: Level of Harm - Minimal harm or potential for actual harm DTI to retrocalcaneal bursa (Achilles area) apply betadine QD one time a day. (Order date 8/14/2023) DTI to L heel apply betadine 4x4 gauze and wrap with kerlix QD one time a day. (Order date 8/14/2023) Residents Affected - Few SKIN ASSESSMENTS Record review of Resident #2's Weekly Skin Evaluation, date of assessment 9/8/2023, stated, Site - left heel. Type, pressure. Stage, suspected deep tissue injury. Date wound developed: 8/14/2023. Wound developed, In house. Record review of Resident #2's Weekly Skin Evaluation, date of assessment 9/8/2023, stated, Site - right heel. Type, pressure. Stage, suspected deep tissue injury. Date wound developed: 8/14/2023. Wound developed, In house. Interview and record review on 9/26/2023 at 11:03 AM, RN C was shown September 2023 TARs for Resident #2 and agreed they had missing entries. Observation and interview on 9/27/2023 at 9:04 AM, LVN B, was observed prepping for Resident #2's treatment to his right heel DTI. During the preparation, LVN B was observed wiping down a bed side table with a disinfectant wipe. LVN B then utilized the same disinfectant wipe to disinfect the scissors being utilized to remove Resident #2's bandages. During an interview at this time, the LVN B was informed of this error and agreed it presented an infection control concern. LVN B proceeded to push the bed side table into Resident #2's room but did not re-sanitize the scissors. Observation and interview on 9/27/2023 9:13 AM, LVN B initiated wound treatment for Resident #2's DTI to his right heel. During this observation, LVN B removed Resident #2's bandages and placed Resident #2's exposed heel on Resident #2's mattress. During an interview at this time, LVN B was informed of this observation and agreed that it was a concern relative to wound treatment and infection control. Observation on 9/27/2023 at 9:20 AM, LVN B was observed packaging all soiled bandages into a hazardous material bag. LVN B then pushed the bed side table out of Resident #2's room and proceeded to place her hand into her pocket to retrieve a key for her wound cart. LVN B then opened the wound cart and started placing non-used items back into the cart. During an interview at this time, LVN B was informed of this observation and agreed that it was a concern relative to wound treatment and infection control. Observation and interview on 9/27/2023 at 2:46 PM, Resident #2 was observed lying in his bed. When asked about Resident #2's wounds to both of his heels, Resident #2 said, I didn't have them until I came here. When asked if they were causing him pain, Resident #2 responded, yes. When asked if Resident #2 required assistance from his bed, Resident #2 responded, yes. When asked if staff were good about getting Resident #2 up to use his walker, Resident #2 responded, they don't ask and neither do I, I guess I should. When asked why Resident #2 acquired the pressure ulcers to his heel, Resident #2 responded, because I lay down too much? Resident #2 then said he was recently informed by an Asian nurse who only comes here on the weekends that the nurses should be treating my wounds every day (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 28 of 29 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 675395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840 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 but they don't and I wish they would. Level of Harm - Minimal harm or potential for actual harm Record review of facility policy, title, Infection Prevention and Control Program, revised, 1/2018, stated, The elements of the infection prevention and control program consist of coordination/oversight policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675395 If continuation sheet Page 29 of 29