Health inspection·May 26, 2022

F 0550 Record review of the list for Resident Smokers indicated two Residents on the list: Level of Harm - Minimal harm or potential for actual harm Resident #54 Resident #60 Residents Affected - Few Record review of facility's undated schedule for Supervised Smoking Times revealed: 08:00 AM - Maintenance Department 11:00 AM - Administration Department 01:00 PM - Housekeeping Department 03:00 PM - DON/ADONs 04:00 PM - Activities/Social Services Department 06:00 PM - Dietary Department 08:00 PM - Nursing Department Observation on 05/26/22 at 11:00 AM revealed no one at the gazebo/smoking area. In an interview on 05/26/22 at 11:04 AM Resident #54 said he is a smoker and went out to smoke earlier today. Surveyor asked Resident #54 if he had gone to smoke at 9:00 or 9:30 AM and Resident #54 said he had gone at that time. Resident #54 said the facility does not keep to the schedule because they were supposed to go out to smoke at 11:00 AM and no one has asked him to go smoke. Resident said if the maintenance man does not come to take them to go smoke, they will not go out. Resident said he must wear a smoking apron and be supervised by staff. In an interview on 05/26/22 at 11:13 AM Maintenance Director said he took the Residents out to smoke early in the morning. Maintenance Director said he is a smoker and will take the residents out to smoke between 8:00 AM and 9:00 AM. Maintenance Director said someone else is scheduled to take the residents out to smoke at 11:00 AM. Maintenance Director said if the other staff have not taken the residents out to smoke, he will do so after lunch around 12:30 PM or 1:00 PM. Maintenance Director said he does not mind taking the residents out to smoke, but he gets busy. Observation on 05/26/22 at 11:25 AM revealed Resident #54 sitting by the nurse's station. Observation on 05/26/22 11:30 AM of the gazebo/smoking area revealed no staff or residents outside. In an interview on 05/26/22 at 12:34 PM Resident #54 said his family member came to visit him and took him out to the gazebo to smoke around 12:00 PM. Resident said he had just come back in. Observation on 05/26/22 at 01:00 PM of the gazebo/smoking area did not reveal any staff or residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675606 If continuation sheet Page 2 of 21 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 675606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harlingen Nursing and Rehabilitation Center 3810 Hale St Harlingen, TX 78550 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 0550 Level of Harm - Minimal harm or potential for actual harm In an interview on 05/26/22 at 01:10 PM Resident #60 said, It is difficult to find someone to take us out to smoke. It is usually the maintenance man who takes us out to smoke. If he is busy, we do not go out to smoke. When asked if he minded waiting to go out to smoke, Resident #60 replied, It's not like we have a choice. Resident #60 said he wears an apron, all residents who smoke must wear an apron or they don't smoke. Residents Affected - Few In an interview on 05/26/22 at 01:44 PM the Administrator said they have set times for residents to be taken out to go smoke and the times are posted. They have smoke aprons, a smoke blanket, an ash container, and a fire extinguisher at the gazebo. The Administrator said the cigarettes and lighters are to be kept at the nurse's station. The administrator said each department has a scheduled time to take residents out to smoke. The administrator said the residents had not voiced any complaints to him about not being taken out to smoke, but he will correct the situation and have staff who are smokers take the residents out to smoke at the scheduled times. The administrator said he did not have a policy for smoking. Observation on 05/26/22 at 3:15 PM revealed Resident #54 outside in the gazebo with two maintenance staff members. Resident #54 sitting in his wheelchair with the smoking apron on. In an interview on 05/26/22 at 3:23 PM the DON said Resident #54's admission assessment has Resident #54 as a previous smoker and has not seen him go out to smoke. DON said Resident #54 was a previous admission and he was smoking. When Resident #54 was admitted on [DATE] he was not smoking. The DON said the Maintenance Supervisor takes residents out to smoke. DON said the residents are taken at resident's request also and both residents who smoke are verbal. The DON said she would speak with Resident #54 and ask if he wanted to go out to smoke. In an interview on 05/26/28 at approximately 4:00 PM the DON said she had talked with Resident #54 and he said he would like to go out to smoke three times a day. 2). Record review of Resident #6's admission Record dated 05/26/22 revealed an [AGE] year-old female admitted on [DATE] with diagnoses that included acute kidney failure, urinary tract infection, dysphagia (inability to swallow), cognitive communication deficit, hypotension (low blood pressure) and obstructive uropathy (hinderance of normal urine flow). Record review of Resident #6's physician orders dated 05/26/22 revealed Resident #6's foley catheter drainage bag should be changed on the 15th of each month. Record review of Resident #6's quarterly MDS dated [DATE] indicated -resident usually understood (difficulty communicating some words or finishing thoughts but is able if prompted or given time). -was sometimes able to understand others (responds adequately to simple, direct communication only). -required extensive assistance by two persons for bed mobility, dressing, toilet use and personal hygiene. -used an indwelling catheter. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675606 If continuation sheet Page 3 of 21 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 675606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harlingen Nursing and Rehabilitation Center 3810 Hale St Harlingen, TX 78550 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #6's care plan revised on 05/25/22 revealed Resident #6 had indwelling catheter for diagnosis of obstructive uropathy. Interventions included to position catheter bag and tubing below the level of the bladder and away from entrance room door. Observation on 05/24/22 at 10:02 am revealed Resident #6 lying in her bed in B bed, closest to window. Resident #6 was alert and smiling. Resident # 6's catheter bag was observed hanging on the bed rail below bladder level and facing the entrance door to the bedroom. The catheter bag and tubing were full of dark, purple urine. Resident's catheter bag was without a privacy bag cover. Resident #6's catheter bag was facing her roommate in A bed, by the room door. Interview on 05/24/22 at 10:02 am with Resident #6 revealed she was not aware her catheter bag was not in a privacy bag or why her urine was dark purple. Interview and observation of Resident #6's catheter bag with dark purple urine and without a privacy bag on 05/24/22 at 10:21 am with RN C revealed all nurses and CNAs were responsible to ensure Resident #6's catheter bag was in a privacy bag. RN C said Resident #6's urine was dark purple because resident had been on antibiotics that had been discontinued on 05/18/22. Interview on 05/24/22 at 11:51 am with Resident #6 revealed she did not want anyone to see her urine bag. She would get visitors to come visit her and she did not feel comfortable that anyone could see her urine, especially since it was dark purple as she was told by the nurses. Interview on 05/24/22 at 11:51 am with Resident #6's Family Member D revealed he visited Resident #6 weekly. Family Member D said he did not like seeing Resident #6's urine output. Interview on 05/26/22 at 1:15 pm with CNA F revealed Resident #6's catheter bag should be in a privacy bag because it could affect the resident's dignity if visitors saw the urine. All CNAs and nurses must ensure that the catheter bag is in a privacy bag. Interview on 05/26/22 at 1:20 pm with LVN B revealed the catheter bags should be placed inside a privacy bag for resident's dignity, so no one sees urine level, color, etc. LVN B said all CNAs, nurses were responsible to ensure that catheter bags are placed inside a privacy bag. Interview on 05/26/22 at 2:20 pm with the DON revealed if a catheter bag was not placed in a privacy bag, this might cause embarrassment to the resident. The DON said all nurses were responsible to ensure all catheter bags were placed inside a privacy bag. Record review of the facility's Statement of Resident Rights, not dated indicated You have a right to privacy, including privacy during visits and telephone calls, and an elderly individual has the right to be treated with dignity and respect for the personal integrity of the individual FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675606 If continuation sheet Page 4 of 21 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 675606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harlingen Nursing and Rehabilitation Center 3810 Hale St Harlingen, TX 78550 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** FACILITY Resident Assessment Residents Affected - Some 05/26/22 09:20 AM Initial Record Review: Submission Dates [NAME]: Record review verified the ARD reports are done quarterly and annually. The PCC states that ARD quarterly report should be completed on 05/21/22, but the status on this report is in progress. Although this report is past due for the PCC expected completion date, it falls within the 14 day time frame before it will officially be considered late. [NAME]: In the PCC, the submission due date for the ARD is 05/31/22. This resident's ARD is currently in progress and is within the window of the submissions date. [NAME]: According to the PCC, the next date for ARD submission is 06/03/22 and this resident's documentation is currently up to date. As of now, each resident falls within the estimated ARD completion dates and can be considered up to date. Follow up should be given for resident [NAME] to verify a timely completion. 05/26/22 10:15 AM Spoke with MDS nurses [NAME] and Letty [NAME] Regarding accepted and completed submissions. [NAME]: [NAME] is under the VA. MDS reports that are accepted are the ones that are submitted to CMS that show the VA he is getting any kind of approved therapy. Once therapy is complete we do a separate survey to submit to VA that show he is not under anymore therapy survey and the pay changes. [NAME] is under VA as well. Submit to CMS a couple of times at least twice a week. I probed how long after a MDS has been completed, do you submit this information to CMS. [NAME] replied that she has 14 days post assessment completion. 05/26/22 10:54 AM Follow Up Questions with MDS Nurse [NAME] stated that she did not submit to CMS because CMS is not paying us, only the VA pays that resident. Some of them were completed just for the VA but the ones to CMS just show the treatment is done. CMS is a courtesy to just say that the resident is here and receiving treatment. All residents who are under the VA will show the same pattern in the PCC MDS reporting profile. Confirmed she did not submit the MDS reports to CMS on 10/17 and 03/01 for [NAME] and 03/01 [NAME]. 05/26/22 03:22 PM Asked the MDS nurse's [NAME] and Letty if there was a facility policy that stated that if a resident is VA funded, they did not have to submit the MDS assessment to CMS and they could not provide one. ********************************** (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675606 If continuation sheet Page 5 of 21 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 675606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harlingen Nursing and Rehabilitation Center 3810 Hale St Harlingen, TX 78550 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 0640 05/26/22 01:16 PM DON [NAME]: Follow Up Level of Harm - Potential for minimal harm VA has access to all records, not sure if they are sent to VA. They are not sent but they can check in if needed. They will request and they will get the information. Unsure if all MDS reports are sent to CMS. MDS reports may be out of cycle. Residents Affected - Some 05/26/22 01:21 PM [NAME](Head of Care): We only submit the OBRA assessment because this is an open assessment. The VA has assessments that are required are at a different time than the quarterly MDS. This discloses why the frequency is off from the CMS completed reports. The MDS assessment is used to submit reports to the VA because it is a good indicator report to meet all the required fields from the VA. ******************* To summarize, this facility has failed to submit quarterly MDS reports to CMS for 2 out of the 3 residents flagged. Although the argument is understood that each assessment preformed in the PCC may not be intended to go to CMS, but may be used to satisfy the requirements of the VA, the pattern of accepted submissions are invalid. Following resident D. [NAME], his chart indicates that on 10/04/21 and 10/11/21, his MDS assessment was submitted and accepted to CMS. Following this breakdown, the next MDS assessment preformed on 10/17/21, was sent to the VA. On 11/19/21, another MDS assessment was preformed and submitted to CMS. Analyzing the trend from the initial assessment submitted in October, the next CMS deadline date will fall in January and the submission is documented on 1/17/22. The next quarterly assessment should have been completed in April, but there is no indication that this has been preformed. On 2/28/22, an assessment was marked completed but was not summitted to CMS. From the information provided by the DON and Head of Care, it can be assumed that the assessment completed on 02/28/22 was intended for the VA, but the next quarterly submission is dated for 05/21/22, which is one month after the April quarterly submission date. This leaves ground for a citation and coincides with tag F640, severity level 1. The same pattern can be found in another VA funded resident, W. [NAME]. The last MDS assessment was preformed on 03/18/22 and was marked as completed, but was not submitted and accepted to CMS. This documentation signifies that the last MDS assessment submitted and accepted fell on [DATE], which indicates that by CMS standards, this resident is 5 months behind on his quarterly assessment. The improper submission of the MDS form for this resident also warrants a citation that falls under tag F640, severity level 1. Inside chapter 5 of the CMS RAI Manual Submission and Correction of the MDS Assessment, it states all Nursing homes are required to submit Omnibus Budget Reconciliation Act (OBRA) required Minimum Data Set (MDS) records for all residents in Medicare- or Medicaid-certified beds regardless of the pay source. This shows an inconsistency on the guidelines the facility follows and the what is required by law. TAG: Based on interview and record review, the facility failed to submit a 3-month quarterly resident assessment to CMS for 2 of 3 residents (Resident #1 and Resident #4) reviewed for data encoding and transmission in a timely manner. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675606 If continuation sheet Page 6 of 21 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 675606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harlingen Nursing and Rehabilitation Center 3810 Hale St Harlingen, TX 78550 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 0640 Level of Harm - Potential for minimal harm 1. The facility failed to submit/transmit one OBRA 3-month quarterly MDS assessment for Resident #1 dated for 03/18/22. 2. The facility failed to submit/transmit two 3-month quartely MDS assessments dated for 10/17/21 and 03/01/22. Submission of documents are inconsistent for resident. Residents Affected - Some This failure placed the residents at risk of having incomplete records and can affect the funding received by this facility for their care. Findings Include: 1. Record review of Resident #1's face sheet displays that he is a [AGE] year-old male, United States Veteran. He was admitted to the facility on [DATE] with a diagnosis of hypotension (low blood sugar) and muscle wasting atrophy. On 05/26/22, review of Resident #4's electronic health record in the section for MDS revealed that 03/18/22, a MDS assessment was preformed and completed, however, the last submitted and accepted MDS assessment to CMS was dated on 12/09/21, making Resident #1's quarterly assessment more than 5 months delayed. 2. Record review of Resident #4's face sheet displays that he is an [AGE] year-old male United States Veteran. He was admitted on [DATE] with a diagnosis of hypertension (high blood pressure), Parkinson's disease (disorder of the central nervous system), and unspecified dementia (memory loss) with behavioral disturbance. Review of Resident #4's electronic health record in the section for MDS revealed on 10/17/21 and 03/01/22, no MDS assessments were submitted and accepted to CMS to satisfy the 3-month quarterly requirements for the facility. During an interview on 05/26/22 10:15 a.m. with Case Manager G and Case Manager I, they stated Because [Residents #1 and #4] were funded under the Veteran Administration , the facility is required to submit assessments as needed to show the VA that this facility is conducting all approved therapy. Case Manager G stated the facility submitted to CMS a minimum of twice per week and no later than 14 days post the assessment submission date. During a follow up interview on 05/26/2022 at 10:54 a.m. with Case Manager G regarding the missing MDS submissions, she stated that documentation was submitted to CMS only as a courtesy because the VA funded [Residents #1 and #4] stay at this facility. Case Manager G confirmed that Case Manger I and herself are responsible for submitting the MDS assessment to the VA and CMS. However, she admitted that they only submitted the MDS reports dated for 10/17/21 and 03/01/22 for Resident #4, and the report dated for 03/01/22 for Resident #1 to the VA and no submissions were made to CMS. During a phone interview on 05/26/22 at 01:21 p.m., the Head of Care J stated that in relation to Residents #1 and #4 the facility used the MDS assessment tool to submit reports to the VA because it is a good indicator to meet all the required fields. The OBRA assessment is submitted to CMS quarterly, but the required submissions for the VA are required at an alternate time. Head of Care J oversees the submission of MDS assessments made by Case Manager G and I. Head of Care J did not provide any information regarding the effect of not submitting the MDS to CMS, only that timely submission to the VA was required. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675606 If continuation sheet Page 7 of 21 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 675606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harlingen Nursing and Rehabilitation Center 3810 Hale St Harlingen, TX 78550 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 0640 Level of Harm - Potential for minimal harm Review of the RAI Manual OBRA Assessment Summary, dated October 2019, section 2.3 states that: The requirements for the RAI are found at 42 CFR 483.20 and are applicable to all residents in Medicare and/or Medicaid certified long-term care facilities. The requirements are applicable regardless of age, diagnosis, length of stay, payment source or payer source. Federal RAI requirements are not applicable to individuals residing in non-certified units of long-term care facilities or licensed-only facilities. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675606 If continuation sheet Page 8 of 21 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 675606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harlingen Nursing and Rehabilitation Center 3810 Hale St Harlingen, TX 78550 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 0641 Ensure each resident receives an accurate assessment. 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 ensure assessments accurately reflected the status for 2 of 8 residents (Residents #35 and #86) reviewed for MDS assessment accuracy. Residents Affected - Few 1. The facility failed to ensure the Quarterly MDS dated [DATE] reflected an accurate assessment of Resident #86's weight loss. 2. The facility failed to ensure the Significant Change MDS assessment dated [DATE] reflected an accurate assessment of Resident#35's PASRR (Preadmission Screening and Resident Review) status. This deficient practice could place residents at risk of inappropriate care, due to inaccurate information about the resident being used to determine care. Findings Included: 1. Record review of Resident #86's admission Record, dated 05/26/22, revealed resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident 86's diagnosis included COVID-19, encephalopathy (brain disease), altered mental status, protein-calorie malnutrition, diabetes (body does not make enough insulin) and acquired absence of left leg below knee. Record review of Resident #86's Quarterly MDS assessment dated [DATE] revealed Resident #86 -cognitive status was severely impaired. -required extensive assistance by two persons for bed mobility, transfer, dressing, toilet use and personal hygiene. -had no weight loss in the last month or loss of 10% or more in the last 6 months. -had one stage 2 pressure ulcer upon admission or reentry. -had three venous and arterial ulcers present. Record review of Resident #86's care plans dated 02/11/22 indicated -resident had unplanned/unexpected weight loss of 45 pounds in one month related to COVID-19 and recent hospitalization. Interventions included dietitian referral, monitor, and evaluate any weight loss, determine percentage lost and follow facility protocol for weight loss and weekly weights. Record review of Resident #86's weights indicated Resident #86 had -20.28% weight loss within six months. 1/21/2022 217.0 Lbs 2/11/2022 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675606 If continuation sheet Page 9 of 21 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 675606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harlingen Nursing and Rehabilitation Center 3810 Hale St Harlingen, TX 78550 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 0641 172.0 Lbs Level of Harm - Minimal harm or potential for actual harm 2/18/2022 173.0 Lbs Residents Affected - Few 2/28/2022 172.0 Lbs 3/10/2022 170.0 Lbs 3/17/2022 170.0 Lbs 3/30/2022 169.0 Lbs 4/8/2022 169.0 Lbs 4/14/2022 167.0 Lbs 4/22/2022 167.0 Lbs 4/29/2022 168.0 Lbs 5/8/2022 167.0 Lbs 5/8/2022 168.0 Lbs 5/15/2022 166.0 Lbs Observation on 05/24/22 at 10:54 am revealed Resident #86 lying in his bed in his bedroom with a catheter bag in a privacy bag, bed against wall and floor mat on his right side. Resident #86 was alert to self and did not respond to greeting by surveyor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675606 If continuation sheet Page 10 of 21 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 675606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harlingen Nursing and Rehabilitation Center 3810 Hale St Harlingen, TX 78550 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 05/26/22 at 8:50 am with the DON revealed Resident #86 was admitted to the facility on [DATE] with positive COVID-19 status, had been placed on peg tube feedings at the hospital on [DATE], with severe cognitive impairment and wounds on lateral (from the sides) right ankle heel and sacrum (area in back part of pelvic cavity) and huge loss of appetite. Resident #86 was weighed again on 02/03/22 and he weighed 203 lbs. Resident #86 was referred to the Dietitian Consultant and on 02/14/22 the Dietitian Consultant made an assessment and made some recommendations to address Resident #86's weight loss. The Dietitian Consultant made recommendations that were implemented, and weekly weights were made. The weekly weights were documented in another binder and provided for review. On 04/11/22 the Dietitian Consultant made additional recommendations that were implemented to address Resident #86's weight loss. The DON said Resident #86 did lose 45 pounds, which was -20.28 % from 01/21/22 to 02/11/22 due to his COVID-19 positive status and other contributing factors as mentioned before. Resident #86's lateral ankle and calf wounds and Stage 2 pressure ulcer to sacrum had already healed and his weights had been stable for several months. The DON said Resident #86 had been a success story from how he was admitted to the present status. Currently Resident #86's weight was 166 lbs. Interview on 5/26/22 at 9:41 am with Case Manager/RN G revealed she was responsible to complete the MDS assessments for Resident #86. Case Manager/RN G said she knew that Resident #86 had lost 45 pounds since he was admitted on [DATE] to 02/11/22 but had not entered the correct information in his quarterly MDS assessment dated [DATE]. Resident #86's quarterly MDS dated [DATE] should have indicated he had lost more than 10% weight in the past six months. Case Manager/RN G said she was responsible to ensure the MDS assessments were correct and accurate. The DON would sign off on all MDS assessments to acknowledge the MDS assessments were completed. Interview on 02/26/22 at 2:20 pm with the DON revealed Resident #86's MDS assessment dated [DATE] had been inaccurately completed on the section of weight loss. The DON said she signed all the MDS assessments to acknowledge they had been completed but not that they were accurate. The Case Managers were responsible to ensure the assessments were completed accurately. The DON said she was not aware that the inaccurate MDS assessment had a negative outcome to the resident because they had addressed his weight loss when it had been occurring. Review of CMS RAI Version 3.0 Manual (dated October 2019) revealed In addition, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts and should also include the resident's medical record, physician, and family, guardian, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. Accessed on 05/27/2022 from Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual | CMS. 2. Record review of Resident #35's face sheet, dated 05/27/2022, revealed a [AGE] year-old female with an initial admission date 03/29/2018 and a readmission date of 04/25/2022. The resident had diagnoses which included: Unspecified Dementia with Behavioral Disturbance (Principle Diagnosis), Schizophrenia, unspecified, Paranoid Schizophrenia, and Unspecified Intellectual Disabilities. Record review of Resident #35's Significant Change MDS assessment, dated 06/04/2021, revealed section A1500 indicated: no, which meant the resident is not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675606 If continuation sheet Page 11 of 21 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 675606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harlingen Nursing and Rehabilitation Center 3810 Hale St Harlingen, TX 78550 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #35's PASRR Evaluation Form, dated 12/05/2018, revealed section C0800 indicated yes, based on the QMHP (Qualified Mental Health Professional) assessment, this individual meets PASRR definition of mental illness. Interview on 05/25/2022 at 03:04 PM with Case Manager I revealed that Significant Change and Annual Assessments are the only assessments that MDS is updated for PASRR status. Resident #35's Significant Change MDS assessment dated [DATE] is the most current assessment identifying Resident #35's PASRR status. Resident #35's PASRR (Preadmission Screening and Resident Review) Evaluation Form dated 12/05/2018 would have been the current PASRR Evaluation form at the time of the 06/04/2021 Significant Change MDS assessment. Interview on 05/26/2022 at 11:09 AM, Case Manager I confirmed Resident #35's PASRR status on the Significant MDS assessment dated [DATE] should have been coded as yes instead of no. Review of CMS RAI Version 3.0 Manual (dated October 2019) in section A1500: Preadmission Screening and Resident Review (PASRR) revealed Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675606 If continuation sheet Page 12 of 21 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 675606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harlingen Nursing and Rehabilitation Center 3810 Hale St Harlingen, TX 78550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to develop and implement a baseline care plan within 48 hours of the resident's admission that included the instructions needed to provide effective and person-centered care of the resident for 1 of 2 residents (Resident #410) reviewed, in that: Resident #410's baseline care plan was completed within 48 hours. This deficient practice could place residents at risk for not having adequate information documented about the plan of care for each resident. The findings were: Record review of Resident #410's face sheet, dated 05/18/2022, revealed the resident was admitted to the facility on [DATE] as an [AGE] year-old male with a primary diagnosis of acute hypotensive anemia (low blood pressure). Record review of Resident #410's baseline care plan dated 05/18/2022 revealed section 2 related to Health Conditions & Orders was indicated as incomplete; in addition, the final review by an RN was indicated as incomplete. admission notes or assessment did not include reference to baseline care plan. Record review of Resident #410's physician's orders revealed orders to continue Keflex antibiotic for treatment of UTI. In an observation on 05/24/2022 at 9:42 AM, Resident #410 was viewed watching television within room [ROOM NUMBER]. An interview was attempted with Resident #410 on 05/24/2022 at 9:45 AM but was incomplete due to Resident #410's low verbal ability and the ability to only speak the Spanish language with light English language comprehension. In an interview on 05/25/2022 at 2:45 PM the DON stated the baseline care plan for Resident #410 was completed on 05/23/2022 and had not been completed within 48 hours due to negligence. The DON stated that baseline care plans are normally completed within the same day of admission, the latest the following day and could not explain why it was completed 5 days after admission. The DON stated she completes the baseline care plans herself and that any RN at the facility could review it. The DON stated section 2 was completed, but it had not been documented properly on the care plan. The DON stated that the risk posed to the resident in not completing a baseline care plan would be that the resident could not be properly assessed for care as a new admission and coordination of care by direct care staff could be incomplete. In an interview on 05/25/2022 at 3:12 PM Staff K stated that the baseline care plan is viewed for new admissions by all care staff of that hall. Staff K stated that the DON is the staff responsible for completing the baseline care plan. Staff K stated that when the baseline care plan was incomplete, staff will ask the DON directly for care protocol. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675606 If continuation sheet Page 13 of 21 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 675606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harlingen Nursing and Rehabilitation Center 3810 Hale St Harlingen, TX 78550 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 - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop the resident's comprehensive care plan for one (Resident #54) of six residents reviewed for care plans that describe the services to be provided to attain the resident's highest practicable physical, mental, and psychological well-being in that: Resident #54 did not have a care plan to address his choice to smoke. This failure could put Residents who smoke at risk of for withdrawal symptoms, low self-esteem and feelings of frustration of having their choices ignored. The findings included: Record review of Resident #54's Initial Baseline/Advanced Care plan dated 01/25/22 and revised 04/08/22 revealed Resident #54 was a [AGE] year-old male admitted to facility on 01/25/22 and readmitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar), Essential (Primary) Hypertension (high blood pressure), Sepsis (a life-threatening complication of infection), and Peptic Ulcer Disease (sore that develops on the lining of the esophagus, stomach, or small intestine). Section G. SAFETY & SKIN RISKS revealed question 3. Is the resident a smoker? The answer was Yes. Record review of the Resident #54's admission MDS assessment dated [DATE] indicated Resident #54: -was able to make himself understood, -was able to understand others, -had intact cognition with a BIMS score of 13, -required extensive assistance with activities of daily living, and -did not use tobacco. Record review of Resident #54's Comprehensive Care Plan dated 04/11/22 did not reveal a care plan for smoking. Record review of the list for Resident Smokers indicated two Residents on the list: Resident #54 Resident #60 In an interview on 05/26/22 at 11:04 a.m. Resident #54 said he was a smoker and had gone out to smoke earlier today. The Surveyor asked Resident #54 if he had gone to smoke at 9:00 a.m. or 9:30 a.m. and Resident #54 said he had gone at that time. Resident #54 said the facility did not keep to the smoking schedule because they were supposed to go out to smoke at 11:00 AM and no one had asked him to go smoke. Resident #54 said he must wear a smoking apron and be supervised by staff. Resident #54 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675606 If continuation sheet Page 14 of 21 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 675606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harlingen Nursing and Rehabilitation Center 3810 Hale St Harlingen, TX 78550 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 said he had not complained to administration about the smoking schedule. Level of Harm - Minimal harm or potential for actual harm Observation on 05/26/22 at 11:25 AM revealed Resident #54 was sitting by the nurse's station. Residents Affected - Few In an interview on 05/26/22 at 3:09 PM RN G said she did not know Resident #54 was a smoker. RN G said she had not seen Resident #54 go out to smoke since he was admitted . RN G said they had seven days after the MDS assessment was completed to complete a resident's comprehensive care plan. RN G said she would go speak with Resident #54 and verify if he was a smoker. Observation on 05/26/22 at 3:15 PM revealed Resident #54 was outside in the gazebo with two maintenance staff members. Resident #54 was sitting in his wheelchair with the smoking apron on. In an interview on 05/26/22 at 3:23 PM the DON said Resident #54 did not have a care plan because Resident #54 was not a smoker. The DON said Resident #54's admission assessment had Resident #54 as a previous smoker and had not seen him go out to smoke. DON said Resident #54 was a previous admission and he was smoking then. When Resident #54 was admitted on [DATE] he was not smoking. The DON said smoking residents were supervised, the Maintenance Supervisor took residents out to smoke. DON said the residents are taken at resident's request also and both residents who smoke were verbal. The DON said the care plans were important to meet the resident's' preferences and choices while in the facility. The DON said it would be better if Resident #54 did not smoke. The DON said she would ask the resident about his preferences and choices and how many times he would like to go outside to smoke. In an interview on 05/26/28 at approximately 4:00 PM the DON said she had talked with Resident #54 and he said he did smoke, and he would like to go out to smoke three times a day. Record review of the policy for Care Planning revised in December 2017 provided by the facility revealed: A comprehensive, person-centered care plan is developed and implemented for each resident to meet the resident's physical, psychosocial and functional needs. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675606 If continuation sheet Page 15 of 21 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 675606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harlingen Nursing and Rehabilitation Center 3810 Hale St Harlingen, TX 78550 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 0692 Provide enough food/fluids to maintain a resident's health. 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 ensure a theraputic diet was offered after being ordered by a healthcare professional for 1 of 6 residents (Resident #10) whose records were reviewed, in that: Residents Affected - Few The facility did not act upon Resident #10s dietician recommendation for adding a house shake 3x a day to improve wound healing and weight stability. Resident #10s physician was not notified of recommendation. This deficient practice could place residents at risk and delay of necessary medical treatment. The findings were: Record review of Resident #10's Physician Order Summary report dated 05/24/2022 revealed Resident #10 was a [AGE] year-old female who was admitted to facility on 02/13/2022 with diagnoses that included: Diabetes (A metabolic disorder in which the body has high sugar levels for prolonged periods of time), Dementia (A group of symptoms that affects memory, thinking and interferes with daily life) and Anxiety (Anxiety is the mind and body's reaction to stressful, dangerous, or unfamiliar situations). Resident #10's orders included: Regular diet Pureed texture, Regular Liquids consistency, fortified foods with all meals (start date 05/12/22). Record review of Resident #10's orders dated 05/26/22 revealed: House Shake with meals for supplement for 30 Days to meet calories/pro needs for wound healing and weight stability (start date 05/26/22). Record review of Resident #10's Quarterly MDS dated [DATE] revealed the resident was not able to complete a brief interview for mental status. Resident #10 required extensive to total assistance for activities of daily living. Record review of Resident #10's comprehensive care plan date initiated 04/21/2019 revealed: Resident #10 had a potential for a nutritional problem due to diet restrictions, regular diet, mechanical soft diet. The intervention reflected to Serve diet as ordered. Record review of Resident #10's Dietitian/Nursing/Physician Communication form dated 05/23/22 revealed: -Resident #10: Modify supplement: 1. Discontinue Prostat. 2. Add house shake TID (three times a day) with meals for 30 days to help meet calorie/pro needs for wound healing and weight stability. Record review of Resident #10's progress notes dated 05/26/22 at 11:30 a.m., revealed: Dietary recommendation: d/c [NAME], add house shake three times with meals x 30 days to help meet kcalorie/pro needs for wound healing and weight stability. Per nurse practitioner for dietary recommendation. In an observation on 05/24/22 at 12:27 p.m. revealed Resident #10 was assisted with feeding by staff. It was observed that there was not house shake or prostat at Resident #10's table. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675606 If continuation sheet Page 16 of 21 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 675606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harlingen Nursing and Rehabilitation Center 3810 Hale St Harlingen, TX 78550 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 05/26/22 at 11:00 a.m., LVN A said she was currently overseeing residents weights. She said the previous nurse that monitored weights was no longer at the facility. LVN A said during the morning meetings residents' dietician recommendations were discussed. LVN A said after the meeting she or the resident's charge nurse would call physician to see if he/she would agree with the dietician recommendations. LVN A said if the doctor agreed with the recommendations, the order would be added to the resident's orders. She said had given the recommendation to LVN B. LVN A said on 05/24/22 dietary recommendations for Resident #10 were discussed during the morning meeting and she or charge nurse were supposed to follow up with Resident #10's doctor. In an interview on 05/26/22 11:26 a.m., the Dietary Manager said he could not implement any dietary recommendations until the order appeared in the resident's electronic record. He said at there was a drawer at the nurse's station that was labeled dietary communication slip and that was where the nurses placed dietary recommendations. He said he checked drawer at least twice a day. He said had not receive any new dietary recommendations for Resident #10. Dietary Manager said the kitchen had the house shakes, and if a resident had an order for it, staff would place the house shake in the meal tray. Observation on 05/26/22 at 12:25 p.m. revealed Resident #10 was in the dining area, eating independently. There was no house shake for Resident #10. In an interview at 05/26/22 at 12:37 p.m., the Dietary Manager said on 06/26/22 around noon he received the order from nursing staff. He said meal trays were already in the dining room. He said Resident #10's lunch meal tray went out to the dining room with no house shake. In an interview on 05/26/22 at 12:58 p.m., the DON said dietician recommendations were discussed in the morning meeting the following day of the dietician's visit. She said last time the dietician was at the facility was on 05/23/22 so the recommendations were reviewed on 05/24/22. The DON said the nurse that was in charge of weights and dietary recommendations was no longer working at facility. She said currently LVN A was in charge of taking care of the dietician recommendations. The DON said LVN A could call the doctor about recommendations or LVN A could tell the resident's charge nurse to call the physician. She said sometimes the implementation of the recommendations could take up to a week if the nurses were not able to talk to the physician. The DON said LVN B had called Resident #10''s physician on 05/24/22 for the dietician recommendation, however LVN B did not document the call made to the physician. The DON said not following the dietician recommendations could cause potential weight loss. In an interview on 05/26/22 at 1:11 p.m., LVN B said on 05/24/22 she called Resident #10's physician to let him know about the dietician recommendations, however, she was not able to talk to him. She said she did not document that she had made the call. She said the dietician order for house shake three times a day during meals was carried out a few days later after 05/24/22. She said even thought it was a few days there was a potential for weight loss. In an interview on 05/26/22 at 01:37 p.m., the DON said there was no policy for following physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675606 If continuation sheet Page 17 of 21 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 675606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harlingen Nursing and Rehabilitation Center 3810 Hale St Harlingen, TX 78550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of each resident, for one resident (Resident #104) of four residents observed for medication administration. MA H did not check Resident #104's blood pressure or pulse rate before administering Carvedilol ( blood pressure medication), as ordered by Resident #104's physician. This failure could place residents who take blood pressure medications at risk for hypotension (low blood pressure). The findings were: Record review of Resident #104's admission Record, dated 05/26/22, revealed Resident #104 was a [AGE] year old male, admitted to the facility on [DATE]. Resident #104's diagnoses included: Essential hypertension (abnormally high blood pressure), nontraumatic intracranial hemorrhage (bleeding within the skull), and atherosclerotic heart disease of native coronary artery without angina pectoris (coronary arteries become narrowed or blocked by plaque). Record review of Resident #104's Entry MDS was not yet completed, due to being a recent admission. Record review of Resident #104's care plan revealed, Resident #104 was care planned for hypertension and received medication at risk for s/e, Date initiated and revised on 05/25/22. The interventions included to give anti-hypertensive medications as ordered. Record review of Resident #104's Order Summary Report, dated 05/16/22 revealed an order for Coreg(Carvedilol) tablet 3.125mg, give 1 tablet by mouth two times a day for HTN, hold if BP <100/60 or HR <60. Notify MD if continues. Observation on 05/25/22 at 8:55 a.m., revealed Medication Aide H prepared Resident #104's medications, which included: Aspirin 81mg one tablet (interferes with how blood clots to help prevent heart attacks or blot related strokes), Folic Acid 800mcg one tablet (supplement), Brillinta 90mg one tablet (used for coronary artery disease), Gabapentin 100mg one capsule (used for neuropathy), Isosorbide 60mg one tablet (used for angina), Carvedilol 3.125 mg one tablet (used for high blood pressure), Spironolactone 25mg one tablet (used for fluid retention), Vitamin D 50,000 u one capsule (supplement), Vitamin B6 100mg one tablet (supplement), Vitamin C 500mg one tablet (supplement), Vitamin B12 1000mcg one tablet (supplement), Multi vitamin one tablet (supplement), Ferrous Sulfate 325mg one tablet (supplement), and Levocetirizine 5mg one tablet (used for allergies). At 9:17 AM, Medication Aide H, administered Resident #104's medications, without checking Resident #104's blood pressure or pulse rate, prior to administering the Carvedilol 3.125mg. In an interview on 05/25/22 at 9:31 a.m. Medication Aide H said she used the nurses blood pressure for Resident #104 which was checked at 8:17 a.m. Medication Aide H said she also checked it at 8:30 a.m. and it was around the same, so she used the blood pressure from 8:17 a.m. Medication Aide H said it was possible for Resident #104's blood pressure to go down during the time the nurse last checked it to the time the medications were actually administered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675606 If continuation sheet Page 18 of 21 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 675606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harlingen Nursing and Rehabilitation Center 3810 Hale St Harlingen, TX 78550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 05/25/22 at 10:43 a.m., the DON said the staff were supposed to check the blood pressure right before giving the medications. The DON said the expectation was that the staff were to check the blood pressure themselves. In an interview on 05/25/22 at 3:10 p.m., the DON nodded yes, when asked if the blood pressure and pulse rate could drop within an hour. The DON said that nurses and medication aides received training at hire and every year on medication administration. Record review of Resident #104's blood pressure and pulse rate record revealed: Blood pressure on 05/25/22 at 8:06 a.m. - 118/76 Pulse rate on 05/25/22 at 8:06 a.m. -76 bpm There was no record of a blood pressure or pulse rate at 8:17 a.m., or 8:30 a.m. Record review of facility policy, titled Medication Administration, dated 10/01/19 revealed: Right assessment/response - Medications like blood pressure medications always warrant a quick blood pressure check before giving a blood pressure medication. Nurses must be aware of paraments for administration, these to be done as specified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675606 If continuation sheet Page 19 of 21 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 675606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harlingen Nursing and Rehabilitation Center 3810 Hale St Harlingen, TX 78550 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 - Potential for minimal 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 record reviews, observation, and interviews the facility failed to maintain medical records on each resident that are accurately documented for 1 of 2 (Resident #410) residents in that: Resident #410's chart reflected an order for droplet precautions with no end date when the resident was not on isolation. This deficient practice could result in and could affect the treatment and care provided to the resident by facility staff due to not having accurate information. The findings were: Record review of Resident #410's face sheet, dated 05/18/2022, revealed the resident was admitted to the facility on [DATE] as an [AGE] year-old male with a primary diagnosis of acute hypotensive anemia (low blood pressure). Record review of Resident #410's physician's orders revealed droplet precautions beginning on 05/24/2022 without a listed end date. The order did not include why Resident #410 was on droplet precautions. Record review of Resident #410's physician's orders revealed orders to continue Keflex antibiotic for treatment of UTI. In an observation on 05/24/2022 at 9:42 AM, Resident #410 was viewed watching television within room [ROOM NUMBER]. Signage of isolation or signs and symptoms were not found outside of Resident #410's room. An interview was attempted with Resident #410 on 05/24/2022 at 9:45 AM but was incomplete due to Resident #410's low verbal ability and the ability to only speak the Spanish language with light English language comprehension. In an interview on 05/25/2022 at 3:12 p.m. Staff K stated Resident #410's physician's orders indicated the resident was on droplet precautions however staff and visitors were not to follow the droplet precautions order as it was a clerical error in documentation. Staff K stated the physician's orders were entered with batch orders automatically with any new admission by an admitting nurse and that the orders were likely entered incorrectly. In an interview on 05/25/2022 at 2:45 p.m. the DON on 05/24/2022, the DON stated physician's orders were completed upon admission and updated after new orders were received from the physician. The DON stated the physician's orders containing a droplet precautions order were entered for all new admissions until a COVID-19 vaccination can be confirmed, or the droplet isolation has elapsed for 14 days from admission. The DON stated that vaccination status was confirmed on the day of admission. The DON stated the resident was not at risk by the incorrect physician's orders due to the physician order being a clerical issue that was removed within 24 hours. Record review of undated facility admission policy revealed physician orders are to be entered into (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675606 If continuation sheet Page 20 of 21 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 675606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harlingen Nursing and Rehabilitation Center 3810 Hale St Harlingen, TX 78550 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 electronic record immediately upon admission of residents. Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675606 If continuation sheet Page 21 of 21