Health inspection·November 15, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation of R #3 on 11/08/23 at 1:45 PM. R #3's hands were contracted and R #3's fingers and fingernails were facing down and somewhat inward towards R #3's hands (claw hand). There was no hand device or towel roll for R #3's contractures to R #3's hands. Interview with CNA B on 11/08/23 at 2:40 PM. CNA B said if any resident wanted their nails cut, CNA B would check with the nurse to see if the resident was diabetic. CNA B said if the resident was diabetic, then the CNAs could cut the nails, but the nurses could. CNA B said the CNAs usually focused on nail care on Sundays since that was the day there were no scheduled showers. CNA B said there were no residents with their nails too long. Interview with DON on 11/08/23 at 3:30 PM. DON was taken to observe R #3 along with HHSC Investigator. DON asked R #3 to see R #3's nails. DON said R #3's nails were too long. DON asked R #3 if R #3 wanted his nails to be cut, and R #3 responded, uhm yeah. DON said to HHSC investigator that maybe R #3 had refused nail care. HHSC Investigator informed DON there were no refusals documented in R #3's file. DON said the nurses would be the ones to cut R #3's nails since R #3 was diabetic, not the CNAs. DON said the CNAs would have informed the nurses about R #3's nails being too long. DON said R #3 could have also voiced R #3's nails being too long to the nurses or staff himself. DON said she was unsure of how R #3's nails went unnoticed, but DON would have them cut. Interview with LVN A on 11/14/23 at 12:35 PM. LVN A said if a resident was diabetic, and they have long nails, the nurses could file their nails. LVN A said if the CNAs noticed that the nails were long or the resident voiced that they wanted their nails cut, the CNAs or the resident could inform the nurses. LVN A said since there were no scheduled showers on Sundays, that was when the CNAs concentrated on nail care. LVN A said LVN A had not been informed that R #3's nails were too long or that R #3 wanted his nails to be cut. LVN A said if R #3's care plan indicated that R #3's fingernails needed to be kept short, then that was what should have been followed. LVN A said the nails were part of the skin. LVN A said R #3's nails should have been kept short for R #3's impairment to skin integrity as R #3 could sustain wounds and infections. Interview with R #3 on 11/15/23 at 12:05 PM. R #3 said he was doing well. R #3 said the nurse trimmed his nails. R #3 showed this investigator R #3's nails which were much shorter, clean, and filed (not sharp). R #3 said he felt much better. Interview with ADM on 11/15/23 at 4:30 PM. ADM said ADM was aware of the concern regarding that R #3's nails were too long. ADM said a nurse had already performed nail care and R #3 was doing well. ADM said the facility addressed this concern with all staff. Interview with DON on 11/15 /23 at 5:10 PM. DON said R #3's care plan indicated to keep R #3's fingernails short related to impairment of skin integrity as R #3 already had wounds. DON said R #3 did not have any skin tears or incidents from R #3's nails being too long. DON said R #3 could have scratched himself although R #3 was calm and not combative. DON said not keeping R #3's fingernails short could have resulted in a scratch or skin tear, and if left untreated or was not noticed, it could have led to an infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675606 If continuation sheet Page 2 of 6 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 11/15/2023 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 - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 2 of 3 residents (R #2 and R #3) reviewed for accuracy of records. The facility did not document R #2 and R #3's wound care treatments in the MAR/TAR on 10/07/23, 10/14/23, 10/15/23, and 10/22/23. This failure could place residents with wound care at risk of not receiving adequate care and services. The findings included: Record review of R #2's face sheet reflected a [AGE] year-old female with original admission date of 10/19/18. Her diagnosis included: local infection of the skin and subcutaneous tissue, pressure ulcer of sacral region, zoster (shingles) without complications, paraplegia, fibromyalgia, osteoporosis, hyperlipidemia, major depressive disorder, and dysphagia. Record review of R #2's MDS assessment dated [DATE] reflected a BIMS score of 10 (cognitively moderately impaired). Functional abilities for ADLs of bed mobility and personal hygiene required extensive assistance. Record review of R #2's care plan dated 07/21/23 reflected R #2 had a stage 4 pressure ulcer to the sacrum related to immobility, incontinence of bowel, refuses repositioning, ADL care, and getting out of bed. Date initiated: 05/08/23. Interventions included: Administer treatments as ordered and monitor for effectiveness. Record review of R #2's MAR/TAR dated October 2023 reflected; On 10/07/23, 3 orders - Gentamicin Sulfate External Ointment 0.1 % apply to sacral stage 4 topically one time a day (start date- 06/14/23 8:00 AM, discontinue date- 10/10/23 8:37 AM), Collagenase (enzymes that break the peptide bonds in collagen) External Ointment 250 unit apply to sacral stage 4 topically one time a day (start date- 06/27/23 8:00 AM, discontinue date- 10/24/23 at 8:35 AM), and wound care as follows for right heel discoloration, skin prep daily, once a day, until resolved (start date- 10/04/23 at 8:00 AM, discontinue date- 10/18/23 at 4:53 PM) for diagnosis of sacral stage 4 pressure ulcer were not documented as administered or otherwise. On 10/14/23 and 10/15/23, 3 orders - cleanse sacral ulcer with wound cleanser, pat dry with gauze, apply Collagenase with collagen, cover with silicone super absorbent dressing daily (start date- 10/11/23 8:00 AM, discontinue date- 10/24/23 8:36 AM), Collagenase External Ointment 250 unit apply to sacral stage 4 topically one time a day (start date- 06/27/23 8:00 AM, discontinue date- 10/24/23 at 8:35 AM), and wound care as follows for right heel discoloration, skin prep daily, once a day, until resolved (start date- 10/04/23 at 8:00 AM, discontinue date- 10/18/23 at 4:53 PM) for diagnosis of sacral stage 4 pressure ulcer were not documented as administered or otherwise. Record review of R #3's face sheet reflected a [AGE] year-old male with original admission date of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675606 If continuation sheet Page 3 of 6 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 11/15/2023 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 - Minimal harm or potential for actual harm Residents Affected - Few 11/10/22. His diagnosis included: local infection of the skin and subcutaneous tissue, pressure ulcer of left buttock, Guillain-Barre syndrome (disorder in which your body's immune system attacks your nerves), quadriplegia, type 2 diabetes, hyperlipidemia, and dysphagia. Record review of R #3's MDS assessment dated [DATE] reflected a BIMS score of 12 (cognitively intact). Functional abilities for ADLs of bed mobility and personal hygiene were dependent. R #3 had impairment to both sides of upper and lower extremities. Record review of R #3's care plan dated 08/30/23 reflected R #3 had a pressure ulcer stage 3 (left gluteal fold) related to extensive bed immobility and diagnosis of quadriplegia. Date Initiated: 11/11/22. Interventions included: Administer treatments as ordered and monitor for effectiveness. R #3 had an alteration in skin integrity related to the presence of a stage 3 pressure ulcer to the buttock area (left gluteal fold). Date initiated: 12/09/22. Interventions included: Apply treatment per Medical Practitioner's order and monitor for effectiveness of current treatment. Record review of R #3's MAR/TAR dated October 2023 reflected On 10/07/23, 1 order - wound care for left gluteal fold wound as follows, cleanse with wound cleanser, pat dry with 4x4 apply dressing, cover with sterile dressing daily until resolved (start date- 09/13/23 8:00 AM, discontinue date- 10/09/23 8:47 AM) for left gluteal fold stage 3 pressure ulcer was not documented as administered or otherwise. On 10/15/23, 1 order - wound care for left gluteal fold wound as follows, cleanse with wound cleanser, pat dry with 4x4 apply dressing, cover with sterile dressing daily until resolved (start date- 10/10/23 8:00 AM, discontinue date- 10/16/23 3:45 PM) for unstageable pressure wound was not documented as administered or otherwise. On 10/22/23, 2 orders - Collagenase External Ointment 250 unit, apply to left gluteal fold topically one time a day (start date- 10/17/23 8:00 AM, discontinue date- 10/24/23 11:20 AM), and wound care for left gluteal fold wound as follows, cleanse with wound cleanser, pat dry with gauze, apply Collagenase dressing, cover with sterile dressing daily until resolved (start date- 10/17/23 8:00 AM, discontinue date- 10/24/23 11:23 AM) for diagnosis of unstageable pressure wound were not documented as administered or otherwise. Interview with R #2 on 11/08/23 at 12:45 PM. R #2 said R #2 was doing well and received all the care needed. R #2 said R #2 received wound care daily. R #2 said there had not been a day that R #2 had gone without wound care or that R #2 knew the wound care was missed. R #2 said R #2 had no concerns regarding wound care or treatment. Interview with R #3 on 11/08/23 at 1:30 PM. R #3 said R #3 was doing well. R #3 said R #3 received wound care on certain days but was unsure of the days. R #3 said the wound care might have been daily. R #3 said R #3 was always done and R #3 did not know of any time that the wound care was missed or not completed for R #3. R #3 said R #3 had no concerns regarding wound care or treatment. Interview with LVN B on 11/14/23 at 1:05 PM. LVN B said LVN B worked the 2-10 PM shift. LVN B said R #3 would have been assigned to LVN B to complete R #3's wound care as R #3 was on the left side of the hall. LVN B said LVN B worked with R #3 but did not recall specific dates. LVN B said when there was no treatment nurse working, then the floor nurses, including LVN B, would be responsible to do the wound care. LVN B said there was no time that the wound care was not done for R #3 as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675606 If continuation sheet Page 4 of 6 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 11/15/2023 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 - Minimal harm or potential for actual harm Residents Affected - Few LVN B said the treatments were done, but LVN B possibly forgot to document in the MAR/TAR. LVN B said that should not have happened, but sometimes LVN B got busy and probably forgot to document. Interview with LVN D on 11/14/23 at 3:20 PM. LVN D said R #3 would have been assigned to LVN D to complete R #3's wound care as R #3 was on the left side of the hall and the afternoon shift would complete the left side of the hall for wound care. LVN D said LVN D worked the afternoon, 2-10 PM shift. LVN D said LVN D worked with R #3 a few times. LVN D said LVN D worked with R #3 on 10/07/23 and 10/15/23. LVN D said LVN D would have done the wound care treatments for R #3 on those dates. LVN D said LVN D did not miss any treatments or fail to complete the treatments with R #3. LVN D said perhaps LVN D forgot to mark the check offs on the MAR/TAR. LVN D said maybe LVN D marked it off, but it did not save on the MAR/TAR. LVN D said maybe LVN D forgot to document, but LVN D was sure the treatments were completed. Interview with ADON on 11/14/23 at 3:45 PM. ADON said the team tried to review documentation to ensure proper documentation was done. ADON said for R #3, on 10/07/23, 10/15/23 and 10/22/23, the documentation was missing for wound care in the MAR/TAR. ADON said for R #2, 10/14/23, 10/15/23, and 10/22/23, the documentation was missing for wound care in the MAR/TAR. ADON said the staff and residents did not voice that the treatments were not completed, but the documentation was missing. Interview with DON on 11/14/23 at 5:00 PM. DON said the facility identified the missing documentation for the MAR/TAR when DON initiated an audit on 11/06/23. DON said the plan of correction included to check the documentation at least weekly, however, DON was checking the documentation daily to ensure accuracy. DON said the nurses were also in-serviced to ensure the treatments were checked off on the MAR/TAR. DON said there were no negative outcomes to the residents. DON said for R #3, on 10/07/23, 10/15/23 and 10/22/23, the documentation was missing for wound care in the MAR/TAR. DON said for R #2, 10/14/23, 10/15/23, and 10/22/23, the documentation was missing for wound care in the MAR/TAR. DON said the treatments were done but the nurses failed to document. DON said although there would not be a risk of a negative outcome for the resident, the medical record needed to be accurately documented to ensure the doctors' orders were being followed for the residents. Interview with ADM on 11/15/23 at 4:30 PM. ADM said ADM was aware of the concern regarding that R #2 and R #3 missing documentation in the MAR/TAR. ADM said there were no concerns that the treatments were not done, but the lack of documentation. ADM said the facility addressed this concern with the nurses and the plan of correction was put in place on 11/06/23. Documentation in Medical Record Policy date implemented 10/24/22 reflected; Policy: 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. Policy Explanation and Compliance Guidelines: 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. Record review of performance improvement plan and Ad Hoc (unplanned meeting focusing on specific problems) meeting dated 11/06/23 reflected upon performing chart audits, noted treatments were not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675606 If continuation sheet Page 5 of 6 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 11/15/2023 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 - Minimal harm or potential for actual harm consistently being performed per doctor's orders on weekends and when treatment nurse was not available. Immediate interventions: in-service nurses regarding completion of wound care on weekends and/or when treatment nurse was not available. Systemic changes: DON or designee will conduct weekly audits of TAR. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675606 If continuation sheet Page 6 of 6