Health inspection·February 20, 2026

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident #1) reviewed for quality of care.The nurse practitioner failed to recognize and place orders for treatment for Resident #1 who was experiencing significant increased glucose levels. Resident #1 did not have orders in place for glucose checks and had an episode of high blood sugar beginning on 02/04/26 through 02/13/26 that required her to be hospitalized . An IJ was identified on 02/17/26. The IJ began on 02/04/26 and removed 02/14/26. The facility took action to remove the IJ before survey began. While the IJ was removed on 02/14/26, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm because staff failed to ensure, recognize, evaluate and advocate for resident experiencing change in condition.Resident #1 did not have orders in place for glucose checks and had an episode of high blood sugar beginning on 02/04/26 through 02/13/26 that required her to be hospitalized .This failure could affect residents by placing them at risk of delay medical treatment, hospitalization, decline in condition, and death.Findings included: Record review of Resident #1's admission Record dated 02/19/26 revealed a [AGE] year-old-female, admitted to facility on 06/19/23 with diagnoses of Alzheimer's Disease Unspecified (brain disorder that slowly destroys memory and thinking skills), Moderate Protein-Calorie Malnutrition, Type 2 Diabetes Mellitus with Mild Nonproliferative Diabetic Retinopathy without Macular Edema, Bilateral (early stage of eye disease), Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease (high blood sugar and blood pressure damage the kidney's filtering units), Type 2 Diabetes Mellitus with Diabetic Cataract (increase risk of developing cataracts sooner than non-diabetics), Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene (high blood sugar causing poor circulation on legs and feet), and Chronic Kidney Disease Stage 3A (mild to moderate kidney damage).Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS of 00 indicating his cognition was severely impaired.Record review of Resident#1's care plan with an initiation date of 07/06/23 reflected Resident #1 had a history of Diabetes Mellitus, DM with CKD. Monitor, document, report signs and symptoms of hyperglycemia such as sweating, confusion, and lack of coordination.Record review of Resident #1's Laboratory Comprehensive Metabolic Panel dated 02/04/26 revealed glucose levels were at 310 mg/dL indicating a high level.Record review of Resident #1's Laboratory Comprehensive Metabolic Panel dated 02/06/26 revealed glucose levels were at 336 mg/dL indicating a high level.Record review of Resident #1's Laboratory Comprehensive Metabolic Panel dated 02/13/26 revealed results of glucose levels were at 625 mg/dL indicating a high level.Record review of Resident #1's nursing notes revealed no new orders were requested for treatment of high glucose levels for lab work that had been done on 02/04/26, 02/06/26 or 02/13/26.Record review of Resident #1's Medication Orders revealed no orders for monitoring glucose levels or orders for glucose checks.Record review of Resident #1's electronic medical Residents Affected - Few Note: The nursing home is disputing this citation. Page 1 of 2 675606 675606 02/20/2026 Harlingen Nursing and Rehabilitation Center 3810 Hale St Harlingen, TX 78550

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation. record progress note dated 02/05/26 revealed laboratory results being communicated to nurse practitioners with no new orders for high glucose levels.Record review of Resident #1's electronic medical record progress note dated 02/09/26 revealed laboratory results being communicated to nurse practitioners with no new orders for high glucose levels.Record review of Resident #1's electronic medical record progress note dated 02/13/26 revealed critical lab results were communicated to the nurse practitioner with no new orders.Record review of Resident #1's electronic medical record progress note dated 02/14/26 revealed Resident #1 was sent to hospital for glucometer indicating high and weakness.During an interview with hospital nurse LVN A on 02/17/26 at 3:44 p.m. she stated resident #1 had been admitted to hospital with a diagnosis of hyperglycemia which was critically high glucose levels, COVID -19 and a UTI. LVN A stated Resident #1 was given an IV insulin drip. She also stated that Resident #1 was confused but was stabilized.During an interview with LVN B on 02/18/26 at 3:31 p.m. she stated Resident #1's lab work results were reported to the nurse practitioner and no new orders for treatment of glucose were given. LVN B said she had followed the nurse practitioner's orders but they had not included any treatment for Resident #1's high glucose levels. She said they follow doctor's orders. She said if a diabetic patient is left untreated with high blood sugar levels, they can go into diabetic ketoacidosis.During a telephone interview with the Nurse Practitioner on 02/18/26 at 4:04 p.m. she stated she had reviewed Resident #1's labs and was aware of her increasing glucose levels and said she had been treating Resident #1 for hydration and weight loss issues. She also said she had been ordering labs because she suspected Resident #1 had an infection but was unsure what it could be. She said she was focused on the other medical issues and did not place any new orders to address the residents increase in glucose levels. The Nurse Practitioner said kidney injury can be caused but only if exposed to chronically high levels of glucose. During an interview with LVN C on 02/18/26 at 4:36 p.m. she stated Resident #1 did not have orders for blood sugar checks. She said Resident #1 had never had any issues with her glucose. LVN C said she had communicated the critical labs on 02/13/26 to the nurse practitioner but received no orders for treatment. She said she did not make any recommendations to treat the critical labs because she said she followed doctor/nurse practitioner orders. LVN C said something could have happened to a Resident #1 with high blood sugar levels but she said she followed doctor orders.During an interview with the DON on 02/18/26 at 5:44 p.m. she stated Resident #1 was being treated for weight loss and other medical conditions but had not received orders for her high glucose levels. She said resident had had a fall as well but had no injuries. DON said Resident #1 had a possible infection that the nurse practitioner was trying to identify and had ordered antibiotics for Resident #1 on 02/13/26. DON said Resident #1 was admitted to the hospital with a diagnosis of hyperglycemia and COVID - 19. DON said since the nurse practitioner had not given orders for Resident #1 the facility staff did not ask if anything should be ordered for her. She said had Resident #1's glucose levels continued to be high she would have eventually been sent to the hospital.At the time of the investigation, Resident #1 was at the hospital.Facility did not provide a policy for Quality of Care. 675606 Page 2 of 2