Health inspection·August 17, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Self-extubation, Tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension, tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Dehydration. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Provide local care to G-Tube site as ordered and monitor for s/sx of infection. Record Review of R#2's weight dated 06/08/2023 was 153.4lbs; weight dated 07/13/2023 was 153.8lbs; and weight dated 08/11/2023 was 157.2lbs Record review of R#2's Physician's Orders dated 02/28/2022 revealed, documented Enteral Feed Order every night shift total amount of feeding in 24 hours and total amount of water in 24 hours. Record review of R#2's Physician's Orders dated 02/28/2022 revealed, Enteral Feed Order every shift Flush with 10cc H2O between medications, and Enteral Feed Order every shift Flush with 30cc H20 before and after medications. Record review of R#2's Physician's Orders dated 03/31/2023 revealed, Increase TF to Glucerna 1.2 at 70mL/HR X 22 hr to provide 1540mL. Continue to flush with 145mL water Q6hrs. Record review of R #2's Medication Administration Record/Treatment Administration Record dated March 2023- August 2023, revealed R#2 receiving 1452ml tube feeding and 800ml of water every 24 hours. During an observation on 08/16/2023 at 1:23PM revealed R#2 was receiving Glucerna 1.2 at an infusion rate of 70mL/HR. The volume delivered was 783mL. The date of the Glucerna written on the bottle was 8/15/2023 and had 6PM as the start time. Also inscribed on the Glucerna 1.2 bottle was a rate of infusion of 70mL/HR. 200mL was left in the Glucerna 1.2 bottle. During an interview on 08/17/2023 at 10:11AM, the RD stated she submitted on 03/31/2023, her dietary recommendation order to increase infusion tube feeding rate for R#2, to 70mL/HR for 22hr. The RD stated she was unaware of which staff member would transcribe her recommendation order into R#2's electronic health record. The RD stated R#2 was due for a quarterly review, and stated R#2's ideal body weight was 140+or - 10%, and R#2 was in his designated weight range. The RD stated she did not include water flushes in conjunction with the water administered with medication administration. The RD stated if R#2 was not receiving the prescribed nutrition, R#2's healing process, and nutritional status could potentially be compromised, leading to major detrimental effects to R#2's well-being. The RD stated prior to March 31, 2023, R#2 was receiving 66mL/HR of tube feeding which equated to 1452mL every 24 hours. The RD stated her theory was that the facility did begin to administer the new order of Glucerna 1.2 70mL/HR and 145ml Q6hr but did not change the documentation to equate to 1540mL tube feeding and 540mL of water every 24 hours. The RD stated R#2 did not have a significant weight change of more than 5%, and R#2's weight increase of 3lb a month was not significant. The RD stated that she does not normally oversee MARs-TARs but does look at weights and did not find a 3lb increase from 7/13/2023-08/11/2023 to be a significant increase. During an interview on 08/16/2023 at 3:19 PM, the DON stated the order for 1452ml was incorrect. The DON stated he input the new physician's order, in R#2's electronic health record, dated March 31, 2023, but does not recall who he gave the new instructions to. The DON stated he did not know where the total water flushes of 800ml came from. The DON stated the amount could be calculated including each water flush for each of R#2's medication. The DON stated each medication was administered through R#2's G-tube and as a safety measure and standard of practice, each medication needed to be independently administered through the G-tube to ensure R#2 does not have an adverse or allergic reaction (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675630 If continuation sheet Page 2 of 3 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 675630 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulf Shores Rehabilitation & Healthcare Center 1301 S Terrell St Falfurrias, TX 78355 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 due to medication interaction. The DON stated the accumulative amount of water could have potentially came from the additional water given during medication administration. The DON stated what could potentially happen was a person could see lower mL and not feed R#2 the recommended amount. The DON stated if orders are not followed R#2's healing process as well as nutritional status could be impacted negatively leading to bigger issues that affect R#2's well-being. The DON stated the total tube feeding amount that was documented for R#2 does not match the tube feeding amount ordered. The DON stated the total amount of tube feeding should be 1540mL for every 24 hours, not 1452mL every 24 hours. The DON stated the expectation of the facility was to follow orders and document accurately. The DON stated his clinical staff were following physician's orders of infusing 70mL/HR of Glucerna 1.2 for R#2 but were not documenting accurately. The DON stated it was an unacceptable practice of his clinical staff to inaccurately document the tube feeding amount. The DON stated it was a standard of practice for each nurse to check orders prior to any administration, as well as to check the MAR to ensure R#2 was getting the right dose. The DON stated he checks tube feeding rates daily for all residents receiving tube feeding and does not know what happened with the documentation. The DON stated he and the ADON administered skill checkoffs to the clinical staff yearly, which includes how to document. Record review of the facility's Charting and Documentation Policy dated revised July 2017 reflected, 3. Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675630 If continuation sheet Page 3 of 3