Health inspection·August 1, 2025

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some white count. It reflected she had skin breakdown to the back of her right arm, stage 1 decubitus ulcer to her buttocks, and no rash or lesions noted. Review of Resident #1's weekly skin assessment, dated 06/26/25, reflected MASD redness noted to groin area, MASD to her right buttock measuring 4.0 cm x 2.5 cm x 0.1 cm, MASD to right hip measuring 1.0 cm x 1.0 cm x 0.1 cm, and a rash to her right/left Axilla. Review of Resident #1's physician orders, dated 06/26/25, reflected to apply triad paste to buttocks and posterior upper thighs q shift for MASD. Review of Resident #1's MD progress note, dated 07/01/25, reflected the following: Wound of buttock, unspecified laterality, initial encounter. Appears to have MASD to buttocks with one open area to right gluteal cleft. Will order Triad paste every shift. Will refer to wound care provider. Review of Resident #1's WCN progress note, dated 07/02/25, reflected the following: [Resident #1] seen for follow-up. Fungal rash to axilla improved but she has rash now present to periarea worsened, left hip and bilateral buttocks. She is having pain with pericare. MASD with skin breakdown to axilla, bilateral buttocks, periarea: moisture erythema and fungal rash present, scattered areas of skin breakdown with red wound beds exposed. Review of Resident #1's physician order, dated 07/02/25, reflected MASD to buttocks, groin, peri area, and left hip: apply 50/50 mix antifungal powder and triad paste two times a day for candidiasis (fungal infection) of the skin. Review of Resident #1's weekly skin assessment, dated 07/03/25, reflected MASD to groin and bilateral buttocks. Review of Resident #1's NP progress note, dated 07/07/25, reflected the following: She reports a worsening rash and maceration to the groin area, which is spreading to the bilateral buttocks and down the medial thighs, secondary to persistent diarrhea. Brief changes and bed baths are extremely painful for [Resident #1]. She has an order for PRN Imodium Q6H as of today. [Resident #1] also has bleeding and chapped lips, and Aquaphor has been ordered for application to assist in healing. She is tearful and moans with pain with any kind of touch or repositioning. Review of Resident #1's WCN progress note, dated 07/09/25, reflected the following: [Resident #1] with increased skin breakdown to buttocks and groin. She is having constant stooling, linens and gown saturated with liquid stool. They are unable to insert rectal tube at this facility. Unsure how often she is being cleaned. Discussed with nurse and primary team, [Resident #1] may need to be sent out to ER if they cannot control her pain and stop stooling. Review of Resident #1's weekly skin assessment, dated 07/10/25, reflected MASD to groin and bilateral buttocks. Review of Resident #1's NP progress note, dated 07/10/25, reflected the following: Rash and maceration in groin, bilateral buttocks, and medial thighs; subsequent breakdown with maceration and erythema in affected areas. Very little improvement from prior visit. Review of Resident #1's progress notes, dated 07/10/25 at 10:59 AM and documented by RN B, reflected the following: [Resident #1's RP D] called by this nurse to update on [Resident #1]'a continued refusals to get up in WC to eat in dining room. Worsening MASD to groin and buttocks and upper thighs and hips from continued diarrhea even with PRN loperamide 2 mg. Review of Resident #1's progress notes, dated 07/10/25 at 1:08 PM and documented by RN B, reflected the following: Lips noted crusted and red, this nurse tried to provide oral care with a warm washcloth on [Resident #1], [Resident #1] jerked her head back and forth saying no, no. Review of Resident #1's progress notes, dated 07/11/25 at 6:36 AM and documented by RN C, reflected the following: [Resident #1] was noted with dried blood on face from bleeding crack [sic] lips. Tried to clean up face and apply lip ointment but [Resident #1] let turning her head away and said no, no, no. Please, no. During per-care [Resident #1] would scream in pain but wouldn't take any pain meds prior to. She takes them crushed in apple sauce and would not open her mouth. Review of Resident #1's SBAR, dated 07/12/25 at 1:17 PM and documented by RN A, reflected the following: The change in condition, symptoms or signs: bleeding (other than GI); diarrhea; pain (uncontrolled); skin wound or ulcer; urinary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675651 If continuation sheet Page 2 of 16 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 675651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Marcos Rehabilitation and Healthcare Center 1600 N I H 35 San Marcos, TX 78666 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some incontinence (new or worsening) Is the resident displaying any of the following signs/symptoms? Symptoms or signs of pain; not eating or drinking at all; acute declined in ADL abilities; nausea, vomiting, or diarrhea; new or worsened incontinence, pain with urination or blood in urine; new skin condition Abdominal/GI Evaluation: diarrhea; decreased appetite/fluid intake Describe diarrhea: Persistent multiple loose with stable vital signs Describe decreased appetite: Significant decline in food and fluid intake in resident with marginal hydration and nutritional status Skin Evaluation: pressure ulcer, rash, wound Document location and details: coccyx, groin, right/left buttock, right/left gluteal fold Does the resident have pain? Yes Is the resident cognitively able to rate their pain scale? Yes Rate pain on scale of 0-10: 8 Is the pain: Acute Recommendation of Primary Clinician(s): Transfer to higher level of care. Review of Resident #1's progress note, dated 07/12/25 at 2:10 PM and documented by RN A, reflected the following: [Resident #1] transferred to (hospital name) ER for evaluation. [Resident #1] is having increased pain and skin failure in the perianal/vaginal, thighs, and buttocks. Lesions, scabs, bleeding on lips, mouth. Review of Resident #1's hospital records, dated 07/12/25, reflected the following: [Resident #1] arrives via EMS from (nursing facility) with excoriation to bilateral buttock up to mid back, entire groin area, under bilateral armpits, and with lips dried with blood. Per EMS [Resident #1] was found laying in brief, gown and linens completely soiled. [Resident #1] moaning and groaning and can barely answer questions.General: She is in acute distress.Appearance: She is ill-appearing. Skin: Desquamation in the groin area with involvement to medial thigh and buttocks are with scattered surrounding erythematous lesions, occasional pustule. Macerated erythematous region surrounding scattered lesions noted to bilateral axilla. Unknown when this was noted but it has not been improving. [Resident #1] appears to be in pain moaning and groaning, unable to answer further questions. Exam significant for: Ill appearing woman in no acute distress. Extensive involvement of the mucosal membrane of oral cavity and lips. Desquamating rash in the groin, axilla, estimating 7% BSA involvement. Plan: Transfer initiated as this will likely require high-level care perhaps burn, dermatology. give fentanyl for pain control, IV fluids. Review of pictures of Resident #1 taken in the ER, dated 07/12/25, reflected the following: Picture #1 - Taken from Resident #1's left side as she was lying supine:Full thickness open area covering pubis, labia, and upper inner thighs visible. Wound edges irregularly shaped. Skin at edges dry and curling. Wound bed mostly pink. Some dark brown/black area in the right groin fold. Dry white paste-like substance around outer edges and lower right thigh wound. Yellow/brown substance, consistent with fecal matter visible on the brief, in left groin fold wound and mixed in with white paste-like substance at top of pubis wound. Several small irregularly shaped open areas above the pubis wound. Picture #2 - Taken from Resident #1's feet, legs separated as she was lying supine:The same full thickness open areas were visible on the pubis, labia, and upper inner thighs. The wounds on the thigh extend to mid-thigh. The wound on the perineum extends to the vaginal area. More yellow/brown substance, consistent with fecal matter, was visible between the labia and the thigh. Picture #3 - Taken while Resident #1 was lying supine with her right arm extended away from her body:Right axilla (armpit) with large open area. The edges of the wound were irregularly shaped. The wound extends from the inner aspect of her right arm, through the armpit and on to the side of the chest. The wound bed had some pink and red areas. A white paste-like substance covers part of the wound bed. There were four other small open areas, separate from the large wound, visible on the upper arm. Picture #4 - Taken while Resident #1 was lying supine with her head on the pillow:Resident # 1 had a deeply furrowed brow, eyes and mouth partially open. Her face was consistent with a pain level of 8 or 9 using the Wong-Baker FACES Pain Rating Scale (a self-assessment tool used to help individuals communicate the severity of their (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675651 If continuation sheet Page 3 of 16 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 675651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Marcos Rehabilitation and Healthcare Center 1600 N I H 35 San Marcos, TX 78666 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some pain). There was an area on the right upper lip that has a cluster of raised circular areas covered with what appeared to be dried blood or scabs. The center of the upper lip had a dark circular raised area covered with what appears to be dried blood or scabs. The left side of the upper lip had several more similar raised areas. The lower left corner of her mouth had a large clump of raised areas covered with dried blood or scabs. This clump included both the upper and lower lip. This clump extended from the lips to her frown line. There were three other clumps of dried blood or scabs that extended from her frown line on to her cheek. The right side of the lower lip there was a raised area with dried blood or scabs. In the center of the lower lip there was a large, raised area covered with dried blood or scabs. There were a few small patches of what appeared to be dried blood in the frown line on the right side of her face running from the corner of her mouth to her chin. Picture 5 - Taken while Resident #1 was lying on her right side, being held in position, to show her back side. The left side of the picture showed her legs, just above her knees. The right side of the picture was about mid-back. There was a wound visible on the left side that extends from her hip to above her waist. The side wound had red open areas with irregular edges. Much of the visible areas of this wound were covered with a white paste-like substance. There was a wound from about mid-thigh, on both legs, that encompassed both buttocks and the sacrum. The edges were irregular. There were multiple open areas with red moist areas. There were multiple open areas with dark pink tissue visible. There were multiple areas with light pink. There was an area on the left buttock, near the gluteal cleft where the skin appeared to be rolled up. Scattered areas had a coating of a white paste-like substance. Some of the paste like substance is tinged yellow, consistent with the yellow substance visible on the brief. The brief also had areas of blood-tinged drainage. Above the large open wound noted above, there were multiple open areas on her upper buttocks and back. These open areas vary in size and shape. Most have irregular borders. There were multiple dark spots that did not appear to be open. Review of Resident #1's hospital records (burn unit), dated 07/12/25 - 07/17/25, reflected the following: Per Dermatology:4. Hemorrhagic mucositis on the upper and lower mucosal lip, poor dentition. Upper and lower extremities were bandaged today, however prior exam showed: Pink erosions on the buttocks with leading scaleRight axilla pink papules coalescing into a plaque with superficial erosionsPink papules with erosions on the mons pubis with background erythema of the mons pubis, perineum, and inner thighsPhysical Exam: General: Alert, in mild distress due to pain.Skin: Erosive, desquamative erythematous rash in sacral, perineal, perianal, and gluteal region with scattered open/bleeding areas. Weeping and secretions noted. Similar rash identified in right axilla. [Resident #1]'s metabolic acidosis likely in setting of diarrhea (diagnosed with C. Diff). Review of Resident #1's hospital records, dated 07/17/25 - 07/22/25, reflected the following: At the (nursing facility), [Resident #1] had developed skin rash lesions in her mouth, buttocks, and inner thigh area and was concerned for [NAME] Syndrome (a rare but serious condition characterized by the sudden onset of painful rashes, blisters, and peeling skin.) [Resident #1] was subsequently sent over via EMS to our ER where she was transferred to (hospital) for higher level care. [Resident #1] had biopsy that was negative for [NAME] Syndrome. There was suspicion for herpetic lesions and steroids started. Biopsy shows nonspecific necrotizing inflammatory lesions. Overall, the lesions have since slowly improved. [Resident #1]'s hospital course also complicated by C. difficile colitis and currently on day 2 of 10 treatment. C. diff: [Resident #1] with FMS in place to divert stool from woundsUrinary Incontinence: Foley catheter in place WOUNDS: Right axilla: scattered circular wounds with full thickness skin breakdown, red wound beds, small serosanguineous drainage, no erythemaLeft and right buttock upper posterior thighs: scattered circular wounds with full thickness skin breakdown, red wound beds, mild slough, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675651 If continuation sheet Page 4 of 16 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 675651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Marcos Rehabilitation and Healthcare Center 1600 N I H 35 San Marcos, TX 78666 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some small serosanguineous drainage, no erythema, attached edges. New epithelial growth throughoutPubis: scattered circular wounds with full thickness skin breakdown, red wound beds, scant serosanguineous drainage, no erythema, attached edges. New epithelial growth throughoutOral lesions: crusted blood, dry lesions to upper and lower lip Discharge Exam (O7/22/25): HEENT atraumatic, normocephalic, oropharynx clear moist, extraocular motor intact Crusting of her lesions around her mouth noted. Significantly. Improved. Some crusting lesions on her bottom. During an interview on 07/29/25 at 12:07 PM, RN B stated Resident #1's skin was very macerated and very broken down. She stated before her last hospital stay (06/20/25 - 06/23/25), she had some redness to her bottom but it was more controlled. She stated when she returned from the hospital it became worse and it started spreading down her legs which was very alarming. She stated their WCN did give them orders, but they did not seem to be working. She stated Resident #1's lips were bad and very strange, they were swollen with sores and bleeding. She stated she would use a warm washcloth to clean them, but it was not working. She stated everything was getting worse and worse. She stated Resident #1's diarrhea got worse, and they got an order for PRN Imodium. She stated it did not help the diarrhea, and that was why it was not given that often. She stated it probably should have been scheduled. She stated Resident #1 would often refuse Tramadol because it hurt for her to open her mouth. She stated she was in excruciating pain and her skin was very disturbing. She was shown the weekly skin assessment she had completed on 07/10/25 and admitted that it did not depict her skin accurately. She stated people are sent to the burn unit at a hospital when they have a top layer of skin missing. During a telephone interview on 07/29/25 at 12:34 PM, Resident #1's RP E stated one of her family members was there at least once a week to visit her. She stated a few days prior to going to the hospital on [DATE], they were informed she had a rash. She stated two days after they were notified of her having continuous diarrhea, RP D got a call from a nurse stating that her rash on her privates had gotten pretty severe and she felt like she needed to be sent to the hospital. She stated they were shocked that a little rash turned into needing to go to the hospital two days later. She stated the nurse also sent a picture of her mouth/lips and they were horrified. She stated a few weeks before the hospitalization they requested a care plan meeting. She stated the nursing staff discussed in the meeting about sending her to (higher-level of care hospital). She stated the family was under the impression they wanted to send her there for PT, they were not aware of her wounds, so they declined sending her to that hospital, because she would not have benefited from PT. She stated Resident #1 had never had wounds or anything like that before. She stated her wounds were blistered and bleeding and it was horrible. She stated the nursing facility should have 100% sent her out sooner. She stated Resident #1 was diagnosed with C. Diff and believed the nursing facility should have caught that. She stated she believed the constant diarrhea was what made her wounds worse. She stated Resident #1 was sent to a burn unit due to her wounds being so severe. She stated she was now residing at another facility and was doing much better. She stated she still had memory issues but was alert and talking now. She stated her skin was healing, her mouth was much better, and she was now able to eat. During an interview on 07/29/25 at 1:03 PM, CNA F stated she worked on Resident #1's hall and was very familiar with her. She stated her skin was bad and she had never seen anything like it before. She stated she started having diarrhea when she came from the hospital (on 06/23/25) and it was a lot. She stated she was always changing her and assumed it was what made her skin worse. She stated it was the worst in her groin area and it progressively got worse. She stated she was in so much pain and would cry when she changed her brief. She stated she would ask the nurse to give her PRN pain medication before she changed her, so she believed she was getting it. She stated she would assume she would have been getting Imodium because (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675651 If continuation sheet Page 5 of 16 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 675651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Marcos Rehabilitation and Healthcare Center 1600 N I H 35 San Marcos, TX 78666 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the diarrhea was so bad and so much. She stated if she was getting it, it was not helping. She stated she would try and wet her lips with sponges, but the crust would rip off and it would bleed. CNA F stated all of it was super sad. During a telephone interview on 07/29/25 at 1:04 PM, the WCN stated Resident #1 had some rashes to her axilla a couple weeks prior and started treating it with triad paste and power. She stated that seemed to resolve the following week when she was there, but she had developed some rashes on her buttocks and thighs. She stated a week after that, she had some rashes and skin breakdown. She stated she and her sheets were soaking wet. She stated it continued to get worse on her buttocks and upper thighs and it was raw like diaper rash. She stated the skin breakdown was MASD, and her treatment orders were to keep her clean and dry and to treat with triad and zinc cream. She stated if the diarrhea continued, the creams would not stay on. She stated she had pain when the staff changed her, when she was repositioned, and when assessing her arm pits and skin. She stated she was not sure what the sores were on her lips. WCN stated she believed they sent her out to the hospital because they were not able to do a fecal management system at the facility. During an interview on 07/29/25 at 1:45 PM, RN A stated she only worked weekends but did work with Resident #1. She stated her lips were awful - they were bloody and crusty. She stated she correlated what was on her lips to what was on her backside - they looked like the same type of lesions. She stated there were circular areas and all were excoriated. She stated what prompted her to send Resident #1 to the hospital on [DATE] was because she saw her skin and lips, saw she was in pain and agony, and said, No way - something is going on. She stated she had a gut feeling she needed a higher level of care because they were not doing anything for her here. She stated she was in so much pain and would scream when you would just touch her and she looked so fearful. She stated her skin was so much worse than it was the weekend prior. She stated all her diarrhea could have been an indicator for C. Diff, but she was not tested for it at the facility. She was shown Resident #1's skin assessment from 07/10/25 and asked if it accurately depicted her skin. She stated, Not even close. She stated her skin was sloughing off, she had irregular pattern areas of redness/MASD, and severe excoriation. She stated her skin was like a big burn. She stated since she only worked the weekends, she could not say if she should have been sent out sooner. During a telephone interview on 07/29/25 at 2:10 PM, Resident #1's RP D stated she was never made aware of the extent of her wounds. She stated a few days before she was hospitalized on [DATE], she was called and notified she had some redness, and they were putting an ointment on it. She also was told she had some loose stools but never mentioned excessive diarrhea. She stated a nurse sent her a picture of Resident #1's lips on 07/12/25 and they were grotesque and bleeding. She stated she was horrified to see how bad her skin was. She stated she was now residing at another nursing facility and was back to her baseline. She stated she was eating, drinking, and her lips had made a complete 180 and were healed. She stated Resident #1 even told her she liked the new place so much better than the old one. She stated when she was first admitted to the hospital, they staff told her they did not know how it got so bad in just two weeks from her previous admission. She stated they told her it was preventable and should not have gotten that bad. During a telephone interview on 07/29/25 at 3:46 PM, Resident #1's NP stated she was new to the facility and only assessed her one time. She stated when she assessed her (on 07/07/25), she had skin breakdown associated with maceration to her groin and inner thighs. She stated it looked very painful. She stated she talked to the WCN who had seen her that morning to come up with a new treatment plan because apparently it had gotten way worse. She stated she was going to wait and see if the new treatment plan was going to help resolve it. She stated she knew she was having continuous/excessive diarrhea and started her on Imodium. She stated she wanted to see if that would help slow the diarrhea. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675651 If continuation sheet Page 6 of 16 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 675651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Marcos Rehabilitation and Healthcare Center 1600 N I H 35 San Marcos, TX 78666 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some She stated there was no odor that would have indicated C. Diff. She stated she had a lot going on and did not want to over-load her. She stated she was not exhibiting anything they could not manage in-house. She stated her labs were stable and she did not see anything that would indicate she needed to be sent out. During an interview on 07/29/25 at 4:45 PM, the ADM stated the RCN had looked through the hospital records for Resident #1 and had found that her skin issues were due to herpes. He asked if the RCN could join, and she entered the room a few moments later. The ADM stated she (Resident #1) must have had a herpes outbreak and the redness on her skin was how her body reacted to the outbreak. He stated she did not have MASD on her body and asked the RCN to Google for the surveyor what MASD looked like. The surveyor showed the RCN the picture of Resident #1 that was sent to her by one of her nurses, and pointed to the area of redness between her thighs. She stated that there may have been some MASD, but the records reflected it was due to herpes. At this time, the ADM requested the surveyor's PM be contacted as he did not feel as the surveyor had all the information needed for an IJ to be called. The surveyor's PM was contacted, and he (the PM) stated he would contact his supervisor and would get back to them. While waiting for the PM to call back, the ADM continued to focus on how Resident #1's skin issues was due to herpes continued to ask how the surveyor could call and IJ without all relevant information. The surveyor became uncomfortable, received approval from her PM to leave, and respectfully told the ADM and the RCN that her PM would be in contact to provide them with information on how to proceed. Review of the facility's Pain Recognition and Management Policy, revised 04/2025, reflected the following: It is the policy of this to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, comprehensive and routine assessments, person-centered care plan, and the resident's goals and preferences. Acute pain refers to pain that is usually sudden in onset and time-limited with a duration of less than one (1) month and often is caused by injury, trauma, surgery, or infection. Review of the facility's Skin and Wound Monitoring and Management Policy, revised 04/2025, reflected the following: Ongoing Skin and Wound Assessments:1. A licensed nurse will assess/evaluate a resident's skin at least weekly.2. Areas of breakdown, excoriation, or discoloration or other unusual findings must be documented in the nursing noes or on the appropriate weekly assessment form.3. A licensed nurse will assess/evaluate at least weekly each area of alteration/injury, whether present on admission or developed after admission, which exists on the resident. This assessment/evaluation should include but not limited to:1. Measuring the skin injury2. Staging the skin injury (when the cause is pressure)3. Describing the nature of the injury4. Describing the location of the skin alteration5. Describing the characteristics of the skin alteration6. Describing the progress with healing, and any barriers to healing which may exist7. Identifying any possible complications or signs/symptoms consistent with the possibility of infectionReview of the facility's Significant Change of Condition Policy, revised 12/2023, reflected the following: It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. The ADM was notified on 07/29/25 at 5:43 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 07/31/25 at 3:18 PM: The notification of Immediate jeopardy states as follows: Resident #1 acquired C. Diff and wounds covering her backside, and peri area of her body causing unmanaged pain and subsequently being sent to a burn unit. The facility needs to take immediate action to ensure all residents are receiving the necessary care to avoid pain and hospitalization. The facility submits this Plan of Removal to address the immediate threat identified on 7/29/25.Patient was sent to the hospital on 7/12/25 and is no longer a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675651 If continuation sheet Page 7 of 16 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 675651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Marcos Rehabilitation and Healthcare Center 1600 N I H 35 San Marcos, TX 78666 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete resident at the facility. Resident has been sent to another local SNF, per family choice. Resident Identification: Action: All residents, including residents with wounds, had a pain assessment completed to identify if they are in pain to avoid hospitalization. Any resident that indicates that their pain is not controlled with their current pain medication regiment will be reviewed by their attending physician/NP for possible changes. The results were that 8 residents were not completely satisfied with their pain relief. NP was notified and the NP is conducting a medication review on these 8 residents. Start Date: 7/29/25 Completion Date: 7/30/25Responsible: Facility Nurse Managers. Corrective Action:Action: Adhoc QAPI Committee Meeting held with facility medical director. Start Date: 7/29/25Completion Date: 7/29/25Responsible: Facility Administrator Action: Clinical resource provided in-service training to DON/Nurse Management Team on pain management, recognition, pain assessment tools to prevent hospitalization. Inservices were conducted on accurate pain assessment, changes of condition, and physician notification of changes. Start Date: 7/29/25Completion Date: 7/29/25Responsible Clinical Resource Action: DON/ designee will in-service facility nursing staff regarding pain recognition and management, including verbal and non-verbal signs of pain, to prevent hospitalization. The facility does not use agency staff. All new hires will be trained during the orientation process, prior to working with residents. PRN staff/staff on vacation will be notified and provided training and quiz via telephone. Inservices were conducted for facility nurses on accurate pain assessment, changes of condition, and physician notification of changes. Start Date: 7/29/25 Completion Date: 7/30/25Responsible: DON/Designee MonitoringAction: A Quiz will be given to the facility nursing staff to ensure that staff can recognize resident pain. The facility does not use agency staff. All new hires will be trained during the orientation process, prior to working with residents. PRN staff/staff on vacation will be notified and provided training and quiz via telephone. Start Date: 7/29/25 Completion Date: 7/30/25Responsible: DON/Designee Systemic Changes to prevent recurrenceAction: Residents will be evaluated for pain on admission, quarterly and with every change of condition. NP/ MD will be notified upon occurrence to ensure pain is managed. Residents' skin will be evaluated on admission, weekly, and on change of condition. Any changes will be communicated to the MD/NP. Start Date: 7/29/25Completion Date: On-going Responsible: DON/DesigneeAction Event ID: Facility ID: 675651 If continuation sheet Page 8 of 16 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 675651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Marcos Rehabilitation and Healthcare Center 1600 N I H 35 San Marcos, TX 78666 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of five residents reviewed for quality of care. The facility failed to: Manage Resident #1's diarrhea and urine when her MASD worsened causing her skin to be inflamed with erosions and severe excoriation (rubbing of the skin leading to abrasions or erosions) to her groin, buttocks, thighs, and axilla (arm pit) which consequently required treatment in the burn unit at the hospital from [DATE] - 07/17/25. Manage Resident #1's pain when her wounds were causing her excruciating pain in July of 2025 causing her to cry, moan, and groan during personal care. Address the wounds on Resident #1's mouth in July 2025 which became so severe she could/would not open her mouth to eat or take medicationComplete Resident #1's weekly skin assessments to accurately depict the status of her wounds/skin integrity on 07/03/25 and 07/10/25. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 07/29/25 at 5:43 PM and a template was provided. While the IJ was removed on 08/01/25 at 3:20 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of deterioration of wounds, increased pain, hospitalization, and a decreased quality of life. Findings included:Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including need for assistance with personal care, adult failure to thrive, type II diabetes, history of stroke, and cognitive communication deficit. Review of Resident #1's quarterly MDS assessment, dated 06/05/25, reflected a BIMS score of 0, indicating she was severely cognitively impaired. Section M (Skin Conditions) reflected she was at risk of developing pressure ulcers/injuries and did not have any unhealed pressure ulcers/injuries. Review of Resident #1's quarterly care plan, dated 06/03/25, reflected she had a pressure ulcer or potential for pressure ulcer development with an intervention of encouraging fluid intake and assisting to keep skin hydrated. Review of Resident #1's physician order, dated 07/07/25, reflected Imodium A-D Oral Capsule - 2 MG - Give 1 capsule by mouth every 6 hours as needed for diarrhea. Review of Resident #1's MAR, July 2025, reflected she was administered Imodium one time on 07/07/25, 07/09/25, and 07/12/25. Review of Resident #1's Bowel Incontinence log, from 07/05/25 - 07/12/25, reflected the number of times she had diarrhea each day. She had no formed stools during this time: 07/05/25 - 207/06/25 - 307/07/25 - 307/08/25 - 207/09/25 - 207/10/25 - 207/11/25 - 107/12/25 - 4 Review of Resident #1's physician order, dated 07/08/25, reflected Tramadol HCl Oral Tablet - 50 MG - Give 1 tablet by mouth every 8 hours as needed for pain. Review of Resident #1's MAR, July 2025, reflected she was administered Tramadol one time on 07/08/25, twice on 07/09/25, and once on 07/11/25. Review of Resident #1's hospital records, from 06/20/25 - 06/23/25, reflected she was admitted with c/f occult infection due to rising white count. It reflected she had skin breakdown to the back of her right arm, stage 1 decubitus ulcer to her buttocks, and no rash or lesions noted. Review of Resident #1's weekly skin assessment, dated 06/26/25, reflected MASD redness noted to groin area, MASD to her right buttock measuring 4.0 cm x 2.5 cm x 0.1 cm, MASD to right hip measuring 1.0 cm x 1.0 cm x 0.1 cm, and a rash to her right/left Axilla. Review of Resident #1's physician orders, dated 06/26/25, reflected to apply triad paste to buttocks and posterior upper thighs q shift for MASD. Review of Resident #1's MD progress note, dated 07/01/25, reflected the following: Wound of buttock, unspecified laterality, initial encounter. Appears to have MASD to buttocks with one open area to right gluteal cleft. Will order Triad paste every Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675651 If continuation sheet Page 9 of 16 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 675651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Marcos Rehabilitation and Healthcare Center 1600 N I H 35 San Marcos, TX 78666 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some shift. Will refer to wound care provider. Review of Resident #1's WCN progress note, dated 07/02/25, reflected the following: [Resident #1] seen for follow-up. Fungal rash to axilla improved but she has rash now present to periarea worsened, left hip and bilateral buttocks. She is having pain with pericare. MASD with skin breakdown to axilla, bilateral buttocks, periarea: moisture erythema and fungal rash present, scattered areas of skin breakdown with red wound beds exposed. Review of Resident #1's physician order, dated 07/02/25, reflected MASD to buttocks, groin, peri area, and left hip: apply 50/50 mix antifungal powder and triad paste two times a day for candidiasis (fungal infection) of the skin. Review of Resident #1's weekly skin assessment, dated 07/03/25, reflected MASD to groin and bilateral buttocks. Review of Resident #1's NP progress note, dated 07/07/25, reflected the following: She reports a worsening rash and maceration to the groin area, which is spreading to the bilateral buttocks and down the medial thighs, secondary to persistent diarrhea. Brief changes and bed baths are extremely painful for [Resident #1]. She has an order for PRN Imodium Q6H as of today. [Resident #1] also has bleeding and chapped lips, and Aquaphor has been ordered for application to assist in healing. She is tearful and moans with pain with any kind of touch or repositioning. Review of Resident #1's WCN progress note, dated 07/09/25, reflected the following: [Resident #1] with increased skin breakdown to buttocks and groin. She is having constant stooling, linens and gown saturated with liquid stool. They are unable to insert rectal tube at this facility. Unsure how often she is being cleaned. Discussed with nurse and primary team, [Resident #1] may need to be sent out to ER if they cannot control her pain and stop stooling. Review of Resident #1's weekly skin assessment, dated 07/10/25, reflected MASD to groin and bilateral buttocks. Review of Resident #1's NP progress note, dated 07/10/25, reflected the following: Rash and maceration in groin, bilateral buttocks, and medial thighs; subsequent breakdown with maceration and erythema in affected areas. Very little improvement from prior visit. Review of Resident #1's progress notes, dated 07/10/25 at 10:59 AM and documented by RN B, reflected the following: [Resident #1's RP D] called by this nurse to update on [Resident #1]'a continued refusals to get up in WC to eat in dining room. Worsening MASD to groin and buttocks and upper thighs and hips from continued diarrhea - even with PRN loperamide 2 mg. Review of Resident #1's progress notes, dated 07/10/25 at 1:08 PM and documented by RN B, reflected the following: Lips noted crusted and red, this nurse tried to provide oral care with a warm washcloth on [Resident #1], [Resident #1] jerked her head back and forth saying no, no. Review of Resident #1's progress notes, dated 07/11/25 at 6:36 AM and documented by RN C, reflected the following: [Resident #1] was noted with dried blood on face from bleeding crack [sic] lips. Tried to clean up face and apply lip ointment but [Resident #1] let turning her head away and said no, no, no. Please, no. During per-care [Resident #1] would scream in pain but wouldn't take any pain meds prior to. She takes them crushed in apple sauce and would not open her mouth. Review of Resident #1's SBAR, dated 07/12/25 at 1:17 PM and documented by RN A, reflected the following: The change in condition, symptoms or signs: bleeding (other than GI); diarrhea; pain (uncontrolled); skin wound or ulcer; urinary incontinence (new or worsening) Is the resident displaying any of the following signs/symptoms? Symptoms or signs of pain; not eating or drinking at all; acute declined in ADL abilities; nausea, vomiting, or diarrhea; new or worsened incontinence, pain with urination or blood in urine; new skin condition Abdominal/GI Evaluation: diarrhea; decreased appetite/fluid intake Describe diarrhea: Persistent multiple loose with stable vital signs Describe decreased appetite: Significant decline in food and fluid intake in resident with marginal hydration and nutritional status Skin Evaluation: pressure ulcer, rash, wound Document location and details: coccyx, groin, right/left buttock, right/left gluteal fold Does the resident have pain? Yes Is the resident cognitively able to rate their pain scale? Yes Rate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675651 If continuation sheet Page 10 of 16 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 675651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Marcos Rehabilitation and Healthcare Center 1600 N I H 35 San Marcos, TX 78666 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some pain on scale of 0-10: 8 Is the pain: Acute Recommendation of Primary Clinician(s): Transfer to higher level of care. Review of Resident #1's progress note, dated 07/12/25 at 2:10 PM and documented by RN A, reflected the following: [Resident #1] transferred to (hospital name) ER for evaluation. [Resident #1] is having increased pain and skin failure in the perianal/vaginal, thighs, and buttocks. Lesions, scabs, bleeding on lips, mouth. Review of Resident #1's hospital records, dated 07/12/25, reflected the following: [Resident #1] arrives via EMS from (nursing facility) with excoriation to bilateral buttock up to mid back, entire groin area, under bilateral armpits, and with lips dried with blood. Per EMS [Resident #1] was found laying in brief, gown and linens completely soiled. [Resident #1] moaning and groaning and can barely answer questions.General: She is in acute distress.Appearance: She is ill-appearing. Skin: Desquamation in the groin area with involvement to medial thigh and buttocks are with scattered surrounding erythematous lesions, occasional pustule. Macerated erythematous region surrounding scattered lesions noted to bilateral axilla. Unknown when this was noted but it has not been improving. [Resident #1] appears to be in pain moaning and groaning, unable to answer further questions. Exam significant for: Ill appearing woman in no acute distress. Extensive involvement of the mucosal membrane of oral cavity and lips. Desquamating rash in the groin, axilla, estimating 7% BSA involvement. Plan: Transfer initiated as this will likely require high-level care perhaps burn, dermatology. give fentanyl for pain control, IV fluids. Review of pictures of Resident #1 taken in the ER, dated 07/12/25, reflected the following: Picture #1 - Taken from Resident #1's left side as she was lying supine:Full thickness open area covering pubis, labia, and upper inner thighs visible. Wound edges irregularly shaped. Skin at edges dry and curling. Wound bed mostly pink. Some dark brown/black area in the right groin fold. Dry white paste-like substance around outer edges and lower right thigh wound. Yellow/brown substance, consistent with fecal matter visible on the brief, in left groin fold wound and mixed in with white paste-like substance at top of pubis wound. Several small irregularly shaped open areas above the pubis wound. Picture #2 - Taken from Resident #1's feet, legs separated as she was lying supine:The same full thickness open areas were visible on the pubis, labia, and upper inner thighs. The wounds on the thigh extend to mid-thigh. The wound on the perineum extends to the vaginal area. More yellow/brown substance, consistent with fecal matter, was visible between the labia and the thigh. Picture #3 - Taken while Resident #1 was lying supine with her right arm extended away from her body:Right axilla (armpit) with large open area. The edges of the wound were irregularly shaped. The wound extends from the inner aspect of her right arm, through the armpit and on to the side of the chest. The wound bed had some pink and red areas. A white paste-like substance covers part of the wound bed. There were four other small open areas, separate from the large wound, visible on the upper arm. Picture #4 - Taken while Resident #1 was lying supine with her head on the pillow:Resident # 1 had a deeply furrowed brow, eyes and mouth partially open. Her face was consistent with a pain level of 8 or 9 using the Wong-Baker FACES Pain Rating Scale (a self-assessment tool used to help individuals communicate the severity of their pain). There was an area on the right upper lip that has a cluster of raised circular areas covered with what appeared to be dried blood or scabs. The center of the upper lip had a dark circular raised area covered with what appears to be dried blood or scabs. The left side of the upper lip had several more similar raised areas. The lower left corner of her mouth had a large clump of raised areas covered with dried blood or scabs. This clump included both the upper and lower lip. This clump extended from the lips to her frown line. There were three other clumps of dried blood or scabs that extended from her frown line on to her cheek. The right side of the lower lip there was a raised area with dried blood or scabs. In the center of the lower lip there was a large, raised area covered with dried blood or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675651 If continuation sheet Page 11 of 16 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 675651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Marcos Rehabilitation and Healthcare Center 1600 N I H 35 San Marcos, TX 78666 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some scabs. There were a few small patches of what appeared to be dried blood in the frown line on the right side of her face running from the corner of her mouth to her chin. Picture 5 - Taken while Resident #1 was lying on her right side, being held in position, to show her back side. The left side of the picture showed her legs, just above her knees. The right side of the picture was about mid-back. There was a wound visible on the left side that extends from her hip to above her waist. The side wound had red open areas with irregular edges. Much of the visible areas of this wound were covered with a white paste-like substance. There was a wound from about mid-thigh, on both legs, that encompassed both buttocks and the sacrum. The edges were irregular. There were multiple open areas with red moist areas. There were multiple open areas with dark pink tissue visible. There were multiple areas with light pink. There was an area on the left buttock, near the gluteal cleft where the skin appeared to be rolled up. Scattered areas had a coating of a white paste-like substance. Some of the paste like substance is tinged yellow, consistent with the yellow substance visible on the brief. The brief also had areas of blood-tinged drainage. Above the large open wound noted above, there were multiple open areas on her upper buttocks and back. These open areas vary in size and shape. Most have irregular borders. There were multiple dark spots that did not appear to be open. Review of Resident #1's hospital records (burn unit), dated 07/12/25 - 07/17/25, reflected the following: Per Dermatology:4. Hemorrhagic mucositis on the upper and lower mucosal lip, poor dentition. Upper and lower extremities were bandaged today, however prior exam showed:Pink erosions on the buttocks with leading scaleRight axilla pink papules coalescing into a plaque with superficial erosionsPink papules with erosions on the mons pubis with background erythema of the mons pubis, perineum, and inner thighsPhysical Exam: General: Alert, in mild distress due to pain.Skin: Erosive, desquamative erythematous rash in sacral, perineal, perianal, and gluteal region with scattered open/bleeding areas. Weeping and secretions noted. Similar rash identified in right axilla. [Resident #1]'s metabolic acidosis likely in setting of diarrhea (diagnosed with C. Diff). Review of Resident #1's hospital records, dated 07/17/25 07/22/25, reflected the following: At the (nursing facility), [Resident #1] had developed skin rash lesions in her mouth, buttocks, and inner thigh area and was concerned for [NAME] Syndrome (a rare but serious condition characterized by the sudden onset of painful rashes, blisters, and peeling skin.) [Resident #1] was subsequently sent over via EMS to our ER where she was transferred to (hospital) for higher level care. [Resident #1] had biopsy that was negative for [NAME] Syndrome. There was suspicion for herpetic lesions and steroids started. Biopsy shows nonspecific necrotizing inflammatory lesions. Overall, the lesions have since slowly improved. [Resident #1]'s hospital course also complicated by C. difficile colitis and currently on day 2 of 10 treatment. C. diff: [Resident #1] with FMS in place to divert stool from woundsUrinary Incontinence: Foley catheter in place WOUNDS: Right axilla: scattered circular wounds with full thickness skin breakdown, red wound beds, small serosanguineous drainage, no erythemaLeft and right buttock upper posterior thighs: scattered circular wounds with full thickness skin breakdown, red wound beds, mild slough, small serosanguineous drainage, no erythema, attached edges. New epithelial growth throughoutPubis: scattered circular wounds with full thickness skin breakdown, red wound beds, scant serosanguineous drainage, no erythema, attached edges. New epithelial growth throughoutOral lesions: crusted blood, dry lesions to upper and lower lip Discharge Exam (O7/22/25): HEENT atraumatic, normocephalic, oropharynx clear moist, extraocular motor intact Crusting of her lesions around her mouth noted. Significantly. Improved. Some crusting lesions on her bottom. During an interview on 07/29/25 at 12:07 PM, RN B stated Resident #1's skin was very macerated and very broken down. She stated before her last hospital stay (06/20/25 - 06/23/25), she had some redness to her bottom but it was more controlled. She stated when she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675651 If continuation sheet Page 12 of 16 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 675651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Marcos Rehabilitation and Healthcare Center 1600 N I H 35 San Marcos, TX 78666 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some returned from the hospital it became worse and it started spreading down her legs which was very alarming. She stated their WCN did give them orders, but they did not seem to be working. She stated Resident #1's lips were bad and very strange, they were swollen with sores and bleeding. She stated she would use a warm washcloth to clean them, but it was not working. She stated everything was getting worse and worse. She stated her pain was bad and she cried constantly but would not open her mouth for pain medication. She stated Resident #1's diarrhea got worse, and they got an order for PRN Imodium. She stated it did not help the diarrhea, and that was why it was not given that often. She stated it probably should have been scheduled. She stated Resident #1 would often refuse Tramadol because it hurt for her to open her mouth. She stated she was in excruciating pain and her skin was very disturbing. She was shown the weekly skin assessment she had completed on 07/10/25 and admitted that it did not depict her skin accurately. She stated people are sent to the burn unit at a hospital when they have a top layer of skin missing. During a telephone interview on 07/29/25 at 12:34 PM, Resident #1's RP E stated one of her family members was there at least once a week to visit her. She stated a few days prior to going to the hospital on [DATE], they were informed she had a rash. She stated two days after they were notified of her having continuous diarrhea, RP D got a call from a nurse stating that her rash on her privates had gotten pretty severe and she felt like she needed to be sent to the hospital. She stated they were shocked that a little rash turned into needing to go to the hospital two days later. She stated the nurse also sent a picture of her mouth/lips and they were horrified. She stated a few weeks before the hospitalization they requested a care plan meeting. She stated the nursing staff discussed in the meeting about sending her to (higher-level of care hospital). She stated the family was under the impression they wanted to send her there for PT, they were not aware of her wounds, so they declined sending her to that hospital, because she would not have benefited from PT. She stated Resident #1 had never had wounds or anything like that before. She stated her wounds were blistered and bleeding and it was horrible. She stated the nursing facility should have 100% sent her out sooner. She stated Resident #1 was diagnosed with C. Diff and believed the nursing facility should have caught that. She stated she believed the constant diarrhea was what made her wounds worse. She stated Resident #1 was sent to a burn unit due to her wounds being so severe. She stated she was now residing at another facility and was doing much better. She stated she still had memory issues but was alert and talking now. She stated her skin was healing, her mouth was much better, and she was now able to eat. During an interview on 07/29/25 at 1:03 PM, CNA F stated she worked on Resident #1's hall and was very familiar with her. She stated her skin was bad and she had never seen anything like it before. She stated she started having diarrhea when she came from the hospital (on 06/23/25) and it was a lot. She stated she was always changing her and assumed it was what made her skin worse. She stated it was the worst in her groin area and it progressively got worse. She stated she was in so much pain and would cry when she changed her brief. She stated she would ask the nurse to give her PRN pain medication before she changed her, so she believed she was getting it. She stated she would assume she would have been getting Imodium because the diarrhea was so bad and so much. She stated if she was getting it, it was not helping. She stated she would try and wet her lips with sponges, but the crust would rip off and it would bleed. CNA F stated all of it was super sad. During a telephone interview on 07/29/25 at 1:04 PM, the WCN stated Resident #1 had some rashes to her axilla a couple weeks prior and started treating it with triad paste and power. She stated that seemed to resolve the following week when she was there, but she had developed some rashes on her buttocks and thighs. She stated a week after that, she had some rashes and skin breakdown. She stated she and her sheets were soaking wet. She stated it continued to get worse on her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675651 If continuation sheet Page 13 of 16 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 675651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Marcos Rehabilitation and Healthcare Center 1600 N I H 35 San Marcos, TX 78666 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some buttocks and upper thighs and it was raw like diaper rash. She stated the skin breakdown was MASD, and her treatment orders were to keep her clean and dry and to treat with triad and zinc cream. She stated if the diarrhea continued, the creams would not stay on. She stated she had pain when the staff changed her, when she was repositioned, and when assessing her arm pits and skin. She stated she was not sure what the sores were on her lips. WCN stated she believed they sent her out to the hospital because they were not able to do a fecal management system at the facility. During an interview on 07/29/25 at 1:45 PM, RN A stated she only worked weekends but did work with Resident #1. She stated her lips were awful - they were bloody and crusty. She stated she correlated what was on her lips to what was on her backside - they looked like the same type of lesions. She stated there were circular areas and all were excoriated. She stated what prompted her to send Resident #1 to the hospital on [DATE] was because she saw her skin and lips, saw she was in pain and agony, and said, No way - something is going on. She stated she had a gut feeling she needed a higher level of care because they were not doing anything for her here. She stated she was in so much pain and would scream when you would just touch her and she looked so fearful. She stated her skin was so much worse than it was the weekend prior. She stated all her diarrhea could have been an indicator for C. Diff, but she was not tested for it at the facility. She was shown Resident #1's skin assessment from 07/10/25 and asked if it accurately depicted her skin. She stated, Not even close. She stated her skin was sloughing off, she had irregular pattern areas of redness/MASD, and severe excoriation. She stated her skin was like a big burn. She stated since she only worked the weekends, she could not say if she should have been sent out sooner. During a telephone interview on 07/29/25 at 2:10 PM, Resident #1's RP D stated she was never made aware of the extent of her wounds. She stated a few days before she was hospitalized on [DATE], she was called and notified she had some redness, and they were putting an ointment on it. She also was told she had some loose stools but never mentioned excessive diarrhea. She stated a nurse sent her a picture of Resident #1's lips on 07/12/25 and they were grotesque and bleeding. She stated she was horrified to see how bad her skin was. She stated she was now residing at another nursing facility and was back to her baseline. She stated she was eating, drinking, and her lips had made a complete 180 and were healed. She stated Resident #1 even told her she liked the new place so much better than the old one. She stated when she was first admitted to the hospital, they staff told her they did not know how it got so bad in just two weeks from her previous admission. She stated they told her it was preventable and should not have gotten that bad. During a telephone interview on 07/29/25 at 3:46 PM, Resident #1's NP stated she was new to the facility and only assessed her one time. She stated when she assessed her (on 07/07/25), she had skin breakdown associated with maceration to her groin and inner thighs. She stated it looked very painful. She stated she talked to the WCN who had seen her that morning to come up with a new treatment plan because apparently it had gotten way worse. She stated she was going to wait and see if the new treatment plan was going to help resolve it. She stated she knew she was having continuous/excessive diarrhea and started her on Imodium. She stated she wanted to see if that would help slow the diarrhea. She stated there was no odor that would have indicated C. Diff. She stated she had a lot going on and did not want to over-load her. She stated she was not exhibiting anything they could not manage in-house. She stated her labs were stable and she did not see anything that would indicate she needed to be sent out. During an interview on 07/29/25 at 4:45 PM, the ADM stated the RCN had looked through the hospital records for Resident #1 and had found that her skin issues were due to herpes. He asked if the RCN could join, and she entered the room a few moments later. The ADM stated she (Resident #1) must have had a herpes outbreak and the redness on her skin was how her body reacted to the outbreak. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675651 If continuation sheet Page 14 of 16 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 675651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Marcos Rehabilitation and Healthcare Center 1600 N I H 35 San Marcos, TX 78666 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some stated she did not have MASD on her body and asked the RCN to Google for the surveyor what MASD looked like. The surveyor showed the RCN the picture of Resident #1 that was sent to her by one of her nurses, and pointed to the area of redness between her thighs. She stated that there may have been some MASD, but the records reflected it was due to herpes. At this time, the ADM requested the surveyor's PM be contacted as he did not feel as the surveyor had all the information needed for an IJ to be called. The surveyor's PM was contacted, and he (the PM) stated he would contact his supervisor and would get back to them. While waiting for the PM to call back, the ADM continued to focus on how Resident #1's skin issues was due to herpes continued to ask how the surveyor could call and IJ without all relevant information. The surveyor became uncomfortable, received approval from her PM to leave, and respectfully told the ADM and the RCN that her PM would be in contact to provide them with information on how to proceed. Review of the facility's Pain Recognition and Management Policy, revised 04/2025, reflected the following: It is the policy of this to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, comprehensive and routine assessments, person-centered care plan, and the resident's goals and preferences. Acute pain refers to pain that is usually sudden in onset and time-limited with a duration of less than one (1) month and often is caused by injury, trauma, surgery, or infection. Review of the facility's Skin and Wound Monitoring and Management Policy, revised 04/2025, reflected the following: Ongoing Skin and Wound Assessments:1. A licensed nurse will assess/evaluate a resident's skin at least weekly.2. Areas of breakdown, excoriation, or discoloration or other unusual findings must be documented in the nursing noes or on the appropriate weekly assessment form.3. A licensed nurse will assess/evaluate at least weekly each area of alteration/injury, whether present on admission or developed after admission, which exists on the resident. This assessment/evaluation should include but not limited to:1. Measuring the skin injury2. Staging the skin injury (when the cause is pressure)3. Describing the nature of the injury4. Describing the location of the skin alteration5. Describing the characteristics of the skin alteration6. Describing the progress with healing, and any barriers to healing which may exist7. Identifying any possible complications or signs/symptoms consistent with the possibility of infectionReview of the facility's Significant Change of Condition Policy, revised 12/2023, reflected the following: It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. The ADM was notified on 07/29/25 at 5:43 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 07/31/25 at 3:18 PM: The notification of Immediate jeopardy states as follows: Resident #1 acquired C. Diff and wounds covering her backside, and peri area of her body causing unmanaged pain and subsequently being sent to a burn unit. The facility needs to take immediate action to ensure all residents are receiving the necessary care to avoid pain and hospitalization. The facility submits this Plan of Removal to address the immediate threat identified on 7/29/25.Patient was sent to the hospital on 7/12/25 and is no longer a resident at the facility. Resident has been sent to another local SNF, per family choice. Resident Identification: Action: All residents, including residents with wounds, had a pain assessment completed to identify if they are in pain to avoid hospitalization. Any resident that indicates that their pain is not controlled with their current pain medication regiment will be reviewed by their attending physician/NP for possible changes. The results were that 8 residents were not completely satisfied with their pain relief. NP was notified and the NP is conducting a medication review on these 8 residents. Start Date: 7/29/25Completion Date: 7/30/25Responsible: Facility Nurse Managers. Corrective Action:Action: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675651 If continuation sheet Page 15 of 16 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 675651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Marcos Rehabilitation and Healthcare Center 1600 N I H 35 San Marcos, TX 78666 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Adhoc QAPI Committee Meeting held with facility medical director. Start Date: 7/29/25Completion Date: 7/29/25Responsible: Facility Administrator Action: Clinical resource provided in-service training to DON/Nurse Management Team on pain management, recognition, pain assessment tools to prevent hospitalization. Inservices were conducted on accurate pain assessment, changes of condition, and physician notification of changes. Start Date: 7/29/25Completion Date: 7/29/25Responsible Clinical Resource Action: DON/ designee will in-service facility nursing staff regarding pain recognition and management, including verbal and non-verbal signs of pain, to prevent hospitalization. The facility does not use agency staff. All new hires will be trained during the orientation process, prior to working with residents. PRN staff/staff on vacation will be notified and provided training and quiz via telephone. Inservices were conducted for facility nurses on accurate pain assessment, changes of condition, and physician notification of changes. Start Date: 7/29/25Completion Date: 7/30/25Responsible: DON/Designee MonitoringAction: A Quiz will be given to the facility nursing staff to ensure that staff can recognize resident pain. The facility does not use agency staff. All new hires will be trained during the orientation process, prior to working with residents. PRN staff/staff on vacation will be notified and provided training and quiz via telephone. Start Date: 7/29/25Completion Date: 7/30/25Responsible: DON/Designee Systemic Changes to prevent recurrenceAction: Residents will be evaluated for pain on admission, quarterly and with every change of condition. NP/ MD will be notified upon occurrence to ensure pain is managed. Residents' skin will be evaluated on admission, weekly, and on change of condition. Any changes will be communicated to the MD/NP Event ID: Facility ID: 675651 If continuation sheet Page 16 of 16