Inspection·March 27, 2024

F 0689 Level of Harm - Actual harm due to the diagnosis of Parkinson's and interventions included: avoid leaving resident unattended for excessive periods. Likewise, staff was to observe to ensure appropriate use of safety/assistive devices. Preventive fall measures included: low bed, call light, beside mat, room next to nurse station, routine rounds, scoop mattress, and a customized innovative wheelchair. Residents Affected - Few Record review of resident #1's physician's orders dated February 2024 revealed order for a UTI: order was as follows [initiated 2/1/24 and completed 2/6/24] Ceftriaxone( Sodium) Solution Reconstituted 1 GM . Use 1 gram intravenously every 24 hours for Empiric Treatment for 5 Days. Record review of Resident#1's Physician' Orders, dated March 2024, reflected: monitor the resident's forehead every shift. Monitoring also included monitoring for Anxious/Restless/Panic. The Physician's order included resident prescribed an Anti-coagulant (Xarelto 20 mgs once per day). Record review of Resident#1's MAR dated January 2024 reflected the following anticoagulant: Xarelto 20 mgs once per day. Record review of Resident#1's Skin Assessments reflected : (dated 1/31/24 ) laceration to forehead: 2.9 cm X 0.9 cm (10 sutures) and 3 bruises to face and left finger . Current skin assessment (dated 3/20/24) reflected skin intact with a bruise to the forehead. Record review of Resident #1's SBAR dated 1/30/24 revealed: Laceration to the forehead; sent to ER. Record review of Resident #1's fall risk assessment dated [DATE] revealed a description of High risk. Record review of Resident#1's TAR (dated February 2024) revealed, the resident received treatment for laceration to forehead. Treatment was to cleanse with normal salient, pad dry, leave open to air twice per day. Also, monitor the sutures to facial area, and discoloration every shift. Record review of Resident#1's hospital record, dated 1/30/24, reflected: unwitnessed fall with possible nose fracture on blood thinners. CT dated 1/31/24 revealed: bilateral nasal bone fracture. Ten sutures to the forehead. Record review of Resident #1's hospital labs dated 1/30/24 revealed the resident had a UTI at the time of fall. Record review of Resident #1's rehab assessment dated [DATE] revealed: resident was an 80- year- old female patient who was referred for skilled PT Evaluation and Treatment for range of motion, mobility, to enhance balance, and coordination. Resident #1's assessment reflected she had limitations in bed mobility, balance, and positioning. Record review of Resident #1's Rehab note at discharge, dated 1/14/23 authored by PT C reflected: improved to partial and minimal assistance with rolling. But the resident required maximum assistance with transfer from W/C to bed. Record review of Resident #1's assessment on 2/6/24 and nurse note on 2/6/24 revealed: RP refused rehab services. RP wanted to wait until resident was better from fall on 01/30/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675677 If continuation sheet Page 2 of 5 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 675677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Rio Nursing and Rehabilitation Center 301 W Martin St Del Rio, TX 78840 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 0689 Record review of Resident #1's rehab note dated 01/30/24 by Rehab Director reflected: RP was called but refused referral for skilled therapy services and W/C management. Level of Harm - Actual harm Residents Affected - Few Record review of Resident #1' Nurse note dated 01/31/23 at 3:18 PM by the DON reflected: resident returned from hospital (one day stay) with nasal fracture and laceration to center of forehead with sutures. CT scan was negative. MD notified and Eliquis (anticoagulant medication) was withheld for 7 days. Record review of Resident#1's Nurse Note, dated 01/30/24 at 6:50 PM authored by LVN B reflected: CNA A came running out of Resident #1's room telling LVN B that the resident had fallen out of the W/C. LVN B found Resident #1 faced down with blood on the floor. First aid was administered and another nurse arrived to assist. MD was notified and the resident was sent to the ER. The DON and RP were also notified. During an observation and interview on 3/26/24 at 11:31 AM, Resident #1 was in an innovative customized W/C [ chair made to fit a resident for posture and comfort; not a restraint] and was alert and not oriented. Resident's room had a pressure release mattress, call light was present, scoop mattress, clutter free room, and bed was at lowest position. Resident had impairment to lower limbs. The resident's specialized W/C had working breaks and was tilted at a 20-degree angle. Resident #1's Hoyer sling was on the chair and the resident wore skid proof soaks. The resident had a bruise to the right of the forehead. The bruise color was yellow and blue. There was no fracture to the nose and sutures were not present to the forehead. The resident could not answer any direct questions. The resident was unable to lift herself out of the specialized wheelchair. During an interview on 3/16/24 at 11:35 AM, the DON stated: CNA A informed her that resident was taken to her room on 01/30/24 for a mechanical transfer from wheelchair to bed. The DON stated CNA A responded to a call light and left the resident unsupervised for about 5 minutes. The DON stated that when CNA A returned to the resident's room she found her on the floor. The specialized wheel chair had not fallen with the resident. The DON stated: Resident #1 used her upper strength to pull out of the wheelchair and suffered a fall with an injury. The hospital x-ray revealed a fracture to the nose and an injury to the head requiring sutures. We conducted training on fall prevention for the nursing staff. The DON stated that 100% of nursing staff was in-serviced on date range of 1/31/24 (nursing staff on 1/31/24 equaled thirty paid staff). The DON stated the in-service was on fall prevention, monitoring, and abuse and neglect. The DON stated the resident likely pulled her weight forward and fell to the floor. The DON stated the roommate did not witness the fall. Instead, the roommate entered the room after CNA A left and found Resident #1 on the floor and triggered the call light. The DON's expectation was that the CAN sought assistance from another nurse aide for the answering of the call light and not leave a resident unsupervised that was pending a mechanical lift; and could pull herself forward on a specialized wheelchair. During an interview on 3/26/24 at 11:44 AM, CNA A stated: she had provided ADL assistance to Resident #1 for about six months which included transfer with the use of a mechanical lift. CNA A stated that after dinner on 01/30/24, she took the resident to her room, put on the breaks to the special W/C and responded to a call light. The CNA A stated the resident was in a reclined position, she was calm, and not agitated in the W/C when taken to the room. The CNA A stated, I left the resident unsupervised for about five minutes. The roommate [Resident #2] triggered the call light. I found the resident on the floor with blood on the floor. I went to get help from the charge nurse [LVN B]. The resident was unable to explain the fall. The special w/c was stationary with the breaks on. CNA A stated that two staff were needed for a Hoyer lift and she did not bring the Hoyer lift with her. CNA A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675677 If continuation sheet Page 3 of 5 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 675677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Rio Nursing and Rehabilitation Center 301 W Martin St Del Rio, TX 78840 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 0689 Level of Harm - Actual harm Residents Affected - Few stated she did not take another staff with her in anticipation to transfer her from bed to W/C. CNA A stated her plan was to get the Hoyer lift and another staff member when she was ready to do the mechanical lift. CNA A stated that she was trained that a mechanical lift required two staff members and a resident had to be monitored during the performance of a mechanical lift. The CNA denied she was planning a one- person transfer, given there was no mechanical lift in the room. CAN A stated after receiving an in-service training from LVN B she should not have left to answer a call light; and should have requested assistance from another nurse aide in the answering of the call light. During telephone interview on 3/26/24 at 12:27 PM, the MD stated: he did not know whether the specialized wheelchair was a restraint. He had no orders for the 24- hour monitoring of the resident (Resident #1). The MD did not want to express an opinion as to whether nursing staff needed to have a staff present when anticipating a mechanical lift. The MD stated he saw Resident #1 in the ER and she was treated and returned to the facility the next day. The MD stated that Resident #1 was on blood thinners which could lead to quick bleeding if the resident had a fall. Attempted telephone call on 3/26/24 at 2:25 PM, message left for family member to call the state surveyor. During an observation and interview on 3/26/24 at 2:40 PM, Resident #2 was in bed trying to sleep, pressure release call light was present. The resident stated that on the day of the incident [1/30/24] she returned to her room and found Resident #1 on the floor in the room crying and blood present on the floor. Resident #2 could not remember pushing the call light to request nursing assistance during the incident. [Record review of Resident 2's face sheet, dated 3/26/24 revealed, the resident was admitted on [DATE] with diagnoses that included: stroke, diabetes type 2, and dementia. The resident was a female; age [AGE]. RP was listed as: a family member. BIMs score of 10 dated 1/11/24.[score of 10 means moderately impaired in cognition] During an interview on 3/26/24 at 2:45 PM, LVN B stated, she was at the nurse station on 1/30/24 and after the dinner meal CNA A came out screaming saying Resident #1 was on the floor bleeding from a fall. LVN B stated she was accompanied by LVN D and assessed the resident and called 911. LVN B's assessment revealed the resident was on the floor with a puddle of blood, she was crying. LVN B stated first aid was applied, pressure to the forehead, until EMS arrived. The resident returned the next day. LVN B notified the MD and tried to notify the RP. LVN B stated, I have no clue how the fall happened. LVN B stated, if a Hoyer lift is anticipated, the nurse aides should arrive together to assess and assist each other .also the nurse aide should stay with the resident until the Hoyer lift is brought to the room by another nurse aide. LVN B stated, I have no idea why nurse practice was not followed when a Hoyer lift was anticipated for Resident (#1) by CNA A. I told her (CNA A) after the incident not to leave a resident by themselves when a Hoyer lift was anticipated. CNA A did not provide an explanation for failure to follow nursing practice. LVN B stated that she received training on abuse and neglect and fall prevention; which included monitoring of residents when a mechanical lift was anticipated and done. During an interview on 3/26/24 at 3:07 PM, the Rehab Director stated, Resident #1 was fitted for a customized innovative W/C which was not a restraint about 2-3 years ago. The Rehab Director stated, the said chair had a cushion and was usually angled at 20 degrees. The Rehab Director stated that Resident #1 has the freedom to move forward and has core strength to fall from the chair forward. The Rehab Director stated that I have always seen two nurse aides when anticipating or initiating a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675677 If continuation sheet Page 4 of 5 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 675677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Rio Nursing and Rehabilitation Center 301 W Martin St Del Rio, TX 78840 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 0689 Level of Harm - Actual harm Residents Affected - Few Hoyer lift. When Resident #1 was in therapy we never left her alone because we have seen her in therapy sessions moving forward with her core strength which shows the chair is not a restraint. The Rehab Director stated that at the time of the incident the resident was not getting therapy. The Rehab Director stated, after the incident (01/30/24) the RP was notified to initiate PT or OT but the RP refused. The Rehab Director stated the RP's latter refusal could prevent Resident #1 receiving therapy to improve mobility and transfer. During an interview on 3/27/24 at 10:15 AM, the Administrator stated: the fall was unwitnessed and the findings were unfounded. The Administrator stated her investigation revealed that CNA A left Resident #1 in her room to attend to a call light. The W/C was secured, and the resident was calm. The Administrator stated, CNA A felt the resident was safe to be left in the room unsupervised. The Administrator stated there was no neglect because CNA A ensured the resident was safe before answering the call light. The Administrator stated the incident was a past event because: the facility initiated an in-service on fall prevention before the entrance of the state surveyors for the reported incident to the state. The in-service included, per the Administrator, the topic of Do not leave residents in room in W/C unattended. The Administrator stated, the resident has had no falls since the incident and the CP was reviewed and updated. The Administrator stated, interventions put in place for Resident #1 included: floor mat, monitoring more often, low bed, scoop mattress, and specialized wheelchair, antibiotics for a UTI, and referral to rehab services declined by the RP. The Administrator stated a resident should not be left alone when a mechanical lift was anticipated or done; and nursing aides could assist each other in answering call lights. Observation on 3/27/24 at 11:24 AM, Resident #1 was sitting in the innovative customized W/C and attempting to lean forward by grabbing the handle bars. Nursing staff were present. During an interview on 3/27/24 at 11:25 AM, the DON stated, Resident #1 has the upper body strength to lean forward and attempt to push herself forward to get out of the chair. The DON stated, nursing staff closely monitor Resident #1 so that she does not fall again from the W/C by thrusting herself forward. Record review of facility's in-service training on 1/31/24 on the topics of fall prevention and abuse and neglect revealed: 30 signatures for 100 % completion rate. Record review of facility's incident fall list for the past 90 days (January, February, and March 2024) revealed: Resident #1 only had one fall on 1/30/24. Record review of facility's Fall Prevention policy dated 10/2022 reflected: Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision .to minimize the risk of falls . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675677 If continuation sheet Page 5 of 5