Health inspection·January 26, 2024

F 0842 position, call light within reach, tracheostomy, and oxygen via trach. Level of Harm - Minimal harm or potential for actual harm During an attemted interview on 01/24/2024 at 10: 05 a.m., Resident #73 was not able to answer any questions. Residents Affected - Few 2. Record review of Resident #305's face sheet reflected a [AGE] year-old female with an admission date of 01/09/2024. Her relevant diagnoses included: type 2 diabetes mellitus, obesity, hyperlipidemia ( a condition that incorporates various genetic and acquired disorders that describe elevated lipid levels within the human body), hypertension (High pressure in the arteries , vessels that carry blood from the heart to the rest of the body), and absence of right foot. Record review of Resident #305's MDS admission assessment dated [DATE] reflected a BIMS score of 15 (cognitively intact) and an active diagnosis of diabetes mellitus. Record review of Resident #305's physician's order dated 01/09/2024 reflected BS checks BID and PRN. Notify MD if BS is less than 60 or greater than 350. Record review of Resident #305's weights and vitals on PCC reflected a blood sugar reading of 361.0 mg/dl on 01/21/2024 at 4:41 p.m., recorded by Staff A. Record review of Resident #305's progress notes on 01/21/2024 did not reflect any documentation related to her blood sugar reading of 361 mg/dl at 4:41 p.m. An observation on 01/23/2024 at 10:25 a.m. Resident #305 was observed lying in bed, dressed in her own personal clothing, bed set to lowest position, and call light within reach. An interview on 01/23/2024 at 10:27 a.m., Resident #305 said she was satisfied with the care she was receiving at facility. She said she was admitted to facility to receive physical therapy after right foot was amputated. She said her vitals had been normal since she was admitted . An interview on 01/24/2024 at 3:45 p.m., Staff A said Resident #305's blood sugar had been within normal range since being admitted . She said she did not remember entering a blood sugar reading of 361 mg/dl on 01/21/2024 for Resident #305. She said, I am going to be honest with you, on 01/21/2024, I was having a bad day. She said she was there when resident kept crying and she was under a lot of stress. Staff A said she made a mistake when entering Resident #305's blood sugar reading on PCC under weights and vitals. Staff A said the correct sugar level reading was 261 and not 361 mg/dl. She said she did not do a change of condition or notified MD because a blood sugar reading of 261 mg/dl was within normal range for Resident #305. Staff A said there were no negative outcome because it was just a documentation error. An interview on 01/25/2024 at 3:15 p.m., Staff A said she did not remember Resident #73's blood sugar on 01/24/2024 being 32 mg/dl. While being interviewed, Staff A checked Resident #73's weights and vitals on PCC and said she made a mistake when she documented a blood sugar level of 32 mg/dl on 01/24/2024. Staff A said the correct blood sugar reading was 132 mg/dl and not 32 mg/dl, she said she must have forgotten to enter the 1. Staff A said she did not do a change of condition, notified MD because in her mind, she knew [Resident #73's] blood sugar level was 132 mg/dl and was within her normal range. Staff A said no negative outcome for Resident #73 because it was just a documentation error. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675689 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Healthcare and Rehabilitation 615 N Ware Rd McAllen, TX 78501 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm In an interview on 01/26/2024 at 2:00 p.m., the DON said the correct blood sugar reading for Resident #73 was 132 mg/dl on 01/24/2024 at 3:51 p.m. and 261 mg/dl for Resident #305 on 01/21/2024. The DON said Staff A had entered an incorrect reading for both residents on PCC. She said their MD was not notified and no change of condition was done because it was only a documentation error. The DON said no negative effects on Resident #73 or Resident #305 due to the documentation error. Residents Affected - Few Record review of facility's policy on Documenting and Charting (no date) reflected: Policy: It is the policy of this facility to provide: 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care. 3. The facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident. Procedures: 23. Vital signs: A. Date and time vital signs taken. B. Any deviations from the resident's normal pattern. D. Date and time physician was notified, as well as the physician's response. E. All pertinent observations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675689 If continuation sheet Page 3 of 3