Health inspection·April 10, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews the facility failed to ensure the residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 10 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from abuse. CNA A attempted to provide Resident #1 care at bed side by herself knowing that Resident #1 required two person assistance for all activities, which lead to Resident #1 falling off the bed and sustaining a right humerus fracture. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 11/06/24 and ended on 11/13/24. The facility had corrected the noncompliance before the survey began. The facility was informed about the past non-compliance on 4/10/25 at 3:55 pm. This failure could place residents at risk of neglect . Findings included: Record review of Resident #1's admission record reflected she was a [AGE] year-old female with an admission date of 02/08/2024. Her relevant diagnoses included cerebral infraction (is a condition where brain tissue dies due to insufficient blood flow, leading to a lack of oxygen and nutrients) and morbid obesity. Resident #1's cognition was moderately impaired. Record review of Resident #1 care plan dated 10/3/2019 revealed Resident #1 was a two person assist for toileting. Record review of Resident #1 MDS dated [DATE] revealed Resident#1 was always incontinent to bowel and bladder. Section GG revealed Resident#1 was dependent 2 persons assist to toileting hygiene. In an interview on 04/9/25 at 2:40 pm, CNA A said she knew Resident #1 was a two person assist for incontinent care but still decided to do it on her own on 11/06/2024. CNA A said that she did not want to wait because it was lunch time. CNA A said while she performed incontinent care to Resident #1 on 11/6/24, CNA A turned Resident #1 to her right side and she slipped off the bed and landed on the floor. CNA A said that she started yelling for help and CNA B arrived to assist. CNA A said as soon as CNA B arrived, she went out to look for a nurse. CNA A said she and CNA B stayed with Resident #1 while she was being assessed by RN C. CNA A said 11/06/2024 was not the first time she had performed incontinent care to Resident #1 by herself. Page 1 of 18 675689 675689 04/10/2025 Village Healthcare and Rehabilitation 615 N Ware Rd McAllen, TX 78501

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few In an interview on 4/9/2025 at 2:50 pm, CNA B said that she heard CNA A screaming and she went into Resident #1 room. CNA B said she saw Resident#1 on the floor. CNA B said that she stayed with resident while CNA A went to inform RN C. CNA B said that she checked the [NAME] to know how many assist each resident needed, and asked the nurse. In an interview on 04/09/2025 at 3:00 pm, RN C said after he assessed Resident#1, Resident #1 complained of right shoulder pain. RN C said that it took 4 therapists to transfer Resident #1 back to her bed. RN C said that he immediately called NP and got stat orders for x-rays to right shoulder and right hip. RN C said that x-rays results showed Resident #1 had sustained an acute displaced fracture to the right distal humerus ( a bone break where the broken pieces have moved out of alignment with each other, resulting in a gap between the fragments). In an interview on 4/9/25 at 4:40 pm Physical Therapy Director said Resident #1 was dependent 2 person assist for all activities of daily living prior to and after the incident. In an interview on 04/09/2025 at 3:30 pm, the DON said she had been informed Resident #1 had fallen while she was being repositioned. The DON said that she had interviewed CNA A. The DON said CNA A told her that she was repositioning Resident #1 and resident slipped out of bed. During an interview on 04/10/2025 at 3:00 pm, the Administrator said the DON informed him of Resident #1's fall. The Administrator stated he spoke with RN C and CNA A during the investigation. The Administrator said CNA A told him she was performing care on Resident #1. He stated CNA A was not terminated at that time. He said she was terminated at another time for insubordination. Records show CNA A was terminated on 03/13/2025. The Administrator stated they did in-servicing on abuse/neglect, bed mobility, transfers, and falls. He stated they also went through all the resident's charts to ensure whether they were one or two person assists and ensured all CNAs were able to locate the assists on the [NAME] (a copy of the care plan focused on the amount of assist each resident needed). The Administrator stated they also reported the incident to State. Interview on 4/10/24 at 2:40 pm, the DON said they monitor CNAs by doing frequent observations, in services on how to access the [NAME], and print out the [NAME] to see if it matches section GG and update as needed. The facility had corrected the noncompliance before the survey began. Record review of the following interventions put into place: 1. Head to toe assessment completed on 11/06/2024. Record review dated 11/6/24 of resident assessment revealed Resident #1 was complaining of right shoulder pain. Resident #1 was not able to move right arm due to pain. 2. Pain assessment was completed, and pain medication was administered. Record Review dated 11/6/24 of resident pain assessment revealed Resident #1 was assessed on 11/6/24 and pain medication was administered on 11/6/24 at 12:20 pm. 675689 Page 2 of 18 675689 04/10/2025 Village Healthcare and Rehabilitation 615 N Ware Rd McAllen, TX 78501

F 0600 3. Level of Harm - Immediate jeopardy to resident health or safety Record review dated 11/6/25 revealed FNP was notified, and he ordered stat x-rays. X rays to right shoulder and right hip were done on 11/6/24 and were reported to FNP on 11/7/24. 4. Residents Affected - Few Record review dated 11/7/24 of Resident #1 revealed Resident #1 was transferred to the local hospital for further evaluation. 5. Random residents were selected for the safety survey, no negative findings. Resident #3, Resident #4, Resident #5 and Resident #6. 6. Record review dated 11/6/24 revealed All staff were in-serviced on date of incident abuse and neglect, [NAME] use to determine bed mobility and transfer, fall prevention, and demonstration of Point Click Care and Plan Of Care. 7. Interviews with other CNA's revealed they were aware of where to find the resident's level of care and not to deviate from plan. 8. Pain assessment was completed, and pain medication was administered. Record Review dated 11/6/24 of resident pain assessment revealed Resident #1 was assessed on 11/6/24 and pain medication was administered on 11/6/24 at 12:20 pm. 9. Record review dated 11/6/25 revealed FNP was notified, and he ordered stat x-rays. X rays to right shoulder and right hip were done on 11/6/24 and were reported to FNP on 11/7/24. 10. Record review dated 11/7/24 of Resident #1 revealed Resident #1 was transferred to the local hospital for further evaluation. 11. Random residents were selected for the safety survey, no negative findings. Resident #3, Resident #4, Resident #5 and Resident #6. 12. 675689 Page 3 of 18 675689 04/10/2025 Village Healthcare and Rehabilitation 615 N Ware Rd McAllen, TX 78501

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Record review dated 11/6/24 revealed All staff were in-serviced on date of incident abuse and neglect, [NAME] use to determine bed mobility and transfer, fall prevention, and demonstration of PCC and POC. 13. Record review dated 11/13/24 revealed CNA A have been inserviced ont he following topics abuse and neglect, [NAME] use to determine bed mobility and transfer, fall prevention, and demonstration of PCC and POC. Residents Affected - Few 4/8/2025 at 1:54 pm, CNA N 4/8/2025 at 3:00 pm, CMA AA 4/8/2025 at 3:15 pm, CNA F 4/8/2025 at 3:24 pm, LVN CC 4/8/2025 at 6:00 pm, RN O 4/8/2025 at 6:10 pm, CNA DD 4/9/2025 at 10:03 am, LVN EE 4/9/2025 at 2:43 pm, CNA P 4/8/2025 at 2:50 pm, CNA BB 4/9/2025 at 2:50 pm, CNA B 4/9/1025 at 3:00 pm, RN C 4/9/2025 at 4:21 pm, CNA FF 4/9/2025 at 4:30 pm, CNA L Record review of facility's policy titled freedom from abuse, neglect, exploitation revealed: It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals. If there is an allegation or suspicion of abuse, the facility will make a report to the appropriate agencies as designated by state and federal laws. 675689 Page 4 of 18 675689 04/10/2025 Village Healthcare and Rehabilitation 615 N Ware Rd McAllen, TX 78501

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to incorporate the recommendations from the PASRR Level II determination and the PASRR evaluation report for 1 of 5 residents (Resident #2) reviewed for PASRR. The facility failed to initiate an NFSS within 20 business days following the date the services were agreed upon in the IDT meeting. This failure could cause residents with mental health disorders and psychiatric conditions to have a delay in services or not receive specialized services or equipment that may be needed. Findings included: Record review of Resident #2's face sheet, dated 04/09/25, revealed a [AGE] year-old male originally admitted [DATE], and most recent admission date of 10/02/23. His diagnoses included Cerebral Palsy (lifelong brain disorder caused by non-progressive brain damage during prenatal, neonatal, or early infant period that affects movement, balance, and posture), muscle weakness, DM (diabetes mellitus where the body either doesn't produce enough insulin or can't effectively use the insulin it produces leading to high blood sugar levels) and hypertension (high blood pressure). Record review of Resident #2's Quarterly MDS assessment, dated 03/29/25, revealed a BIMS score of 09, indicating moderately impaired cognition. The MDS assessment also revealed Resident #2 had impairment to an upper and lower extremity on one side and utilized a wheelchair, as well as Resident #2 was dependent in shower/bathe self, lower body dressing, putting on/taking off footwear, needed substantial/maximal assistance with toileting hygiene and personal hygiene. Record review of Resident #2's undated care plan revealed resident was a positive PASSR for IDD/CP Date Initiated: 10/06/2022 Revision on: 07/31/2024. It also revealed W/C purchased through PASSR services and if discharged equipment to follow Resident #2 currently use a loaner custom w/c due to request for new w/c denied secondary to last w/c was not over 5 years therapy to continue to request for w/c Date Initiated: 10/06/2022 Revision on: 03/30/2025. Record review of Resident #2's PASRR evaluation, dated 04/20/23, revealed resident had an intellectual disability which manifested before the age of 18, and she had a developmental disability other than the intellectual disability that manifested before the age of 22. Specialized service recommendations included: self-monitoring and coordinating treatments; self-help with ADLs such as toileting, grooming, dressing, and eating; and independent living skills such as cleaning, shopping, and money management, laundry, accessibility within the community. Record review of Resident #2's progress notes revealed progress notes concerning IDT meetings or PASRR updates for dates 05/17/24 through 02/10/25 in which they notified the HHS PASRR Program Specialist that specialized services had been completed and needs met, or that needs and services were no longer warranted or needed. Record review of Resident #47's PASRR PCSP, dated 02/10/25, revealed the quarterly meeting was held. New requests will be done for CMWC, habilitative, OT and PT. 675689 Page 5 of 18 675689 04/10/2025 Village Healthcare and Rehabilitation 615 N Ware Rd McAllen, TX 78501

F 0644 Level of Harm - Minimal harm or potential for actual harm In an interview via email on 04/09/25 at 9:47 AM with the HHSC PASSR Unit Program Specialist, she wrote, I sent an email to the DON and the Administrator on 1/28/2025. I was not told why they did not do it. The IDT meeting was 5/17/2024. The NF has 20 business days from this meeting date to initiate the service that was recommended/documented for this resident. Residents Affected - Few The 26 Texas Administrative Code (TAC), Chapter 554, Subchapter BB, section §554.2704(i)(7), a nursing facility must initiate nursing facility specialized services within 20 business days following the date that the services are agreed to in the IDT meeting. Currently, your nursing facility is out of compliance as per this TAC Rule. (HHSC PASSR Unit Program Specialist, personal communication, 4/9/2025). In an interview on 4/9/25 at 2:00 pm MDS K said they conducted the IDT meeting, and therapy took over the initiation of the NFSS to initiate the request for PASRR specialized service of Resident #2's customized manual wheelchair. He said he submitted information to PASSR regarding recommendations such as independent living skills within the 20-day time frame. He said therapy takes over initiating requests for items dealing with PT, OT, ST and/or wheelchairs. He said the DOR took over NFSS. He said as soon as they get an alert on the online portal, they should initiate it right away. In an interview on 4/9/25 at 2:16 pm the DOR said she was aware now about the requirement of submitting the NFSS request 20 days from IDT. She said she became aware of the requirement from the DME company. She said they helped and guided her through the process. She said she had not received any emails from PASSR HHSC. She said she started this position in February of 2025, so she was not sure if the former DOR was receiving those emails. She said the facility provided Resident #2 with a customized wheelchair. His insurance denied the request because it had not been more than 5 years since his last customized wheelchair. She said she scheduled an IDT meeting for this Friday, 4/11/25 to review continuation of therapy services and the CMWC. In an interview on 4/9/25 at 3:42 pm the DON said that she found out a couple of days ago that a new meeting was being set up so they could re-initiate the NFSS and restart the 20 days. She said the prior DOR did not work longer than 6 months and the current DOR was new to the process since she started working this past February. The DON said she never received an email from HHSC PASRR. She said she did receive an email from quality monitoring that a visit was going to be done, but not from HHSC PASRR. She said the DOR and MDS were responsible for logging on and ensuring all the information required was placed onto the online portal. She said she was not sure what happened and was not sure what training the current DOR received from the prior DOR, but LVN/MDS was very involved, and he assisted with that. The DON said it was a collaboration between therapy and MDS. She said therapy usually took over the online portal entrance when it dealt with customized wheelchairs. She was not sure where the problem occurred. She said when she worked MDS, they logged into Simple to see the alert and recalls she was required to log onto the portal within 20 days. In an interview on 4/10/25 at 10:30 am with the Administrator, he said when they had the IDT meeting for Resident #2 and recommended the WC, the request was then submitted on simple. He said it was his understanding they did complete the process. He said he feels there was a misunderstanding on the time frame, but the resident never went without the services. He said they provided him with the customized manual wheelchair Resident #2 required as a loaner. He said normally, the DOR will conduct evaluations for therapy, coordinate with DME, then DOR will submit for services and complete follow 675689 Page 6 of 18 675689 04/10/2025 Village Healthcare and Rehabilitation 615 N Ware Rd McAllen, TX 78501

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ups. He said as the administrator, he oversees and supervises MDS and PASRR services, so ultimately it was his responsibility to ensure the submission of the NFSS (Nursing Facility Specialized Services) request on the LTC Online Portal within 20 business days after the date of the Interdisciplinary Team meeting. The administrator said he was responsible for ensuring the requests were being submitted and follow ups being done to make sure they were meeting the requests. He said he looked into this specific case once it was brought to his attention, and it was not submitted within the 20-day time frame. He said their new DOR has initiated an IDT meeting this Friday, 4/11/25, and he will ensure the 20-day time frame was met. Record review of the facility's undated PASRR policy reflected: Policy: It is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the State. Procedures: 2. Based upon the assessment, the facility will ensure proper referral to appropriate state agencies for the provision of specialized services to residents with MI/MR. 3. Social Services shall contact the appropriate State Agency for referral of specialized care and services the resident may require. 675689 Page 7 of 18 675689 04/10/2025 Village Healthcare and Rehabilitation 615 N Ware Rd McAllen, TX 78501

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents remained free from accidents, hazards and each resident received adequate supervision and assistance when being transferred for 1 of 10 residents (Resident #1) reviewed for accidents and hazards. The facility failed to provide adequate supervision to prevent Resident #1 from falling from bed, fracturing her right humerus. The non-compliance was identified as past non-compliance. The Immediate threat began on 11/06/24 and ended on 11/13/24. The facility had corrected the noncompliance before the survey began. This deficient practice has the potential to affect all residents in the building by causing resident injuries, such as falls, fractures, and even death due to improper supervision. Findings included: Record review of Resident #1's admission record reflected she was a [AGE] year-old female with an admission date of 02/08/2024. Her relevant diagnoses included cerebral infraction (is a condition where brain tissue dies due to insufficient blood flow, leading to a lack of oxygen and nutrients) and morbid obesity. Resident #1's cognition was moderately impaired. Record review of Resident #1 care plan dated 10/3/2019 revealed Resident #1 was a two person assist for toileting. Record review of Resident #1 MDS dated [DATE] revealed Resident#1 was always incontinent to bowel and bladder. Section GG revealed Resident#1 was dependent 2 persons assist to toileting hygiene. In an interview on 04/9/25 at 2:40 pm, CNA A said she knew Resident #1 was a two person assist for incontinent care but still decided to do it on her own on 11/06/2024. CNA A said that she did not want to wait because it was lunch time. CNA A said while she performed incontinent care to Resident #1 on 11/6/24, CNA A turned Resident #1 to her right side and she slipped off the bed and landed on the floor. CNA A said that she started yelling for help and CNA B arrived to assist. CNA A said as soon as CNA B arrived, she went out to look for a nurse. CNA A said she and CNA B stayed with Resident #1 while she was being assessed by RN C. CNA A said 11/06/2024 was not the first time she had performed incontinent care to Resident #1 by herself. CNA A said that on 11/13/24 she had beed inserviced on the following topics abuse and neglect, [NAME] use to determine bed mobility and transfer, fall prevention, and demonstration of PCC and POC. CNA A said she was reeducated on the types of abuse and neglect and to follow the plan of care. In an interview on 4/9/2025 at 2:50 pm, CNA B said that she heard CNA A screaming and she went into Resident #1 room. CNA B said she saw Resident#1 on the floor. CNA B said that she stayed with resident while CNA A went to inform RN C. In an interview on 04/09/2025 at 3:00 pm, RN C said after he assessed Resident#1, Resident #1 complained of right shoulder pain. RN C said that it took 4 therapists to transfer Resident #1 back to her bed. RN C said that he immediately called NP and got stat orders for x-rays to right shoulder and 675689 Page 8 of 18 675689 04/10/2025 Village Healthcare and Rehabilitation 615 N Ware Rd McAllen, TX 78501

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few right hip. RN C said that x-rays results showed Resident #1 had sustained an acute displaced fracture to the right distal humerus. In an interview on 4/9/25 at 4:40 pm Physical Therapy Director said Resident #1 was dependent 2 person assist for all activities of daily living prior to and after the incident. In an interview on 04/09/2025 at 3:30 pm, the DON said she had been informed Resident #1 had fallen while she was being repositioned. The DON said that she had interviewed CNA A. The DON said CNA A told her that she was repositioning Resident #1 and resident slipped out of bed. During an interview on 04/10/2025 the Administrator said the DON informed him of Resident #1's fall. The Administrator stated he spoke with the RN C and CNA A during the investigation. The Administrator said CNA A told him she was performing care on Resident #1. He stated CNA A was not terminated at that time. He said she was terminated at another time for insubordination. Records show CNA A was terminated on 03/13/2025. The Administrator stated they did in-servicing on abuse/neglect, bed mobility, transfers, and falls. He stated they also went through all the resident's charts to ensure whether they were one or two person assists and ensured all CNAs were able to locate the assists on the [NAME]. The Administrator stated they also reported the incident to State. Interview on 4/10/24 at 2:40 pm, the DON said they monitor CNAs by doing frequent observations, in services on how to access the [NAME], and print out the [NAME] to see if it matches section GG and update as needed. The facility had corrected the noncompliance before the survey began. Record review of the following interventions put into place: 7. Head to toe assessment completed on 11/06/2024. Record review dated 11/6/24 of resident assessment revealed Resident #1 was complaining of right shoulder pain. Resident #1 was not able to move right arm due to pain. 8. Pain assessment was completed, and pain medication was administered. Record Review dated 11/6/24 of resident pain assessment revealed Resident #1 was assessed on 11/6/24 and pain medication was administered on 11/6/24 at 12:20 pm. 9. Record review dated 11/6/25 revealed FNP was notified, and he ordered stat x-rays. X rays to right shoulder and right hip were done on 11/6/24 and were reported to FNP on 11/7/24. 10. Record review dated 11/7/24 of Resident #1 revealed Resident #1 was transferred to the local hospital for further evaluation. 675689 Page 9 of 18 675689 04/10/2025 Village Healthcare and Rehabilitation 615 N Ware Rd McAllen, TX 78501

F 0689 11. Level of Harm - Immediate jeopardy to resident health or safety Random residents were selected for the safety survey, no negative findings. Residents Affected - Few 12. Resident #3, Resident #4, Resident #5 and Resident #6. Record review dated 11/6/24 revealed All staff were in-serviced on date of incident abuse and neglect, [NAME] use to determine bed mobility and transfer, fall prevention, and demonstration of PCC and POC. 13. Record review dated 11/13/24 revealed CNA A have been inserviced ont he following topics abuse and neglect, [NAME] use to determine bed mobility and transfer, fall prevention, and demonstration of PCC and POC. 7. Interviews with other CNA's revealed they were aware of where to find the resident's level of care and not to deviate from plan. 4/8/2025 at 1:54 pm, CNA N 4/8/2025 at 3:00 pm, CMA AA 4/8/2025 at 3:15 pm, CNA F 4/8/2025 at 3:24 pm, LVN CC 4/8/2025 at 6:00 pm, RN O 4/8/2025 at 6:10 pm, CNA DD 4/9/2025 at 10:03 am, LVN EE 4/9/2025 at 2:43 pm, CNA M 4/8/2025 at 2:50 pm, CNA BB 4/9/2025 at 2:50 pm, CNA B 4/9/1025 at 3:00 pm, RN C 4/9/2025 at 4:21 pm, CNA K 4/9/2025 at 4:30 pm, CNA L Record review of facility's policy titled Quality of care with revision date 6/2023 revealed, it is the policy of this facility to create a safe environment for the resident. 675689 Page 10 of 18 675689 04/10/2025 Village Healthcare and Rehabilitation 615 N Ware Rd McAllen, TX 78501

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #78) of 33 residents whose records were reviewed for pharmacy services. The facility failed to ensure Resident #78 was not prescribed an antipsychotic (Aripiprazole) without appropriate diagnosis for its use. This deficient practice could place residents without a proper diagnosis for taking antipsychotic medications at risk for receiving unnecessary medications. The findings were: Record review of Resident #78's admission record, revealed he was a [AGE] year old male, admitted to the facility on [DATE], with diagnoses of heart disease, Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), dementia (a group of thinking and social symptoms that interferes with daily functioning), and type 2 diabetes mellitus (a long term condition in which the body has trouble controlling blood sugar and using it for energy). Record review of Physician Order dated 03/11/2025, ARIPiprazole Oral Tablet 20 MG (Aripiprazole) Give 1 tablet enterally at bedtime for Dementia w/ behavioral disturbance. Start 03/11/2025 1706 (05:06 p.m.) Record review of March 2025 MAR and April 2025 MAR revealed Resident #78 received ARIPiprazole Oral Tablet 20 MG (Aripiprazole) Give 1 tablet enterally at bedtime for Dementia w/ behavioral disturbance at bedtime from 03/11/2025 through 04/06/25. Record review of Resident #78's comprehensive person-centered care plan dated 03/12/2025 revealed FOCUS: o Resident #78 requires the use of Psychotropic medications use r/t Disease process (dementia with behaviors) Date Initiated: 03/12/2025 Created on: 03/12/2025 . And FOCUS: o Resident #78 requires the use of Anti psychotic medication (ARIPiprazole Oral Tablet) r/t Dementia with behaviors Date Initiated: 03/12/2025 Created on: 03/12/2025 Revision on: 03/12/2025 . Record review of Resident #78's Medicare 5 Day MDS assessment dated [DATE], revealed Resident #78 had a BIMS of 00 which indicated his cognition was severely impaired. Resident #78 had adequate hearing and staff could usually understand him and he was usually able to understand. Resident #78 was always incontinent of bladder and bowels. In an interview on 04/09/25 at 01:53 PM CNA E stated Resident #78 was not a difficult resident (no behaviors). She said he was very nice and easy (to work with). 675689 Page 11 of 18 675689 04/10/2025 Village Healthcare and Rehabilitation 615 N Ware Rd McAllen, TX 78501

F 0758 Level of Harm - Minimal harm or potential for actual harm In an interview on 04/09/25 at 01:53 PM CNA D stated Resident #78 was a nice resident and she had no problems with him. CNA D stated resident had no behaviors. In an interview on 04/09/25 at 01:54 PM CNA F stated Resident #78 had no behaviors and was not a difficult resident. Residents Affected - Few In an interview on 04/09/25 at 01:55 PM RN C stated Resident #78 was very polite. RN C stated he had not experienced any behaviors with Resident #78. In an interview on 04/10/25 at 04:10 PM RN G stated the admission nurse was the one who usually put the orders in for newly admitted residents. RN G stated the admission nurse would also reconcile the medications with the doctor. RN G stated ADON H would reconcile the antipsychotics and psychotropics. RN G stated the ADON H would also get the consents (for psychotropics and antipsychotics) from the resident or RP. In an interview on 04/10/25 at 04:20 PM ADON H stated she was usually the one who puts the antipsychotics in the computer. She said if she would see an admission where a resident had an antipsychotic, she would contact psych or hospice to notify that an antipsychotic could not have the diagnosis as dementia. ADON H stated she knew that was not accepted. In an interview on 04/10/25 at 04:45 PM the DON stated the admitting nurse was the one who put the medication orders in the computer. The DON stated ADON H was the one who reviewed the antipsychotics and psychotropics (before putting the medication orders in the computer). In an interview on 04/10/25 at 05:10 PM the Administrator stated Resident #78 had come in from another facility with the antipsychotic with dementia diagnosis and he knew that was not allowed. Record review of facility's Psychotropic Policy, date implemented 05/2007 Revision/Review Date(s): 12/2019; 2/2022; 12/2023, revealed: Policy: It is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Psychotropic medications shall not be administered for the purpose of discipline or convenience. Based on a comprehensive assessment, the facility will ensure that: -Residents who use psychotropic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; -Residents do not receive psychotropic drugs pursuant to an as needed (PRN) order unless medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; - PRN orders for psychotropic drugs are limited to 14 days. Except for PRN orders for anti-psychotic medications, if the attending physician or prescribing practitioner believes that it is appropriate for the PRN psychotropic med order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order; 675689 Page 12 of 18 675689 04/10/2025 Village Healthcare and Rehabilitation 615 N Ware Rd McAllen, TX 78501

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. Definitions Psychotropic Medication: The Centers for Medicare and Medicaid Services (CMS) defines a psychotropic medication as any drug that affects brain activities associated with mental processes and behavior. This category includes medications in the categories of antipsychotics, anti-depressants, anti-anxiety, and hypnotics . 675689 Page 13 of 18 675689 04/10/2025 Village Healthcare and Rehabilitation 615 N Ware Rd McAllen, TX 78501

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions, and the expiration date when applicable in 1 of 3 medication carts (medication cart located in 200 hallway) reviewed for medication storage and labeling. The facility failed to ensure that all insulin in medication cart in 200 hallway were not past their expiration date. The facility's failure could result in residents receiving medications at their best therapeutic level. The findings included: During an observation on 04/8/25 at 04:10 PM the medication cart on 200 hallway revealed 1 insulin vial passed the 28th day, opened date was 3/9/2025. During an interview on 04/8/25 at 02:40 PM LVN I stated residents could get adverse reactions if expired medications were given to the residents. LVN I stated insulins need to be discarded after 30 days from the opening date. LVN A stated expired insulin was not as potent as it supposed to be. During an interview on 04/8/25 at 03:57 PM LVN J stated the insulin vials needed to be discarded in the sharps container and the vials were good for 30 days after the opened date. LVN J stated if given to a resident after the 30 days, the insulin could cause an adverse reaction, or the insulin would not work as it is supposed to. During an interview on 04/8/25 at 04:30 PM the ADON stated the insulin must be discarded after 28 days from the opened date. The ADON also stated the charge nurse of each hallway had to make sure the insulin was not expired, and it was not appropriate to give expired insulin to residents because it could cause an adverse reaction. During an interview with on 04/9/25 at 04:10 PM the DON stated the insulins were good for 28 days after the insulins were open. The DON stated that the insulin would not be as effective and could cause adverse effects to the resident. Record review of policy titled Medication Storage Limits with revision date of April 2023 revealed: It is the policy of this facility to store medications in a safe manner. All medications are to be stored according to facility policy unless the consultant pharmacist for the facility has approved an exception based on resident safety and pharmaceutical products integrity. Insulin vials: At room temperature for 30 days. Record review of Novolog pamphlet titled novolog insulin aspart injection with revision date of 02/2023 revealed: 675689 Page 14 of 18 675689 04/10/2025 Village Healthcare and Rehabilitation 615 N Ware Rd McAllen, TX 78501

F 0761 16.2 Recommended storage: 10milliliters multiple-dose vial in use (opened), do not use after the 28 days. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675689 Page 15 of 18 675689 04/10/2025 Village Healthcare and Rehabilitation 615 N Ware Rd McAllen, TX 78501

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for, 1 of 1 resident (Resident # 63) observed for infection control issues in that: Residents Affected - Few CNA B reused wipes when she cleansed the perineal area and did not sanitize hands between glove changes. This deficient practice could place residents at risk for infection due to improper hand sanitizing and incontinent care practices. The findings were: Record review of Resident #63's electronic face sheet dated 04/10/25 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis DM (diabetes mellitus where the body either does not produce enough insulin or cannot effectively use the insulin it produces leading to high blood sugar levels), unsteadiness on feet, muscle weakness, muscle wasting and atrophy (decrease in size or wasting away of muscle), and lack of coordination. Record review of Resident #63's undated comprehensive person-centered care plan reflected she had an ADL self-care and mobility performance deficit. Date Initiated: 09/01/2024. Revision on: 10/08/2024. Toilet hygiene: requires substantial/maximal assistance of one staff member to assist with task. Record review of Resident #63's Quarterly MDS dated [DATE] reflected she required substantial/maximal assistance with self-care of toileting hygiene and was always bladder and bowel incontinent. During an incontinent care observation for Resident #63, on 4/10/24 at 8:30 AM., CNA B performed incontinent care on Resident #63. CNA B performed hand washing for the appropriate amount of time prior to starting perineal care. CNA B donned (put on) clean gloves. CNA B grabbed a couple of wipes to clean the vaginal area, wiped horizontal above pubic area, then wiped downward from front to back of the labia working outwards towards both thighs, then wiped down the center of the urethral area, separated labia, folded over wipes, then wiped down the center over the urethral area. CNA B used the same side of the wipes throughout the entire process, folding over and using the same wipes to clean the urethral area. CNA B changed gloves. CNA B grabbed a couple of wipes, wiped the buttocks area, folded over the wipes, and then wiped the rectum using the same wipes. CNA B changed gloves. CNA B performed hand washing for the appropriate amount of time at the end of providing care. CNA B did not sanitize hands between glove changes throughout the whole procedure. In an interview on 4/10/25 at 8:58 AM, CNA B said every time she changed gloves, she should sanitize her hands, but she noticed she did not have sanitizer in her pocket, so she could not do it. She said she knows she should sanitize and usually always did. CNA B said she remembered at school she was able to use the four corners technique. She said she forgot it was when using a washcloth, not when using wipes. CNA B said about a week ago they did a hand hygiene in-service for washing hands and how to use wipes. She said she knew to use one wipe per swipe and discard, she just forgot. 675689 Page 16 of 18 675689 04/10/2025 Village Healthcare and Rehabilitation 615 N Ware Rd McAllen, TX 78501

F 0880 Level of Harm - Minimal harm or potential for actual harm In an interview on 4/10/25 at 9:29 AM CNA L said they must clean hands before, during and after patient care. She said every time she changes gloves, she must sanitize her hands. She said she must always be sure when using wipes, to use one wipe per swipe, it does not matter how many wipes she used. CNA when they were in-serviced on hand hygiene they were told they must sanitize between glove changes and always hand hygiene before and after care. She said they were reminded daily throughout the week. Residents Affected - Few In an interview on 4/10/25 at 9:50 am CNA M said she was involved in training CNAs in incontinent care. She said they do in-services for hand hygiene and incontinent care monthly and PRN. She said they have staff meetings once a week and go over incontinent care. She said the CNAs know they must hand sanitize or wash hands before entering and leaving a room. She said anytime they change gloves and when going from dirty to clean, they must hand sanitize. She said they were instructed to use one swipe per wipe and then must throw the wipe away. She said if they do not it could cause a UTI. She said they get checked off upon hire and throughout the year as often as can. In an interview on 4/10/25 at 10:00 AM DON said she was involved in the hand hygiene/incontinent care training. She said she had training at least once a month and as needed. She said they do random check offs on hand hygiene. She said incontinent care check offs were done upon hire, annually and randomly as needed. She said staff were instructed to hand hygiene before and after incontinent care and between glove changes during incontinent care. She said they should always use wipes cleaning from front to back. They should always use a wipe and then discard and grab another and discard. They should always discard after using a wipe once. She said not sanitizing between glove changes or discarding gloves could cause cross contamination or an infection. Record review of the Skills Checklist - Perineal Care for CNA B dated 02/19/25 reflected: Perineal Care Procedure . A. Female Procedure: . 1. Separated labia cleaning downward from front to back using a clean part of cloth with each stroke . Record review of facility's undated Perineal Care policy and procedure reflected: Policy: It is the policy of this facility to: . Prevent skin irritation or infection to perineal area . Procedures: . 4. Wash hands properly. Supplies: Disposable wipes . 675689 Page 17 of 18 675689 04/10/2025 Village Healthcare and Rehabilitation 615 N Ware Rd McAllen, TX 78501

F 0880 Hand sanitizer . Level of Harm - Minimal harm or potential for actual harm Female - without catheter . 4. Cleanse pubic area, including upper, inner aspect of both thighs and frontal portion of perineum. Residents Affected - Few A. Use long strokes from the most anterior down to the base of the labia. (Wash from the cleanest area to the dirtiest area.) B. After each stroke, use a new disposable wipe. 8. Wash perennial area thoroughly, with each stroke beginning at the base of the labia and extending up over the buttocks. A. Use a new disposable wipe after each stroke. For all variations, complete procedure as follows: . Wash hands properly Record review of facility's Hand Washing policy and procedure - Nursing Clinical, revised 10/2023 reflected: Policy: It is the policy of this facility to cleanse hands to prevent transmission of possible infections material and to provide clean, health environment for residents and staff. Purpose: Hand washing is generally considered the most important single procedure for preventing nosocomial infections. Antiseptics control or kill microorganisms contaminating skin and other superficial tissues and are sometimes composed of the same chemicals that are used for disinfection of inanimate objects. Although antiseptics and other hand washing agents do not sterilize the skin, they can reduce microbial contamination depending on the type and the amount of contamination, the agent used, the presence of residual activity and the hand washing technique followed. Waterless handwashing products 1. Some situations require hand washing in areas where sinks are not readily available. In these limited circumstances, waterless hand washing products may be used. 675689 Page 18 of 18