Health inspection·August 21, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few woman in his room on the floor. Resident #1 was found on her left side, and two CNAs were called to room for assistance. There was a small hematoma to left brow. Resident #1 was in severe pain to left thigh. Staff assisted Resident #1 into wheelchair and assisted her to bed. Left leg was shorter than right leg. Record review of Resident #1's Hospital Summary - Orthopedic Discharge Instructions dated 06/05/25 revealed Resident #1 underwent open reduction with internal fixation (surgical procedure to repair broken bones) on 06/02/25. Pertinent information included per [family member], [Resident #1] was found in another resident's room and had fallen. The Assessment and Plan portion of the hospital summary revealed unwitnessed fall. The Hospital Diagnoses portion of the hospital summary revealed unwitnessed fall. In an interview on 07/30/25 at 3:35 PM LVN-I stated she had not seen Resident #1 fall. She stated it was an unwitnessed fall, and Resident #2 had found Resident #1 on the floor in his room. LVN-I stated Resident #1 had severe pain with facial grimacing and moaning, and when she assessed Resident #1 she was noted to have had some bruising as well as a deformity in which one leg was noted to be longer than the other leg. She stated two CNAs assisted her with getting Resident #1 up and to the wheelchair, then to the bed in her room, then notified provider and EMS. LVN-I stated she notified the facility on-call number (the afterhours number to be notified) of the fall like she was supposed to, as well as documented the fall in Resident #1's chart. In an interview on 07/30/25 at 3:48 PM ADON-A stated Resident #1 had not had any other recent falls since 09/04/24 in which she had wandered into another resident's room and had a fall. She also stated she only knew what she had read about the fall from LVN-I's progress note as an investigation had not been done. ADON-A stated she had discussed Resident #1's fall with the DON, and an incident report had been done, but an investigation was not done. She stated the DON and Administrator determine if an investigation should be completed and if an incident was considered a reportable incident. In an interview on 07/30/25 at 4:21 PM the DON stated Resident #1's fall was reported to him during the morning meeting the next morning. The DON stated he did not further investigate the incident after he was made aware. The DON also stated he did not investigate the staffing supervision at the time of the incident. He also stated LVN-I reported to whomever was on-call the night of the fall, then it was discussed at the morning meeting the next morning, in which he went over clinical needs and reviewed the incidents and accidents. The DON stated Resident #1's fall was reported to the administrator in the morning meeting as well, but he and the administrator both assumed it was a witnessed fall because they interpreted LVN-I's progress note as there was a resident in the room with Resident #1 when she fell, and they did not feel it needed to be investigated any further or reported to the state. In an interview on 07/30/25 at 4:45 PM the Administrator stated he remembered an incident report was done, and Resident #1 had a fracture from the fall. He stated Resident #2 had reported there was a lady on his floor, and Resident #2 had found her on the floor. The Administrator stated he did not conduct an investigation regarding the supervision of the staff or how the fall occurred, and he had not done any further interviews or investigations into this incident because he had not thought it was necessary or a reportable at the time, but he stated now looking back he felt like this incident should have been investigated further, and if he would have realized it was an unwitnessed fall with a major injury, he would have reported it within 2 hours. The administrator stated unwitnessed falls with major injuries should always be reported, and he was the person who should have, and typically did, report incidents to the state. The Administrator stated there was no specific policy on how or what to report, but he followed the stated and CMS guidelines on how and what to report. Record Review of the Long-Term Care Regulation Provider Letter, issued 08/29/2024, revealed 2.1 Incidents that a NF must report to HHSC: A NF must report to CII the following types of incidents, in accordance with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675717 If continuation sheet Page 2 of 15 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 675717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Rafael Nursing and Rehabiliation 3050 Sunnybrook Rd Corpus Chrisit, TX 78415 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 0609 Level of Harm - Minimal harm or potential for actual harm applicable state and federal requirements: Abuse, Neglect, Suspicious injuries of unknown source, and/or Emergency situations that pose a threat to resident health and safety. When to report: Immediately, but not later than two hours after the incident occurs or is suspected. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675717 If continuation sheet Page 3 of 15 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 675717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Rafael Nursing and Rehabiliation 3050 Sunnybrook Rd Corpus Chrisit, TX 78415 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have evidence that all alleged violations were thoroughly investigated and measures were taken to prevent further potential abuse, neglect, exploitation or mistreatment in accordance with State law, and if the alleged violation was verified appropriate, corrective action must have been taken for 1 (Resident #1) of 5 residents reviewed for abuse, neglect, and/or misappropriation. The facility failed to do a thorough investigation to include interviewing Resident #1, as well as other residents or staff which may have been involved in or witnessed the incident. This failure placed residents at risk of not having their allegations investigated thoroughly or timely. The findings included: Record review of Resident #1's face sheet dated 07/31/25 revealed an [AGE] year-old female with an original admission date of 01/12/23 and a current admission date of 06/05/25. Pertinent diagnoses included Displaced Intertrochanteric Fracture of Left Femur (a common hip fracture which occurs in the upper part of the femur which typically requires surgical intervention); Other Abnormalities of Gait and Mobility, Dementia (a decline in cognitive function which affects daily life, memory, reasoning, and language skills), Alzheimer's Disease (the most common form of dementia, characterized by problems with memory, thinking, and behavior), and Blindness to the Left Eye. Record review of Resident #1's Quarterly MDS assessment dated [DATE] section C, cognitive patterns, revealed a BIMS score of 0 (severe impairment). Record review of Resident #1's care plan initiated 06/15/2023 and revised 07/25/25 revealed resident was at risk for falls related to gait and balance problems. Interventions included anticipate and meet the resident's needs, be sure call light was within reach, follow facility fall protocol, and evaluate and treat as ordered. Record review of Resident #1's care plan initiated 01/16/23 and revised 01/03/25 revealed resident was an elopement risk related to dementia, as evidenced by wandering around unit and into other residents' rooms. Interventions included distract resident from wandering, evaluate and screen quarterly for memory unit, redirect when wandering into other residents' rooms, and Resident #1 would reside in memory care unit for safety. Record review of Resident #1's care plan initiated 06/03/2025 revealed resident had an actual fall on 06/01/25. Interventions included continue post fall follow up x 72 hours, determined and addressed causative factors, and physical therapy to consult for strength and mobility. Record review of Resident #1's fall risk dated 03/04/25 revealed Resident #1 had a balance problem while standing and/or walking. Record review of Resident #1's progress noted dated 06/01/25, written by LVN-I, revealed a male resident came out of his room and said there was a woman in his room on the floor. Resident #1 was found on her left side, and two CNAs were called to room for assistance. The skin check was done, and there was a small hematoma to left brow. Resident #1 was in severe pain to left thigh. Staff assisted Resident #1 into wheelchair and assisted her to bed. Left leg was shorter than right leg. Record review of Resident #1's progress noted dated 06/01/25 revealed Resident #1's family member called to let the facility know Resident #1 had a hip fracture, and they were waiting to speak with Orthopedic Doctor regarding options. Record review of Resident #1's Hospital Summary - Orthopedic Discharge Instructions dated 06/05/25 revealed Resident #1 underwent open reduction with internal fixation (surgical procedure to repair broken bones) on 06/02/25. Pertinent information included per [family member], [Resident #1] was found in another resident's room and had fallen. The Assessment and Plan portion of the hospital summary revealed unwitnessed fall. The Hospital Diagnoses portion of the hospital summary revealed unwitnessed fall. In an interview on 07/30/25 at 3:35 PM LVN-I stated she had not seen Resident #1 fall. She stated it was an unwitnessed fall, and another (male) resident had found her on the floor in his room. The male resident came out of his room and notified staff there was a woman in the floor in his Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675717 If continuation sheet Page 4 of 15 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 675717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Rafael Nursing and Rehabiliation 3050 Sunnybrook Rd Corpus Chrisit, TX 78415 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few room. She stated Resident #1 was having severe pain with facial grimacing and moaning. LVN-I stated she assessed Resident #1, and she was noted to have had some bruising, as well as a deformity in which one leg was noted to be longer than the other leg. She then had two CNAs assist her with getting Resident #1 up and to the wheelchair, then to the bed in her room, and notified provider and EMS. LVN-I stated severe pain and a deformity with the hip and leg could mean an injury or possible fracture, and the resident should not have been moved because movement could possibly have made the injury worse. She stated she notified the facility on-call of the fall, as well as documented it. In an interview on 07/30/25 at 3:48 PM ADON-A stated Resident #1's fall on 06/01/25 with a hip fracture was the most recent fall, and she had not had any other recent falls. ADON-A stated she was informed another resident walked in and found Resident #1 on the floor in his room. She stated she only knew what she had read about the fall from LVN-I's progress note, and Resident #1 had severe pain, the left leg was shorter than the right leg, and the staff moved Resident #1 to the wheelchair and then to the bed. ADON-A stated Resident #1 should not have been moved, but assessed for injuries, vital signs checked, neuro checks started, and the nurse should have checked to see if she had anything for pain. The nurse should have kept her there on the floor and not moved her until EMS arrived to evaluate and stabilize her. LVN-I should have notified the on-call for the facility, the DON, the administrator, and the family. She stated if the resident was moved while having severe pain and a leg deformity, indicating a major injury, this could cause further injury to the resident. In an interview on 07/30/25 at 4:21 PM the DON stated Resident #1's fall was reported to him during the morning meeting the next morning. He stated LVN-I reported to whomever was on-call the night of the fall, then it was discussed at the morning meeting the next morning. The DON stated he went over clinical needs and reviewed the incidents and accidents in the morning meetings. He stated what he knew about the fall was Resident #1 entered another resident's room, and the other resident reported Resident #1 had fallen. He also stated LVN-I assessed Resident #1 for pain. He stated if Resident #1 was identified to have had an injury, then moving her might have exacerbated the injury. He stated the protocol for falls included body and skin assessment, vital sign assessment, neuro checks, and if any abnormalities were noted, she should not have been moved until EMS arrived to evaluate. If a fall was unwitnessed the administrator should have been notified, and he would have then determined the next step. The DON stated Resident #1's fall was reported to the administrator in the morning meeting as well, but he and the administrator both assumed it was a witnessed fall because they interpreted the note as there was a resident in the room with Resident #1 when she fell, and they did not feel it needed to be investigated any further or reported to the state. In an interview on 07/30/25 at 4:45 PM the Administrator stated he remembered an incident report was done, and Resident #1 had a fracture from the fall. He stated another resident reported there was a lady on the floor. The other resident had found her on the floor and she had a fall. The Administrator stated he did not recall who reported it to him, but it would have been reported and discussed in the morning clinical meeting. He also stated he did not consider this a reportable type of incident as he did not believe it was an unwitnessed fall, but he did state unwitnessed falls with major injuries would be reported. The Administrator stated he had not done any further interviews or investigations into this incident because he had not thought it was necessary at the time. He also stated it was probably questionable as to whether or not the resident who reported the fall was competent enough to answer questions with a BIMS of 3, which indicated severely impaired cognition. The Administrator stated now looking back he felt like this incident should have been investigated further, and if he would have realized it was an unwitnessed fall with a major injury, he would have reported it within 2 hours. The Administrator stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675717 If continuation sheet Page 5 of 15 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 675717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Rafael Nursing and Rehabiliation 3050 Sunnybrook Rd Corpus Chrisit, TX 78415 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete there was no specific policy on how or what to report, but he followed the stated and CMS guidelines on how and what to report. In an interview on 07/31/25 at 8:32 AM ADON-S stated she was the one who did fall trending and tracking as well as fall investigations. She stated Resident #1 had only had 1 fall this year, and it was this unwitnessed fall with a major injury. ADON-A stated she completed her report based on the note written by the nurse, and according to the documentation, the nurse called the DON and reported the fall. ADON-A stated she followed up with the resident regarding post-fall questions and the reporting nurse, and LVN-I told her Resident #1 was found in floor, and after assessing Resident #1, LVN-I asked the CNAs to transport Resident #1 to the wheelchair and then to her bed. ADON-A stated LVN-I should not have moved Resident #1 while in severe pain or after noting one leg was longer than the other because it could have meant there was a fracture or major injury, and movement could have caused further injury. In an interview on 07/31/25 at 11:05 AM, CNA-J stated she heard the male resident say there was a woman on the floor in his room. She stated no one questioned the male resident as to what happened to Resident#1 and how she ended up on the floor. CNA-J stated LVN-I went and assessed the Resident #1 while she was lying on the floor, and Resident #1 kept moaning and groaning in pain as well as making faces like she was in severe pain. She stated the LVN-I never said anything to about one leg being longer than the other, so both CNAs assumed it was okay to move Resident #1. CNA-J stated she realized moving a resident with an injury could make it worse. Event ID: Facility ID: 675717 If continuation sheet Page 6 of 15 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 675717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Rafael Nursing and Rehabiliation 3050 Sunnybrook Rd Corpus Chrisit, TX 78415 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to enforce the post-fall assessment policy leading to Resident #1 being moved from the floor to her wheelchair, and from her wheelchair to her bed after a fall while having severe pain and an obvious hip and leg deformity. The failure could affect residents currently residing in the facility, resulting in them not receiving the needed care to maintain optimal health and placing them at risk for injury or deterioration in their condition. The findings included: Record review of Resident #1's face sheet dated 07/31/25 revealed an [AGE] year-old female with an original admission date of 01/12/23 and a current admission date of 06/05/25. Pertinent diagnoses included Displaced Intertrochanteric Fracture of Left Femur (a common hip fracture which occurs in the upper part of the femur which typically requires surgical intervention); Other Abnormalities of Gait and Mobility, Dementia (a decline in cognitive function which affects daily life, memory, reasoning, and language skills), Alzheimer's Disease (the most common form of dementia, characterized by problems with memory, thinking, and behavior), and Blindness to the Left Eye. Record review of Resident #1's Fall Risk Evaluation dated 06/05/25 revealed a history of 1-2 falls in the past 3 months, regularly incontinent, requires use of assistive devices, and Resident #1 was considered high risk for potential falls. Record review of Resident #1's Quarterly MDS assessment dated [DATE] section C, cognitive patterns, revealed a BIMS score of 0 (severe cognitive impairment). Record review of Resident #1's care plan initiated 06/15/2023 and revised 07/25/25 revealed resident was at risk for falls related to gait and balance problems. Interventions included anticipate and meet the resident's needs, be sure call light was within reach, follow facility fall protocol, and evaluate and treat as ordered. Record review of Resident #1's care plan initiated 01/16/23 and revised 01/03/25 revealed resident was an elopement risk related to dementia, as evidenced by wandering around unit and into other residents' rooms. Interventions include distract resident from wandering, evaluate and screen quarterly for memory unit, redirect when wandering into other residents' rooms, and Resident #1 would reside in memory care unit for safety. Record review of Resident #1's care plan initiated 06/03/2025 revealed resident had an actual fall on 06/01/25. Interventions included continue post fall follow up x 72 hours, determined and addressed causative factors, and physical therapy to consult for strength and mobility. Record review of Resident #1's fall risk dated 03/04/25 revealed Resident #1 had a balance problem while standing and/or walking. Record review of Resident #1's progress noted dated 06/01/25, written by LVN-I, revealed a male resident came out of his room and said there was a woman in his room on the floor. Resident #1 was found on her left side, and two CNAs were called to room for assistance. The skin check was done, and there was a small hematoma to left brow. Resident #1 was in severe pain to left thigh. Staff assisted Resident #1 into wheelchair and assisted her to bed. Left leg was shorter than right leg. Record review of Resident #1's progress noted dated 06/01/25 revealed Resident #1's family member called to let the facility know Resident #1 had a hip fracture, and they were waiting to speak with Orthopedic Doctor regarding options. Record review of Resident #1's Hospital Summary - Orthopedic Discharge Instructions dated 06/05/25 revealed Resident #1 underwent open reduction with internal fixation (surgical procedure to repair broken bones) on 06/02/25. Pertinent information included per [daughter], [Resident #1] was found in another resident's room and had fallen. The Assessment and Plan portion of the hospital summary revealed unwitnessed fall. The Hospital Diagnoses portion of the hospital summary revealed unwitnessed fall. In an interview on 07/30/25 at Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675717 If continuation sheet Page 7 of 15 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 675717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Rafael Nursing and Rehabiliation 3050 Sunnybrook Rd Corpus Chrisit, TX 78415 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 - Actual harm Residents Affected - Few 3:35 PM LVN-I stated she had not seen Resident #1 fall. She stated it was an unwitnessed fall, and another (male) resident had found her on the floor in his room. The male resident came out of his room and notified staff there was a woman on the floor in his room. She stated Resident #1 was having severe pain with facial grimacing and moaning. LVN-I stated she assessed Resident #1, and she was noted to have had some bruising, as well as a deformity in which one leg was noted to be longer than the other leg. She then had two CNAs assist her with getting Resident #1 up and to the wheelchair, then to the bed in her room, and notified provider and EMS. LVN-I stated severe pain and a deformity with the hip and leg could mean an injury or possible fracture, and the resident should not have been moved because movement could possibly have made the injury worse. In an interview on 07/30/25 at 3:48 PM ADON-A stated Resident #1's fall on 06/01/25 with a hip fracture was the most recent fall, and she had not had any other recent falls. ADON-A stated she was informed another resident walked in and found Resident #1 on the floor in his room. She stated she only knew what she had read about the fall from LVN-I's progress note, and Resident #1 had severe pain, the left leg was shorter than the right leg, and the staff moved Resident #1 to the wheelchair and then to the bed. ADON-A stated Resident #1 should not have been moved, but assessed for injuries, vital signs checked, neuro checks started, and the nurse should have checked to see if she had anything for pain. The nurse should have kept her there on the floor and not moved her until EMS arrived to evaluate and stabilize her. LVN-I should have notified the on-call for the facility, the DON, the Administrator, and the family. She stated if the resident was moved while having severe pain and a leg deformity, indicating a major injury, this could cause further injury to the resident. In an interview on 07/30/25 at 4:21 PM the DON stated Resident #1's fall was reported to him during the morning meeting the next morning. He stated LVN-I reported to whomever was on-call the night of the fall, then it was discussed at the morning meeting the next morning. The DON stated he went over clinical needs and reviewed the incidents and accidents in the morning meetings. He stated what he knew about the fall was Resident #1 entered another resident's room, and the other resident reported Resident #1 had fallen. He also stated LVN-I assessed Resident #1 for pain. He stated if Resident #1 was identified to have had an injury, then moving her might have exacerbated the injury. He stated the protocol for falls included body and skin assessment, vital sign assessment, neuro checks, and if any abnormalities were noted, she should not have been moved until EMS arrived to evaluate. If a fall was unwitnessed the administrator should have been notified, and he would have then determined the next step. The DON stated Resident #1's fall was reported to the administrator in the morning meeting as well, but he and the administrator both assumed it was a witnessed fall because they interpreted the note as there was a resident in the room with Resident #1 when she fell, and they did not feel it needed to be investigated any further or reported to the state. In an interview on 07/30/25 at 4:45 PM the Administrator stated he remembered an incident report was done, and Resident #1 had a fracture from the fall. He stated another resident reported there was a lady on the floor. The other resident had found her on the floor and she had a fall. The Administrator stated he did not recall who reported it to him, but it would have been reported and discussed in the morning clinical meeting. He also stated he did not consider this a reportable type of incident as he did not believe it was an unwitnessed fall, but he did state unwitnessed falls with major injuries would be reported. The Administrator stated he had not done any further interviews or investigations into this incident because he had not thought it was necessary at the time. He also stated it was probably questionable as to whether or not the resident who reported the fall was competent enough to answer questions with a BIMS of 3, which indicated severely impaired cognition. The Administrator stated now looking back he felt like this incident should have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675717 If continuation sheet Page 8 of 15 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 675717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Rafael Nursing and Rehabiliation 3050 Sunnybrook Rd Corpus Chrisit, TX 78415 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete been investigated further, and if he would have realized it was an unwitnessed fall with a major injury, he would have reported it within 2 hours. In an interview on 07/31/25 at 8:32 AM ADON-S stated she was the one who did fall trending and tracking as well as fall investigations. She stated Resident #1 had only had 1 fall this year, and it was this unwitnessed fall with a major injury. ADON-A stated she completed her report based on the note written by the nurse, and according to the documentation, the nurse called the DON and reported fall. ADON-A state she followed up with the resident and nurse post fall, and LVN-I told her Resident #1 was found in floor, and after assessing Resident #1, LVN-I asked the CNAs to transport Resident #1 to the wheelchair and then to her bed. ADON-A stated LVN-I should not have moved Resident #1 while in severe pain or after noting one leg was longer than the other because it could have meant there was a fracture or major injury, and movement could have caused further injury. In an interview on 07/31/25 at 11:05 AM, CNA-J stated she heard the male resident say there was a woman on the floor in his room. She stated no one questioned the male resident as to what happened Resident#1 and how she ended up on the floor. CNA-J stated LVN-I went and assessed the Resident #1 while she was lying on the floor, and Resident #1 kept moaning and groaning in pain as well as making faces like she was in severe pain. She stated the LVN-I never said anything to about one leg being longer than the other, so both CNAs assumed it was okay to move Resident #1. CNA-J stated she realized moving a resident with an injury could make it worse. Record review of an all-staff in-service dated 04/30/25 revealed a fall is signified as any break in plane regardless of where the patient lands. If a resident fall occurred it must be immediately reported to the charge nurse so they can assess resident and situation and determine if resident is safe to move or transfer, then incident report must be completed by charge nurse. Record review of the facility's Fall, and Fall Risk, Managing Policy, revised March 2018, revealed Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. The staff will implement a fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. Event ID: Facility ID: 675717 If continuation sheet Page 9 of 15 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 675717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Rafael Nursing and Rehabiliation 3050 Sunnybrook Rd Corpus Chrisit, TX 78415 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 - 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 observation, interviews, and record reviews the facility failed to ensure residents received adequate supervision to prevent accidents and/or hazards as possible for 1 of 5 residents (Resident #1) reviewed for supervision, accidents, and hazards. The facility failed to keep Resident #1 free from accident and/or hazards when she fell on [DATE] which caused her to sustain a left hip fracture by not providing the necessary monitoring and supervision for Resident #1 with known history of behaviors of wandering into other resident rooms. The three staff assigned to supervise the secure unit were at the nurse's station distracted and engaged in personal conversation when Resident #1 wandered out of her room and into another resident's room. An IJ was identified on 08/20/25. The IJ template was provided to the facility on [DATE] at 3:22 PM. While the IJ was removed on 08/21/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because new procedures implemented to prevent future errors were still in process. This failure could place residents at risk for injuries and a decline in health.The findings included: Record review of Resident #1's face sheet dated 07/31/25 revealed an [AGE] year-old female with an original admission date of 01/12/23 and a current admission date of 06/05/25. Pertinent diagnoses included Displaced Intertrochanteric Fracture of Left Femur (a common hip fracture which occurs in the upper part of the femur which typically required surgical intervention); Other Abnormalities of Gait and Mobility, Dementia (a decline in cognitive function which affects daily life, memory, reasoning, and language skills), Alzheimer's Disease (the most common form of dementia, characterized by problems with memory, thinking, and behavior), and Blindness to the Left Eye. Record review of Resident #1's care plan initiated 06/15/2023 and revised 07/25/25 revealed Resident #1 was at risk for falls related to gait and balance problems. Interventions included anticipate and meet the resident's needs, follow facility fall protocol, and evaluate and treat as ordered. Resident #1's care plan initiated 01/16/2023 and revised 01/03/2025 revealed Resident #1 was an elopement risk as evidenced by wandering; interventions included distracting Resident #1 from wandering by offering diversions, structured activities, food, conversation, television, books, and/or listening to the radio in her room. Other interventions included Resident #1 would be redirected when wandering into other residents' rooms or as needed, and Resident #1 would reside in the memory care unit for safety. Resident #1's care plan also included the actual fall on 06/01/25 with serious injury. It was initiated on 06/03/25. Interventions included determine and address causative factors of the fall. Record review of Resident #1's Quarterly MDS assessment dated [DATE], section C, cognitive patterns, revealed a BIMS score of 00 (severe cognitive impairment). This MDS revealed no falls since admission, entry, reentry, or prior assessment. Record review of Resident #1's Quarterly MDS assessment dated [DATE], section C, cognitive patterns, revealed a BIMS score of 00 (severe cognitive impairment). This MDS revealed fall with major injury requiring surgical intervention. There was no provider investigation or internal investigation for the fall of the unsupervised Resident #1 done by the facility, so there was no review done of a provider or facility investigation. Record review of Resident #1's Fall Risk Evaluation dated 03/04/25 revealed Resident #1 wanders; no falls in the past 3 months; regularly incontinent; balance problem while standing/walking. Resident was considered a high risk for falls. Record review of Resident #1's progress note dated 06/01/25, written by LVN-I, revealed a male resident came out of his room and said there was a woman in his room on the floor. Resident #1 was found on her left side, and two CNAs were called to the room for assistance. The skin check was done, and there was a small hematoma to the left brow. Resident #1 was in severe pain to left thigh. Staff assisted Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675717 If continuation sheet Page 10 of 15 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 675717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Rafael Nursing and Rehabiliation 3050 Sunnybrook Rd Corpus Chrisit, TX 78415 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 - Immediate jeopardy to resident health or safety Residents Affected - Few #1 into the wheelchair and then assisted her to bed. Left leg was noted to be shorter than the right leg. Record review of Resident #1's Hospital Summary - Orthopedic Discharge Instructions dated 06/05/25 revealed Resident #1 underwent open reduction with internal fixation (surgical procedure to repair broken bones) on 06/02/25. Pertinent information included per family member, [Resident #1] was found in another resident's room and had fallen. The Assessment and Plan portion of the hospital summary revealed unwitnessed fall. The Hospital Diagnoses portion of the hospital summary revealed unwitnessed fall. Record review of the Staffing Schedule for the locked unit revealed a census of 26 and the following staff: 05/31/25 revealed 6AM - 6PM had 2 CNAs and an LVN (from 6AM-1:30PM) and another LVN (from 1:30PM-12AM). 6Pm - 6AM had 2 CNAs and an LVN (from 12AM-6AM).06/01/25 revealed 6AM - 6PM had 2 CNAs and an LVN (from 6AM-1:30PM) and another LVN (from 1:30PM-6PM). 6PM - 6AM had 2 CNAs and an LVN.06/02/25 revealed 6AM - 6PM had 2 CNAs and 2 LVNs. 6PM - 6AM had 2 CNAs and an LVN. In an observation on 08/19/25 at 9:40 AM revealed Resident #1 lying in bed. She smiled and nodded her head to every question asked. Attempted to interview Resident #1, but she was pleasantly confused. In an observation on 08/19/25 at 9:45 AM the locked unit revealed 5 residents walking down the hallway assisted by 1 CNA. LVN was off the unit (had stepped away) and 2nd CNA was providing patient care. In an observation on 08/20/25 at 1:05 PM the locked unit revealed some residents sitting in the television room, some residents sitting in the activities/dining room, while multiple other residents were wandering up and down the hall. Three residents were noted to have gone into rooms which did not belong to them, and staff did redirect these residents. In an observation on 08/20/25 at 1:30 PM the locked unit revealed 8 camera monitors located at the nurses' station to be able to view all angles of the hallway. In an interview on 07/30/25 at 3:35 PM LVN-I stated she had not seen Resident #1 fall as she was sitting at the nurses' station at the time. She stated it was an unwitnessed fall, and Resident #2 had found her on the floor in his room. Resident #2 came out of his room and notified staff there was a woman on the floor in his room. She stated Resident #1 had severe pain with facial grimacing and moaning. LVN-I stated she assessed Resident #1, and she was noted to have had some bruising, as well as a deformity in which one leg was noted to be longer than the other leg as a result of the fall. She stated two CNAs assisted her with getting Resident #1 up and to the wheelchair, then to the bed in her room, and LVN-I notified the provider and Emergency Medical Services. In an interview on 07/30/25 at 3:48 PM ADON-A stated Resident #1 had not had any other recent falls since 09/04/24 in which she had wandered into another resident's room and had a fall. She also stated she only knew what she had read about the fall from LVN-I's progress note as an investigation had not been done. In an interview on 07/30/25 at 4:21 PM the DON stated Resident #1's fall was reported to him during the morning meeting the next morning. The DON stated he did not further investigate the incident after he was made aware. DON also stated he did not investigate the staffing supervision at the time of the incident. In an interview on 07/30/25 at 4:45 PM the Administrator stated he remembered an incident report was done, and Resident #1 had a fracture from the fall. He stated another resident reported there was a lady on the floor. The Administrator stated he did not conduct an investigation regarding the supervision of the staff or how the fall occurred. The Administrator stated he had not done any further interviews or investigations into this incident because he had not thought it was necessary or a reportable incident at the time, but he stated now looking back, he felt like this incident should have been investigated further, and if he would have realized it was an unwitnessed fall with a major injury, he would have reported it within 2 hours. In an interview on 07/31/25 at 11:05 AM CNA-J stated she heard Resident #2 say there was a woman on the floor in his room. She stated no one questioned Resident #2 as to what happened to Resident#1 or how she ended up on the floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675717 If continuation sheet Page 11 of 15 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 675717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Rafael Nursing and Rehabiliation 3050 Sunnybrook Rd Corpus Chrisit, TX 78415 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 - Immediate jeopardy to resident health or safety Residents Affected - Few CNA-J stated she did not remember exactly what she was doing at the time she was notified of the fall, but she believed she was either assisting or watching another resident. In an interview on 07/31/25 at 11:20 AM CNA-K stated she was could not remember what she was doing at the time, but believed she was at the nurses' station with the nurse because she remembered Resident #2 came out and told them at the same time Resident #1 had fallen in his floor. She stated she remembered seeing Resident #2 go in his room, but did not recall seeing Resident #1 go in Resident #2's room. She stated Resident #2 was in his room a minute or two before he came out to notify staff about Resident #1. In an interview on 08/19/25 at 10:09 AM ADON-A stated all residents in the locked unit have wandering behaviors, and this was why they were located on the locked unit, so they are monitored more closely and cannot exit the facility unattended. In an interview on 08/19/25 at 1:45 PM the DON stated he was not here when the fall occurred, but the facility called him to tell him Resident #1 had fallen and he called the Administrator to report there was a fall. He stated not all the residents in the locked unit wander, and if one CNA was off the floor doing patient care the other CNA or nurse was monitoring the hall. He also stated the staff monitor residents, if they attempt to go into the wrong room, staff would redirect them with things such as the tv room or activities to keep them entertained. The DON stated he was not sure how Resident #1 got missed by staff when she wandered into another resident's room on the night of 06/01/25. The DON stated he felt like 2 CNAs and one LVN were enough staff to monitor the locked unit, but he felt like it was more manageable at night because not as many residents wandered. He stated he did not remember interviewing the staff about where they were or what they were doing when Resident #1 entered Resident #2's room and had the fall. He also stated he felt like he should have interviewed and investigated this incident further. In an interview on 08/19/25 at 1:55 PM the Administrator stated he got a call and was told Resident #1 had fallen. He stated he was not sure where the CNAs or nurse were when the fall occurred because he never asked or interviewed the staff. The Administrator stated there were always 2 CNAs and a nurse on the locked unit, and the residents were free to move around the locked unit as they pleased. The Administrator stated if one of the CNAs was performing patient care, the other CNA was watching the hall, and if both the CNAs were busy, then the LVN steps forward to watch the hall. He stated he did have cameras back there, but he never went back and looked at the footage because at the time he was not investigating the fall, and he stated you cannot go back more than 72 hours, so he would not be able to review it now. The Administrator stated the staff get training upon hire on monitoring and handling dementia patients, as well as routine in-services, so they understand the concerns and needs of dementia patients. He also stated staff redirect the residents as needed, but he was unsure what redirection techniques were used. The Administrator stated he felt like 2 CNAs and 1 LVN were enough staff for the locked unit. In an interview on 08/19/25 at 6:09 PM CNA-K stated she remembered she was standing in the hallway talking to the nurse when Resident #2 stated a lady had fallen. She was not sure if CNA-J was standing with her and the nurse, or if she was doing something else. CNA-K stated she saw Resident #1 approximately 3 minutes prior to Resident #2 coming out of his room to notify them Resident #1 had fallen. She stated she was not sure how she missed seeing Resident #1 walk into Resident #2's room since they were standing in the hallway observing. CNA-K stated if she saw residents wandering around she would guide them back to the activities room or living room. CNA-K stated she felt like 2 CNAs and 1 LVN were enough staff to take care of the residents, and if one of the CNAs was doing patient care, the other was observing the residents in the hall, but if both CNAs were busy, the nurse would sit outside of the nurses desk in the hall so she was able to observe both ends of the hall. She also stated she recalled being in-serviced regarding monitoring and redirecting residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675717 If continuation sheet Page 12 of 15 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 675717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Rafael Nursing and Rehabiliation 3050 Sunnybrook Rd Corpus Chrisit, TX 78415 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 - Immediate jeopardy to resident health or safety Residents Affected - Few that wander. In an interview on 08/19/25 at 6:30 PM CNA-J stated she was at the nurses' station with CNA-K and LVN-I on the night of 06/01/2025 just chatting and talking about life in general. She stated she could see down both halls, so she was unsure how she missed Resident #1 walking into Resident #2's room. CNA-J stated it had only been a matter of minutes since she had last seen Resident #1 in the hallway, but she was unsure of how many minutes it had been. CNA-J stated Resident #1 was a quick walker and hard to keep up with sometimes, and she would redirect her often to keep her occupied or sometimes sit Resident #1 close to the nurses' station so as to keep a closer eye on her. CNA-J stated hanging out at the nurses' station and chatting maybe was not the best idea because they weren't as focused as they should have been on the residents. She also stated she recalled being in-serviced regarding monitoring and redirecting residents that wander. 08/20/25 at 1:05 PM Requested policy regarding staffing the locked unit, as well as a policy regarding monitoring and redirecting on the locked unit. Regional personnel and Administrator both stated there were no such policies, so this surveyor requested any general policies regarding staffing/adequate staffing, as well as any general policies regarding monitoring and redirecting residents. Both stated they would look for something. 08/20/25 at 2:00 PM the Administrator brought a policy regarding behavioral assessment, intervention and monitoring and stated this was all they had in regard to monitoring a resident. They did not have any other policy outlining staffing, monitoring, redirecting, or the locked unit in general. Record review of the facility's Wandering and Elopements policy, revised March 2019, revealed The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. IJ template and notification of immediacy was provided to both the Administrator and the DON on 08/20/2025 at 3:21 PM. Plan of Removal 08/20/2025Issue identified by surveyor: The facility failed to ensure the safety of Resident #1 by not providing consistent supervision to prevent Resident #1 from entering another resident's room on the secure unit, resulting in a fall with left femur fracture. Corrective Actions: **On 7/30/2025 LVN-I was terminated.**On 7/30/2025 the DON, ADON-A, and ADON-B in-serviced all direct care staff on the Fall Policy with focus on assessment after incident and including monitoring specific to the secure unit. Any new employee would be educated prior to start of shift.- One person conducts peri care while another was sitting in the hall monitoring the other residents.- Redirect residents back into activities room or living area when trying to enter other residents' rooms, and occupy them with a distraction (TV, coloring, games.)- Nurse should be positioned at the end of the nurse's station where she could visibly see down the hall when/if the CNAs were providing care.**On 7/30/2025, safe surveys were completed with residents by the DON and ADON. **On 7/30/2025, the Administrator and Director of Nursing were in-serviced on Reportable Guidelines, to include investigating all unwitnessed falls.**On 7/31/2025, all falls within the last 3 months were reviewed for documentation and assessment accuracy with no other issues noted.**On 7/31/2025, Ad Hoc QAPI was conducted with the Medical Director to review the plan of action and monitoring results will be reviewed monthly X 3 months in monthly QAPI.**On 7/31/2025 and going forward, all falls will be reviewed after morning meeting by the DON, the Administrator, ADON-A, and ADON-B to ensure a thorough assessment had been completed.**On 8/19/2025, 8 cameras were installed on the secure unit with a screen for viewing all angles of the hall at the nurse's station in the event the nurse was unable to position themselves at the end of the station.**On 8/20/2025, the IDT determined which residents were at highest risk of wandering into other rooms and care plans were updated to indicate on the Kardex for staff communication. Assessments would be conducted by DON/ADON/MDS nurses on admission, quarterly, and with a change of condition.**On 8/20/2025, the IDT in coordination with secure unit staff determined 4 residents required (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675717 If continuation sheet Page 13 of 15 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 675717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Rafael Nursing and Rehabiliation 3050 Sunnybrook Rd Corpus Chrisit, TX 78415 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 - Immediate jeopardy to resident health or safety Residents Affected - Few additional supervision due to daily redirection from other residents' room. Care Plan updated for supervision to hourly while awake and CNAs to document in the plan of care. **Starting 8/20/2025 the Administrator, the DON, or the ADON will round 3x a week for 3 months, and monthly thereafter, to ensure staff were effectively supervising residents.This plan of removal was developed, implemented, and completed as designed in this document. It was requested the Plan of Removal be accepted. Record review and verification of Plan of Removal implemented action performed 08/21/25: -On 07/30/25 LVN-I was terminated; verified by record review. -On 07/30/25 the DON and ADON in-serviced all direct care staff on the fall policy with a focus on assessment after incident and including monitoring specific to the secured unit; verified by record review of the in-service and staff signature page. -On 07/30/25 safe surveys were completed; verified by record review of the safe surveys completed. -On 07/30/25 the Administrator and the DON were in-serviced on Reportable Guidelines, to include investigating all unwitnessed falls; verified by record review of the e-mail containing the in-service. -On 07/31/25 a three-month review of all falls was reviewed for documentation and assessment accuracy. No tool was utilized. It was a discussion between the Administrator and the DON. -On 07/31/25 an Ad Hoc QAPI was conducted to review the plan of action; verified by record review of the QAPI signature page. -On 07/31/25 and moving forward, all falls are being reviewed after the morning meeting by the DON, the Administrator, and ADONs; no tool was being utilized to verify this process. It was being discussed after morning meetings. No fall assessments available at this time for review. -0n 08/19/25 8 cameras were installed on the secured unit with a monitor at the nurse's station for viewing all angles of the hall; surveyor verified by visually inspecting and observing all cameras and the monitor at the nurse's station. -On 08/20/25 the IDT determined 4 residents at highest risk for wandering and required additional supervision due to daily redirection; verified by reviewing the care plans for Residents #6, #7, #8, and #9 were updated to reflect hourly supervision while awake. -On 08/20/25 and moving forward, the Administrator, DON, or ADON will round three times per week for three months and monthly thereafter to ensure staff were effectively supervising residents; there was no tool being utilized to verify this, so unable to observe or verify. In an interview on 08/19/2025 at 10:09 AM, ADON-A stated all staff have been in-serviced regarding monitoring residents, fall policies and procedures, abuse and neglect, as well as procedures on providing appropriate supervision In an interview on 08/19/25 at 10:25 AM, CNA-O stated there were always two CNAs on the unit, and most of the residents on the locked unit wander. The CNAs and nurse watch up and down the halls to see who was wandering and tried to redirect them to either their room, the dining area, or the activity area. If one CNA was in a room providing assistance, the other CNA was in the hall monitoring the other residents. If they had to assist the other CNA with care, they inform the nurse to keep an eye on the residents in hall. If a resident had a fall or was found on the floor, the CNA would notify the charge nurse to assess them. Do not move the resident unless the nurse stated they were okay. CNA-L stated the staff try different things to keep the residents from wandering such as sit and do puzzles, read books, eat snacks, or watch television to occupy their mind and time. CNA-L stated she had been in-serviced regarding monitoring and redirecting residents, fall policies and protocols, abuse and neglect, documenting and reporting. In an interview 08/19/125 at 10:45 AM, CNA-P stated there was always someone monitoring the halls when the other staff were doing patient care, as well as the person from activities was there a lot during the daytime hours to do activities with many of the residents on the locked unit. CNA-M stated they do a lot of redirection while monitoring residents who wander, which could include sitting them in the tv area, or giving them a magazine or book, sometimes providing an activity such as a puzzle works as well, and many of them would sit to have a snack. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675717 If continuation sheet Page 14 of 15 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 675717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Rafael Nursing and Rehabiliation 3050 Sunnybrook Rd Corpus Chrisit, TX 78415 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 - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete CNA-M stated she had been in-serviced regarding monitoring and redirecting residents, fall policies and protocols, abuse and neglect, documenting and reporting. In an interview 08/19/125 at 10:55 AM, LVN-Q stated she had been in-serviced regarding monitoring and redirecting residents, fall policies and protocols, abuse and neglect, documenting and reporting. She stated most of the residents were easily redirected with things such as activities, snacks, television, radio, etc. She stated there was always someone watching the halls. If both CNAs had to be in a room providing care, the nurse was monitoring the halls, and if the nurse had to step away from the locked unit, the ADON or another nurse would monitor the unit until the nurse returns. In an observation on 08/19/25 at 1:30 PM it was revealed many of the residents on the locked unit were in the dining/common room doing activities with 1 staff from activities. There were 5 residents noted to be wandering in the hallways, but CNA's were monitoring and redirecting them as needed, and the charge nurse was seated at the nurse's station across from the living area where some residents were seated watching television. In an interview on 08/19/25 at 1:45 PM the DON stated there were always 2 CNAs and a nurse on the locked unit, and there was always at least one of the CNAs or nurses in the hallways observing at all times. If the two CNAs were busy providing patient care, the LVN steps forward, and if the LVN had to step off the locked unit, the ADON or another nurse would cover until they return. The DON stated most of the residents on the locked unit only needed one staff to assist with incontinent or patient care, so it rarely required both CNA's to be in a room together and off the hall at the same time, but if it did, they just notify the charge nurse, and the charge nurse monitored the halls until the CNAs returned. The DON stated staff had been in-serviced regarding monitoring and redirecting residents, fall policies and protocols, abuse and neglect, documenting and reporting. In an interview on 08/19/25 at 1:45 PM the Administrator stated there was always 2 CNAs and a nurse on the locked unit, and the residents were free to move around the locked unit as they pleased. He stated he would perform random spot checks which would always reveal one of the CNAs or nurses in the hallways observing any residents who may be wandering. The Administrator stated if both CNAs were busy performing patient care, then the charge nurse steps forward to monitor the halls. In an interview on 08/20/25 at 10:55 AM, LVN-R stated there were always at least two CNAs and the charge nurse on the locked unit, and many times during the day there were others such as the person from activities, or the DON or ADON rounding. He stated someone was always watching the hall, and if both CNAs must be in a room providing care, he was the one on the hall monitoring for residents who wander. He stated he had been in-serviced regarding monitoring and redirecting residents, fall policies and protocols, abuse and neglect, documenting and reporting. The Administrator was informed the Immediate Jeopardy was removed on 08/21/25 at 4:35 PM. The facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems which were put into place. Event ID: Facility ID: 675717 If continuation sheet Page 15 of 15