Inspection·December 1, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete sure the care plan was updated. The DON stated care plans were updated so staff had the most up to date and accurate information regarding a resident's care. 2.Record review of Resident #17's face sheet dated 09/24/25 reflected a [AGE] year-old-male with an original admission date of 09/17/21. Diagnoses included heart disease, hypertension (high blood pressure), and type two diabetes (insufficient insulin production in the body). Record review of Resident #17's physician orders dated 05/07/25 reflected: Lisinopril oral tablet 10 MG by mouth one time a day for hypertension. Hold if blood pressure is less than 110/60. Record review of Resident #17's care plan initiated on 05/15/25 did not reflect the use of antihypertension medications. Record review of Resident #17's quarterly MDS dated [DATE] reflected a BIMS of 13 (cognition intact) and an active diagnosis of hypertension. In an interview on 09/25/2025 at 3:15 pm, the MDS nurse stated the care plan should have been updated to reflect Resident #17's use of hypertensive medications. The MDS nurse stated she was not sure how or why it got missed but she was ultimately responsible for updating the clinical portion of the care plan, so it reflected the most current information. The MDS nurse stated if care plans were not updated accurately, residents may not get the care they needed. In an interview on 09/25/25 at 3:26 pm, the RMDS stated hypertensive medications should be care planned so staff are aware to monitor for signs and symptoms of hypertension. The RMDS stated care plans were reviewed daily but were audited approximately every 3 months. The RMDS could not state why Resident #17's hypertensive medications had not been care planned. In an interview on 09/25/2025 at 3:40 pm, the DON stated the MDS nurse updated the clinical portion of the comprehensive care plan and ultimately it was the MDS nurse's responsibility to make sure the care plan was updated. The DON stated care plans were updated so staff had the most up to date and accurate information regarding a resident's care. Record review of facility's Care Plans, Comprehensive Person-Centered dated December 2016 reflected: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The comprehensive, person-centered care plan will: G. Incorporate identified problem areas; H. incorporate risk factors associated with identified problems; K. reflect treatment goals, timetable and objectives in measurable outcomes; O. reflect currently recognized standards of practice for problem areas and conditions. 8. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 12. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. Event ID: Facility ID: 675717 If continuation sheet Page 2 of 9 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 12/01/2025 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on Interviews and record reviews, the facility failed to ensure the director of nursing did not serve as a charge nurse when the facility had an average daily occupancy of 60 or higher for 4 days (08/03/25, 08/11/25, 09/08/25, and 09/14/25) reviewed for DON staffing in the last 2 months. The facility failed to ensure the DON did not work as a charge nurse for 4 different shifts in August and September 2025 while the average census was above 60. This failure could lead to dividing the DON's attention, preventing them from performing duties assigned to the DON leading to possible harm to a resident. The findings included:Record review of the daily clinical staff schedules revealed the DON was scheduled to work as charge nurse from 2:00 PM - 6:00 PM on 08/03/25 in the 100 hall, 6:00 AM - 6:00 PM on 08/11/25 in the 300 hall, 6:00 AM - 6:00 PM on 09/08/25 in the 100 hall, and 6:00 AM - 6:00 PM on 09/14/25 in the 300 hall. Record review of the resident census data from the facility revealed the daily census for 08/03/25 was 118, 08/11/25 was 121, 09/08/2025 was 116, and 09/14/25 was 116. In an interview with ADON B on 09/25/25 at 1:50 PM, ADON B stated a charge nurse was a nurse that was in charge of residents on a hall. ADON B stated there multiple charge nurses working at a time. ADON B stated there were typically 5 charge nurses working during the 6:00 AM - 6:00 PM shift and 3 charge nurses for 6:00 PM - 6:00 AM. ADON B stated the DON had come in and worked as a charge nurse when they were short-staffed. ADON B stated she had seen the DON working as a change nurse. ADON B stated the DON was used as a last resort to fill in as a charge nurse if they could not find anyone else. In an interview with the ADM on 09/25/25 at 3:09 PM, the ADM stated the DON has filled in as a charge nurse on the halls a few times. The ADM stated the DON was the last person on the list to call when a charge nurse was needed. The ADM stated they did not schedule the DON to work as a charge nurse ahead of time, but that he only ever filled in for another nurse. The ADM stated if the DON was scheduled on a daily basis to work as a charge nurse they would not be able to perform their DON duties effectively. In an interview with the DON on 09/25/25 at 3:28 PM, the DON stated he had worked as a nurse on the floor at the facility approximately four times in the past 2 months. The DON stated when he worked as a floor nurse he was not able to perform all of his responsibilities as a DON. The DON stated he was never scheduled to work on the floor ahead of time. The DON stated he would find out he was needed to fill in as a floor nurse about an hour before he was needed to be at the facility. A facility policy was requested from the ADM on 9/25/25 at 3:40 PM regarding the DON working as a charge nurse but the ADM stated the facility did not have a policy covering that. Event ID: Facility ID: 675717 If continuation sheet Page 3 of 9 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 12/01/2025 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 0760 Ensure that residents are free from significant medication errors. 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 ensure residents were free from significant medication errors for 2 of 5 residents (Resident #2 and Resident #16) reviewed for pharmacy services. 1. The facility failed to administer Resident #2's Clonidine (a medication used to treat high blood pressure) per the prescribed order and blood pressure parameters in June of 2025. 2. The facility failed to administer Resident #16's Clonidine (a medication used to treat high blood pressure) per the prescribed order and blood pressure parameters in September of 2025. These failures could place residents at risk for complications and jeopardize their health and safety. Findings Included: 1.Record review of Resident #2's face sheet, dated 09/25/2025, revealed a [AGE] year-old female with an original admission date of 04/22/2025, and a current admission date of 09/05/2025. Pertinent diagnosis included Essential Primary Hypertension (high blood pressure). Record review of Resident #2's quarterly MDS assessment, dated 06/20/2025, revealed a BIMS score of 13, which revealed intact cognition. The MDS also revealed an active diagnosis of hypertension. Record review of Resident #2's physician orders, started 06/11/2025 and revised 07/22/2025, revealed an order for Clonidine 0.1 MG, give one tablet by mouth every 8 hours as needed for a systolic blood pressure greater than 170 or a diastolic blood pressure greater than 100. Record review of Resident #2's care plan for hypertension, initiated 06/23/2025 and revised 07/29/2025, revealed an intervention to give anti-hypertensive medications as ordered, to include Clonidine 0.1 MG. Record review of Resident #2's June 2025 MAR revealed Clonidine 0.1 MG, give one tablet by mouth every 8 hours as needed for a systolic blood pressure greater than 170 or a diastolic blood pressure greater than 100. The MAR also revealed Resident #2's day shift blood pressure on 06/21/2025 was 172/103, taken by LVN-D, but no prn Clonidine was administered. In an interview on 09/24/2025 at 3:00 PM, ADON-B stated LVN-D was a good nurse and always checked her residents blood pressures and administered their medication appropriately. ADON-B stated she was not sure why LVN-D did not administer Resident #2's blood pressure medication. She stated if a resident's blood pressure was already elevated, and they did not receive their blood pressure medication, and the blood pressure continued to rise, the resident could have had a stroke and possibly death. In an interview on 09/25/2025 at 2:30 PM, LVN-D stated she did not remember Resident #2 having an order for clonidine, but she remembered her having some issues with her blood pressure being elevated around this time. LVN-D stated she was not sure why she did not give the clonidine because she did not remember Resident #2's blood pressure ever being that elevated or the Clonidine order itself. She stated maybe she wrote the number down wrong or maybe she got distracted. LVN-D stated she did not recall Resident #2 ever complaining of signs or symptoms of excessively elevated blood pressure around this time, such as headache, dizziness, or chest pain. LVN-D stated if Resident #2's blood pressure had continued to rise, she could have had a stroke or heart attack. In an interview on 09/25/2025 at 3:55 PM, the DON stated nurses should always recheck an elevated blood pressure and administer any prn blood pressure medication the resident had. The DON also stated if a blood pressure was already elevated, and the prn medication was not administered, the blood pressure could have continued to rise, and the resident could have had a stroke. In an interview on 09/25/2025 at 4:33 PM, Resident #2 stated she took blood pressure medication for her blood pressure because sometimes it got high, and she stated the nurses at the facility was good about checking her blood pressure and giving her medication to her. Resident #2 denied remembering being told her blood pressure ever being 172/103 in June 2025, as well as she denied ever feeling or having symptoms of her blood pressure being that high such as headache, dizziness, or blurred vision. She stated she knew when her blood pressure was high and did not remember it being high. 2. 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 9 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 12/01/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of Resident #16's face sheet dated 09/25/25 reflected a [AGE] year-old-male with an original admission date of 10/16/20. Diagnoses included acute chronic kidney failure, hypertension (high blood pressure), congestive heart failure (long-term condition in which the heart cannot pump blood well enough to meet the body's needs), and type two diabetes (insufficient insulin production in the body). Record review of Resident #16's care plan dated 12/12/23 reflected: Resident #16 had hypertension. Interventions included: Give anti-hypertensive medications as ordered. Record review of Resident #16's physician orders dated 03/06/25 reflected: Clonidine HCI oral tablet 0.1 by mouth every 6 hours as needed for a systolic greater than 160 and a diastolic greater than 100. Record review of Resident #16's blood pressure log reflected: 9/20/2025 08:20 164 / 66 mmHg; 9/20/2025 06:48 164 / 66 mmHg. Record review of Resident #16's September 2025 MAR reflected Clonidine HCI oral tablet 0.1 MG was not given for any days in September. In an interview on 09/25/25 at 9:23 am, LVN C stated sometimes when he administered blood pressure medication, the previous blood pressure was populated, and he would not change it. LVN C stated he would check resident's blood pressure prior to administration but sometimes would not record it. LVN C stated if blood pressure medication was not given as ordered, the resident's blood pressure could decline, the resident could become dizzy or hypotensive (low blood pressure), and experience headaches or fainting. In an interview 09/25/25 at 10:00 am, Resident #16 stated he would get his blood pressure checked daily but could not say if he got his blood pressure medication as needed. In an interview on 09/25/2025 at 2:02 pm, ADON B stated it was important to document blood pressures accurately to understand where the resident was at. ADON B also stated it was important to see if the blood pressure medication needed to be held, if Resident #16 needed any additional medications, or if the physician needed to be contacted in case the blood pressure was out of parameters. ADON B stated Resident #16 could experience a possible stroke, hypertension or death if Resident #16's was given the blood pressure medication outside of parameters. ADON B stated there was no current process for auditing blood pressure. In a phone interview on 09/25/25 at 2:28pm, MA E stated she was new to the facility and worked at another facility where their computers were bigger, and she was simply not used to this facility's small computers. MA E stated if Resident #16's blood pressure was out of parameters then she would have given the medication. MA E stated if Resident #16's blood pressure was not documented then she did not know what to say. MA E stated she always took blood pressure on the residents that required them. MA E stated she did not use the same blood pressure as before, and if they were the same blood pressures, then that's what they were. MA E stated she did not know what else to say as she had always taken residents blood pressures and documented accurately. In an interview on 09/25/2025 at 3:55 PM, the DON stated nurses should always recheck an elevated blood pressure and administer any prn blood pressure medication the resident had. The DON also stated if a blood pressure was already elevated, and medication was not administered as ordered, the blood pressure could have continued to rise, and the resident could have had a stroke. Record Review of the facility's Administering Medications policy, dated December 2012, reflected: Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. 3. Medication must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meals). Refer to Liberalized Medication Pass Policy if used. 19. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Event ID: Facility ID: 675717 If continuation sheet Page 5 of 9 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 12/01/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to maintain clinical records that were accurately documented for 3 (Resident #1, Resident #2,and Resident #16) of 5 residents reviewed for medical records. 1. The facility failed to ensure Resident #1's vital signs were accurately documented in the MAR on 08/15/25.2. The facility failed to ensure Resident #2's blood pressure was accurately documented in the MAR during the month of September 2025.3. The facility failed to ensure Resident #16's blood pressure was accurately documented for the month of September 2025. These failures could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment. The findings included:1. Record review of Resident #1's face sheet dated 09/25/25 reflected a [AGE] year-old male with an original admission date of 11/03/23. Diagnoses included end stage renal disease (when the kidneys lose the ability to remove waste and balance fluids), hypertension (high blood pressure), anemia (low levels of healthy red blood cells to carry oxygen in the body), and type two diabetes (insufficient insulin production in the body). Record review of Resident #1's physician orders active as of 08/15/25 reflected in part: Vital signs twice daily, every day shift for 14 Days. Start date: 08/12/25. Vital signs twice daily in the evening for 14 Days. Start date: 08/12/25. Record review of Resident #1's August 2025 vital signs log reflected in part: 08/15/25 9:06 AM by LVN D: blood pressure 115/62, temperature 97.7, pulse 86, respiratory rate 18, and O2 sats 98. There was no other entry for 08/15/25 as Resident #1 was not in the facility again until 08/18/25 because he was admitted to the hospital on [DATE] at 11:38 AM. Record review of Resident #1's August MAR reflected in part: LVN D documented Resident #1's blood pressure as 115/62, temperature 97.7, pulse 86, respiratory rate 18, and O2 sats as 98 in the space for the 6:00 AM vital signs. LVN C documented Resident #1's blood pressure as 115/62, temperature 97.7, pulse 86, respiratory rate 18, and O2 sats as 98 in the space for the 6:00 PM vital signs. 2. Record review of Resident #2's face sheet dated 09/25/25 reflected a [AGE] year-old female with an original admission date of 04/22/25. Diagnoses included chronic kidney disease (when the kidneys are damaged and can't filter blood as well as they should), dependence on renal dialysis (process of filtering blood through a machine to remove excess water and toxins in the blood when the kidneys no longer function), hypotension (low blood pressure), hypertension (high blood pressure), and type 1 diabetes (a lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels). Record review of Resident #2's care plan reflected in part: Resident #2 had hypertension. Interventions included: Give anti-hypertensive medications as ordered. Resident #2 had episodes of hypotension (low blood pressure) at dialysis r/t end stage renal disease. Interventions included: Give medications as ordered. Monitor for side effects and effectiveness. Record review of Resident #2's physician orders reflected in part: HOLD medications on dialysis days, every day shift every Mon, Wed, Fri. Start date: 07/30/25 at 6:00 am. End date: 09/05/25 at 8:48 am. May hold medications on dialysis days. every shift every Mon, Wed, Fri related to Dependence on renal dialysis. Start date: 09/24/25 at 10:00 pm. Losartan Potassium Oral Tablet 50 MG (Losartan Potassium) Give 1 tablet by mouth two times a day for HTN Hold for Systolic BP <110 or HR<60. Start Date: 06/11/25 at9:00 am. D/C Date:09/05/25 at 8:48 am. Losartan Potassium Oral Tablet 50 MG (Losartan Potassium) Give 1 tablet by mouth two times a day for HTN. HOLD IF BP <110/60. Start date: 09/06/25 at 9:00 am. Record review of Resident #2's September 2025 blood pressure log and documentation of blood pressures for Losartan administration on the September 2025 MAR reflected in part: Log: 09/01/25 at 8:30 am 148/80 by LVN H MAR: 09/01/25 at 9:00 am: BP X by MA F. MAR: 09/01/25 at 5:00 pm: BP X by MA F. Log: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675717 If continuation sheet Page 6 of 9 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 12/01/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 09/03/25- no 9:00 am or 5:00 pm blood pressure recorded. MAR: 09/03/25 at 9:00 am: BP X by MA F. MAR: 09/03/25 at 5:00 pm: BP X by MA F. Log: 09/08/25- no 9:00 am blood pressure recorded. MAR: 09/08/25 at 9:00 am: BP X by MA F. Log: 09/10/25 at 1:00 am 142/63 by ADON A. Log: 09/10/25 at 11:47 am 132/78 by LVN C. Log: 09/10/25- no 9:00 am or 5:00 pm blood pressure recorded. MAR: 09/10/25 at 9:00am: BP 142/63 by LVN C. MAR: 09/10/25 at 5:00 pm: BP 132/78 by LVN C. Log: 09/11/25- no 9:00 am blood pressure recorded. MAR: 09/11/25 at 9:00 am: BP 132/78 by LVN C. Log: 09/11/25 at 5:21 pm 122/77 by LVN C. MAR: 09/11/25 at 5:00 pm: BP 132/78 by LVN C. Log: 09/14/25 at 5:13 pm 177/58 by LVN G. Log: 09/15/25- no 9:00 am blood pressure recorded. MAR: 09/15/25 at 9:00 am: BP 177/58 by LVN C. Log: 09/15/25 at 5:12 pm 134/87 by LVN C. MAR: 09/15/25 at 5:00 pm: BP 177/58 by LVN C. Log: 09/16/25 at 12:13 am 142/84 by ADON A. Log: 09/16/25- no 9:00 am or 5:00 pm blood pressure recorded. MAR: 09/16/25 at 9:00 am: BP 142/84 by LVN C. MAR: 09/16/25 at 5:00 pm: BP 142/84 by LVN C. Log: 09/22/25no 9:00 am blood pressure recorded. MAR: 09/22/25 at 9:00 am: BP X by LVN D. 3.Record review of Resident #16's face sheet dated 09/25/25 reflected a [AGE] year-old-male with an original admission date of 10/16/20. Diagnoses included acute chronic kidney failure, hypertension (high blood pressure), congestive heart failure (long-term condition in which the heart cannot pump blood well enough to meet the body's needs), and type two diabetes (insufficient insulin production in the body). Record review of Resident #16's care plan dated 12/12/23 reflected: Resident #16 had hypertension. Interventions included: Give anti-hypertensive medications as ordered. Record review of Resident #16's physician orders dated 03/06/25 reflected: Clonidine HCI oral tablet 0.1 by mouth every 6 hours as need for a systolic greater than 160 and a diastolic greater than 100. Record review of Resident #16's blood pressure log reflected: 9/20/2025 08:20 164 / 66 mmHg 9/20/2025 06:48 164 / 66 mmHg 9/24/2025 09:06 141 / 81 mmHg 9/24/2025 06:42 141 / 81 mmHg 9/19/2025 08:36 157 / 66 mmHg 9/19/2025 08:30 157 / 66 mmHg In an interview on 09/25/25 at 9:23 am, LVN C stated sometimes when he administered Resident #2's and Resident #16's blood pressure medication, the previous blood pressure would populate, and he would not change it. LVN C stated he would check Resident #2's and Resident #16's blood pressure prior to administration but sometimes did not record the blood pressure. LVN C did not have a reason why Resident #2's or Resident #16's blood pressure was not accurately recorded. LVN C stated it was important to update and record each blood pressure to ensure correct medication administration. In an interview 09/25/25 at 9:40 am, Resident #16 stated he would get his blood pressure checked daily but could not state if he was getting his medication as needed. In an interview on 09/25/2025 at 10:00 am, the DON stated Resident #2's and Resident #16's blood pressure should have been taken and accurately documented to assess vitals and see where the patients were at. The DON stated Resident #2's and Resident #16's blood pressures could have fluctuated, and the medication needed would not have been given. The DON stated in-service on medication administration was done at least annually and as needed. In an interview on 09/25/24 at 1:05 pm, ADON B stated vital signs could be entered manually into the vital signs page. She stated if nurses or medication aides did not check a blood pressure before giving or holding a blood pressure medication, the resident's blood pressure could go too low or too high and cause hospitalization, stroke, or even death. ADON B stated medication administration was in-serviced about every month, but she was not sure when the last one was. In an interview on 09/25/2025 at 2:02 pm, ADON A stated it was important to document blood pressures accurately to understand where the resident was at and to see if the medication needed to be held or if the physician needed to be contacted in case the blood pressure was out of parameters. ADON A stated Resident #16 could experience a possible stroke, hypertension or death if given the blood pressure medication outside of parameters. ADON A stated there was no current process for auditing blood pressures. ADON A stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675717 If continuation sheet Page 7 of 9 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 12/01/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the blood pressure usually fluctuated and would not typically be the same in the morning and in the evening or for consecutive days. In an interview on 09/25/25 at 2:13 pm, LVN D stated she checked Resident #2's blood pressure that morning (9/22/25) but she did not give her the Losartan because she was going to dialysis and there was an order to hold her medications on dialysis days. LVN D stated vital signs were checked every time before blood pressure medications were given. LVN D stated medication administration was in-serviced every few months, but she was not sure when the last one was. It covered following doctor's orders, documenting, and checking blood pressures/vital signs before giving medications. In a phone interview on 09/25/25 at 2:28 pm, MA E stated she was new to the facility and worked at another facility where their computers were bigger. MA E stated she was not used to the facility's small computers. MA E stated if Resident #16's blood pressure was not documented then she did not know what to say as she would have documented and gave medication as ordered. MA E stated she always took blood pressures on the residents that required them. MA E stated she did not use the same blood pressure previously recorded and if the blood pressures were recorded the same, then they were the same. MA E kept stating she just started at the facility and had vision problems. MA E stated she did not know what to say as she always took resident blood pressures and documented what the blood pressures were at that time. In an interview on 09/25/25 at 4:10 pm, Resident #2 stated the staff usually checked her blood pressure a couple of times a day. She stated she used to be on a lot of blood pressure medication, but since she got back from the hospital, she only took one. In an interview on 9/25/25 at 4:22 pm, LVN H stated typically the medication aide checked blood pressures for morning medications. For Resident #2, the nurse checked it before she went to dialysis and when she got back from dialysis. She stated the last medication administration in-service may have been sometime last month. In an interview on 09/25/25 at 4:53 pm, MA F stated Resident #2 was a dialysis patient who usually had very high blood pressure. MA F stated some nurses (did not say which ones) told her not to give blood pressure medication on days she was going to dialysis. MA F stated if she did not give blood pressure medications, she documented it in the progress notes that it was not given and would document the blood pressure in the vital signs tab. MA F stated she checked blood pressures before she administered any blood pressure medications and she did not know why it did not show up in the vital signs log or the MAR. MA F stated if the blood pressure was not checked it could cause the resident to bottom out and end up in the hospital. She stated she had not yet been in-serviced on medication administration, but she was oriented and observed for 3 days when she started working at the facility in the middle of June. 3. Record review of Resident #16's face sheet dated 09/25/25 reflected a [AGE] year-old-male with an original admission date of 10/16/20. Diagnoses included acute chronic kidney failure, hypertension (high blood pressure), congestive heart failure (long-term condition in which the heart cannot pump blood well enough to meet the body's needs), and type two diabetes (insufficient insulin production in the body). Record review of Resident #16's care plan dated 12/12/23 reflected: Resident #16 had hypertension. Interventions included: Give anti-hypertensive medications as ordered. Record review of Resident #16's physician orders dated 03/06/25 reflected: Clonidine HCI oral tablet 0.1 by mouth every 6 hours as need for a systolic greater than 160 and a diastolic greater than 100. Record review of Resident #16's blood pressure log reflected: 9/20/2025 08:20 164 / 66 mmHg 9/20/2025 06:48 164 / 66 mmHg 9/24/2025 09:06 141 / 81 mmHg 9/24/2025 06:42 141 / 81 mmHg 9/19/2025 08:36 157 / 66 mmHg 9/19/2025 08:30 157 / 66 mmHg In an interview on 09/25/25 at 9:23 am, LVN C stated sometimes when he administered Resident #16's blood pressure medication, the previous blood pressure would populate and he would not change it. LVN C stated he would check Resident #16's blood pressure prior to administration but sometimes did not record the blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675717 If continuation sheet Page 8 of 9 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 12/01/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete pressure. LVN C did not have a reason why Resident #16's blood pressure was not accurately recorded. LVN C stated it was important to update and record each blood pressure to ensure correct medication administration. In an interview 09/25/25 at 9:40 am, Resident #16 stated he would get his blood pressure checked daily but could not state if he was getting his medication as needed. In an interview on 09/25/2025 at 10:00 am, the DON stated Resident #16's blood pressure should have been taken and accurately documented to assess vitals and see where the patient was at. The DON stated Resident #16's blood pressure could have fluctuated, and the medication needed would not have been given. In an interview on 09/25/2025 at 2:02 pm, ADON A stated it was important to document blood pressures accurately to understand where the resident was at and to see if the medication needed to be held or if the physician needed to be contacted incase the blood pressure was out of parameters. ADON A stated Resident #16 could experience a possible stroke, hypertension or death if given the blood pressure medication outside of parameters. ADON A stated there was no current process for auditing blood pressures. ADON A stated the blood pressure usually fluctuated and would not typically be the same in the morning and in the evening. In a phone interview on 09/25/25 at 2:28pm, MA E stated she was new to the facility and worked at another facility where their computers were bigger. MA E stated she was not used to the facility's small computers. MA E stated if Resident #16's blood pressure was not documented then she did not know what to say as she would have documented and gave medication as ordered. MA E stated she always took blood pressures on the residents that required them. MA E stated she did not use the same blood pressure previously recorded and if the blood pressures were recorded the same, then they were the same. MA E kept stating she just started at the facility and had vision problems. MA E stated she did not know what to say as she always took resident blood pressures and documented what the blood pressures were at that time. Record review of the facility's Charting and Documentation dated July 2017 reflected: Policy Statement All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 2. The following information is to be documented in the resident medical record: b. Medications administered; c. Treatments or services performed 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; c. the assessment data and/or any unusual findings obtained during the procedure/treatment; e. whether the resident refused the procedure/treatment; Event ID: Facility ID: 675717 If continuation sheet Page 9 of 9