Health inspection·January 1, 2026

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete police officer said he was going to contact the facility to verify Resident #1 was a resident at the facility and take the resident back. During an interview on 12/30/2025 at 8:50 a.m. the DON stated she did not notify the Administrator that Resident #1 was brought back to the facility by a police officer. The DON stated the Administrator was out on vacation and did not want to bother her. The DON stated that since Resident #1 was returned safe and with no injuries, she felt there was no need to notify the Administrator. During an interview on 01/01/2026 at 3:00 p.m., the Administrator stated that on 11/17/2025, she was not notified Resident #1 had been returned to the facility for being lost. The Administrator stated it was not until days later that the DON mentioned the incident. The Administrator stated she felt she did not report the incident to HHSC for the same reasons the DON did not notify her; Resident #1 had returned to the facility safely. The Administrator said that on 12/06/2025, the HRC notified her that the resident had left the building in his own vehicle. The Administrator initiated a code purple, the code used to notify staff there was a resident missing. The Administrator said that at 6:45 p.m., she received a call from a nearby nursing facility reporting they had Resident #1. The nearby facility was approximately 0.6 miles away. The Administrator said she sent three staff members to bring Resident #1 back to the facility. One of the three staff members drove Resident's truck back to the facility. The Administrator stated that Resident #1 had arrived at that other facility because he was confused as to which facility he was a resident of. The Administrator stated that Resident #1's RP had his truck picked up after the incident. The administrator stated that it was best that Resident #1 did not have a vehicle on premises because Resident #1 could hurt himself or others while driving. Resident #1 could become confused and cause an accident. Record review of TULIP (Texas Unified Licensure Information Portal) did not reflect a facility reported incident that corresponded to the allegations in the incident described above. TULIP is a web-based program used by facilities to report incidents involving residents. HHSC then takes that information and performs an investigation into those incidents reported. Record review of facility policy titled, Abuse, Neglect, and Exploitation dated 8/15/22, revealed:VII. Reporting/Response1. Reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:b. Not later 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Event ID: Facility ID: 675785 If continuation sheet Page 2 of 7 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 675785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/01/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edinburg Nursing and Rehabilitation Center 5215 S Sugar Rd Edinburg, TX 78539 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, interview and record review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for 1 of 4 resident (Resident #1) reviewed for accidents and supervision who had a vehicle on the facility premises. The facility failed to evaluate R#1s safety awareness and risks for elopement after multiple incidents of R#1 leaving the facility without staff awareness or supervision. On 10/27/2025 R#1 left the facility and returned driving a vehicle he had purchased in another city. On 11/27/2025, R#1 left the facility and was returned by police due to driving around lost. On 12/06/2025, R#1 left the facility without being signed out on pass and was found at a nearby facility. The noncompliance was identified as PNC. The Immediate Jeopardy was identified on 12/06/2025 and ended on 12/06/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of sustaining accidents, injuries, and/or death.Findings include: Record review of Resident #1's face sheet dated 12/29/2025, revealed a [AGE] year old male admitted into the facility on [DATE] with diagnosis of Alzheimer's disease (a progressive brain disorder and the most common cause of dementia, characterized by gradual memory loss, impaired thinking, and behavioral changes that worsen over time, eventually affecting daily activities), Type 2 diabetes (a chronic condition where the body either doesn't make enough insulin or doesn't use insulin effectively leading to high blood sugar levels), unspecified protein calorie malnutrition (a nutritional deficiency from not getting enough protein and calories), and hypertension (a common condition where the force of blood against your artery walls is consistently too high, making your heart work harder and increasing the risk of heart attack, stroke, and other serious problems). Record review of Resident #1's BIMS assessment dated [DATE] revealed a score of 8 which indicated moderately impaired cognition. Record review of Resident #1's baseline care plan dated 09/13/2024 revealed the resident had impaired cognitive function or impaired thought process related to Alzheimer's; included cue, reorient, and supervise as needed. The same care plan also revealed, The resident is (dependent on staff) for meeting emotional, intellectual, physical, and social needs related to cognitive deficits; The resident needs assistance with ADLs as required. Record review of Resident #1's Release of Responsibility for Leave of Absence log revealed, Resident #1's Relative V had signed Resident #1 out on 10/26/25 with anticipated date of return as PM. There was no sign-in date, time, or facility representative initials to confirm Resident #1 had returned. Record review of LVN A's progress note dated 10/27/2025 time stamped 9:00 a.m. revealed Received call from [family member] to resident stating resident was stranded in City W, SN informed him resident had signed out for out on pass and taken medication with him. SN informed to let us know if any changes with resident. City W is approximately 233 miles away from the facility. Record review of Resident #1's care plan initiated on 09/05/2024 did not reveal any new interventions regarding the 10/27/2025 incident. Record review of Resident #1's Release of Responsibility for Leave of Absence log revealed, Resident #1's Relative V had signed Resident #1 out on 11/27/2025 with anticipated date of return as PM. There was no Sign-in date, time, or facility representative initials to confirm Resident #1 had returned. Record review of LVN B's progress note dated 11/27/2025 time stamped 7:45 p.m., revealed Resident back at facility from out on pass, arrived via wheelchair accompanied by City X Police Department. Per Officer, resident was driving in his GMC truck around City X and got lost. Per resident, he did not know his way back to facility. RP made aware. Informed RP that resident's truck was left at City X. Resident's car keys and driver's license kept under lock and key in 300-Hall Nurse cart. DON and ADON made aware of situation. City X is approximately 5 miles from the facility. Record review of Resident #1's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675785 If continuation sheet Page 3 of 7 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 675785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/01/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edinburg Nursing and Rehabilitation Center 5215 S Sugar Rd Edinburg, TX 78539 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 care plan revised on 11/27/2025, revealed Resident #1 was unable to return to facility without assistance due to forgetfulness and intermittent cognition; removed keys and kept with nurse, administer medications as ordered, monitor behavior episodes and attempt to determine underlining cause, and provide a program of activities. Record review of Resident #1's Release of Responsibility for Leave of Absence log revealed, Resident #1's Relative V had signed Resident #1 out on 12/06/2025. Resident #1 was signed back in by his brother on 12/06/2025 at 11:00 a.m. There were no facility representative initials on the form to confirm Resident #1 had returned. Record review of LVN C's progress noted dated 12/06/2025 time stamped 1:41 p.m. revealed: Facility receptionist saw patient leaving facility & HRC questioned if patient had signed out to go out on pass. I checked the sign out book and noted that the patient did not sign out. I then notified Administrator, DON and ADONs that patient was seen leaving the facility in a vehicle. I attempted to call patient on his cell phone multi times, but he did not answer. I also notified RP. City Y police is notified by HRC. Record review of LVN B's progress note dated 12/06/2025 time stamped 7:00 p.m. revealed: At 7:00 p.m., resident safely returned to facility. DON, ADON, and Administrator present during resident's return. Assisted resident to room. Performed head-to-toe assessment and obtained vital signs. When asked where resident left to, resident states he was driving around town in his truck. Administrator requesting resident's car keys for safekeeping, resident cooperative and in agreement. MD notified of resident's return. RP notified of resident's safe return. Safety plan reviewed with staff and team. Continuing to monitor for exit-seeking behavior. Staff present at bedside for 1:1 monitoring. Record review of Resident #1's care plan revised on 12/06/25, revealed Resident #1 was at risk for elopement; 1:1 staff member monitoring, monitor exit seeking behavior, labs, Allow the resident to make decisions about treatment regime, to provide sense of control, Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care, and Encourage as much participation/interaction by the resident as possible during care activities. Record review of Resident #1's care plan initiated on 09/05/2024 did not reveal any interventions regarding Resident #1 having a vehicle on premises or having the capability to drive. During an interview on 12/29/2025 at 9:24 a.m. Resident #1 could not recall the incident on 12/06/2025. Resident #1 stated he remembered a time when he had left in his van to City W. Resident #1 stated the van he had been driving broke down and left him stranded. Resident #1 was redirected to the incident of 12/06/2025 but he reverted to talking about the other incident. During an interview on 12/29/2025 at 10:49 a.m., the HRC stated DA had informed her that he had witnessed Resident #1 drive off in his car. The HRC stated she called the nurse's station and had asked the nurse if Resident #1 was allowed to drive in which the nurse responded, No. The HRC stated she called the Administrator to notify her that Resident #1 had left. The HRC stated she was aware Resident #1 had a truck at the facility. During an interview on 12/29/2025 at 11:02 a.m., the DA stated he was covering for the receptionist on the day of 12/06/2025. The DA stated that on the day of the incident, Resident #1's Relative V had signed him out on pass in the morning but had returned soon after. The DA stated that when he saw Resident #1 leaving for the last time, he questioned the resident if he had been signed out. Resident #1 responded by saying that Relative V had signed him out. The DA stated he then saw Resident #1 wheel himself to his truck, place the wheelchair in the back seat and drive off. The DA then notified HRC what he had witnessed. The DA stated he knew he was supposed to call the nurse's station to verify if Resident #1 had been signed out but stated he did not.During an interview on 12/29/2025 at 11:44 a.m. Resident #1's RP stated on that on 10/26/2025, Resident #1's Relative V had signed him out for an outing. Somehow, Resident #1 then drove his own van to City W. Resident #1's van broke down and left him stranded on the side of the road. RP stated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675785 If continuation sheet Page 4 of 7 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 675785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/01/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edinburg Nursing and Rehabilitation Center 5215 S Sugar Rd Edinburg, TX 78539 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 Resident #1 was picked up by a passerby and drove him into the city. The following day, Resident #1 was able to purchase a truck at a dealership. Resident #1 then drove the new truck back to the facility. RP stated she was able to locate the dealership and informed the general manager that Resident had a diagnosis of Alzheimer's and was not able to make decisions on his own. RP stated that on 11/27/2025, she received a call from a police officer stating Resident #1 had been stopped due to being lost and driving around. RP stated the officer had said Resident #1 was confused and did not know how to get back to the facility. RP stated that on 12/06/2025, Resident #1 had left the faciity on his own. RP stated that a staff member had seen Resident #1 drive off in his truck. RP stated that Resident #1 should not have been driving due to forgetfulness. RP stated she had Resident #1's truck picked up by family so Resident #1 would not leave in it. RP stated she was afraid he could hurt himself or others while driving. During an interview on 12/29/2025 at 5:10 p.m., the DON said she received a call on 12/06/25 from the Administrator notifying her that Resident #1 had left the facility. The DON assisted with making calls to local authorities and family. The DON said that on 10/06/2025, Resident #1 was out on pass with his family member and returned with no injuries. The DON said that on 11/27/2025, Resident #1 was signed out by his family member and was dropped off by the PD because he was confused. The DON stated that the officer had said Resident #1 did not know how to get back to the facility because he was confused. The DON stated she was unaware that Resident #1 was able to drive. The DON stated she did not know if Resident #1 was capable of driving even thought he had the diagnosis of Alzheimer's. During an interview on 12/29/2025 at 5:30 p.m., the Administrator said that on 12/06/2025, the HRC notified her that the resident had left the building in his own vehicle. The Administrator initiated a code purple, the code used to notify staff there was a resident missing. The Administrator said that at 6:45 p.m., she received a call from a nearby nursing facility reporting they had Resident #1. The nearby facility was approximately 0.6 miles away. The Administrator said she sent three staff members to bring Resident #1 back to the facility. One of the three staff members drove Resident's truck back to the facility. The Administrator stated that Resident #1 had arrived at that other facility because he was confused as to which facility he was a resident of. The Administrator stated that Resident #1's RP had his truck picked up after the incident. The administrator stated that it was best that Resident #1 did not have a vehicle on premises because Resident #1 could hurt himself or others while driving. Resident #1 could become confused and cause an accident. During an interview on 12/30/2025 at 2:22 p.m., ADON said he was one of three staff members who picked up Resident #1 at a nearby facility. ADON stated when he saw Resident #1, the resident appeared fine. Resident #1 had no visible injuries. ADON said Resident #1 might have been a bit confused due to Resident #1 ending up at the wrong facility. ADON stated that he drove Resident #1 back to the facility in the resident's own truck. ADON stated that he did not feel it was safe for Resident #1 to drive his own truck back to the facility because Resident # 1 had been confused to which facility he belonged to. During an interview on 12/31/2025 at 9:28 a.m., NP stated that every patient with Alzheimer's is different. Generally, a patient with Alzheimer's should not be driving. NP stated it is unknown the state of mind that the patient can have while driving. NP stated, I would not recommend for a patient with Alzheimer's to drive. The patient could have caused an accident in which he could have gotten hurt or could have hurt others. Record review of facility's Elopements and Wandering Residents policy dated 11/21/22 revealed:Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.4. Monitoring and Managing Residents at Risk for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675785 If continuation sheet Page 5 of 7 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 675785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/01/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edinburg Nursing and Rehabilitation Center 5215 S Sugar Rd Edinburg, TX 78539 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 Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. F689 Quality of Care Immediate Action Taken:Upon return to the facility on [DATE] Resident #1 received a head-to-toe assessment no issues noted. Resident #1 was placed on 1:1 monitoring. The physician was notified and lab orders were obtained on December 6, 2025 with no abnormalities noted. The care plan was updated on December 6, 2025, with updated interventions of 1:1 monitoring, documenting exit seeking behaviors, and laboratory studies were completed. The vehicle belonging to Resident #1 which was on the premises was removed on December 7, 2025, by resident's Relative Z and moved to her premises. R#1 has not driven a vehicle since December 6, 2025. The employee monitoring the reception desk on December 6, 2025, was suspended on 12/6/25 and returned to work on 12/7/25. Staff member was provided with 1:1 education on following proper out on pass process. On 12/6/25 nursing administration conducted a facility wide audit of all current residents to determine if any residents were operating personal vehicles that ere on the facility's premises. The facility completed an audit of all residents wandering evaluations. No new residents found at risk for wandering/elopement. The center developed and implemented a process to ensure safe and proper leaves of absence for residents: On December 7, 2025, the center developed and implemented a Front Door Safety & Sign-Out Procedure, staff members who assist with front desk reception duties were educated on the new process of Front Door Safety & Sign-Out Procedure to include competency check off. The facility initiated 100% reeducation on Elopement Protocols and the supervision of residents and ANE with completion date of 12/08/25. The facility initiated 100% reeducation with the Charge Nurses on the process of Front Door Safety & Sign-Out Procedure. The training of direct care staff was completed on December 7, 2025, in person or via telephone. Those that were not scheduled on 12/7/25 completed reeducation prior to accepting assignment for the next scheduled work. Verification of 100% of direct care staff education was verified by the Director of Nursing/ designee. Employee roster was utilized to validate completion. Verification: Started on 01/01/2026 at 11:00 a.m. and included:The following observations, record reviews and interviews were conducted by the survey team to ensure the staff's understanding of in-service training received between 12/06/2025 and 12/07/2025:Observation on 01/01/2025 at 12:05 p.m., the Receptionist was observed verifying a resident leaving with family. The Receptionist called the nurse's station via a 2-way radio, and the nurse confirmed the resident had been signed out.Record review of progress notes dated 12/06/2025 - 12/18/2025 on Resident #1's 1:1 supervision.Record review of Resident #1 neuro checks dated from 12/06/2025 12/09/2025. Record review of Resident #1's head to toe assessment completed on 12/06/2025.Record Review of Resident #1's RP and physician notification on incident dated 12/06/2025.Record review of DA's suspension and 1:1 counseling.Record review of Resident #1's care plan revision on Risk of elopement for 12/06/2025.Record review of an In-Service Attendance Record with the topic of Out on Pass Protocol and Elopement Protocol, revealed that all staff was in-serviced on 12/06/2025.Record review of an In-Service Attendance Record with the topic of Receptionist Competency-Front Door Safety and Resident Sign-Out Verification, revealed that staff who are assigned to assist with covering for receptionist duties were in-serviced on 12/07/2025.During interviews on 01/01/2026 from 11:05 a.m. to 5:55 p.m., CNA F, CNA G, CNA I, CNA L, CNA M, CNA N, CNA O, CNA P, CNA T, LVN A, LVN, B, LVN C, LVN D, LVN E, LVN H LVN J, LVN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675785 If continuation sheet Page 6 of 7 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 675785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/01/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edinburg Nursing and Rehabilitation Center 5215 S Sugar Rd Edinburg, TX 78539 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 K, LVN Q, LVN R, LVN S, LVN U, Social Worker, and Human Resource Coordinator revealed the staff were all knowledgeable of the out on pass protocol and elopement protocol. The CNAs interviewed stated they were to report to their nurse immediately if and when a resident voiced, they wanted to go out on pass. The nurses interviewed stated they would verify that the family member that signed out the resident was approved to sign the resident out. They were aware and voiced understanding of the new expectations to verify all residents were signed out through the nurse's station and ensure all residents were signed back in. During an interview via telephone on 01/01/2026 at 4:02 p.m., the DA was able to verbalize understanding of the following in services received: Out on Pass Protocol and Elopement Protocol and Receptionist Competency-Front Door Safety and Resident Sign-Out Verification. Event ID: Facility ID: 675785 If continuation sheet Page 7 of 7