Health inspection·October 28, 2022

F 0558 light within reach but risked needing assistance and not having means of letting anyone know. Level of Harm - Minimal harm or potential for actual harm Interview with Resident #76 on 10/26/2022 at 11:40 am revealed the resident stated, I don't know why they leave my call light so far from me; I would have to scream for help! Residents Affected - Few 2. A record review of Resident #77's face sheet, dated 10/26/22, revealed an admission date of 10/24/2018, with diagnoses which included: Alzheimer's disease (is a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), Major Depressive Disorder Single Episode (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Post Traumatic Stress Disorder (PTSD) (is a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), mood disorder (can be feelings of distress, sadness or symptoms of depression, and anxiety), anxiety disorder (a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday situations), Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and osteoporosis (causes bones to become weak and brittle), hypertension (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease),. Review of Resident #77's care plan, with a revision date of 07/18/2022, revealed the resident was at risk for falls related to unsteady gait with one of the interventions being to provide a safe environment and place a working and reachable call light. Record review of Resident #77's most recent MDS Quarterly Assessment, dated 09/15/2022, revealed the resident had a BIMS score of 06 (severe cognitive impaired) and for ADLs Resident #77 required supervision with setup help only and with dressing and personal hygiene Resident #77 required extensive assistance with the assistance of 1 person. Observations on 10/25/2022 at 11:20 a.m. during initial observations revealed Resident #77's call light was behind the bedside dresser. Resident # 77 was observed lying in bed asleep so, the call light was not accessible or within reach. Observation on 10/25/2022 at 03:48 p.m. revealed Resident #77's call light remained behind the bedside dresser and was not accessible or within reach if Resident #77 needed to use the call light. Observation and interview on 10/25/2022 at 03:50 p.m. with LVN I revealed she confirmed the call light for Resident #77 was behind the bedside dresser and not within Resident #77's reach. LVN I had to move the bedside dresser to get to the light. LVN stated by the call light not being accessible the resident risked needing some thing and could possibly fall while trying to reach for item . Interview on 10/28/2022 at 2:30 p.m. with the DON revealed concerning Resident #77's call light, she stated potentially not being able to get to the call light is a safety concern. We want to try and make all call lights within reach of the resident. Interview on 10/26/2022 at 08:30 a.m. with Resident #77 was attempted but, he did not understand what the surveyor was saying. Record review of the facility's policy titled Accommodation Needs, revised 5-19-15, revealed, The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675863 If continuation sheet Page 2 of 19 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 675863 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114 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 0558 community attempts to adapt schedules, call systems, and room arrangements to accommodate residents' preferences, desires, and unique needs. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675863 If continuation sheet Page 3 of 19 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 675863 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' physical, mental, and psychosocial needs that are identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 1 of 36 residents (Resident #6) reviewed for care plans, in that: 1. The facility failed to implement a comprehensive person-centered care plan to address Resident #6's diagnosis of hypertension. These failures could affect residents who have care areas not addressed by the care plan by not having their needs met and putting them at risk of not receiving appropriate care. The findings were: 1. Record review of Resident #6's face sheet, dated 10/28/2022, revealed an admission date of 08/19/2020 with diagnoses that included: Chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), dysphagia (swallowing problems occurring in the mouth and/or the throat) essential hypertension (high blood pressure with no secondary cause identified), and peripheral vascular disease (disease or disorder of the circulatory system outside of the brain and heart). Record review of Resident #6's annual MDS, dated [DATE], revealed the resident had a BIMS score of 15, which indicated the resident was intact cognitively. Further review revealed in Section I, Active Diagnoses, under the category Heart/Circulation that 10700. Hypertension was checked. Record review of Resident #6's Report of Active Diagnoses in his electronic health record revealed the diagnosis of Essential (Primary) Hypertension, dated 08/19/2020. Under the heading Classification it stated, Admission. Record review of Resident #6's Care Plan, last revision date 06/01/2022, revealed no focus area related to depression, monitoring for signs or symptoms of hypertension, goals or interventions related to the management of hypertension. During an interview on 10/28/2022 at 2:30 p.m. with the MDS Coordinator, the MDS Coordinator stated that she is responsible for updating care plans. They are done on a quarterly basis, or after the morning meeting when she finds out that changes need to be made, such as with diet orders or information that should be discontinued. When asked about Resident #6's care plan missing the diagnosis of hypertension, the MDS coordinator stated that, Hypertension is one of the big ones I always put in, but I don't see it either. It's not like me, but I'm human. During an interview on 10/28/2022 at 3:00 p.m. with the DON, the DON confirmed that the focus area of Hypertension was a diagnosis listed as one of Resident #6's diagnoses, was indicated in the resident's MDS dated [DATE], and was not addressed in Resident #6's care plan and should have been. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675863 If continuation sheet Page 4 of 19 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 675863 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete DON stated that it is the MDS nurse's responsibility to update care plans. The DON added that up until recently there had been only one MDS nurse at the facility responsible for the care plans of all the residents with a census that was routinely over 125 residents. They had just hired another individual; however, this was her first week and she was still in training. Record review of the facility's policy titled, Care Plans, implemented February 2017, revealed, The community develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan will describe: the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Event ID: Facility ID: 675863 If continuation sheet Page 5 of 19 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 675863 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 36 residents (Resident #79) reviewed for treatment and services, in that: Residents Affected - Few The facility failed to ensure Resident#79's physician was called if the residents' systolic blood pressure (SBP) exceeded 160 after checking manually per the physician's order. This failure could affect residents with high blood pressure and place them at risk for a delay in treatment, a decline in health, hospitalization and/or death. The findings included: Record review of Resident #79's face sheet, dated 10/25/2022, revealed he was admitted to the facility on [DATE] with diagnoses that included: atherosclerotic heart disease (the buildup of fats, cholesterol and other substances in and on the artery walls), Type II diabetes with diabetic neuropathy (high blood sugar that includes nerve damage, most common in the hands and feet), gastroesophageal reflux disease (a chronic digestive disease where the liquid content of the stomach refluxes into the esophagus), the tube connecting the mouth and stomach, and anxiety disorder (fear characterized by behavioral disturbances) and pain, unspecified. Record review of Resident #79's quarterly MDS dated [DATE] revealed a BIMS of 15, indicating the resident was cognitively intact. Further review revealed in Section I, Active Diagnoses, under the category Heart/Circulation that 10700. Hypertension was checked. Record review of Resident #79's Report of Active Diagnoses in his electronic health record revealed the diagnosis of Essential (Primary) Hypertension, dated 04/06/2018. Under the heading Classification it stated, Admission. Record review of Resident #79's Order Summary Report for the month of October 2022 revealed orders for Coreg Tablet, 25 mg (Carvedilol). Give 1 tablet by mouth every morning and at bedtime related to essential (primary) hypertension. Hold if SBP is less than 110 or pulse less than 60. Call MD is SBP greater than 160 after checking manually (start date 7/11/2022); Doxazosin Mesylate Tablet 2 mg - Give 1 tablet by mouth at bedtime related to essential hypertension. Hold if SBP is less than 110 or pulse less than 60. Call MD is SBP greater than 160 after checking manually (start date 7/11/2022); and Lisinopril tablet 10 mg - Give 10 mg by mouth one time a day related to essential (primary) hypertension. Hold if SBP is less than 110 or pulse less than 60. Call MD is SBP greater than 160 after checking manually (start date 8/31/2022). Record review of Resident #79's Medication Administration Record (MAR) for the month of October revealed that the same instructions to Hold if SBP is less than 110 or pulse less than 60. Call MD is SBP greater than 160 after checking manually was present with each of Resident #79's three medications for essential hypertension - Coreg, Doxazosin Mesylate and Lisinopril. Further review of this MAR revealed that on 10/23/2022, Resident #79's blood pressure, as recorded next to each of these medications, was 178/85. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675863 If continuation sheet Page 6 of 19 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 675863 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114 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 - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #79's electronic health record (EHR) revealed there was no progress note written by any staff member on 10/23/2022 and there was no record of any communication with the resident's physician for that date anywhere in the EHR. During an interview 10/25/2022 at 3:30 p.m. with Resident #79, Resident #79 stated that on 10/23/2022, his morning medications were delivered particularly late - 2 hours later than they should have been. The resident stated that the regular nurses have been out, and when he finally got his blood pressure medications it was around 10:45 a.m. and his blood pressure was around 178/80s. The resident stated that he usually gets his medications around 8:00 AM. During an interview on 10/28/2022 at 10:30 a.m. with the Administrator, the Administrator confirmed that there was no communication between the facility and Resident #79's physician regarding his elevated systolic blood pressure. The Administrator stated that the facility used three companies for agency nurses, and they all provided licensed nurses. The agencies were responsible for the training and verification of competence of the nurses, and there was a staff RN supervisor on duty 24-hours to orient the nurses to the facility. During an interview on 10/28/2022 at 10:35 a.m. with the DON, the DON confirmed that there was no communication between the facility and Resident #79's physician regarding his elevated systolic blood pressure. The DON stated that agency nurses whose performance has been found to be substandard in any manner were flagged so that they are blocked from seeing available shifts at the facility, and therefore, do not return to work at the facility. During a telephone interview with LVN L on 10/28/2022 at 11:04 a.m., LVN L stated that, Sunday (10/23/2022) was pretty stressful. I passed out meds late without a med aide. I tried to keep up but it wasn't working out. I just had to get it done. I couldn't follow-up. I know I took notes. I called some doctors. If I called the doctor, I put a note in the chart. If there's no note, I didn't call. Record review of facility policy, Medication Administration dated March 2019 revealed, Resident medications are administered in an accurate, safe, timely, and sanitary manner. 2. a. The nurse/medication aide shall be responsible to read and follow precautionary or instructions on prescription labels. 6. Administer medications as ordered by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675863 If continuation sheet Page 7 of 19 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 675863 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 36 residents (Resident #46) reviewed for respiratory care in that: Residents Affected - Few Resident #66's oxygen canister on the back of the electric wheelchair, with the nasal cannula, did not have a date written on it. This failure could place residents who receive oxygen at risk of infection and respiratory compromise. The findings included: Record review of Resident #66's face sheet, dated 10/26/22, revealed an admission date of 08/25/2022, with a diagnosis that consists of Radiculopathy, Cervical Region-occurs when a nerve in the neck is compressed or irritated at the point where it leaves the spinal cord. (This can result in pain in the shoulders and muscle weakness and numbness that travels down the arm into the hand). Type 2 Diabetes Mellitus -occurs when your body's cells resist the normal effect of insulin, which is to drive glucose in the blood into the inside of the cells. Malignant Neoplasm of Lung- malignant cancer that originates in the bronchi, bronchioles, or other parts of the lung. Record review of Resident #66's admission MDS dated [DATE] revealed Resident #66's BIMS of 15, which indicates the patient is cognitively intact A record review of resident # 66's admission MDS dated [DATE] Revealed in Section O of MDS revealed documentation of yes for Oxygen usage. Record review of Resident #66's care plan dated 10/26/2022 revealed: That resident #66 has oxygen therapy I am at risk for experiencing shortness of Breath, provide oxygen as ordered . Record review of Resident #66's, Medication order report dated 10/26/2022 revealed that Continuous Oxygen 2-3 Liters per nasal cannula every shift for Hypoxia. Observation and interview on 10/26/2022 at 10:05 a.m. revealed Resident #66's oxygen canister on the back of the electric wheelchair, with the nasal cannula, did not have a date written on it. During an interview and observation on 10/26/2022 at 10:00 a.m. LVN C confirmed Resident #66's disposable nasal cannula did not have a date on it, indicating it was unknown when it was placed. LVN C stated the oxygen and nasal cannulas should have a date written on them to indicate when they are opened. LVN C further revealed night shift is supposed to change the oxygen bottles and nasal cannulas weekly on Sundays or when dirty, and the date was to be written on the nasal cannulas. LVN C further revealed this was to prevent infection or bacteria build-up. LVN C stated no harm had come to the resident by nasal canula not dated as Resident #66 only uses the electric wheelchair when he goes to medical appointments, the last one being one week ago. During an interview on 10/27/2022 at 12:00 p.m. the DON stated the oxygen nasal cannulas were to be dated when opened by the nurse on duty. She further revealed that the night shift changes the nasal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675863 If continuation sheet Page 8 of 19 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 675863 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114 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 0695 Level of Harm - Minimal harm or potential for actual harm cannulas weekly and as needed. She stated it was her expectation that the charge nurses on duty do this. The DON stated all the nurses should date nasal cannulas with dates on them. Record Review of Policy dated 03/12/2018, revised 01/2022, Titled Oxygen Respiratory tubing/equipment management revealed, replace tubing set up, weekly. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675863 If continuation sheet Page 9 of 19 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 675863 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each Resident, for 1 of 2 residents (# 40) reviewed for accurate insulin administration. Resident #40's physician order for Humalog insulin subcutaneously (injection), (used to treat people with type 1 or type 2 diabetes for the control of high blood sugar.) was inaccurately transcribed thus prescribing a dose for after meals (PC) instead of before meals (AC). This failure could have placed Residents receiving insulin at the wrong time at risk for adverse reactions, to include inaccurate dosing causing hypoglycemia (low blood sugar) The findings include: Observation on 10/27/2022 at 9:20 a.m. during the Medication Administration task, revealed after LVN J, had taken Resident #40's blood sugar (results 252), LVN J drew up 40 units of Humalog insulin and administered the insulin subcutaneously into Resident #40's abdomen on his left side. Record review of Resident #40's electronic admission face sheet dated 10/27/2022 revealed the resident was admitted on [DATE] with diagnoses which included Cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Chronic kidney disease stage 3 (your kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of your blood), Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Type 2 Diabetes mellitus (a chronic (long-lasting) health condition that affects how your body turns food into energy, major depression (recurrent) (a disorder characterized by repeated episodes of depression, the current episode being of moderate severity), anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), right bundle branch block (right bundle branch block is a problem with your right bundle branch that keeps your heart's electrical signal from moving at the same time as the left bundle branch), hypertension- (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease). Record review of Resident #40's electronic clinical physician orders dated 10/27/2022 revealed an order for Humalog Solution 100 unit/ml, inject 40 units subcutaneously after meals . Hold if BS (blood sugar) < (less than) 100. The order was documented to start on 10/26/2022 at 09:00 a.m. Record review of a hand-written physician order dated 10/25/2022 for Resident #40 stated in part Humalog 40u (units) SQ (subcutaneous) TID (three times a day) (AC meals (before meals)) hold if BS (blood sugar) < (less than) 100. Record review on 10/27/2022 of the physician order summary report dated 10/27/2022 revealed an order for Humalog Solution 100 units/ml inject 40 units subcutaneously after meals and hold if BS, < (less than) 100. Order date 10/25/2022 and start date 10/26/2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675863 If continuation sheet Page 10 of 19 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 675863 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #40's Medication Administration record dated 10/01/2022 to 10/31/2022 revealed Humalog insulin 40 units was given to Resident #40 was given the insulin 4 times. Three times on 10.26/2022 three times and once on 10/27/2022. Resident #40's BS ranged from 140 to 252. When this surveyor on 10/27/2022 at 9:40 a.m., questioned LVN J about giving the Humalog insulin after meals, LVN J stated, that was the orders Resident #40 came in with (return from the hospital). Interview on 10/27/2022 at 02:30 p.m. with LVN J revealed the orders used to go to the ADON to review and now she had no idea who checks them to make sure they are correct. Interview on 10/28/2022 at 02:30 p.m. with the DON (director of nursing) reviewed the order for Resident #40's Humalog insulin which was in the computer dated 10/28/2022 stating to give Humalog after (PC) meals. When this surveyor asked if the order for Resident #40 was wrong, the DON would not answer. When this surveyor asked if it was transcribed wrong, the DON would not answer. When this surveyor asked her, where the order came from, the DON revealed the order for Resident #40's Humalog insulin was from a telephone order and the physician signed the orders electronically (electronic signatures are valid in all U.S. states and are granted the same legal status as handwritten signatures under state laws), and the charge nurse inputs the order into the computer. On 10/28/2022 at 3:00 p.m. with the DON revealed she had talked with the physician and stated it was alright to give the insulin after meals. When asked about what could happen if not given was it is not good. On 10/28/2022 at 2:03 p.m. an attempt was made to call the physician and the call went directly to voice mail. On 10/28/2022 at 5:00 p.m. when the Administrator was asked for a policy concerning transcribing orders the facility did not have one. On 11/03/2022 at 10:37 a.m. another attempt was made, and a message was left with the receptionist at the physician's office to have the physician or his nurse to call this surveyor. On 11/03/2022 at 12:12 p.m. the physician returned the call and stated, it was ok to give the Humalog insulin after (PC) Resident #40's meals since there has been no harm and the insulin is given right after Resident #40's meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675863 If continuation sheet Page 11 of 19 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 675863 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: Residents Affected - Some 1. There was an opened commercially prepared container of pimiento cheese spread in the walk-in cooler stamped with a use-by date of 10/08/2022. 2. There was a gallon-sized zip-locked bag of chili dated 10/15/2022. These deficient practices can place residents who ate food from the kitchen at risk for food borne illness. The findings were: 1. An observation on 10/25/2022 at 10:08 a.m. in the walk-in cooler revealed an opened 5-lb. plastic tub of commercially-prepared pimiento cheese spread that had been opened and had approximately 75% of the contents remaining in the container. The stamp on the container indicated that the use-by date of the spread was 10/08/2022. 2. An observation on 10/25/2022 at 10:13 a.m. in the walk-in cooler revealed a gallon-sized bag that contained facility-prepared chili. The date on the bag read 10/15/2022. During an interview with the DM, the DM indicated that the other markings on the container indicated that the container was received by the facility on 8/05/2022 and was opened on 09/10/2022, and should have been discarded before the use-by date. The DM stated that it was the facility's policy to discard food prepared by the facility within 7 days, and that the chili should have been discarded not later than 10/22/2022. The DM stated that any dietary staff member that stores food in the coolers and freezer are responsible for labeling and dating food items, and that she, the regional dietary manager, and the consultant dietitian provide training on food labeling and dating and other dietary subjects to all dietary employees at least monthly. Record review of facility policy dated 03.03.003 , Food Storage, approved 12/01/11, revealed, e. All refrigerated foods are dated, labeled and tightly sealed, including leftovers, using clean, nonabsorbent covered containers that are approved for food storage. Al leftovers are used within 48 hours. Items that are over 48 hours old are discarded. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS , revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (A) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 3-501.17, revealed: Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) Except as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675863 If continuation sheet Page 12 of 19 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 675863 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete specified in (E) -(G) of this section, refrigerated, ready-to-eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer ' s use-by date if the manufacturer determined the use-by date based on food safety. Event ID: Facility ID: 675863 If continuation sheet Page 13 of 19 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 675863 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 36 resident (Resident #25) reviewed for hospice services, in that: The facility did not have Resident #25's most recent hospice Plan of Care, Hospice Consent and Election Form, Physician Certification of Terminal Illness, names and contact information for hospice personnel involved in hospice care of each resident, documentation by specific interdisciplinary hospice staff providing services to the resident, and hospice medication information specific to each resident. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. The findings were: Record review of Resident #25's face sheet, dated 10/25/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Major Depressive Disorder - mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life. Post-Traumatic Stress Disorder - a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock, typically involving disturbance of sleep and constant vivid recall of the experience, with dulled responses to others and the outside world. Hypertension Heart Disease - The pressure inside the blood vessels (called arteries) is too high. As a result, the heart pumps against this pressure, and it must work harder. Over time, this causes the heart muscle to thicken. Record review of Resident #25's Significant change in status MDS, dated [DATE], revealed the resident had a BIMS score of 99, which indicated the resident was unable to complete the interview. Further review revealed the resident had a life expectancy of fewer than 6 months and had received hospice care while a resident at the facility. Record review of Resident #25's electronic medical record Physician Orders, dated 10/20/2022, revealed orders for: Admit to [Hospice Company]. Record review of Resident #25's electronic medical record revealed the following information was not in the resident's record: - Most recent hospice Plan of Care - Hospice Consent and Election Form - Physician Certification of Terminal Illness (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675863 If continuation sheet Page 14 of 19 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 675863 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114 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 0849 - Names and contact information for hospice personnel involved in hospice care of the resident Level of Harm - Minimal harm or potential for actual harm - Documentation by specific interdisciplinary hospice staff providing services to the resident - Hospice medication information specific to the resident. Residents Affected - Few Observation on 10/26/2022 at 1:25 p.m. revealed Resident #25's hospice binder could not be located at the nurses' station. During an interview with LVN D on 10/26/2022 at 1:25 p.m., at the same time as the observation, LVN D confirmed Resident #25 did not have a hospice binder at the nurse's station with the required documentation. LVN D stated, they haven't brought it yet; possibly tomorrow, it will be here. During an interview with the DON on 10/26/2022 at 01:40 p.m., the DON stated, they usually have them here the following day. During a follow-up interview with the DON at 2:30 p.m., the DON stated the hospice agency informed her they had been waiting for binders to come in. The DON stated that by not having the Hospice Binders in the facility, the residents risked not coordinating with the hospice company. Record review of the facility's policy titled, End of Life Care type care & coordination, 3/13/2019, revealed, The IDT should complete a systematic review of residents' palliative care needs and document goals for care and advance directives. Record review of the facility's hospice services agreement with [Hospice Company], effective 04/03/2020, revealed, Services to be provided by hospice, Section 2.14, Hospice shall promote open and frequent communication with facility and shall provide the facility with sufficient information to ensure that the provision of facility services under this agreement is in accordance with the Hospice plan of care, assessments, treatment planning, and care coordination At a minimum Hospice shall provide the following information to facility for each hospice patient residing in the facility: (A) Hospice plan of care, medications, and orders. The most recent Hospice Plan of Care, medication information, and physician orders specify to each to each Hospice patient residing in the facility; (B) Election Form. The Hospice Election form and any advanced directives ;(C) Certifications. Physician certifications and recertification of terminal illness ;(D) Contact information. Name and contact information for hospice personnel involved in providing Hospice Services, and (E) On-call information. Instructions on how to access the Hospice 24-hour on-call system. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675863 If continuation sheet Page 15 of 19 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 675863 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review; the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 of 2 residents (Residents #130 and #121) and 1 of 4 halls (D Hall) reviewed for environment, in that: 1. The facility did not ensure Resident #130's wheelchair was clean. 2. A medication in the form of a capsule was observed on the ground in the hallway of the D Hall of the facility. 3. The Facility failed to ensure Resident #121's grab bar in the restroom was sturdy on the wall. This deficient practice could place the resident at risk of infection and other health conditions caused by an unsanitary environment. The findings include: 1. Record review of Resident #130's face sheet, dated 10/25/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), cerebral infarction, essential hypertension essential hypertension (high blood pressure with no secondary cause identified), anxiety disorder (fear characterized by behavioral disturbances), peripheral vascular disease (disease or disorder of the circulatory system outside of the brain and heart) and gout (a form of arthritis characterized by severe pain, redness, and tenderness in joints). Record review of Resident #130's admission MDS, dated [DATE], revealed the resident had a BIMS score of 07, which indicated the resident had severely impaired cognition. Record review of Resident #130's care plan, created on 10/06/2022, revealed that the resident used a wheelchair and that the resident would be referred for strength/mobility and coordination. Observation on 10/25/2022 at 1:30 p.m. revealed there was a cap missing on right side of the base of Resident #130's wheelchair, exposing a rough surface in close proximity to the resident's leg. There was rust accumulation around every screw on the chair, and there was visible dirt on the spokes and tires of the wheelchair that was easily removed when rubbing a finger over it. The cushion on the wheelchair was smaller than the seat of the chair and did not reach the full length of the seat by approximately 3- 4. During an interview on 10/25/2022 at 1:35 p.m. with Resident #130's family member, the family member expressed concern that the cushion on the wheelchair did not extend to the end of the seat on the chair, and that the chair was dirty. The family member stated, He's in it all the time. Resident #130 was sitting in the wheelchair at the time of this interview. When asked if he would like his wheelchair cleaned, Resident #130 nodded his head up and down, indicating an affirmative answer. During an interview on 10/26/2022 at 10:56 a.m. with the Environmental Services Director (ESD), the ESD stated that if wheelchairs need to be cleaned, Nursing will prepare a schedule, provide the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675863 If continuation sheet Page 16 of 19 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 675863 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Maintenance Department with the schedule, and Maintenance will do pressure washing. The ESD further stated that it had been 3-4 months since they pressure washed wheelchairs. During an interview on 10/27/2022 at 12:38 p.m. with Speech Therapist (ST), the ST stated that the Rehabilitation department usually provides the wheelchairs. When asked about the condition of Resident #130's wheelchair, the ST stated, I can see that it's dirty. Wheelchairs are hard to come by here. But we'll get a better cushion and clean it up. During an interview on 10/27/2022 at 1:15 p.m. with the DON, the DON stated that when residents come in, if they don't have their own wheelchair, the facility will provide one of their own until the Department of Veteran's Affairs (abbreviated, VA) can outfit them with one, though that can take a while. The DON further stated that the Nursing department is responsible for providing residents with wheelchairs, though the Therapy department provides assistance. The DON confirmed that Resident #130's wheelchair had a cushion that did not extend to the end of the chair, there was a cap missing on right side of the base of the wheelchair exposing a rough surface in close proximity to the resident's leg, there was rust accumulation around ever screw on the chair and there was visible dirt on the spokes and tires of the wheelchair. The DON stated she was unaware that Resident #130's wheelchair was in that condition, that someone probably grabbed the first one they saw in the storage room, and that she would get Resident #130 a new wheelchair. 2. An observation on 10/25/2022 at 11:25 a.m. revealed a capsule on the ground on the D Hall of the facility. The capsule was close to the wall, in close proximity to room [ROOM NUMBER]. During an interview 10/25/2022 at 11:32 a.m. with the pharmacy consultant RN, upon observing the capsule, the RN stated, That's Gabapentin, and it should not be there. Record review of the residents in room [ROOM NUMBER] revealed that this resident was not prescribed this medication. Further review of all the residents in the rooms in close proximity to the location of the medication (#611, #612 and #614) revealed that the only resident who was prescribed this medication was Resident #79 in room [ROOM NUMBER]. Record review of Resident #79's face sheet, dated 10/25/2022, revealed he was admitted to the facility on [DATE] with diagnoses that included: atherosclerotic heart disease (the buildup of fats, cholesterol and other substances in and on the artery walls), Type II diabetes with diabetic neuropathy (high blood sugar that includes nerve damage, most common in the hands and feet), gastroesophageal reflux disease (a chronic digestive disease where the liquid content of the stomach refluxes into the esophagus), the tube connecting the mouth and stomach, and anxiety disorder (fear characterized by behavioral disturbances) and pain, unspecified. Record review of Resident #79's quarterly MDS dated [DATE] revealed a BIMS of 15, indicating the resident was cognitively intact. Record review of Resident #79's Order Summary Report for October 2022 revealed the resident had orders for: Gabapentin Capsule, 300 mg - Give 1 capsule by mouth one time a day related to Type II Diabetes Mellitus with Diabetic Neuropathy. Give this dose at Mid-day. Start date: 03/22/2021. Gabapentin Capsule, 400 mg. Give 1 capsule by mouth one time a day related to pain, unspecified, in the morning. Start date: 03/29/2022. Gabapentin tablet 600 mg - Give 1 tablet by mouth one time a day related to pain, unspecified, at bedtime. Start date: 03/28/2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675863 If continuation sheet Page 17 of 19 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 675863 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with with Resident #79 on 10/25/2022 at 3:30 p.m., Resident #79 stated, I take Gabapentin 3x/day, 400 mg in the morning, 300 mg in the afternoon and 600 at night. It really makes a difference. I was given all my medication. If I was missing my gabapentin, I would notice. During a later interview on 10/26/2022 at 9:00 a.m. with the pharmacy consultant RN, the RN stated that she had spoken with the med aide (MA) K, who had worked the previous day, and that MA K told her that when she popped the 400 mg capsule of Gabapentin out of the blister pack, it had rolled off the cart. MA K subsequently assumed it had rolled into the trash bin adjacent to the cart, because she could not find it after searching for it. MA K proceeded to dispense another capsule to Resident #79. During an interview with the DON on 10/26/2022 at 9:30 a.m., the DON confirmed that a medication in the form of a capsule was found on the ground on the D hall on 10/25/2022 at 11:25 a.m. and it should not have been there, as it presented a hazard to residents who could find it, possibly consume it, and suffer negative consequences as a result of this consumption. 3. Record review of Resident 121's face sheet, dated 10/28/2022, revealed the resident was admitted on [DATE] with diagnoses that included: heart failure (heart muscle unable to pump enough blood to meet the body's need), dementia (disorder that causes memory, personality changes and impaired thinking), osteoporosis (bones become brittle), paranoid schizophrenia (paranoia experiences that feed into delusions and hallucinations), anxiety, and secondary Parkinsonism (symptoms like Parkinson's but caused from medications) Record review of Resident #121's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 3, which indicated severe cognitive impairment. Observation on 10/25/2022 at 11:54 am revealed the grab bar by the toilet in Resident #121's bathroom was not sturdy and very loose on both sides that attached to the wall. Observation on 10/28/2022 at 11:59 am revealed the grab bar by the toilet in Resident #121's bathroom was still not sturdy. During an interview and observation on 10/28/2022 at 12:02 p.m., CNA G confirmed the grab bar was not sturdy. She stated she was not aware of the grab bar being loose. CNA G further stated the potential harm for a resident was getting hurt. CNA G stated when she saw something needed fixed, she tells her supervisor, which is the charge nurse. During an interview and observation on 10/28/2022 at 12:04 p.m., LVN H confirmed the grab bar was not sturdy and needed to be fixed. She stated she was not aware of the grab bar being loose. LVN H further stated the resident could potentially get hurt by pulling on it and falling. She stated anytime something needed to be fixed she entered it into the online maintenance log. But if it is an emergency, like this was, she would call her supervisor for maintenance to come fix it as soon as possible. LVN H stated Resident #121 did use the bathroom as well. During an interview on 10/28/2022 at 3:24 p.m., The ESD stated he was not aware that Resident #121's grab bar in his bathroom was loose and not sturdy to the wall. He stated the potential for harm was the resident could fall and hurt themselves. The ESD also stated that everyone was responsible for ensuring a resident's room is safe and not potential accident hazards, when doing angel rounds for their assigned residents. The ESD further stated that the (Name of Stete) Land board did room rounds (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675863 If continuation sheet Page 18 of 19 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 675863 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114 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 0921 last week and wrote down each item that needed to be fixed, prior to the next quarter review. Level of Harm - Minimal harm or potential for actual harm Record review of (Name of State) Land Board's, undated, submitted list of items needed fixing revealed Resident #121's loose grab bar was not listed as an item needed to be fixed. Residents Affected - Some During an interview on 10/28/22 at 3:34 p.m., the Administrator stated it depended on how loose the grab bar was to determine if Resident #121's was considered to be an emergency fix or if it just needed to be inputted into the online maintenance log system. She stated if the item was an emergency type fix than it is done verbally through a supervisor. The Administrator also stated that when items are listed in the online maintenance log system all the maintenance personnel are notified as soon as it was submitted. She further stated, as a result the maintenance personnel are good about getting items fixed fairly quickly. Record review of facility policy, Accident Prevention dated February 2017 revealed, The community ensures that the resident environment remains as free of accident hazards as possible. Accident hazards are defined as physical features in the environment that can endanger a resident's safety. Hazards may include, but are not limited to, the following: Equipment or devices that are defective, poorly maintained, or not in use with manufacturer's specifications. A requested policy on 10/28/2022 regarding the cleaning of wheelchairs was not provided by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675863 If continuation sheet Page 19 of 19