Inspection·February 5, 2024

F 0607 Level of Harm - Minimal harm or potential for actual harm wheelchair sitting on the car floor against driver and passenger seat. Right foot was folded in and left below knee amputation (BKA) was bearing some weight. There was no active bleeding noted, and the resident denied any pain. Staff was called and Resident #1 was lifted back to the wheelchair, taken to his room, and assessed for injuries. No injuries were noted, range of motion remained intact. There was no change in his baseline motor skills, and his condition was within normal limits. Residents Affected - Few Record review of Resident #1's change in condition dated 01/24/24 reflected the primary care physician for Resident #1 was notified on 01/24/23 at 8:42pm with the recommendation to continue with facility protocol. Record review of Resident #1's skin assessment dated [DATE] reflected, Weekly skin assessment done, continues with surgical incision to left BKA, unstageable pressure ulcer to right lateral (to the side, aware from middle) heel, tolerating treatment in place with no discomfort, no new skin issues noted at this time. Record review of Resident #1's orders did not reveal any orders for imaging after the fall incident on 01/24/24. Record review of a facility grievance dated 01/24/24 for Resident #1 reflected a family member of Resident #1 initiated a complaint regarding Resident #1 having a fall while being transported to an appointment. The facility grievance resolution form reflected the grievance was resolved on 01/26/24 and reflected, Front office staff was in-serviced on the appropriate use of the safety requirements and on abuse and neglect. Incident was reported on 01/24/24 and investigated. The grievance and investigation were completed by the Administrator with the resolution marked as reviewed with the concerned person. Record review of manufacture user instructions for securement system in the facility van reflected in section B, SECURE PASSENGER. 1. 1. Attach Lap Belts - Use integrated stiffeners to feed belts through openings between seat backs and bottoms, and/or armrests to ensure proper belt fit around occupant. A. On the aisle side, attach belt with female buckle to rear tie-down pin connector .ensuring buckle rests on passenger's hip. B. On the window-side, attach belt with male tongue to rear tie-down pin connector .and insert into female buckle. 2. Attach Shoulder Belt - Extend shoulder belt over passenger's shoulder and across upper torso . and fasten pin connector onto lap belt. Note: combination lap/shoulder belts serve as both window-side lap belt and shoulder belt. 3. Ensure belts are adjusted as firmly as possible, but consistent with user comfort. Record review of Driver A's training revealed on 08/09/23 he had completed a Paratransit Operation Proficiency Evaluation Checklist which covered wheelchair securement and patient restraint. On 07/27/23 Driver A completed a fleet safety program and was in-serviced over appropriate use of safety straps on 01/26/24. Record review of the facility vehicle inspections completed on 01/08/24, 01/15/24, 01/22/24, 01/29/24, and 02/05/24 by the Maintenance Supervisor reflected no issues with straps or anchor systems in place. Record Review of TULIP (HHSC online incident reporting application) on 02/05/24 at 6:30pm revealed no related self-reports by the facility. During an observation and interview with Resident #1 on 02/01/24 at 2:26pm he stated he was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675933 If continuation sheet Page 2 of 16 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 675933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Hills Healthcare and Rehabilitation Cente 2204 Pease St Harlingen, TX 78550 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few transported to doctor appointments and dialysis with the use of the facility van. Resident #1 stated he had 1 incident during transportation. Resident #1 did not give an exact date of when the incident occurred. When asked who buckled him in Resident #1 did not give a name and only stated, the driver. Resident #1 stated the driver of the van had made a sudden stop due to the car in front of the vehicle and caused Resident #1 to slide off his wheelchair which he stated rolled under itself due to the driver only securing the back of the wheelchair. Resident #1 stated the driver had only secured the back of the wheelchair and had not hooked up the front. Resident #1 stated he was not secured with any seatbelt style hook up but stated he was now, and that the facility had corrected the issue. Resident #1 stated he had slid off the wheelchair about .8 miles away from the facility and had remained on the floor until arriving to the facility. Resident #1 stated the driver kept driving with him on the floor and stated he had told the driver to pull over, stop and get him on the chair and stated the driver did not and did not give Resident #1 a reason why. Resident #1 stated he sustained a few scratches on his leg. Resident #1 showed the surveyor a circular skin tear on his right lower shin measuring approximately 5mm. Resident #1 stated he had 1 or 2 other similar sized skin tears on his left leg but stated he would not be able to show it to due to it being wrapped up due to a previous amputation. Resident #1 stated the facility has since corrected the issue and stated he is now buckled in with a seat belt style securement and has had no other incidents. During an observation and interview with Driver A on 02/01/24 at 2:56pm revealed he demonstrated how he got a passenger into the facility van and secured both the chair and the resident. Driver A wheeled in the wheelchair with the Administrator seated in the chair as a passenger. Driver A secured the wheelchair with 2 hooks on the back of wheelchair and 2 on the bottom front of wheelchair and stated that was the same way he had hooked up Resident #1's wheelchair on the day of Resident #1's fall incident. Driver A also used a chest strap that went over the passenger's chest, Driver A stated that was something new and was recently added on 01/30/24 and was not used with Resident #1 on day of his fall incident. During the demonstration no lap belt/strap or shoulder belt/strap was used. Driver A stated, I don't think so, no. when asked if he used any waist or lap straps/belts to secure residents. Driver A stated approximately .8 miles away from the facility the vehicle in front of him had stopped and he stopped as well and stated Resident #1 had slid forward. Driver A stated he was able to assist Resident #1 into an assisted fall by using his arm to hold Resident #1 back. Driver A stated he could not pull over because he was in the middle lane and drove to the facility while using his arm to hold up Resident #1 as much as he could. Driver A stated Resident #1 was on the floor until they arrived at the facility and once he arrived he stated he ran inside facility to get LVN B to assess and assist Resident #1. Driver A stated he did not see any bleeding or skin tears on Resident #1. Driver A stated he had completed training both before and after the incident with Resident #1. Driver A was shown instruction pages for system used in the facility van that he had retrieved from the vehicle glove box that reflected how to secure both the wheelchair and the passenger. The instruction pages reflected to secure a passenger a lap belt and shoulder belt would be used. Driver A stated he had been trained over those procedures. Driver A stated he had been trained by the BOM. Driver A stated, I don't think so, no. when asked if he was using waist and lap belts/straps to secure residents. Driver A was attempted to be reached via telephone on 02/05/24 at 3:48pm, 4:38pm, 5:20pm and 5:36pm for follow up questions, however no call was answered or returned by Driver A. During observation and interview with Resident #1 on 02/02/24 at 4:20pm and the BOM assisting he was observed buckled in the facility van after arriving back from dialysis. Resident #1 had 4 bottom hooks in place with 2 on the front of the wheelchair and 2 on the back of the wheelchair. Resident #1 had a strap/belt that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675933 If continuation sheet Page 3 of 16 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 675933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Hills Healthcare and Rehabilitation Cente 2204 Pease St Harlingen, TX 78550 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 0607 Level of Harm - Minimal harm or potential for actual harm went around his upper abdomen and under his left arm and had a connector that connected to the top side of the vehicle. Resident #1 stated he was not secured in that same manner on the day he fell. Resident #1 stated on the day he fell only the 2 back bottom hooks were placed on the wheelchair and stated he had no shoulder or waist/lap strap/belt used on him. Resident #1 stated he ended up with his buttocks in the air, his left stump on the floor and under the wheelchair on day of fall. Residents Affected - Few During an interview with the BOM on 02/02/24 at 4:32pm she stated Driver A was responsible for ensuring Resident #1 was secured and positioned correctly in the facility van on the day of Resident #1's fall incident. The BOM stated she was not present during the fall and only heard of about it afterwards. The BOM stated she spoke to Resident #1 on 2 different occasions after the fall, and he initially stated he was not strapped in when the BOM asked Resident #1 if he was secured and fastened. The BOM stated she later took a staff member with her as a witness to interview Resident #1 again and Resident #1 then stated he had been strapped in on the day of his fall incident in the facility van. The BOM stated they had recently added a new shoulder strap to position the residents closer to the front of the van. The BOM stated the new shoulder strap was added on 01/30/24 by Maintenance. The BOM stated previously they only had a shoulder strap in the back of the van but some residents liked to sit closer to the front and were secured with a lap band. The BOM stated the shoulder strap in the front of vehicle was added after the incident with Resident #1. The BOM stated Driver A had been trained before starting to drive. The BOM stated they reviewed a video that was provided, along with user instructions and had completed a return demonstration before starting to drive. The BOM stated Driver A had been trained over securement of a passenger and the use of shoulder and waist/lap belt/straps. The BOM stated that was the only time she was aware of that a resident was not secured with use of a shoulder/waist strap/belt. The BOM was unable to answer why Resident #1 was not correctly secured due to not being there that day. The BOM stated if the seat belt was not on Resident #1 then he was not properly secured. The BOM stated she monitored staff to ensure residents were being secured during transportation by doing spot checks, 1 to 1's, going on drives with staff and demonstrating what to do. The BOM stated she had provided Driver A an orientation on 01/25/24 and on 01/26/24 rode with Driver A in the vehicle and had Driver A perform a return demonstration, Inservice record provided was dated 01/26/24 and stated they covered the appropriate use of safety straps. The BOM stated not securing a resident during transport could affect residents emotionally by not feeling secure. The BOM stated for Resident #1, his amputation surgery site could reopen and could be devastating for residents when they don't heal. During an interview with LVN B on 02/05/24 at 4:46pm he stated he was called outside by Driver A and was told Resident #1 had fallen or slid off his wheelchair when Driver A broke when the vehicle in front of him stopped abruptly. LVN B stated Resident #1 was on the floor in front of his wheelchair and was against the driver and passenger seat. LVN B stated Resident #1 had his right leg folded in and up against the passenger side and his left leg amputation stump was bearing weight, and he was in a crouched position and his feet and bottom were on the floor. LVN B stated he did not see a belt on Resident #1 but the wheelchair was strapped. LVN B stated Driver A had unclipped everything and he was not able to tell which ones or how many securements there were. LVN B stated he took Resident #1's vitals, completed assessment, and notified family, the DON, Resident #1's primary care physician and was provided with no new orders. LVN B stated Resident #1 had no pain, no injuries and further stated Resident #1 did not have any new skin tears; and stated his wound location where his amputation was on left leg was intact and fine with no active bleeding. During an interview with the Administrator on 02/05/24 at 2:54pm she stated she was the abuse coordinator and was responsible for reporting any allegations of abuse, neglect or exploitation to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675933 If continuation sheet Page 4 of 16 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 675933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Hills Healthcare and Rehabilitation Cente 2204 Pease St Harlingen, TX 78550 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few state agencies. The Administrator stated she completed training over abuse, neglect and exploitation reporting requirements to state agencies annually through an online training and stated she had last completed it in October of 2023. The Administrator stated Resident #1 had a BIMS of 15 that indicated his cognition was within normal limits. The Administrator stated Resident #1 had an incident in the facility van during transportation on his way back from dialysis on 01/24/24 when he slid off his wheelchair. The Administrator stated from the interviews she completed she gathered Resident #1 had the bottom part of his wheelchair secured and had been advised he had on a lap belt but as far as she knew no use of a shoulder strap. The Administrator stated Resident #1 was not properly secured during his transportation. The Administrator stated Driver A was responsible for securing Resident #1 on the day of the fall incident on 01/24/24. The Administrator stated they used a 4-point system on the floor to secure the wheelchair itself and a strap that goes behind chair with a lap and shoulder strap. The Administrator stated she was not certain why the shoulder straps were not being used and was not sure if it was patient preferences or what the reason was and stated if it was patient preferences she should have been notified. The Administrator stated she was made aware of incident by the DON on 01/24/24 but did not provide an exact time and stated Resident #1 had a head to toe assessment completed with his skin assessment showing no indication of injury. The Administrator stated the following day a family member for Resident #1 was requesting an incident report and stated they had advised Resident #1's family member that incident reports were internal documents but could provide her with a progress note. The Administrator stated she needed to follow up with medical records to see if that document was provided. The Administrator stated the family for Resident #1 was also asking for in-services completed. The Administrator stated Driver A was present during the time of the incident however she was not sure if Driver A had directly witnessed Resident #1 slide off his wheelchair. The Administrator stated Resident #1 was interviewed by her on 01/26/24 and did not verbally say he was strapped in but gave her the hand motion of a lap belt around his waist. The Administrator stated the frequent verbiage that was used by Driver A and Resident #1 was that Resident #1 slid off the wheelchair which she stated gave her no indication that Resident #1 as not strapped in. The Administrator stated she came to that conclusion based off physics, and that Resident #1 would have gone nose forward and into the dash board if he was not strapped in. The Administrator stated the appropriate time to report allegations of abuse, neglect and exploitation to state agencies was within 2 hours if injury and 24 hours for an allegation. The Administrator stated the facility policy for reporting allegations of abuse, neglect and exploitation was also the same as the state's requirements. The Administrator stated she did not report to any state agency within a 24-hour time frame and stated she did not report because based on the clinical pathways there was no indication that neglect had occurred and did not think it was necessary because Resident #1 did not sustain injury and did not claim neglect. The Administrator stated she monitored what incidents needed to be reported and ensured they were reported within the appropriate time frame by doing extensive training with staff over reporting and posting her name and number up throughout the facility and making staff aware that any allegation along with anything out of the ordinary needed to be immediately reported to her. The Administrator stated not appropriately reporting allegations of abuse, neglect and exploitation could cause lack of follow up and could result in the incident occurring again. Record review of facility policy titled Policy/Procedure - Administration. That specified, Section: Residents Rights Subject: Abuse: Prevention of and Prohibition Against with a revision date of 11/28/17 stated under section H. titled REPORTING/RESPONSE . 2. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675933 If continuation sheet Page 5 of 16 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 675933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Hills Healthcare and Rehabilitation Cente 2204 Pease St Harlingen, TX 78550 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 0607 State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations. 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: 675933 If continuation sheet Page 6 of 16 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 675933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Hills Healthcare and Rehabilitation Cente 2204 Pease St Harlingen, TX 78550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 1 of 5 residents (Resident #3) reviewed for reporting alleged allegation of abuse. The facility did not report, within 24 hours, when Resident #1 was not properly secured and slid off his wheelchair during transport. This failure could place residents at risk for undetected abuse, neglect and/or decline in feelings of safety and well-being. The findings were: Record review of Resident #1's face sheet, dated 02/05/24, revealed the resident was a [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses that included: heart failure, unspecified (condition in which the heart muscle doesn't pump blood as well as it should), essential (primary) hypertension (high blood pressure), type 2 diabetes mellitus (high blood sugar) with unspecified complications, peripheral vascular disease, unspecified (narrowed blood vessels reduce blood flow to the limbs), end stage renal disease (when kidneys no longer work as they should to meet the body's needs), acquired absence (amputation) of left leg below knee. Record review of Resident #1's admission minimum data set assessment (MDS), dated [DATE], revealed Resident #1 had a BIMS score of 15, indicating no cognitive impairment. Based off this MDS assessment Resident #1's independence level for car transfers was not attempted to due to medical condition or safety concern. Record review of Resident #1's care plan revealed he had a fall with no injury, further stating Called outside by facility driver, on arrival, resident was in front of wheelchair sitting on the car floor against driver and passenger seat. Right foot was folded in and left below knee amputation (BKA) was bearing some weight. No active bleeding noted, resident denied any pain. Staff called, and was lifted back to wheelchair , taken to room, and assessed for injuries. I slipped forward when the driver stopped. Some interventions were anti-tilt to back and high back wheelchair with an initiated date of 01/26/24. Record review of Resident #1's most recent fall risk evaluation dated 01/24/24 revealed he was a medium fall risk. Record review of Resident #1's nursing notes with an effective date of 01/24/24 at 8:48pm by LVN B revealed was called outside by facility driver, on arrival, resident was in front of wheelchair sitting on the car floor against driver and passenger seat. Right foot was folded in and left below knee amputation (BKA) was bearing some weight. No active bleeding noted, resident denied any pain. Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675933 If continuation sheet Page 7 of 16 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 675933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Hills Healthcare and Rehabilitation Cente 2204 Pease St Harlingen, TX 78550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few called, and Resident #1 was lifted back to wheelchair , taken to room, and assessed for injuries. No injuries noted, range of motion (ROM) remained intact, no change in baseline motor skills, condition within normal limits (WNL). Record review of Resident #1's change in condition dated 01/24/24 stated the primary care physician (PCP) for Resident #1 was notified on 01/24/23 at 8:42pm with recommendation to continue with facility protocol. Record review of Resident #1's skin assessment dated [DATE] stated, Weekly skin assessment done, continues with surgical incision to left BKA, unstageable pressure ulcer to right lateral heel, tolerating treatment in place with no discomfort, no new skin issues noted at this time. Record review of Resident #1's orders did not reveal any orders for imaging after fall incident on 01/24/24. Record review of a facility grievance dated 01/24/24 for Resident #1 reflected a family member of Resident #1 initiated a complaint regarding Resident #1 having a fall while being transported to an appointment. The facility grievance resolution form reflected this grievance was resolved on 01/26/24 stating, Front office staff was in-serviced on the appropriate use of the safety requirements and on abuse and neglect. Incident was reported on 01/24/24 and investigated. The grievance and investigation were completed by the Administrator with the resolution marked as reviewed with the concerned person. Record review of manufacture user instructions for securement system in facility van stated in section B, SECURE PASSENGER. 1. 1. Attach Lap Belts - Use integrated stiffeners to feed belts through openings between seat backs and bottoms, and/or armrests to ensure proper belt fit around occupant. a. On the aisle side, attach belt with female buckle to rear tie-down pin connector .ensuring buckle rests on passenger's hip. b. On the window-side, attach belt with male tongue to rear tie-down pin connector .and insert into female buckle. 2. Attach Shoulder Belt - Extend shoulder belt over passenger's shoulder and across upper torso . and fasten pin connector onto lap belt. Note: combination lap/shoulder belts serve as both window-side lap belt and shoulder belt. 3. Ensure belts are adjusted as firmly as possible, but consistent with user comfort. Record review of Driver A's training revealed on 08/09/23 he had completed a Paratransit Operation Proficiency Evaluation Checklist which covered wheelchair securement and patient restraint. On 07/27/23 Driver A completed fleet safety program and was in serviced over appropriate use of safety straps on 01/26/24. Record Review of TULIP (HHSC online incident reporting application) on 02/05/24 at 6:30pm revealed no related self-reports by the facility. During an observation and interview with Resident #1 on 02/01/24 at 2:26pm he stated he was transported to doctor appointments and dialysis with the use of the facility van. Resident #1 stated he had 1 incident during transportation. Resident #1 did not give an exact date of when incident occurred, when asked who buckled him in Resident #1 did not give a name and only stated, the driver. Resident #1 stated the driver of the van had made a sudden stop due to the car in front of the vehicle and caused Resident #1 to slide off wheelchair which he stated rolled under itself due to the driver only securing the back of the wheelchair. Resident #1 stated the driver had only secured the back of the wheelchair and had not hooked up the front. Resident #1 stated he was not secured with any seatbelt (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675933 If continuation sheet Page 8 of 16 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 675933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Hills Healthcare and Rehabilitation Cente 2204 Pease St Harlingen, TX 78550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few style hook up but stated he is now, stating the facility had corrected the issue. Resident #1 stated he had slid off the wheelchair about .8 miles away from the facility and had remained on the floor until arriving to the facility. Resident #1 stated the driver kept driving with him on the floor and stated he had told the driver to pull over, stop and get him on the chair and stated the driver did not and did not give Resident #1 a reason why. Resident #1 stated he sustained a few scratches on his leg. Resident #1 showed this surveyor a circular skin tear on right lower shin measuring approximately 5mm. Resident #1 stated he had 1 or 2 other similar sized skin tears on his left leg but stated he would not be able to show it to me due to it being wrapped up due to previous amputation. During an observation and interview with Driver A on 02/01/24 at 2:56pm he demonstrated how he got a passenger into the facility van and secured both the chair and the resident. Driver A wheeled in the wheelchair with the Administrator seated in the chair as a passenger. Driver A secured the wheelchair with 2 hooks on the back of wheelchair and 2 on the bottom front of wheelchair and stated that was the same way he had hooked up Resident #1's wheelchair on the day of Resident #1's fall incident. Driver A also used a chest strap that went over the passenger's chest, Driver A stated this was something new and was recently added on 01/30/24 and was not used with Resident #1 on day of his fall incident. During this demonstration no lap belt/strap or shoulder belt/strap was used. Driver A stated I don't think so, no. when asked if he used any waist or lap straps/belts to secure residents. Driver A stated approximately .8 miles away from the facility the vehicle in front of him had stopped and he stopped as well and stated Resident #1 had slid forward. Driver A stated he was able to assist Resident #1 into an assisted fall by using his arm to hold Resident #1 back. Driver A stated he could not pull over because he was in the middle lane and drove to the facility while using his arm to hold up Resident #1 as much as he could. Driver A stated Resident #1 was on the floor until they arrived at the facility and once he arrived he stated he ran inside facility to get LVN B to assess and assist Resident #1. Driver A stated he did not see any bleeding or skin tears on Resident #1. Driver A stated he had completed training both before and after incident with Resident #1. Driver A was shown instruction pages for system used in facility van that he had retrieved from vehicle glove box that stated how to secure both the wheelchair and the passenger. The instruction pages stated to secure a passenger a lap belt and shoulder belt would be used. Driver A stated he had been trained over these procedures. Driver A stated he had been trained by the BOM. Driver A stated, I don't think so, no. when asked if he was using waist and lap belts/straps to secure residents. Driver A was attempted to be reached via telephone multiple times on 02/05/24 for follow up questions, however no call was answered or returned by Driver A. During observation and interview with Resident #1 on 02/02/24 at 4:20pm and the BOM assisting he was observed buckled in facility van after arriving back from dialysis. Resident #1 had 4 bottom hooks in place with 2 on front of wheelchair and 2 on the back of wheelchair. Resident #1 had a strap/belt that went around upper abdomen and under left arm and had a connector that connected to the top side of vehicle. Resident #1 stated he was not secured in that same manner on the day he fell, Resident #1 stated on the day he fell only the 2 back bottom hooks were placed on the wheelchair and stated he had no shoulder or waist/lap strap/belt used on him. Resident #1 stated he ended up with his buttocks in the air, his left stump on the floor and under the wheelchair on day of fall. During an interview with the BOM on 02/02/24 at 4:32pm she stated Driver A was responsible for ensuring Resident #1 was secured and positioned correctly in the facility van on day of Resident #1's fall incident. BOM stated she was not present during fall and only heard of about it afterwards. The BOM stated she spoke to Resident #1 on 2 different occasions after fall, stating he initially stated he was not strapped in when the BOM asked Resident #1 if he was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675933 If continuation sheet Page 9 of 16 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 675933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Hills Healthcare and Rehabilitation Cente 2204 Pease St Harlingen, TX 78550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few secured and fastened. The BOM stated she later took a staff member with her as a witness to interview Resident #1 again and stated Resident #1 then stated he had been strapped in on day of his fall incident in facility van. The BOM stated they had recently added a new shoulder strap to position the residents closer to the front of the van. The BOM stated the new shoulder strap was added on 01/30/24 by Maintenance. The BOM stated previously they only had a shoulder strap in the back of the van but stated some residents liked to sit closer to the front and were secured with a lap band. The BOM stated the shoulder strap to front of vehicle was added after the incident with Resident #1. The BOM stated Driver A had been trained before starting to drive. The BOM stated they reviewed a video that was provided, along with user instructions and had to completed return demonstration before starting to drive. The BOM stated Driver A had been trained over securement of a passenger and the use of shoulder and waist/lap belt/straps. The BOM stated this was the only time she was aware of that a resident was not secured with use of a shoulder/waist strap/belt. The BOM was unable to answer why Resident #1 was not correctly secured due to not being there that day. The BOM stated if the seat belt was not on resident #1 then he was not properly secured. The BOM stated she monitors staff to ensure resident are being secured during transportation by doing spot checks, 1 to 1's, going on drives with staff and demonstrating what to do. The BOM stated not securing a resident during transport could affect residents emotionally by not feeling secure. The BOM stated for Resident #1 his amputation surgery site could reopen and could be devastating for residents when they don't heal. During an interview with LVN B on 02/05/24 at 4:46pm he stated he was called outside by Driver A and was told Resident #1 had fallen or slid off his wheelchair when Driver A broke when the vehicle in front of him stopped abruptly. LVN B stated Resident #1 was on the floor in front of wheelchair and was against the driver and passenger seat. LVN B stated Resident #1 had his right leg folded in and up against the passenger side and his left leg amputation stump was bearing weight, stating he was in a crotched position and his feet and bottom were on the floor. LVN B stated he did not see a belt on Resident #1 but stated the wheelchair was strapped. LVN B stated Driver A had unclipped everything and he was not able to tell which ones or how many securements there were. LVN B stated he took Resident #1's vitals, completed assessment, and notified family, DON, Resident #1'sprimary care physician and was provided with no new orders. LVN B stated Resident #1 had no pain, no injuries further stating Resident #1 did not have any new skin tears and stated his wound location where his amputation was on left leg was intact and fine with no active bleeding. During an interview with the Administrator on 02/05/24 at 2:54pm she stated she was the abuse coordinator and was responsible for reporting any allegations of abuse, neglect or exploitation to state agencies. The Administrator stated she completed training over abuse, neglect and exploitation reporting requirements to stated agencies annually through an online training and stated she had last completed it in October of 2023. The Administrator stated Resident #1 had a BIMS of 15 that indicated his cognition was within normal limits. The Administrator stated Resident #1 had an incident in the facility van during transportation on his way back from dialysis on 01/24/24 when he slid off his wheelchair. The Administrator stated from the interviews she completed she gathered Resident #1 had the bottom part of his wheelchair secured and had been advised he had on a lap belt but as far as she knew no use of shoulder strap. The Administrator stated Resident #1 was not properly secured during his transportation. The Administrator stated Driver A was responsible for securing Resident #1 on day of fall incident on 01/24/24. The Administrator stated they use a 4-point system on the floor to secure the wheelchair itself and a strap that goes behind chair with a lap and shoulder strap. The Administrator stated she was not certain why the shoulder straps were not being used and was not sure if it was patient preferences or what (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675933 If continuation sheet Page 10 of 16 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 675933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Hills Healthcare and Rehabilitation Cente 2204 Pease St Harlingen, TX 78550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the reason was and stated if it was patient preferences she should have been notified. The Administrator stated she was made aware of incident by the DON on 01/24/24 but did not provide an exact time and stated Resident #1's had a head to toe assessment completed with his skin assessment showing no indication of injury. The Administrator stated the following day a family member for Resident #1 was requesting an incident report and stated they had advised Resident #1's family member that incident reports were internal documents but could provide her with a progress note, The Administrator stated she needed to follow up with medical records to see if that document was provided. The Administrator stated family for Resident #1 was also asking for in-services completed. The Administrator stated Driver A was present during time of incident however she was not sure if Driver A had directly witnessed Resident #1 slide off wheelchair. The Administrator stated Resident #1 was interviewed by her on 01/26/24 and did not verbally say he was strapped in but gave her the hand motion of a lap belt around waist. The Administrator stated the frequent verbiage that was used by Driver A and Resident #1 was that Resident #1 slid off the wheelchair which she stated gave her no indication that Resident #1 as not strapped. The Administrator stated she came to that conclusion based off physics, stating Resident #1 would have gone nose forward and into the dash board if he was not strapped in. The Administrator stated the appropriate time from to report allegations of abuse, neglect and exploitation to state agencies was 2 hours if injury and 24 for allegation. The Administrator stated the facility policy for reporting allegations of abuse, neglect and exploitation was also the same as the states requirements. The Administrator stated she did not report to any state agency within a 24-hour time frame and stated she did not report because based on the clinical pathways there was no indication that neglect had occurred and did not think it was necessary because Resident #1 did not sustain injury and did not claim neglect. The Administrator stated she monitored what incidents needed to be reported and ensured they were reported within the appropriate time frame by doing extensive training with staff over reporting and posting her name and number up throughout the facility and making staff aware that any allegation along with anything out of the ordinary needed to be immediately reported to her. The Administrator stated not appropriately reporting allegations of abuse, neglect and exploitation could cause lack of follow up and could result in the incident occurring again. Record review of facility policy titled Policy/Procedure - Administration. That specified, Section : Residents Rights Subject: Abuse: Prevention of and Prohibition Against with a revision date of 11/28/17 stated under section H. titled REPORTING/RESPONSE . 2. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675933 If continuation sheet Page 11 of 16 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 675933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Hills Healthcare and Rehabilitation Cente 2204 Pease St Harlingen, TX 78550 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 - Minimal harm or potential for actual harm 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 that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure staff properly secured Resident #1 during transportation. Driver A did not secure Resident #1 with a lap belt and shoulder belt during transport resulting in Resident #1 sliding off wheelchair during transport. This deficient practice could place the residents at risk for harm or serious injury. The findings were: Record review of Resident #1's face sheet, dated 02/05/24, revealed the resident was a [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses that included: heart failure, unspecified (condition in which the heart muscle doesn't pump blood as well as it should), essential (primary) hypertension (high blood pressure), type 2 diabetes mellitus (high blood sugar) with unspecified complications, peripheral vascular disease, unspecified (narrowed blood vessels reduce blood flow to the limbs), end stage renal disease (when kidneys no longer work as they should to meet the body's needs), acquired absence (amputation) of left leg below knee. Record review of Resident #1's admission minimum data set assessment (MDS), dated [DATE], revealed Resident #1 had a BIMS score of 15, indicating no cognitive impairment. Based off this MDS assessment Resident #1's independence level for car transfers was not attempted to due to medical condition or safety concern. Record review of Resident #1's care plan revealed he had a fall with no injury, further stating Called outside by facility driver, on arrival, resident was in front of wheelchair sitting on the car floor against driver and passenger seat. Right foot was folded in and left below knee amputation (BKA) was bearing some weight. No active bleeding noted, resident denied any pain. Staff called, and was lifted back to wheelchair , taken to room, and assessed for injuries. I slipped forward when the driver stopped. Some interventions were anti-tilt to back and high back wheelchair with an initiated date of 01/26/24. Record review of Resident #1's most recent fall risk evaluation dated 01/24/24 revealed he was a medium fall risk. Record review of Resident #1's nursing notes with an effective date of 01/24/24 at 8:48pm by LVN B revealed was called outside by facility driver, on arrival, resident was in front of wheelchair sitting on the car floor against driver and passenger seat. Right foot was folded in and left below knee amputation (BKA) was bearing some weight. No active bleeding noted, resident denied any pain. Staff called, and Resident #1 was lifted back to wheelchair , taken to room, and assessed for injuries. No injuries noted, range of motion (ROM) remained intact, no change in baseline motor skills, condition within normal limits (WNL). Record review of Resident #1's change in condition dated 01/24/24 stated the primary care physician (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675933 If continuation sheet Page 12 of 16 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 675933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Hills Healthcare and Rehabilitation Cente 2204 Pease St Harlingen, TX 78550 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 - Minimal harm or potential for actual harm Residents Affected - Few (PCP) for Resident #1 was notified on 01/24/23 at 8:42pm with recommendation to continue with facility protocol. Record review of Resident #1's skin assessment dated [DATE] stated, Weekly skin assessment done, continues with surgical incision to left BKA, unstageable pressure ulcer to right lateral heel, tolerating treatment in place with no discomfort, no new skin issues noted at this time. Record review of Resident #1's orders did not reveal any orders for imaging after fall incident on 01/24/24. Record review of a facility grievance dated 01/24/24 for Resident #1 reflected a family member of Resident #1 initiated a complaint regarding Resident #1 having a fall while being transported to an appointment. The facility grievance resolution form reflected this grievance was resolved on 01/26/24 stating, Front office staff was in-serviced on the appropriate use of the safety requirements and on abuse and neglect. Incident was reported on 01/24/24 and investigated. The grievance and investigation were completed by the Administrator with the resolution marked as reviewed with the concerned person. Record review of manufacture user instructions for securement system in facility van stated in section B, SECURE PASSENGER. 1. 1. Attach Lap Belts - Use integrated stiffeners to feed belts through openings between seat backs and bottoms, and/or armrests to ensure proper belt fit around occupant. a. On the aisle side, attach belt with female buckle to rear tie-down pin connector .ensuring buckle rests on passenger's hip. b. On the window-side, attach belt with male tongue to rear tie-down pin connector .and insert into female buckle. 2. Attach Shoulder Belt - Extend shoulder belt over passenger's shoulder and across upper torso . and fasten pin connector onto lap belt. Note: combination lap/shoulder belts serve as both window-side lap belt and shoulder belt. 3. Ensure belts are adjusted as firmly as possible, but consistent with user comfort. Record review of Driver A's training revealed on 08/09/23 he had completed a Paratransit Operation Proficiency Evaluation Checklist which covered wheelchair securement and patient restraint. On 07/27/23 Driver A completed fleet safety program and was in serviced over appropriate use of safety straps on 01/26/24. During an observation and interview with Resident #1 on 02/01/24 at 2:26pm he stated he was transported to doctor appointments and dialysis with the use of the facility van. Resident #1 stated he had 1 incident during transportation. Resident #1 did not give an exact date of when incident occurred, when asked who buckled him in Resident #1 did not give a name and only stated, the driver. Resident #1 stated the driver of the van had made a sudden stop due to the car in front of the vehicle and caused Resident #1 to slide off wheelchair which he stated rolled under itself due to the driver only securing the back of the wheelchair. Resident #1 stated the driver had only secured the back of the wheelchair and had not hooked up the front. Resident #1 stated he was not secured with any seatbelt style hook up but stated he is now, stating the facility had corrected the issue. Resident #1 stated he had slid off the wheelchair about .8 miles away from the facility and had remained on the floor until arriving to the facility. Resident #1 stated the driver kept driving with him on the floor and stated he had told the driver to pull over, stop and get him on the chair and stated the driver did not and did not give Resident #1 a reason why. Resident #1 stated he sustained a few scratches on his leg. Resident #1 showed this surveyor a circular skin tear on right lower shin measuring approximately 5mm. Resident #1 stated he had 1 or 2 other similar sized skin tears on his left leg but stated he would not be able to show it to me due to it being wrapped up due to previous amputation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675933 If continuation sheet Page 13 of 16 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 675933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Hills Healthcare and Rehabilitation Cente 2204 Pease St Harlingen, TX 78550 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 - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview with Driver A on 02/01/24 at 2:56pm he demonstrated how he got a passenger into the facility van and secured both the chair and the resident. Driver A wheeled in the wheelchair with the Administrator seated in the chair as a passenger. Driver A secured the wheelchair with 2 hooks on the back of wheelchair and 2 on the bottom front of wheelchair and stated that was the same way he had hooked up Resident #1's wheelchair on the day of Resident #1's fall incident. Driver A also used a chest strap that went over the passenger's chest, Driver A stated this was something new and was recently added on 01/30/24 and was not used with Resident #1 on day of his fall incident. During this demonstration no lap belt/strap or shoulder belt/strap was used. Driver A stated I don't think so, no. when asked if he used any waist or lap straps/belts to secure residents. Driver A stated approximately .8 miles away from the facility the vehicle in front of him had stopped and he stopped as well and stated Resident #1 had slid forward. Driver A stated he was able to assist Resident #1 into an assisted fall by using his arm to hold Resident #1 back. Driver A stated he could not pull over because he was in the middle lane and drove to the facility while using his arm to hold up Resident #1 as much as he could. Driver A stated Resident #1 was on the floor until they arrived at the facility and once he arrived he stated he ran inside facility to get LVN B to assess and assist Resident #1. Driver A stated he did not see any bleeding or skin tears on Resident #1. Driver A stated he had completed training both before and after incident with Resident #1. Driver A was shown instruction pages for system used in facility van that he had retrieved from vehicle glove box that stated how to secure both the wheelchair and the passenger. The instruction pages stated to secure a passenger a lap belt and shoulder belt would be used. Driver A stated he had been trained over these procedures. Driver A stated he had been trained by the BOM. Driver A stated, I don't think so, no. when asked if he was using waist and lap belts/straps to secure residents. Driver A was attempted to be reached via telephone multiple times on 02/05/24 for follow up questions, however no call was answered or returned by Driver A. During observation and interview with Resident #1 on 02/02/24 at 4:20pm and the BOM assisting he was observed buckled in facility van after arriving back from dialysis. Resident #1 had 4 bottom hooks in place with 2 on front of wheelchair and 2 on the back of wheelchair. Resident #1 had a strap/belt that went around upper abdomen and under left arm and had a connector that connected to the top side of vehicle. Resident #1 stated he was not secured in that same manner on the day he fell, Resident #1 stated on the day he fell only the 2 back bottom hooks were placed on the wheelchair and stated he had no shoulder or waist/lap strap/belt used on him. Resident #1 stated he ended up with his buttocks in the air, his left stump on the floor and under the wheelchair on day of fall. During an interview with the BOM on 02/02/24 at 4:32pm she stated Driver A was responsible for ensuring Resident #1 was secured and positioned correctly in the facility van on day of Resident #1's fall incident. BOM stated she was not present during fall and only heard of about it afterwards. The BOM stated she spoke to Resident #1 on 2 different occasions after fall, stating he initially stated he was not strapped in when the BOM asked Resident #1 if he was secured and fastened. The BOM stated she later took a staff member with her as a witness to interview Resident #1 again and stated Resident #1 then stated he had been strapped in on day of his fall incident in facility van. The BOM stated they had recently added a new shoulder strap to position the residents closer to the front of the van. The BOM stated the new shoulder strap was added on 01/30/24 by Maintenance. The BOM stated previously they only had a shoulder strap in the back of the van but stated some residents liked to sit closer to the front and were secured with a lap band. The BOM stated the shoulder strap to front of vehicle was added after the incident with Resident #1. The BOM stated Driver A had been trained before starting to drive. The BOM stated they reviewed a video that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675933 If continuation sheet Page 14 of 16 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 675933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Hills Healthcare and Rehabilitation Cente 2204 Pease St Harlingen, TX 78550 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 - Minimal harm or potential for actual harm Residents Affected - Few was provided, along with user instructions and had to completed return demonstration before starting to drive. The BOM stated Driver A had been trained over securement of a passenger and the use of shoulder and waist/lap belt/straps. The BOM stated this was the only time she was aware of that a resident was not secured with use of a shoulder/waist strap/belt. The BOM was unable to answer why Resident #1 was not correctly secured due to not being there that day. The BOM stated if the seat belt was not on resident #1 then he was not properly secured. The BOM stated she monitors staff to ensure resident are being secured during transportation by doing spot checks, 1 to 1's, going on drives with staff and demonstrating what to do. The BOM stated not securing a resident during transport could affect residents emotionally by not feeling secure. The BOM stated for Resident #1 his amputation surgery site could reopen and could be devastating for residents when they don't heal. During an interview with LVN B on 02/05/24 at 4:46pm he stated he was called outside by Driver A and was told Resident #1 had fallen or slid off his wheelchair when Driver A broke when the vehicle in front of him stopped abruptly. LVN B stated Resident #1 was on the floor in front of wheelchair and was against the driver and passenger seat. LVN B stated Resident #1 had his right leg folded in and up against the passenger side and his left leg amputation stump was bearing weight, stating he was in a crotched position and his feet and bottom were on the floor. LVN B stated he did not see a belt on Resident #1 but stated the wheelchair was strapped. LVN B stated Driver A had unclipped everything and he was not able to tell which ones or how many securements there were. LVN B stated he took Resident #1's vitals, completed assessment, and notified family, DON, Resident #1'sprimary care physician and was provided with no new orders. LVN B stated Resident #1 had no pain, no injuries further stating Resident #1 did not have any new skin tears and stated his wound location where his amputation was on left leg was intact and fine with no active bleeding. During an interview with the Administrator on 02/05/24 at 2:54pm she stated from the interviews she completed she gathered Resident #1 had the bottom part of his wheelchair secured and had been advised he had on a lap belt but as far as she knew no use of shoulder strap. The Administrator stated Resident #1 was not properly secured during his transportation. The Administrator stated Driver A was responsible for securing Resident #1 on day of fall incident on 01/24/24. The Administrator stated Driver A had to brake abruptly due to vehicle in front and Resident #1 slid off wheelchair. The Administrator stated Driver A had been trained over securing a resident during transport prior to fall incident with Resident #1. The Administrator stated when they received the van they did not receive training but stated they had recently received a video after the incident with Resident #1 and stated she had requested if someone from the company that modified the facility van could provide 1 to 1 training at this time. The Administrator stated she had understood the van came with standard seatbelt straps as per regulations for wheelchair. The Administrator stated the shoulder strap this surveyor had reviewed with the BOM was not the new strap that had been added, The Administrator stated they had implemented a chest strap that goes across resident's chest but stated they won't be implementing it. The Administrator stated she was not certain why the shoulder straps were not being used and was not sure if it was patient preferences or what the reason was and stated if it was patient preferences she should have been notified. The Administrator stated they use a 4-point system on the floor to secure the wheelchair itself and a strap that goes behind chair with a lap and shoulder strap. The Administrator stated they do annual inspections, audits and maintenance to ensure the securement system in the facility van is working. The Administrator stated she monitored staff to ensure resident were being secured during transport by going over education and training during transportation during a 2-week training provided to staff before they drive on their own along with online training, annual evaluation, and stated if any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675933 If continuation sheet Page 15 of 16 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 675933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Hills Healthcare and Rehabilitation Cente 2204 Pease St Harlingen, TX 78550 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 - Minimal harm or potential for actual harm issues arose they would complete an Inservice. The Administrator stated not securing a resident properly during transportation could result in a fall. The facility did not have a policy that contained verbiage regarding securement of passengers during transportation. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675933 If continuation sheet Page 16 of 16