Health inspection·August 20, 2024

F 0760 Review of Resident #1's MAR, August 2024, reflected she was not administered the Insulin Glargine Solution on 08/02/24. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #1's physician order, dated 07/21/24, reflected Insulin Lispro Injection Solution - Inject as per sliding scale: Residents Affected - Some If 71 - 149 = 0 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 6 units; 300 - 349 = 8 units; 350 - 399 = 10 units; Greater than 399 = 12 units and notify Provider Three times a day for Diabetes before meals Review of Resident #1's MAR, July 2024, reflected her BS was not checked and she was not administered the Insulin Lispro Injection on 07/25/24 (11:00 AM and 4:00 PM), 07/26/254 (4:00 PM), 07/29/24 (7:00 AM and 4:00 PM), and 07/30/24 (11:00 AM and 4:00 PM). Review of Resident #1's MAR, August 2024, reflected her BS was not checked and she was not administered the Insulin Lispro Injection 08/02/24 (7:00 AM). Review of Resident #1's Change of Condition Communication form, dated 08/02/24, reflected the following: Signs/Symptoms: high blood sugar greater than 300, low blood pressure, change in mental status .increased confusion . slurred speech . decreased appetite. Review of Resident #1's progress notes, dated 08/02/24 at 1:15 PM and documented by LVN B, reflected the following: At 11:45 (AM) [Resident #1]'s [FM D] called inquiring about [Resident #1]. Stated her blood sugars were elevated, didn't feel good and was not going to dialysis. Shortly after the phone call, [LVN A] came and informed me that [Resident #1]'s BS was high . I notified the NP which was present in the facility. 12:10 PM - NP gave an order to administer 12 units of insulin, hydrate with water, and to recheck in 30 minutes. 12:35 PM - BS rechecked - still elevated - NP provided another order of 12 units per sliding scale to be administered. [Resident #1] had been exhibiting changes in mental status. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675942 If continuation sheet Page 2 of 5 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 675942 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Towers Nursing Home 372 Hill Road Smithville, TX 78957 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 12:40 PM - NP assessed [Resident #1] and decided to send her to the hospital for evaluation and management. Level of Harm - Immediate jeopardy to resident health or safety 1:15 PM - [Resident #1] loaded on stretcher and left facility by Ambulance to (hospital). Residents Affected - Some Review of Resident #1's progress notes, dated 08/02/24 at 11:44 PM and documented by LVN B, reflected the following: Around 12:00 (PM), [LVN A], LVN charge nurse came and informed me that [Resident #1]'s BS was reading High (glucometer unable to read) VS 102/42, 90, 99.1. [Resident #1] in bed with [FM D] at bedside - had been exhibiting changes in mental status. [LVN A] rechecking her blood sugars while I went and notified the NP. Review of Resident #1's NP assessment, dated 08/02/24, reflected the following: [Resident #1] is seen today to follow up accucheck reading of high and refusing dialysis d/t not feeling well. This was reported to this provider and orders were given to [LVN A] to admin 12 units of SSI now, vital signs, encourage water, recheck blood sugar in apx 30 mins, monitor closely and report changes/concerns. I am here now to follow up with [Resident #1] after interventions administered above, nurse rechecked accucheck s/p insulin, result reads high, therefore new orders given to nurse to administer 12 additional units of SSI. On exam, [Resident #1] appears more confused than baselined, oriented to self, unable to follow commands, notable leg jerking, she endorses headache and dizziness. D/t hx of diabetes with DKA and ESRD , recommend transfer to ED to eval and treat. Review of Resident #1's hospital medical records, dated 08/02/24, reflected the following: .BIBEMS after reportedly altered at nursing home earlier this afternoon. Nursing home reports that [Resident #1] is usually AOx4, but found confused and altered, only oriented to self. .[Resident #1] with recent admission on [DATE], briefly: . [Resident #1] was altered/not oriented on arrival, found to be in DKA and admitted to (hospital) .admitted w/DKA w/significant acidosis. Reported missed insulin dose while at SNF, which was likely precipitation factor for DKA.Found altered in nursing home by staff; given 24 lispro in nursing home, 500 mL in EMS and 1 L LR in ED. BG 574 -> 649 . Started on DKA protocol . During an interview on 08/20/24 at 10:34 AM, the ADM stated it was the DON's responsibility to ensure the MARs were completed and medication doses were not being missed. He stated she had been working closely with LVN E because she was new to long-term care. He stated once he was made aware of the medication discrepancies and lack of oversight by the DON, both LVN A and the DON were terminated. During an interview on 08/20/24 at 11:24 AM, LVN B stated Resident #1's FM D had called the nurses station on 08/02/24 around 12:00 PM. She stated FM D was upset because Resident #1 did not feel well and did not want to go to dialysis. She stated she located LVN A who told her the glucometer was reading high when she tested Resident #1's blood sugar. She stated the glucometer stops reading blood sugar levels when they are above 500. She stated she asked LVN A what her levels were that morning and LVN A stated, I did not do them. She stated she asked her why she had not checked her blood sugar, but LVN A had no answer for her. She stated missing doses of insulin repeatedly could lead to DKA. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675942 If continuation sheet Page 3 of 5 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 675942 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Towers Nursing Home 372 Hill Road Smithville, TX 78957 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some She stated it was hard to say if the missing dose of insulin on 08/02/24 was what caused Resident #1 to go into DKA, but she did have a history of it, so it was likely. She stated the importance of checking blood sugar levels and not missing insulin doses was to avoid situations like that one. She stated it was important when someone's body was not producing insulin that insulin gets administered. She stated the nurses were recently in-serviced on glucometer checks and administering insulin. During an interview on 08/20/24 at 11:55 AM, LVN C stated she worked with Resident #1 and had heard about her requiring hospitalization for DKA. She stated Resident #1 was a type I diabetic which made it more imperative that her blood sugar levels were checked regularly, and no doses of her insulin were missed. She stated with type I diabetics, they were unable to produce insulin, so no matter what they ate, the sugar levels would always spike high. She stated it was a life-or-death situation and missed doses could lead to coma, DKA, or death, especially for someone like Resident #1 who had a history of DKA. She stated the nurses had recently been in-serviced on accuchecks and insulin administration. During an interview on 08/20/24 at 1:14 PM, the NP stated when the nursing staff alerted her on 08/02/24 that Resident #1's blood sugar was reading high, she ordered 12 units of insulin, asked them to push fluids, and to re-check her levels in an hour. She stated when it was still high, she gave orders for more insulin. She stated that along with Resident #1's comorbidities and her being altered for her baseline, she made the decision to send her to the hospital at that time. She stated that there were multiple risk factors for DKA and did not believe missing the insulin doses was what caused her to go into DKA. During an interview on 08/20/24 at 1:37 PM, the MD stated if a resident was missing multiple doses of insulin, it would concern him as it could cause blood sugar to be unstable. He stated Resident #1's blood sugar was controlled until that day (08/02/24), so he would not say the missed dose that morning was what had caused DKA. He stated individuals with type I diabetes go into DKA a lot. During an interview on 08/20/24 at 4:15 PM, LVN E stated the nursing staff had recently been provided in-serviced on accuchecks, insulin, following physician orders, and administering medications timely. She stated they also did check-offs with the DON. She stated it was important for insulin to get administered as ordered because it could lead to coma or death. During an inteview on 08/20/24 at 4:33 PM, the Interim DON stated she reviewed a report of missed medications the prior day that was generated by their EMR system every morning to investigate the reasoning for the missed doses. On 08/20/24, several attempts were made to contact LVN A. A returned call was not received prior to exiting . Review of the facility's QAPI Meeting Agenda, dated 08/02/24, reflected the ADM, the DON, the MD, the ADON, and the RNRCS were in attendance to discuss diabetics, accuchecks, physician orders, changes in condition, and medication administration. Review of the DON an LVN A's termination documents, dated 08/04/24, reflected both were terminated. Review of a statement, dated 08/02/24 and documented by the ADM, reflected the following: [Pharmacist] consultant was notified via phone by the Administrator regarding the medication error (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675942 If continuation sheet Page 4 of 5 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 675942 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Towers Nursing Home 372 Hill Road Smithville, TX 78957 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some that occurred on 08/02/24. Administrator request a pharmacist visit to review all resident in facility with orders for accuchecks and or insulin orders/antidiabetic medications. Visit was scheduled for 08/09/24. Review of an audit conducted by the Pharmacist, dated 08/09/24, reflected no recommendations were made. Review of an audit conducted by the DON/clinical team, dated 08/02/24, reflected no residents with orders for accuchecks and insulin had been affected and had been receiving treatments according to physician orders. Review of in-services entitled AccuChecks/Medication Administration, from 08/02/24 - 08/06/24 and conducted by the DON and ADON, reflected all nurses were in-serviced on timely accuchecks and medication administration: Importance of Timely Accuchecks and Medication Administration - Resident Safety: Consistent and timely blood glucose checks and medication administration are vital to managing chronic conditions like diabetes, preventing adverse events such as hypo- or hyperglycemia. - Compliance with Physician Orders: Adherence to prescribed schedules ensures that residents receive their treatments as intended by their healthcare providers. - Legal and Regulatory Compliance: Accurate and timely documentation is necessary to meeting regulatory requires and avoid potential legal liabilities. Review of in-services entitled Accu Checks/Medication Administration, from 08/02/24 - 08/03/24 and conducted by the DON and the ADON, reflected all nurses were in-serviced on timely accuchecks and medication administration. Review of in-services entitled Medication Administration, from 08/02/24 - 08/06/24 and conducted by the DON and the ADON, reflected all nurses were in-serviced on their Medication Administration Policy. Review of the facility's Medication Administration Policy, dated 10/01/19, reflected the following: Medications are administered as prescribed in accordance with good nursing principles and practices only by persons legally authorized to do so. Review of Medication Pass and Obtaining Blood Sugar Readings checkoffs, dated 08/02/24 - 08/07/24, reflected all nurses and medication aides completed competency checkoffs with no concerns. The noncompliance was identified as PNC. The IJ began on 08/02/24 and ended on 08/09/24. The facility had corrected the noncompliance before the survey began. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675942 If continuation sheet Page 5 of 5