Health inspection·September 22, 2023

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the electronic health record revealed that Resident #61 did not have a consent for use of the wander guard. Record review of Resident #61's physician orders revealed Wander guard placed to right wrist to alert staff if resident attempts to exit facility unassisted d/t high risk for wandering. EXP August 2026 with no start date for the order. During an interview and observation with Resident #61 on 09/21/23 beginning at 10:58 a.m., resident stated he was trying to figure out how to go home and didn't understand why his wife did not visit more often. A wander guard was observed on Resident #61's wrist during this conversation. 2. Record review of Resident #82's face sheet, dated 09/22/23 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), delusional disorders, intermittent explosive disorder, and altered mental status. Record review of Resident #82's most recent admission MDS assessment, dated 08/16/23 revealed the resident was severely cognitively impaired for daily decision-making skills and used a wander/elopement alarm daily. Record review of Resident #82's comprehensive care plan, revision date 09/08/23 revealed the resident was an elopement risk/wanderer with wander guard placed on the resident's left lower extremity with interventions that included to alert staff if resident attempts to exit facility unassisted due to high risk for wandering. Record review of Resident #82's Wandering/Elopement Risk Evaluation, dated 08/09/23 revealed the resident was at moderate risk for elopement. Record review of the electronic record revealed Resident #82 did not have a consent for the use of a wander guard. During an observation on 09/20/23 at 11:31 a.m., Resident #82 was observed self-ambulating in the 300 Unit and a wander guard was observed on the resident's left ankle. During an observation and interview on 09/22/23 beginning at 10:09 a.m., Resident #82 was observed lying in bed and a wander guard was observed on the resident's left ankle. Resident #82 stated she did not know what the thing on her left ankle was and it was placed on her ankle by the facility and was told not to take it off. Resident #82 stated was told by facility staff, could not remember who, that the thing on her ankle was supposed to tell where she was. Resident #82 stated she could not remove the thing and did not like that because it's my body. During an interview on 09/22/23 at 10:23 a.m., LVN B revealed Resident #82 wore a wander guard on the left ankle and was checked daily to ensure the wander guard was operating effectively. LVN B stated Resident #82 had worn the wander guard since the resident had been living in the facility. 3. Record review of Resident #40's face sheet, dated 09/22/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included psychotic disorder with delusions, dementia, major depressive disorder, and age-related physical debility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 2 of 26 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 675974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Valley Health & Rehabilitation Center 913 Hwy 90 W Castroville, TX 78009 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #40's most recent quarterly MDS assessment, dated 08/24/23 revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #40's comprehensive care plan, revision date 09/21/23 revealed the resident was an elopement risk/wandered related to history of attempts to leave facility unattended, had impaired safety awareness with interventions that included wander guard placed to left ankle to alert staff if resident attempts to exit facility unassisted due to high risk for wandering. Record review of Resident #40's Wandering/Elopement Risk Evaluation, dated 07/13/23 revealed the resident was at moderate risk for elopement. Record review of the electronic record revealed Resident #40 did not have a consent for the use of a wander guard. During an interview on 09/22/23 at 4:40 p.m., the Administrator revealed, any documents related to the use of a wander guard were found in the electronic record. The Administrator revealed the facility had a wander guard binder that identified each resident with a wander guard, and it included a picture of the resident and a brief synopsis of the resident such as name, date of birth and diagnosis. The Administrator revealed residents who used wander guards needed to have a physician's order, a quarterly assessment and the wander guard needed to be care planned. The Administrator revealed she was unsure about having to have a consent. The Administrator revealed, families of residents who used wander guards were notified either in person or by phone and documented in the resident's progress note in the electronic record. The Administrator stated the charge nurse assigned to the resident was responsible for notifying the family/responsible party and documenting the notification in the resident's electronic records under the progress notes. During an observation and interview on 09/22/23 beginning at 4:48 p.m., the DON revealed after a resident is assessed for wandering and a wander guard is deemed necessary, the facility will obtain an order. The DON revealed the charge nurse assigned to the resident would be responsible for notifying the family/responsible person that a wander guard was placed, and the notification should have been documented in the resident's electronic record under the progress notes. After reviewing the electronic record for Residents #61, #82 and #40, the DON was unable to locate a progress note indicating the resident's family/responsible party had been notified the residents were using a wander guard. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 3 of 26 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 675974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Valley Health & Rehabilitation Center 913 Hwy 90 W Castroville, TX 78009 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible, for 1 of 2 Residents (Resident #76) reviewed for perineal/incontinent care, in that: CNA C failed to clean between Resident #76's vaginal folds during incontinent/peri care This deficient practice could place residents at risk of increased urinary tract infections due to improper care. The findings included: Record review of Resident #76's face sheet, dated 9/22/23 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included urinary tract infection, lack of coordination and stage 3 chronic kidney disease (kidneys are damaged and can't filter blood the way they should). Record review of Resident #76's most recent quarterly MDS assessment, dated 6/23/23 revealed the resident was moderately cognitively impaired for daily decision-making skills and was always incontinent of bowel and bladder. Record review of Resident #76's comprehensive care plan, revision date 7/19/23 revealed the resident was at risk of urinary tract infections related to history of urinary tract infections with interventions that included for caregiver teaching to include good hygiene practices, wipe and cleanse from front to back and clean peri area well after bowel movement in order to help prevent bacteria in urinary tract. During an interview on 9/19/23 at 10:39 a.m., Resident #76 revealed she believed she had a urinary tract infection and stated, they leave me soiled most of the time, not always. Observation on 9/21/23 at 4:43 p.m., during incontinent/peri care revealed, CNA C took one wipe and wiped Resident #75's vaginal area from front to back with one pass. CNA C did not clean between Resident #76's vaginal folds. During an interview on 9/21/23 at 5:02 p.m., CNA C stated she had done competency training of female incontinent/peri care approximately 6 months ago. CNA C stated she did not clean between Resident #76's vaginal folds because the resident was contracted, and the resident would not be able to open her legs. CNA C stated, if we move Resident #76's legs too far apart you can actually hear her legs 'crackle' that's why we can't do too much peri care on her. During an interview on 9/22/23 at 1:24 p.m., the DON revealed she was aware Resident #76 had contractures but should have been able to tolerate incontinent/peri care. The DON revealed, wiping down the middle of Resident #76's vagina with one wipe but not cleaning between the vaginal folds was not proper peri care and was considered incomplete incontinent/peri care. The DON revealed, CNA C should have cleaned between Resident #76's vaginal folds because there could be bacteria or urine or feces (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 4 of 26 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 675974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Valley Health & Rehabilitation Center 913 Hwy 90 W Castroville, TX 78009 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 0690 between the vaginal folds and it could cause an infection. Level of Harm - Minimal harm or potential for actual harm Record review of the competency training titled, CNA Proficiency/Evaluation Tool, Perineal Care, dated 9/1/23 revealed CNA C had satisfied the requirements for completing incontinent/peri care. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 5 of 26 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 675974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Valley Health & Rehabilitation Center 913 Hwy 90 W Castroville, TX 78009 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, and described in the plan of care for 4 of 7 residents (Resident #19, #80, #24, and #20) reviewed for nursing competencies, in that: LVN A failed to administer 7 medications outside of acceptable parameters for safe medication administration for Residents #19, #80, #24 and #20 and stored 2 medication cups with loose pills inside the medication cart. This failure could place residents at risk for not receiving their medications, not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions. The findings included: Record review of the nursing competency dated 7/25/23 for LVN E revealed she had satisfied the requirements for medication administration that included executing the 5 rights of medication administration (right patient, right medication, right dose, right time, right route) and giving medication to client following instructions noted in medication book. Observation on 9/20/23 beginning at 3:26 p.m. to 4:40 p.m., of the medication pass in the 300 Unit, revealed LVN A administered two medications to 1 resident at 4:10 p.m. LVN A then excused herself in the middle of medication pass and was observed leaving the unit, going in and out of resident's rooms within the 300 Unit and sat behind the nurse's station in the 300 Unit between 3:26 p.m. to 4:40 p.m. LVN A returned to her medication cart in the 300 Unit and announced to the surveyor she was finished with medication pass. During an observation and interview on 9/20/23 beginning at 4:40 p.m., LVN A opened her medication cart used on the 300 Unit and revealed 2 medication cups with loose pills stored on the top drawer of the medication cart. LVN A stated Resident #82 found the medication cups with loose pills in her room and gave them to LVN A. LVN A identified one medication cup had an Eliquis (an anticoagulant) pill and the other cup had two acetaminophen (over the counter fever reducer, pain relieving) pills. LVN A stated the cups with pills were given to her by Resident #82 at approximately 3:15 p.m. today and should have been discarded at that time but got busy and forgot. During an observation and interview on 9/20/23 beginning at 4:47 p.m., the DON walked into the 300 Unit and looked at the two medication cups with loose pills and was asked if she could identify the pills in the cups placed on top of the 300 Unit medication cart used by LVN A. The DON stated, no I cannot, not by looking at them. The DON asked LVN A about the medication cups with loose pills and LVN A stated the medication cups with loose pills were given to her by Resident #82 and were placed inside the top drawer of the medication cart and forgot to discard them. The DON instructed LVN A to dispose of the two medication cups with loose pills. During a follow up interview on 9/20/23 at 4:50 p.m., LVN A revealed, the two medication cups with loose pills found on the 300 Unit top drawer of the medication cart should have been discarded at the time she received them from Resident #82 because loose pills in the medication cart were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 6 of 26 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 675974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Valley Health & Rehabilitation Center 913 Hwy 90 W Castroville, TX 78009 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 0726 considered contaminated. LVN A stated she got busy and forgot to discard the pills. Level of Harm - Minimal harm or potential for actual harm During a follow up interview on 9/20/23 at 5:15 p.m., the DON stated, medications should not be pulled in advance and stated, in my mind it sounds like maybe she (LVN A) popped the pills and then couldn't find the resident, then LVN A put it back in the cart and LVN A knew what it was (the pills) without looking it up. LVN A should not have done that. The DON was asked to provide a Medication Administration Audit Report of the medication pass for LVN A for 9/20/23. Residents Affected - Few 1a. Record review of Resident #19's face sheet, dated 9/21/23 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] and 3/24/23 with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with agitation, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy). Record review of Resident #19's most recent quarterly MDS assessment, dated 8/24/23 revealed the resident was severely cognitively impaired and required insulin injections. Record review of Resident #19's comprehensive care plan, revision date 9/21/23 revealed the resident had diabetes and was at risk for acute diabetic episodes with interventions that included to administer diabetes medications as ordered by doctor. Record review of Resident #19's order summary report, dated 9/21/23 revealed the following: -Admelog Solostar Subcutaneous Solution Pen Injector 100 unit/ml (Insulin Lispro), inject as per sliding scale subcutaneously before meals and at bedtime related to type 2 diabetes with order date 4/12/23 and no end date 1b. Record review of Resident #80's face sheet, dated 9/21/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included heart failure, dementia, hyperlipidemia (high cholesterol), altered mental status, cognitive communication deficit and paroxysmal atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Record review of Resident #80's most recent quarterly MDS assessment, dated 8/11/23 revealed the resident was severely cognitively impaired for daily decision-making skills and required an anticoagulant and diuretic. Record review of Resident #80's comprehensive care plan, revision date 9/8/23 revealed the resident used anticoagulant therapy related to atrial fibrillation with interventions that included to administer anti-coagulant medications as ordered by the physician. Record review of Resident #80's order summary report, dated 9/21/23 revealed the following: -Eliquis oral tablet 5 mg, give 1 tablet by mouth two times a day related to chronic atrial fibrillation with order dated 6/22/23 and no end date 1c. Record review of Resident #24's face sheet, dated 9/21/23 revealed an [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 7 of 26 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 675974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Valley Health & Rehabilitation Center 913 Hwy 90 W Castroville, TX 78009 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few vascular dementia (a common form of dementia caused by an impaired supply of blood to the brain, stroke), dysphagia (difficulty swallowing), hemiplegia affecting right dominant side (paralysis of partial or total body function on one side of the body), gastroesophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach, esophagus), and seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movement, behaviors, sensations or states of awareness.) Record review of Resident #24's most recent significant change MDS assessment, dated 6/29/23 revealed the resident was severely cognitively impaired for daily decision-making skills, and required insulin injections. Record review of Resident #24's comprehensive care plan, revision date 9/18/23 revealed the resident had a history of refusing to take medications with interventions that included to re-approach the resident at intervals and had diabetes and gastroesophageal reflux disease with interventions to administer medications as ordered and had a seizure disorder with interventions to give medications as ordered. Record review of Resident #24's order summary report, dated 9/21/23 revealed the following: -Dexcom G6 device used to check blood sugars with order date 3/27/23 and no end date -Famotidine oral tablet 20 mg, give 1 tablet by mouth two times a day related to gastroesophageal reflux disease with order date 3/29/23 and no end date -Humalog injection solution 100 unit/ml (Insulin Lispro) inject per sliding scale subcutaneously before meals related to type 2 diabetes with order date 3/30/23 and no end date -Levetiracetam (Keppra) oral solution 100 mg/ml give 10 ml by mouth two times a day related to seizures with order date 3/29/23 and no end date -Metformin oral tablet 500 mg, give 1 tablet by mouth two times a day related to type 2 diabetes with order date 3/29/23 and no end date 1d. Record review of Resident #20's face sheet, dated 9/21/23 revealed an [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), heart failure, cognitive communication deficit, edema (swelling of extremities), hyperlipidemia (high cholesterol), hypertension (high blood pressure), and chronic kidney disease (longstanding disease of the kidneys leading to kidney failure). Record review of Resident #20's most recent quarterly MDS assessment, dated 8/31/23 revealed the resident was severely cognitively impaired for daily decision-making skills and required an anticoagulant. Record review of Resident #20's comprehensive care plan, revision date 9/19/23 revealed the resident received anticoagulant therapy with interventions that included to administer anticoagulant medications as ordered by the physician. Record review of Resident #20's order summary report, dated 9/21/23 revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 8 of 26 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 675974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Valley Health & Rehabilitation Center 913 Hwy 90 W Castroville, TX 78009 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 0726 Level of Harm - Minimal harm or potential for actual harm -Xarelto oral tablet 15 mg, give 1 tablet by mouth in the evening related to atherosclerotic heart disease, take with dinner with order date 1/10/23 and no end date. Record review of the Medication Administration Audit Report, dated 9/21/23 and provided by the DON revealed the following: Residents Affected - Few -9/20/23 Resident #19 was scheduled Admelog (Lispro) Solostar Insulin per sliding scale at 4:30 p.m. The audit revealed LVN A documented the insulin to Resident #19 was administered at 4:01 p.m. and documented as given at 4:02 p.m. -9/20/23 Resident #80 was scheduled Eliquis 5 mg at 5:00 p.m. The audit revealed LVN A documented the Eliquis for Resident #80 was administered at 4:03 p.m. and documented as given at 4:03 p.m. -9/20/23 Resident #24 was scheduled Keppra 100 mg/ml, Famotidine 20 mg, Metformin 500 mg and Humalog insulin at 4:00 p.m. The audit revealed LVN A documented Keppra, Famotidine and Metformin for Resident #24 was administered at 4:23 p.m. and documented as given at 4:23 p.m. The audit further revealed LVN A documented the Humalog insulin to Resident #24 was administered at 4:34 p.m. and documented as given at 4:34 p.m. -9/20/23 Resident #20 was scheduled Xarelto 15 mg at 5:00 p.m. The audit revealed LVN A documented the Xarelto for Resident #20 was administered at 4:34 p.m. and documented as given at 4:34 p.m. During a joint interview on 9/21/23 at 2:39 p.m., the DON and Administrator revealed, after reviewing the random audits of the Medication Administration Audit Report dated 9/21/23, revealed LVN E had been suspended for allowing Resident #43 to self-administer his Advair inhaler without an order or an assessment and for lying to HHSC Surveyor. The DON revealed monthly audits were performed by the ADON who would pull a random MAR (medication administration record) and check to ensure medications were given within the time frame allowed, to ensure there were no blank spaces in the MAR and to check for errors. The DON revealed if an error was found then the facility would investigate. The DON and Administrator revealed it could not be determined LVN A had not given Resident #19, #80, #24 and #20 their medications based on the report but after the surveyor gave a timeline of the events during the medication pass, it was determined LVN A had falsified the medication record. During a telephone interview on 9/22/23 at 3:43 p.m. LVN E revealed, she had administered the medications to Resident's #19, #80, #24 and #20, but admitted she had given the medications before the scheduled time. LVN E revealed, in order to remember who she had given medications to before the scheduled time, she took a piece of paper in which vital signs were written, flipped the page over and wrote down each resident's name. LVN E stated she then went to the computer at a later time and documented in the MAR. LVN E stated she worked the 2:00 p.m. to 10:00 p.m. shift and would make rounds at the beginning of her shift and start to administer medications to stay ahead. LVN E stated, Resident #24 gets combative and it's easier for me to try to give (his medications) early. LVN E stated once the medications were documented in the computer, the piece of paper she used to write the names of the residents she had given medications to was put in the shredder box. LVN E stated she admitted ly was taking shortcuts to stay ahead. LVN E revealed, it was wrong and incorrect to administer medications before the scheduled time because medications given too close together could negatively interact with other medications, such as insulin or antibiotics, because those medications needed to be given at a specific time to keep the medication working. LVN E stated, again, I was taking shortcuts, trying to get by, but it was not okay to break the rules. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 9 of 26 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 675974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Valley Health & Rehabilitation Center 913 Hwy 90 W Castroville, TX 78009 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the facility policy and procedure titled Medication Storage, copyright 2023 revealed in part, .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .All drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) .During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart . Record review of the facility policy and procedure titled Documentation of Medication Administration, revision date April 2007 revealed in part, .The facility shall maintain a medication administration record to document all medications administered .A nurse .shall document all medications administered to each resident on the resident's medication record (MAR) .Administration of medication must be documented immediately after (never before) it is given. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 10 of 26 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 675974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Valley Health & Rehabilitation Center 913 Hwy 90 W Castroville, TX 78009 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 0759 Ensure medication error rates are not 5 percent or greater. 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 it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 32% based on 8 out of 25 opportunities, which involved 5 of 7 Residents (Residents #43, #19, #80, #24, and #20) reviewed for medication administration, in that: Residents Affected - Few LVN A allowed Resident #43 to self-administer his inhaler without a physician's order or assessment and failed to administer 7 medications outside of acceptable parameters for safe medication administration for Residents #19, #80, #24 and #20. This failure could place residents at risk for not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions. The findings included: 1. Record review of Resident #43's face sheet, dated 9/21/23 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included chronic respiratory failure with hypoxia (not enough oxygen in your blood, but your levels of carbon dioxide are close to normal), heart failure, morbid obesity, hypertension (high blood pressure), dependence on supplemental oxygen and edema (swelling of extremities). Record review of Resident #43's most recent quarterly MDS assessment, dated 6/2/23 revealed the resident was moderately cognitively impaired for daily decision-making skills. Record review of Resident #43's comprehensive care plan revealed the resident had congestive heart failure with interventions that included to administer cardiac medications as ordered and was on anticoagulant therapy related to atrial fibrillation with interventions that included to administer medication as ordered by the physician. Further review of the comprehensive care plan revealed Resident #43 used oxygen therapy related to shortness of breath with interventions for continuous oxygen therapy. Record review of Resident #43's order summary report, dated 9/21/23 revealed the following: -Eliquis tablet 5 mg, give 1 tablet two times a day related to paroxysmal atrial fibrillation, order date 10/21/22 and no end date -Advair Diskus Inhalation Aerosol Powder Breath Activated 250-50 mcg/act, 1 puff inhale orally two times a day related to acute respiratory failure with hypoxia, rinse mouth after each use, with order dated 2/3/23 and no end date. -Review of the order summary report revealed there was no order for Resident #43 to self-administer medications Record review of Resident #43's clinical record revealed there was no assessment for the resident to be able to self-administer medications Observation on 9/20/23 at 4:10 p.m. revealed LVN A dispensed one Eliquis tablet 5mg to Resident #43 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 11 of 26 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 675974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Valley Health & Rehabilitation Center 913 Hwy 90 W Castroville, TX 78009 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and then handed the Advair Diskus Inhalation Aerosol Powder Breath Activated 250-50 mcg/act inhaler to Resident #43. Resident #43 administered the inhaler without LVN A's help. LVN A then took the inhaler from Resident #43 and stored it in the medication cart. During an interview on 9/20/23 at 4:50 p.m., LVN A revealed she was not sure if Resident #43 was able to self-administer the Advair Diskus inhaler and was not sure if the resident had had an assessment but had encouraged the resident to self-administer the inhaler in the past. LVN A stated she was not sure if Resident #43 was able to self-administer medications. During an interview on 9/20/23 at 5:15 p.m., the DON revealed, Resident #43 had not had an assessment to self-administer medications and in addition to the assessment, the resident would have to have it care planned that the resident could self-administer medications. 2a. Record review of Resident #19's face sheet, dated 9/21/23 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] and 3/24/23 with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with agitation, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy). Record review of Resident #19's most recent quarterly MDS assessment, dated 8/24/23 revealed the resident was severely cognitively impaired and required insulin injections. Record review of Resident #19's comprehensive care plan, revision date 9/21/23 revealed the resident had diabetes and was at risk for acute diabetic episodes with interventions that included to administer diabetes medications as ordered by doctor. Record review of Resident #19's order summary report, dated 9/21/23 revealed the following: -Admelog Solostar Subcutaneous Solution Pen Injector 100 unit/ml (Insulin Lispro), inject as per sliding scale subcutaneously before meals and at bedtime related to type 2 diabetes with order date 4/12/23 and no end date 2b. Record review of Resident #80's face sheet, dated 9/21/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included heart failure, dementia, hyperlipidemia (high cholesterol), altered mental status, cognitive communication deficit and paroxysmal atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Record review of Resident #80's most recent quarterly MDS assessment, dated 8/11/23 revealed the resident was severely cognitively impaired for daily decision-making skills and required an anticoagulant and diuretic. Record review of Resident #80's comprehensive care plan, revision date 9/8/23 revealed the resident used anticoagulant therapy related to atrial fibrillation with interventions that included to administer anti-coagulant medications as ordered by the physician. Record review of Resident #80's order summary report, dated 9/21/23 revealed the following: -Eliquis oral tablet 5 mg, give 1 tablet by mouth two times a day related to chronic atrial (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 12 of 26 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 675974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Valley Health & Rehabilitation Center 913 Hwy 90 W Castroville, TX 78009 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 0759 fibrillation with order dated 6/22/23 and no end date Level of Harm - Minimal harm or potential for actual harm 2c. Record review of Resident #24's face sheet, dated 9/21/23 revealed an [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), vascular dementia (a common form of dementia caused by an impaired supply of blood to the brain, stroke), dysphagia (difficulty swallowing), hemiplegia affecting right dominant side (paralysis of partial or total body function on one side of the body), gastroesophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach, esophagus), and seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movement, behaviors, sensations or states of awareness.) Residents Affected - Few Record review of Resident #24's most recent significant change MDS assessment, dated 6/29/23 revealed the resident was severely cognitively impaired for daily decision-making skills, and required insulin injections. Record review of Resident #24's comprehensive care plan, revision date 9/18/23 revealed the resident had a history of refusing to take medications with interventions that included to re-approach the resident at intervals and had diabetes and gastroesophageal reflux disease with interventions to administer medications as ordered and had a seizure disorder with interventions to give medications as ordered. Record review of Resident #24's order summary report, dated 9/21/23 revealed the following: -Dexcom G6 device used to check blood sugars with order date 3/27/23 and no end date -Famotidine oral tablet 20 mg, give 1 tablet by mouth two times a day related to gastroesophageal reflux disease with order date 3/29/23 and no end date -Humalog injection solution 100 unit/ml (Insulin Lispro) inject per sliding scale subcutaneously before meals related to type 2 diabetes with order date 3/30/23 and no end date -Levetiracetam (Keppra) oral solution 100 mg/ml give 10 ml by mouth two times a day related to seizures with order date 3/29/23 and no end date -Metformin oral tablet 500 mg, give 1 tablet by mouth two times a day related to type 2 diabetes with order date 3/29/23 and no end date 2d. Record review of Resident #20's face sheet, dated 9/21/23 revealed an [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), heart failure, cognitive communication deficit, edema (swelling of extremities), hyperlipidemia (high cholesterol), hypertension (high blood pressure), and chronic kidney disease (longstanding disease of the kidneys leading to kidney failure). Record review of Resident #20's most recent quarterly MDS assessment, dated 8/31/23 revealed the resident was severely cognitively impaired for daily decision-making skills and required an anticoagulant. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 13 of 26 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 675974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Valley Health & Rehabilitation Center 913 Hwy 90 W Castroville, TX 78009 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 0759 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #20's comprehensive care plan, revision date 9/19/23 revealed the resident received anticoagulant therapy with interventions that included to administer anticoagulant medications as ordered by the physician. Record review of Resident #20's order summary report, dated 9/21/23 revealed the following: Residents Affected - Few -Xarelto oral tablet 15 mg, give 1 tablet by mouth in the evening related to atherosclerotic heart disease, take with dinner with order date 1/10/23 and no end date. Record review of the Medication Administration Audit Report, dated 9/21/23 and provided by the DON revealed the following: -9/20/23 Resident #19 was scheduled Admelog (Lispro) Solostar Insulin per sliding scale at 4:30 p.m. The audit revealed LVN A documented the insulin to Resident #19 was administered at 4:01 p.m. and documented as given at 4:02 p.m. -9/20/23 Resident #80 was scheduled Eliquis 5 mg at 5:00 p.m. The audit revealed LVN A documented the Eliquis for Resident #80 was administered at 4:03 p.m. and documented as given at 4:03 p.m. -9/20/23 Resident #24 was scheduled Keppra 100 mg/ml, Famotidine 20 mg, Metformin 500 mg and Humalog insulin at 4:00 p.m. The audit revealed LVN A documented Keppra, Famotidine and Metformin for Resident #24 was administered at 4:23 p.m. and documented as given at 4:23 p.m. The audit further revealed LVN A documented the Humalog insulin to Resident #24 was administered at 4:34 p.m. and documented as given at 4:34 p.m. -9/20/23 Resident #20 was scheduled Xarelto 15 mg at 5:00 p.m. The audit revealed LVN A documented the Xarelto for Resident #20 was administered at 4:34 p.m. and documented as given at 4:34 p.m. Observation on 9/20/23 beginning at 3:26 p.m. to 4:40 p.m., of the medication pass in the 300 Unit, revealed the following: -3:26 p.m., LVN A removed a pill from a medication blister pack and placed it on her ungloved hand and placed the pill in a medication cup. LVN A was approached by this surveyor and was asked if she was in the middle of medication pass. LVN A confirmed she was in the middle of medication pass and was instructed to finish with the medication she was observed placing in the medication cup with her ungloved hand and was informed this surveyor would observe the next medication administered. -3:28 p.m., LVN A entered room [ROOM NUMBER]B in the 300 Unit with the medication cup intended for Resident #57 -3:31 p.m., LVN A continued in room [ROOM NUMBER] and assisted Resident #57, sitting in a wheelchair into the bathroom -3:32 p.m., LVN A exited the bathroom in room [ROOM NUMBER] and went to the linen cart across from room [ROOM NUMBER], in front of the nurse's station on the 300 Unit and retrieved a pair of socks. LVN A returned to room [ROOM NUMBER] and helped Resident #64 in room [ROOM NUMBER]A put on his socks. -3:43 p.m., LVN A continued in room [ROOM NUMBER] and was seen talking to Resident #57 after she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 14 of 26 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 675974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Valley Health & Rehabilitation Center 913 Hwy 90 W Castroville, TX 78009 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 0759 helped him to his side of the room from the bathroom Level of Harm - Minimal harm or potential for actual harm -3:44 p.m., LVN A exited room [ROOM NUMBER], returned to the medication cart still in the 300 Unit and documented in her tablet. LVN A stated, Resident #57 had requested x-ray results from the previous day and would take her tablet into the resident's room to provide education. This surveyor told LVN A I would wait for her until she was finished with the Resident #57. Residents Affected - Few -3:52 p.m., LVN A exited room [ROOM NUMBER] and told this surveyor she needed to make a phone call to a medical clinic and went to the nurse's station in the 300 Unit, sat behind the computer and was seen making a phone call -4:06 p.m., LVN A left the nurse's station on the 300 Unit, returned to her medication cart, and excused herself and stated she needed to do something first and left the 300 Unit. -4:10 p.m., LVN A returned to the 300 Unit, opened the medication cart, and revealed she was ready to continue medication pass. LVN A then retrieved an Eliquis 5 mg pill from the blister pack, placed the pill in her ungloved hand and placed the pill in a medication cup. LVN A then retrieved the Advair Diskus Inhalation inhaler from the medication cart. LVN A then took the Eliquis and the Advair inhaler into Resident #43's room. LVN A gave the Eliquis pill to Resident #43 and the resident took the pill with water. LVN A then gave Resident #43 the Advair Diskus inhaler and the resident took the inhaler and administered one puff into his mouth and handed the inhaler back to LVN A. -4:13 p.m., LVN A returned to the medication cart, and then excused herself once again. LVN A stated she needed to do something first and left the unit. -4:19 p.m., LVN A returned to the 300 unit, walked behind the computer at the nurse's station and sat down. LVN A stated she needed to go into the computer and look up a telephone number for Resident #57. -4:21 p.m., LVN A then got up from behind the nurse's station, retrieved a piece of paper from the copy machine at the 300 Unit nurse's station and went back into room [ROOM NUMBER]. LVN A then returned to the 300 Unit nurse's station and sat behind the computer. -4:25 p.m., LVN A then left the 300 Unit nurse's station and entered a room within the 300 Unit with a mechanical lift. -4:32 p.m., LVN A then exited the room within the 300 Unit with the mechanical lift and a plastic bag with clothing. LVN A entered room [ROOM NUMBER] to wash her hands, returned to the 300 Unit nurse's station and sat down behind the computer. -4:40 p.m., LVN A then eventually returned to the medication cart in the 300 Unit and stated to the surveyor she was done with medication pass and stated, I thought you were only observing. During an interview on 9/20/23 at 4:50 p.m., LVN A revealed, Resident #43 had been encouraged to self-administer his Advair inhaler but was not aware if the resident had an assessment or an order to self-administer medication. LVN A then stated, Resident #43 was able to self-medicate. During a joint interview on 9/21/23 at 2:39 p.m., the DON and Administrator revealed, after reviewing the random audits of the Medication Administration Audit Report dated 9/21/23, revealed LVN E had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 15 of 26 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 675974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Valley Health & Rehabilitation Center 913 Hwy 90 W Castroville, TX 78009 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few been suspended for allowing Resident #43 to self-administer his Advair inhaler without an order or an assessment and for lying to HHSC Surveyor. The DON revealed monthly audits were performed by the ADON who would pull a random MAR (medication administration record) and check to ensure medications were given within the time frame allowed, to ensure there were no blank spaces in the MAR and to check for errors. The DON revealed if an error was found then the facility would investigate. The DON and Administrator revealed it could not be determined LVN A had not given Resident #19, #80, #24 and #20 their medications based on the report but after the surveyor gave a timeline of the events during the medication pass, it was determined LVN A had falsified the medication record. During a follow up telephone interview on 9/22/23 at 3:43 p.m. LVN E revealed, she had administered the medications to Resident's #19, #80, #24 and #20, but admitted she had given the medications before the scheduled time. LVN E revealed, in order to remember who she had given medications to before the scheduled time, she took a piece of paper in which vital signs were written, flipped the page over and wrote down each resident's name. LVN E stated she then went to the computer at a later time and documented in the MAR. LVN E stated she worked the 2:00 p.m. to 10:00 p.m. shift and would make rounds at the beginning of her shift and start to administer medications to stay ahead. LVN E stated, Resident #24 gets combative and it's easier for me to try to give (his medications) early. LVN E stated once the medications were documented in the computer, the piece of paper she used to write the names of the residents she had given medications to was put in the shredder box. LVN E stated she admitted ly was taking shortcuts to stay ahead. LVN E revealed, it was wrong and incorrect to administer medications before the scheduled time because medications given too close together could negatively interact with other medications, such as insulin or antibiotics, because those medications needed to be given at a specific time to keep the medication working. LVN E stated, again, I was taking shortcuts, trying to get by, but it was not okay to break the rules. Record review of the nursing competency dated 7/25/23 for LVN E revealed she had satisfied the requirements for medication administration. Record review of the facility policy and procedure titled Documentation of Medication Administration, revision date April 2007 revealed in part, .The facility shall maintain a medication administration record to document all medications administered .A nurse .shall document all medications administered to each resident on the resident's medication record (MAR) .Administration of medication must be documented immediately after (never before) it is given . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 16 of 26 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 675974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Valley Health & Rehabilitation Center 913 Hwy 90 W Castroville, TX 78009 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents are free of any significant medication errors for 2 of 7 residents (Resident #19 and #24) observed during medication administration in that: Residents Affected - Few LVN A failed to administer Resident #19's insulin and Resident #24's insulin and seizure medication as prescribed by the physician. These deficient practices placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. The findings included: 1. Record review of Resident #19's face sheet, dated 9/21/23 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] and 3/24/23 with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with agitation, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy). Record review of Resident #19's most recent quarterly MDS assessment, dated 8/24/23 revealed the resident was severely cognitively impaired and required insulin injections. Record review of Resident #19's comprehensive care plan, revision date 9/21/23 revealed the resident had diabetes and was at risk for acute diabetic episodes with interventions that included to administer diabetes medications as ordered by doctor. Record review of Resident #19's order summary report, dated 9/21/23 revealed the following: -Admelog Solostar Subcutaneous Solution Pen Injector 100 unit/ml (Insulin Lispro, a short-acting insulin), inject as per sliding scale subcutaneously before meals and at bedtime related to type 2 diabetes with order date 4/12/23 and no end date 2. Record review of Resident #24's face sheet, dated 9/21/23 revealed an [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), vascular dementia (a common form of dementia caused by an impaired supply of blood to the brain, stroke), dysphagia (difficulty swallowing), hemiplegia affecting right dominant side (paralysis of partial or total body function on one side of the body), gastroesophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach, esophagus), and seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movement, behaviors, sensations or states of awareness.) Record review of Resident #24's most recent significant change MDS assessment, dated 6/29/23 revealed the resident was severely cognitively impaired for daily decision-making skills, and required insulin injections. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 17 of 26 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 675974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Valley Health & Rehabilitation Center 913 Hwy 90 W Castroville, TX 78009 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #24's comprehensive care plan, revision date 9/18/23 revealed the resident had a history of refusing to take medications with interventions that included to re-approach the resident at intervals and had diabetes and gastroesophageal reflux disease with interventions to administer medications as ordered and had a seizure disorder with interventions to give medications as ordered. Residents Affected - Few Record review of Resident #24's order summary report, dated 9/21/23 revealed the following: -Dexcom G6 device used to check blood sugars with order date 3/27/23 and no end date -Humalog injection solution 100 unit/ml (Insulin Lispro, a short-acting insulin) inject per sliding scale subcutaneously before meals related to type 2 diabetes with order date 3/30/23 and no end date -Levetiracetam (Keppra) oral solution 100 mg/ml give 10 ml by mouth two times a day related to seizures with order date 3/29/23 and no end date -Metformin oral tablet 500 mg, give 1 tablet by mouth two times a day related to type 2 diabetes with order date 3/29/23 and no end date Record review of the Medication Administration Audit Report, dated 9/21/23 and provided by the DON revealed the following: -9/20/23 Resident #19 was scheduled Admelog (Lispro) Solostar Insulin per sliding scale at 4:30 p.m. The audit revealed LVN A documented the insulin to Resident #19 was administered at 4:01 p.m. and documented as given at 4:02 p.m. -9/20/23 Resident #24 was scheduled Keppra 100 mg/ml, Metformin 500 mg and Humalog insulin at 4:00 p.m. The audit revealed LVN A documented Keppra and Metformin for Resident #24 was administered at 4:23 p.m. and documented as given at 4:23 p.m. The audit further revealed LVN A documented the Humalog insulin to Resident #24 was administered at 4:34 p.m. and documented as given at 4:34 p.m. Observation on 9/20/23 beginning at 3:26 p.m. to 4:40 p.m. of the medication pass in the 300 Unit with LVN E revealed Resident #19 and Resident #24 were not observed receiving their medications during that time frame as indicated on the MAR (medication administration record). During a joint interview on 9/21/23 at 2:39 p.m., the DON and Administrator revealed, after reviewing the random audits of the Medication Administration Audit Report dated 9/21/23, revealed LVN E had been suspended. The DON revealed monthly audits were performed by the ADON who would pull a random MAR (medication administration record) and check to ensure medications were given within the time frame allowed, to ensure there were no blank spaces in the MAR and to check for errors. The DON revealed if an error was found then the facility would investigate. The DON and Administrator revealed it could not be determined LVN A had not given Resident #19 and Resident #24 their medications based on the report but after the surveyor gave a timeline of the events during the medication pass, it was determined LVN A had falsified the medication record. During a telephone interview on 9/22/23 at 3:43 p.m., LVN E revealed, she had administered the medications to Resident's #19, and #24 but admitted she had given the medications before the scheduled time. LVN E revealed, in order to remember who she had given medications to before the scheduled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 18 of 26 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 675974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Valley Health & Rehabilitation Center 913 Hwy 90 W Castroville, TX 78009 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few time, she took a piece of paper in which vital signs were written, flipped the page over and wrote down each resident's name. LVN E stated she then went to the computer later and documented in the MAR. LVN E stated she worked the 2:00 p.m. to 10:00 p.m. shift and would make rounds at the beginning of her shift and start to administer medications to stay ahead. LVN E stated, Resident #24 gets combative and it's easier for me to try to give (his medications) early. LVN E stated once the medications were documented in the computer, the piece of paper she used to write the names of the residents she had given medications to was put in the shredder box. LVN E stated she admitted ly was taking shortcuts to stay ahead. LVN E revealed, it was wrong and incorrect to administer medications before the scheduled time because medications given too close together could negatively interact with other medications, such as insulin or antibiotics, because those medications needed to be given at a specific time to keep the medication working. LVN E stated, again, I was taking shortcuts, trying to get by, but it was not okay to break the rules. Record review of the nursing competency dated 7/25/23 for LVN E revealed she had satisfied the requirements for medication administration. Record review of the facility policy and procedure titled Documentation of Medication Administration, revision date April 2007 revealed in part, .The facility shall maintain a medication administration record to document all medications administered .A nurse .shall document all medications administered to each resident on the resident's medication record (MAR) .Administration of medication must be documented immediately after (never before) it is given . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 19 of 26 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 675974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Valley Health & Rehabilitation Center 913 Hwy 90 W Castroville, TX 78009 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. The facility failed to ensure proper dating was used on dry and refrigerated items. 2. The facility failed to ensure dry food was stored in a proper container. 3. The facility failed to ensure there was paper towels at the hand washing sink. 4. The facility failed to ensure raw meat was thawed properly. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings were: 1. During an observation on 09/21/23 at 9:32 a.m. a bag of chocolate pudding was in inside of a plastic container with a label butterscotch pudding, Dated: 7/24-8/24. A box next to the plastic container of pudding read CHO PUDDING 06/08/23. No date was on the bag of chocolate pudding. A box of vanilla pudding read VAN PD 06/07/2023. A sticker label on the front of the box of vanilla pudding contained a bar code, item number, item name, and a date of 07/24/23. A date of 07/24 was written in black marker on the front of the box. No date was on the bags of vanilla pudding. A plastic container of syrup condiments with a sticker label read Syrup, date 08/14-09/14. The syrup condiments did not have dates. A plastic container of picante condiments packets had a sticker label that read Picante sauce, date 08/07-09/07. The picante packets did not have dates. A plastic container of brown gravy packets read PG 071223 19:10. The container had a sticker label that read Brown Gravy, 08/14-09/14. During an interview on 09/21/23 at 9:33 a.m. the Dietary Manager stated she was not sure what the expiration date was on the bag of chocolate pudding in the plastic container. The DM stated it came from a box. The DM pointed to a box of other chocolate pudding. The DM stated there was a date on the box but she was not sure what the date meant or what the expiration date was. The DM stated they write dates with a maker on the product boxes when they receive them. The DM stated the date they received the vanilla pudding was 07/24. The DM stated she would need to find out what the dates on the sticker labels or boxes meant. The DM stated they keep condiments for one month. The DM stated they should have thrown out the syrup, picante sauce, and gravy mix because they were past the 1 month, they keep them for. The DM stated the condiments came from boxes that had the expiration dates listed on them, but they had since been discarded because they go by the label on the plastic bin to know when to discard the condiments. During an observation on 09/21/23 at 9:46 a.m. a box with a bag of scrambled egg mix had no date on the box or bag. During an interview on 09/21/23 at 9:47 a.m. the DM stated she did not know what the expiration date was on the scrambled egg mix. The DM stated they normally came with a label which showed the expiration date. The DM stated she needed to ask and find out what the expiration date was for the egg (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 20 of 26 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 675974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Valley Health & Rehabilitation Center 913 Hwy 90 W Castroville, TX 78009 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 product. The DM stated she had no way of known in that moment if the egg product was expired or not. The DM stated either her or other staff regularly check the food storage for expired food, and they check everything and wrote received dates when they received a shipment. During a follow up interview and observation on 09/22/23 at 10:04 a.m. the DM stated the for the labels that contained a bar code, product name and number, and a date; the date was the shipping date. The DM stated she would check on the dates for the egg products. The DM stated she was told the random letters and numbers on the box was what links the date and she needed to ask corporate what the expiration date was. The DM went to the fridge and pulled a different box of scrambled egg product from the one observed on 09/21/23. During a follow up interview on 09/22/23 at 11:52 a.m. the DM showed this surveyor an email she received which stated 216= August 4th, 3=2023. The expiration date would be August 3rd, 2024. The DM said this date showed the box of egg product observe earlier that morning was not expired. 2. During an observation on 09/21/23 at 9:42 a.m. a bag of dry powdered milk was on a bottom shelf. The top half of the bag of powdered milk was open and exposed. A date of 7/16 was written on the powered milk bag in black marker. Two bags of opened cereal bags were on the shelf. Each one was in a plastic storage bag. Both Ziploc bags of cereal were not sealed and exposed. During an interview on 09/21/23 at 9:42 a.m. the DM stated the bag of powdered milk is normally stored in a plastic container once opened but had accidentally ripped open. The DM stated the plastic storage bags were not properly sealed and should be closed. 3. During an observation on 09/22/23 at 9:40 a.m. the hand washing sink in the kitchen used by all staff did not have any paper towels. This surveyor had to ask for paper towels. The DM came over and refilled the paper towel holder. A staff member at a sink stated he had just used the last paper towel. 4. During an observation on 09/22/23 at 9:41 a.m. a two-compartment sink in the kitchen contained plastic containers on each side with water and two plastic bags of raw fish. There was no running water. During an observation on 09/22/23 at 10:03 a.m. the sink still contained the plastic containers with water and bags of raw fish. During an interview on 09/22/23 at 10:05 a.m. the assistant cook stated he did not realize he grabbed the last paper towel from the hand washing sink. He stated it was an honest mistake and not replacing the paper towels prevents everyone else from drying their hands. The assistant cook stated he got the fish from the freezer earlier and placed it in plastic containers inside a bag and put cold water in the containers. This surveyor asked why there was no running water and the assistant cook then turned on the faucet and began to run water on one side of the sink over one bag of raw fish. This surveyor asked about the other side that was still sitting there without running water and he stated he would need to switch the faucet back and forth to alternate which side had running water. The assistant cook stated he could not give an answer why there needed to be running water over thawing raw meat but if he had to say it was to make sure it was drained down the sink. During a follow up interview on 09/22/23 at 12:05 p.m. the DM stated raw meats thawed in the sink need to be on one side with running water to prevent contamination. The DM stated the paper towels (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 21 of 26 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 675974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Valley Health & Rehabilitation Center 913 Hwy 90 W Castroville, TX 78009 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 should be restocked by staff when they are low before they run out or staff cannot dry their hands. The DM stated if you do not use a paper towel to turn off the faucet after washing your hands then you contaminate your hands. During an interview on 09/22/23 at 5:17 p.m. the Administrator stated on Monday they receive food products for the menus they will use, and they use the products before they expire. The administrator stated the supplier should be sending food products with the expiration dates. The Administrator stated they have not had issues receiving expired products, they do not stockpile food products, and they use what they received up the week they receive it. The administrator stated if a product does not have a date, they can reach someone to get the date. The administrator stated she would need to review the policy to see how long they hold on to condiments. The administrator stated thawing raw meats in the sink required continuous slow running water or it could be dangerous. The administrator stated the cooks should only be thawing raw meats on one side of the sink, so it was always under continuous running water. The Administrator stated the handwashing sink should always have soap and paper towels. The Administrator stated they have supplies in the kitchen. Record review of the facility's policy titled Food Safety Requirements, dated 2023, stated Policy: it is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety 1. Food safety practices shall be followed throughout the facilities entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following: a. procurement (obtaining) of food from sources approved or considered satisfactory by federal, state, and local authorities. B. The storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. C. Preparation of food, including thawing, cooking, cooling, holding, and reheating. f. Employee hygienic practices. 3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/ receipt and ensure timely and proper storage. a. Follow contract/ vendor procedures when food arrives damage or concerns are noted. Remove these foods from use. B. Dry food storage. c. refrigerated storage Practices to maintain safe refrigerated storage include .iv. labeling, dating, and monitoring refrigerated foods, including, but not limited to leftovers, so it's used by its use by date, or frozen (where applicable)/ discarded; and v. keeping foods covered or in tight containers. 4. When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce, or eliminate potential hazard. A. Thawing approved methods for thawing frozen foods include thawing in the refrigerator, submerging under cold water, falling in a microwave oven, or as part of a continuous cooking process. Thawing at room temperature is not acceptable. 7. Staff shall adhere to safe hygienic practices to prevent contamination of food from hands or physical objects. a. Staff shall wash hands according to facilities procedures. Record review of the facility's policy titled Hand Hygiene, dated 2023, stated Policy: all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy explanation and compliance guidelines. 5. Hand hygiene technique when using soap and water. e. dry thoroughly with a single use towel. f. use clean towel to turn off the faucet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 22 of 26 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 675974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Valley Health & Rehabilitation Center 913 Hwy 90 W Castroville, TX 78009 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly, for 1 of 2 dumpsters in that: Residents Affected - Few Dumpster #1 had the side door open with garbage items visible and garbage on the ground outside the dumpster. This deficient practice could place residents who reside at the facility at risk of unsanitary conditions that could result in the attraction of vermin and rodents and expose them to germs and diseases carried by vermin and rodents. The findings were: Observation on 09/22/23 at 9:50 a.m. revealed Dumpster #1 had a side door and a glove and mask behind the dumpster on the ground. During an Interview with the DM on 09/22/23 at 9:50 a.m. the DM stated the dumpster side door should be closed after use. The DM stated the entire facility staff has access to this dumpster and she normally makes sure it is closed. The DM stated it should be closed to keep rodents out of the dumpsters. During an Interview with Administrator on 09/22/23 at 5:17 p.m., the Administrator stated the dumpsters should not be open, all staff have access to them, maintenance and housekeeping access the dumpsters, if staff saw the dumpster open they should close it. The Administrator stated they needed to stay closed to keep vermin out. Record review of the facility's policy titled Disposal of Garbage and Refuse, dated 2023, stated Policy: the facility shall properly dispose of kitchen garbage and refuse. Policy explanation and compliance guidelines .7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitted lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insects/ rodent attractions are minimized. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 23 of 26 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 675974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Valley Health & Rehabilitation Center 913 Hwy 90 W Castroville, TX 78009 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 0880 Provide and implement an infection prevention and control program. 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Resident #76 and #43) reviewed for infection control practices, in that: Residents Affected - Some 1. CNA C and RN D did not utilize appropriate hand hygiene during incontinent/peri care to Resident #76 2. LVN A placed a medication into the palm of her ungloved hand intended for Resident #43 These failures could place residents at risk of infection or a decline in health. The findings included: 1. Record review of Resident #76's face sheet, dated 9/22/23 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included urinary tract infection, lack of coordination and stage 3 chronic kidney disease (kidneys are damaged and can't filter blood the way they should). Record review of Resident #76's most recent quarterly MDS assessment, dated 6/23/23 revealed the resident was moderately cognitively impaired for daily decision-making skills and was always incontinent of bowel and bladder. Record review of Resident #76's comprehensive care plan, revision date 7/19/23 revealed the resident was at risk of urinary tract infections related to history of urinary tract infections with interventions that included for caregiver teaching to include good hygiene practices, wipe, and cleanse from front to back and clean peri area well after bowel movement in order to help prevent bacteria in urinary tract. Observation on 9/21/23 at 4:43 p.m., during incontinent/peri care, CNA C wiped Resident #76's rectal area with a wipe, removed her gloves, did not utilize appropriate hand hygiene, and put on a new pair of gloves and completed incontinent/peri care. Further observation during incontinent/peri care revealed, RN D applied barrier cream to Resident #76's buttock area, removed his gloves, did not utilize appropriate hand hygiene, put on a new pair of gloves, and applied barrier cream to Resident #76's upper left thigh. During an interview on 9/21/23 at 5:02 p.m., CNA C revealed she was supposed to utilize appropriate hand hygiene, such as using hand sanitizer, between glove changes when providing incontinent/peri care to Resident #76 because it was considered cross contamination and could cause the resident to develop an infection such as a urinary tract infection. During an interview on 9/21/23 at 5:14 p.m., RN D revealed he usually carried hand sanitizer with him, did not have hand sanitizer with him and did not want to leave the bedside and keep Resident #76 waiting for a long period of time. RN D stated not utilizing appropriate hand hygiene could result in cross contamination and cause the resident to develop an infection. RN D revealed he had received training on utilizing appropriate hand hygiene by the DON. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 24 of 26 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 675974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Valley Health & Rehabilitation Center 913 Hwy 90 W Castroville, TX 78009 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 9/22/23 at 1:24 p.m., the DON revealed staff should be utilizing appropriate hand hygiene practices to prevent an infection. The DON revealed it was necessary to sanitize or wash the hands between glove changes. Record review of the competency training titled, Personal Protective Equipment (PPE) Competency Validation, dated 9/1/23 revealed CNA C had satisfied the requirements for hand washing and effective use of PPE. The competency training revealed in part, .Don gloves: Extend to cover wrist .Remove gloves: Grasp outside of glove with opposite gloved hand; peel off .perform hand hygiene . Record review of the competency training, titled, Licensed Nurse: RN/LVN: Proficiency/Evaluation Tool, dated 2/4/23 revealed RN D had satisfied the requirements for utilizing appropriate hand hygiene. 2. Record review of Resident #43's face sheet, dated 9/21/23 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included chronic respiratory failure with hypoxia (not enough oxygen in your blood, but your levels of carbon dioxide are close to normal), heart failure, morbid obesity, hypertension (high blood pressure), dependence on supplemental oxygen and edema (swelling of extremities). Record review of Resident #43's most recent quarterly MDS assessment, dated 6/2/23 revealed the resident was moderately cognitively impaired for daily decision-making skills. Record review of Resident #43's comprehensive care plan revealed the resident had congestive heart failure with interventions that included to administer cardiac medications as ordered and was on anticoagulant therapy related to atrial fibrillation with interventions that included to administer medication as ordered by the physician. Record review of Resident #43's order summary report, dated 9/21/23 revealed the following: -Eliquis tablet 5 mg, give 1 tablet two times a day related to paroxysmal atrial fibrillation, order date 10/21/22 and no end date Observation on 9/20/23 at 4:10 p.m., during the medication pass, LVN A excused herself, was seen placing a phone call at the nurse's station, returned to the medication cart, did not utilize appropriate hand hygiene and then took one Eliquis tablet 5 mg from the blister pack, placed the tablet on her ungloved hand, put the tablet in a medication cup and administered to Resident #43. During an interview on 9/20/23 at 4:50 p.m., LVN A stated, we don't usually put on gloves when we give out medications, but I was not supposed to touch the pill because it was now contaminated. LVN A revealed, Resident #43's Eliquis tablet 5 mg should have been discarded after it was placed on her ungloved hand. During an interview on 9/20/23 at 5:15 p.m., the DON revealed, LVN A should have discarded Resident #43's Eliquis tablet 5 mg after touching with ungloved hand because it was contaminated and an infection control issue. Record review of the competency training titled Licensed Nurses: RN/LVN: Proficiency/Evaluation Tool dated 7/15/23 revealed LVN A had satisfied the requirements for utilizing appropriate hand hygiene practices. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 25 of 26 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 675974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Valley Health & Rehabilitation Center 913 Hwy 90 W Castroville, TX 78009 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the facility policy and procedure titled Administering Oral Medications, revision date October 2010 revealed in part, .The purpose of this procedure is to provide guidelines for the safe administration of oral medications .Wash your hands . Record review of the facility policy and procedure titled Hand Hygiene, access date June 2023 revealed in part, .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility .hand hygiene .before preparing or handling medications . Event ID: Facility ID: 675974 If continuation sheet Page 26 of 26