Health inspection·November 15, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (Donning and doffing are terms that refer to putting on and taking off personal protective equipment (PPE)) according to recommendations, which is before any high contact resident care activities like . dressing, bathing/showering, transferring, providing hygiene, changing linens, toileting or assisting with toileting and remove prior to leaving the room, and Standard precautions to be observed regardless of suspected or confirmed infection or colonization status. These precautions are based on the principal that all blood, body fluids, secretions and excretions may contain transmissible infectious agents. Record review of Resident #15's Progress Notes on [DATE] at 4:00 p.m. revealed no notes about Resident #15 reporting dysuria or hallucinations in the previous 9 days. Record review of Resident #15's progress notes, revealed a note created [DATE], for effective date [DATE], stated Late entry: On [DATE] The nurse spoke with the resident about how she had been feeling. The resident stated she felt fine she had some burning during urination however, she did not have any other symptoms concerning a UTI she was encouraged to drink water instead of soda's. The resident was not in any distress or having any behavioral concerns nor did she express concerns on moving to another room. The note was written by LVN A and did not mention if the resident's provider was contacted. During an interview on [DATE] at 3:03 p.m. Resident #15 stated she thought she currently had a UTI. Resident #15 stated she felt burning every time she urinated. Resident #15 stated she knew it was a UTI because she had felt this way before when she had a UTI. Resident #15 stated she also mentally did not feel right. Resident #15 stated she told LVN A the day before [DATE] and told him she had thick mucus she was coughing up. Resident #15 stated LVN A had not done anything, but she knew she had told him a few times about the issues she was having. During a follow up interview on [DATE] at 3:05 p.m. Resident #15 stated what she meant by not feeling right mentally was she experienced a relative who came to visit her and hugged her but later realized she was hallucinating because this relative was deceased . Resident #15 stated this happened to her once before when she had a UTI. Resident #15 stated she was still having burning and hallucinations and no staff or providers had followed up with her about the symptoms at that time. During an interview on [DATE] at 9:42 a.m. LVN A stated the facility used the McGeers criteria (a set of guidelines used to identify healthcare-associated infections (HAIs) in long-term care facilities. The criteria are used to retrospectively count infections, and different categories are used for different types of infections, such as urinary tract infections, respiratory tract infections, and skin and soft tissue infections) to see if symptoms needed to be reported to a provider and treated. LVN A stated a resident would have to have 2 symptoms from the McGeers criteria list, such as painful urination, burning, frequency, flank pain, color, smell, before they would treat the symptoms. LVN A stated if he informed the Resident's NP, he would document this in a nursing note. LVN A stated if he did not document it in a note then he did not notify the provider. LVN A stated he thought he reported the resident's symptom of burning during urination to the NP but could not recall. LVN A stated he did add a note on [DATE] where he recalled the resident reported dysuria on [DATE] but he could not recall other details. LVN A stated he was not required to report the new onset symptom of dysuria to the NP because it did not meet criteria, but he was sure he did pass the information on to the NP. LVN A stated it should have also been passed on during shift change and would be noted in the 24 hour report. LVN A stated however there was nothing in his personal notes or the 24 hour report on [DATE] about the symptoms the resident reported to him. LVN A stated he did have a note in his personal notes on [DATE] where he reported to the NP the resident had new symptoms of mucus and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 2 of 30 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 11/15/2024 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few NP ordered a chest x-ray and an antibiotic. LVN A stated the NP was aware Resident #15 reported burning during urination but did not order anything for her. During an interview on [DATE] at 10:41 a.m. the NP stated he did not expect nurses to report every symptom a resident has to the provider. The NP stated he was not sure if they reported to him Resident #15 had burning during urination on [DATE] and he would not have any notes about this symptom being reported to him because one symptom does not trigger treatment for a UTI unless something else happened. The NP stated he had not ordered treatment since [DATE] to address the discomfort Resident #15 was experiencing during urination. The NP stated he was not aware the resident was still reporting dysuria or had reported hallucinations. The NP stated the resident was known to drink sodas often and this would be considered noncompliance but that also did not mean it should be left untreated. The NP stated if a Resident had an untreated UTI, they could go septic (when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body. This can cause a cascade of changes that damage multiple organ systems, leading them to fail, sometimes even resulting in death.) if left untreated. The NP stated they would need to collect labs to see if she had any infections but there was no reason for them to do that at the time of the interview on [DATE] at 10:41 a.m The NP stated nursing staff had contacted him on [DATE] about respiratory symptoms Resident #15 had. The NP stated he planned to treat the respiratory symptoms with an antibiotic that could also help with a UTI, but they would still need to do a culture and screen, if it was an infection, to ensure they used the correct antibiotic. During an interview on [DATE] at 3:54 p.m. the DON stated nursing staff is expected to report a change in status to the provider and staff should document they reported symptoms to the provider. The DON stated staff should follow up with a resident when they report symptoms like dysuria and document it. The DON stated the facility charts by exception and dysuria would be considered an exception. The DON stated staff was expected to chart by the end of the day or shift. The DON stated the 24-hour report should have noted the dysuria Resident #15 was experiencing so the next nurse would know about it and monitor the resident. The DON stated she had not personally spoken to Resident #15, dysuria alone was not a symptom of a UTI, she did not think Resident #15 reported mental symptoms, and it was speculation to say the resident had dysuria for the past 10 days. The DON stated the note written by LVN A, entered 10 days after [DATE], stated the resident reported no other symptoms so she was not treated. Record review of the facility's policy titled Notifications of Changes, dated 8/2024, stated The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification .Circumstances requiring notification include .2.Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include .or b. Clinical complications. 3. Circumstances that require a need to alter treatment. This may include: a. a new treatment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 3 of 30 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 11/15/2024 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 0641 Ensure each resident receives an accurate assessment. 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 the assessment accurately reflected the resident's status for 1 of 7 Residents (Resident #36) whose records were reviewed for assessments. Residents Affected - Few MDS staff failed to ensure Resident #36's MDS assessment reflected he was hearing impaired and used an amplifier as a hearing aid. This deficient practice could affect any resident and could result in residents not receiving the care and services as needed. The findings were: Review of Resident #36's face sheet, dated 11/15/24, revealed he was admitted to the facility on [DATE] with diagnoses including unspecified sequelae of cerebral infarction and Major Depressive disorder, recurrent severe without psychotic symptoms. Review of the significant change MDS,, dated 10/1/24, revealed Resident #36's BIMS score was 11 reflecting moderate cognitive impairment; he had minimal difficulty hearing and did not use a hearing device. Review of progress note dated 11/12/2024 read: Was informed by [Resident #36] that he amplifier we provided had worked well for him, but since the wire got damaged and he is not able to hear from it. Administration is in process to try to get another amplifier. Review of Resident #36's Care Plan, revised on 10/8/24, read: The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t dependent Physical Limitations and one of the interventions included Ensure that adaptive equipment that the resident needs is provided and is present and functional. Observation and interview on 11/13/24 at 10:40 AM revealed Resident #36 was lying in bed. He stated he thought he was getting a new amplifier and showed the one he had. He pointed to the the cord and it was noted to be frayed. Interview on 11/15/24 at 5:20 PM with LVN/MDS Coordinator F revealed Resident #36 was hearing impaired and used an amplifier to help him hear. She stated the MDS assessment, dated 10/1/24, did not reflect the use of a hearing device. MDS Coordinator F stated the purpose of an MDS assessment was to identify the needs of the resident and to ensure the resident received services as needed. LVN/MDS Coordinator F was asked for a facility policy for resident assessment on 11/15/24 at 5:30 PM. She did not provide a copy of the facility policy by exit at 8:15 PM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 4 of 30 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 11/15/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all PASRR Level I residents with mental illness were provided with a PASRR Level II Evaluation and Assessment for 1 of 2 residents (Resident #55) reviewed for PASRR services. The facility failed to identify Resident#55 as having diagnoses indicative of Mental Illness including MDD on the PASRR screening dated 3/10/23, which would require a PASRR Level II assessment. This deficient practice could place residents at risk of a diminished quality of life related to not receiving or benefiting from specialized services. The findings include: An interview of Resident #55 was attempted on 11/12/24, the resident was a poor historian. Review of Resident #55's admission sheet, dated 7/8/24, noted the resident was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Anxiety Disorder, Dementia, Hypertension, Hyperlipidemia, MDD. Review of Resident #55's quarterly MDS assessment, dated 8/12/24, noted the resident BIMS was 8, indicating he had moderate cognitive impairment; mood indicators were present including little interest or pleasure in doing things and feeling down, depressed, or hopeless; and active diagnoses of Dementia, MDD and Anxiety Disorder. Review of Resident #55's order summary, dated November 2024 indicated the resident received antidepressants, an anxiolytic (a medication to treat anxiety), and a mood stabilizer. Review of Resident #55's care plan, updated on 10/1/24 noted the resident uses psychotropic medications r/t MDD. One of the approaches was to monitor and document the occurrence of for target behavior symptoms (Sadness, inappropriate response to verbal communication, violence/aggression towards staff/others. Review of the admission sheet on 11/15/24 at 4:41 PM, noted an original admission date of 03/10/2023 with documentation of the diagnosis date of MDD as 04/03/2023. Review of the medical record for Resident #55, showed a negative PASRR assessment, dated 3/10/23. Review of the assessments contained in the electronic health record of Resident #55 showed no follow up PASRR Level I or II conducted after the diagnosis of MDD on 04/03/2023. In an interview with the Administrator on 11/15/24 at 4:49 PM regarding the omission of the PASRR assessment, the Administrator acknowledged that Resident #55 did not have a PASRR performed after his diagnosis of MDD on 04/03/2023. The Administrator stated a follow up PASRR was not performed for the resident after his diagnosis of MDD, because the resident was a VA beneficiary, and VA beneficiaries must receive services through the VA. The Administrator stated a PASRR assessment should be conducted even for residents who might qualify to receive services from the Veteran's Administration. The Administrator stated if the facility performed PASRR assessments for all residents with mental illness, no one could get overlooked and not get the services they need. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 5 of 30 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 11/15/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy, undated, titled Resident Assessment-Coordination with PASRR Program stated all applicants to the facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. The policy further stated that a negative Level I screen permits admission to proceed and ends the PASRR process unless a possible serious mental disorder or intellectual disability arises later. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 6 of 30 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 11/15/2024 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify a diagnosis of mental illness on the preadmission screening and resident review (PASRR) assessment for 1 of 2 residents (Resident #52) whose records were reviewed for PASRR services. Residents Affected - Few The facility failed to recognize on the Level I PASRR screening that Resident #52 had the mental illness diagnoses of Post Traumatic Stress Disorder (PTSD) and Major Depressive Disorder (MDD) which would qualify Resident #52 for a PASRR evaluation. This deficient practice could place residents with mental illness at risk for not obtaining the services needed to treat their mental health diagnoses. The findings include: Attempted to interview Resident #52 on 11/13/24, resident was a poor historian. Record review of Resident #52's admission sheet, dated 5/26/24, noted the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (a movement disorder of the nervous system), Angina (a condition of insufficient oxygen in the blood causing chest discomfort or shortness of breath), Atrial Fibrillation (abnormal heart rhythm), Chronic Kidney Disease, PTSD, Insomnia, and MDD. Record review of Resident #52's quarterly MDS assessment, dated 10/4/24, noted the resident BIMS was 7, indicating he had severe cognitive impairment; mood indicators were present including little interest or pleasure in doing things and feeling down, depressed, or hopeless; and diagnoses of depression and PTSD. Record review of Resident #52's order summary from November 2024 indicated the resident receives an antidepressant. Record review of Resident #52's care plan, updated on 6/7/24 noted the resident uses and antidepressant r/t Depression. One of the approaches was to monitor and document the change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal. Record review of Resident #52's admission sheet on 11/13/24 at 9:07 AM documented diagnoses including PTSD and MDD. The original date of the admission sheet was noted as 03/27/21. The date of diagnosis for the PTSD was noted as 03/37/21, and the date of diagnosis for the MDD was noted as 03/27/21. Record review on 11/14/24 at 2:56 PM of the assessments in the electronic health record for Resident #52 showed three PASRR Level I assessments were performed on 03/26/21, 08/19/21, and 03/38/22. All three PASRR Level I assessments recorded an answer of 0 (No) in response to the question, Is there evidence or an indicator this is an individual that has a Mental Illness? In an interview with the Administrator on 11/14/24 at 03:16 PM, regarding the error in not identifying Resident #52 with mental illness, the Administrator stated the resident should have had a positive PASRR Level I outcome noted on the assessments and a follow up PASSR Level II performed in accordance with state and federal guidelines. The Administrator stated a PASRR was not performed for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 7 of 30 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 11/15/2024 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete resident, because the resident was a VA beneficiary, and VA beneficiaries must receive services through the VA. Review of the facility policy, undated, titled Resident Assessment-Coordination with PASSR Program stated all applicants to the facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. Event ID: Facility ID: 675974 If continuation sheet Page 8 of 30 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 11/15/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review revealed the facility failed to ensure the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 of 7 Residents (Resident #36 and Resident #15) whose records were reviewed for Care Plans. 1. Staff failed to ensure Resident #36's Care Plan reflected he was hearing impaired and used an amplifier as a hearing aid. 2. The facility failed to update Resident #15's Care Plan to reflect a history of UTIs with interventions for staff to monitor the resident for possible UTI symptoms. This deficient practice could affect any resident and result in residents not receiving the care and services they needed. 1. Review of Resident #36's face sheet, dated 11/15/24, revealed he was admitted to the facility on [DATE] with diagnoses including unspecified sequelae of cerebral infarction and Major Depressive disorder, recurrent severe without psychotic symptoms. Review of significant change MDS, dated [DATE], revealed Resident #36's BIMS was 11 reflecting moderate cognitive impairment; he had minimal difficulty hearing and did not use a hearing device. Review of progress note dated 11/12/2024 read: Was informed by [Resident #36] that he amplifier we provided had worked well for him, but since the wire got damaged and he is not able to hear from it. Administration is in process to try to get another amplifier. Review of Resident #36's Care Plan, revised on 10/8/24, read: The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t dependent Physical Limitations and one of the interventions included Ensure that adaptive equipment that the resident needs is provided and is present and functional. Further review revealed the Care Plan did not reflect Resident #36 was hearing impaired and that he used a hearing device. Observation and interview on 11/12/24 at 12:37 PM revealed Resident #36 was lying in bed. He engaged in conversation; was difficult to understand but he made his needs known. Resident #36 stated about two months ago he started having problems hearing. He stated he loved baseball and not able to hear it. Observation and interview on 11/13/24 at 10:40 AM revealed Resident #36 was lying in bed. He stated he thought he was getting a new amplifier and showed the one he had. He pointed to the cord and it was noted to be frayed. Interview on 11/15/24 at 5:20 PM with LVN/MDS Coordinator F revealed Resident #36 was hearing impaired and used an amplifier to help him hear. She stated the Care Plan, dated 10/8/24, did not reflect he was hearing impaired and he used a hearing device. MDS Coordinator F stated the purpose of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 9 of 30 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 11/15/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Care Plan was to address the needs and services the resident would receive. She stated nursing staff had access to the Care Plan to help them understand the needs of the residents. 2. Record review of the admission Record, printed 11/15/24, reflected Resident #15 was a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing an area of dead brain tissue), extended spectrum beta lactamase (ESBL) resistance ( enzymes that make bacteria resistant to many antibiotics, including penicillins, cephalosporins, and aztreonam), unspecified Escherichia coli [E. Coli] as the cause of disease ( bacteria commonly found in the intestines of humans and animals, and while most strains are harmless, certain types can cause illness), and personal history of urinary tract infections. Record review of Resident #15's quarterly MDS assessment, dated 10/4/24, showed her memory was full intact for daily decision making. Section I of active diagnoses showed she had a UTI in the last 30 days. Record review of the Resident #15's Care Plan showed she was on enhanced barrier precautions related to history of ESBL of the urine, initiated on 9/28/24, revised on 11/12/24, with interventions of staff will educate resident on Enhanced Barrier Precautions, proper signage to be clearly indicated, PPE including gown and gloves available outside or near room, alcohol based handrub available, trash can inside room near exit for discarding PPE prior to exit of the room, Proper use of PPE to be observed, use of gown and gloves during high contact resident care activities that promote opportunities for transfer of MDROs (Multidrug-resistant organisms (MDROs) are microorganisms, primarily bacteria, that are resistant to multiple classes of antibiotics and antifungals.), Staff to DON and DOFF PPE (Donning and doffing are terms that refer to putting on and taking off personal protective equipment (PPE)) according to recommendations, which is before any high contact resident care activities like . dressing, bathing/showering, transferring, providing hygiene, changing linens, toileting or assisting with toileting and remove prior to leaving the room, and Standard precautions to be observed regardless of suspected or confirmed infection or colonization status. These precautions are based on the principal that all blood, body fluids, secretions and excretions may contain transmissible infectious agents. Another care area initiated and revised on 9/28/24 stated The resident has bowel & bladder incontinence r/t Impaired mobility, Loss of peritoneal tone with interventions to the resident uses disposable briefs, ensure that call light is in reach and assist resident to bathroom PRN, and Check (q 2hrs ) and as required for incontinence. Clean peri-area with each incontinence episode. Change clothing PRN after incontinence episodes. Record review of Resident #15's hospital discharge paperwork, dated 5/16/24, stated chief complaint was respiratory distress and dx of acute respiratory failure and recent UTI. Record review of Resident #15's hospital discharge paperwork, dated 9/24/24, chief complaint was AMS and dx of UTI with sepsis . During an interview on 11/12/24 at 3:03 p.m. Resident #15 stated she thought she currently had a UTI. Resident #15 stated she felt burning every time she urinated. Resident #15 stated she knew it was a UTI because she had felt this way before when she had a UTI. Resident #15 stated she also mentally did not feel right. Resident #15 stated she told LVN A the day before and told him she had thick mucus she was coughing up. Resident #15 stated LVN A had not done anything, but she knew she had told him a few times about the issues she was having. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 10 of 30 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 11/15/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/14/24 at 9:42 a.m. LVN A stated the facility used the McGeers criteria (a set of guidelines used to identify healthcare-associated infections (HAIs) in long-term care facilities. The criteria are used to retrospectively count infections, and different categories are used for different types of infections, such as urinary tract infections, respiratory tract infections, and skin and soft tissue infections) to see if symptoms needed to be reported to a provider and treated. LVN A stated a resident would have to have 2 symptoms from the McGeers criteria list, such as painful urination, burning, frequency, flank pain, color, and smell before they would treat the symptoms. Interview on 11/15/24 at 5:21 PM with LVN/MDS Coordinator F stated she was new to the role and was told the care plans were all good and already done. The MDS nurse stated Resident #15's care plan did not need to address monitoring for a UTI because staff knew to provide incontinent care and change her brief when residents were prone to UTIs. The MDS nurse stated the resident was oriented and can report UTI symptoms to staff. The MDS nurse stated care areas and interventions should be specific for each resident regardless of if they were oriented or not. LVN/MDS Coordinator F was asked for a facility policy for resident Care Plans on 11/15/24 at 5:30 PM. She did not provide a copy of the facility policy by exit at 8:15 PM. During an interview on 11/15/24 at 6:06 p.m. the DON stated Resident #15's history of UTI's were addressed on the care plan under the enhanced barrier precautions care area. The DON stated some resident with a history of UTIs had a separate care area on their care plans for staff to monitor for UTI symptoms, but it depended on if the resident had a history of UTIs. The DON stated the resident had a few hospital documents that showed a diagnosis of UTI and a personal history of them. The DON stated many times a residents would go to the hospital for other reasons, and they would also find they had a UTI. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 11 of 30 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 11/15/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 residents who were unable to carry out activities of daily living received the necessary services to maintain good personal and oral hygiene for 1 of 7 Residents (Resident #36) whose records were reviewed for activities of daily living. Residents Affected - Few Nursing staff failed to brush Resident #36's teeth and wash his face for 1 of 4 survey dates, 11/14/24 and nursing staff failed to clip his nails for an undetermined amount of time. This deficient practice could affect residents who required assistance and could result in poor hygiene and feelings of dissatisfaction. The findings were: Review of Resident #36's face sheet, dated 11/15/24, revealed he was admitted to the facility on [DATE] with diagnoses including unspecified sequele of cerebral infarction and Major Depressive disorder, recurrent severe without psychotic symptoms. Review of significant change MDS assessment, dated 10/1/24, revealed Resident #36's BIMS was 11 reflecting moderate cognitive impairment; his range of motion was impaired on one side (upper and lower extremities) and he was dependent for most ADLs including oral hygiene. Review of Resident #36's Care Plan, revised on read: The resident has an ADL self-care performance deficit r/t CVA with left hemiplegia & right femur head osteonecrosis. Interventions included Provide the level of assistance resident requires in ADL care as follows: GROOMING: (TD) [totally dependent] x 1 Staff. Review of Resident #36's progress notes from 11/1/24 to 11/15/24 did not reveal Resident #36 had refused any type of hygiene care. Review of Resident #36's personal hygiene tracking document How resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers) revealed on 11/15/24 at 8:25 am, not applicable. Observation and interview on 11/13/24 at 10:40 AM revealed Resident #36 was lying in bed. He had left hand contracture. His hair looked uncombed, he had not shaven and overall he looked unkept. Further observation revealed his nails were long; about an inch passed his nail beds . The nail on his right pinkie was about 1 and 1/2 inches beyond the nail bed. Resident #36 stated he was diabetic and the nurses had to cut his nails. He stated he asked but nursing staff had staff not cut them. He stated staff only washed his face if he went out for an appointment which was some time last week. He stated other than that staff had not washed his face in a long time. He stated another thing that really bothered him was that staff did not brush his teeth. He stated when he was receiving hospice services staff brushed his teeth regularly. He stated at times nursing staff would swab his mouth but it was not the same. He stated it was important to him and stated he used to brush his teeth regularly. Interview on 11/14/24 at 2:05 PM with CNA D revealed she was the CNA assigned to work with Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 12 of 30 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 11/15/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #36 on this date, 11/14/24. She stated normally she would help Residents wash their face and brush their teeth in the morning as needed. She stated she would also help Residents brush their teeth after meals per their request. CNA D stated on this date, 11/14/25, she did not have time to wash Resident #36's face or help him brush his teeth. She stated he required assistance but she spent most of her time showering Residents who were scheduled to be showered. Further interview revealed CNA D stated she would mark on his hygiene task not applicable if she did not provide a Resident with assistance on her scheduled shift. Observation and interview on 11/14/24 at 03:20 PM with LVN I revealed he had worked at the facility since September 2024 and was a new nurse. He stated nail care for Residents was done on Sundays. He stated he was not sure if it was any different for Residents who had diabetes. LVN I stated he made rounds at the beginning and at the end of his shift. He stated he was familiar with Resident #36, but did not know if he was diabetic. He stated the aides had not said anything to him about Resident #36 needing any specific care. Observation revealed Resident #36 lying in bed. He showed LVN I his nails. Resident #36 told LVN I a nurse had to cut his nails because he was diabetic. His nails were long passed his nail beds and some of them were black under the nails. The LVN I revealed he stated he did not know only nurses could cut a Resident's nails. He stated there was brown gunk underneath his nails. He stated it could become an infection control problem if he touched any open areas on his body. Interview with the DON on 11/14/24 at 04:25 PM revealed the charge nurse on duty would be able to cut a Resident's nails who had diabetes on any date as needed. However, typically speaking the charge nurse scheduled to work on Sundays would cut the Resident's nails. This was the day scheduled for Resident nail care. The DON stated Resident #36 had a history of refusing care and it was documented on his Care Plan. The DON stated she expected staff to document refusal of care in a progress note at the time the Resident refused care unless he refused specific care on a daily basis then it would be documented on the Care Plan. Further interview with the DON revealed the CNAs were responsible for providing daily hygiene care as needed and the nurses were to ensure it was done while making their rounds. Observation and interview on 11/14/24 at 04:45 PM revealed Resident #36 lying in bed. He showed the DON his nails and again stated he had asked nursing staff to cut his nails. Resident #36 was able to re-state he understood the nurses should cut his nails because he was diabetic. The DON asked Resident #36 if he refused nail care at any point. He told her he had not refused. She asked again, you never refused. Resident #36 shook his head and stated no. The DON asked Resident #36 if he would allow the nurse to cut his nails. He agreed and it was noted the DON asked ADON E to cut his nails. Further interview with the DON revealed she stated Resident #36's nails were long and according to the length it did not happen overnight. The DON stated the charge nurse should be monitoring residents care needs and should address it at the time they noted an issue. She stated the ADONs were responsible for overseeing the process and should address any concerns brought up by nursing staff and or by the Resident. Review of facility policy, Activities of Daily Living (ADLs) copyright date 2024, read in relevant part: Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 13 of 30 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 11/15/2024 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 observations, interviews, and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 (Resident #191 and Resident #15) of 2 residents reviewed for catheter care and or incontinent care. 1. The facility failed to ensure CNA L and CNA M did not leave stool on Resident #15 when performing incontinent care. 2. The facility failed to ensure CNA J and CNA K kept Resident #191's urine catheter bag below the level of the bladder during incontinent care. This failure could place residents at risk for urinary tract infections. Findings included: 1. Record review of the admission Record, printed 11/15/24, reflected Resident #15 was a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing an area of dead brain tissue), extended spectrum beta lactamase (ESBL) resistance ( enzymes that make bacteria resistant to many antibiotics, including penicillin's, cephalosporins, and aztreonam), unspecified Escherichia coli [E. Coli] as the cause of disease ( bacteria commonly found in the intestines of humans and animals, and while most strains are harmless, certain types can cause illness), and personal history of urinary tract infections. Record review of Resident #15's quarterly MDS assessment, dated 10/4/24, showed her memory was fully intact for daily decision making. Section I of active diagnoses showed she had a UTI in the last 30 days. Section H showed the resident was always incontinent of bladder and bowel. Record review of the Resident #15's Care Plan showed she was on enhanced barrier precautions related to history of ESBL of the urine, initiated on 9/28/24, revised on 11/12/24, with interventions of staff will educate resident on Enhanced Barrier Precautions, proper signage to be clearly indicated, PPE including gown and gloves available outside or near room, alcohol based handrub available, trash can inside room near exit for discarding PPE prior to exit of the room, Proper use of PPE to be observed, use of gown and gloves during high contact resident care activities that promote opportunities for transfer of MDROs (Multidrug-resistant organisms (MDROs) are microorganisms, primarily bacteria, that are resistant to multiple classes of antibiotics and antifungals.), Staff to DON and DOFF PPE (Donning and doffing are terms that refer to putting on and taking off personal protective equipment (PPE)) according to recommendations, which is before any high contact resident care activities like . dressing, bathing/showering, transferring, providing hygiene, changing linens, toileting or assisting with toileting and remove prior to leaving the room, and Standard precautions to be observed regardless of suspected or confirmed infection or colonization status. These precautions are based on the principal that all blood, body fluids, secretions and excretions may contain transmissible infectious agents. During an observation on 11/15/24 at 11:16 a.m. CNA L was observed wiping fecal matter from Resident #15's perineal and gluteal area. The fecal soiling was extensive and had spread to the bedding. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 14 of 30 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 11/15/2024 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 While the CNA performed multiple wipes, the final pass left visible fecal residue in Resident #15's gluteal cleft. CNA L then put on a clean brief. During an interview on 11/15/24 at 11:48 a.m. CNA L stated she should have kept wiping the resident until the wipe was clean. CNA L stated she did not pay attention to see if the last wipe was heavily soiled or if the resident still had feces on her. CNA L stated she just discarded the wipe and put on a clean brief. CNA L stated she should keep wiping until the wipe had no feces and the resident was clean to prevent infections. 2. Record review of the admission Record, dated 11/15/24, reflected Resident #191 was a [AGE] year-old female originally admitted on [DATE] with diagnoses that included malignant neoplasm of unspecified site of left female breast (cancerous breast tumor), other intervertebral disc degeneration, lumbosacral region with discogenic pain and lower extremity pain (pain in the lower back (lumbosacral area) due to a degenerated intervertebral disc (discogenic pain), which then radiates down into the leg, causing pain in the lower extremity), and retention of urine (unable to empty their bladder, either partially or completely). Record review of Resident #191's admission MDS assessment, dated 10/4/24, showed her memory was fully intact for daily decision making. Section H showed the resident had a urinary catheter and was always incontinent of bowel. Record review of the Resident #191's Care Plan, initiated 11/7/24, showed she had an indwelling foley catheter related to neuromuscular dysfunction of the bladder, with interventions to position catheter bag and tubing below the level of the bladder and off the floor at all times. During an observation on 11/14/24 at 11:41 a.m. CNA J and CNA K were positioning Resident #191 for catheter and incontinent care. CNA J handed the urinary catheter bag to CNA K and raised it above the level of Resident #191's bladder, urine in the tube was observed flowing back toward the resident's bladder. During an interview on 11/14/24 at 11:55 a.m. CNA J and CNA K stated they should keep the catheter bag low on the bed if they need to move it to prevent urine from back flowing and it could cause infection. During an interview on 11/14/24 at 3:23 p.m. the DON stated staff were expected to keep the catheter bag below the level of the residents' bladder so there was no flow back into the bladder, but the facility did only purchase anti flow catheter bags. The DON stated staff should wipe until the resident was clean and there was no visible feces on the resident only. The DON stated a resident could have skin break down if they still had feces on them. Record review of the facility's policy titled Perineal Care, dated 2024, stated It is the practice of this facility to provide perinea! care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown .7. If perineum is grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard. a. Cleanse buttocks and anus, front to back; vagina to anus in females, scrotum to anus in males using a separate washcloth or wipes. Thoroughly dry . Record review of the facility's policy titled Catheter Care, dated 2023, stated It is the policy of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 15 of 30 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 11/15/2024 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 this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use .9. Ensure drainage bag is located below the level of the bladder to discourage backflow of urine or provide anti-flowback device . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 16 of 30 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 11/15/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for two of ten residents (Resident #24 and Resident #41) reviewed for pharmacy services. The facility failed to ensure medication doses noted on the electronic Medication Administration Record (MAR) matched doses recorded on the Controlled Drug Reconciliation Log for Resident #24 and #41. This deficient practice could put residents at risk for pain, anxiety, misappropriation, and drug diversion. Findings include: Review of Resident #24's admission sheet, dated 8/18/24, noted the resident was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Anxiety Disorder, Dementia, Angina, Hypertension, Hyperlipidemia, and Major Depressive Disorder (MDD). Review of Resident #24's quarterly MDS assessment, dated 8/22/24, noted the resident BIMS was 0, indicating she had severe cognitive impairment. The resident had both mood and behavior indicators noting verbal abuse and refusal of care. Review of Resident #24's order summary from November 2024 indicated the resident received an anxiolytic, an antidepressant, and a mood stabilizer. Review of Resident # 24's care plan, updated on 8/25/24 noted the resident uses Klonopin (Clonazepam) r/t anxiety disorder. One of the approaches was to monitor and document target behavior symptoms ANXIOUS, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. Review of Resident #41's admission sheet, dated 3/8/19, noted the resident was admitted to the facility on [DATE] with diagnoses including Pain in Right Knee, Cerebral Infarction, Major Depressive Disorder, Dementia, Coronary Artery Disease, Hypertension, and Generalized Anxiety Disorder. Review of Resident #41's quarterly MDS assessment, dated 10/22/24, noted the resident BIMS was 9, indicating he had moderate cognitive impairment, and received a scheduled pain medication regimen. Review of Resident #41's order summary from November 2024 indicated the resident received an opioid analgesic (a controlled substance) routinely for pain. Review of Resident #41's care plan, updated on 10/8/24, noted the resident is on pain medication therapy r/t disease process. One of the approaches was to administer ANALGESIC medications as ordered and to review (q2h) for pain medication efficacy. Observation of the medication aide cart for the 300/400 hall and interview with Med Aide B was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 17 of 30 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 11/15/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few conducted on 11/14/24 at 9:20 AM . During the review of the cart including a review of the controlled medication reconciliation log, it was observed that Resident #41 had an order for Tylenol #3 (Tylenol with Codeine), to take two tablets by mouth three times a day. Tylenol #3 is an analgesic (medication for pain). It was observed that the administered dose of Tylenol #3 was logged out on the electronic medication administration record, but it was not logged out on the controlled medication reconciliation log. The blister pack of Tylenol #3 showed 22 pills were left in the pack. The controlled medication log sheet for Tylenol #3 showed 24 pills were left. It was observed that Resident #24 had an order for Clonazepam 0.5mg, to take 1/2 tablet by mouth twice a day. Clonazepam is an anxiolytic (medication for anxiety). It was observed that the administered dose of Clonazepam was logged out on the electronic medication administration record, but it was not logged out on the controlled medication reconciliation log. The blister pack of Clonazepam showed 34 doses were left. The controlled medication log showed 35 doses were left. Med Aide B stated a medication error could happen if controlled medications were not documented on the controlled medication log immediately after being administered. Med Aide B stated a resident could experience pain or anxiety if they do not receive their analgesic or anxiolytic medication. Review of the facility policy, undated, titled Controlled Substance Administration and Accountability stated the facility will have safeguards in place to prevent loss, diversion, or accidental exposure. The policy further states that all controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided. The policy also states that in all cases, the dose noted on the usage form or entered in the automated dispensing system must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified form and placed in the patient's medical record. The Controlled Drug Record (or other specified form) serves the dual purpose of recording both narcotic disposition and patient administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 18 of 30 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 11/15/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all medications were labeled in accordance with currently accepted professional principles for one of ten residents (Resident #55) reviewed for medication labeling and storage. The facility failed to ensure Resident #55's insulin pen was labeled with the date it was opened. This deficient practice could place residents who receive medications at risk of not obtaining the therapeutic level of their prescribed medications. The findings include: Review of Resident #55's admission sheet, dated [DATE], noted the resident was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Anxiety Disorder, Dementia, Hypertension, Hyperlipidemia, and Major Depressive Disorder (MDD). Review of Resident #55's quarterly MDS assessment, dated [DATE], noted the resident BIMS was 8, indicating he had moderate cognitive impairment and a diagnosis of Type 2 Diabetes Mellitus. Review of Resident #55's from [DATE] indicated the resident received a biguanide (insulin response enhancer), insulin glargine, and insulin aspart related to Type 2 Diabetes Mellitus. Review of Resident #55's care plan, updated on [DATE] noted the resident has Diabetes Mellitus with neuropathy. One of the approaches was the resident will receive diabetes medications as ordered by doctor. During an observation of the medication pass on the 200 hall and interview with RN Con [DATE] at 4:30 PM, it was observed that the opened date was not documented on the NovoLog insulin pen for Resident #55. RN C stated the resident could potentially receive expired medication and not get the therapeutic effect of the insulin if the opened date was not recorded on the pen. NovoLog pens expire after 28 days at room temperature. RN C stated without an opened date, it would be unclear when the 28 days had passed. Review of the facility's policy, undated, titled Labeling of Medications and Biologicals stated that all medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. The policy further stated that labels for multi-use vials must include the date the vial was initially opened or accessed (needle-punctured); and all opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 19 of 30 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 11/15/2024 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, 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, reviewed for kitchen sanitation. 1. The facility failed to ensure that sanitizing buckets were not near containers of food. 2. The facility failed to discard expired flour. 3. The ice machine had an unknown black substance inside the top of the machine. 4. The dishwasher sanitation log was not completed for several days and had an expired bottle of test strips. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: During an observation, during the initial kitchen tour, on 11/12/24 starting at 09:41 a.m., revealed there were 2 sanitizing buckets next to a tray of uncovered onions dated 11/11. There was one container of flour with a discard date of 11/7 and another bag of flour with discard date of 10/28. The dish machine sanitation record log was not filled out for 11/8, 11/9, 11/10, 11/11, and the AM shift of 11/12. There was a bottle of sanitation test strips with an expiration date of 09/2024. The ice machine had an unknown black substance at the top of the machine. The ice machine log showed it was last cleaned on 11/7/24. During an interview on 11/13/24 at 4:45 p.m. Dishwasher Aide O stated he was new, but the log should be completed twice daily to show the sanitizer had been tested and was working during both shifts. During an interview on 11/12/24 at 9:45 p.m. the DS stated they should discard the flour in the container and in the bag because they only keep it for one month. The DS stated maintenance was responsible for cleaning the ice machine. The DS stated she expected staff to fill out the dishwasher logs during the morning and evening shift to make sure the sanitizer levels were adequate. During a joint interview on 11/15/24 at 4:53 p.m. the MS stated he cleaned the ice machine monthly. The MS stated he was not aware the ice machine had an unknown black substance but confirmed from a picture that it should not be in that condition because he did not know what it was and could be dirty. The DS stated it could contaminate the ice. Record review of the facility's policy titled Ice Machines and Portable Ice Carts, dated 2024, stated It is the policy of this facility to ensure that ice machines/carts are working in proper order, cleaned, and maintained as per Federal, State, local, or facility guidance, according to manufacturer's instructions and current standards practice. Policy Explanation: Ice machines/carts can be prone to microbial contamination due to improper handling or storage of ice, poor cleaning, or maintenance of equipment, or through ice handling equipment. Proper cleaning, maintenance, and infection (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 20 of 30 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 11/15/2024 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 control in relation to ice machines is important to decrease the risk of illness to residents, staff, and visitors. Compliance Guidelines: 1. Ice machines will be cleaned at a frequency specified by the manufacturer or, if manufacturer specifications are absent, at a frequency necessary to preclude accumulation of soil or mold. 2. The facility will determine the frequency at which the ice machine will be cleaned/ sanitized with documentation to support the cleaning procedures. 3. The maintenance director or other designee is responsible for cleaning and maintaining the ice machine at the facility . 5. The ice machine(s) or carts will be cleaned at any time contamination may have occurred or when visibly soiled . notify the maintenance department for any problems with the ice machine. Record review of the facility's policy titled Date Marking for Food Safety, dated 2024, stated Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food .2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 21 of 30 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 11/15/2024 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 - Potential for minimal harm Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 2 of 2 Dumpsters (Dumpster #1 and Dumpster #2) reviewed for disposal of garbage. Residents Affected - Some The facility failed to ensure the waste in Dumpster #1 and Dumpster #2 was not leaking and staining the ground around the dumpsters. These deficient practices could place residents at risk for exposure to germs and diseases carried by vermin and rodents. The findings were: Observation on 11/13/24 at 12:56 p.m. revealed liquid was leaking from the bottom corner of Dumpster #1. There were large brown and reddish stains in front of either dumpster running down the drive way. During an interview on 11/13/24 at 1:00 p.m. the DS stated she had not noticed the stains from the dumpsters before but Dumpster #1 was leaking liquids on to the driveway. The DS stated she would let the MS know so he could power wash the driveway. During an interview on 11/15/24 at 4:53 p.m. the MS stated he had been power washing the driveway that was stained by the leaking dumpsters for an unknown amount of time. The MS stated he was cleaning the driveway weekly and was waiting for new dumpsters to be delivered but it could take more than a month. Record review of the facility's policy titled Disposal of Garbage and Refuse, dated 2024, stated the facility shall properly dispose of kitchen garbage and refuse .2. Garbage and refuse containers shall be durable, cleanable, and free from cracks or leaks and covered when not in use 7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting 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 insect/rodent attractions are minimized . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 22 of 30 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 11/15/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 2 (Resident #15 and Resident #191) of 8 residents reviewed for accuracy and completeness of clinical records. 1. The facility failed to timely document Resident #15's complaints of dysuria (a painful or uncomfortable feeling when urinating, often described as a burning, stinging, or itching sensation in the urethra or urethral meatus) on 11/03/24 and 11/11/24. 2. The facility failed to document a wound care order in active orders, when it was ordered on 11/12/24, and not active until 11/14/24, for wound care treatment for Resident #191 who developed a open reddened area to her gluteal folds after admission. This failure could affect any residents who have medical records and could result in misinformation about professional care provided. Findings included: Record review of the admission Record, printed 11/15/24, reflected Resident #15 was a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing an area of dead brain tissue), extended spectrum beta lactamase (ESBL) resistance ( enzymes that make bacteria resistant to many antibiotics, including penicillins, cephalosporins, and aztreonam), unspecified Escherichia coli [E. Coli] as the cause of disease ( bacteria commonly found in the intestines of humans and animals, and while most strains are harmless, certain types can cause illness), and personal history of urinary tract infections. Record review of Resident #15's quarterly MDS assessment, dated 10/4/24, showed her memory was fully intact for daily decision making. Section I of active diagnoses showed she had a UTI in the last 30 days. Record review of the Resident #15's Care Plan showed she was on enhanced barrier precautions related to history of ESBL of the urine, initiated on 9/28/24, revised on 11/12/24, with interventions of staff will educate resident on Enhanced Barrier Precautions, proper signage to be clearly indicated. Record review of Resident #15's Progress Notes on 11/12/24 at 4:00 p.m. revealed no notes about Resident #15 reporting dysuria or hallucinations in the previous 9 days. Record review of Resident #15's progress notes, revealed a note created 11/13/24, for effective date 11/04/24, stated Late entry: On 11/03/2024 The nurse spoke with the resident about how she had been feeling. The resident stated she felt fine she had some burning during urination however, she did not have any other symptoms concerning a UTI she was encouraged to drink water instead of soda's. The resident was not in any distress or having any behavioral concerns nor did she express concerns on moving to another room. The note was written by LVN A. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 23 of 30 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 11/15/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/12/24 at 3:03 p.m. Resident #15 stated she thought she currently had a UTI. Resident #15 stated she felt burning every time she urinated. Resident #15 stated she told LVN A a few times before including on 11/11/24, and told him she had thick mucus she was coughing up. Resident #15 stated LVN A had not done anything, but she knew she had told him a few times about the issues she was having. Residents Affected - Few During a follow up interview on 11/14/24 at 3:05 p.m. Resident #15 stated she was still having burning and hallucinations and no staff or providers had followed up with her about the symptoms at that time. During an interview on 11/14/24 at 9:42 a.m. LVN A stated he did add a note on 11/4/24 for 11/3/24 for the resident's report of burning during urination. This surveyor stated the note showed it was entered on 11/13/24. LVN A said sometimes the medical records system did not save his notes, so he had to enter the note on 11/13/24. LVN A stated if something is not documented then it did not occur. During an interview on 11/15/24 at 3:54 p.m. the DON stated staff should follow up with a resident when they report symptoms like dysuria and document it. The DON stated the facility charts by exception and dysuria would be considered an exception. The DON stated staff was expected to chart by the end of the day or shift. The DON stated the 24-hour report should have noted the dysuria Resident #15 was experiencing so the next nurse would know about it and monitor the resident. The DON stated it was acceptable to chart 10 days later as a late entry. 2. Record review of the admission Record, dated 11/15/24, reflected Resident #191 was a [AGE] year-old female originally admitted on [DATE] with diagnoses that included malignant neoplasm of unspecified site of left female breast (cancerous breast tumor), other intervertebral disc degeneration, lumbosacral region with discogenic pain and lower extremity pain (pain in the lower back (lumbosacral area) due to a degenerated intervertebral disc (discogenic pain), which then radiates down into the leg, causing pain in the lower extremity), and retention of urine (unable to empty their bladder, either partially or completely). Record review of Resident #191's admission MDS assessment, dated 10/4/24, showed her memory was fully intact for daily decision making. Section H showed the resident had a urinary catheter and was always incontinent of bowel. Record review of the Resident #191's Care Plan, initiated 11/7/24, showed resident was at risk for pressure injury and to educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, and inform the resident/family/caregivers of any new area of skin breakdown. Record review of Resident #191's active order summary, dated 11/14/24, printed at 8:04 a.m., contained no active orders for wound care. Record review of Resident #191's November 2024 TAR, dated 11/14/24, printed at 8:25 a.m. showed an order for apply collagen and zinc to affected area gluteal folds as needed, as needed apply to affected area as needed, with a start date of 11/12/24, and no end date. There was no documentation for wound care on the 12th, 13th, or 14th of November. Record review of an order audit report, dated 11/14/24, revealed an order for apply collagen and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 24 of 30 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 11/15/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few zinc to affected area gluteal folds as needed as needed apply to affected area as needed, it showed the order was created on 11/14/24 at 8:05 a.m. The audit showed the order was discontinued on 11/14/2024 at 2:00 p.m. Record review of Resident #191's November 2024 TAR, dated 11/14/24, printed at 6:09 p.m. showed new orders for -Bilateral Gluteal folds Impairment: Abrasion every day shift for Wound Healing Clean area with wound cleanser, pat dry. Apply collagen powder and zinc to affected areas. Leave open to air. with a start date of 11/15/24 and no end date. -Sacrum Impairment: Preventive Care, red skin every day shift for Preventive Care Clean area with wound cleanser, pat dry. Apply topical Triad cream and cover with Foam dressing. with a start date of 11/15/24 and no end date. During an interview on 11/14/24 at 8:02 a.m. RN N stated they should have an order for zinc paste and she was unsure if they had entered the order, but they had been providing wound care to Resident #191 who had developed an in-house skin issue to her gluteal fold area. During an observation on 11/14/24 at 11:41 a.m. Resident #191 was observed with reddened abrasions to the left and right gluteal fold area during incontinent and catheter care. Staff applied zinc to the area. During an interview on 11/14/24 at 3:45 p.m. the DON stated there was an order for wound care for Resident #191 with a start date of 11/12/24. The DON stated there was no missing documentation in the TAR for this order because it was a PRN order. The DON stated they did not need to provide the wound care daily because it was only as needed and that is why it was not documented. The DON stated the audit report, showed the order was entered on 11/14/24 at 8:05 a.m., was incorrect. Record review of the facility's policy titled Documentation in Medical Record, stated Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation . 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy . 3. Principles of documentation include, but are not limited to: a. Documentation shall be factual, objective, and resident centered. I . False information shall not be documented. ii. Record descriptive and objective information based on first-hand knowledge of the assessment, observation, or service provided. iii. Subjective information shall be recorded only as relevant, such as the resident's verbalizations, in quotation marks. b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care .h. Only document conclusions that can be supported by data and avoid bias, labels, and value judgments . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 25 of 30 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 11/15/2024 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 1 residents (Resident #191) reviewed for hospice services, in that: The facility failed to ensure Resident #191's most recent Physician Certification of Terminal Illness and Hospice Election form were completed and were part of the hospice documents at the facility. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of the admission Record, dated 11/15/24, reflected Resident #191 was a [AGE] year-old female originally admitted on [DATE] with diagnosis that included malignant neoplasm of unspecified site of left female breast (cancerous breast tumor), other intervertebral disc degeneration, lumbosacral region with discogenic pain and lower extremity pain (pain in the lower back (lumbosacral area) due to a degenerated intervertebral disc (discogenic pain), which then radiates down into the leg, causing pain in the lower extremity), and retention of urine (unable to empty their bladder, either partially or completely). Record review of Resident #191's admission MDS assessment, dated 10/4/24, showed her memory was fully intact for daily decision making. Section O showed she was receiving hospice services while a resident. Record review of the Resident #191's Care Plan, initiated 11/7/24, revised 11/13/24, showed the resident had a terminal prognosis related to malignant neoplasm of the breast and is on hospice services with interventions to work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Record review on 11/14/24 revealed Resident #191's hospice binder and EMR did not have the 3071 Individual election form/cancellation/update and 3074 Physician certification and recertification of the terminal illness form in the records. During an interview on 11/14/24 at 6:47 p.m. the Regional Administrator stated they had reached out to hospice to inquire where the forms were and were told by hospice that they did not need the individual election form because the resident was private pay. During an interview on 11/15/24 at 10:11 a.m. the Director of Clinical Services from the hospice company stated there was confusion previously but they are required to have both forms and they provided them to the facility on [DATE]. The Director stated the hospice company did fill out the forms but did not leave copies with the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 26 of 30 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 11/15/2024 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 0849 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/15/24 at 2:42 p.m. the SW stated she was responsible for ensuring the hospice documents were present at the facility and a part of the medical record for Resident #191. The SW stated she was unsure of what documents were needed and referred to the hospice company who told her the documents were not required. The SW stated she did not know what the risk was for the resident if they did not have the proper documents and would need to ask. Residents Affected - Few During an interview on 11/15/24 at 4:15 p.m. the DON stated the hospice binder needed to have the 3071 Individual election form/cancellation/update and 3074 Physician certification and recertification of the terminal illness form when the resident was admitted to hospice. Record review of the facility's policy titled Hospice Services Facility Agreement, dated 2024, stated It is the policy of this facility to provide and/or arrange for hospice services in order to protect a resident's right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility .5. The facility has a designated (the Assistant Director of Nursing, or specify the member from the interdisciplinary team) to be responsible for working with hospice representatives to coordinate care to the resident provided by facility and hospice staff. This designee: a. Has a clinical background, b. Functions within their state's scope of practice, and c. Has the ability to assess the resident or have someone that has the skill and capabilities to assess the resident. 6. The designated member of the facility working with hospice representative is responsible for: d. Obtaining the following information from the hospice: i. The most recent hospice plan of care specific to each resident ii. Hospice election form iii. Physician certification and recertification of the terminal illness specific to each resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 27 of 30 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 11/15/2024 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 observations, interviews, and record reviews, the facility failed to 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 disease and infection for 1 of 4 residents (Residents #15) reviewed for infection control Residents Affected - Few 1. The facility failed to ensure CNA L and CNA M used appropriate hand hygiene between glove changes when providing incontinent care to Resident #15. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: Record review of the admission Record, printed 11/15/24, reflected Resident #15 was a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing an area of dead brain tissue), extended spectrum beta lactamase (ESBL) resistance ( enzymes that make bacteria resistant to many antibiotics, including penicillins, cephalosporins, and aztreonam), unspecified Escherichia coli [E. Coli] as the cause of disease ( bacteria commonly found in the intestines of humans and animals, and while most strains are harmless, certain types can cause illness), and personal history of urinary tract infections. Record review of Resident #15's quarterly MDS assessment, dated 10/4/24, showed her memory was fully intact for daily decision making. Section I of active diagnoses showed she had a UTI in the last 30 days. Section H showed the resident was always incontinent of bladder and bowel. Record review of the Resident #15's Care Plan showed she was on enhanced barrier precautions related to history of ESBL of the urine, initiated on 9/28/24, revised on 11/12/24, with interventions of staff will educate resident on Enhanced Barrier Precautions, proper signage to be clearly indicated, PPE including gown and gloves available outside or near room, alcohol based handrub available, trash can inside room near exit for discarding PPE prior to exit of the room, Proper use of PPE to be observed, use of gown and gloves during high contact resident care activities that promote opportunities for transfer of MDROs (Multidrug-resistant organisms (MDROs) are microorganisms, primarily bacteria, that are resistant to multiple classes of antibiotics and antifungals.), Staff to DON and DOFF PPE (Donning and doffing are terms that refer to putting on and taking off personal protective equipment (PPE)) according to recommendations, which is before any high contact resident care activities like . dressing, bathing/showering, transferring, providing hygiene, changing linens, toileting or assisting with toileting and remove prior to leaving the room, and Standard precautions to be observed regardless of suspected or confirmed infection or colonization status. These precautions are based on the principal that all blood, body fluids, secretions and excretions may contain transmissible infectious agents. During an observation on 11/15/24 at 11:16 a.m. CNA L and CNA M provided incontinent care to Resident #15. CNA M wiped the resident's peri area, removed her gloves, did not perform hand hygiene, and put on new gloves. CNA M again wiped between Resident #15's thighs, removed her gloves, did not perform hand hygiene, and put on new gloves. CNA L and CNA M rolled the dirty brief up partially, both (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 28 of 30 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 11/15/2024 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 - Few removed their gloves, did not perform hand hygiene, and put on new gloves. CNA M then wiped Resident #15 buttocks and feces fell on the sheets. CNA M then removed her gloves, did not perform hand hygiene, and put on new gloves. CNA L then wiped Resident #15's right side of her buttocks, removed her gloves, did not perform hand hygiene, and put on new gloves. During an interview on 11/15/24 at 11:40 a.m. CNA L and CNA M stated they had been trained on incontinent care at the facility. CNA L and CNA M stated they were unsure if they needed to perform hand hygiene between every glove change but did make sure to wash their hands when they entered a resident room and before they left a resident room. They stated hand hygiene was necessary to prevent infections. During an interview on 11/15/24 at 3:48 p.m. the DON stated staff should perform hand hygiene between each glove change for infection control to prevent infections. Record review of the facility's policy titled Hand Hygiene, dated 2024, stated 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 .6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 29 of 30 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 11/15/2024 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 2 multi compartment sinks (Dishwashing Sink) reviewed for essential equipment. Residents Affected - Few The facility did not ensure the dishwashing sink was not leaking and used a food safe repair sealant. This failure could place the residents at risk of foodborne illness for consuming food washed in potentially contaminated water. Findings included: During an observation on 11/14/24 at 4:48 p.m. the dishwashing sink middle compartment used to rinse dishes was leaking water from the bottom onto the floor. The sink had a soft, yellowish substance, along the inside of the bottom of the right side of the sink. The sink could not hold water for longer than 5 minutes. During an interview on 11/14/24 at 5:00 p.m. the DS stated she was not sure what to call the yellowish substance in the sink, but it was used to repair a leak in the sink. The DS stated that they did not know if the sealant used was food safe. The DS stated she had discussed getting the sink repaired that day with the MS. During a joint interview on 11/15/24 at 4:53 p.m. the MS stated he did not have the original container for the sealant used on the dishwashing sink and was not sure if it was food safe. The MS and DS stated dishes could possibly not be rinsed correctly if there was something in the water and could get stuck on dishes used for residents' food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675974 If continuation sheet Page 30 of 30