Health inspection·January 6, 2023

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation record review and interview the facility failed appropriate treatment and services were received for 1 (Resident #100) of 6 residents with bowel and bladder incontinence, in that: The WCN did not perform hand hygiene between donning and doffing gloves when performing incontinent care for Resident #100. CNA A and the WCN did not use a clean technique or use clean wipes when performing pericare on Resident #100, wiping back to front. CNA A and CNA B did not wash their hands for a minimum of 20 seconds during pericare. This failure could place residents at risk for infections and cross contamination. The findings included: Record review of Resident #100's Face Sheet dated 01/06/23 reflected an [AGE] year-old female admitted to the facility on [DATE], diagnoses included: Pressure ulcer of sacral region (the portion of your spine between your lower back and tailbone), stage 3 (the sore has gone through all layers of skin into the fat tissue, exposing the resident to infection), aftercare following joint replacement (right hip), and dementia. Record review of Resident #100's Admission/Medicare 5-Day MDS dated [DATE] reflected: Extensive assistance with 2+ person assistance was needed for bed mobility, transfers, locomotion on unit, dressing, eating, toilet use, and personal hygiene. Resident #100 was frequently incontinent of bowel and bladder. Record review of Resident #100's Care Plan dated 11/21/22 reflected: -Resident #100 had a STAGE 3 pressure ulcer to her sacrum with intervention of : Follow facility policies/protocols for the prevention/treatment of skin breakdown. -Resident #100 had bowel and bladder incontinence with interventions of: The resident used disposable briefs. Change as needed; Clean peri-area with each incontinence episode; Check as required for incontinence. Wash, rinse, and dry perineum (the thin layer of skin between your genitals - vaginal opening or scrotum - and anus). Change clothing PRN after incontinence episodes. Review of Resident #100's Weekly Pressure Ulcer Evaluation dated 01/04/23 reflected Resident #100's stage 3 sacral pressure ulcer measurement as 4.0cm x 2.5cm x 0.2cm. 12/10/22 Weekly Pressure Ulcer Evaluation documented Resident #100's stage 3 sacral pressure ulcer measurement as 4.0cm x 5.0cm x 0.2cm. Observation on 01/06/23 at 02:26 p.m., during incontinent care for Resident #100 revealed CNA B wiped Resident #100's anal area four times with the same wipe swiping back to front with one swipe. CNA B wiped the resident's anal area three times with the same wipe. CNA B removed gloves and washed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676037 If continuation sheet Page 2 of 10 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 676037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Weslaco Nursing and Rehabilitation Center 422 E 18th St Weslaco, TX 78596 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 her hands for 13 seconds. After washing her hands, CNA B put on new gloves. CNA B removed her gloves. CNA B left the room to get more supplies. CNA B returned to the room and washed her hands for 13 seconds. CNA B put on new gloves. CNA B rolled the linen to the resident's backside on the left. CNA A removed her gloves, used hand sanitizer, and put on new gloves. CNA B placed a clean adult brief and mattress pad under the resident's left side, under soiled linen. Resident #100 soiled the clean mattress pad. CNA B rolled the resident to her left side. CNA A gathered the soiled linen and pulled it to right side. CNA B attached the tabs on adult brief. CNA A removed her gloves and washed her hands for 8 seconds and put on clean gloves. CNA B removed her gloves, washed her hands for 17 seconds, and put on new gloves. CNA B rolled resident to right side and CNA B tucked mattress pad under left side. CNA B rolled resident to left side and CNA A held resident on left side. CNA B pulled clean mattress pad to right side. CNA A removed gloves, used hand sanitizer, and put on new gloves. CNA B put clean pillowcase on pillow. CNA B rolled resident to left and CNA A placed pillow under right side. CNA A rolled resident to right side and CNA B put pillow under left side. CNA A lifted feet and legs and CNA B placed pillow under feet and between legs. CNA A and CNA B covered resident with clean sheet and blanket. CNA B raised head of bed and lowered bed. CNA B removed gloves, washed hands for 22 seconds. CNA A removed gloves and washed hands for 48 seconds. CNAs left room. Interview on 01/06/23 at 10:33 a.m. CNA A stated 30 seconds was the handwashing time. CNA A stated she washed her hands for 30 seconds the first time, but she did not know (how long she washed her hands) for the other times. CNA A stated they were to use one wipe for each swipe. CNA A stated infection could occur if she did not wash her hands for 30 seconds. CNA A said CNA B (CNA Charge) checked them off once a week for pericare. Interview on 01/06/23 at 10:37 a.m. CNA B stated they were to wash their hands for 30 seconds. CNA B stated she thought she washed her hands for 30 seconds each time she washed her hands. CNA B stated she was to use one wipe for each swipe and wipe from front to back. CNA B stated infection could occur if using the same wipe more than once and wiping back to front could cause infection. CNA B stated CNAs were in-serviced (by ADONs) maybe once a week and she (CNA B) checks the other CNAs. CNA B stated she is the Charge CNA who checks the other CNAs during pericare. Wound care observation on 01/06/23 at 10:52 a.m., revealed the WCN sprayed the sacral pressure ulcer with wound cleaner and patted dry. The WCN removed her gloves, put on new gloves. No hand sanitizer was used before putting on new gloves. The WCN applied Santyl, Gentamicin and, collagen powder to sacral pressure ulcer. The WCN covered sacral pressure ulcer with gauze and covered with Optifoam dressing. The WCN removed her gloves, did not perform hand hygiene, and put on new gloves. The WCN placed a clean adult brief under Resident #100's soiled brief. Resident #100 had a moderate bowel movement. CNA B removed her gloves, used hand sanitizer, and put on new gloves. The WCN removed her gloves and put on new gloves. No hand sanitizer used before putting on new gloves. The WCN wiped anal area front to back with one wipe removing bowel movement with five swipes, then using the same wipe and wiped back to front twice. The WCN removed her gloves and put on new gloves. WCN did not use hand sanitizer before putting on new gloves. CNA B wiped anal area with one wipe removing feces. CNA B removed her gloves, washed her hands for 34 seconds. The WCN wiped anal area using one wipe for four swipes back to front attempting to get the feces off, under the dressing. The WCN removed the dressing she had applied over the sacral pressure ulcer before the resident had a moderate bowel movement. The WCN sprayed Resident #100's wound with wound cleaner and patted dry. The WCN removed her gloves and put on new gloves without using hand sanitizer. The WCN applied Santyl/Gentamicin/Collagen, covered with gauze, and applied Optiform dressing to sacral pressure ulcer. Dressing was dated and initialed by WCN. The WCN removed her gloves and put on new gloves not using hand sanitizer. CNA B (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676037 If continuation sheet Page 3 of 10 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 676037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Weslaco Nursing and Rehabilitation Center 422 E 18th St Weslaco, TX 78596 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 attached the adult brief tab on the right side and the WCN attached the adult brief tab on left side. Level of Harm - Minimal harm or potential for actual harm Interview on 01/06/23 at 11:31 a.m. the WCN stated she was supposed to sanitize her hands before putting on new gloves. She stated she was nervous and forgot. WCN stated contamination can occur if she does not use hand sanitizer before putting on new gloves. The WCN stated she is to use one wipe for each swipe with a front to back motion. She stated they are in-serviced on infection control that includes handwashing/hand sanitizer. Residents Affected - Few Interview on 01/06/23 at 01:57 p.m. CNA C stated 20-30 seconds is the handwashing time per policy. CNA C stated check-offs on handwashing are done frequently. CNA C did not know how often. CNA C stated hand sanitizer is used when gloves are removed and before putting on new gloves. CNA C stated when care has been provided, CNA C said she washes her hands. CNA C stated one wipe is used per swipe during pericare and CNAs are to wipe front to back. CNA C stated CNA B does check-offs and so does the ADON. Interview on 01/06/23 at 02:04 p.m. CNA D stated handwashing time is 20 seconds. CNA D stated when changing gloves during resident care, the CNA can either wash their hands before putting on new gloves or use hand sanitizer. CNA D stated they are to use one wipe per swipe when doing pericare. CNA D stated they wipe front to back. CNA D stated if those things are not followed, infection or cross-contamination can occur. CNA D stated check-offs and in-services on pericare or handwashing do not occur often, but when they do, it is either a nurse or CNA B who does the check-off. Interview on 01/06/23 at 02:14 p.m. the DON stated the handwashing policy was soap and water for at least 20 seconds. DON stated after using antibacterial hand sanitizer two to three times, wash hands. The DON stated one wipe should be used per swipe and they are to wipe front to back. The DON stated when changing gloves, hand sanitizer is to be used before putting on clean gloves. DON said the negative outcome is the potential for infection is greatly increased. DON stated the ADON does the check-offs for new hires, yearly, or as needed. DON stated in-services occur very often, especially with COVID-19. Record review of facility's CNA Orientation Skills Checklist including Pericare/Females and Handwashing/Gloves dated 03/31/22, revealed completion by CNA A and CNA B. Record review of facility's Basics of Hand Hygiene, dated 04/11/22 revealed Basics of Hand Hygiene was completed by CNA A. Record review of facility's Basics of Hand Hygiene, dated 04/20/22 revealed Basics of Hand Hygiene was completed by CNA B. Record review of facility's In-service Training Report for CNAs and Nursing on Handwashing dated 12/21/22, revealed CNA A and CNA B attended the training. Review of facility's perineal care revealed; [Corporate name], dated 10/24/22, Policy: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676037 If continuation sheet Page 4 of 10 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 676037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Weslaco Nursing and Rehabilitation Center 422 E 18th St Weslaco, TX 78596 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 the extent possible, and to prevent and assess for skin breakdown. Level of Harm - Minimal harm or potential for actual harm Definition 'Perineal care' refers to the care of the external genitalia and the anal area. Residents Affected - Few Policy Explanation and Compliance Guidelines: 9. 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. b. Thoroughly dry. Record review of facility's hand hygiene policy revealed: [Corporate name] dated 10/24/22 Hand Hygiene Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: 'Hand hygiene' is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy Explanation and Compliance Guidelines: 1.Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 5.Hand hygiene technique when using soap and water: a. Wet hands with water. Avoid using hot water to prevent drying of skin. b. Apply to hands the amount of soap recommended by the manufacturer. c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of hands and fingers. 6.Additional considerations: a. Then 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. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676037 If continuation sheet Page 5 of 10 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 676037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Weslaco Nursing and Rehabilitation Center 422 E 18th St Weslaco, TX 78596 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 Record review of How to Perform Perineal Care (https://cna.plus/faq/promotion-of-health/perineal-care-how-to/) on 01/06/2023 revealed: 5. Cleanse the perineum, using front to back motions. Use a fresh washcloth for each pass from front to back. Residents Affected - Few 6. Never wash back to front; this causes contamination and can cause infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676037 If continuation sheet Page 6 of 10 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 676037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Weslaco Nursing and Rehabilitation Center 422 E 18th St Weslaco, TX 78596 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral feeding received the appropriate treatment and services to prevent potential complications for two (Resident #61 and Resident # 45) of 3 residents reviewed with feeding tubes in that; 1)The facility did not ensure Resident #61's enteral feeding formula (fed through gastric tube) and water bag were not initialed, date and time started and name of formula and water bag for tube feeding were not labeled when first placed and as required by standard of care. 2) The facility did not ensure Resident #45's enteral feeding water bag was not initialed, dated, or timed when first placed and as required by standard of care. These failures could place residents with feeding tubes at risk for dehydration or calorie deficiency. Findings included: 1)Record review of the admission record for Resident # 61 dated 01/04/23 indicated Resident #61 was initially admitted on [DATE] and re-admitted on [DATE] with diagnosis that included parkinson's disease (progressive disorder that affects nervous system), alzheimer's disease (common type of dementia), dysphagia (difficulty in swallowing), dementia (impaired ability to remember), abnormal weight loss and polydipsia (excessive thirst or excess drinking). Record review of Resident #61's quarterly MDS dated [DATE] indicated. -cognitive skills were moderately impaired, -required extensive assistance by two persons for bed mobility, transfers, dressing and toilet use, -required extensive assistance by one person for personal hygiene and -received 51% or more of total calories through tube feeding. Record review of Resident #61's Physician Orders dated 01/04/23 indicated an order. Every shift (Jevity 1.2) at (65ml per hour), via G-tube stationary pump. Feeding to provide (Total 1710 Kcals, 79.2 gm protein, 300ml of free water, total fluids 1730ml, start date, 11/21/22. Record review of care plan revised on 11/25/22 indicated Resident #61 required use of peg tube for all nourishment and hydration needs. During an observation on 01/03/23 at 10:35 am Resident #61was lying in bed with G-tube feeding turned off. The formula bottle had 250ml left in the bottle of formula labeled Jevity 1.2 and the water bag contained 200ml of water. Both the formula bag and water bag had no information labeled such as date it was started, time started, name of formula or the initials of the staff who placed the formula and water bag for Resident #61. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676037 If continuation sheet Page 7 of 10 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 676037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Weslaco Nursing and Rehabilitation Center 422 E 18th St Weslaco, TX 78596 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 01/03/23 at 11:33 am with LVN G she said both the formula bottle and water bag should be labeled with date started, time started, name of formula, and initials of the staff who had placed the new feeding bottle and water bag. LVN G said the night nurse, LVN H had placed the new feeding bag and water bag. LVN G said she had come in late during the morning and had not done her rounds for the morning. LVN G said she had not seen the formula and water bag missing the labels that they required. LVN G said Resident #61 feeding was on downtime. Interview on 01/06/23 at 4:04 pm with LVN H revealed she had not noticed she forgot to label the feeding bottle and water bag for Resident #61. LVN H said if the feeding bottle and water bag are not labeled with date, time, name of formula or initials of staff who started the feeding, staff might not be able to know if the resident was getting less or more feeding or water that was ordered by the physician. Record review of the admission record for Resident # 45 dated 01/05/23 indicated Resident 45 was admitted to the facility on [DATE] with diagnosis that included encephalopathy (altered mental state), end stage renal disease (permanent stage of kidney disease), diabetes (metabolic disorders caused by high blood sugars), dysphagia (difficulty in swallowing), and urinary tract infection. Record review of Resident #45's admission MDS dated [DATE] indicated. -cognitive status was moderately impaired, -required extensive assistance by two persons for bed mobility, transfers, dressing, toilet use and personal hygiene. -received 25% or more of total calories through tube feeding. Record review of Resident #45's Physician Orders dated 01/04/23 indicated an order. Every shift (Jevity 1.5) at (60ml per hour), via G-tube stationary pump, continuous for 20 hours. 75ml H2) flush Q4hrs. Downtime; 3pm -7pm, start date 12/25/22. Record review of care plan revised on 12/27/22 indicated Resident #45 required use of tube feeding related to dysphagia. During an observation on 01/04/23 at 8:58 am, Resident #45 was lying in bed with G-tube feeding on at 60ml per hour. The formula bag was labeled with name of formula, Jevity 1.5, dated 01/04/23 and time of start and the staff initials. The water bag did not have a date started, or timed or initials of staff who started the feeding bag and water bag. Interview on 01/04/23 at 9:10 am with LVN I revealed the night nurse LVN J had started the tube feeding formula and water bag but had not labeled the water bag with date started, or time started and the initials. LVN I said she did rounds in the morning and did not notice the water bag for tube feeding for Resident #45 was not labeled. LVN I said both the feeding and water bag should be labeled to be sure the feeding and water were dispensed as ordered. Interview on 01/04/23 at 3;30 pm with LVN J revealed he had remembered to label the water bag with date of start and time and his initials for Resident #45. LVN J said if the feeding bags or water bags are not labeled, staff will not know when the feedings were started or by who and if the feeding (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676037 If continuation sheet Page 8 of 10 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 676037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Weslaco Nursing and Rehabilitation Center 422 E 18th St Weslaco, TX 78596 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 0693 bags are dispensing as ordered. Level of Harm - Minimal harm or potential for actual harm Interview on 01/05/23 at 4:10 pm with the facility DON revealed the feeding and water bags should be labeled with date initiated, correct formula, resident name, rate of administration, time of start and initials of staff who started the feeding. The DON said she had no policy or procedure on labeling of the feeding and water bags, and she had not in-serviced her staff on the proper procedure of labeling the feeding and water bags. The DON said she would start in-servicing her staff on the proper procedure to label the feeding and water bag. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676037 If continuation sheet Page 9 of 10 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 676037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Weslaco Nursing and Rehabilitation Center 422 E 18th St Weslaco, TX 78596 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen, in that: Residents Affected - Some The boxes of dry goods, bread, vegetables, and paper goods were placed directly on the floor in the pantry instead of on pallets. This deficient practice could place residents who received meals from the kitchen at risk of food-borne illness. The findings were: Observation during initial tour of the kitchen with the [NAME] on 01/03/23 at 9:15 AM revealed 14 boxes that included canned fruit and vegetables, sugar packets, flour, salt, and rice on the floor in the pantry. The [NAME] said the delivery from the food distributor had just arrived. Observation on 01/03/23 at 9:19 AM revealed the delivery driver from the food distributor had placed three more boxes of foam cups, plastic cutlery, and canned vegetables in the pantry. In an interview on 01/03/22 at 9:20 AM, the Delivery Driver said he had been given instructions by his supervisor to put the boxes on pallets, but he had not seen any pallets in the pantry so, he placed the cases on the floor. In an interview on 01/03/23 at 9:21 AM, the [NAME] said the delivery from the food distributor had just arrived and the driver had put them on the floor. The [NAME] said the boxes should be up on pallets. The [NAME] said there were three staff working in the kitchen, the cook, the dietary aide, and the dishwasher. The [NAME] said no one had been assigned to put away the deliveries; all staff had to assist with putting the deliveries away. The [NAME] said the deliveries should be put on a pallet, but the drivers were in a hurry and didn't put them on a pallet. In an interview on 01/03/23 at 2:02 PM, the DC said he had in-serviced the staff on ensuring that they instructed the driver to place all deliveries on a pallet. The DC said he placed two pallets in the janitors closet for easy access. The DC said he told the dietary staff to be a little more forceful with the drivers when they dropped of the deliveries. The DC said it was important to keep the food off the floor to prevent cross contamination and prevent food borne illnesses. Record review of a policy on Food Storage revised on 06/01/19 indicated: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal, and US Food Codes and HACCP Guidelines. Procedure: h. Store all items at least 6 above the floor with adequate clearance between goods and ceiling to protect from overhead pipes and other contamination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676037 If continuation sheet Page 10 of 10