Health inspection·September 15, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents environment remained as free of accidents and hazards as possible, and each resident received adequate supervision to prevent accidents for 2 (Resident #2 and Resident #12) of 5 residents reviewed for quality of care.1. The facility failed to ensure the call light was within reach, assist bars were in place, and the bedside table was positioned away from Resident #2 on 8/28/25.2. The facility failed to ensure an PT/OT evaluation was completed for Resident #12, who required an assessment for assist bars to support bed mobility.These failures could place residents at risk for falls, injuries, loss of independence, and unmet care needs, which may result in a decline in overall health, safety, and quality of life. Findings included: 1. Record review of Resident #2's face sheet dated 9/11/25 revealed [AGE] year-old male was admitted to the facility on [DATE]. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed his cognition was severely impaired. For rolling left and right Resident #2 required substantial/ maximal assistance. Record review of Resident #2's history and physical dated 10/1/24 revealed a diagnosis of right sided hemiparesis (weakness on the right side of the body) seizure (sudden surge of electrical activity in the brain that can cause shaking, staring spells, confusion, or loss of awareness for a short period), vascular dementia (memory loss and difficulty thinking caused by poor blood flow in the brain, often after strokes or mini-strokes), hemorrhagic stroke (type of stroke that happens when a blood vessel in the brain bursts, causing bleeding and damage to brain cells), BPH (enlarged prostate gland (not cancer) that can make urination slow, frequent, or difficult, usually in older men). Record review of Resident #2's care plan dated 5/1/25 revealed a focus area of ADL self-care performance deficit related to Hemiplegia and risk for falls and interventions that included the resident requires (maximal assistance) by x1 staff to turn and reposition in bed every 2 hours and as necessary and assist Resident with ambulation and transfers, utilizing therapy recommendations. At risk for injury/falls r/t Traumatic hemorrhage, fall prior to admission with interventions that included Call light within reach when in bed and provide assistive devices for mobility as indicated. Record review of Resident #2's side rail assessment dated [DATE] revealed consideration due to medical needs and mobility/transfer assistance; benefits included assist resident with movement while in bed, assists with positioning/turning side to side in bed, provides with feeling of comfort and security in bed, defines bed parameters; no risks were identified; siderail were recommended at the time for medical reason; resident and resident RP were marked notified and discussed the risks and benefits from using siderails. Record review of Resident #2's electronic medical records for August and September 2025 revealed no side rail assessment was completed.Record review of Resident #2 video picture dated 8/28/25 at 4:22 pm, call light does not appear within reach, and bedside table was arm's length from the bed, and side rails were not in place. Record review of Resident #2's progress note dated 8/28/25 written by LVN Unit Manager F read in part 1625 hours Nurse was notify by CNA that resident was on the floor at principal for pain on left hip, hospice, to inform that resident situation, and has previous hip surgery. RN supervisor perform head to toe assessment, resident complain of pain on left hip, ambulance was the same place, ok sent him to hospital, call 911 at 1630, and leave facility at 1700 to [local hospital] main campus notify ADON DON, RN, we continue as protocol of this facility.Record review of Resident #2's progress note dated 8/28/25 written by DON Was notify by floor nurse that resident was on the floor, resident was on his left side scooting around, resident was partially off the floor matt. Resident alert and oriented times 1 left hip, unable to move extremity, resident unable to fully extend upper extremity and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676060 If continuation sheet Page 2 of 14 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 676060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambrosio Guillen Texas State Veterans Home 9650 Kenworthy St El Paso, TX 79924 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some noticed abrasions to shin area. Resident unable to fully extend the upper extremity, normal baseline noticed. Called [family member] to notify of incident, [family member] stated he will call hospice. Floor nurse called hospice and got okay to send him to hospital for further treatment. Record review of Resident #2's local EMS care report dated 8/28/25 revealed cause of injury was fall from bed and height of fall was 2 feet tall. The narrative read in part he was normal baseline, GCS of 13, history of dementia, distal pulses (heartbeat felt farthest from the heart) present, and lung sounds clear. The patient sustained a bedside fall, no LOC, no blood thinners, but was found to be trauma hypotensive with systolic of 105. He denied any pain. Record review of Resident #2's local hospital note dated 8/28/25 revealed a [AGE] year-old male with a history of vascular dementia, prior hemorrhagic stroke with right-sided weakness, seizures, and BPH, was admitted to the hospital on [DATE] after an unwitnessed fall from bed at the nursing facility. On arrival, he was confused but hemodynamically stable with a GCS of 13. A CT scan of the brain showed no acute bleeding or injury but revealed chronic changes, including left frontal lobe scarring, brain shrinkage, and small-vessel disease. The pelvis X-ray showed no fractures or dislocations. It did show weaker bones, moderate arthritis in both hips. He was managed as a trauma case, received IV fluids, and continued home medications including Keppra, lorazepam, and morphine as needed. On 8/29/25, his son requested discharge back to the nursing facility despite risks being explained, and [Resident #2] was discharged against medical advice.2. Record review of Resident #12's face sheet dated 9/12/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Record review of Resident #12's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14, his cognition was intact. For rolling left and right, Resident #12 was marked as requiring substantial/ maximal assistance. Record review of Resident #12's history and physical dated 5/6/15 revealed diagnoses of morbid obesity, unspecified osteoarthritis, and COPD (lung disease that block airflow and make it difficult to breathe). Record review of Resident #12's care plan dated 5/29/25 revealed focus area for ADL self-care performance deficit related to impaired balance, spinal stenosis (happens when the space inside the backbone is too small), artificial right knee; prefers call light for easier accessibility to be wrapped on his bed side rail with interventions that included bed mobility: requires dependent assistance by x2 staff to turn and reposition in bed every 2 hours and as necessary and SIDE RAILS: 1/4 side rails up as per doctor's order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition every 2 hours and as necessary to avoid injury was resolved/ discontinued on 8/27/25. Record review of Resident #12's electronic medical records for revealed there was no side rail assessment completed. During an interview on 9/11/25 at 10:36 am, LVN Unit Manager F stated therapy had begun evaluating all residents for the use of assist bars as of the previous week. Prior to that, admissions would ask residents if they wanted assist bars and would place them. He stated that after admission, if a resident requested assist bars, the nurse would conduct a side rail assessment and proceed from there. He stated he was familiar with Resident #2 and that a side rail assessment had been completed for him on 7/2/25, which indicated medical necessity for a side rail. He stated that later in August, the facility received new beds and were pending therapy assessments to determine who required them. Because of this, not many residents had bed rails at that time. He referred to the notes from 7/27/25 and stated he had written a note after Resident #2's family member requested full bed rails. He stated he educated the family member that only quarter assist bars could be provided, which Resident #2 had prior to receiving the new bed. He stated that full assist bars would have been considered a restraint since Resident #2 would not have been able to get out of bed. He explained that when a side rail assessment warranted rails, an order would be placed in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676060 If continuation sheet Page 3 of 14 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 676060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambrosio Guillen Texas State Veterans Home 9650 Kenworthy St El Paso, TX 79924 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some electronic health records, and maintenance, through the DOR, would install them. He was shown the picture and the date and stated that during that week the new beds had been delivered, which was why assist bars were not in place. He stated Resident #2 had a history of falls, and interventions included a low bed, floor mat, and call light within reach. He stated the bedside table should not have been placed close to Resident #2 because he could have attempted to lean over to grab items, increasing the fall risk. He stated CNAs and nurses were responsible for ensuring fall precautions were in place, and rounds were conducted every two hours at a minimum. He stated failure to follow interventions could result in falls, as in the incident where Resident #2 fell and was sent to the hospital. Based on the picture, he stated the call light was not in reach and the bedside table was too close.During an interview on 9/11/25 at 11:06 am, CNA J stated she was familiar with Resident #2 and recalled he was a high fall risk. She stated interventions included a low bed, floor mats, and a call light within reach. She stated Resident #2 had assist bars, but they were removed about 2-3 weeks earlier. She stated he sometimes used them. She stated that because Resident #2 was confused and had very few belongings, which were kept on his dresser, the bedside table did not need to be close. She stated that if placed too close, Resident #2 would have been tempted to reach over and possibly fall. She stated she had worked on 8/28/25 and was the CNA assigned. After being shown the picture, she stated she could not see the call light and that it was not in reach. She also stated the table should not have been placed close. She stated Resident #2 was at risk for falls, though she did not recall whether he fell that day. She did not know why the call light was not in reach or why the table was placed that way. She stated she had received training on fall precautions.During an interview on 9/12/25 at 11:22 am, the DON stated that when she met Resident #2, he did not need assist bars. She stated the rails were intended to aid in mobility, and he was not conscious enough to use them for that purpose. She stated any intentional movement had to be assisted by staff. She stated she had started in early June of 2025. She reviewed the side rail assessment dated [DATE] and stated that in her personal observation, he did not need assist bars. She stated the floor nurses were responsible for assessments. She also stated that at the end of July 2025, therapy began evaluating residents to determine their need for assist bars, though Resident #2 had not yet been evaluated by therapy. She explained that when the beds were replaced, the old assist bars were not compatible with the new ones, so no rails were installed. She stated Resident #2 had a seizure diagnosis, which increased his risk for injury. She explained that interventions included keeping the bed in a low position, using mats, and checking on him every hour due to family involvement. She stated that during the fall on 8/28/25, Resident #2 had been restless. She recalled seeing him on the floor and that EMS had placed him back in bed. She stated he did not appear to be in pain and had no visible head injury when he returned. She stated the call light was not visible in the picture. She noted that policy required items to remain within reach, but the bedside table did not specifically care planned to be away from him. She stated that with restless residents, staff could add care plan interventions to remove or reposition tables if needed.During an interview on 9/12/25 at 2:05 am, the DOM stated he did not know which residents required side assistance bars, as he was waiting on PT evaluations. He stated all new beds were installed the last week of August 2025, and the assist bars were placed in storage pending therapy's list for installation.During an observation and interview on 9/12/25 at 2:33 pm, Resident #12, Alert and Oriented x4, was in bed and no assist bars were noted. He stated his bed rails were removed about 2-3 weeks ago when the new beds arrived. He stated he had used them for bed mobility, but now had to wait for staff assistance. He stated this change affected his independence. He stated he had asked about it and was only told they were waiting for the new bed rails to arrive.During (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676060 If continuation sheet Page 4 of 14 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 676060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambrosio Guillen Texas State Veterans Home 9650 Kenworthy St El Paso, TX 79924 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete an interview on 9/12/25 at 3:23 pm, the DOR stated PT and OT completed evaluations to determine their need and this would take about 30 minutes. He stated the bars were meant to assist with bed mobility and transfers for ADLs. He stated the new beds were installed about two weeks earlier. He stated approximately 71 evaluations had been completed, a little less than half of the residents. Some residents did not yet have bars because the assist bars were not available. He stated once evaluations were complete, physicians had to approve the orders, including those for enablers.During a follow up interview on 9/12/25 at 4:16 pm, the DON stated Resident #12 was still pending evaluation. She stated she had been told the therapy evaluations took about 30 minutes but had seen little progress in three weeks. During an interview on 9/15/25 at 9:34 am, the Administrator stated clinical leadership, unit managers, and DONs were responsible for prevention, call light placement, and ensuring staff were aware of fall risks. He stated post-fall risk meetings were held to identify causes and implement interventions such as footwear, low beds, and call lights. He stated he was familiar with Resident #2, describing him as paralyzed and later confused. He stated a fall mat was in place, the bed was in the lowest position, and although a call light was expected to be within reach, it could not be seen in the picture. He stated if the call light was thrown off the bed, frequent rounding should have ensured it was replaced. He stated the bedside table could obstruct pathways unless specifically care planned to be removed. Regarding assist bars, he stated this was a new process with the new beds and therapy assessments were pending. He stated the facility already had the bars but had not made progress on installations. He stated frequent rounding and call light placement were the main interventions, though ideally the bars would enhance independence.Record review of the facility's Fall Prevention and Reduction Program policy not dated revealed in part A fall is defined as the act of unintentionally coming to rest on the ground, floor, or other lower level (e.g., onto a bed, chair, or bedside mat) but not as a result of an overwhelming external force (e.g., a resident pushes another resident). The fall may be witnessed, reported by the resident or an observer, or identified when a resident is observed on the floor or ground and can occur anywhere. A near miss or an episode where a resident lost his or her balance and almost fell is also considered a fall, as well as a fall that does not result in injury. Individualized approaches may include, but are not limited to: evaluating the resident for recent change in medication; evaluating the resident for changes (mental/physical); therapy referral for evaluation; toileting plan to include before meals and bedtime; use of bed and chair alarms; non-restrictive Velcro alarming seatbelt; protective equipment such as non-skid material to wheelchair or anti-tippers; non-skid socks; properly fitted shoes; bed in low position; bed on floor if feasible; bed against the wall; defined perimeter mattress; use of side rails to aid in bed mobility and to define bed perimeter; and equipment to aid with access to items in room.Record review of the facility's Side Rail/ Bed Rails policy not dated read in part Purpose: To utilize a person-centered approach when determining the use of side rails/bed rails and enhance resident's mobility and functional independence. Procedure: Side rail screen to be completed prior to use of side rail(s) which will address alternatives attempted and how those alternatives failed to meet the resident's assessed needs. Facility will assess if the side rail(s) meets the definition of a restraint. Refer to restraint screen as indicated. Review the risk/benefits and reason for the use of side rail(s) with the resident and/or resident representative. Obtain informed consent prior to installation/use of side rail(s). Use of side rail will be demonstrated to the resident/resident representative. Event ID: Facility ID: 676060 If continuation sheet Page 5 of 14 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 676060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambrosio Guillen Texas State Veterans Home 9650 Kenworthy St El Paso, TX 79924 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure sufficient nursing staff possess the competencies and skill sets necessary to provide nursing services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being for 1 of 1 staff member (RN C) reviewed for nursing services. 1. The facility failed to ensure RN C followed the facility's policy on blood sugar checks for Resident #6 by delegating the task to Certified Nurse Aide.2. The facility failed to ensure RN C administered injections according to the facility's policy and procedures to Resident #7.These failures could place residents at risk of being cared for not receiving nursing services by adequately trained and licensed staff, which could result in injury and infection. Findings included:Resident #6 -Review of Resident #6's admission Record, dated 09/10/25, revealed resident was admitted to the nursing facility on 06/06/25. -Review of History & Physical dated on 06/11/25 for Resident #6 revealed, [AGE] year-old male with history of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), delusional disorder (is a type if mental health condition in which a person can't tell what's real from what's imagined), type 2 DM (a condition where the body has trouble using insulin, a hormone that helps cells use glucose for energy. This leads to high blood sugar levels because the body doesn't respond well to insulin). -Review of Resident #6's Annual Minimum Data Set (MDS) assessment dated [DATE], revealed short-term/long-term memory problems. Unclear speech. Active Diagnoses: Diabetes Mellitus. Section N - Medications: N0300. Injections. Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days - 7. N0415. High-Risk Drug Classes: Use and Indication: J. Hypoglycemic (including insulin). -Review of Care Plan of Resident #6's Care Plan dated 06/07/25 revealed, at risk for hyper/hypoglycemia related to diagnosis of diabetes mellitus. Interventions/Tasks: Observe percentages of food eaten and report food not eaten. Observe for s/s of hyper/hypoglycemia (i.e. Sweating, tremor, pallor, nervousness, headache, double vision, confusion, lack of coordination etc.), FSBS as ordered by physician. Rotate injection sites. Medication as ordered. FSBS as ordered by physician. -Review of Physician Order Summary for Resident #6 dated 09/11/25 revealed, Insulin Aspart Injection Solution 100 unit/ml inject as per sliding scale: if 0-160 = 0 if BS less than 70 initiate hypoglycemic protocol and notify MD/NP; 161-200 = 4; 201 - 250 = 8; 251 300 = 12; 301 - 350 = 16; 351 - 400 = 20; 400+ notify MD/NP for further orders, subcutaneously before meals related to Type 2 Diabetes Mellitus.-Review of Medication Administration Record (MAR) for Resident #6 dated July 2025 revealed, Humalog Injection Solution 100 unit/ml (Insulin Lispro) Inject as per sliding scale: If 0-160 = 0. 161-200 = 4 units. 201 - 250 = 8 units.251 - 300 = 12 units.301 - 350 = 16 units.351 400 = 20 units.400+ notify MD/NP for further orders, subcutaneously before meals related to Type 2 Diabetes Mellitus. BS at 7:30 AM; BS at 11:30 AM, BS at 5:00 PM. -Review of Resident #6's Medication Administration Record (MAR) dated July 2025 revealed, RN C had administered Humalog Injection Solution 100 unit/ml (Insulin Lispro) Inject as per sliding scale, on 07/19/25 at 11:30 AM for Blood Sugar Level of 238, administered 8 units of insulin Lispro subcutaneously before meals; 5:00 PM for Blood Sugar Level of 337 administered 16 units subcutaneously before meals. -Review of In-Service Training Sign-in Sheet provided by the DON on 09/15/25 revealed the Staff Development Coordinator had in-serviced Certified Nurse Aides on 09/12/25 at 12:00 noon, Topic: CNAs are NOT authorized to check blood sugars in this facility. Failure to comply with the above will result in disciplinary action. -Review of Review of copy of Text Message provided by DON on 09/15/25 revealed, Text (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676060 If continuation sheet Page 6 of 14 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 676060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambrosio Guillen Texas State Veterans Home 9650 Kenworthy St El Paso, TX 79924 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Message was sent to Licensed Staff and Certified Nurse Aides on 09/12/25 at 4:47 pm, by Staff Development Coordinator to 148 recipients. Details of Message documented, ATTN: ALL NURSING STAFF-CNAS are NEVER to check sugars in this facility. Failure to comply will result in disciplinary action. If you are receiving this message, PLEASE contact Staff Development Coordinator from 0800-1700 Monday-Friday and/or RN Supervisor after hours and weekend.-Review of Review of Note to File provided by DON on 09/15/25 revealed, Subject: RN C. Author was left blank. Other participants and witnesses were left blank. Date/time event took place 07/19/25. Date/time note was written 09/10/25. On 07/21/25 Unit Manger F and RN ADON E, had a phone conversation with RN C regarding an incident in which he delegated to a CNA to check blood sugar for him on 07/19/25. RN C was educated on how within long term care nursing assistants and medication aids are not allowed to check blood sugar and that it is strictly the charge nurse responsibility to perform that check. RN C verbalized an understanding with no further questions or concerns. The Note to File was signed on 09/10/25 by RN ADON E, assigned to the Traditional Unit. -Review of Review of Medication Administration Competency Checklist for RN C dated 01/17/25 provided by DON 09/12/25 revealed, Met - Administers injections using proper technique.-During an interview on 09/09/25 at 9:15 AM, with CNA I revealed the CNAs had rotating schedules, so she occasionally worked on the weekends and at times was assigned to work on the 300 Hall. She said, the nursing administration had investigated an incident involving CNA H who worked on the weekends because she had done a blood glucose check for RN C on one of the residents. She said that she did not know the resident's name. She said LVN Unit Manager F, and the DON were aware of this. She said that this happened approximately one month ago. She said, I do not know what was done by LVN Unit Manager or the DON, because CNAs are not to be doing finger sticks. -During an interview on 09/09/25 at 2:10 PM, with LVN Unit Manager F assigned to the Traditional Unit revealed, said he was not aware of any concerns related to CNA doing blood glucose checks on the weekends. He said CNAs were not allowed to do blood glucose checks at the nursing home. -During an interview on 09/09/25 at 2:21 PM, with RN G Supervisor revealed, she rotated working on the weekends. She said, Restorative CNA B, had reported to her that CNA H was doing blood glucose checks for RN C who was assigned to the 300 Hall on the weekends. She said, I immediately reported this to the DON, on that day. I also talked to RN C and CNA H on that day, and he said he was sorry; he had asked CNA H to check the blood sugar on one of the residents. She said, I did not ask RN C or CNA H when I talked to them, who was the resident that she had checked the blood glucose, and I did not check the resident on that day. I know that DON investigated this, and it has not happened again. I know the nurses are always rushing to do the blood glucose checks prior to the residents eating their meals to administer the insulins according to physician's order, but I have never seen the CNAs doing the blood glucose checks for the nurses. -During an interview on 09/09/25 at 2:29 PM, with the DON revealed, RN G Supervisor assigned to the Traditional Unit called her to report CNA H, who worked on the weekends, had checked the blood glucose on a resident. She said, I did not ask RN G who was the resident. She said, RN G talked to RN C and CNA H and told them not to do it again. She said RN ADON E, had discussed this with RN C that CNAs were not allowed blood glucose checks per facility policy. The DON, said, We do not have any written documentation of the conversation between the RN ADON E and RN C related to him directing CNA H to check the blood glucose on the resident. We also do not have any documentation of in-service training provided to RN C about not delegating blood glucose checks to the CNAs. The DON said she could not remember if she had reported to the Administrator, that RN C had asked CNA H on one occasion to check the blood glucose on a resident in the 300-Hall. The DON said, I do not recall if this was mentioned during the morning meeting or just mentioned it to him on passing. - During an interview on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676060 If continuation sheet Page 7 of 14 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 676060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambrosio Guillen Texas State Veterans Home 9650 Kenworthy St El Paso, TX 79924 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 09/09/25 at 2:39 PM, with DON, RN Supervisor G, LVN Unit Manager F and RN ADON E assigned to the Traditional Unit revealed, RN Supervisor G did not recall when she had notified the DON, that CNA H had been seen on one occasion checking the blood glucose on one of the residents. RN Supervisor G said, she remembered talking to RN C and CNA H on that day and informed them that CNAs were not allowed to check blood glucose on the residents at the nursing home. RN Supervisor G said, RN C said he was sorry that he had asked CNA H to check the blood sugar on one of the residents and that she had told CNA H, CNAs were not allowed to do blood glucose checks in the nursing and did not have any written documentation related to this incident. The DON said it was an isolated occurrence, and they had not asked who the resident was or who was involved in this matter. RN ADON E said she had completed re-education with RN C and CNA H, and she had informed them that the nurses were not allowed to delegate blood glucose checks to the CNAs. She said she had not documented the conversation that she had with RN C or CNA H on that day. The DON said she did not remember if this had been reported to the Administrator. RN Supervisor G and RN ADON E said that after that incident nursing administration randomly checked during rounds that the nurses were doing the blood glucose checks, but did not have any written documentation of the random audits. The DON, said, they immediately took corrective action but did not have any written documentation of the conversations that were done with RN C and CNA H. RN ADON E said the DON, had reported to her on Monday 07/21/25, RN C had delegated to CNA H to check the blood glucose on a resident and corrective action was immediately addressed with the nurse and the CNA involved in this matter but did not have any written documentation. The nursing administration team reported they had not consulted with HR to determine what type of documentation needed to be completed to address this issue. The DON said they had been trained to consult with HR to determine what corrective action needed to be taken to address failure to follow facility policies and procedures.- During an interview on 09/09/25 at 3:48 PM, with the Administrator, revealed he was not aware RN C had instructed a CNA H to do a blood sugar check on one of the residents. He said he expected the nursing administration to immediately report to him situations like this, because this could harm the resident by allowing staff that had not been trained or qualified to perform nursing tasks. He said the nurses could not delegate tasks that were not within the scope of practice to the CNAs. He said he was not aware if the nursing administration had re-educated the staff, investigated the occurrence or if they had obtained written statements from the RN C and CNA H. He said, the nursing administration should have consulted with HR, for guidance on how to handle this situation to prevent it from reoccurring. -During a telephone interview on 09/09/25 at 4:42 PM, with CNA H, revealed RN C had asked her to do a blood glucose on Resident #6 on 07/19/25 during the weekend. She said, RN C knew that she had worked in the hospital and that CNAs were trained and were allowed to do blood glucose checks. She said, I was not aware that CNAs in the nursing homes were not allowed to do blood glucose checks. RN Supervisor G, informed me on that day, that CNAs were not allowed to do blood glucose checks in the nursing home and was told not to do it again. -During an interview on 09/10/25 at 8:51 AM, with RN C Charge Nurse on the 300 Hall, revealed he had 9 years of experience working in the Acute Hospital setting and that the CNAs were trained and allowed to perform Blood Glucose Checks on the patients. He said he had started working in a supervisory position at the nursing facility and had started working as a floor nurse a month ago. He said he was given a 2-3-day orientation before he started working on the floor independently. He said the staffing pattern was different on the weekends. He said, So sometimes we do not have a Medication Aide, so we are rushing to do blood glucose checks and administer insulin before meals. He said, I knew that CNA H had worked in acute care, so I asked her on one occasion to check the blood sugar on Resident #6, but do not remember the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676060 If continuation sheet Page 8 of 14 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 676060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambrosio Guillen Texas State Veterans Home 9650 Kenworthy St El Paso, TX 79924 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few exact date. This was a couple of months ago. I was not aware that the CNAs were not allowed to do blood glucose checks at the nursing homes. On that day, RN Supervisor G was on duty, and she informed me later during the shift that CNAs were not allowed to do blood glucose checks in the nursing homes. He said, LVN Unit Manager F called me on Monday or Tuesday to inform me that CNAs were not allowed to perform blood glucose checks at the nursing home. I was very honest with him and confirmed that I had asked CNA H to help me check the blood glucose on Resident #6, and I reassured him that it would not happen again. He said, on that day Resident #6 was already in the main dining room. He said that sometimes the CNAs wheeled the residents to the dining room before he checked the blood glucose before meals according to physician's orders. He said, I remember that on that day, Restorative Aide C, had wheeled Resident #6 to his room, before I had done the blood glucose check, and that is why I asked CNA H to go do the blood glucose check for Resident #6. I remember that I administered insulin to the resident on that day, after I got the blood glucose level from CNA H. The resident did not have any adverse reaction to the insulin on that day. He said that he had never asked other CNAs to do blood glucose checks and that he had only asked CNA H to do a blood glucose check only on one occasion. - During an interview on 09/15/25 at 10:45 AM, DON said, I do not have anything in writing for RN C when he asked CNA H to check the blood sugar check on Resident #6 or about injecting Resident #7 over the shirt, but I did confirm that RN ADON E, LVN Unit Manager F, and RN Supervisor G had talked to RN C.Resident #7 -Review of Resident #7's admission Record, dated 09/11/25, revealed resident was admitted to the nursing facility on 08/15/24. -Review of History & Physical dated on 08/13/25 for Resident #7 revealed, [AGE] year-old male with Past Medical History of diabetes. -Review of Resident #7's Annual Minimum Data Set (MDS) dated [DATE], revealed, Brief Interview for Mental Status (BIMS) documented a BIMS Score of 14 (cognitively intact); Section I Active Diagnoses Diabetes Mellitus. Section N - Medications - N0350. Insulin administered during the last 7 days. N0415. High-Risk Drug Classes: Use and Indication - Hypoglycemic (including insulin). -Review of Resident #7's Care Plan revised on 08/16/24 revealed, at risk for hyper/hypoglycemia related to diagnosis of diabetes mellitus. Interventions/Tasks: Rotate injection sites. Observe percentages of food eaten and report food not eaten. Observe signs and symptoms of hyper/hypoglycemia (i.e. Sweating, tremor, pallor nervousness, headache, double vision, confusion, lack of coordination, etc.). Medication as ordered. FSBS as ordered by physician. -Review of Resident #7's Physician Order Summary dated 09/11/25 revealed, Insulin Aspart Injection Solution 100 Unit/ML inject as per sliding scale: If 90-140 = 2; 141 - 200 = 3; 201-275 = 4 276-350 = 5. If above 401 notify NP for further orders, subcutaneously before meals related to Type 1 Diabetes Mellitus. -Review of Resident #7's MAR dated September 2025 revealed, Insulin Aspart Injection Solution 100 Unit/ML inject as per sliding scale: If 90-140 = 2141 - 200 = 3 201-275 = 4 276-350 = 5. If above 401 notify NP for further orders, subcutaneously before meals related to Type 1 Diabetes Mellitus. -During a confidential interview on 09/09/25 at 10:25 AM, Restorative CNA B had said that she had seen RN C give an insulin injection to Resident #7 in the main dining room area. Restorative CNA B said RN C had stuck the needed through the shirt and had not cleaned the injection site prior to giving the insulin injection. Restorative CNA B said she had reported this to the RN Supervisor G that worked on that weekend, and she had said, Don't tell me, that is not my problem. The administration said they would handle this problem internally. -Telephone interview on 09/09/25 at 10:54 AM, with RN C, revealed he was rushing to administer insulin to Resident #7, because he was already in the dining room and he administered the insulin through the shirt, because he had on a long sleeve shirt and did not want to roll the sleeve up in the dining room to give him his insulin. He said he could not recall the date when he had done this. He said, I remember that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676060 If continuation sheet Page 9 of 14 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 676060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambrosio Guillen Texas State Veterans Home 9650 Kenworthy St El Paso, TX 79924 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete RN Supervisor G and LVN Unit Manager F informed me when they called me on that day, to let me know that insulins could not be administered in the dining room. He said, he had not followed the technique on insulin administration like he was trained to do in nursing school. I know that the injection site needs to be cleaned prior to administering the injections. He said he was also trained in nursing school not to administer insulin through the clothes. He said, this could place the resident at risk for infection. -During an interview on 09/09/25 at 1:53 PM, with Restorative CNA B revealed, she had reported to RN G who was the week-end Supervisor on that weekend that she had seen RN C inject insulin to a resident in the main dining room through the clothing, and that RN C was passing by the resident and did not tell the resident he was going to give him an insulin injection and just poked the resident with the needle through his shirt. She said the resident was startled when RN C had done this to him. I don't think that what RN C did to the resident was right, because he had not cleaned the area on the arm prior to injecting the insulin to the resident, and that placed the resident at risk for infection. This happened more than a month ago on the weekend, and I do not remember who the resident was. I later followed up with RN G, to see what had been done about my concern and all she said was that she had reported this to the DON. -During an interview on 09/09/25 at 2:29 PM, with the DON revealed, she was not aware that Restorative CNA B had reported to RN Supervisor G that she had seen RN C inject a resident through his T-Shirt in the main dining room. The DON said The RN Supervisor G should have reported this to me or to RN ADON E and LVN Unit Manager F right away, to immediately address this concern to prevent it from reoccurring. This practice could place the resident at risk of infection. -During an interview and record review on 09/12/25 at 11:30 AM, with the DON revealed the facility did not have a Skills Checklist on Insulin Administration for the licensed staff. She informed the state surveyor she had found a Skills Checklist on Insulin Administration in one of the facility's Manuals that she was going to start using to check licensed staff on Insulin Medication Administration. She said the checklist documented, to select an appropriate injection site, free from edema, induration, tenderness, or skin irritation. Cleanse site with alcohol swab beginning at center of site and rotating outward approximately 2 inches. Allow skin to dry completely; do not fan or blow on site. With non-dominant hand, spread skin across injection site or pinch skin around injection site. Inform resident he/she will feel a slight pinch, pressure, or stinging sensation as the insulin is injected. She said, This will ensure licensed staff do not inject insulin over the clothes without cleaning the injection site, prior to administering the insulin. She said she was still looking for a policy & procedure on insulin administration and would provide the state surveyor a copy of the policy if she found one. The surveyor requested a copy of Nursing Policy & Procedures on Injection Administration. The DON did not provide the requested document before exit. The surveyor requested a copy of Pharmacy Policy & Procedures on Injection Administration. The DON did not provide the requested document before exit. Review of the facility's policy and procedures on Medication Administration revised July 1, 2025, revealed administer medications as ordered in accordance with manufacturer specifications. According to Manufacturer's specifications obtained on 09/10/25 at https://www.novo-pi.com Subcutaneous injection: inject subcutaneously within 5-10 minutes before a meal into the abdominal area, thigh, buttocks or upper arm. Event ID: Facility ID: 676060 If continuation sheet Page 10 of 14 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 676060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambrosio Guillen Texas State Veterans Home 9650 Kenworthy St El Paso, TX 79924 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents are free of any significant medication errors for 1 (Resident #6) of 2 residents reviewed for pharmaceutical services.-The facility failed to administer insulin to Resident #6 according to physician orders.-The facility failed to ensure LVN D administered insulin to Resident #6 according to Manufacturer's Specifications. This deficient practice could place residents at risk of inadequate therapeutic outcomes, increased adverse side effects, and a decline in health.The findings include: -Review of Resident #6's admission Record, dated 09/10/25, revealed resident was admitted to the nursing facility on 06/06/25. -Review of History & Physical dated on 06/11/25 for Resident #6 revealed, [AGE] year-old male with history of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), delusional disorder (is a type if mental health condition in which a person can't tell what's real from what's imagined), type 2 DM (a condition where the body has trouble using insulin, a hormone that helps cells use glucose for energy. This leads to high blood sugar levels because the body doesn't respond well to insulin). -Review of Resident #6's Annual Minimum Data Set (MDS) dated [DATE], revealed short-term/long-term memory problems. Unclear speech. Active Diagnoses: Diabetes Mellitus. Section N - Medications: N0300. Injections. Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days - 7. N0415. High-Risk Drug Classes: Use and Indication: J. Hypoglycemic (including insulin). -Review of Care Plan of Resident #6's Care Plan dated 06/07/25 revealed, at risk for hyper/hypoglycemia related to diagnosis of diabetes mellitus. Interventions/Tasks: Observe percentages of food eaten and report food not eaten. Observe for s/s of hyper/hypoglycemia (ie. Sweating, tremor, pallor, nervousness, headache, double vision, confusion, lack of coordination etc.), FSBS as ordered by physician. Rotate injection sites. Medication as ordered. FSBS as ordered by physician. -Review of Physician Order Summary for Resident #6 dated 09/11/25 revealed, Insulin Aspart Injection Solution 100 unit/ml inject as per sliding scale: if 0-160 = 0 if BS less than 70 initiate hypoglycemic protocol and notify MD/NP; 161-200 = 4; 201 - 250 = 8; 251 - 300 = 12; 301 - 350 = 16; 351 - 400 = 20; 400+ notify MD/NP for further orders, subcutaneously before meals related to Type 2 Diabetes Mellitus. -Review of facility's mealtimes revealed Breakfast was served at 7:00 a.m., Lunch at 11:30 a.m., and Dinner at 5:00 p.m. -Review of Medication Administration Record dated September 2025 for Resident #6 revealed LVN D had not checked Resident #6's Blood Glucose on 09/09/25 at 5:00 PM before meals according to physician's order. -Review of Resident #6's Nursing Progress Note dated 09/09/25 at 6:47 p.m. written by LVN D, revealed Resident was in activities and went straight to the dining room. -Review of Note to File dated 09/09/25 at 6:30 PM written by RN ADON E, revealed LVN D was educated by LVN Unit Manager F on 09/09/25 regarding proper documentation and timely administration of insulin. LVN D was also educated on following orders for residents regarding assessment of blood glucose levels prior to mealtimes. LVN D verbalized an understanding at this time. -Review of Medication Error Report dated 09/09/25 at 6:45 PM, written by DON revealed, Incident Description: On 09/09/25 approximately 6:45 p.m., Resident #6 did not have his blood glucose checked prior to dinner and therefore did not receive any sliding scale coverage for his dinner. Immediate Action Taken: Upon discovery of incident, Unit Manager assessed resident. Morning BGL 181. The resident was covered with 4 units of short acting insulin and scheduled dose of long-acting insulin. The Resident did not exhibit any signs of hyper/hypoglycemia. NP notified - no new orders obtained. Notes: Resident #6 is an [AGE] year-old male admitted [DATE]. Resident diagnosis includes dementia and type 2 diabetes. DON identified medication error made night Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676060 If continuation sheet Page 11 of 14 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 676060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambrosio Guillen Texas State Veterans Home 9650 Kenworthy St El Paso, TX 79924 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few prior - resident was not administered sliding scale insulin because resident did not get his blood glucose read prior to dinner. NP notified of findings in morning and reported most recent BGL in am and that resident did not exhibit any signs of hypo or hyperglycemia. No new orders obtained from NP. Resident POA notified about incident. LVN D educated about proper procedure if resident blood glucose not checked prior to dinner - call NP that blood glucose was not checked prior to dinner and obtain orders for how to proceed. Nurse verbalized understanding. -Review of Resident #6's Nursing Progress Note dated 09/10/25 at 8:30 AM, written by LVN Unit Manager F revealed, Spoke with NP regarding blood sugar not being checked yesterday evening. His BS this morning was 181, given 4 units of Novolog for sliding scale coverage and 23 units of insulin Glargine scheduled. No new orders given. No s/s of hypo/hyperglycemia. Will continue to monitor. -Review of Medication Administration Record for September 2025 for Resident #6 revealed, LVN D documented on 09/09/25 blood glucose had not been completed at 5:00 PM and had not administered Aspart insulin according to sliding scale coverage as ordered by the attending physician. LVN D documented, on 09/10/25 BS at 5:00 PM was 242 and had administered 8 units of Aspart insulin according to sliding scale coverage. -Review of In-Service Training Sign-in Sheet dated 09/10/25 at 6:20 PM presented by LVN K Staff Development Coordinator, revealed Oral Presentation: All Licensed Staff. SNACKS/MEAL POST SLIDING SCALE COVERAGE: Sliding Scale Coverage MUST be given within 30 minutes after checking a resident's blood sugar. A snack/meal tray MUST also be given within 15 minutes of sliding scale insulin administration. If the resident refuses the snack/meal tray. The refusal must be documented in resident's clinical record. -Review of Note to File dated 09/10/25 at 6:22 PM, written by RN ADON E, revealed LVN D was educated on informing the NP of any time medications, including insulin is held was educated on reporting whenever BGL is unavailable/she is unable to assess to the nurse practitioner. She was also educated at this time on providing a substantial snack or assure their tray will be in front of them within 15 minutes of insulin administration. LVN D verbalized understanding. -Review of Medication Error Report dated 09/10/25 at 6:39 PM, written by RN ADON E revealed, Incident Description: Resident #6 was administered Insulin Aspart 8 units at 4:08 p.m., and received his dinner tray at approximately 5:15 PM. Immediate Action Taken: Resident was observed to be asymptomatic and noted to consume dinner with no issues. Notes: Resident #6 is an [AGE] year-old male admitted [DATE]. Resident diagnosis includes dementia and type 2 diabetes. LVN D was observed to have administered 8 units of insulin Aspart to the resident with a BGL of 242 at approximately 4:08 PM prior to dinner time. Resident received his tray at approximately 5:15 PM. LVN D reeducated at this time on providing a substantial snack or assure their tray will be in front of them within 15 minutes of insulin administration. Charge nurse verbalized an understanding of this procedure. DON, ADON, Administrator, POA and NP notified.Record review of Pharmacy Consultant reports dated May - August did not reveal any concerns related to insulin administration. During an interview on 09/09/25 at 4:00 PM, with LVN D, revealed she had already administered insulin to her assigned residents. During an observation and interview on 09/09/25 at 5:01 PM, with the CNA L revealed Resident #6 was sitting in the dining room at the assisted feeding table waiting for dinner to be served. The CNA informed the state surveyor, the resident was hard of hearing and occasionally answered simple questions. Resident did not respond to the surveyor when asked simple questions. During an interview and record review on 09/09/25 at 5:13 PM, with RN, ADON E revealed, Medication Administration Record dated July 2025 for Resident #6 revealed LVN D, had documented she had checked the resident's blood glucose level before meals according to physician's orders. During an observation on 09/09/25 at 5:23 PM, revealed Resident #6 was served his meal tray and CNA started to spoon feed the resident. During an interview on 09/09/25 at 5:25 PM, with LVN D, revealed, she had not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676060 If continuation sheet Page 12 of 14 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 676060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambrosio Guillen Texas State Veterans Home 9650 Kenworthy St El Paso, TX 79924 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few checked the blood sugar for Resident #6 before dinner according to physician's orders, because she was busy handling a medical emergency with another resident. During an interview on 09/09/25 at 5:26 PM, with CNA L, revealed she was new and did not know which residents got insulin before meals. She said, there is always a tray with snacks at the nurse's station to give to the residents as needed until dinner is served. During an interview and record review on 09/09/25 at 5:31 PM, LVN Unit Manager F revealed, Licensed Staff had been trained to check blood sugar according to physician's order. He said, LVN D, should have checked the blood sugar ac dinner so insulin could be administered to physician's orders. During an interview on 09/09/25 at 5:33 PM, with DON revealed Licensed Staff had been trained to check blood glucose ac meals according to physician's order, to ensure insulin was administered according to physician's order. During an observation on 09/10/25 at 5:00 PM, revealed Resident #6 was in dining room waiting for dinner to be served. During an observation on 09/10/25 at 5:14 PM, revealed Resident #6 was served his dinner tray and the CNA started to spoon feed the resident. During an observation and interview on 09/11/25 at 1:29 PM with LVN MDS Nurse M revealed, Resident #6 was a diabetic on insulin and had orders for blood sugars to be done before meals and had orders to administer Aspart insulin according to sliding scale coverage according to physician's orders. During Telephone interview on 09/12/25 at 9:52 AM, with Pharmacy Consultant Pharmacist in the presence of supervisor, revealed she did not have the records for her visits to know if there were any issues related to insulin administration and could not reply to the surveyor's question. She said if a resident had an order for blood glucose checks ac meals, she was not aware of a timeframe as to when glucose checks should be done, because it would be facility specific due to the times that meals are served. She said that physician's orders for sliding scale coverage are for Rapid Acting Insulins such as Insulin Aspart or Lispro. She said if blood glucose checks were not done as ordered and sliding scale insulin was not administered due to that, it would be considered an omission. This could be because a resident was out on an appointment and/or not in the room or under other circumstances. During an interview on 09/12/25 at 2:17 PM, with LVN D in the presence of the DON revealed, Resident #6 was non-verbal and would only say a word or two. She said she had not checked Resident's blood sugar on 09/09/25 at 5:00 PM, before dinner according to MD order, so she had not covered the resident with Aspart sliding scale coverage as ordered. She said they had been trained to do blood glucose checks prior to meals and administer insulin according to physician's orders. She said, On that day the resident was taken to the dining room prior to her checking the blood sugar. LVN D said she had administered 8 units of Insulin Aspart to Resident #6 at 4:08 PM on 09/10/25 and did not given the resident a snack within 15 minutes of administering the insulin to the resident. She said Insulin Aspart is Rapid Acting, and residents should be given a snack if the meal tray is not served within 15 minutes of administering the insulin to prevent hypoglycemia. Review of facility's policy and procedure on Medication Administration Revised July 1, 2025, revealed administer medications as ordered in accordance with manufacturer specifications. Medication times may vary based upon facility or location. Medication times/periods should remain consistent with standards of practice and resident needs. Specific medications may not be able to be generalized (such as insulins, etc.) depending upon the desired outcome and/or need to maintain a consistent level. Review of facility's policy and procedure on Medication Administration Times revised 11/15/24, revealed Policy: Sets forth the procedures related to medication administration times. Procedure: Facility should ensure that authorized personnel, as determined by Applicable Law, administer medications according to times of administration as determined by Facility's pharmacy committee and/or Physician/Prescriber. Facility staff should refer to Facility's medication administration policy to determine whether certain medications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676060 If continuation sheet Page 13 of 14 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 676060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambrosio Guillen Texas State Veterans Home 9650 Kenworthy St El Paso, TX 79924 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 require different administration times. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676060 If continuation sheet Page 14 of 14