Health inspection·June 4, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some affects memory and thinking), high blood pressure, anxiety disorder (significant and uncontrollable feelings of restlessness, irritability) and arthritis (joint pain). Record review of Resident #2's MDS Significant Change assessment dated [DATE] revealed a BIMS score of 3 (on a scale of 1-15) which indicated his cognitive skills for daily decision making were severely impaired, no behaviors towards others, required 2-person assistance to transfer from his bed to the wheelchair and could propel himself in the wheelchair. Record review of Resident #2's Progress Note dated 05/31/2023 at 4:39 p.m. by LVN A revealed an unidentified staff member saw Resident #2 on the 400 hallway when another resident [Resident #1] in the hallway started hitting Resident #2 several times in the face and Resident #2 attempted to block the punches. Staff immediately ran to the residents and separated them. A head-to-toe assessment was done on Resident #2 with noted redness to left cheek and ear. Resident #2 denied being in distress and was given pain medication. Resident #2's physician and Responsible Party were notified. Record review of Resident #2's Skin Audit, dated 05/31/2023, revealed redness to the resident's left cheek and ear. 3. Record review of Resident #1's face sheet dated 06/03/2023 revealed he was admitted to the facility 11/16/2022 with diagnoses which included cerebral infarction (stroke), diabetes (chronic elevated blood sugar levels which can damage other organs), vascular dementia (decreased blood flow to the brain which affects memory, thinking skills, behavior, and personality), high blood pressure, hemiplegia, and hemiparesis (partial weakness and paralysis to one side of the body). Record review of Resident #1's MDS Assessment, a Quarterly Assessment, dated 03/23/2023 revealed a BIMs score of 7 (on a scale of 1-15) which indicated his cognitive skills for daily decision making were severely impaired, no behaviors towards others, required assistance of 2 persons with transfer to a wheelchair and he could propel himself in the wheelchair. Record review of Resident #1's Care Plan for the problem area of Resident with physical aggression related to anger, dementia towards another resident with a start date of 03/24/2023 and was revised on 05/04/2023, 05/26/2023, and 05/31/2023. Interventions initiated on 03/23/2023 were moving the resident to a different hall and medication review. Revised interventions initiated on 05/04/2023 included an outside hospitalization for psych evaluation, the resident was placed on one-on-one monitoring upon return to the facility and his medications were reviewed. Revised interventions initiated on 05/26/2023 involved a trial discontinuation of the one-on-one monitoring due to no recent behavior noted. Revised interventions initiated 05/31/2023 were to send the resident to the hospital for a psych evaluation, the local mental health authority was contacted to seek assistance with placing the resident in another facility, and the one-on-one monitoring was resumed due to the resident struck out at another resident. Record review of Resident #1's Critical Behavior Monitoring Logs (one-on-one monitoring) from 05/05/2023 to 05/26/2023 revealed the last time the resident had aggressive behavior was on 05/16/2023 and his behavior was calm from 05/17/2023 to 05/26/2023. Record review of Resident #1 Care Plan Collaboration and Review meeting notes, dated 05/26/2023, revealed an interdisciplinary team meeting was held regarding Resident #1 with no behaviors noted and the one-on-one monitoring would be discontinued on a trial basis with continued monitoring for behaviors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676133 If continuation sheet Page 2 of 7 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 676133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maverick Nursing and Rehabilitation Center 3106 Bob Rogers Dr Eagle Pass, TX 78852 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #1's Progress Note dated 05/31/2023 at 6:05 p.m. by LVN A revealed: Resident was on the hallways and another resident [Resident #2] was passing by, he turned aggressive to the resident and started punching him several times in the face, staff removed them apart. A. Record review of HHSC Form 3613A Provider Investigation Report for Intake #422661 revealed on 05/04/2023 at 4:30 p.m. when the Administrator was walking down the hall, she heard a scream from Resident #3's room. As the Administrator approached the room, Resident #1 was observed wheeling himself out of the room. As the Administrator walked into the room she saw Resident #3 on the floor with RN C next to the resident and a male resident (Resident #4) in the middle of the room in a wheelchair. Resident #4 was redirected to his room and the nurse assessed Resident #3 with no injuries noted. Resident #3 stated Resident #1 had pulled her to the floor by her hair. The residents' physician and responsible parties were notified. Resident #1's medications were reviewed, and he was placed on one-on-one monitoring. The incident was reported to HHSC on 05/05/2023 at 3:30 p.m., 23 hours later. The undated typed statement from the Social Worker from the facility's investigation revealed he interviewed Resident #1 in Spanish immediately after the event on 05/04/2023, asked why the event occurred and Resident #1 stated in Spanish To put her in her place. The Social Worker reinterviewed Resident #1 on 05/05/2023, asked him why the events transpired on 05/04/2023, and Resident #1 stated it was because Resident #3 was speaking to another male resident (Resident #4). During an interview with the Social Worker on 06/02/2023 at 3:45 p.m. he revealed Resident #1 had developed a romantic interest in Resident #3 and would react aggressively when he felt jealous or intimidated. The Social Worker stated Resident #3 had a male resident (Resident #4) who was her friend, in her room visiting. The Social Worker thought the other male resident might have sparked some jealousy in Resident #1 and he grabbed Resident #3 by her hair and pulled her to the ground. During an interview on 06/02/2023 at 4:19 p.m. with Resident #3, with Spanish translation by the Social Worker, revealed Resident #3 stated Resident #1 was well behaved with her and she did not remember the incident with Resident #1. The Social Worker asked her if her hair was pulled which she said it was pulled by Resident #1, but she did not remember what happened. The Social Worker asked Resident #3 if she felt safe in the facility and the resident stated she did. Observation on 06/02/2023 at 4:19 p.m. of Resident #3 revealed she resided on the secured unit, was ambulatory, had long black hair and was well dressed wearing a coordinating skirt, blouse, and hat. During an interview on 06/03/2023 at 7:59 a.m. with RN C revealed Resident #1 was placed on one-on-one monitoring after the incident with Resident #3. During an interview on 06/03/2023 at 9:12 a.m., RN C stated on the day of the incident with Resident #1 and Resident #3, she was in the hallway when she heard a female scream and a thump on the floor. When she entered Resident #3's room she saw Resident #3 on the floor by the foot of her bed, Resident #4 was in the center of the room and Resident #1 was near the door. RN C stated she removed Resident #1 from the room. RN C asked Resident #4 what happened, he stated Resident #3 came out of the bathroom and Resident #1 grabbed Resident #3's long hair and pulled her to the ground. RN C assessed Resident #3 with no injuries noted and the resident did not have any physical complaints or emotional distress after the incident. RN C stated Resident #3 liked to be around Resident #1 and after the incident staff would try to keep them apart. During an interview on 06/03/2023 at 9:35 a.m. with Resident #4, with Spanish translation by MA F, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676133 If continuation sheet Page 3 of 7 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 676133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maverick Nursing and Rehabilitation Center 3106 Bob Rogers Dr Eagle Pass, TX 78852 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some revealed Resident #3 was in her bathroom and he was in Resident #3's room waiting for Resident #3 to come out of the bathroom. While Resident #3 was in the bathroom Resident #1 came by the room and waited for Resident #3 to come out of the bathroom. As Resident #3 walked out of the bathroom, Resident #1 (who was in a wheelchair) grabbed her hair and pulled her down to the floor. In an interview on 06/04/2023 at 11:32 a.m. the Interim DON she was not aware of any problems between Resident #1 and Resident #3 before the incident on 05/04/2023. The Interim [NAME] stated after the 05/04/2023 incident, Resident #1 was placed on one-on-one monitoring which continued until 05/26/2023 when it was decided in an Interdisciplinary Team meeting to stop the one-on-one monitoring on a trial basis because there was no further outburst toward other residents. The Interim DON stated the facility continued to monitor Resident #1's behavior after the one-on-one monitoring was stopped. The Interim DON stated Resident #1 was very pleasant to talk with, but he could be very possessive and protective about Resident #3. During an interview on 06/04/2023 from 11:59 a.m. to 12:46 p.m., the Administrator stated she was in her office when she heard a commotion on 05/04/2023 and walked down towards the sound which came from the hall where Resident #3 resided. The Administrator stated she observed Resident #1 in the hallway in his wheelchair. When she entered Resident #3's room, RN C was in the room next to Resident #3 who was on the floor and Resident #4 was in the center of the room. Resident #3 was assessed for injuries with none noted and she refused to go to the hospital for further evaluation. The Administrator stated she asked Resident #1 in Spanish why he pulled Resident #3's hair until she fell, and he stated in Spanish that he was upset that Resident #3 allowed another man (Resident #4) to be in her room. Resident #1 was sent to the hospital for a psych evaluation and was placed on one-on-monitoring when he returned. The Administrator stated the one-on-one monitoring continued until 05/26/2023, when the Interdisciplinary Team decided to stop the one-on-one monitoring on a trial basis, and continued to monitor Resident #1's behavior which there was none until the incident on 05/31/2023 with Resident #1 and Resident #2. During an interview on 06/04/2023 at 2:27 p.m., the Administrator stated the incident between Resident #1 and Resident #3 was reported to HHSC within 24 hours instead of 2 hours because she considered it to be a behavior and not abuse, and Resident #3 did not have any injuries or bruising noted. The Administrator stated she could not think of any harm that could happen to a resident by not reporting the incident to HHSC within 2-hours of the incident and stated the facility started their internal investigation right away. B. Record review of the facility's confirmation email dated 06/01/2023 at 4:19 p.m., from TULIP (the state website to notify HHSC of incident) to the Administrator revealed HHSC received information on the self-report for the 05/31/2023 incident between Resident #1 and Resident #2, 24 hours after the event; and the intake number for the self-report was #427905. Record review of the facility's partially completed investigation for Intake #427905 revealed a typed, undated/untitled summary page that indicated on 05/31/2023, the DOR observed Resident #1 and Resident #2 exchanged words followed by Resident #1 hit Resident #2. The DOR attempted to stop the incident but was unsuccessful, called for help and was assisted by the Medical Records Clerk in separating the residents. When Resident #1 was asked what had occurred, he stated no one was going to take his woman from him so he proceeded to punch Resident #2. When Resident #2 was asked what happened, he said Resident #1 told him No one was going to take his woman and then Resident #1 hit him. Both residents' physicians were notified, Resident #2's responsible party was notified, Resident #1 was his own responsible party. Both residents were assessed for injuries. Resident #1 was sent to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676133 If continuation sheet Page 4 of 7 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 676133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maverick Nursing and Rehabilitation Center 3106 Bob Rogers Dr Eagle Pass, TX 78852 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 0609 hospital for further evaluation, the local mental health authority was notified, and the police were contacted. Level of Harm - Minimal harm or potential for actual harm The undated typed statement from the Medical Record Clerk revealed on 05/31/2023 at around 4:30 [p.m.] the Medical Records Clerk was in the Administrator's office when she heard a staff member yell for help. She ran towards the sound and saw Resident #1 hitting Resident #2 on his face and assisted the DOR with separating the two residents. Residents Affected - Some During an interview with the Social Worker on 06/02/2023 at 3:45 p.m. he revealed he thought the incident that occurred on 05/31/2023 with Resident #1 and Resident #2 was related to Resident #3. The Social Worker stated Resident #1 was on the hall where Resident #3 resided looking for her when he saw Resident #2 on the same hall near her room. Resident #1 reacted stating that no one was going to take his woman to Resident #2, and he struck Resident #2 which was witness by the DOR. After the incident Resident #1 was placed back on one-on-one monitoring and the facility was seeking another facility to transfer him to. During an interview on 06/02/2023 at 4:06 p.m. with Resident #2, with Spanish translation by the Social Worker, the resident stated he had backed up and scrapped his ear. The Social Worker asked Resident #2 in Spanish if he remembered being hit and the resident did not and did not remember the incident in the hallway. The Social Worker asked Resident #2 if he felt safe in the facility and the resident stated he did. Observation on 06/02/2023 at 4:06 p.m. of Resident #2 revealed he was sitting on his bed in a room by himself with a wheelchair by the bed and no visible injuries or redness to his face. During an interview on 06/02/2023 at 4:47 p.m. with Resident #1, with Spanish translation by the Social Worker, the resident stated he had a problem with Resident #2 because the resident would run his mouth a lot and stated Resident #2 hit him first and he returned the hit. Observation on 06/02/2023 at 4:47 p.m. revealed Resident #1 was sitting in a wheelchair in the activity room with slight weakness noted to his left arm and leg. Resident #1 was able to propel himself around in the wheelchair. HA D was monitoring Resident #1 and had papers in his hand. Resident #1 started to propel himself out of the activity area and HA D followed Resident #1. Observation on 06/02/2023 at 5:16 p.m. of Resident #1's room revealed he was the only resident in the room. Observation on 06/03/2023 at 8:08 a.m. of Resident #1 revealed he was asleep in bed and in the doorway Receptionist E was sitting in a chair monitoring the resident. During an interview on 06/03/2023 at 8:10 a.m., Receptionist E stated he was doing one-on-one monitoring of Resident #1. He said every 15 minutes he would record on the monitoring sheets what activity Resident #1 was doing, his location, and what his behavior was. During an interview on 06/03/2023 at 10:00 a.m., Medical Records Clerk stated on 05/31/2023 she was in the administrator's office around 4:30 in the afternoon when she heard someone yelling on the 400 Hall. She ran over to 400 Hall, saw Resident #1 hit Resident #2 on his face with his fist and assisted with separating the two residents along with the DOR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676133 If continuation sheet Page 5 of 7 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 676133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maverick Nursing and Rehabilitation Center 3106 Bob Rogers Dr Eagle Pass, TX 78852 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 06/03/2023 at 3:41 a.m., DOR stated on 05/31/2023, she had left the therapy gym open and when she returned around 3:30 p.m she found Resident #1 and Resident #3 in the gym. The DOR stated she directed both residents out of the gym and she walked with Resident #3 to her room to ensure she was safe since the DOR was aware of the previous incident with Resident #3 and Resident #1. The DOR stated Resident #1 was not moody at all when she saw him in the gym with Resident #3. The DOR stated around 4:30 p.m. she was coming out of the therapy room near the dining room and saw Resident #1 and Resident #2 raise their upper bodies in a posturing motion, each leaning forward in their wheelchairs. They exchanged words with each other which she could not hear, and Resident #1 appeared to be upset. The DOR stated she yelled for assistance, ran towards Resident #1 and Resident #2 but before she could reach them, Resident #1 struck out at Resident #2. The DOR stated Resident #1 hit Resident #2 several times on his left side of his face and Resident #2 hit Resident #1 twice. The DOR stated she tried to separate the two residents but could not do it by herself, yelled for assistance and the Medical Records Clerk came and assisted her. During an interview on 06/03/2023 at 4:02 p.m., LVN A stated on 05/31/2023 she saw Resident #1 shortly before the incident in his wheelchair heading towards 400 hall and he appeared calm and was not agitated. LVN A stated she did not witness the incident between Resident #1 and Resident #2, but she did assess both residents after the incident with no injuries noted to Resident #1 and Resident #2 had some redness on his left jaw and ear. LVN A stated there had not been any altercations, hostility, or anger between Resident #1 and Resident #2 before the incident on 05/31/2023. During an interview on 06/04/2023 at 11:32 a.m., Interim DON stated on 05/31/2023 she was in the conference room, heard some screams and headed towards the sound. When she arrived on the 400 hall, the DOR and Medical Records Clerk had separated Resident #1 and Resident #2 who were both in wheelchairs and were close to Resident #3's room. The Interim DON stated Resident #1 appeared to be calm like nothing had happened. The Interim DON stated she assessed Resident #2 for injuries with a faint dime-size reddish discoloration on his jaw and the resident stated he was fine. The Interim DON stated the one-on-one monitoring of Resident #1 was restarted after the incident on 05/31/2023 and would continue indefinitely; his medications were reviewed and the facility was looking for placement for Resident #1. During an interview on 06/04/2023 from 11:59 a.m. to 12:46 p.m., the Administrator stated on 05/31/2023 she was in her office, heard a yell, ran over to the hall where the yelling was coming from and saw the DOR holding the back of Resident #1's wheelchair and the Medical Records Clerk was holding the back of Resident #2's wheelchair. The Administrator stated she asked Resident #1 what happened, and he responded in Spanish that no one was going to take his woman away. The Administrator stated Resident #3 was not in the hallway by the two residents but both residents were near Resident #3's room. The Administrator stated Resident #1 might have seen Resident #2 propel himself in the direction of Resident #3's room and might have thought he was going that way. The Administrator stated she asked Resident #2 what happened, and he said in Spanish that Resident #1 stated to him that no one is going to take away my woman. Resident #1 was sent to the hospital for psych evaluation and the local mental health authority was contacted to assist with placement of Resident #1. The administrator stated Resident #1 was placed back on one-on-one monitoring when he returned to the facility which would continue until while the facility searched for another facility to care for Resident #1. The Administrator reported Resident #1 was his own responsible party and the Responsible Party for Resident #2 was notified of the incident along with the residents' physician. Observation on 06/04/2023 at 12:49 p.m. with the Administrator showed the surveyor where the incident between Resident #1 and Resident #2 occurred, which was in middle of the hallway near Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676133 If continuation sheet Page 6 of 7 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 676133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maverick Nursing and Rehabilitation Center 3106 Bob Rogers Dr Eagle Pass, TX 78852 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 0609 #3's room. Level of Harm - Minimal harm or potential for actual harm During an interview on 06/04/2023 from 11:59 a.m. to 12:46 p.m., the Administrator stated abuse could be verbal or physical abuse and would be reported to HHSC between 2 to 24 hours after the incident occurred. The Administrator stated she refers to the HHSC provider letter to determine which incidents would be reported within 2 hours such as abuse or neglect incidents. The Administrator stated the incident between Resident #1 and Resident #2 on 05/31/2023 was reported within 24-hours and was not reported within 2-hours because Resident #2 did not have serious bodily injury and Resident #1 had been sent to the hospital for evaluation, so he was not a further threat to Resident #2 or any other resident. The Administrator stated she felt the incident with Resident #1 and Resident #2 was a behavior incident and not abuse because the incident occurred close to Resident #3's room, because there was no serious injury to Resident #2 when Resident #1 struck him, and because of the statement Resident #1 had made, therefore she did not report it within 2 hours. The Administrator stated she was still working on completing the HHSC Form 3613A Provider Investigation Report as it had not yet been five working days from the incident date. Residents Affected - Some During an interview on 06/04/2023 at 2:27 p.m., the Administrator stated she could not think of any harm that could happen to a resident by not reporting the incident to HHSC within 2-hours of the event and stated the facility started their internal investigation right away. Record review of the facility's Abuse, Neglect and Exploitation policy, dated 08/15/2022, revealed 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse .VII. Reporting/Response. A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes; a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676133 If continuation sheet Page 7 of 7