Inspection·March 21, 2024

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #1's progress notes dated 03/18/2024 at 17:42 written by LVN D reflected: after being up for a short period easily arouses no s/s of acute distress discomfort noted .Mod amount of hematuria noted. Np notified of hematuria, verbalizes to obtain a stat cbc, cmp . Review of Resident #1's progress notes from 03/16/2024 to 03/18/2024 reflected no documentation of in and out catheter or insertion of an indwelling Foley catheter. During an interview on 03/20/2024 at 11:33 am LVN D stated she worked with Resident #1 on 03/18/2024 from 6 am to 2 pm. LVN D stated she was told by LVN C that there was an order for Resident #1 for UA to rule out UTI. LVN D stated LVN C verbalized that attempts were made to collect urine sample but to no avail. LVN D also stated she was made aware by CNA E that Resident #1 had a Foley catheter in place and there were blood in the drainage bag. LVN D stated she observed an indwelling Foley catheter in Resident #1 meatus on 03/18/2024 at about 10 am to 11 am with moderate amount of blood in the drainage bag with approximately 200 cc. LVN D stated maybe the blood was from inserting the Foley catheter. LVN D stated she notified the NP and got an order for STAT CBC and CMP labs to be done. LVN D stated she collected the urine specimen to send to the lab. LVN D also stated, if there was an order for UA with clean catch, that indicates the resident was able to void in a urinal or a hat, Foley catheter was not indicated for clean catch. During an observation on 03/20/2024 at about 12:54 pm, LVN D presented a specimen cup with dark red opaque fluid about 30 cc labeled with Resident #1's name, date of birth , dated 03/18/2024 at 11:30 am. During an interview on 03/20/2024 at 1:21 pm the NP A stated she receive a call from LVN C on 03/18/204 at about 3:19 am indicating Resident #1 was having behaviors and needed an order to rule out UTI. NP A stated she ordered urine analysis to rule out UTI, the means of collection was not specified. NP A stated she did not order an in/out catheter or an indwelling catheter because the concerns were not for urinary retention, it was strictly for change in behaviors so catheter was not needed. NP stated she was not familiar with Resident #1 so everything that was discussed with LVN C was documented. During an interview on 03/20/2024 at 2:38 pm CNA E stated she worked with Resident #1 on 03/18/2024 from 6 am to 2 pm. CNA E stated at about 6:30 am she noticed Resident #1 had an indwelling Foley catheter and that was the first time she had seen it with him. CNA E also stated at about 10:30 to 11:00 am, she took Resident #1 to the shower and noticed a lot of blood in the catheter drainage bag containing about 200 cc urine mixed with blood. CNA E stated she did not empty the drainage bag while in the shower because she wanted the charge nurse to see it. CNA E stated she notified LVN D and the DON of the blood in Resident #1's catheter drainage bag. CNA E said she saw LVN D go to Resident #1's room after. During an interview on 03/20/2024 at 02:52 pm the NP B stated she was the regular NP in the facility and had worked with Resident #1 in the past during his initial and most recent admission to the facility. NP B stated usually when a urine analysis was ordered, it is ordered to collect the specimen via clean catch but if the resident was unable to void, an in and out Cath (catheter) was indicated. NP S also stated there should be a standing order regarding how to collect the urine specimen. NP B stated the nurse calling should be able to call the on-call staff if the Resident was able to void or not to enable the on-call staff to know how to give the orders. NP S stated, an order was needed for in an out catheter but if a urine sample was needed and that was the only way, the nurse can get the sample and notify the MD or NP to approve the order. Foley catheters require an order, we (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 2 of 4 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 676180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 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 would approve an order if there were a problem or a need. I will have to speak with the MD on standing orders for in and out catheter, there should be one. The blood in the catheter, could be due to different reasons like pulling of the catheter, UTI, Kidney stones, history of kidney cancer. During an interview on 03/20/2024 at about 3:11 pm LVN C stated she worked with Resident #1 on the evening of 03/17/2024 at 6 pm to the morning of 03/18/2024 6:00 am. LVN C stated Resident #1 was confused, and the family was concerned that the Resident had UTI. LVN C stated she notified the on-call NP (NP A) gave an order for u/a with clean catch. LVN C stated she thought she was able to get Resident #1 to urinate in the urinal, but she was unable to. LVN C stated she tried an in and out catheter but there was no urine output, so she inserted a 16 Fr regular indwelling Foley catheter with a 10 cc balloon sometime between 3:30 am to 4:00 am, no urine output, no blood was noted. LVN C stated there was no order for in and out catheter or indwelling Foley catheter, but she wanted to get the urine specimen. LVN C stated there were no explanation for what she did, she forgot to contact the nurse practitioner back or the MD. LVN C also stated she verbally passed it on in report to LVN D that urine specimen was needed to rule out UTI. LVN C also stated she forgot to document that an in and out catheter attempt and an indwelling Foley catheter was inserted and left in. During an interview on 03/21/2024 at 09:12 am, the DON stated the facility had a standing order for in and out cath as needed as a means for collecting urine specimen to rule out UTI, but the catheter was never left in the resident. The DON stated a doctor's order was needed for Foley catheter insertion. The DON stated LVN C should have documented all her interventions, the procedure, what was used, how did Resident #1 tolerate the procedure, the content that came out of the catheter, the size of the Foley that was used. The DON stated we need a doctor's order for a regular catheter, but the indications for the catheter were for the right reasons. The DON stated the hematuria was due to maybe UTI or Resident history of kidney cancer that was why the urine needed to be sent out and labs were ordered. According to the DON, the facility did not have a policy on Foley catheter insertion of care but follow the Lippincott Nursing Procedures. The DON provided pages used by the facility. Review of Lippincott Nursing Procedures, Seventh Edition, pages 394-397 presented by the facility's DON reflected: Indwelling Urinary Catheter Insertion- An indwelling urinary (Foley) catheter remains in the bladder co provide continuous urine drainage. A balloon inflated at the catheter's distal end prevents it from slipping out of the bladder after insertion. An indwelling urinary catheter should be inserted only when absolutely necessary because its use is associated with an increased risk of developing a urinary tract infection, with the risk increasing with each day of use. Ensure that you insert an indwelling urinary catheter only for an appropriate indication, including acute urinary retention or bladder outlet obstruction, the need for accurate urine output measurements in a critically ill patient Review the need for the indwelling urinary catheter daily and remove it as soon as it's no longer necessary. Implementation--Verify the practitioner's order. Check the-patient's medical record for allergies, including to latex-and iodine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 3 of 4 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 676180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 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 Gather the appropriate equipment. Use the smallest bore catheter possible that will support adequate urine drainage (unless otherwise clinically indicated) to minimize bladder neck and urethral trauma. Assess the patient to make sure that an indwelling urinary catheter is indicated; assess for alternatives to indwelling urinary catheter use. If necessary, use bladder ultrasonography to measure the volume of urine in the patient's bladder to avoid unnecessary catheterization. Review of facility's Standing orders presented by DON titled Geriatric Post-Acute Specialists guidelines effective 2/21/2024 reflected: EMERGENCY CARE STATEMENT INTRODUCTION AND PURPOSE In accordance with The Texas Medical Board, a standing order or medical guideline is a written instruction issued by a medical practitioner. It authorizes a specified person or class of people such as: Paramedics, Registered Nurses and/or other Clinical Staff who do not have prescribing rights to administer, perform and/or supply specified meds and procedures. Questions or concerns about these GPS guidelines please contact XXX, MD. NOTE: Orders and protocols are not intended to be a substitute for emergency interventions of care. Nurses must notify the attending Physician/Provider or Agent for serious injury or illness. Emergency situations due to serious injury or medical changes involving mental, respiratory, or circulatory systems require immediate notification of on call practitioner. As a guide, the following issues MUST be called in immediately and reported to ON CALL provider. This list is not exhaustive. Please call ON CALL provider for any eminent concerns requiring immediate action. Urinary Tract Infection--- If patient is symptomatic (pain, fever, dysuria, elevated WBC) order a UA and C&S (in and out Cath if necessary.) Review of facility's policy titled Documentation in Medical Record dated 10/24/2022 reflected: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical records in accordance with state law and facility policy. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 4 of 4