Inspection·December 4, 2025

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few blister packs asking if the medications had been removed and placed on the nurse cart or possibly in the medication room. They could not be immediately found in another cart of med room. Upon review of the count sheet record and narcotic sheet by this staff, they appeared to have recently been tampered with. Specifically, you could see that the narcotic count sheet and the Narcotic Substance Record had been scratched through in a suspicious manner. At this time, they notified the Director of Nurses, who in turn notified the Administrator. Upon arrival, the Director of Nurse expanded the investigation.The facility investigation included record reviews, observations and interviews. Interviews and record reviews reflected on September 19, 2025, following the 2p-1 Op shift, there were no discrepancies identified in the narcotic sheets and blister packs. At 2pm on September 19, 2025, there was noted a total of 31 narcotic sheets reflected on the count sheets. This included 3 blister packs of Amphetamine Dextroamphetamine (one a partial, one with a count of 20 tablets and one with a count of 30 tablets. After the following 10p-6a shift, worked by [LVN B] from September 19th through 20th, 2025, it appeared the narcotic count sheet and related blister pack had been altered by pen. It appeared the blister pack and count sheets were deliberately altered to hide the missing medications. This was apparent because one can see through the scratched over numbers. In total, it appears there is one card of 20 tablets and another card of approximately 6 tables that are missing.Staff interviews did not identify an eyewitness to the medications being taken. The facility could not identify anyone with access to the carts besides those designated to be on their designated shifts. The pharmacy confirmed delivery of 10 tablets on September 16, 2025, and the additional two cards of 20 & 30 were delivered on September 18, 2025. Record review in conjunction with the questioning of [Resident #1] reflects he missed no doses. In addition, there was no time in which this medication was not available for the residents.On the evening of 9-25-2025 an additional finding was identified. [LVN B] also worked previously on Thursday, September 17, 2025, on the 2p-10p shift. A narcotic count sheet for Hydrocodone APAP-325 appeared to be altered in a similar fashion to what the facility found on the investigation of the Amphetamine-Dextroamphetamine. It is apparent white out and overmarking was used to alter each number prior to [NAME]'s shift, then the original count sheet appeared to be replaced with a copy, making the alterations less obvious but having the effect of making the count match.Initially, the facility investigation did not provide eyewitness confirmation of a specific employee taking the medications and evidence was not sufficient for employee termination.However, upon expanded review of the facility investigation and the additional findings being found similar to those of the original incident, the facility has elected to terminate [LVN B] to occur in the meeting scheduled 9-29-2025. During the period of time related to both discrepancies, [LVN B] was the nurse in possession of this cart having access to these medications and documentation. The second incident draws a clearer line to Mrs. [NAME] and the altered documentation (see attached). [LVN B] has been working under the capacity of Treatment Nurse since her hire on 4-25-2025, giving her limited and only occasional access to narcotics. However, in the last two shifts [LVN B] has had access to these medications in question, discrepancies have been identified on both occasions.Review of Resident #2's face sheet printed 09/29/2025 reflected a [AGE] year-old male admitted to the facility 08/22/2017. His diagnoses included bilateral primary osteoarthritis of the knee (is a condition where the cartilage in both knees gradually breaks down, leading to pain, stiffness, and loss of function.), chronic pain syndrome (isa condition characterized by persistent pain that lasts for at least six months), need assistance with personal careReview of Resident #2's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 12 indicating mild impaired cognition. Section GG (Functional Abilities) reflected Resident #1 had impairment on one side of both upper and lower (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 2 of 6 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 12/04/2025 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few extremities, He required moderate assistance with hygiene and bathing and only supervision with eating. other. Section J (Health Conditions) the resident did not complain about pain during the assessment period and was on a scheduled pain medication regimen.Review of Resident #2's quarterly care plan, initiated 08/28/2018, reflected Resident #2 the resident had an ADL self-care performance deficit resident has left side hemiplegia (total or partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain.)related to history of CVA (Cerebrovascular Accident- It refers to a condition where blood flow to the brain is interrupted, causing brain damage.) the resident has an alteration in musculoskeletal status related to contractures of hand and leg and arthritis of bilateral knees. Resident #1 had left side hemiplegia related to history of CVA.Review of Resident #2's physician order reflected an order dated 10/23/2024 for Norco Oral Tablet 5-325 MG (Hydrocodone- Acetaminophen) Give 1 tablet by mouth three times a day for pain.Review of Resident #1's medication administration record for September 2025, reflected Resident #2 did not miss a dose of Norco Oral Tablet 5-325 MG (HydrocodoneAcetaminophen).Review of Resident #2's clinical records reflected pain assessment dated [DATE] was conducted on Resident #2 and his pain level was at 2 on the scale from 0-10, 10 being the worst pain ever. Observation on 09/29/2025 of the 200-hall nurse's narcotics book and cart, 200 and 400-halls medication aide narcotics book and cart revealed all medications and blister packets were correct per the narcotic count by the staff. During an interview on 09/29/2025 at about 11:12 am, Resident #1 stated he had not had concerns of not getting his medications. Resident #1 stated all was well. During an interview on 09/29/2025 at about 11:55 am, Resident #2 stated he did not have issues with his pain medication not being administer. Resident #2 stated his pain medication helps. Review of facility's narcotics count sheet for the 400-hall medication aide reflected on 09/07/2025 pharmacy delivered 87 pills of Norco Oral Tablet 5-325 MG (Hydrocodone- Acetaminophen) for Resident # 2 and noted pen written on the 87 to indicate 30 pills.Review of Pharmacy consolidated delivery sheets dated 09/26/2025 reflected 90 pills of Norco Oral Tablet 5-325 MG (Hydrocodone- Acetaminophen) delivered for Resident #2. During an interview on 09/29/2025 at about 12:15 pm, the DON stated Resident #2's had 87 pills of hydrocodone that was delivered on 09/07/2025 and 57 of those pills were missing on 09/25/2025. The DON stated there was no evidence of the count sheet. The DON stated LVN F called the pharmacy for refill of Resident #2's hydrocodone and was told it was too early to refill, refill was due 10/07/2025. The DON stated that was when they noticed someone had written on the 87 on Resident #2's narcotic sheet to reflect 30 pills were delivered. Resident #2 was running out of The DON stated the facility called pharmacy to send Hydrocodone for Resident #2 and the facility would pay, because the refill was not due until 10/7/2025. The DON stated Resident #2's hydrocodone was delivered on 09/26/2025 and never went without his pain medication. Attempted to call MA A on 09/29/2025 at 12:46 pm and MA A stated she was not in the position to talk. MA A stated she wrote a statement for the DON and the Administrator. Attempt made to 09/29/2025 at 1:21 pm, left a voice message for call back. During another interview with the DON on 09/29/2025 at 2:20 pm, she stated the MAs, and the Nurses count the narcotic sheets everyday along with the narcotics during shift change. The DON stated, whenever there was an addition to the narcotic sheet, 2 nurses' signatures were required. The DON stated whenever medication was completed or discontinued, only the Nurse Managers were required to remove the sheets and sign. The DON stated when she was made aware of Resident #1's Amphetamine-Dextroamphetamine Oral Tablet 20 MG, about 25 pills reported missing on 09/20/2025 by LVN C, she asked both LVN C and MA A to search all carts and the medication room. The DON stated all medication carts were searched and Resident #1's Amphetamine-Dextroamphetamine Oral Tablet 20 Amphetamine-Dextroamphetamine Oral Tablet 20 MG, about 25 pills reported (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 3 of 6 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 12/04/2025 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few missing on 09/20/2025, were not found. The DON stated she went to the facility the same day and searched for Resident #1's Amphetamine-Dextroamphetamine Oral Tablet 20 MG, as well and did not see it. The DON stated she notified the Administrator and Law Enforcement was notified. The DON stated on 09/15/2025 Pharmacy sent 10 pills of Resident #1's Amphetamine-Dextroamphetamine Oral Tablet 20 MG tablets, and PARTIAL was written on the blister packet. She stated on 09/16/2025 pharmacy delivered the remaining 50 pills, a blister [NAME] of 20 pills and a blister packet of 30 pills. The DON stated the blister packets of 30 pills and the remaining of the 10 pills could not be found along with the count sheets. The DON stated count sheet inventory was tampered with to reflect less sheets. The DON stated LVN B worked as the Nurse on the evening of 09/18/2025 taking over the 200-hall medication aide cart from MA D. During an interview on 09/29/2025 at 3:02 pm, MA D stated he worked as the medication aide on the 200-hall on 09/19/2025 on the 2-10 pm shift. MA D stated he got a report from MA A who worked the 6am to 2 pm shift. MA D stated when he counted with MA A at the beginning of his shift, he remembered that the narcotic sheet was 31. MA A stated he also remembered specifically Resident #1's Amphetamine-Dextroamphetamine Oral Tablet 20 MG, blister packet of 10 pills that had PARTIAL, it was hard to miss because it was written on it boredly. MA D stated he remembered Resident #1 had 2 additional blister packets of the same medication, 1 of 20 pills and the other of 30 pills. MA D stated when he gave LVN B report the night of 09/19/2025, the medications were correct, the count sheet was correct but on 09/20/2025, Resident #1's Amphetamine-Dextroamphetamine Oral Tablet 20 MG, about 25 pills (blister of 20 and blister of less than 10) were reported missing. MA D stated the Mas does not remove narcotic sheet, only the DON or the ADONs. He also stated the nurses are the only ones that sign for medication from pharmacy. MA D stated he was in-serviced on drug diversion. During an interview on 09/29/2025 at 3:16 pm, LVN F stated she had worked on the 2pm -10 pm shift on the 400-hall when the 6am -2 pm nurse asked her to call pharmacy for Resident #2' Hydrocodone because the medication was running low. LVN F stated she couldn't remember the exact date, but she called the pharmacy for refill and was told by pharmacy that it was too early to refill because 29 days' worth of medication was sent on 09/07/2025. LVN F stated she later heard the medication was missing. LVN F stated they were in-serviced on drug diversion and misappropriation of property. During an interview on 09/29/2025 LVN C stated she worked the morning on 09/20/2025 on the 200-hall. LVN C stated she was approached by MA A asking about the rest of Resident #1's Amphetamine-Dextroamphetamine Oral Tablet 20 MG. LVN C stated together she and MA A looked in both medication carts and the medication was not found. LVN C stated she called the DON and was told to look in all the carts in the facility and the medication which she did but did not find the rest of Resident #1's Amphetamine-Dextroamphetamine Oral Tablet 20 MG. LVN C stated the DON later showed up to the facility and looked in all the cart but did not find the medication. LVN C stated the DON started an in-service on drug diversion, called the Administrator and Law Enforcement. LVN C stated she called Resident #1's family to notify them of the missing medication. LVN C stated Resident #1 still had 30 pills of his Amphetamine-Dextroamphetamine Oral Tablet 20 MG and did not run out completely. LVN C stated usually 2 nurses sign when narcotics were delivered, and a count sheet is added. She also stated the Nurse managers were responsible to remove the count sheets whenever a medication was completed or discontinued. LNV C stated during shift change, the off going and incoming count the narcotics to verify the count and also count the narcotic count sheets. In an interview on 09/29/2025 at 3:41 pm the Administrator stated he found out about the medication diversion on the weekend of 9/19/2025. He stated the staff had called and told him that the medication for Resident #1 documentation did not seem right. The Administrator stated the DON got to the facility before him and started an audit of all the carts in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 4 of 6 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 12/04/2025 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility while he reported the incident to the HHSC. The Administrator stated the facility started an education for staff, suspended the suspected staff, called the police, reported to the state. The Administrator stated the police did nothing because the staff in question was not seen physically with the medication, there was no eye witnessed. The Administrator stated 4-5 days into the investigation was when they found the second drug diversion for Resident #2. The Administrator stated LVN B was at the center of both incidents. The Administrator stated the facility did not drug screen any staff because by the time it was narrow down, it was late to drug screen. The Administrator stated the facility reordered both medications for Resident #1 and 2 on the facility's expense. Review of facility's in-services dated 09/20/2025 reflected an in-service titled Preventing drug diversion reflected: Nurses signature required when checking in medication from pharmacy.--Sheets to be counted each shift removal of sheet require nurse manager signature.--Narcotics counted each shift--Narcotics must be signed out from sheet and--Any discrepancies must be reported, to include tampering with documents. Review of facility's Investigation document reflected Nurses and Medication aides were given questionnaire on 09/20/2025 regarding drug diversion. Review of LVN B's statement typed by the facility dated 09/20/2025 reflected: Upon [LVN B] being suspended, she was given the opportunity to make a statement about the incident in question. The documents reflecting the medication discrepancy was reviewed with her by the Director of Nurses. [LVN B] stated she had no idea who or how this documentation was altered and stated she did not do any of it. To her knowledge, all medications were accounted for.Follow up interview with [LVN B] was conducted on 9-23-2025 again, [LVN B] reiterated she had no knowledge of the discrepancy in question. Review of MA A's statement dated 09/25/2025 reflected: Re: Missing MedicationsEmployee: [MA A], Certified Medication AideOn the morning of 9-20-2025 on the 6a-2p shift, I received the cart from, [LVN B]. Later, this morning at approximately 10:30am, I was giving the resident his first dose I noticed a discrepancy. I questioned the charge nurse of 200 Hall, [LVN C], if any medication changes were made recently or if she happened to have any additional medications for [Resident #1], specifically the Amphetamine-Dextroamphetamine in her cart. I recalled there were more of these pills the day before. I could not recall exactly how many there were previously, but there was at least a partial card appearing less than 10, and two other cards, one a count of 20 and the other a count 30. We went back to the narcotic count sheet, and they appeared to have been tampered with. It appeared they were written over or modified. At this time, I called the Director of Nurse to report the matter. Review of MA D's statement dated 09/25/2025 reflected: On 9-19-2025 following the 2:00p to 1 0:00p shift, I was competing narcotic medication count with [LVN B] and recall there were a total of 31 sheets noted. I further recall with the specific medication Amphetamine-Dextroamphetamine there was a partial blister pack of approximately less than 10 and two other blister packs including one of 20 count and another of 30 count tablets. Review of MA E's statement dated 09/25/2025 reflected: In reviewing the narcotic sheet in question for Amphetamine-Dextroamphetamine I recalled adding a sheet to the total count upon its arrival and signed accordingly. At this time, the sheet did not appear tampered with, specifically the writing over and scratching out that I currently see was not present at this time. At the time of this count, I recall a total of 31 count sheets. Review of facility's investigation document dated 09/26/2025 reflect the facility had an Impromptu QAPI to address the drug diversion. Review of LVN B's personnel file Termination notice dated 09/29/2025 reflected:LVN B has been terminated as a result of the investigation beginning 09/19/2025 and ending on 09/29/2025, regarding a drug diversion. Discrepancies were identified on 2 different occasions involving narcotics documentation and subsequent missing medication.Level three offense-falsification of any records, job resumes, or job application.Other offenses: Violation of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 5 of 6 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 12/04/2025 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete any other policy or procedure contained in employee Manual: Narcotic Management Policy.Review of facility's policy dated 07/11/2025 titled Abuse, Neglect and Exploitation: Policy: It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent.Review of facility's policy dated 10/01/2019 titled Medication Policy reflected: Policy--The following procedures are designed to serve as guidelines for the facility when any type of medication diversion or tampering has occurred.Procedure--If drug diversion is suspected by a Licensed Nurse, it is his/her responsibility to report this to the Director of Nursing.If The Controlled Substances Count Is Incorrect:1. Determine if the medication was given and not charted.2. Determine if the medication may have been lost, incorrectly stored/misfiled, discarded, or sent home with a discharged patient.3. The incident must be reported to the Director of Nursing immediately. The DON will determine how the investigation is to proceed.4. Document that the individual count is correct in the controlled substances book or log to allow patient care to continue (unless medication has been tampered with*). The incorrect count should be documented on the product specific page and the shift count signature page by entering No under status of count exact yes/no.5. Sign the shift count record in the usual manner once the incorrect count has been documented. Give keys to the on-coming shift nurse.6. Working with nurse on the shift on which the count became incorrect, fills out a facility incident report. The report should summarize the events leading up to the discovery of the diversion/tampering and indicate what actions were taken to locate the medication.* If medications appear to have been tampered with:1. Telephone the dispensing pharmacy to identify medications on hand.2. Order replacement medications to allow patient care to continue.3. The Director of Nursing or designee should secure the suspected medications for further investigation. The DEA may confiscate these drugs as evidence. If this should occur, make certain that you document the type and quantity of medications being released to the DEA with witnessed signatures. Photocopy when possible. Remember that controlled medications should not be returned to the pharmacy. Event ID: Facility ID: 676180 If continuation sheet Page 6 of 6