Health inspection·November 3, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of an incident with an allegation of pharmaceutical services involving Resident #5 revealed the incident was reported to HHSC on 06/17/23. Record review on TULIP revealed no provider investigation report had been submitted on TULIP. Record review of an incident with an allegation of infection control involving one staff who was positive for COVID-19 revealed it was reported to HHSC on 07/18/23. Record review on TULIP revealed no provider investigation report had been submitted on TULIP. Interview on 11/01/23 at 09:00 a.m., Interim Adm A revealed he was looking for all the provider investigation reports that were not submitted to HHSC when the reports were made. Interim Adm A stated he was trying to obtain hard copies from both corporate and TULIP when the investigations were submitted. Interview on 11/03/23 at 01:40 p.m., Interim Adm A revealed the facility was not able to locate any of the provider investigation reports. Interim Adm A stated the previous administrator and director of nurses were responsible for filing; however, they were no longer employed at the facility. The Interim Adm A stated that as administrator it was their responsibility to maintain the provider investigation reports and would fax or email them to TULIP. Record review of facility policy and practices titled Abuse, Neglect, Exploitation or Misappropriation Reporting and investigating with a revised date of 04/2021, quoted in part, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676346 If continuation sheet Page 2 of 16 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 676346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidalgo Nursing and Rehabilitation Center 4503 S Sugar Rd Edinburg, TX 78539 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 - Immediate jeopardy to resident health or safety Residents Affected - Few 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 each resident received adequate supervision to prevent accidents for one (1) of seven (6) residents (Resident #1) reviewed for accidents and hazards: The facility failed to develop and implement interventions to prevent Resident #1 's elopement from the facility. Resident #1 eloped from the facility on 03/31/23 and was returned to the facility by local police department. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 03/31/2023 and ended on 03/31/2023. The facility corrected the non-compliance before the investigation began. This deficient practice could place the residents at risk for harm, serious injury or death. The findings were: Record review of Resident #1's admission record dated 10/31/23 documented an [AGE] year-old male admitted to the facility on [DATE] and discharged on 04/01/23. The form further documented Resident #1 with diagnoses including, unspecified atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the atrial chambers of the heart), muscle weakness generalized (reduction in the power exerted by muscles resulting in an inability to perform a given task on first attempt), muscle wasting and atrophy (a decrease of muscle mass and strength), abnormalities of gait and mobility (any unusual or unexpected patters of movement or changes in the way an individual walks or moves), lack of coordination (group of symptoms that cause impaired direction), fall, Alzheimer's disease onset (progressive disease that destroys memory and other important mental functions). Resident #11 was not identified as his own responsible party. Record review of Resident #1's MDS assessment dated [DATE] revealed cognitive pattern was not tested. The MDS documented a 0 when asked Has the resident wandered?, indicating the behavior had not been exhibited. Record review of Resident #1's comprehensive care plan revealed that Resident #1 was an elopement risk/wanderer related to disoriented to place, history of attempts to leave facility unattended, resident wanders aimlessly with an initiated date of 03/31/23 and a revision date of 04/01/23. Listed goals included the resident's safety will be maintained through the review date. Listed interventions included, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Other goals included identify pattern of wandering and initiate visual checks Q2hrs (every two hours) . All with initiation date of 04/01/23. Record review of Resident #1's physician order revealed an order for behavior monitoring for (wandering, agitation, exit seeking behavior) medication (name of med) document # of times resident has exhibited the above behavior during shirt. Intervention codes: 00 none; 1) 1 on 1; 2) Activity; 3) Adjust room temperature; 4) Backrub; 5) Change position; 6) Give fluids; 7) Give food; 8) Redirect; 9) Remove resident from environment; 10) Return to room; 11) Toilet .every shift document resident outcome following intervention using the following codes . with a start date 03/31/23 and that was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676346 If continuation sheet Page 3 of 16 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 676346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidalgo Nursing and Rehabilitation Center 4503 S Sugar Rd Edinburg, TX 78539 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 discontinued with no end date noted. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's April 2023 licensed nurse administration record of dated 11/03/23 revealed order had been completed and documented for every shift on 04/01/23 as ordered. Residents Affected - Few Record review of Resident #1's Wandering Evaluation completed upon admission on [DATE] at 01:08 a.m., documented a summary of finding score of eight (8) indicating resident was a moderate risk for wandering. Additional comments included Patient tries to get out of bed and voices that he wants to leave the facility. A&Ox1 (alert and oriented to self). Record review of Resident #1's progress notes signed and dated by LVN D on 03/29/23 at 01:14 p.m. revealed, Resident was constantly getting up from bed and trying to go into other resident's room, [Nurse practitioner] was notified by night SN (skilled nurse) and got new orders for melatonin 5 mg (milligrams) prn (as needed) at bedtime. SN got verbal consent from resident's sister to administer medication as ordered. Medication was administered. Orders carried out. Record review of Resident #1's progress notes signed and dated by LVN E on 03/30/23 at 01:20 p.m. revealed, Behavioral issues: plays with feces, goes into other resident's rooms, and undresses .melatonin for insomnia. Record review of Resident #1's progress notes signed and dated by LVN B on 03/31/23 at 03:29 revealed, [Police] came to facility to ask if we were missing a resident. Did a quick head count and resident was not in bed. It was confirmed that it was our resident. Resident was placed in wheelchair and brought into facility and back to his room. Assessed resident and no injuries noted. Case # left by PD. Reported to [administrator] and RP made aware. Record review of Resident #1's progress notes signed and dated by MSW on 03/31/23 at 10:07 a.m. revealed, LMSW (licensed master social worker) spoke to patient's daughter/POA (power of attorney) via telephone. SW (social worker) informed patient's daughter that patient needs a memory care unit due to elopement and wandering behaviors. Patient's daughter in agreement with referral and chose [nursing facility]. SW sent clinical information to liaison for [nursing facility for processing. SW to follow. Record review of Resident #1's progress notes signed and dated by LVN A on 03/31/23 at 11:26 a.m. revealed, resident agitated wandering in 100 and 400 halls, redirected resident several times. Spoke with [physician assistant] regarding resident's condition and elopement episode from previous shift. New order for Zyprexa 5 mg (milligram) po (by mouth) x 1 (times one) dose and continue with Zyprexa 5 mg po qhs (every night at bedtime) orders carried out. Placed call to RP and second contact x 3 attempts to obtain consent for Zyprexa. No answer left voicemail. [Nurse Practitioner] aware of new order for Psych consult, pending at this time. Record review of Resident #1's progress notes signed and dated 03/31/23 at 07:54 p.m. by LVN C revealed, visual check every 2 hours. Record review of TULIP (HHSC online incident reporting application on 10/31/23 at 09:00 a.m. revealed the facility made a self-reported incident on 04/01/23 p.m. at 05:18 p.m. regarding Resident #1's elopement). Record review of facility Incidents by Incident Type dated 10/24/23 for reporting period March 2023 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676346 If continuation sheet Page 4 of 16 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 676346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidalgo Nursing and Rehabilitation Center 4503 S Sugar Rd Edinburg, TX 78539 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 listed elopement incidents: Resident #1 dated 03/31/23 at 03:00 a.m. Level of Harm - Immediate jeopardy to resident health or safety Record review of the facility map and evacuation routes, a total of eight (8) exits were identified as exit doors. Residents Affected - Few Initial rounds were conducted on 10/31/23 beginning at 08:30 a.m. throughout the facility. The facility was well lit, temperature was comfortable, and staff were seen appropriately interacting and assisting residents in their rooms and in the hallways. The facility census was ninety-eight (98). Resident rooms were clean, orderly, without any noted hazards or clutter. There were no sounds of yelling, screaming, or moaning. Residents in bed had their call lights within their reach. Call lights were observed activated and timely answered. Nurses were administering care and medications in a timely manner. Water and belongings were observed at the bedside of the residents and within their reach. No resident was observed to display any disrupting or aggressive behaviors. No injuries or bruising was noted on any resident that would raise suspicion of abuse or neglect. There were no active cases of COVID-19 positive residents in the building. Visitors were observed entering and exiting through the main entrance after being allowed entrance. Other exit doors locked and secured with codes and screech alarm. Observation on 10/31/23 at 09:00 a.m. of the surrounding streets revealed a highly trafficked four lane road with a center lane and a speed limit of 40 miles per hour. Interview on 11/01/2023 at 10:45 a.m., CNA P revealed she had been employed eight (8) years by the facility and her responsibilities included assisting the nurses and residents on hall 100. CNA P stated exit doors have a code that allows entry or exit through them. CNA P stated staff should not be sharing codes with residents or visitors. CNA P stated she did not recall a resident who may have eloped anytime within the past year. Interview on 11/01/2023 at 11:00 a.m., CNA Q revealed she had been employed three (3) weeks by facility and her responsibilities were assisting the nurses and residents on hall 100. CNA Q stated she received report and rounded on all residents assigned to her on the hall she worked. CNA Q stated she tried to maintain an open communication with other staff to account for all residents. CNA Q stated she was not aware of any residents who had been missing recently. CNA Q stated if a resident was missing she would ask a coworker or nurse to assist in helping find the resident. that exit doors had alarms that activated if pushed. CNA Q stated she did not have access codes to the exit doors. Interview on 11/01/23 at 11:35 a.m., CNA R revealed she had been employed for three (3) years by the facility and her responsibilities included assisting the nurses and residents of hall 200. CNA R stated exit doors do not have cameras, but they do have alarms that are activated if pushed. CNA R stated alarms on the doors could be deactivated when a code is entered on the keypad. CNA R stated that not all staff members had the codes and if they did they should not share them with residents and visitors. CNA R stated she was unaware of how often the exit door codes were changed. CNA R stated residents could only go outside if they were signed out with a family member. CNA R stated she had not been in a situation like that. CNA R stated staff are instructed to search for the resident in every hall and room. CNA R stated she would ask other nurses or CNAs for the whereabouts of the resident and that the nurse would decide what protocol to follow. CNA R stated the nurse will notify administration and family. Interview on 11/01/23 at 12:20 p.m., CNA S revealed she had been employed for eight (8) years by the facility and her responsibilities including assisting the nurses and residents of hall 300. CNA S (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676346 If continuation sheet Page 5 of 16 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 676346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidalgo Nursing and Rehabilitation Center 4503 S Sugar Rd Edinburg, TX 78539 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 - Immediate jeopardy to resident health or safety Residents Affected - Few stated residents were not allowed to go outside unless with family members after they had signed them out but not by themselves or unsupervised. CNA S stated the facility was a nonsmoking facility and there was no designated area for smoking or staff to assist residents outside of the building. CNA S stated if a resident was missing, she would ask a nurse and other staff on the whereabouts of the resident and inform the administrator or the DON. CNA S stated she would look for the resident in hallways, rooms and everywhere until found. CNA S stated the next step would be to involve the police. CNA S stated exit doors have an alarm that is deactivated with a code that secures the exit. CNA S stated exit doors will alarm if a resident attempts to exit. CNA S stated staff do not share codes with residents or visitors. Interview on 11/01/23 at 12:35 p.m., CNA T revealed she had been employed for three (3) months by the facility and her responsibilities included assisting the nurses and residents of hall 300. CNA T stated residents are not allowed to go outside unsupervised. CNA T stated residents may go outside if accompanied by family. CNA T stated there was no assigned area outside for residents to out to. CNA T stated exit doors are secured by an alarm that would deactivate with a code entered on a keypad. CNA T stated codes are not shared with residents or visitors. CNA T stated residents were accounted for on each round. CNA T stated rounds were done every two (2) hours or more often if needed. Interview on 11/01/23 at 12:55 p.m., CNA U revealed she had been employed for five (5) months by the facility and her responsibilities included assisting the nurses and residents of the facility as a float CNA. CNA U stated residents are not allowed to go outside unsupervised unless with family. CNA U stated exit doors are secured with an alarm that will activate if opened. CNA U stated alarms can be deactivated by codes that must be entered on a keypad. CNA U stated residents nor visitors have access to the codes. CNA U stated she made sure all residents were in the facility during rounds and rounds are done every two hours or more often if needed. CNA U stated she will report to the nurse if a resident is not found in the facility. CNA U stated staff will look for resident in his/her room, restroom, and all areas of the facility. Interview on 11/01/23 at 02:50 p.m., RN/MDS revealed she had been employed for two and a half (2.5) years by the facility and her responsibilities included infection control duties, assistant director of nursing duties and as part of the interdisciplinary team to create patient care plans. RN/MDS stated the facility had no designated areas for smoking and residents were only allowed to go outside if supervised as part of their therapy or with family. RN/MDS stated residents were accounted for when staff performed their rounds. RN/MDS stated exit doors had codes that were not shared with residents or visitors. RN/MDS stated she was not aware of any incidents involving elopement. Interview on 11/01/23 at 03:20 p.m., LVN A revealed she had been employed for 9 years by the facility and her responsibilities included floor nurse and was recently promoted to assistant director of nursing one (1) month prior to this date. LVN A stated she accounts for all residents in the facility by doing a walking round when getting report. LVN A stated if a resident is missing at any time she will look in each room and ask other staff to help locate the resident in other areas of the facility. LVN A stated she would then notify the family, the physician, the administrator, and the police. LVN A stated she would then search outside the facility in each direction. LVN A stated this process is not delayed stating, immediately, you do not wait minutes, if you cannot find the resident in the facility you activate the elopement protocol if a resident cannot be found. LVN A stated rounds by staff are done every two (2) hours and more often if needed and this is how often it is checked to see if residents are here. LVN A stated if residents are at risk of elopement the rounds are increased to every thirty (30) minutes. LVN A stated the facility does not have a locked memory care unit. LVN A stated the facility had an elopement incident months ago, we did have a resident during (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676346 If continuation sheet Page 6 of 16 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 676346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidalgo Nursing and Rehabilitation Center 4503 S Sugar Rd Edinburg, TX 78539 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 - Immediate jeopardy to resident health or safety Residents Affected - Few night shift. LVN A stated staff did not know resident was at risk for elopement and continued by stating, he was a new patient. LVN A stated, he never voiced an intent to leave. He was in room [ROOM NUMBER], I was not here and was not the nurse. LVN A stated LVN B was the nurse assigned. LVN A stated residents are not allowed to go outside unsupervised and can only go with family members. LVN A stated residents nor visitors have access to the exit door codes. LV A stated staff do not know the exit door codes and do not share the codes with residents or visitors. LVN A stated exit doors have an alarm that will be activated if pushed. LVN A stated the push bar must be held for fifteen (15) seconds for the door to release and the alarm will sound. LVN A stated abuse including physical, mental, sexual, verbal, and negligence is reported to the abuse coordinator, the administrator. Interview on 11/01/23 at 04:00 p.m., LVN F revealed she was a new nurse to the facility only having been employed there for three (3) days and her responsibilities included floor nurse and administering medications. LVN F stated she was present when incident happened and did not know any of the details; however, she stated she was aware she needed to perform walking rounds to ensure all residents were in the facility. LVN F stated rounds were performed every two (2) hours or more often if needed. LVN F stated that if a resident could not be located within the facility, the elopement protocol would be initiated and that involved looking at all areas within the facility and outside the facility. LVN F stated physician, family and the police would be notified. LVN F stated exit doors were secured by alarms that were deactivated with a code. LVN F stated the alarm will not stop until someone deactivates it. LVN F stated abuse including verbal, physical, misappropriation of property, and neglect are reported to the abuse coordinator, the administrator. Telephone interview on 11/01/23 at 04:35 p.m., LVN C revealed he had been employed for eight (8) months by the facility and his responsibilities included floor nurse of hall 300. LVN C stated Resident #1 was admitted around 10:00 p.m. during his shift on 03/28/23. LVN C stated he performed his assessment, which included an elopement risk assessment, and it indicated Resident #1 was a Moderate risk. LVN C stated Resident #1 was ambulatory, he was curious about going to the therapy room, the halls, and going to other rooms. LVN C stated Resident #1 used a walker. LVN C stated his family was present at the time of admission and did not mention Resident #1 having a history of leaving or eloping. LVN C stated Resident #1 was alert and oriented only to self and not oriented to situation. LVN C stated, Resident #1's judgment and critical skills were impaired. LVN C stated he did not remember all of the details of the incident being that time had elapsed; however, LVN C stated Resident #1 was only at the facility for a short period due to Resident #1 being sent to the hospital. LVN C stated Resident #1 was brought back to the facility after his hospital stay but did not give me any details only that he [Resident #1] was brought back and no new implementations were placed. LVN C further went on to state he ensures all residents are in the facility by doing a walking round. LVN C stated rounds are performed every two (2) hours or more often if needed. LVN C stated other staff can alert nurses if a resident is missing. LVN C stated verify if resident was not out on pass, stepped out with family, on an appointment, or in an activity. LVN C stated staff involve other staff when searching for a missing resident and they must all look at other areas of the building including restrooms. LVN C stated the facility has no designated smoking area and residents are not allowed to go outside unsupervised. LVN C stated if a resident is unable to be located, the local authorities, director/administrator must be notified. LVN C stated that once the resident is found and returned to the facility a full head-to-toe assessment, skin assessment, vital signs must be completed. LVN C stated that the resident must also be interviewed if possible and it must be determined if the resident needs to go to the emergency room for further evaluation and treatment. LVN C stated exit doors have an alarm on top called a screamer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676346 If continuation sheet Page 7 of 16 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 676346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidalgo Nursing and Rehabilitation Center 4503 S Sugar Rd Edinburg, TX 78539 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 - Immediate jeopardy to resident health or safety Residents Affected - Few LVN C stated the alarm can be turned off by a key located at the nurse's station. LVN C stated only staff have access to the key. LVN C stated alarms can be deactivated with codes. LVN C stated staff do not know the codes. LVN C stated codes should not be shared with other staff, visitors, or residents. Telephone interview on 11/02/23 at 02:20 p.m., LVN B revealed she had been a nurse employed by the facility for two (2) years and her responsibilities included floor nurse of halls 100, 200 and 300. LVN B stated she was assigned to work hall 100 on 03/31/23. LVN B stated she did not recall the exact details of the incident that happened on 03/31/23 that involved Resident #1. LVN B stated she had performed her initial rounds and ensured the residents were in the facility. LVN B stated she physically rounded to ensure residents were in the rooms and in the facility every two (2) hours and more often if needed. LVN B stated no resident was missing during her last round. LVN B stated no exit door alarm was heard. LVN B stated that the local police department brought the resident to the facility and asked if the resident was missing. LVN B stated that after performing a quick headcount of the residents, the staff realized the resident was from hall 100. LVN B stated she could not remember resident's name or when exactly it happened. LVN B stated her CNA was on break during that time and the resident could not have been gone more than 30 minutes. LVN B stated resident was found by police walking towards [NAME] Road on Sugar Avenue. LVN B stated she performed a head-to-toe assessment upon his return, notified the administrator, the director, and the resident's family of his elopement. LVN B stated staff and herself inspected exit doors and discovered that the exit door at the end of hall 100 had been left unlocked. LVN B stated staff will check exit door to make sure they are locked. LVN B stated a red light above the door indicates the door is locked. LVN B stated that a turn switch can unlock the door and the red light will turn green. LVN B stated after Resident #1's return, the exit door was inspected and a green light indicating the door was unlocked was observed. LVN B stated she did not know how or who left the door unlocked. LVN B stated she could not predict any negative outcome that could have happened to Resident #1 or any other resident with elopement. Interview on 11/02/23 at 04:00 p.m., DON/RN revealed she had been a nurse employed by the facility and assigned to her position for two (2) months. DON/RN stated her responsibilities included oversight of the nurses and staff and oversight for the care of the residents. DON/RN stated she was not employed by the facility on 03/31/23 when the incident happened. DON/RN stated there was no provider investigation report related to the incident and could not reference or give any information related to the incident. DON/RN noted the resident was discharged from the facility since 04/01/23 and was unable to further investigate the incident. DON/RN outlined the facility's current elopement emergency response (ER) plan being implemented. DON/RN stated a code green announced to staff indicated an elopement or missing resident. DON/RN stated all staff were assigned to look in assigned areas and they had routes (such as emergency exit routes) to look for the missing resident. DON/RN outlined two different phases as part of their elopement ER plan. DON/RN stated phase I was when staff searched inside the facility and in the parking area. DON/RN stated phase II was when staff searched anywhere outside the property line. DON/RN stated the resident representative, physician and police would be notified of the resident's missing status. DON/RN stated staff did not waste time. DON/RN stated that once the resident was found, staff should perform a head-to-toe assessment of the resident, notify the resident representative and the physician, document, and place a one to one (1:1) observation of the resident. DON/RN stated the facility had taken an initiative to prevent future elopements including frequent in-servicing of staff on topics of elopement, perform wander/elopement risk assessment to identify high risk elopement residents, and frequent testing of the facility exit doors to make sure doors are locked and secured. Furthermore, the DON/RN stated the facility made (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676346 If continuation sheet Page 8 of 16 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 676346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidalgo Nursing and Rehabilitation Center 4503 S Sugar Rd Edinburg, TX 78539 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 - Immediate jeopardy to resident health or safety Residents Affected - Few sure someone was always at the reception area and that staff rounded to make sure doors remained locked. DON/RN stated exit door codes do not frequently change because not everyone has access to the codes and not everyone has access to the main key located at the nurse's station. Interview on 11/03/23 at 01:40 p.m., Interim Adm A revealed he had been an interim administrator for the facility and that 11/03/23 would be his last day before he was assigned to a different location. Interim Adm A stated he was not familiar with the incident that happened on 03/31/23 involving Resident #1 because he was not there. Interim Adm A stated there was no provider investigation report and he could not reference the report to give any information. Interim Adm A also noted Resident #1 was no longer an active resident of the facility. Interim Adm A stated he was informed a resident was missing and was not sure what process was done or not done. Interim Adm A stated the facility did have a code system that was announced when a resident was missing. Interim Adm A stated the code was divided into two (2) phases: phase I was characterized by immediately informing facility staff and searching for the resident within the facility, informing the ADON, DON and family and performing a head count of all residents. Interim Adm A continued explaining that phase II was characterized by calling the police and helping the entire interdisciplinary team locate the resident outside the facility. Interim Adm A stated exit doors are equipped with a secondary alarm with a 15 second delayed egress and a stop alarm (screech annunciator). Interim Adm A stated exit doors also backup system that was put up in April or May and had a key system with a light system indicating when the door was unlocked and locked (red indicates the door is locked and green indicates the door is unlocked). Interim Adm A stated the facility has prevented future elopements by conducting elopement drills and in-services amongst the staff, evaluation of every exit door at regular intervals, ensuring no one is given the codes to the exit doors, and changing the codes once the codes have been breached. Interim Adm A stated no other elopements have occurred since the single incident that occurred in March. Interim Adm A stated staff have been in-serviced. The following record reviews were conducted by the survey team to ensure the Past Non-Compliance was corrected The following interviews were conducted by the Survey Team on 11/02/2023 and 11/03/2023: 6 CNA's, 2 LVN's, and 2 RN. -Staff acknowledged understanding of the topics they were in-serviced regarding wandering and elopement. -Inservices reflected 45 nursing staff were trainined. Record review of work history report documentation stating, Category: Doors: Task Completion .Marked done on-time . marked each exit tested for dates 11/05/2022 through 10/31/2023 Record review of facility in-service training report revealed facility had a training over Missing Resident In-service on 04/04/23. Record review of facility policy and practices titled Door Alarm/Exit Stopper with no implemented date noted, quoted in part, Exit doors have a Door Alarm/Exit Stopper to provide safety for residents that are confused and have a tendency to wander about the facility . Record review of facility policy and practices titled Wandering/Missing Residents with no implemented date noted, quoted in part, some of the SCC''s facilities do not have secured units and it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676346 If continuation sheet Page 9 of 16 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 676346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidalgo Nursing and Rehabilitation Center 4503 S Sugar Rd Edinburg, TX 78539 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 - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete becomes very important to identify residents who walk or wheel themselves unrestricted and become a threat to leave the facility unattended due to their confusion .The facility must ensure the resident's safety while utilizing the least restrictive means available . Record review of facility policy and practices titled Missing Resident/Patient (Code Green) with no implemented date noted, quoted in part, Process .to help ensure all resources available are coordinated to locate a missing resident/patient, an aggressive campaign may be organized to safely locate and return the resident/patient who has wandered or is deemed missing . Event ID: Facility ID: 676346 If continuation sheet Page 10 of 16 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 676346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidalgo Nursing and Rehabilitation Center 4503 S Sugar Rd Edinburg, TX 78539 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to ensure drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 1 of 24 residents (Resident # 2) being reviewed for pharmacy services. The facility failed to ensure that narcotics were reconciled as being given from the resident's eMAR to the resident's narcotic reconciliation form on the medication cart. This failure could place residents at risk of not receiving their narcotic medications and drug diversions. The findings included: Record review of Resident #2's admission Record dated [DATE] revealed Resident was a [AGE] year-old male admitted on [DATE]. The form further documented Resident #2 with diagnosis including: traumatic subarachnoid hemorrhage with loss of consciousness (bleeding into the brain in the area between the arachnoid membrane and the [NAME] matter), respiratory failure (condition in which the respiratory system fails in one or both of its gas exchange functions), muscle wasting and atrophy (a decrease of muscle mass and strength), muscle weakness (generalized) (reduction in the power exerted by muscles resulting in an inability to perform a given task on first attempt), abnormalities of gait and mobility (any unusual or unexpected patters of movement or changes in the way an individual walks or moves), lack of coordination (group of symptoms that cause impaired direction), and dysphagia (condition with difficulty in swallowing). Record review of Resident #2's quarterly minimum data set (MDS) revealed a brief interview for mental status (BIMS) score of 02 indicating severe impairment. Form also documented Resident #2 required extensive assistance with two-person assist for bed mobility and dressing and total dependence on transfer, toilet use and personal hygiene. Form documented Resident #2 was dependent on functional abilities such as eating, oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing and putting on/taking off footwear. Record review of a signed prescription order dated [DATE] for Resident #2 for Tramadol 25 mg (milligrams) PEG (via Percutaneous Endoscopic gastrostomy tube) Q4 (every 4 hours) prn (as needed) #60 (sixty tablets). On [DATE] at 08:30 a.m., inspection of medication carts revealed a medication in the cart of hall 200 with no order on eMAR. Further inspection of the medication revealed that the facility failed to reconcile Resident #2's order for Tramadol 50 mg (milligrams) PEG (via Percutaneous Endoscopic gastrostomy tube) Q4 (every 4 hours) prn (as needed) #60 (sixty tablets) as being given from the resident's eMAR to the resident's narcotic reconciliation form on the medication cart beginning [DATE]. The medication was available in the narcotic drawer for administration with no discontinuation date. Record review of Resident #2's Controlled Administration Record Tablet (NARC Sheet) for Tramadol 50 mg tablet generic for Ultram with the following orders ½ tablet (25 mg milligram) via tube (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676346 If continuation sheet Page 11 of 16 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 676346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidalgo Nursing and Rehabilitation Center 4503 S Sugar Rd Edinburg, TX 78539 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some every 4 (four) hours as needed. Further review of the NARC sheet revealed initial count of 60 tablets failed to be initialed by the receiving nurse. Tramadol 50 mg were signed off on the Controlled Administration Record Tablet (NARC Sheet) on the following occasions: From April, 07/23 to July, 17/23 a total of thirty-one doses (31) of Tramadol 50 mg (milligrams) were signed off on the Controlled Drug Administration Record Tablet (NARC sheet). Record review of Resident #2's order summary dated [DATE] revealed the following active orders: Order summary failed to reveal an active or discontinued order for Tramadol 50 mg PEG (via Percutaneous Endoscopic gastrostomy tube) Q4 (every 4 hours) prn (as needed) #60 (sixty tablets). Monitor for pain every shift use 0-10 scale (A) for alert residents use pain (B) for confused residents document which pain scale used to assess residents pain rating every shift with an order start date [DATE]. Monitoring of pain-if pain is noted chart in nurse's notes the interventions/treatments used and the effectiveness - Intervention code: 0 - none, 1 - medication, 2 - reposition, 3 - heat, 4 - cold, 5 - gentle range of motion, 6 - other (see nurse's notes) every shift with an order start date [DATE]. Record review of Resident #2's progress notes revealed a note entered on date [DATE] quoted in part, Reason for follow up: Thrush .Plan .Rx given for Tramadol 25 mg via PEG q4 prn pain #60 1 refill . Record review of Resident #2's electronic medication record for the months of April through July failed to reflect documentation that doses of Tramadol were given for dates listed above. Further record review of Resident #2's electronic medication record for the months of April through July, reflected assessments for pain. Interview on [DATE] at 10:30 a.m., LVN G revealed she had been employed by the facility for one year and three months (1.3 years) and her responsibilities included taking care of residents in halls 200 and 300. LVN G stated narcotic counts are performed before the ongoing shift of every shift, therefore twice a shift beginning and end of shift. LVN G stated if one of the counts is off the supervisor is notified, nurses who were performing the count would verify against the eMAR to see what medications were given, count several times, check the narcotic box and any surrounding areas for the missing medications. LVN G stated they would check several times to make sure they had not missed the medication. LVN G stated nurses ensure the counts were correct by matching the blister pack with the count in the book and matching the counts with the eMAR when administering the medications. Interview on [DATE] at 10:55 a.m., LVN H revealed he had been employed by the facility for nine (9) months and his responsibilities included taking care of residents in hall 400. LVN H stated the facility used the eMAR to monitor medication administration. LVN H stated he assured orders for medication monitoring were being implemented by checking progress notes and checking physician orders. LVN H stated staff evaluated whether medications should be initiated, continued, reduced, discontinued, or modified every time the physician rounds. LVN H stated nurses ensured counts were correct by counting each medication package with a witness and against the eMAR. Interview on [DATE] at 11:45 a.m., LVN I revealed she had been employed by the facility for seven (7) years) and her current responsibilities included taking care of residents in hall 200. LVN I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676346 If continuation sheet Page 12 of 16 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 676346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidalgo Nursing and Rehabilitation Center 4503 S Sugar Rd Edinburg, TX 78539 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated she performs a narcotic count on the medication cart she was assigned at the beginning of her shift. LVN I stated Resident #2 was last administered Tramadol on [DATE]. LVN I stated Resident #2 had no current or active order for Tramadol and no order that was discontinued that was found in the order summary. LVN I stated expired narcotics were stored in a locked drawer in the ADON/DON. LVN I stated the facility monitors medication administration through nurse check offs. LVN I stated the facility used point click care (PCC) and a module to check nurses off as a monitoring tool to track medication administration. LVN I stated nurses ensured orders were being implemented, initiated, continued, discontinued, or modified every time the physician rounds and daily when the medication reconciliations were done. LVN I stated nurses ensured the narcotic counts were correct by counting the blister packs and Nexys. Observation and interview on [DATE] at 12:00 p.m., Resident #2 was sitting in his wheelchair in the dining room. Resident #2 was awake, alert, oriented to self, well-groomed and waiting to receive his lunch. Resident #2 was unable to provide any details regarding his medication administration schedule or the type of medications he was receiving. Interview on [DATE] at 12:55 p.m., ADON/RN revealed she had been employed by the facility for one (1) month and her duties included oversight of the staff, completing in-services, and assisting administration. ADON/RN stated Resident #2's order was sent given to facility on [DATE]. ADON/RN stated the nurse who received order never put the order into PCC. ADON/RN stated nurses were not checking the order before administering the medication to the resident. ADON/RN stated nurses were not following their 5 rights because that is their first thing is to check against PCC. ADON/RN stated, I was not here at that time and would not be able to know how many nurses actually gave this medication. ADON/RN stated her duties included checking medication carts/medications monthly. ADON/RN stated the facility monitors nurses for medication administration by checking PCC for missing documentation. ADON/RN stated the facility used PCC as their system for tracking medication errors and administrations. ADON/RN stated the facility compared new orders and checked to make sure the orders were compared to hospital orders to make sure medication orders were being implemented. ADON/RN stated the facility made sure medication orders were initiated, continued, reduced, discontinued, or modified by ensuring nurses wrote a progress note every time a physician changed an order. ADON/RN stated the evaluation for modification is conducted within one week of admission and monthly. Telephone interview on [DATE] at 02:35 p.m. with LVN J revealed she had been employed by the facility for two (2) years and her duties included taking care of residents in hall 100. LVN J stated narcotic counts were done at the beginning of their shift before handing the medication cart, keys, and assignment over to the oncoming nurse. LVN J stated narcotic counts were done twice a shift (before and after each shift). LVN J stated narcotics were not usually checked against the eMAR when counting narcotics, instead they counted the blister pack and checked against the narcotic sheets. LVN J stated narcotics were only checked against the eMAR when administering that certain medication. LVN J confirmed her initials signed off on the narcotic sheet. LVN J stated, yes I would mark it in the eMAR. LVN J stated I would then make sure to mark it against the paper. LVN J stated not documenting medication administration would not affect the resident because she documented on paper first and then on the eMAR. LVN J stated there would not be a negative effect to the resident because she assessed the resident for pain before giving medication. LVN J stated physician will write an order for one week, the pharmacy will provide for two weeks, but the order will ride off the eMAR and the nurse would have to reach out to the physician for a new order. LVN J stated the facility monitored medication administration through the eMAR. LVN J stated the facility used PCC and the narcotic sheets as tools to monitor medication administration. LVN J stated the facility made sure medication orders were initiated, continued, reduced, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676346 If continuation sheet Page 13 of 16 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 676346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidalgo Nursing and Rehabilitation Center 4503 S Sugar Rd Edinburg, TX 78539 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some discontinued, or modified by assessing the resident and reaching out the to the physician. LVN J stated the evaluation for modification of medications was conducted depending on when the physician rounds. LVN J stated nurses ensured the narcotic medication counts were correct by pharmacy and pyxis. LVN J stated nurses were not able to administer medications without a verbal or faxed order. LVN J stated if an order was faxed the nurse receiving the order was responsible for inputting the order into PCC. LVN J stated they would call the physician or ask the nurse to follow up on the order if there were questions regarding an order. LVN J stated if the order was not in the eMAR, the nurse could document drug errors and adverse reactions via progress notes from previous days. Interview on [DATE] at 04:00 p.m. with DON revealed she had been employed by the facility for two (2) months. DON stated narcotic counts are done at the beginning and end of every shift. DON stated the admitting nurse or the nurse who obtained the order was the person responsible for entering the orders into PCC. DON stated orders faxed would be sent to pharm script and the facility would not be aware when the order was sent in. DON stated nurses had to routinely check for faxed orders. DON stated narcotics could be documented in PCC under the pain assessment or in a progress notes. DON stated it would be an issue if the nurse was unable to document and unable to assess for pain and follow up on the pain assessment. DON stated nurses using the NARC sheet as the only means of documenting narcotics were using the five (5) rights of medication administration with the exception of documentation. DON stated she was not sure if not documenting medication administration was acceptable and would have to follow up with the response. DON stated floor staff checked medication carts every morning and the ADON performed random checks two to three times per week. DON stated pharmacy checked medication carts only one times per month. Interview on [DATE] at 11:30 a.m. with LVN K revealed he had been employed by the facility for eight (8) years and his responsibilities included taking care of residents in hall 400. LVN K stated he could not recall why he failed to document the narcotic administration in PCC. LVN K stated, maybe PCC was out that day. LVN K stated, I usually do check orders and assess for pain prior to administering pain medications. LVN K stated since he did not have an order for pain medication in PCC he would check for pain medications in the medication cart for Resident #2. LVN K stated he guessed he would have known there was a narcotic pain medication available for Resident #2 because he performed narcotic count before and after his shift. LVN K stated the handwritten prescription order for Tramadol for Resident #2 was not a valid order because there was no way of showing there was an order for that medication on PCC and no way of signing off on it. LVN K stated nurses were not allowed to administer mediations without a valid order as it was against the law. LVN K stated the narcotic drug administration record was a valid way of documenting drug administration, but it had to be corroborated with the eMAR. LVN K stated the facility was able to track drug errors and adverse drug reactions because the facility had an emergency eMAR only used if there was a power outage or if the computer goes down. LVN K stated there was no need to use an emergency MAR on each of the dates listed on the NARC sheet that he knew of. LVN K stated this could potentially cause a negative effect to the resident because we only have the medication but do not know if there is an order and staff were administering a medication without an order. LVN K stated one would have to ask each nurse to make sure the narcotic was in fact administered. Interview on [DATE] at 01:20 p.m. with LVN A revealed she had been employed by the facility for nine (9) years and her responsibilities included floor nurse and was recently promoted to assistant director of nursing one (1) month prior to this date. LVN A stated the facility would monitor medication administration through the eMAR. LVN A stated the facility could monitor if orders were being implemented by checking the eMAR against parameters given. LVN A stated the facility could evaluate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676346 If continuation sheet Page 14 of 16 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 676346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidalgo Nursing and Rehabilitation Center 4503 S Sugar Rd Edinburg, TX 78539 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some whether medications should be initiated, continued, reduced, discontinued, or modified during the review, when they checked the 24-hour report, when they checked the eMAR and when they followed up with the nurses. LVN A stated nurses ensured narcotic counts were correct when the nurses counted the narcotic counts at the beginning and end of their shift. LVN A stated she had was not sure how long the order was in place and what nurse took the order. LVN A stated Tramadol 50 mg was still available to be given to Resident #2 but was not supposed to be given. LVN A stated no nurse questioned the order. LVN A stated nurses must assess for pain prior to giving that pain medication. LVN A stated that if a medication was not listed n the eMAR she would not give the medication without an order. LVN A stated she would obtain an order from the physician. LVN A stated the written prescription for Tramadol 50 mg for Resident #2 was a written order and a prescription, but it needed to be in PCC in order for it to be valid. LVN A stated nurses were not supposed to administer mediations without a valid order. LVN A stated the NARC administration sheet was a legal form and could be used as a means of documenting drug administration. LVN A stated the facility was not able to track drug errors and adverse drug reactions and whoever administered the medications needed to monitor for side effects. LVN A stated the nurse or LVN that was taking care of the resident was the person who was responsible for entering new orders into PCC. LVN A stated she assumed the nurses saw Tramadol 50 mg listed in the narcotic binder for Resident #2, which is how the nurses knew there was a narcotic available to be administered for Resident #2. LVN A stated the nurses are supposed to check the orders on PCC for narcotics. LVN A stated she did not think it would be a negative outcome for Resident #2 because staff did do something for the resident but they didn't do it the right way, nothing happened to the resident, and it did not harm the resident. In an ensuing telephone interview on [DATE] at 01:20 p.m. with the DON stated she was not sure if the narcotic was available to be given to Resident #2 because she was not in the facility. The DON stated the prescription order was a valid order. The DON stated they send the order through pharm script, and it is valid for nurses to use within the facility if it is a narcotic. The DON stated, they need an actual script, they can send an electronic order for narcotics, but you have to have a script. The DON stated that she was not 100% sure what the policy stated regarding that situation, because we have our eMAR electronic that can do our paper trail. The DON stated the nurses continued to document on paper since it was not transcribed onto the order summary. The DON stated, I do not understand how they were continuing to do paper; I do not know why they did not put it on PCC . I do not know what happened. The DON stated, for it (prescription) to go through pharm script, so if they are giving and documenting an error or it was back then, I am not aware. The DON stated, the count was there, the count was accurate, we are not missing any narcotic count, I do not know what issue happened. The DON stated, ADON/RN said it must have been documented on paper, but it is an assumption .I do not know who the nurse was. The DON stated at what point is it ok for paper charting .power outage or if there is an issue with the medication .there has to be a backup. The DON stated she was not sure how long it was acceptable for paper charting to continue, but until the medication was discontinued. The DON stated a physician can be prompted to discontinue a medication when the patient is no longer having pain, the nurse would have to call and verify the order and ask for discontinuation of the medication. The DON stated she assumed all nurses were aware this medication was available to the resident if it was being given. The DON stated she could not tell if there was a glitch in the system, the nurse would have to send the script to the pharmacy. The DON stated, I cannot tell you what happened anything about April, I would not know. Interview on [DATE] at 01:40 p.m., the Interim Adm A revealed he had been an interim administrator for the facility and that [DATE] would be his last day before he was assigned to a different (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676346 If continuation sheet Page 15 of 16 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 676346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidalgo Nursing and Rehabilitation Center 4503 S Sugar Rd Edinburg, TX 78539 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some location. The Interim Adm A stated narcotics were checked in by a nurse and validated by count. Interim Adm A stated a senior nurse/ADON takes them over and inputs the order into PCC to verify the count. The Interim Adm A stated was not sure of the more intricacy part of that, I cannot tell you more details. The Interim Adm A stated the process is it had to be in the order, anything that comes in should be inserted and executed in the eMAR system. The Interim Adm A stated he did not know what happened. The Interim Adm A stated we would have done a drug diversion and verified policy to make sure facility had a process in place. The Interim Adm A stated he did not have a response regarding how the facility monitored medication administrations. The Interim Adm A stated that the facility used cross counts, nurse check offs, and PCC as the facility monitoring systems. Record review of facility policies and practices titled Drug Administration, with no revision or implementation date noted, quoted in part, The facility has established drug administration procedures to ensure 1) drugs being administered are checked against physician's orders; 2) the resident is identified prior to administering the drug; 3) each resident has an individual medication record where doses of drugs administered can be recorded by the person administering the drug; 4) drugs and biologicals are administered by the same person; and 5) drugs prescribed for one resident are not administered to any other resident . Record review of facility policies and practices titled, Controlled Substances with no revision or implementation date noted, quoted in part, The facility will adhere to the Controlled Substance Act. All schedule II drugs are kept secured under a double lock. A separate record will be maintained for each drug covered by Schedule II, III, and IV of the Controlled Substance Act. This record will contain the prescription number, name, and strength of drug, date received by the facility, date and time administered, name of resident, dose, physician's name, signature of person administering dose, ad original amount dispensed with the balance verifiable by drug inventory at every shift change. Schedule V drugs are exempt from this record keeping. Record review of facility policies and practices titled Drug orders with no revision or implementation date noted, quoted in part, All drugs must be prescribed by the resident's physician or consulting physician, dentist, podiatrist, or other individual allowed by law to prescribe. If drugs orders are verbal, they must be taken by a licensed nurse, pharmacist, physician assistant, or a physician, and immediately recorded and signed by the person receiving the order. All drugs will be counter-signed by the prescriber and returned to the chart in a timely manner. Verbal drug orders for Schedule II drugs are permitted in an emergency. Medications will be ordered and reordered on a timely basis so as to ensure residents do not miss doses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676346 If continuation sheet Page 16 of 16