Health inspection·June 8, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm facility reported allegations of abuse for six residents which included Resident #5. The report revealed SNA B had witnessed SNA C and D physically abuse residents, and cited specifically Resident #5, and had not immediately reported the witnessed physical abuse to anyone; Facility-initiated staff interviews; 05/15/2023 at 08:30 PM CNA B reported she has witnessed SNA C and SNA D purposely provoking resident [Resident #5] to get upset specifically SNA C was .poking Resident #5's stomach to cause a reaction from her. Residents Affected - Few A record review of the facility's Provider Investigation Report, dated 05/19/2023, revealed a witness statement, dated 05/07/2023, name of witness CNA B, issue related to SNA C, [translated from Spanish] on my turn to work I could see my co-worker SNA C was molesting a Resident [Resident #5] by picking / poking provoking them to anger them. I also know that SNA C and SNA D have pranked residents for their enjoyment .the statement above is true to the best of my knowledge, signed CNA B. A record review of the facility's Provider Investigation Report, dated 05/19/2023, revealed a witness statement, dated 05/07/2023, name of witness CNA B, issue related to SNA D, [translated from Spanish] I was able to see my co-worker SNA D entered residents [unidentified] rooms and took their perfumes and duly applied the perfumes on herself, I told her That should not be done! she was upset because we pressed her to answer call lights. The statement above is true to the best of my knowledge, signed CNA B. During an interview on 06/07/2023 at 12:15 AM CNA B stated she witnessed student nurse aides SNA C and SNA D mistreated residents in the past, I can't recall dates and times .but it was on the 06:00 PM-06:00 AM shift. CNA B stated on 1 occasion she witnessed SNA C poke Resident #5 in the stomach as if to attempt to provoke a negative reaction from Resident #5. CNA B stated she intervened and rebuked SNA C and set the expectation that the behavior is not acceptable. CNA B stated she did not report the incident to anyone since she believed SNA C was inexperienced and required additional education which she provided. CNA B stated she believed SNA C would improve. During an interview on 06/07/2023 at 05:00 PM the DON stated during an investigation to allegations of abuse allegedly perpetrated by SNA C, CNA B reported she witnessed mistreatment towards residents, by SNA C, in the recent past and had rebuked SNA C but did not report the incident to anyone. The DON stated CNA B reported she had witnessed, date unknown, SNA C poked Resident #5 in the stomach to provoke anger. The DON stated she recognized CNA B should have reported the witnessed mistreatment to residents by SNA C immediately. The DON stated the expectation was to immediately report the incident and the facility would report the incident to the state survey agency within 2 hours of the original report. The DON stated the delayed report of allegations of abuse could have placed residents at risk for abuse. During an interview on 06/08/2023 at 10:00 AM the Administrator stated she immediately suspended SNA C and SNA D and restricted them from the facility, when she received the report from SNA A of witnessed Resident abuse by SNA C and SNA D [05/15/2023]. The Administrator stated she initiated an investigation and revealed CNA B had witnessed SNA C and SNA D physically abused unidentified residents sometime in the recent past. during the investigation CNA B reported she had witnessed prior to the investigation, date unknown, SNA C poked Resident #5 in the stomach to provoke anger. The Administrator stated CNA B was re-educated to recognize the witnessed abuse was an incident that warranted immediate reporting to leadership and included herself the Administrator. The Administrator stated the failed immediate report of Resident abuse from SNA C and D, could have placed other residents at risk for abuse. The Administrator stated the expectation was to immediately report allegations of ANE incidents and the facility would report the incident to the state survey agency within 2 hours of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676419 If continuation sheet Page 2 of 3 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 676419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Hacienda DE Paz Rehabilitation and Care Center 3333 Bob Rogers Dr Eagle Pass, TX 78852 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 original report. Level of Harm - Minimal harm or potential for actual harm A facility policy for Abuse, Neglect, Exploitation Policy was requested on 06/07/2023, and not provided by survey exit. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676419 If continuation sheet Page 3 of 3