Health inspection·July 12, 2023

F 0677 document the showers she completed as that was the responsibility of the CNA of that shift. Level of Harm - Minimal harm or potential for actual harm Interview on 7/12/2023 at 8:44 AM, CNA H stated he operated as a CNA primarily and would assist with showering residents with shower aides on that shift. CNA H stated he would document the showers completed by the shower aids of that shift but if he did not do them himself he would not complete the questions within the ADL task sheet and would instead mark Not Applicable. CNA H stated he understood the showers to have been completed by the shower aides, but it was their nursing protocol to document only from the shift CNA. Residents Affected - Some Interview on 7/12/2023 at 9:14 AM, the DON stated showers should be documented in the electronic health record. The DON stated the individual shower aides and CNAs all had access to the ADL task sheet and could complete the questions themselves to affirm the ADL care was provided and should be completing them for the showers that they completed. The DON stated the shower documentation did not reflect that the showers were completed for Resident #52 due to the discrepancy in the Not Applicable answer choices selected on the ADL shower sheet. The DON stated the risk associated with the CNAs completing the ADL task in the EHR would be that documentation could potentially be recorded incorrectly and result in insufficient care provided to residents. Record review of the policy entitled Resident Showers, copyrighted 2022, revealed the facility's policy was to . Assist residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues . Under the section entitled Policy Explanation and Compliance Guidelines: 1.) . provided showers as per request, or as per facility schedule protocols, and based upon resident safety. 11.) Assist the resident was showering as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676419 If continuation sheet Page 2 of 15 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 07/12/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm 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 observations, interviews, and record reviews, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for 1 of 3 Residents (Resident #49) reviewed for accidents and hazards, in that: The facility failed to ensure Resident #49 did not keep cigarettes in her room. This deficient practice could place residents at risk of harm or injury and contribute to avoidable accidents. The findings included: Record review of Resident #49's face sheet, dated 7/9/23 revealed a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia unspecified severity, mood disturbance, difficulty in walking, lack of coordination, respiratory failure with hypoxia (means that you don't have enough oxygen in your blood, but your levels of carbon dioxide are close to normal), chronic obstructive pulmonary disease (diseases that cause airflow blockage and breathing-related problems) and nicotine dependence with withdrawal. Record review of Resident #49's most recent quarterly MDS assessment, dated 5/23/23 revealed the resident was moderately cognitively impaired for daily decision-making skills and received oxygen therapy. Record review of Resident #49's comprehensive care plan, dated 6/7/23 revealed the resident smoked and was at risk for complications with interventions that included, no smoking materials or igniters will be stored in the resident rooms. Record review of Resident #49's Smoking Assessment, dated 7/5/23 revealed all smoking materials will be kept at the nurse's station. Record review of the Social Worker's progress note, dated 10/25/21 revealed, Resident #49 was noted smoking in the facility restroom and having cigarettes and lighter in her possession. Observation and interview on 7/9/23 at 2:22 p.m. revealed Resident #49 sitting up in bed eating lunch with the oxygen concentrator operating via a nasal canula. Resident #49 revealed smoking was allowed several times throughout the day with staff supervision and she had last gone out to smoke at 1:00 p.m. Resident #49 revealed smoking was allowed only in a designated area and with staff supervision. Resident #49 revealed facility staff kept the cigarettes and lighters in the nurse's station. A pack of cigarettes was observed on the seat of the resident's wheelchair and Resident #49 revealed the pack of cigarettes on the seat of the wheelchair belonged to her, but the pack was empty because I don't want them to throw away the boxes, so I save the empty ones. Upon further inspection, and with the resident's permission, the pack of cigarettes was opened and there were at least 6 unused cigarettes in the pack. Resident #49 revealed she may have mistakenly given the staff an empty pack of cigarettes and kept the pack with the cigarettes. Resident #49 revealed the next smoke break was at 3:00 p.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676419 If continuation sheet Page 3 of 15 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 07/12/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation and interview on 7/9/23 at 3:00 p.m., Housekeeping Staff A entered Resident #49's room to take the resident on smoke break. Housekeeping Staff A revealed, Housekeeping Staff B had last taken the residents out for smoke break at 1:00 p.m. and Housekeeping Staff A had asked Housekeeping Staff B about Resident #49's cigarettes. Housekeeping Staff A revealed Housekeeping Staff B told her she had asked Resident #49 for the cigarette pack, but the resident didn't give it back to her. Housekeeping Staff A revealed she did not ask why Housekeeping Staff B didn't get the cigarettes back. Housekeeping Staff A revealed, Resident #49 was not supposed to have the cigarettes in her room. During an interview on 7/10/23 at 9:38 a.m., Housekeeping Staff B revealed it was the housekeeping staff's responsibility to accompany those residents who smoked and had to ensure the cigarettes and lighters were kept locked in a box at the nurse's station. Housekeeping Staff B revealed she had taken Resident #49 out for a smoke break on 7/9/23 at 1:00 p.m. and revealed there was a problem with Resident #49 keeping the cigarette packs. Housekeeping Staff B revealed, Resident #49 had the box of cigarettes that I gave her, and she had 2 boxes of her own that the resident said were empty but she won't let me see if the boxes have cigarettes. Housekeeping Staff B revealed, Resident #49 did not want to give her the pack of cigarettes back after she had smoked. Housekeeping Staff B revealed she did not tell anyone about it. Housekeeping Staff B revealed Resident #49 was not supposed to have cigarettes in her room because if she were to smoke in the room, she could burn herself or start a fire. During an interview on 7/11/23 at 1:54 p.m., the DON and the Administrator revealed, the housekeepers pick up the smoking supplies from the nurse's station. The DON revealed, the nurses were only concerned with ensuring the residents are getting a smoke break, but the housekeepers keep track of the smoking materials and should be reporting to the nurses. The DON further revealed, the person taking the resident out to smoke is responsible for ensuring the smoking supplies are retrieved and locked in the box and placed in a drawer in the nurse's station. The Administrator revealed, Resident #49 is not a safe smoker as evidenced by the recent smoking assessment done by the Social Worker. The Administrator further revealed, if Resident #49 were to smoke in the facility without being supervised she could burn or hurt herself or start a fire and hurt others. Record review of the facility policy and procedure titled Smoking Policy, revision date 11/1/17 revealed in part, .Smoking policies must be formulated and adopted by the facility .The facility is responsible for enforcement of smoking policies which must include at least the following provisions .Matches, lighters, or other ignition sources for smoking are not permitted to be kept or stored in a resident's room . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676419 If continuation sheet Page 4 of 15 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 07/12/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 6 Residents (Resident #49) reviewed for medication administration in that: Resident #49 was observed with a medication cup identified as cough syrup at the bedside. This deficient practice could affect residents who received medication and place them at risk of not receiving the appropriate amount of medication and could results in an adverse reaction or a decline in health. The findings included: Record review of Resident #49's face sheet, dated 7/9/23 revealed a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia unspecified severity, mood disturbance, difficulty in walking, lack of coordination, respiratory failure with hypoxia (means that you don't have enough oxygen in your blood, but your levels of carbon dioxide are close to normal), chronic obstructive pulmonary disease (COPD; diseases that cause airflow blockage and breathing-related problems) and nicotine dependence with withdrawal. Record review of Resident #49's most recent quarterly MDS assessment, dated 5/23/23 revealed the resident was moderately cognitively impaired for daily decision-making skills. Record review of Resident #49's comprehensive care plan, dated 6/7/23 revealed the resident received oxygen therapy related to COPD and was at risk for complications with interventions that included to give medications as ordered by physician and the resident was also non-compliant with medication administration and was at risk for complications. Record review of Resident #49's Order Summary Report, dated 7/9/23 revealed the following: -Robitussin 12 Hour Cough Suspension Extended Release 30 mg/5 ml, give 10 ml by mouth as needed for cough/congestion every 12 hours, with order date 1/22/23 and no end date Record review of Resident #49's Medication Administration Record for July 2023 revealed there was no documentation for medication administration of Robitussin 12 Hour Cough Suspension Extended Release. Observation and interview on 7/9/23 at 2:22 p.m. revealed Resident #49 sitting up in bed eating lunch with the oxygen concentrator operating via a nasal canula. Resident #49 was observed with two medication cups on the nightstand to the left of the resident's bed. One medication cup had a small oblong yellow item and the other medication cup had approximately 5 ml of a red liquid. Resident #49 revealed the one medication cup had a piece of pineapple and the second medication cup with the red liquid the resident identified as her cough medication. Resident #49 revealed an unidentified female nurse had provided her with the cough syrup at approximately 1:00 p.m. but the resident did not take the medication because she wanted to go smoke instead. Resident #49 revealed she planned on taking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676419 If continuation sheet Page 5 of 15 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 07/12/2023 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 0755 the cough syrup later. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 7/9/23 at 3:25 p.m., LVN C identified the red liquid in the medication cup in Resident #49's nightstand was cough syrup that the resident requested. LVN C revealed Resident #49 was not supposed to have medications left at the bedside because there were residents in the facility who wandered and could have taken the medication by mistake. Residents Affected - Few During a follow up interview on 7/9/23 at 3:43 p.m., LVN C revealed she was certain the medication cup with the red liquid observed in Resident #49's nightstand as cough syrup because it was the only cough syrup prescribed to the resident. LVN C revealed Resident #49's Medication Administration Record did not reflect the cough syrup was signed out and identified LVN D as the nurse administering medications in the morning to Resident #49. LVN C revealed, if the cough syrup was given sooner than the prescribed 12 hours the resident could have received a double dose causing a stronger effect or an adverse effect. During an interview on 7/10/23 at 11:17 a.m., LVN D revealed she had only given Resident #49 two scheduled medications on 7/9/23 but did not give the resident the Robitussin 12 Hour Cough Suspension Extended Release. LVN D stated, only me and LVN C were the only two people giving out medications on Resident #49's hall, I have no idea who put the cough syrup in the Resident #49's room. LVN D revealed, Resident #49 was alert and oriented and was aware of what medications she was being given. During an interview on 7/10/23 at 1:54 p.m., the DON revealed, medications should not be left at the bedside because there was the potential for other residents to consume the medication. Record review of the facility policy and procedure titled, Medication Administration Procedures, Pharmacy Policy and Procedure Manual 2003, revealed in part, .1. All medications are administered by licensed medical or nursing personnel .The 10 rights of medication should always be adhered to .Right medication .Right dose .Right to refuse .Any deviation from specified and recommended procedures in dispensing or administering medications to the resident .shall be in concurrence with current statutes and regulations . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676419 If continuation sheet Page 6 of 15 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 07/12/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 7.14%, based on 2 errors out of 28 opportunities, which involved 2 of 7 residents (Resident #44 and #29) reviewed for medication administration in that: Residents Affected - Some 1. RN E failed to administer Resident #44's Furosemide (a diuretic used to treat swelling caused by fluid retention) as ordered. 2. RN F administered Resident #29's Nifedipine (used to treat high blood pressure) extended-release medication in crushed form instead of whole. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. The findings included: 1. Record review of Resident #44's face sheet, dated 7/11/13 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included edema (swelling), hyperlipidemia (high cholesterol), hypertension (high blood pressure), morbid (severe) obesity, atrial fibrillation (an irregular and often very rapid heart rhythm [arrhythmia] that can lead to blood clots in the heart) and presence of aortocoronary bypass graft (surgery in which a healthy blood vessel taken from another part of the body is used to make a new path for blood around a blocked artery leading to the heart). Record review of Resident #44's comprehensive care plan, revision date 7/10/23 revealed the resident was on diuretic therapy related to edema with interventions that included to administer medications as ordered. Record review of Resident #44's Order Summary Report dated 7/11/23 revealed the following: -Furosemide 40 mg, give 1 tablet by mouth one time a day for edema with order date 7/5/23 and no end date Observation on 7/11/23 at 7:45 a.m., during the medication pass, RN E dispensed 3 tablets of Furosemide to equal 60 mg to Resident #44 as indicated on the medication blister package. During an observation and interview on 7/11/23 at 10:49 a.m., RN E removed the blister pack of the Furosemide medication prescribed to Resident #44 from the medication cart for review and revealed she had dispensed 3 tablets of Furosemide to equal 60 mg to Resident #44 but discovered an additional blister pack of Furosemide medication prescribed to Resident #44 with the prescription label that indicated 40 mg tablets. RN E revealed she had given the wrong dose to Resident #44 resulting in a medication error because the resident should have been given 40 mg of Furosemide instead of 60 mg. RN E revealed, if Resident #44 did not receive the correct dosage of Furosemide as prescribed the resident would be dosed incorrectly and not getting the therapeutic benefit of the medication. 2. Record review of Resident #29's face sheet, dated 7/11/23 revealed an [AGE] year-old male (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676419 If continuation sheet Page 7 of 15 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 07/12/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some admitted to the facility on [DATE] and re-admitted on [DATE] and 6/28/23 with diagnoses that included heart failure, type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), hyperlipidemia (high cholesterol) and hypertension (high blood pressure). Record review of Resident #29's comprehensive care plan, dated 6/8/23 revealed the resident had hypertension and was at risk for complications with interventions that included to give anti-hypertensive medications as ordered. Record review of Resident #29's Order Summary Report dated 7/11/23 revealed the following: -Nifedipine XL Oral Tablet Extended Release 24 Hour 60 mg, give 1 tablet by mouth two times a day related to hypertension. Do not crush, with order date 7/10/23 and no end date. Observation on 7/11/23 at 6:25 p.m., during the medication pass, revealed RN F crushed 5 of Resident #29's medications including the Nifedipine XL Oral Tablet Extended Release 24 Hour 60 mg, mixed them in apple sauce and administered the medications to the resident. During an observation and interview on 7/11/23 at 6:41 p.m., RN F revealed Resident #29 received his medications crushed with thickened liquid because the resident was at risk of choking. RN F observed the pharmacy label on the medication blister pack and confirmed the label indicated the Nifedipine XL Oral Tablet Extended Release 24 Hour 60 mg indicated Do Not Crush Or Chew on the label. RN F revealed she was not sure how that would affect Resident #29 and would have to notify the physician to find out. During a follow up interview on 7/11/23 at 6:53 p.m., RN F revealed she had notified the physician regarding Resident #29's Nifedipine medication and revealed the physician did not want to change the order or the medication at this time and would review at the next appointment. RN F revealed she had notified the pharmacist and was told the Nifedipine XL Oral Tablet Extended Release 24 Hour should not have been crushed because the medication was designed to distribute slowly and if crushed would lose its effectiveness. RN F revealed, crushing the medication when it was not supposed to be crushed resulted in a medication error. During a telephone interview on 7/11/23 at 7:05 p.m., the Pharmacist revealed, Resident #29's Nifedipine XL Oral Tablet Extended Release 24 Hour was not supposed to be crushed because the medication in extended-release form was designed to distribute over a period of time and if crushed it would destroy that mechanism resulting in the dose given all at once. The Pharmacist revealed facility staff would have to be monitoring blood pressure readings for Resident #29 to determine if there were any negative effect. During an interview on 7/12/23 at 7:53 a.m., the DON revealed only that Resident #29's Nifedipine XL Oral Tablet Extended Release 24 Hour would be changed to a different medication by the physician. The DON revealed the facility had completed a medication error report. Record review of the facility policy and procedure titled, Medication Administration Procedures, Pharmacy Policy and Procedure Manual 2003, revealed in part, .The 10 rights of medication should always be adhered to .Right medication .Right dose .Any deviation from specified and recommended procedures in dispensing or administering medications to the resident requires documented approval .and shall be in concurrence with current statutes and regulations . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676419 If continuation sheet Page 8 of 15 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 07/12/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. The facility failed to maintain the cleanliness of the ice maker found within the kitchen 2. The facility failed to label and date food containers found within the kitchen. 3. The facility failed to complete daily temperature logs of reach-in refrigerators and freezers found within the kitchen and nourishment room. 4. The facility failed to ensure the walk-in freezer and nourishment room freezer maintained a temperature below 0 degrees Fahrenheit. These failures could place residents at risk for cross-contamination and foodborne illnesses. The findings included: Observation on 7/9/23 at 11:10 AM revealed a black substance build-up within the ice maker in the kitchen. Upon further inspection revealed a reach-in fridge with the corresponding temperature log completed through 7/6/23 containing three plastic containers of food without labels or dates. Inspection of the walk-in freezer revealed the temperature log completed through 7/6/23 and an internal freezer temperature of 20 degrees Fahrenheit. Displayed on the digital thermometer to the freezer read an error code of APn6. Interview on 7/9/2022 at 11:11 AM, the DM stated the kitchen staff was responsible for emptying and cleaning out the ice maker every 3 months by draining and emptying the ice maker and cleaning it from the inside. She stated the MS had just cleaned the ice maker within the last few weeks. The DM stated she did not notice the black substance build-up and could not identify what it was. The DM stated the ice maker should be cleaned and would contact his MS to have it partially disassembled to remove the black substance build up as the substance could cause foodborne illness in residents who consume ice from the ice maker. The DM stated the staff who enter the kitchen in the morning are responsible for completing the temperature logs for all fridges and freezers, in addition to reporting to herself and the MS if the fridges or freezers are reaching high temperatures. The DM stated the cook who assembled the food was responsible for storing the food and placing the content/date sticker on the food for recording. The DM stated the risks associated with these failures was a potential for foodborne illness in residents. Observation on 7/11/23 at 4:42 PM, of the nourishment room refrigerator/freezer combination unit revealed to contain a temperature log for the refrigerator but not the freezer portion of the unit. Additionally, the internal temperature was revealed to be 8 degrees Fahrenheit. Interview on 7/12/23 at 9:14 AM, the DON stated it was her expectation that food prepared in the kitchen be dated and labeled, that the ice provided to residents be from a clean ice maker, that the freezer be at a freezing temperature, and all fridges and freezers intended for resident use be continuously documented in their respective temperatures. The DON stated these aforementioned concerns (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676419 If continuation sheet Page 9 of 15 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 07/12/2023 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 0812 have a direct correlation to resident health and safety in that they could cause foodborne illness. Level of Harm - Minimal harm or potential for actual harm Record review of the facility nutritional policy titled Refrigerator/Freezer Temperature log, undated, reflected Person assigned or DSM must record temperature for each refrigerator and freezer and sign in column provided . take temperatures at same time every morning (AM) and evening (PM). The morning reaching should preferably be taken upon opening the department. Residents Affected - Many Record review of the facility nutritional policy titled Cleaning of the Ice Machine, undated, reflected The ice machine shall be cleaned and sanitized according to manufacturer's instructions to maintain sanitary conditions in order to prevent food contamination and the growth of disease producing organisms and toxins. Record review of the facility nutritional policy titled Food Storage and Supplies, undated, reflected All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry, and protected from vermin and insects . Record review of US FDA Food Code, dated 2022, revealed Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as . ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. Some equipment manufacturers and industry associations, e.g., within the tea industry, develop guidelines for regular cleaning and sanitizing of equipment . and 3-304.11 Food Contact with Equipment and Utensils. FOOD shall only contact surfaces of: (A) EQUIPMENT and UTENSILS that are cleaned as specified under Part 4-6 of this Code and SANITIZED as specified under Part 4-7 of this Code; P (B) Single-service and single-use articles. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676419 If continuation sheet Page 10 of 15 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 07/12/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 8 residents (Resident #18, #44, #70 and #36) reviewed for infection control practices, in that: Residents Affected - Some During the medication pass, RN E failed to: - perform hand hygiene between residents - did not wear gloves when administering medications via a peg tube, when cleaning a resident's eye lids with prescribed eye scrub, when obtaining an accu check (a test used to obtain a rapid assessment of blood glucose concentration results) or when injecting insulin - did not sanitize the wrist blood pressure cuff between residents, did not sanitize the glucometer prior or after use, did not clean the syringe after it was used to check for residual (stomach contents) and after administering medications via a feeding tube - touched and administered a medication with her ungloved hand These failures could place residents at risk for infection, transmission for communicable diseases and or a decline in health. The findings included: 1. Record review of Resident #18's face sheet, dated 7/11/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included protein calorie malnutrition, quadriplegia (paralysis that affects all a person's limbs and body from the neck down), dysphagia (difficulty swallowing) and adult failure to thrive. Record review of Resident #18's most recent annual MDS assessment, dated 6/23/23 revealed the resident was moderately cognitively impaired for daily decision-making skills and required a feeding tube. Record review of Resident #18's comprehensive care plan, dated 7/10/23 revealed the resident had a potential risk for malnutrition due to dependent on staff for tube feedings with interventions that included to administer enteral feedings as ordered. Record review of Resident #18's Order Summary Report, dated 7/11/23 revealed the following: -Enteral Feed Order every shift check tube residual before medications and feeding administration. If more than 100 cc, hold feeding/meds, return stomach contents, and notify MD, with order date 9/14/21 and no end date 2. Record review of Resident #44's face sheet, dated 7/11/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included edema, hyperlipidemia (high cholesterol), hypertension (high blood pressure), aftercare following joint replacement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676419 If continuation sheet Page 11 of 15 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 07/12/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm surgery and type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy). Record review of Resident #44's most recent quarterly MDS assessment, dated 5/12/23 revealed the resident was cognitively intact for daily decision-making skills. Residents Affected - Some Record review of Resident #44's comprehensive care plan, dated 7/10/23 revealed the resident had hypertension and was at risk for complications with interventions that included to give anti-hypertensive medications as ordered and to obtain blood pressure readings. Resident #44 also had diabetes and was at risk for complications with interventions that included to monitor/document/report to the physician signs and symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) Record review of Resident #44's Order Summary Report, dated 7/11/23 revealed the following: - Novolog Solution 100 unit/ml, inject as per sliding scale subcutaneously two times a day related to type 2 diabetes. Notify physician if blood sugar is less than 60 mg/dl or more than 300 mg/dl, with order date 8/29/22 and no end date -Multivitamin Adult Minerals tablet, give 1 tablet by mouth one time a day related to unspecified protein-calorie malnutrition, with order date 1/21/22 and no end date 3. Record review of Resident #70's face sheet, dated 7/11/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia, gastrostomy status (feeding tube, a surgical opening into the stomach from the abdominal wall), hypertension (high blood pressure) and heart disease. Record review of Resident #70's most recent significant change MDS assessment, dated 4/26/23 revealed the resident was severely cognitively impaired for daily decision-making skills and required a feeding tube. Record review of Resident #70's comprehensive care plan, dated 6/7/23 revealed the resident had potential for fluid deficit and was dependent on staff for tube feedings and flushes with interventions that included to administer medications as ordered and the resident had coronary artery disease and was at risk for complications of cardiac problems with interventions that included to monitor blood pressure. Record review of Resident #70's Order Summary Report, dated 7/11/23 revealed the following: - Enteral Feed Order every shift check g-tube residual before medications and feeding administration. Hold meds/feed if residual more than 100 cc. Return stomach contents and notify MD, with order date 4/21/23 and no end date - Losartan Potassium Oral Tablet 25 mg, give 1 tablet via PEG-Tube one time a day related to hypertension, hold if systolic blood pressure is less than 100 mm hg, with order date 6/4/23 and no end date 4. Record review of Resident #36's face sheet, dated 7/11/23 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676419 If continuation sheet Page 12 of 15 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 07/12/2023 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 0880 hypertension (high blood pressure), hyperlipidemia (high cholesterol) and cognitive communication deficit. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #36's most recent quarterly MDS assessment, dated 3/24/23 revealed the resident was severely cognitively impaired for daily decision-making skills and received insulin injections. Residents Affected - Some Record review of Resident #36's comprehensive care plan, dated 6/7/23 revealed the resident had impaired visual function with interventions that included to administer Occusoft lid scrubs as ordered, had hypertension with interventions that included to obtain blood pressure readings and the resident had diabetes with interventions that included to monitor/document/report to the physician signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar). Record review of Resident #36's Order Summary Report, dated 7/11/23 revealed the following: - Occusoft Lidscrubs to both eyes one time a day with order date 2/23/22 and no end date - Novolog Injection Solution 100 unit/ml, inject as per sliding scale subcutaneously three times a day related to type 2 diabetes with foot ulcer with order date 6/19/23 and no end date. Observation on 7/11/23 at 7:36 a.m., during the medication pass, revealed RN E went into Resident #18's room after crushing the medications, took a large syringe, inserted it into the feeding tube port and pulled back on the plunger to check for residual. RN E then removed the plunger and administered medications to Resident #18 with the same syringe inserted into the resident's feeding tube and did not wear gloves. RN E then removed the syringe from Resident #18's feeding tube and placed it in a plastic sleeve without rinsing it. RN E then returned to the medication cart, took a wrist blood pressure cuff, and obtained Resident #44's blood pressure. RN E then replaced the wrist blood pressure cuff back in the medication cart without sanitizing it. RN E did not perform hand hygiene and pulled Resident #44's medications from the medication cart and placed them in a medication cup. RN E, after dispensing 6 medications into the medication cup for Resident #44, took the 7th pill identified as a Multivitamin Adult Minerals tablet, placed it on her ungloved hand and placed the pill in the medication cup with the other 6 medications. RN E then returned to Resident #44's bedside to obtain an accu check, did not sanitize the glucometer prior to use, did not perform hand hygiene and did not wear gloves when she obtained the accu check. RN E then returned to the medication cart to document medication administration. RN E then took the same wrist blood pressure cuff from the medication cart and obtained Resident #70's blood pressure. RN E did not perform hand hygiene and did not sanitize the wrist blood pressure cuff prior to obtaining a blood pressure on Resident #70. RN E then returned to the medication cart, pulled Resident #70's medications for administration via a feeding tube. RN E then returned to Resident #70's bedside, did not perform hand hygiene, took a large syringe, and inserted into the resident's feeding tube and did not wear gloves. RN E then pulled back on the plunger to check for residual, removed the plunger and administered Resident #70's medications into the feeding tube without using gloves. RN E then removed the syringe from Resident #70's feeding tube and placed the syringe in a plastic sleeve without rinsing the syringe. RN E then returned to the medication cart and obtained the glucometer and the wrist blood pressure cuff. RN E then went into Resident #36's room, did not perform hand hygiene, did not wear gloves, and took Resident #36's Occusoft Lidscrubs from the package and cleansed the resident's eye lids. RN E then took the glucometer, did not sanitize it prior to use, did not perform hand hygiene and did not wear gloves when she obtained Resident #36's accu check. RN E then took the wrist blood pressure cuff, did not sanitize it prior to use and obtained Resident #36's blood pressure. RN E then returned to the medication cart, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676419 If continuation sheet Page 13 of 15 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 07/12/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some documented the accu check results and the blood pressure results for Resident #36 and then retrieved the resident's Novolog insulin solution. RN E then dispensed 4 units of the insulin, did not perform hand hygiene or wear gloves, and administered the insulin to Resident #36. During an interview on 7/11/23 at 10:49 a.m., RN E revealed she had failed to perform hand hygiene between resident care to Resident #18, #44, #70 and #36. RN E further revealed she had not been using gloves when obtaining the accu check, when administering an insulin injection, during administration of medications via a feeding tube or when cleansing Resident #36's eye lids. RN E revealed she also had not been sanitizing the wrist blood pressure cuff or the glucometer between resident use. RN E revealed she was not sure about having to wash the syringe after medication administration via a feeding tube. RN E revealed these failures were considered an infection control issue and cross contamination and could results in the residents or herself getting sick. RN E revealed she had worked for the facility for the past 3 months and was assigned a very heavy hall and had an emergency earlier in the morning and it was too much, one thing after another. During an interview on 7/12/23 at 7:53 a.m., the DON revealed she was uncertain about having to rinse the syringe after it was used to check for residual and when administering medications via a feeding tube. The DON revealed it was best nursing practice to rinse the syringe after using it for administration of feeding tube medications because the residual from the medications and from gastric juices could be left in the syringe causing bacteria to grow and possibly causing an infection that would make the residents sick. The DON revealed all shared medical equipment, such as blood pressure cuffs and glucometers had to be sanitized before and after use to prevent cross contamination. The DON revealed, not performing hand hygiene between patient care or not using gloves during procedures such as medication administration via a feeding tube, insulin injections, accu checks or scrubbing eye lids was an infection control issue and risk for cross contamination. The DON revealed RN E should have thrown away the medication she touched without wearing gloves as it was also cross contamination. Record review of the competency document titled Enteral Medication Administration for RN E, dated 4/13/23 revealed she had satisfied the requirements for administering medications via a feeding tube. Record review of the Nurse Proficiency Audit for RN E dated 4/10/23 revealed she had satisfied the requirements for subcutaneous injections, enteral feedings, glucometer use, proper hand washing technique, preventing cross contamination and universal precautions. Record review of the facility policy and procedure titled, Gastrostomy Tube Care, revision date 2/13/07 revealed in part, .3. Wash hands. Apply gloves .8. Remove supplies, wash, rinse, dry and cover on a tray .Change out supplies weekly . Record review of the facility policy and procedure titled, Enteral Medications Administration, revision date 1/25/13 revealed in part, .Wash hands and put on a clean pair of disposable gloves .12. Change the medication syringe as directed by the manufacturer's label. If the syringe is used for 24 hours, clean after each use .Remove gloves and wash hands . Record review of the facility policy and procedure titled, Glucometer, revision date 2/13/07 revealed in part, .3. Gloves must be worn at all times during specimen collection .1. Clean and inspect meter exterior with each use .2. Meter will be cleaned with a germicidal and allowed to air dry between patient testings . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676419 If continuation sheet Page 14 of 15 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 07/12/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the facility policy and procedure titled, Blood Pressure, Brachial, dated 2003 revealed in part, .3. Perform handwashing . Record review of the facility policy and procedure titled, Fundamentals of Infection Control Precautions, updated 3/2023 revealed in part, .A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility .1. Hand Hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene .Before and after performing any invasive procedure (e.g., fingerstick blood sampling) .Upon and after coming in contact with a resident's intact skin (e.g., when taking a pulse or blood pressure .) Event ID: Facility ID: 676419 If continuation sheet Page 15 of 15