Inspection·May 20, 2022

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shift flush feeding tube with 30 ml water before and after medication administration. Resident #32's orders did not include directions for water flushes between medications. Observation of medication pass on 05/18/22 at 9:22 AM revealed LVN A gathered Resident #32's scheduled medications, a total of seven, that consisted of: Ascorbic Acid 500mg one tablet, Carbidopa-Levodopa 25mg one tablet, Carvedilol 25mg one tablet, Docusate Sodium 100mg one tablet, Gabapentin 100mg one capsule, Hydralazine 50mg one tablet, and Zinc one tablet. LVN A crushed each tablet separately to a powdered form, opened up the Gabapentin capsule, placed each medication in a separate medication cup, and added 5ml of water to each medication. After LVN A checked Resident #32's tube placement, she flushed the g-tube with 30 ml of water then administered each medication, one by one. LVN A administered the Docusate sodium, followed by the Carbidopa- Levodopa without flushing the gastric tube with water after administering each medication. In an interview with LVN A on 05/18/22 at 10:15 AM, she said she did not separately flush Resident #32's gastric tube between each medication administration because she added the 5ml of flushed water into each medication cup. LVN A said she did not want to add too much water. In an interview with LVN A on 05/18/22 at 2:42 PM, she said the medications could get stuck if they were not flushed after each medication In an interview with the DON on 05/18/22 at 3:28 PM, she said the medications were to be dissolved/diluted in 5-10ml of water, prior to administering each medication. The DON said each medication should be flushed with 10ml of water, after each medication was given. The DON said the medications could get stuck in the gastric tube, if they were not flushed. The DON said each nurse was trained upon hire, and annually, regarding administering medications via peg tube. The DON said nurses were taught to flush after each medication, and there was also a book kept at the nurses station for reference, in case needed. Record review of RN/LVN Orientation Skills Checklist for LVN A, revealed she was checked off on Medication Administration, including enteral meds on 01/28/22. Record review of the facility's Medication Administration, Enteral Tube Medication Administration, dated and revised on 10/01/19 revealed: Pour dissolved/dilute medication in syringe and unclamp tubing, allowing medication to flow by gravity. Flush with 5-10ml warm water between each medication. If administering more than one medication, flush with 5ml of water, or prescribed amount, between each medication, or per physician's orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676495 If continuation sheet Page 2 of 9 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 676495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Starr County Nursing and Transitional Care 5260 Brand St Rio Grande City, TX 78582 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 residents who need respiratory care are provided and consistent with professional standards of practice and the resident's care plan for 1 (Resident #21) of 1 resident reviewed for oxygen use, in that, Residents Affected - Few Resident #21 received oxygen at 3 Liters Per Minute via nasal canula instead of 2 LPM as per physician's order. This deficient practice could place residents receiving respiratory care and services at risk of respiratory complications. The findings included: Record review of Resident #21's admission Record dated 05/18/22 revealed Resident #21 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Osteomyelitis (infection of a bone), Sepsis (a life-threatening complication of an infection), Peripheral Vascular Disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), Unspecified Dementia (memory loss), and Essential (Primary) Hypertension (high blood pressure). Record review of Resident #21's Significant Change in Status MDS Assessment, dated 04/11/22, revealed: -had no speech; -was rarely/never able to make herself understood by others; -was rarely/never able to understand others; -had severely impaired cognitive skills for Daily Decision Making; -required extensive assistance of two persons for activities of daily living and; -was on oxygen therapy. Record review of Resident #21's care plan, dated 05/02/22, revealed: Resident #21 has oxygen therapy. The interventions reflected: Change resident's position every 2 hours to facilitate lung secretion movement and drainage. Oxygen settings: Oxygen at 2 LPM via nasal cannula every shift for hypoxia date initiated 05/02/22. Record review of Resident #21's Physician's Orders for May 2022 revealed: Oxygen at 2LPM via Nasal Cannula every shift for hypoxia (low oxygen in the tissues).; start date was on 04/05/22. Observation on 05/17/22 at 10:11 a.m. revealed Resident #21 was lying in bed with the head of bed raised at 30 degrees, coughing. Resident #21 was receiving oxygen via nasal cannula connected to an oxygen concentrator set at 3 LPM. On 05/17/22 at approximately 11:19 a.m. LVN A and the surveyor went into Resident #21's room and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676495 If continuation sheet Page 3 of 9 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 676495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Starr County Nursing and Transitional Care 5260 Brand St Rio Grande City, TX 78582 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few LVN A observed and acknowledged Resident #21's oxygen was set at 3 LPM. LVN A said she was not sure what the oxygen setting was supposed to be on but would check the physician's orders on her computer. On 05/17/22 at 11:21 a.m. LVN A said she had checked the orders in the computer and the physician's orders reflected 2 LPM for Resident #21's oxygen. LVN A said she checked the setting in the morning, and it was at 2 LPM. LVN A said she was responsible for checking the oxygen concentrator settings. LVN A said she did not know why the setting was at 3 LPM. In an interview on 05/17/22 at 3:27 p.m. the DON said the nurses had to check the oxygen concentrators every shift for placement setting. The DON said it was important to have the right O2 setting to maintain their oxygen saturation. The DON said she did not know the orders for Resident #21, but she would check the physician's orders. The DON said she checked the orders in the computer and the orders were for 2 LPM, but the resident was on hospice. Hospice residents' O2 saturation fluctuates at times and need the oxygen set at 3, 4, or 5 sometimes. The DON said she would call the doctor and see if he would change the orders. In an interview on 05/17/22 at 4:00 PM the DON said she called the doctor, and he did not want to change the orders. The DON said the doctor said they could move the O2 up or down as necessary, but to leave the order for O2 at 2 LPM. The DON said she would make an addendum to say if a resident's oxygen saturation rates were below 90 to start at 2 LPM and if resident was still de-sating to increase the setting up to 5 LPM. Record review of Resident #21's revised Physician's Orders dated 05/18/22 revealed: Oxygen at 2LPM via Nasal Cannula every shift for hypoxia. IF O2 SAT ,90% START O2 AT 2LPM VIA NC AND IF PT CONTINUES DESATING (oxygen levels dropping) MAY INCREASE UP TO 5LPM VIA NC. Observation on 05/18/22 at 10:18 a.m. revealed Resident #21 was in bed, on her back, with her feet off-loaded. The oxygen concentrator was set at 2 LPM. In an interview on 05/18/22 at 4:00 p.m. the DON said the facility did not have a policy on oxygen administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676495 If continuation sheet Page 4 of 9 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 676495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Starr County Nursing and Transitional Care 5260 Brand St Rio Grande City, TX 78582 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 its medication error rate was not five percent, or greater The facility had a medication error rate of 8%, based on 2 errors out of 25 opportunities, which involved one resident (Resident #32) of three residents observed during medication administration. Residents Affected - Few LVN A administered two of seven of Resident #32's medications via feeding tube (gastrostomy:g-tube) without flushing the feeding tube between medications, contradicting the facility's policy and procedure. This failure could place residents with feeding tubes at risk for feeding drug interactions, tube clogging, and malfunction. The findings were: Record review of Resident #32's admission Record dated 05/20/221 reflected a [AGE] year-old male admitted [DATE] with the following diagnosis: Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement), gastrostomy status (surgical opening in the stomach), and type 2 diabetes mellitus (a condition results from insufficient production of insulin, causing high blood sugar) with diabetic nephropathy (kidney disease). Record review of Resident #32's care plan, revealed: Date initiated: 04/22/22, and revised on 04/23/22, Resident #32 requires tube feeding, Interventions included: every shift flush feeding tube with 30ml of water before and after medication administration. Care plan did not include directions for water flushes between medications. Record review of Resident #32's admission Medicare 5 day, dated 04/27/22, revealed: -had unclear speech -was rarely/never understood -rarely/never understands Record review of Resident #32's May 2022 Order Summary Report reflected, Enteral Feed Order- every shift flush feeding tube with 30 ml water before and after medication administration. Resident #32's orders did not include directions for water flushes between medications. Observation of medication pass on 05/18/22 at 9:22 AM revealed LVN A gathered Resident #32's scheduled medications, a total of seven, that consisted of: Ascorbic Acid 500mg one tablet, Carbidopa-Levodopa 25mg one tablet, Carvedilol 25mg one tablet, Docusate Sodium 100mg one tablet, Gabapentin 100mg one capsule, Hydralazine 50mg one tablet, and Zinc one tablet. LVN A crushed each tablet separately to a powdered form, opened up the Gabapentin capsule, placed each medication in a separate medication cup, and added 5ml of water to each medication. After LVN A checked Resident #32's tube (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676495 If continuation sheet Page 5 of 9 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 676495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Starr County Nursing and Transitional Care 5260 Brand St Rio Grande City, TX 78582 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 - Few placement, she flushed the g-tube with 30 ml of water then administered each medication, one by one. LVN A administered the Docusate sodium, followed by the Carbidopa- Levodopa without flushing the gastric tube with water after administering each medication. In an interview with LVN A on 05/18/22 at 10:15 AM, she said she did not separately flush Resident 32's gastric tube between each medication administration because she added the 5ml of flush water into each medication cup. LVN A said she did not want to add too much water. In an interview with LVN A on 05/18/22 at 2:42 PM, she said the medications could get stuck if they are not flushed, after each medication. LVN A said she did not dissolve the medication, prior to administering each one, with a spoon, because the medication would still sit at the bottom of the medication cup. In an interview with the Director of Nurses (DON) on 05/18/22 at 3:28 PM, she verbalized the that the medications are to be dissolved/diluted in 5-10ml of water, prior to administering each medication. DON said each medication should be flushed with 10ml of water, after each medication. DON said the medications can get stuck in the gastric tube, if they are not flushed. DON said that each nurse is trained upon hire, and annually. DON said nurses are taught to flush after each medications, and there is also a book kept at the nurses station for reference, in case needed. Record review of RN/LVN Orientation Skills Checklist for LVN A, revealed she was checked off on Medication Administration, including enteral meds on 01/28/22. Record review of the facility's Medication Administration, Enteral Tube Medication Administration, dated and revised on 10/01/19 revealed: Pour dissolved/dilute medication in syringe and unclamp tubing, allowing medication to flow by gravity. Flush with 5-10ml warm water between each medication. If administering more than one medication, flush with 5ml of water, or prescribed amount, between each medication, or per physician's orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676495 If continuation sheet Page 6 of 9 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 676495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Starr County Nursing and Transitional Care 5260 Brand St Rio Grande City, TX 78582 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 two (Resident #15 and Resident #44) of six residents reviewed for infection control. Residents Affected - Few 1. RN D recapped an insulin syringe after redrawing insulin for Resident #44(medication that helps with blood sugar). 2. CNA B sanitized her gloves then continued to provide incontinent care to Resident #15. These failures could place residents at risk for cross contamination and infections The findings were: 1.Record review of Resident #44's admission Record, dated 05/20/22, revealed Resident #44 was an [AGE] year-old male, who was admitted to the facility on [DATE], with the following diagnosis: Type 2 diabetes mellitus without complications (body either doesn't produce enough insulin, or it resists insulin), and essential hypertension (high blood pressure). Record review of Resident #44's Order Summary Report, dated 05/20/22 revealed an order for Humulin R Solution, inject as per sliding scale. Observation and interview during medication pass on 05/18/22 at 3:50 PM revealed RN D cleaned the top of the insulin bottle with an alcohol swap. RN D proceeded to inject 6 units of air and withdrew 6 units of insulin. RN D recapped the insulin syringe and walked into the resident's room. RN D administered the insulin, with donned gloves. RN D said she was able to recap the insulin syringe, as long as it had not been administered but once administered they could no longer recap it. In an interview on 05/19/22 at 9:40 a.m. with the DON, regarding insulin administration, said the process was to check the expiration date of the insulin, clean the top of the insulin bottle with an alcohol swab, and go by the parameters or ordered. The DON said they withdraw the insulin, and never recap any needle, regardless if the medication had been given or not. The DON said they could poke themselves, and the needle was not sterile. Record review of RN/LVN Orientation Skills Checklist for RN D revealed she was checked off on medication administration, including subcutaneous injections on 04/07/22. Record review of facility policy, titled Medication Administration, Injectable Administration, dated and revised on 10/01/19 revealed: Clean stopper with alcohol pad and allow to air dry (Except on pen devises and pre-filled syringes). With the bevel of the needle pointing up, inject a volume of air equal to the volume of the dose into the dial and withdraw the medication create air lock. Do no recap needles. Except on pen devices and pre-filled syringes). 2. Record review of Resident's #15's admission Record, dated 05/20/22, documented a [AGE] year-old male admitted to the facility on [DATE], with the following diagnosis: Dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with you daily life) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676495 If continuation sheet Page 7 of 9 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 676495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Starr County Nursing and Transitional Care 5260 Brand St Rio Grande City, TX 78582 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 without behavioral disturbance, hypertension (high blood pressure), and muscle weakness. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #15's Quarterly MDS, dated [DATE], revealed Resident #15: -had a BIMS of 13 (little to no impairment); Residents Affected - Few -required extensive assistance by one staff for transfers, dressing, toilet use, and personal hygiene; and -was always incontinent to bowel and bladder. Record review of Resident #15's care plan revealed: date initiated 12/16/21, and revised on 12/17/21, Resident #15 has an ADL self-care performance deficit, interventions included: The resident requires assistance X1 staff for toilet use as needed. Observation of incontinent care on 05/19/22 at 10:49 a.m. revealed CNA B and CNA C providing incontinent care to Resident #15. CNA B grabbed a wipe with her gloved hand, cleaned the head of the penis in a circular motion, grabbed the trash can with her gloved hand, and threw away the wipe. CNA B proceeded to sanitize her gloved hands and proceeded to provide incontinent care to Resident #15. At this time CNA B was interviewed and she stated she was told in another facility, when gloves were not visibly dirty, they could use hand sanitizer, but if they were visibly soiled, then they had to remove their gloves, and wash their hands. CNA B did not answer the question when asked if she had any initial training when she was first hired and did not answer if this practice was acceptable in the facility. In an interview on 05/19/22 at 1:35 p.m. the DON said staff shouldn't sanitize gloves, it could mess up the gloves, then cause cross contamination. The DON said the staff were checked off on incontinent care, upon hire, and annually. The DON said the facility had a mannequin that the staff were checked off on for incontinent care. Record review of CNA Orientation Skills Checklist for CNA B revealed she was checked off on infection control, including handwashing/gloves, general guidelines, and incontinent care on male and female on 02/01/22. Record review of the facility policy, titled Handwashing-Hand Hygiene, updated on June 2019, revealed: This facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: Before donning sterile gloves. After handling used dressings, contaminated equipment, etc.; After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676495 If continuation sheet Page 8 of 9 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 676495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Starr County Nursing and Transitional Care 5260 Brand St Rio Grande City, TX 78582 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 infections. Level of Harm - Minimal harm or potential for actual harm Record review of facility Incontinent Care Proficiency Checklist, revealed: Wash hands ANY TIME you are unsure if you touched something dirty Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676495 If continuation sheet Page 9 of 9