Health inspection·July 28, 2022

F 0609 -locomotion on unit did not occur Level of Harm - Minimal harm or potential for actual harm Record review of Resident #42's Nurses Progress Note dated 07/17/22 at 2:43 p.m., written by LVN I, revealed Note Text: Hospice nurse came and requested to have the Admitting Dx change to Dementia instead sub acute Osteomyelitis (bone infection), right ankle and foot. Pls ask medical record if they can change it. Residents Affected - Few Record review of Resident #42's Nurses Progress Note dated 07/15/22 at 2:30 p.m., written by LVN I, revealed Note Text: Called (hospice) to verify order for resident Right ankle/lower leg splint and spoke to (staff) ask to Keep the right leg immobile, no dressing change x 2 weeks and until re-evaluated Record review of Resident #42's Nurses Progress Note dated 07/11/22 at 2:30 p.m., written by LVN I, revealed Note Text: (Hospice nurse) called and informed me that Dr gave an order to sent (sic) out resident to (hospital) with Dx: Right Ankle Fracture for Splint Placement and carried out. Record review of Resident #42's Nurses Progress Note dated 07/11/22 at 10:44 a.m., written by LVN I, revealed Note Text: Called (hospice) and spoke to (staff) and verify with her about the Right Ankle splint, who will provide it and according to her they will provide it with in this week and to placed resident on Bedbound or no getting out of bed x 2 weeks until evaluated by them. Record review of Resident #42's Nurses Progress Note dated 07/11/22 at 3:25 a.m., written by LVN H, revealed Note Text: Spoke to hospice RN in person, Sn ask about receiving Splint and she said hospice does not provide them. Also mention she will be back today 7/11/22 to bring new order of Morphine for pain. Record review of Resident #42's Nurses eMar - Medication Administration Note dated 07/10/22 at 10:39 p.m., written by LVN H, revealed Note Text: Splint to right ankle every shift for fracture on order. Record review of Resident #42's Nurses Progress Note dated 07/10/22 at 12:16 p.m., written by LVN A, revealed Note Text: NP (hospice) made aware of fracture to right ankle. Gave new order for splint to right ankle. All orders acknowledged, and carried out. Record review of Resident #42's Nurses Progress Note dated 07/10/22 at 9:12 a.m., written by LVN A, revealed Note Text: Reported findings of x-ray to right ankle to RN from (hospice). Per Dr., change tramadol from PRN, to scheduled. All orders acknowledged, and carried out. Record review of Resident #42's Health status note dated 07/09/22 at 5:53 p.m., written by LVN A, revealed Note Text: Resident was noted with deformity to rt ankle by W/C (wound care) nurse. Upon assessment ankle note with edema, and was uneven to touch. Called (hospice) to report findings. Per (hospice RN G) Dr. gave new order for x-ray rt ankle. Record review of Resident #42's Nurses Progress Note dated 07/09/22 at 2:24 p.m., written by LVN A, revealed Note Text: Resident noted with deformity to RLE. Contacted Hospice RN G from (hospice), okay for x-ray to right ankle. Noted. Record review of Resident #42's Nurses Progress Note dated 07/02/22 at 4:59 p.m., written by LVN F, revealed Note Text: Called (hospice) multiple times got transferred to nurse and no answer. pending (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 2 of 10 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 455761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Nursing & Rehabilitation Center 1013 S Bryan Rd Mission, TX 78572 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a call back if not call back and follow up. resident shows no pain or distress noted right foot still swollen. continue monitoring right foot. Record review of Resident #42's Nurses Progress Note dated 07/02/22 at 3:14 p.m., written by LVN F, revealed Note Text: (Treatment nurse) noticed right foot was swollen and off went to check on it and noticed the same findings. resident doesn't show signs of pain or distress. Called (hospice) to report to nurse and Dr. and no answer. Notified treatment nurse. Pending a call back from (hospice). Record review of Resident #42's right ankle x-ray - 2 views result, dated 07/09/22 at 4:15 p.m. revealed: Findings: There are acute osteoporotic fractures involving medial lateral malleoli (formed by the lower part of the tibia and makes up the inner side of the ankle) with medial (lower part of the tibia) displacement. The joint alignment is maintained. There is associated soft tissue swelling. Impression: Acute bimalleolar fracture (break at the lower ends of the fibula and tibia at the ankle) Record review of Resident #42's Addendum Right Ankle X-ray - 2 views dated 07/28/2022 at 3:47 p.m. revealed: The patient is confined to the bed and has no history of trauma. No history of a fall. Review of films demonstrates the fractures are transverse (when bone is broken perpendicular to its length) and osteoporotic. Fractures of the distal tibial (lower shinbone) and fibula (smaller than the tibia and runs beside it) are consistent with benign spontaneous osteoporotic fractures. Findings are not suggestive of post-traumatic fractures of this bedbound patient. Impression: The patient is confined to the bed and has no history of trauma. No history of a fall. Review of films demonstrates the fractures are transverse and osteoporotic. Fractures of the distal tibial and fibula are consistent with benign spontaneous osteoporotic fractures. Resource reviewed on 07/29/22 entitled A to Z: Fracture, Bimalleolar (for Parents)-Nemours-Kids Health https://kidshealth.org 1995-2022 The Nemours Foundation reads, A bimalleolar fracture is a type of broken ankle that happens when parts of both the tibia (shinbone) and fibula (smaller than the tibia and runs beside it) called the malleoli are fractured. A bimalleolar fracture is one that involves both the medial malleolus and the lateral malleolus. This type of fracture often happens as a result of the foot and ankle rolling inward, but it can also be caused by a trip or fall, or by a direct blow to the ankle. The bony knobs on the inside and outside of the ankle are called the malleoli, which is the plural form of malleolus. The knob on the inside, the medial malleolus, is part of the tibia, or shinbone. The knob on the outside, the lateral malleolus, is part of the fibula, the smaller bone in the lower leg. In a telephone interview on 07/28/22 at 10:25 a.m., with Resident #42's family member, she stated she could not understand how Resident #42 had a broken right ankle when she was not weight-bearing. Resident #42's family member said it did not matter anymore and Resident #42 was in a better place with no pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 3 of 10 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 455761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Nursing & Rehabilitation Center 1013 S Bryan Rd Mission, TX 78572 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 07/28/22 at 11:37 a.m., the Administrator stated they did not do a self-report on Resident #42's fractured right ankle because the x-ray report showed a pathological fracture (a broken bone caused by disease, often by the spread of cancer to the bone). The Administrator stated, If it were not a pathological fracture, we would have definitely reported it. In an interview on 07/28/22 at 1:00 p.m., with the Administrator and Regional Clinical Director D, the Administrator stated he asked his supervisor (Regional Clinical Director D) about whether he should report and was told that since it was osteoporosis, he did not have to report. Regional Clinical Director D stated since the resident had osteoporosis and the x-ray report showed osteoporosis as the reason for the fractures, he did not think that it had to be reported. Record review of TULIP on 07/27/22, revealed no report was made for Resident #42's right ankle fracture. Record review of the facility policy titled, Reporting Abuse to Facility Management Policy, 2001 MED-PASS, Inc. (Revised December 2009) revealed: Policy Statement It is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. Policy Interpretation and Implementation 2. To help with recognition of incidents of abuse, the following definitions of abuse are provided: g. 'Injury of unknown source' is defined as an injury that meets both of the following conditions: (1) The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and (2) The injury is suspicious because of: -the extent of the injury; or -the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma); or -the number of injuries observed at one particular point in time; or -the incidence of injuries over time. 8. The Administrator and Director of Nursing Services must be notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and Director of Nursing Services must be called at home or must be paged and informed of such incident. When an incident of resident abuse is suspected or confirmed, the incident must be immediately (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 4 of 10 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 455761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Nursing & Rehabilitation Center 1013 S Bryan Rd Mission, TX 78572 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 reported to facility management regardless of the time lapse since the incident occurred. Reporting procedures should be followed as outlined in this policy. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 5 of 10 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 455761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Nursing & Rehabilitation Center 1013 S Bryan Rd Mission, TX 78572 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that PRN (as needed) orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication, for 1 of 6 (Resident # 4) reviewed for unnecessary medications. Resident #4 had a PRN order for Zyprexa (anti-psychotic medication) for more than 14 days without physician documentation re-evaluating the medication to continue its use PRN. This deficient practice could place residents at risk of receiving unnecessary medications. Findings include: Record review of Resident #4's admission Record, dated 07/27/22, revealed the resident was initially admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia (characterized by delusions and hallucinations) , dementia without behavioral disturbance, epilepsy, anxiety disorder, abnormal weight loss, and diabetes. Record review of Resident #4's physician orders revealed -an order dated 07/08/22 for Zyprexa Solution Reconstituted, inject 5 mg intramuscularly every 6 hours as needed for agitation for 30 days. -an order for Latuda tablet, (anti-psychotic) 120 mg, give one tablet by mouth one time a day related to paranoid schizophrenia, start date, 04/16/22. -an order for Alprazolam tablet, (anti-anxiety), 0.25 mg, give one tablet by mouth three times a day for severe anxiety and agitation, start date, 02/02/22. Record review of Resident #4's annual MDS dated [DATE] indicated Resident #4 had: -severe cognitive impairment - verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others). - other behavioral symptoms not directed at others (physical symptoms such as hitting or scratching self). -rejection of care and -received anti-psychotic and anti-depressant medications. Record review of Resident #4's care plan dated 06/22/22 indicated focus problem initiated on 01/06/22. Resident uses psychotropic medications due to diagnosis of schizophrenia. Interventions included (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 6 of 10 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 455761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Nursing & Rehabilitation Center 1013 S Bryan Rd Mission, TX 78572 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 0758 pharmacy consultant/designee to make recommendation for GDR as needed. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #4's MARs for May 2022 revealed Zyprexa was administered on 05/22/22 without any indications of episodes of behaviors on 05/22/22. The May MARs indicated no episodes of agitation or aggressiveness. Residents Affected - Few Record review of Resident #4's MARs for June 2022 revealed Zyprexa was administered on 06/05/22 without any indications of episodes of behaviors on 06/05/22. The MARs indicated two episodes of aggressiveness on 6/21/22. Record review of Resident #4's MAR for July revealed Zyprexa had not been administered. No episodes of aggressiveness or agitation were indicated on the MARs. Record review of nurse's notes dated 05/22/22 did not indicate any episodes of aggression or agitation. Nurse's notes dated 06/05/22 indicated to inject 5 mg intramuscularly of Zyprexa every six hours as needed for agitation, given due to being combative with staff and soiling herself and attempting to throw feces and punch staff. Nurse's notes dated 06/06/22 indicated nurse attempted several times to check blood sugar and to give prescribed anxiety medication, but resident refused. Nurse's notes dated 06/07/22 indicated staff observed three self-inflicted scratches to left forearm. Nurse's notes dated 06/10/22 indicated reported to have continued episodes of behavior as manifested by fixation to a resident, to re-direct resident at all times. Observation on 07/25/22 at 3:13 pm revealed Resident #4 was sitting in the hallway. Resident #4 was observed mumbling to herself. When greeted with a hello, Resident #4 said no, don't come with hello, get out! Observation on 07/25/22 at 3:26 pm revealed Resident #4 was standing up from her wheelchair and yelling at someone by the nurse's station. Resident #4 waved her hand and said F---- you! then went into her room and slammed the door shut. Observation of Resident #4 on 07/27/22 at 8:59 am revealed resident in her room, lying in bed. Resident #4 did not answer surveyor greeting. Interview on 07/27/22 at 9:05 am with LVN A revealed he was the charge nurse for Resident #4. LVN A said Resident #4 had behaviors of aggression and agitation on some days and on some days, she was calmer. Resident #4 had an order for Zyprexa as needed for these behaviors. Interview on 07/27/22 at 9:10 am with ADON C revealed Resident #4's Psychiatric Nurse had prescribed Zyprexa as needed when Resident #4 had behaviors of aggression, agitation and anxiety. This Psychiatric Nurse had prescribed Zyprexa for Resident #4 as needed for over 14 days several times. ADON C said that Resident #4 sometimes got very aggressive, and they had the order for Zyprexa to administer as needed. ADON C said during May and June Resident #4 had orders to administer Zyprexa as needed from 05/08/22 to 07/08/22. The order for Zyprexa as needed had been prescribed again on 07/08/22 to 08/07/22, for thirty days. On 07/27/22 at 9:35 am interview with Psychiatric Nurse via telephone revealed Resident #4 had behaviors that did not occur every day and staff wanted to have the medication Zyprexa on board in case they needed to administer when she had bouts of emergency behaviors such as aggression or agitation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 7 of 10 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 455761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Nursing & Rehabilitation Center 1013 S Bryan Rd Mission, TX 78572 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #4's Psychiatric Nurse said in the past Resident #4's behaviors had been very bad. The Psychiatric Nurse said staff had administered Zyprexa on 05/22/22 and 06/05/22. The last psych evaluation she had completed for Resident #4 was in May 2022. On 07/27/22 at 10:45 am, interview with LVN A revealed staff would document Resident's behaviors on the MARs section for behavior monitoring and sometimes also in nurse's notes. Interview on 07/27/22 on 11:04 am with the DON revealed Resident #4 had behaviors that were monitored and documented. The Psychiatric Nurse had prescribed Zyprexa as needed for over 14 days on last two orders. The nurses would indicate on Resident #4's MARs if there was an episode of behaviors or on the nurse's notes. Resident #4 had behaviors during different times of the day such as refusing care, housekeeping and got agitated when Resident #4's sister came to visit the resident. There was family dynamics going on that created agitation for the resident. Resident #4's behaviors were a roller coaster, very unpredictable and they were trying to handle her aggressive behaviors with Zyprexa, if needed. The DON said they were actively trying to gdr Resident #4's psychotropic, including anti-psychotic medications. On 04/29/22 a meeting was held with Resident #4's Psychiatric Nurse to review Resident 4's medications for Latuda (anti and Zyprexa but no gdr was recommended by the Psychiatric Nurse. Record review of the Pharmacist Consultant's recommendation for Resident #4 dated 04/20/22 revealed a recommendation to gdr the medication Latuda, but the Psychiatric Nurse had declined the gdr due to the resident's target symptoms returned or worsened after previous attempts at gradual dose reduction. Interview on 07/28/22 at 1:46 pm with the DON revealed prn (as needed) orders for Zyprexa for more than 14 days can lead to administering unnecessary medications that can casual resident to be over sedated. Record review of the facility policy titled Antipsychotic Medication Use dated revised December 2016 indicated; PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 8 of 10 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 455761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Nursing & Rehabilitation Center 1013 S Bryan Rd Mission, TX 78572 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 - Few 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, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure sanitary practices were maintained in the kitchen as clean spatulas, ladles, pots were hanging on a fixture above a 3-compartment sink that had dirty pots. This failure could place residents who ate from the kitchen at risk for cross-contamination and food-borne illnesses. Finding included: Observation of the kitchen on 07/26/22 at 9:35 am accompanied by the Dietary Manager revealed pots, pans, tongs, ladles, spatulas and large strainer pots hanging above the 3-compartment sink containing a soiled pot filled with food waste and dirty dish water. Interview on 07/26/22 at 9:35 am with the Dietary Manager revealed kitchen aides stored the clean dishes approximately 12 inches above the 3-compartment sink. The Dietary Manager said the pots and spatulas hanging above the sink were clean. The kitchen aides washed the large dirty pots, pans and large utensils containing food waste in the 3-comparment sink and placed the dishes to dry in the counter area next to sink used to rinse and sanitize the dishes. The Dietary Manager said she had not noticed the potential for the clean dishes stored above the 3-compartment sink to be contaminated with splashes or spillage from the dirty pots and pans during washing. Interview on 07/26/22 at 9:40 am with Kitchen Aide E revealed he washed the large pots and pans in the 3-compartment sink. After the large pots, pans and utensils were washed in the 3-compartment sink, they were placed to dry and then hanged above the sink to store the clean dishes until they were used again by the cook. Kitchen Aide E said when he washed the large pots, pans, and utensils the dishes hanging above the sink could get sprayed with food waste from the dirty dishes. He said he had not noticed this concern until it was discussed with the surveyor. Interview on 07/28/22 at 1:52 pm with the Administrator revealed the process of hanging clean dishes above the 3-compartment sink could cause spillage and contaminate the clean dishes. The clean dishes need to be stored away from dirty dishes. Record review of the facility policy titled Warewashing dated September 2017 indicated all dishware will be air dried and properly stored. Record review of the USDA Food Code dated 2017, revealed in part; 4-403.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles : (A) Except as specified in (D) of this section, cleaned equipment and utensils, laundered linens, and single service and single-use articles shall be stored in a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 9 of 10 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 455761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Nursing & Rehabilitation Center 1013 S Bryan Rd Mission, TX 78572 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 (1) Level of Harm - Minimal harm or potential for actual harm In a dry, clean location; (2) Residents Affected - Few Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 10 of 10