Health inspection·October 6, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm range of motion. RN noted hematoma (bruise) to left frontal-parietal (front top) head approx. 2x5 cm. Skin tear to left hand. Assisted to wheelchair. RN S reported to physician and received order for stat CT scan. Record review of Resident #30's Fall Risk assessment dated [DATE] reflected Resident #30 was scored 18 (high risk for falls). Residents Affected - Few Record review of Resident #30's Progress Note dated 12/18/22 at 03:03 a.m., Nurse Note written by RN S reflected RN S received phone call from hospital reporting CT of head and spine negative (-); XR (x-ray) to right knee related to hematoma S/P Fall negative (-) No fracture. 1 tab. of Hydrocodone was given for pain. Record review of Resident #30's Progress Note dated 12/18/22 03:43 PM Nurse Note written by LVN O: Note Text: Resident #30 c/o pain to left leg. Gave order for x-ray of left leg and hip. All orders acknowledged, and carried out. Record review of x-ray results dated 12/18/22, reflected Resident #30 had an acute left femoral neck fracture. Record review of Resident #30's Progress Note dated 12/19/22 at 01:20 a.m. Health Status Note written by LVN T, reflected x-ray results relayed to physician. Pending call back. Record review of Resident #30's Progress Note dated 12/19/22 at 09:40 a.m. Nurse Note written by LVN U reflected Patient (Resident #30) has an appt with orthopedic surgeon on 12/27/22 at 10:15 a.m. Record review of Resident #30's Progress Note dated 12/19/22 at 12:24 p.m. Nurse Note written by LVN U reflected x-ray results with significant finding of acute left femoral neck fracture were faxed to physician and new orders were received to consult with orthopedic surgeon. Record review of Resident #30's Progress Note dated 12/19/22 at 02:54 p.m., Nurse Note written by LVN U reflecting new orders given by physician for Tylenol 325 mg 2 tablets every 6 hours for pain and Tylenol with codeine #3 300-30 mg 1 tablet by mouth every 8 hours as needed for pain was given. Record review of Resident #30's Progress Note dated 12/19/22 at 03:14 p.m. Nurse Note written by LVN U reflected new orders were given by physician for physical therapy to evaluate/treat and occupational therapy to evaluate/treat. Record review of Resident #30's Progress Note dated 12/20/22 05:24 p.m. Nurse Note written by LVN U reflected new orders received from physician for bed rest and no weight bearing. Record review of Resident #30's Progress Note dated 12/24/22 02:48 p.m. Nurse Note written by LVN U reflected Resident #30 refused any type of bathing. Record review of Resident #30's Progress Note dated 12/27/22 at 02:09 p.m. Nurse Note written by LVN V reflected Resident #30 left for appointment with orthopedic surgeon via stretcher. Record review of Resident #30's Progress Note dated 12/27/22 at 04:06 p.m. Nurse Note written by LVN V reflected Resident #30 back from Orthopedic Surgeon and as per Orthopedic Surgeon, Resident #30 to be sent out to the health main hospital for a left hip bipolar hip replacement (when only the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 2 of 22 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 10/06/2023 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 0580 Level of Harm - Minimal harm or potential for actual harm ball of the hip socket is replaced unlike a total hip replacement where the ball and socket are replaced). LVN V wrote NP informed of surgery request and NP gave the ok to send patient to the hospital. RP aware. Record review of Resident #30's Progress Note dated 12/27/22 05:27 p.m. Nurse Note written by LVN V reflected Resident #30 was sent out via stretcher to hospital for possible left hip replacement. Residents Affected - Few Record review of Resident #30's Progress Note dated 12/30/22 at 09:35 p.m. Nurse Note written by LVN RN S reflecting Resident #30 was admitted back to facility after left hip ORIF endoprosthesis (the use of pins, screws, and plates to repair a complex or severe hip fracture). Record review of Resident #30's eMAR prior to Resident #30's bipolar hip replacement, revealed on 12/18/22 Resident #30 had a pain level of 6 out of 10, and received Tylenol 325 mg 2 tablets. On 12/18/22 Resident received 2 Tylenol 325 mg tablets for pain level of 2 out of 10. On 12/25/22, Resident #30 received Tylenol with codeine #3 for pain level of 2 out of 10. On 12/26/22 Resident #30 received Tylenol with codeine #3 for pain level of 8 out of 10. In an interview on 10/06/23 at 03:06 p.m., Resident #30 stated she fell awhile back and hurt her hip. She said it still hurts some, but she takes medicine for pain and it (the pain) is better. Resident stated the nurses and CNAs are very good and they take very good care of her. She stated she has no complaints or problems. In an interview on 10/06/23 at 03:20 p.m., LVN V stated she was helping out another nurse when she (LVN V) sent Resident #30 out to hospital for a hip replacement. LVN stated she really did not know much about Resident #30. In an interview on 10/06/23 at 05:00 p.m., LVN Y stated when a resident falls, she goes in to assess and check to see what happened. LVN Y stated the doctor, RP, and DON are notified. LVN Y stated if the doctor gives orders, family is updated, DON is updated, and orders are carried out. LVN Y stated CNAs will report to her if a resident falls. In an interview on 10/06/23 at 05:11 p.m., ADON E, acting DON while DON is on vacation, stated she had worked at the facility for 4 and a half years. ADON E stated she just came back in May of 2023 after being gone for almost a year. ADON E stated nurses report changes in condition, if a doctor changed medication, or for clinical (falls, change in condition, resident to resident altercations, staffing). ADON E stated if they called for a fall, ADON E maked sure everything had been done. ADON E stated if there were a fracture, the nurse would tell the ADON E what the doctor said. ADON E stated most the time the resident was sent to the ER for a fracture. ADON E stated if the doctor ordered an ortho consult, the consult was made. ADON E stated if it were a hip fracture, if x-rays came back showing a hip fracture, she would use her nursing judgement and send the resident to the hospital. ADON E stated she would educate the family and tell them with a hip fracture, this needed to be addressed now. ADON E stated she looked over the initial investigation report, then the DON would, and then the Administrator would and then it would be locked. ADON E stated she would not let a resident sit for ten days with a broken hip. She said she would send them to the hospital. In an interview on 10/06/23 at 05:45 p.m., the Administrator stated he started as the Administrator at the facility 03/22/23. The Administrator stated he was not at the facility for the incident with Resident #30, and 5 out of the 7 nurses/CNAs surveyor would like to speak with no longer worked at the facility and 1 CNA works nights and may still be asleep. The Administrator stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 3 of 22 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 10/06/2023 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 0580 Level of Harm - Minimal harm or potential for actual harm appointment for the orthopedic surgeon, 10 days after Resident #30's fall, should have been communicated to the doctor so the doctor could have made the decision to send resident out to the hospital. Review of facility's policy Change in a Resident's Condition or Status 2001 MED-PASS, Inc (Revised May 2017) revealed: Residents Affected - Few Policy Statement Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): e. need to alter the resident's medical treatment significantly; g. need to transfer the resident to a hospital/treatment center 2. A 'significant change' of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. Impacts more than one area of the resident's health status; FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 4 of 22 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 10/06/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop the resident's comprehensive care plan for one (Resident #60) of 18 residents reviewed for care plans that describe the services to be provided to attain the resident's highest practicable physical, mental, and psychological well-being in that: The facility failed to develop a care plan to address Resident #60's feeling anxious when door was closed during incontinent care. Resident #60 would refuse to have the door closed while staff provided care. This failure could affect the residents with behavioral healthcare needs at risk for their psychosocial needs not being met. The findings included: Record review of Resident #60's Face Sheet dated 10/06/23 indicated Resident #60 was an [AGE] year-old male admitted to facility on 03/13/21 and readmitted on [DATE] with diagnosis of vascular dementia a decline in thinking skills caused by conditions that block or reduce the blood flow to various regions of the brain, depriving them of oxygen) and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Record review of Resident #60's Significant Change in Status MDS assessment dated [DATE] indicated Resident #60 was: -usually understood by others, -sometimes understood others, -scored a BIMS of 11 (was moderately impaired cognitively) -did not have any behaviors. Record review of Resident #60's Physician's Orders revealed Resident #60 had an order for Sertraline HCl oral tablet, give one tablet by mouth one time a day for depression, start date 08/25/23. No indication Resident #60 was receiving any antianxiety medication. Record review of Resident #60's care plan dated 09/08/23 did not indicate Resident #60 had a care plan to address Resident's choice to have the door open while staff were providing care. Observation on 10/03/23 at 10:45 AM revealed Resident #60 was sitting up in bed with his knees flexed. Resident #60 had his eyes closed and did not respond to Surveyor's greeting. Observation on 10/03/23 at 11:08 AM revealed call light was on in Resident #60's room and, CNA G went in and asked Resident #60 if he needed to be changed. CNA G walked out of room and went to the linen cart and got wipes, a brief and gloves from the housekeeping cart and then went into Resident #60's room. The curtain around Resident #60's bed was closed but the door was open. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 5 of 22 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 10/06/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 10/03/23 at 11:14 AM, CNA G said she did not close the door because Resident #60 did not like the door to be closed. CNA G said Resident #60 would allow staff to close the curtain. CNA G said she was supposed to close the door for the resident's privacy, but Resident #60 had some sort of phobia and would not allow the door to be closed. CNA G said she closed the door the first time she provided care and Resident #60 had a fainting episode. CNA G said Resident 60's behavior should be in the care plan because the CNAs knew about his behavior. CNA G said she did not normally work Resident #60's hall, but they needed assistance in this hall. CNA G said staff were provided in-services on different topics every two weeks. In an interview on 10/04/23 at 1:42 PM Resident #60 said he does not like to have the door closed because he has anxiety. Resident #60 said when the door is closed, he feels like he was buried and was going to be asphyxiated (depriving him of air). Resident #60 said he can't go in an elevator because he would panic. Resident #60 said he told staff to close the curtain but not the door. In an interview on 10/05/23 at 09:10 AM CNA H said Resident #60 does not like the door to be closed. CNA H said if they close the door Resident #60 will faint and his blood pressure will go up. So, they have to keep the door open during incontinent care. CNA H said when a new CNA is providing care, they will tell her during report not to close the door. In an interview on 10/05/23 at 9:18 AM LVN C said when she started her shift the outgoing nurse gave report and LVN C said she would assess the residents and if any resident was behaving differently, she would inform the ADON. The ADON will call the NP or the physician. LVN C said the nursing staff have meetings in the mornings, and they would discuss any change in condition of residents. After the meeting the nursing staff would implement new orders and the MDS nurse would revise the care plan and would provide the nurse a copy of the revised care plan or the nurse can check in the computer for any changes to the care plan. LVN C said she would tell the oncoming shift there was a change in the care plan so they could monitor the resident. LVN C said she did not know Resident #60 had anxiety when the CNAs closed the door during incontinent care. LVN C said she was aware that Resident #60 had anxiety during transfers to and from his wheelchair. Resident #60 has fainting episodes during the transfers, and it is documented. In an interview on 10/05/23 at 9:57 AM MDS/RN I said she was not aware of Resident #60's choice of having the door open during incontinent care. MDS/RN I said she was aware Resident 60 had fainting episodes when he was transferred to the wheelchair. MDS/RN I said she was responsible for developing the care plan and the behavior of not wanting the door closed needs to be care planned. MDS/RN said they have morning clinical meetings and at that time the nurses can inform the team of any new changes a resident was exhibiting. MDS/RN I said she was not informed of Resident #60 not wanting the door to be closed during incontinent care. MDS/RN I said the nurse did not mention it during the morning meeting so maybe it was a new behavior. MDS/RN I said she would initiate the care plan once she talked with the nurse. In an interview on 10/05/23 at 2:57 PM ADON/LVN E said she was not aware that Resident #60 did not want the CNAs to close the door while providing incontinent care. ADON E said Resident #60 has hypotension and does have fainting episodes, but she did not know he had fainting episodes when they closed the door. ADON E said she would speak with the MDS nurses so they could develop a care plan for this behavior. ADON E said that she would also in-service the CNAs about reporting any changes. Record review of facility's policy on Care Plans, Comprehensive Person-Centered revealed A comprehensive, person-centered care plan that includes, measurable objectives and timetables to meet the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 6 of 22 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 10/06/2023 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 0656 resident's physical, psychosocial and functional needs is developed and implemented for each resident. Level of Harm - Minimal harm or potential for actual harm 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develop and implement a comprehensive, person-centered care plan for each resident. Residents Affected - Few 8. The comprehensive, person-centered care plan: g. Incorporate identified problem areas; Incorporate risk factors associated with identified problems. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 7 of 22 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 10/06/2023 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision for one resident (Resident #49) of three residents reviewed for supervision and ensured the environment remained free of accident hazards for 2 of 2 unlocked resident rooms reviewed for supervision in that. 1) The facility failed to ensure Resident #49 received supervision while in the shower. 2 ) The facility failed to ensure the two resident rooms, 323 and 324 were free of cluttered storage of equipment, furniture, boxes, walkers, wheelchairs in a secured manner. These failures could place residents at risk of being in an unsafe environment and at risk for accidents and injury. Findings included: 1)Record review of Resident #49's admission Record dated 10/06/23 revealed a [AGE] year old male with an admission date of 6/01/22 and diagnoses which included: dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), Huntington's Disease (an inherited condition in which nerve cells in the brain break down over time), traumatic subarachnoid hemorrhage without loss of consciousness (presence of blood within the brain most often caused by head trauma, such as from a serious fall or vehicle accident or by a brain aneurysms where the aneurysm can leak or rupture causing life-threatening bleeding), lack of coordination, repeated falls, and history of falling. Record review of Resident #49's Quarterly MDS assessment dated [DATE] revealed he required extensive assistance with 1 person physical assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #49 was frequently incontinent of bowel and bladder. Record review of Resident #49's Care Plan dated 09/13/23 revealed he had a history of falls at the facility. Bathing interventions included Resident #49 required 1 staff participation with bathing; need varied. Resident #49 will take a shower by himself without notifying the staff. Combination locks have been applied to all the shower rooms so that resident will not be able to enter the shower room and attempt to shower himself. Record review of Resident #49's Progress Note dated 09/23/23 at 05:25 p.m., Nurse Note written by LVN V revealed, Note Text: Resident noted to be on the floor of the shower room as per CNA resident took a shower and CNA left to bring his clothes and when he come back, he noticed resident on his knees voiding into the trash can with scrapes and redness to the elbows. Resident states he was voiding into trash can of the shower room when he fell forward onto his elbows. Performed a head-to-toe assessment and no abnormalities noted other than 1 small scrap (sic) on each elbow noted with redness and minimal bleeding which were cleaned with NS and pat dry with 4x4 gauze, vital signs are within normal limits, resident able to move all extremities, as per resident complaining of pain to the neck, PRN Tylenol offered, and resident agreed. RP and DON made aware. Called NP and as per NP new orders for x ray of c spine and neck and to give Tylenol for pain. Called mobile x-ray and as per tech is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 8 of 22 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 10/06/2023 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 0689 on its way. Level of Harm - Actual harm Record review of Resident #49's Progress Note written on 09/23/23 at 05:35 p.m., Nurse Note written by LVN V revealed, Note Text: Mobile x-ray tech in facility to perform x-ray of c spine and neck. Pending results. Residents Affected - Few Record review of Resident #49's Progress Note written on 09/23/23 at 05:50 p.m., Nurse Note written by LVN V revealed, Note Text: Resident #49 complaining of neck pain and unable to move neck or arms upon request, hand grip strong and equal, PERRLA, and vital signs within normal limits. As per patient requesting to go to hospital. Called NP and as per NP ok to send to hospital. Called hospital and gave report to RN. RP made aware. 911 was called and on its way. Record review of Resident #49's Progress Note written on 09/23/23 06:08 p.m., Nurse Note written by LVN V revealed, Note Text: Resident left to hospital alert and oriented via stretcher accompanied by 2 EMTs, no signs of shortness of breath or any distress noted. Record review of Resident #49's Progress Note written on 09/23/23 11:18 p.m. Nurse Note written by RN Z revealed, Note Text: Called hospital-ER status of the resident S/P fall, per RN resident will be transferred to another hospital d/t mild subdural hematoma (a pool of blood between the brain and its outermost covering). Record review of Resident #49's Progress Note written on 09/24/23 12:50 a.m., Nurse Note written by RN Z revealed, Note Text: Spoke with RN of hospital ER, resident will be transferred to another hospital ER. Record review of Resident #49's Progress Note written on 09/24/23 03:43 a.m., Nurse Note written by RN Z revealed, Note Text: RN of hospital ER called to notify that resident is going to be sent back to facility. Record review of hospital records dated 09/24/23 at 04:30 a.m., Resident #49 was discharged from hospital observation. Record review of Resident #49's Progress Note written on 09/24/23 04:51 a.m., Nurse Note written by RN Z revealed, Note Text: Resident came back from hospital-ER via stretcher. Per RN at hospital ER, CT of the head was performed, and the result presents no danger. Checked V/S and WNL. Resident denies of any pain/discomfort at this time. Will continue with close monitoring and neuro checks. In an interview and observation on 10/06/23 at 03:11 p.m., revealed Resident #49 was standing by the nurse's station saying, I want to go home. Resident #49 stated he had recently fallen and hurt his head. Resident #49 stated it did not hurt anymore. He said he received his medicine and his head did not hurt. Resident #49 stated the nurses are good and take care of him. He said he had no problems with anyone. Resident #49 repeated, I want to go home. In an interview on 10/06/23 at 03:20 p.m., LVN V stated when Resident #49 fell, a CNA in 400 Hall was looking for a chair for a resident. LVN V stated she and another nurse looked in a shower room and Resident #49 was sitting in a shower chair naked. LVN V stated Resident #49 had not taken a shower yet. CNA R came by and they told CNA R Resident #49 was in the shower waiting for his shower. CNA R stated he would be back in a few because he was showering another resident right now. LVN V stated that she and another nurse stayed with Resident #49 until the CNA R came back about twenty minutes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 9 of 22 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 10/06/2023 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 0689 Level of Harm - Actual harm Residents Affected - Few later. CNA R came back to shower Resident #49. LVN V stated she saw CNA R a while later and CNA R told her that Resident #49 fell in the shower and had some scrapes on his elbows. CNA R told LVN V he went to get clothes for Resident #49 since Resident #49 did not take any in with him. LVN V stated Resident #49 told her that he had urinated in the trash can in the shower and fell forward on his elbows. LVN V stated she notified the NP and cleaned Resident #49's elbows. The NP gave orders for Tylenol for pain and x-rays. LVN V stated a few minutes later, Resident #49 complained of neck pain and wanted to go to the hospital. LVN V stated she notified the NP and the NP said to send him to the hospital. LVN V stated she followed the orders and sent Resident #49 to the hospital. LVN V stated CNAs should not leave residents in the shower unattended because they could fall. In an interview on 10/06/23 at 04:35 p.m., CNA W stated she had been working at the facility for six months. CNA W stated if she were to see a resident fall or a resident was on the floor, she would call the nurse. CNA W would not move or leave the resident. CNA W stated she would stay with the resident until the nurse told her they were done. CNA W stated she gave showers. CNA W stated she never would leave a resident alone in the shower. If she would forget something, she would call the nurse to stay with the resident while she went to get whatever she forgot. CNA W stated any accident could happen if a resident were left alone in the shower. In an interview on 10/06/23 at 04:51 p.m., CNA X stated she had been working at the facility for 6 months. CNA X stated if she were to see a resident fall or a resident was on the floor, she would call for the nurse. CNA X stated she would not leave or move the resident. CNA X stated she would stay with the nurse to help until they were done. CNA X stated she gave showers to the residents. CNA X she would never leave the resident alone in the shower. She stated she would use the emergency light and ask the nurse to go get whatever she needs or to stay with the resident while she went to get what she needed. CNA X stated if a resident was left alone in the shower while she went to get the items needed, the resident could fall. CNA stated even resident who showers themselves, they watch to make sure the resident does not fall. In an interview on 10/06/23 at 05:11 p.m., ADON E acting DON while DON is on vacation. ADON E stated she had worked at the facility for 4 and a half years. ADON E stated CNAs are checked off on skills at hire and annually. ADON E stated CNAs should never leave residents alone in the shower. ADON E stated the CNA is not supposed to leave the resident in the shower by themselves unless it is care planned that the resident was able to shower alone. In an interview on 10/06/23 at 05:45 p.m., the Administrator stated he started as the Administrator at the facility 03/22/23. The Administrator stated 5 out of the 7 nurses/CNAs surveyor would like to speak with no longer worked at the facility and 1 CNA works nights and may still be asleep. The Administrator stated CNA should not leave the resident in a dangerous position. The Administrator stated the resident, Resident #49, fell. The Administrator stated Resident #49 had gone in the shower waiting for the CNA (CNA R) and did not take any clothes in with him. The Administrator stated CNA R had been in-serviced and educated. Attempted telephone interview on 10/06/23 at 06:30 p.m. with CNA R concerning Resident #49's fall in the shower while not being supervised, but there was no answer. Unable to leave message. Review of facility's Shower/Tub Bath policy dated 2001 MED-PASS, Inc (Revised October 2010) revealed: Purpose (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 10 of 22 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 10/06/2023 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 0689 The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Level of Harm - Actual harm General Guidelines Residents Affected - Few 1. Stay with the resident throughout the bath. Never leave the resident unattended in the tub or shower. 2. Use the emergency call signal to summon assistance, if needed. Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure: 3.Robe and slippers; 4.Face cloth and bath towels; 5.Clean gown, pajamas, or street clothing; 9.Comb and/or hairbrush 2) Observation on 10/03/23 at 10:50 am revealed rooms #323 and #324 located at the end of the 300 halls, were filled to the doorway in an unorganized manner, beds, wheelchairs, furniture, desks, walkers, computers, televisions, closed and opened boxes stacked to the ceiling. Both rooms were unlocked and accessible to residents or staff to enter. Observation on 10/06/23 at 11:53 am revealed room [ROOM NUMBER] had been placed with a lock and entry was not available. room [ROOM NUMBER] did not have a lock. Interview on 10/06/23 at 9:32 am with Resident #31 revealed he had been in the same hallway for two years. Resident #31 said he could walk anywhere in the facility. Resident #31 said he had not gone into rooms 323 or 324 and did not know who or what was in the rooms. Interview on 10/06/23 at 10:19 am with LVN O, revealed he was the charge nurse for all three halls, including rooms [ROOM NUMBERS]. LVN O said eight residents in the halls 100, 200 and 300 were able to leave their rooms, were ambulatory, and some were cognitively impaired, and some residents were alert and cognitive. LVN O said both room [ROOM NUMBER] and 324 were vacant, not locked and currently were used for storage. LVN O said the rooms were filled with random furniture, beds, wheelchairs and very many boxes, some that were open and some that were closed. The boxes contained paper goods. LVN O said he had never seen any residents go into the rooms [ROOM NUMBERS]. He said there was a potential that residents might go into the rooms and get harmed with the cluttered manner the items were stored. Interviews on 10/06/23 at 10:29 am with CNA P and CNA Q revealed they had never entered the room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 11 of 22 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 10/06/2023 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 0689 Level of Harm - Actual harm [ROOM NUMBER] or 324 and they were not locked. CNA P and CNA Q said they did not know how long the rooms had been used for storage. Both CNAs said if they saw any residents go towards the rooms, they would re-direct them not to go into the rooms because entering those two rooms could be dangerous the way they had all items cluttered in the rooms, items placed on top of each other, etc. Residents Affected - Few Interview on 10/06/23 at 10:34 am with the Maintenance Supervisor revealed the two rooms had been filled with all kinds of furniture, beds, TVs, and boxes for some time. He said the rooms did not have any locks on them because they were still considered residents rooms. Interview on 10/06/23 at 11:00 am with the Administrator revealed the two resident rooms had been used for storage for an undetermined time but the items were stored temporarily. The Administrator said there was a potential that a resident could go into the rooms since they were not locked and could get hurt. The Administrator said his staff would empty the two rooms immediately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 12 of 22 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 10/06/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure and 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 2 of 4 ( Resident #291 and Residents #23) residents reviewed for pharmaceutical services, in that: 1. MA J did not check open date on 2 multi dose medication bottles and was going to administer them to Resident #291. 2. Resident #23's medication (zinc oxide 20%) was found on the bedside dresser drawer. These deficient practices could place residents at risk of not receiving the intended therapeutic effect of the medications resulting in exacerbation of the resident's condition and disease process. Findings included: 1. Record review of Resident #291's face sheet dated 10/06/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included unspecified fracture of lower end of left femur (thigh bone), subsequent encounter for closed fracture with routine healing, unilateral primary osteoarthritis, left knee, hyperlipidemia(high concentration of fats in the blood), essential hypertension (primary high blood pressure), primary osteoarthritis, unspecified site, age related osteoporosis without current pathological fracture. Record review of Resident #291's most recent MDS assessment, dated 9/28/23 revealed the resident's primary medical condition is other Orthopedic conditions, Hypertension, and hyperlipidemia. Record review of Resident #291's comprehensive care plan, revision date 10/04/23 revealed the following: -Focus: Resident #291 has coronary artery disease related to hypercholesterolemia (high cholesterol), hypertension. Intervention: Aspirin tablet chewable 81mg, Give 1 tablet by mouth one time a day for prophylaxis(prevent the spread of disease) . -Focus: Resident #291 has anemia related to comorbid condition. Interventions: Ferrous Sulfate Tablet 325mg, Give 1 tablet by mouth three times a day for supplement. Record review of Resident #291's Medication Orders, revealed the following: -Aspirin tablet chewable 81mg give 1 tablet by mouth one time a day for prophylaxis with order date 9/24/23 and no end date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 13 of 22 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 10/06/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -Ferrous Sulfate tablet 325mg give 1 tablet by mouth three times a day for supplement with order date 9/24/23 and no end date. Observation on 10/05/23 at 7:46 a.m., during the medication pass revealed MA J was going to administer 1 Aspirin 81mg chewable tablet and 1 Ferrous Sulfate 325mg tablet, that were removed from bottles that had no open date, to Resident #291. Interview on 10/05/2023 at 8:12 a.m., MA J stated all medication bottles are supposed to be dated after opening, so they can know when it was opened and does not expire. MA J stated she checks her medication cart once a week for any expired medications and unlabeled open bottles. The last time she checked her medication cart was last week. She stated the ADON checks medication carts too. She stated she is not sure of a negative outcome. Interview on 10/05/2023 at 8:14 a.m., ADON L stated she checked medication carts for any expired medications and unlabeled open bottles yesterday. She stated the charge nurse also checks them weekly. Stated the negative outcome could cause the resident to not get the full effect of the medication. Record review of the facility policy and procedure titled, Administering Medications Policy, revised 12/2012, revealed in Policy Interpretation and Implementation #9., The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. 2. Record review of Resident # 23's admission Record dated 10/04/2023 revealed she was admitted to the facility on [DATE] with diagnosis of Dependence of renal dialysis, right/left hand contracture, cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately), malnutrition, end stage renal disease, type 2 diabetes mellitus, chronic kidney disease, stage 5, chronic pulmonary edema, sequelae of cerebral infarction (residual effects or conditions produced after the acute phase of an illness or injury has ended.) Record review of Resident #23 MDS dated [DATE] revealed Resident #23 had a BIMS of 00, which indicated the resident was severely cognitively impaired. Resident #23 required extensive assistance with a two person assist in bed mobility, transfer, and dressing. Record review of Resident #23's Comprehensive Care Plan dated 07/03/23 revealed she had potential impairment to skin integrity related to fragile skin, Goal: skin injury be healed date initiated 07/03/23, Intervention: apply zinc oxide 20% cream to bilateral buttocks and sacrum BID for irritant dermatitis from incontinence. Record review of Resident #23's physician's order revealed an order to apply zinc oxide 20% cream to bilateral buttocks and all affected areas area's BID. Directions, two times a day for irritant dermatitis (a general term that describes inflammation of the skin) from incontinence for 30 days with a start date of 10/02/23 and end date of 11/01/23. During an observation on 10/03/23 revealed Resident #23 was observed asleep in her bed. She was dressed in her own personal clothing and was well groomed. Resident #23's family member was in the room. Interview on 10/03/2023 at 9:45 a.m., Resident # 23's family member said Resident #23 had just arrived from dialysis and usually sleeps for a couple of hours after returning to facility. She said she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 14 of 22 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 10/06/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few visits Resident #23 7 days a week in the AM. Resident #23's family member said her mother has dialysis scheduled on Tuesdays, Thursdays, and Saturdays from 4:00 am to 9:00 am. She said on the days her mother has dialysis she arrives earlier to remind nursing staff to change her mother's brief as soon as she arrives back from dialysis. She said her mother is incontinent and by the time she returns to the facility she is soiled. Resident #23's family member said if staff take too long to change her mother's brief I do it myself. She said she prefers doing it herself because she has noticed when nursing staff change her mother's brief, they do not clean the rash she has on her buttocks and apply the medication ointment on top of the old one. She said, I don't think that is right. Resident #23's family member opened her mother's bedside table drawer and pointed to two 3 oz. plastic medication cups with a white creamy substance. One of the cups had a double ended wooden spoon and contained about 2 tablespoons of the white creamy substance. The other cup was about half full of the white creamy substance. Also in the drawer was a bottle of a 16 oz Skintegrity wound cleanser. She said LVN D gave it to her to use when she cleaned her mother's rash. She said she did not receive any training on how to change her mother's brief, clean the area where the rash was or how apply the white creamy substance. She said she has been changing her mother's brief and cleaning the area where she has her rash for a long time but was not able to say how long. Interview on 10/05/2023 at 1:31 p.m., CNA A said he changed Resident #23's brief as soon as she returned from the dialysis facility. He said he noticed she had a rash on her buttocks area. CNA A said he is not allowed to apply any medication/ointment on residents. If he notices anything abnormal, he will immediately notify the charge nurse. Interview on 10/05/2023 at 1:42 p.m., LVN B said Resident #23 has redness to her buttocks, like a rash. She said it was a little open but not much. She said it was considered an ulcer and was unstageable at this time. LVN B said Resident #23 had an order of zinc oxide 20 % to be applied two times a day for 30 days. She said the most recent order started on 10/02/23 and will end 11/01/2023. LVN B said as far as she remembers, Resident #23 has had a zinc oxide 20% order for a while but unable to say how long. LVN B said the facility's protocol for when a CNA notices anything abnormal they are to inform an LVN as soon as possible. But in Resident #23's case, they do not have to since she has an order for zinc oxide. LVN B said the zinc oxide 20 % is kept in the medication cart under lock and key. She said LVN's and med aids have the key to the cart. LVN B checked the eMAR and verified the last time Resident #23 was applied zinc oxide 20% was Thursday 10/05/23 at 7:14 a.m. by LVN C. LVN B opened Resident #23's bedside table drawer and pointed to the two plastic cups with a white creamy substance and immediately said I don't know what it is, but it's not supposed to be there. LVN B later said the white creamy substance looked like zinc oxide. She said the zinc oxide was no longer good since it was uncovered and had been contaminated. LVN B said she knows Resident #23 family member had changed her brief in the past but said she was not aware of her applying any medication. Interview on 10/05/2023 at 2:00 p.m., LVN C said she applied zinc oxide 20% to resident on 10/05/2023 right after she came back from dialysis (not sure of time). LVN C checked the eMAR and corrected herself by saying she had applied zinc oxide 20% at 7:13 a.m. LVN C was asked if she could double check the time the zinc oxide was applied and again, she said on 10/05/2023 at 7:13 a.m. LVN C was asked how was it possible for her to have applied the zinc oxide 20 % at 7:13 a.m. when resident left the facility at 4:49 a.m. and didn't return until 9:00 a.m. LVN C said, Well I gave it family member. She said Resident #23's family member always asks for the zinc oxide before Resident #23 gets back from dialysis. She said aside from requesting the zinc oxide she also requests clean sheets, a new brief, wipes to have it ready for her mother comes back from dialysis. She said Every morning I give family member the zinc oxide 20 %. I place it on a medication cup along with a wooden spoon (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 15 of 22 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 10/06/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and cover it with a plastic (like the one used in the kitchen) wrap. LVN C said she has never personally seen Resident #23's family member change her brief or apply the zinc oxide. She was not able to estimate how long she had been giving Resident #23's family member the zinc oxide 20 % but said it has been a while. LVN C opened Resident #23's bedside dresser drawer and identified the two plastic cups with white creamy substance as zinc oxide. She said she was not able to say how long the two plastic cups had been in the bedside dresser drawer. LVN C said the zinc oxide in the bedside dresser drawer was no longer good as it had been exposed to the air and might have been contaminated as it was not covered. She said if a family member who is not trained on how to apply the zinc oxide applies it, they might apply where they are not supposed to. LVN C said Resident #23 had an unstageable pressure ulcer. LNV C said she did not know who gave Resident #23's family member the cleansing spray but it was not her. Interview on 10/06/2023 at 2:25 p.m. LVN D/Wound Care Nurse said Resident #23 was no longer receiving wound care as of 09/20/2023. She said Resident #23 had moisture-associated skin damage on both her buttocks and had an active order of zinc oxide 20%. She said she still did weekly wound care assessments on Resident #23. She described the zinc oxide as a white creamy substance. LVN D opened Resident #23's bedside dresser drawer but the two plastic cups with the white creamy substance were no longer in the drawer. LNV D checked the three drawers, but the 2 plastic cups were not found. LVN D checked Resident #23's closet and found the cleansing spray. She said she had never given Resident #23's family member any cleansing sprays. She said she initials the spray bottles she used and the one found in the closet was not initialed. LVN D said she was not sure how the cleansing spray got to Resident #23's room as she keeps all the cleansing sprays under lock in her office. She said all LVNs have access to her office. The Surveyor showed LVN D a picture of the 2 plastic cups with white creamy substance found in Resident #23's bedside dresser drawer and she identified them as zinc oxide. She said if a family member were to apply the zinc oxide that was left in Resident #23's room, they could make the rash worse because it was exposed to open air. She said if staff finds medication in a resident's room, they are to pick it up and report it to the DON and Administrator. LVN D said only licensed nursing staff are permitted to apply zinc oxide to residents. If a CNA is changing a resident's brief and notices, they need any medication they are to report it to an LVN. Interview on 10/06/2023 at 3:35 p.m., ADON E said the last time Resident #23 was applied the zinc oxide 20% was on 10/05/2023 at 7:13 a.m. She did not know why LVN C entered on the eMAR that time if Resident #23 was not even in the facility. She said I would have to ask (LVN C.) She said generally speaking a medication is marked off on the eMAR right after it has been administered. ADON E identified the two plastic cups found in Resident #23 as zinc oxide and confirmed it had been given to family member by a nurse. ADON E said she has knowledge of Resident #23's family member repositioning, changed her brief, and applied the zinc oxide to Resident #23. She said she was not aware of the wound cleanser spray was left in Resident #23's room. ADON E explained the reason Resident #23's family member changes her brief and applied the zinc oxide is because she helps provide care to her mother. ADON E said the zinc oxide should only be applied by a licensed staff. The Surveyor asked if Resident #23's family member had been educated on how to apply the zinc oxide, she said no. ADON E said in her professional opinion, the zinc oxide found in the bedside dresser drawer was still good to use. The Surveyor asked if Resident #23's family member knew how much to use, and she said it did not matter because the order did not specify whether to apply a thick or thin layer. Record review of the facility's Administering Medication policy revealed: 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 16 of 22 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 10/06/2023 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 0761 Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. 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 17 of 22 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 10/06/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain clinical records on each resident that were complete and accurate, for one Resident (R# 81), of eight residents reviewed for clinical records, in that. LVN did not document the results of two skin assessments for pressure ulcers in the sacrum and in left heel in Resident #81's clinical records. This failure could place residents at risk for not receiving proper care and treatments. The findings were: Record review of Resident #81's admission record dated 10/05/23 reflected Resident #81 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. Resident #81 was an [AGE] year-old female with diagnoses that included pressure ulcer of the sacral region (triangular bone at botom of the spine) stage 4 (a full-thickness tissue loss with exposed bone, tendon, or muscle), diabetes (sustained high blood sugar levels), and pressure ulcer of left heel (localized damage over a bony area.) Record review of Resident #81's admission MDS dated [DATE] reflected Resident #81 had severe cognitive impairment, required two-person assist for bed mobility and toilet use, had a stage 3 pressure ulcer, one unstageable pressure injury presenting as deep tissue injury, that were present upon admission. Record review of the care plans dated 10/05/23 for Resident #81 reflected resident had a stage 4 pressure injury to the sacrum, with potential for further decline, date initiated 09/29/23. Interventions included to assess/record/monitor wound healing weekly. Measure length, width, and depth where possible, date initiated 09/29/23. Record review of the care plans dated 10/05/23 for Resident #81 reflected resident had an unstageable pressure ulcer to left heel with potential for decline, date initiated 09/29/23. Interventions included to assess/record/monitor wound healing weekly. Measure length, width, and depth where possible, date initiated 09/29/23. Observation on 10/03/23 at 10:35 am revealed Resident #81 was in her bed, eyes closed and with heel protectors on both feet. Resident #81 did not respond to the surveyor's greeting. Record review of the weekly skin integrity review dated 09/28/23 for Resident #81 reflected no documentation for the assessment for Resident #81's pressure ulcer to the sacrum or the left heel. Record review of the progress notes for Resident #81 on 10/04/23 reflected no documentation on 09/29/23 or 10/03/23 related to the skin assessment results for Resident #81 pressure ulcer to sacrum and left heel. Interview on 10/04/23 2:51 pm with LVN M revealed she was the wound care nurse. LVN M said she had completed a weekly skin assessment on Resident #81 on 09/29/23. LVM M said she had not entered the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 18 of 22 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 10/06/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few results of the assessment into Resident #81's progress notes or the weekly skin integrity review dated 09/29/23. LVN M said she had written the information on a wound care report form, and she had not downloaded that form into Resident #81's clinical records. LVN M said she was keeping the wound report dated 09/29/23 in her desk and she was going to enter the results of the assessment later in the day. LVN M said she should have entered the weekly assessment results in the resident's clinical records on the same day, in the progress notes and in the weekly skin form dated 09/29/23, but she had not had time. LVN M said Resident #81's wound physician had come to see Resident #81 to assess her wounds, sacrum, and heel in the evening on 10/03/23. LVN M said she had written the results of the wounds assessment on a piece of paper, and she had not entered the information into Resident #81's clinical records, weekly skin assessment form or in the resident's progress notes. LVN M said she had not had time to enter the wound assessments into Resident #81's clinical records, the weekly skin assessment and in progress notes. Record review of the paper wound report for Resident #81 dated 09/29/23 reflected measurements of the wound to the sacrum stage 4 size 4.8 x 4.6 x 0.5, 100% slough, pending orders, called doctor. The report reflected a pressure unstageable for the left heel measurements were 1.9 x 1.7, 100% slough pending orders, called doctor, continue with previous orders. Record review of the assessments for Resident #81 dated 10/03/22 reflected a stage 4 wound to the sacrum measurements 4.9x 4.5 x0.5 with 95% slough, 5% granulation. Report reflected left heel pressure unstageable measurements, 1.7 x 0.9, 100% slough. Continue with current orders. Interview on 10/05/23 at 2:35 pm with LVN B revealed all information pertaining to a resident should be entered into the computer system in the resident's clinical records at least before their shift was over during the day. The information should be entered into the progress notes and if needed a risk assessment form as soon as possible to ensure that information was shared with staff. Interview on 10/05/23 at 2:43 pm with RN N revealed staff should document any assessment or skin concerns in the progress notes and he would notify the wound treatment nurse right away if any skin condition was found. The wound treatment nurse would document in her notes and forms the skin condition. RN N said staff was expected to document in clinical records before they left their shift. Interview on 10/06/23 at 10:14 am with LVN O revealed progress notes and assessments should be documented in the resident's computerized clinical records, in the progress notes and if skin assessments, they should notify the wound treatment nurse so she can enter in her skin assessments and into the resident's clinical records. LVN O said progress notes and risk management are documented as it happens, process and should be documented right away in the clinical chart for the resident at least on the same day. Interview on 10/06/23 at 2:30 pm with the ADON E revealed staff should enter all information into the resident's clinical records as soon as the information was obtained. ADON E said information about weekly skin assessments should be entered into the progress notes and the skin assessments forms right away and failure to document in the resident's clinical records could cause the information to get forgotten, lost, and missed information on assessments. ADON E said it was the DON's responsibility to ensure the nurses were documenting and following the documentation policy. Record review of the facility policy titled Charting and Documentation revised July 2017 reflected All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 19 of 22 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 10/06/2023 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 0842 resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 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 20 of 22 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 10/06/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling Legionella through a program that identifies areas in the water system where Legionella can grow and spread for 1 of 1 facility. Residents Affected - Many The facility failed to have a system in place for preventing and controlling Legionella through a program that identifies areas in the water system where Legionella could grow and spread. This deficient practice places the facility residents at risk for airborne infections. The findings included: Interview on 10/05/23 with the Maintenance Director at 10:10 a.m., he stated he did not know what Legionnaire's was. He stated he had been working at the facility for 2 years. Stated the only thing he checks every week is the water temperatures. Stated to his knowledge, there is no system to monitor effectiveness of control measures. Stated he had training upon hire from the previous maintenance director but not on anything regarding checking for bacteria in the facility water. He is also unaware of the facility policy, Legionella Water Management Program. Interview on 10/05/23 with the Administrator at 11:15 a.m., he stated he thinks there is a system in place for preventing and controlling Legionella in the facility. Stated he will look for the map indicating where Legionella and other opportunistic waterborne pathogens can grow and spread. He stated he would speak to the Maintenance Director regarding not being aware of having a Legionella policy. Interview on 10/06/23 at 5:31 p.m. with the Administrator, he stated he was not able to provide me with any system that had been in place to prior to the state agency's visit, to prevent, detect or control water borne contaminates, including Legionella. A map was not provided of where Legionella and other opportunistic waterborne pathogens can grow and spread. A record review of the facility's Legionella Water Management Program Policy Interpretation and Implementation revised 09/2022 revealed the water management program included the following elements: 5. b. A detailed description and diagram of the water system in the facility, including the following: 1. Receiving 2. Cold water distribution 3. Heating 4. Hot water distribution 5. Waste 5. c. The identification of areas in the water system that could encourage the growth and spread of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 21 of 22 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 10/06/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Legionella or other waterborne bacteria, including the following: storage tanks, water heaters, filters, aerators, showerheads and hoses, misters, atomizers, air washers and humidifiers, hot tubs, fountains, and medical devices such as CPAP machines, hydrotherapy equipment etc. 5. d. The identification of situations that can lead to Legionella growth, such as: Residents Affected - Many 1. Construction 2. Water main breaks 3. Changes in municipal water quality 4. The presence of biofilm, scale, or sediments 5. Water temperature fluctuations 6. Water pressure changes 7. Water stagnation 8. Inadequate disinfection 5. e. Specific measures used to control the introduction and/or spread of legionella (e.g., temperature, disinfectants) f. The control limits or parameters that are acceptable and that are monitored g. A diagram of where the control measures are in place h. A system to monitor control limits and the effectiveness of control measures i. A plan for when control limits are not met or not effective j. Documentation of the program FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455761 If continuation sheet Page 22 of 22