Inspection·June 29, 2023

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some She stated she followed-up with the residents and asked them questions about the concern. She stated she reviewed old business at the next Resident Council Meeting and reviewed concerns and what was done to correct any problems, such as laundry issues. The Activity Director provided copies of last two Resident Council Meeting Minutes and last three months of activity calendars for review. In an interview on 6/27/23 at 3:56 PM, the facility's Social Worker stated she kept a grievance log and would provide the grievance log for 2023 for review. In an interview on 6/28/23 at 3:34 PM, the Activity Director stated a Resident Council meeting was not held during May 2023 because she worked the floor as a CNA. In a confidential group interview on 6/28/23 on 3:42 PM, during a Resident Council Meeting, the 7 residents in attendance stated Resident Council meetings were not held regularly. One resident stated a meeting during May was not held because the Activity Director had to work the floor as a CNA. A resident stated the Activity Director wears many hats, drives the facility van, and does a lot of other things. The Resident Council President stated the meetings were not held routinely and the last meeting was held in April 2023. One resident stated the previous Activity Director held Resident Council Meetings regularly every month, but she had been gone for almost 2 years. The residents stated they did not attend Resident Council Meetings regularly because the meetings were not held regularly. Some of the residents stated they did not know about the Resident Council Meetings so had not ever attended. The residents stated they did not know they could meet as a group to discuss their concerns without the Activity Director or other staff present. In an interview on 6/29/23 at 10:13 AM, the Administrator stated the grievance process started with the Social Worker, who did the tracking log, and initiated the investigation. The Administrator stated anyone could complete the grievance form and give it to the Social Worker. The Administrator stated grievances were discussed in the morning meetings and she assigned the person to address the concern or grievance. The Administrator stated she reviewed and signed the grievance form after verifying the concern has been addressed and resolved. She stated the facility grievance policy was included in the admission packet, as well as resident rights. The Administrator stated maybe she needed to have a meeting with the Resident Council regarding the Grievance Process. She provided a copy of the facility's policy and procedures for filing grievances for review. She stated a copy of the resident rights was included in the admission packet. During an interview and record review on 6/29/23 at 10:35 AM, the Payroll Coordinator stated she had started employment in the facility during December 2022 and had not known the prior Activity Director. She reviewed the files for the Activity Department staff and stated she the current Activity Director was hired on 12/09/21 and was also listed as a CNA. She stated the prior Activity Director had given a 30-day notice and left voluntarily during the first part of December 2021. In an interview on 6/29/23 at 10:47 AM , the Activity Director stated she had taken nurse aide training and passed the certification test last summer, about 1 year ago, so she could drive the facility van and be the transportation driver for resident appointments and activity outings. She stated she took residents to appointments, which were local and out of town. She stated sometimes she found out the morning of the appointment and other times she found out 1 or 2 days in advance. The Activity Director stated some appointments required her to be gone all day. The Activity Director stated she had been filling in as a CNA on the day shift during May and June. She stated she had not been able to have activities and Resident Council meetings as scheduled . The Activity Director stated there was not a Resident Council meeting held during May 2023 and there had not been a Resident Council (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455906 If continuation sheet Page 2 of 8 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 455906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lone Star Rehabilitation & Wellness Center 2601 Northwest Loop Stephenville, TX 76401 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 0565 Meeting for this month [June] so far. Level of Harm - Minimal harm or potential for actual harm In an interview on 6/29/23 at 5:03 PM , the facility's Social Worker and the Administrator stated the stated the Activity Director was good about telling them when the Resident Council had concerns or complaints. The Social Worker stated sometimes she filled out a grievance report form with Resident Council on it and other times she put the resident's name on it. The Administrator stated she did not think there were any grievance forms from the March 2023 and April 2023 Resident Council meetings. The Administrator stated she had not realized the Resident Council meetings were not being held as scheduled. She stated she spoke with the nursing staff and told them that they could not keep pulling the Activity Director from activities and have her work the floor. Residents Affected - Some Review of the facility's policy and procedure for Resident Council, not dated, revealed the following [in part]: Policy Statement The facility supports residents' desires to be involved and have input in the operation of the facility through the Resident Council. Policy Interpretation and Implementation 1. The purpose of the Resident Council is to provide a forum for: a. Residents too have input in the operation of the facility; b. Discussion of concerns; c. Consensus building and communication between residents and facility staff; and d. Staff to disseminate information and feedback from interested residents . 2. Appointment to the council: c. The facility will designate, with the approval of the council, and administrative representative. However, the facility representative will only remain in council meetings as requested by the council. Minutes must reflect such requests. 7. Council meetings are scheduled monthly or more frequently if requested by residents or the Administrator. The date, time, and location of the meetings are noted in the Activities calendar. A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible to address the item(s) of concern. 8. Minutes include names of the council members and guests present; issues discussed; recommendations from the council to the Administrator; and follow-up on prior issues. 9. The Administrator reviews the minutes and any responses from departments within the facility. Responses are presented at the next meeting, or sooner, if indicated FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455906 If continuation sheet Page 3 of 8 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 455906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lone Star Rehabilitation & Wellness Center 2601 Northwest Loop Stephenville, TX 76401 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interview and record review, the facility failed to make information on how to file a grievance or complaint available to the residents, including notifying residents individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed for reviewed for resident rights, in that: 1. The facility failed to ensure residents knew how to file a grievance, as expressed during the Resident Council group meeting held 6/28/23. 2. The facility failed to ensure residents knew who was responsible for addressing and investigating any complaints or concerns they may have regarding life in the facility. The facility's failure placed the residents at risk for concerns not being reported and addressed, decreased quality of life, and a decreased feeling of well-being within their living environment. The findings included: Review of the Resident Council Minutes, dated 4/18/23 at 2:30 PM, revealed documentation that 4 residents had attended, old business from the last month's minutes was reviewed, and new business was discussed. The new business documented concerns regarding new televisions in the residents' rooms. The residents could not see them and needed help learning how to use the new remote controls. The Activity Director documented the concern was reported to the appropriate department. There was no further documented follow-up to the concern regarding the new in-room televisions. The meeting was not held on the originally scheduled dated of 4/04/23. Review of the facility Grievance /Complaint Report form revealed sections to document the date, name of resident and/or representative, nature of the grievance/complaint, documented facility follow-up, and documented resolution of grievance/complaint. Review of the Monthly Grievance Logs and Grievance Report Forms revealed there were no documented grievances from the Resident Council during the past 6 months (December 2022 - June 2023 to date). In an interview on 6/27/23 at 3:30 PM , the Activity Director stated if there were Resident Council concerns, she filled out a grievance form and gave it to the department that needed to address it. She stated she followed-up with the residents and asked them questions about the concern. She stated she reviewed old business at the next Resident Council Meeting and reviewed concerns and what was done to correct any problems, such as laundry issues. In an interview on 6/27/23 at 3:56 PM, the facility's Social Worker stated she kept a grievance log and would provide the grievance log for 2023 for review. In a confidential group interview on 6/28/23 on 3:42 PM, during a Resident Council Meeting, the 7 residents in attendance stated they were not sure how to file a complaint or grievance. One resident stated she did not know how to fill out a grievance form and stated some of the residents could not write. The residents did not know who was in charge for addressing complaints. The stated they could tell concerns to the nurse working on their hall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455906 If continuation sheet Page 4 of 8 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 455906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lone Star Rehabilitation & Wellness Center 2601 Northwest Loop Stephenville, TX 76401 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation of 6/29/23 at 10:04 AM revealed a table desk located in the front lobby against wall outside the door to the Business Office Manager's office. Grievance forms in a tray were located on the upper left hand side corner of the table. In an interview on 6/29/23 at 10:13 AM, the Administrator stated the grievance process started with the Social Worker, who did the tracking log and initiated the investigation. The Administrator stated anyone could complete the grievance form and give it to the Social Worker. The Administrator stated grievances were discussed in the morning meetings and she assigned the person to address the concern or grievance. The Administrator stated she reviewed and signed the grievance form after verifying the concern has been addressed and resolved. She stated the facility's grievance policy was included in the admission packet, as well as resident rights. The Administrator stated maybe she needed to have a meeting with the Resident Council regarding the Grievance Process. She provided a copy of the facility's policy and procedure for filing grievances for review. In an interview on 6/29/23 at 5:03 PM, the facility's Social Worker and the Administrator stated the stated the Activity Director was good about telling them when the Resident Council had concerns or complaints. The Social Worker stated sometimes she filled out a grievance report form with Resident Council on it and other times she put the resident's name on it. The Administrator stated she did not think there were any grievance forms from the March 2023 and April 2023 Resident Council meetings. Review of the facility's policy and procedure for Grievances/Complaints, Filing, dated as revised April 2017, revealed the following [in part]: Policy Statement Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g. the State Ombudsman). The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Policy Interpretation and Implementation 1. Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished. 2. Residents, family and resident representatives have the right to voice or file a grievance without discrimination or reprisal in any form, and without fear of discrimination or reprisal. 3. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. 4. Upon admission, residents are provided with written information on how to file a grievance or complaint . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455906 If continuation sheet Page 5 of 8 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 455906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lone Star Rehabilitation & Wellness Center 2601 Northwest Loop Stephenville, TX 76401 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 6. The contact information for the individual(s) with whom a grievance may be filed is provided to the resident and/or representative upon admission . 8. Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint . 10. The Grievance Officer, Administrator and Staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated . 12. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455906 If continuation sheet Page 6 of 8 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 455906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lone Star Rehabilitation & Wellness Center 2601 Northwest Loop Stephenville, TX 76401 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation interview and record review, the facility failed to ensure that the daily nurse staffing was posted as required for 2 of 3 days (06/27/23 and 06/28/23) reviewed for nursing services and postings. Residents Affected - Many The facility failed to update the daily staffing information posting. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census. Findings included: Observation with the DON on 06/27/23 at 03:49 PM, concerning staffing posting, revealed the DON showed where it was located. It was on a counter near the front entrance, and it was not prominently posted where everyone could see it. It only had the shift with a number identifying who (which type of staff) was working and did not identify the name of the facility. It did have the date and census. It did not identify the total number of hours worked. Interview with the DON on 06/27/2023 at 03:49 PM, The DON said this is the format they have been using for 20 years and did not know of another way to do it. She provided copies of the same form the facility saved that dated back to 06/02/23. Interview with the ADM on 06/27/23 at 04:10 PM, The ADM said staff postings should have the date, number of different types of staff, RN, LVN, CNA. She then read the Texas Health and Human Services required postings from her computer. The ADM said her posting did not have the name of the facility on it. And she also said it does not have the hours worked. Interview with the ADM and DON on 06/28/23 at 02:31 PM, Interview with the Administrator and the DON about nurse staffing posting. The ADM said that the staff reviewed information that was required to be posted. The ADM said discussions about how the form should have the census for each shift and a column for scheduled hours and actual hours worked were done. The DON stated the facility did not have a policy about staff postings. Observation 0n 0627/2023 at 2:55 PM revealed a new posting form for nurse staffing with all required information was presented to the survey team. 06/27/23 at 04:35 PM, record review of the form used by the facility to show nursing staff working each day revealed an 8.5 x 11 white sheet of paper with the following information on it; o Upper left corner, the day's date o Top center of the page, Census o (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455906 If continuation sheet Page 7 of 8 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 455906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lone Star Rehabilitation & Wellness Center 2601 Northwest Loop Stephenville, TX 76401 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 0732 Single column broken down into Day Shift 6A-6P and below that Night Shift 6P-6A Level of Harm - Potential for minimal harm o Residents Affected - Many Under the 6A-6P heading it had RN:, LVN:, CMA:, and CNA: with total number of staff working that shift only. o Beneath Night Shift 6P-6a it had RN:, LVN;, CNA: with total number of staff working that shift only. The form did not include the facility name, the total number and the actual hours worked for each category listed on form for those categories of both licensed and unlicensed nursing staff who had direct contact with residents The facility provided copies of their nurse staffing information for the following dates: 06/02/23, 06/05/23, 06/06/23, 06/09/23, 06/12/23, 06/13/23, 06/14/23, 06/15/23, 06/16/23, 06/19/23, 06/20/23, and 06/23/23. The facility did not provide a policy on nursing staff postings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455906 If continuation sheet Page 8 of 8