Health inspection·June 28, 2023

F 0584 wheelchair to the restroom in room [ROOM NUMBER]. Level of Harm - Minimal harm or potential for actual harm Observation conducted on 06/26/23 02:00 PM Resident #15 and Resident # 35 observed awake and resting in bed. Resident # 35 reported that she had been using the bathroom in room [ROOM NUMBER] down the hallway, which was vacant, due to the in-room toilet not working. Resident #15 reportedly was using a bedside commode in the bathroom. Residents Affected - Few Observation conducted on 06/26/23 at 4:30 PM revealed Resident # 35 self-propelled in her wheelchair to the restroom in room [ROOM NUMBER]. Observation conducted on 06/27/23 at 10:16 AM revealed Resident # 35 self-propelled in her wheelchair to the restroom in room [ROOM NUMBER]. Observation conducted on 06/27/23 at 12:50 PM revealed Resident #35 self-propelled in her wheelchair to the restroom in room [ROOM NUMBER]. Observation conducted on 06/27/23 at 2:50 PM revealed Resident #35 self-propelled in her wheelchair to the restroom in room [ROOM NUMBER]. Observation conducted on 06/28/23 at 8:10 AM revealed Resident #35 self-propelled in her wheelchair to the restroom in room [ROOM NUMBER]. Observation conducted on 6/28/23at 8:30 am revealed measurement from Resident # 35 's bed to bathroom in room [ROOM NUMBER], conducted by surveyor is 175 ft. Observation conducted on 06/28/23 at 9:35 AM revealed Resident # 35 self-propelled in her wheelchair to the restroom in room [ROOM NUMBER]. Observation conducted on 06/28/23 at 10:50 AM revealed Resident # 35 self-propelled in her wheelchair to the restroom in room [ROOM NUMBER] Observation conducted on 06/28/23 at 1:19 PM revealed Resident #35 self-propelling in her wheelchair in the hallway in facility. Resident #35 stated she was going to the restroom in room [ROOM NUMBER]. Observation conducted on 06/28/23 at 3:20 PM revealed Resident # 35 self-propelled in her wheelchair to the restroom in room [ROOM NUMBER]. Observation conducted on 06/28/23 at 5:10 PM revealed Resident# 35 self-propelled in her wheelchair to the restroom in room [ROOM NUMBER]. Review conducted on 6/28/23 at 2:30 pm of Face sheet for Resident #15 dated 6/28/23 revealed a 82 y/o female admitted on [DATE] with the diagnosis that include unspecified Dementia ( a mental disorder in which a person loses the ability to think, remember, learn, make decisions and solve problems) , unspecified abnormalities of gait and mobility (the inability to walk in the usual way), Muscle wasting and atrophy, not elsewhere classified, multiple sites ( the thinning of muscle mass). Review of MDS conducted on 6/28/23 at 2:30 pm for Resident # 15 dated 3/20/23 revealed a BIMS score of 10 ( 8-12 suggest Moderately Impaired cognitive ability) With a activity assessment of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 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 0584 Supervision or touching assistance for toileting hygiene. Level of Harm - Minimal harm or potential for actual harm Review of Care plan conducted on 6/28/23 at 2:30 pm for Resident # 15 revised 6/7/23 revealed incidents of Urinary incontinence due to diuretic therapy with urgency and resident will maintain continence by using briefs, Depends or panty liners when out of bed, offer and assist with toileting routinely and prn, and keeping the call light in reach. Residents Affected - Few Observation conducted on 06/26/23 02:00 PM Resident #15 and Resident # 35 observed awake and resting in bed. Resident # 35 has been using the toilet in room [ROOM NUMBER] down the hallway, which is vacant, due to the in-room toilet not working. Resident #15 was using a bedside commode in the bathroom Interview conducted on 06/28/23 at 9:30 AM -with Resident # 15 stated she would rather have a working toilet in her room due to having incontinence and would not be able to make it down the hall to use the restroom. Furthermore, Resident #15 stated having a bedside commode was a nuisance, but it works, and staff have been good about cleaning it. Review conducted on 6/28/23 at 3:00 pm of Face Sheet for Resident #33 dated 6/28/23 reflected an 90 y/o female admitted on [DATE] with diagnosis that include Alzheimer's disease with late onset, ( A progressive disease that destroys memories and other brain functions), Other lack of coordination( Impaired or loss of coordination), overactive bladder ( a problem with bladder function that causes a sudden need to urinate) , Stage 3 chronic Kidney disease ( mild to moderate damage to the kidneys that can affect their ability to function) Review conducted on 6/28/23 at 3:00 pm of MDS for Resident # 33 dated 4/7/23 reflected a BIMS score of 9 (8-12 suggest moderately impaired cognitive ability) and an active score of set up/ clean up assistance for toileting hygiene. Review conducted on 6/28/23 at 3:00 pm of Care Plan for Resident # 33 dated 5/16/23 reflected urinary incontinence with a history of urinary tract infection, incontinent of bowel and bladder and has stage 3 chronic kidney disease interventions encourage prompt, complete bladder emptying, keep perineal area clean and dry, Interview with on 06/28/23 09:03 AM Resident # 33 observed standing in room with walker. Surveyor observed the toilet to still be running; Resident stated it always ran, she did not even notice it anymore: she stated she was not sure if it was the plumbing. Interview conducted on 06/28/23 at 9:20 AM with Administrator revealed IDM was from another facility to help Maintenance department, as their Maintenance Director was out on vacation. 06/28/23 11:25 AM Interview with HA D stated the Resident # 35 has been coming down to use the restroom for about 3 weeks. she has not had to assist Resident # 35. HA D stated she assist with therapy and resident is currently not on service, so she was unaware of her status, but the resident appears to be very independent. She is not familiar with Resident # 15. 6/28/23 at 12:45 pm Interview with TCNA E revealed that she has been at the facility since March (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 4th of present year and is familiar with Resident # 15. She has not noticed an increase in the residents' incontinent episodes, but she does call for help to clean the bedside commode, she states the resident has mentioned to her that it would be nice to be able to use a toilet again. 6/28/23 2:03 pm interview with Interim Maintenance director stated he is the maintenance director at sister facility called on Monday to be here to help out while the director was on vacation. He stated that the current method of reporting issues is thru a book at the nurse's station, he was not aware of any tracking system. He was aware of the issue with residents #35 and Residents #15 bathroom and to his knowledge the plumbers were here and assessed the issue, it is a wall toilet, and the leak is coming from the wall, and they will need to replace a part and it is difficult to find. He was also under the impression that both resident's responsible parties were given an opportunity to move to a different room and she declined. He was not aware of the toilet in Resident #33 running as he received no report and was not sure what in the book was completed and no one had notified him. He stated that the likely negative outcome if not repaired would be an inconvenienced and upset resident. 6/28/23 2:15 pm Interview with DOR revealed that the Resident #35 has been coming down to the bathroom in room [ROOM NUMBER] for about 3 weeks, the resident was offered a bathroom closer at the nurse's station and she prefers this one. She reports that the Resident # 35's ability changes with her mood, she goes from independent to stand by/one person depending on how interested she is in the activity. She is not currently on Therapy services. When asked if there would be any negative outcome regarding not fixing the toilet, she stated that she does not see one at this time as the resident is safe to travel down the hall and has good balance and is not a fall risk. DOR stated that she is not familiar with Resident # 15 as she has not been on therapy services in the last 6 months. 06/28/23 04:00 PM Interview with DON, revealed that she is aware of both Resident #15 and # 35 and understands that the family did not wish to move the resident. Asked how she is aware of this she reported that the ADM had spoken to both residents' responsible parties, but she had not. Her understanding is that the parts to repair the leak are difficult to find as it is an older toilet. When asked if she sees any negative outcome with the resident not having a toilet in her room she stated that as a nurse she has no issue with Resident #35 as the resident is safe to navigate the w/c . She stated the resident can go to the public bathroom at the nurse's station but prefers the bathroom in room [ROOM NUMBER]. DON is not sure if resident #35 travels down to room [ROOM NUMBER] at night or uses the bedside commode in her room's bathroom. When asked about Resident # 15 she stated that with the bedside commode in the bathroom she need to notify staff when she is finished so the staff can empty and clean the equipment. 06/28/23 04:25 PM Interview with ADM, revealed he has been here since December. Current expectation is to put all request in maintenance book. Staff are expected to utilize the book to log issues. Residents are instructed to let the staff know of any maintenance issues and the staff are responsible for putting them in the book. The leadership team are assigned residents in a program called angel rounds that are made 5 days a week and they are expected to log any maintenance issues as well. the maintenance director is expected to check the book often, the expectation in that routine repairs should be completed within 24 hours and emergencies dealt with at the time. Currently the Maintenance director signs the book the repairs are completed, there is no tracking system in place at this time for when a repair is made. They do have a computer based maintenance program called TELS but currently the maintenance director is the only one with access, when the usernames for the nurses is available he plans to train them on the system and do away with the log book all together, he anticipates the end of July or the first of August, he has requested the usernames and waiting for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few approval, once that happens , training will begin then the expectation is that TELS will be used by all staff. Asked if he was aware of the toilet in Resident # 33 room was running, and it was in the logbook, he stated that he was made aware after this surveyor's interview with the IMD, he was unable to explain why it was not addressed. Asked ADM about the broken toilet in residents #15 and #35 room , he stated that the toilet is leaking for the wall and because of the age of the building a replacement toilet is difficult to find and so they do not have an ETA for repairs as they are still looking for the part, and he has been getting updates from the plumbers weekly, asked if there was another option available he stated rerouting the plumbing from the wall to the floor but that was difficult as well. Inquired as to what the long-term plan for the residents in the room was, he stated that he updates the families weekly and has offered to relocate the resident to a room with a functioning bathroom but because they would have to get new roommates neither family wishes to do that at the moment. When asked if the administrator was aware that none of the conversations were documented in the medical record , he stated that he has been communication with the families by email and text messages, did not offer to provide information. When asked if there were any potential negative outcome for the resident with no access to a working toilet and he was unable to answer. 06/28/23 10:10 AM Review of Maintenance request log noted that there was a request on 6/4/23 for Resident #15 and # 35's toilet not working on 6/7/23 there is a request for bathroom check for Resident # 15 and #35. 6/7/23 report for toilet running in Resident # 33 room. 6/28/23 10:10 am review of Policy Home like environment dated February 2021 paragraph 2 The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting, these characteristics include: A Clean, sanitary and orderly environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all residents who were unable to carry out activities of daily living received the necessary services to maintain goo personal hygiene for one (Resident #31) of six residents reviewed for activities of daily living. Residents Affected - Few The facility failed to provide regular baths to Resident #31 consistent with his needs and choices . This failure could place residents at risk for decreased hygiene, skin issues, and mental anguish. Findings included: A record review of Resident #31's face sheet dated 6/28/2023 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of type 2 diabetes (uncontrolled blood sugar), [NAME]-like syndrome (rare genetic disorder that results in constant sense of hunger), morbid (severe) obesity, hyperlipidemia (high cholesterol), hypertension (high blood pressure), and gastro-esophageal reflux disorder (acid reflux). A record review of Resident #31's MDS assessment dated [DATE] reflected a BIMS score of 6, which indicated severely impaired cognition. A review of Section G (Functional Status) reflected Resident #31 was totally dependent and required a one-person physical assist with bathing. A record review of Resident #31's care plan last revised on 5/18/2023 reflected Resident #31 was at risk for skin breakdown due to obesity and impaired mobility. Resident #31's care plan reflected he preferred to stay in bed the majority of the day and refused showers often. During an observation and interview on 6/26/2023 at 1:31 p.m., Resident #31 was observed lying in bed. Resident #31 stated he had not had a bed bath in over a month. Resident #31 stated he was starting to itch in places and not getting a bath for so long made him upset and disturbed him. Resident #31 stated he would not mind a shower once a month but preferred bed baths most of the time because staff could not get to all of his cracks and crevasses when he sat in the shower chair. Resident #31 stated nurses insisted on putting him in the shower but he was scared of heights, did not like to be in the shower bed, and preferred bed baths. Resident #31 stated he had communicated his bathing preference to CNA I and other nursing staff. Resident #31 stated CNA I told him she would give him a bed bath the previous week but then three residents fell so she could not get to it. Resident #31 stated CNA I told him she would bathe him the next day but she did not. Resident #31 stated he felt the facility was short-staffed. Resident #31 stated he complained to nursing staff every day about not getting bathes, including the DON. Resident #31 stated the DON assured him she would have CNA I give him a bath that night (6/26/2023). During an interview on 6/28/2023 at 2:09 p.m., CNA J stated she just started working as a shower aide the day prior (6/27/2023) and before that she worked the night shift from 6:00 p.m.-6:00 a.m. CNA J stated she was familiar with Resident #31 and gave him a bath the day prior, on 6/27/2023. CNA J stated Resident #31 did not like the shower chair and preferred bed baths. CNA J stated she had just returned from being off work for two and a half weeks and did not remember giving Resident #31 any other baths or showers in June (2023). CNA J stated if she had given Resident #31 a bath or shower, she would have documented it on his POC. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 6/28/2023 at 2:21 p.m., the DON stated if it were a resident's scheduled shower day and there was nothing documented, it meant they did not receive a shower. During an interview on 6/28/2023 at 2:25 p.m., TCNA F stated she started working at the facility in December, worked four days a week, and had worked with Resident #31 before. TCNA F stated Resident #31 had reported to her that he was a big guy and his private areas did not get clean in the shower because he was scrunched up in the shower chair. TCNA F stated Resident #31 had communicated to her his preference to have a shower once a month and bed baths the rest of the time. TCNA F stated there was no way for CNAs to document refusals of baths/showers in their POC system and that some of the entries reflecting activity did not occur could have been refusals. TCNA F stated Resident #31 did not really refuse bed baths though. TCNA F stated she had never bathed Resident #31 before. TCNA F stated CNA J had given Resident #31 a bed bath the day prior (6/27/2023) but before that she was unsure as to when his last bath or shower was. TCNA F stated yes, unfortunately it was possible Resident #31 went from 6/1/2023-6/27/2023 without being bathed. During an interview on 6/28/2023 at 2:34 p.m., TCNA E stated she had worked in the facility since March 2023 and had worked with Resident #31. TCNA E stated she knew TCNA E's preferences were to receive bed baths more often than showers but stated she had never bathed Resident #31 before. TCNA E stated she had assisted with shaving Resident #31's head in the shower room but this was about six to seven weeks ago. TCNA E stated she had not observed any CNAs go into Resident #31's room to bathe him in the month of June (2023). TCNA E stated Resident #31 sometimes refused showers but she was not aware of Resident #31 refusing baths. TCNA E stated Resident #31 complained to her about not getting baths and reported to her he should be able to receive a bed bath instead of a shower. An interview with CNA I was attempted on 6/28/2023 at 2:49 p.m. but she was unable to be reached. During an interview on 6/28/2023 at 2:53 p.m., CNA G stated she had worked as a shower aide for a month. CNA G stated her primary position was shower aide but the girls would ask for help transferring residents so she would help them. CNA G stated helping CNAs cut into her time to give showers and sometimes she was not able to get to Resident #31. CNA G stated she had not given Resident #31 a shower or bed bath in the past week and she did not recall giving him one between 6/1/2023-6/27/2023. CNA G stated it was not documented, she was not 100% sure he got a shower or bath during that period. During an interview on 6/28/2023 at 3:09 p.m., the DON stated the facility's policy on bathing included offering residents a shower/bath three days a week. The DON stated residents had to refuse three times for it to be considered a refusal. When asked where nursing staff documented refusals, the DON stated, from now on the policy will be if they refused, they have to tell the charge nurse and the charge nurse has to put a progress note. When asked what the number 8 meant on the ADL documentation for bathing on Resident #31's ADL documentation, the DON stated it could mean refused or the activity did not occur. The DON stated staff should let the nurses know so they could document a progress note if residents refused a shower/bath. When asked if there were no documented refusals in Resident #31's progress notes or on his POC for ADLs, how she would know the resident refused, the DON stated, up until today I can't give you the answer. When asked who oversaw staff to ensure showers were being done, the DON stated, it was supposed to be the ADON. The DON stated the ADON monitored by running a bathing report for all residents every Monday. The DON stated if residents were not bathed as scheduled, it could cause skin breakdown and it was a dignity issue. During an interview on 6/28/2023 at 3:41 p.m., CNA H stated she had worked in the facility since (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few February but usually did not work on Resident #31's hall. CNA H stated she had never assisted with bathing Resident #31. During an interview on 6/28/2023 at 4:33 p.m., the Administrator stated he started working in the facility in December of 2022. The Administrator stated each resident had a shower schedule that included bathing them three times a week or as preferred. When asked who ensured bathing was being done as scheduled, the Administrator stated the nurses and nurse leadership including the ADON and DON. When asked how staff were monitored to ensure bathing was done, the Administrator stated, there's reporting that they pull and they can look at it. When asked if there was a way to know whether a resident was bathed if it was not documented, the Administrator stated, we could ask the shower aide or ask the nurse. The Administrator stated charge nurses should document progress notes when residents refuse showers. The Administrator stated he recalled Resident #31 refusing showers a few times in June 2023 but could not remember exactly when. The Administrator stated, we can't force him to do it. When asked what a potential negative outcome was of not being bathed regularly, the Administrator stated skin breakdown or odor. A record review of Resident #31's Point of Care History dated 5/31/2023-6/28/2023 reflected the ADON provided him a shower on 6/01/2023 and CNA J provided him a bed bath on 6/28/2023. There were no documented showers or baths between 6/01/2023-6/28/2023. Activity did not occur was documented on 6/02/2023, 6/03/2023, 6/12/2023, and 6/23/2023. A record review of Resident #31's Point of Care ADL Category Report dated 5/29/2023-6/28/2023 reflected his bathing was coded as the following: 6/01/2023 - 2 6/02/2023 - 8 6/03/2023 - 8 6/12/2023 - 8 6/23/2023 - 8 The report key reflected a number 2 indicated limited assistance and number 8 indicated the activity did not occur. A record review of the facility's policy titled Bath, Shower/Tub dated February 2018 reflected the following: Purpose The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Documentation 1. The date and time the shower/tub bath was performed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 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 0677 5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. Level of Harm - Minimal harm or potential for actual harm 6. The signature and title of the person recording the data. Residents Affected - Few A record review of the facility's policy titled Activities of Daily Living (ADLS), Supporting reflected the following: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation 1. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. b. Unavoidable decline may occur if he or she: (3) Refuses care and treatment to restore or maintain functional abilities and: (b) he or she has been offered alternative interventions to minimize further decline; and; (c) the refusal and information are documented in the resident's clinical record. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) 5. A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. Functional decline or improvement will be evaluated in reference to the Assessment Reference Date (ARD) and the following MDS definitions: e. Total Dependence - Full staff performance of an activity with no participation by resident for any aspect of the ADL activity. Resident was unwilling or unable to perform any part of the activity over entire 7-day look-back period. 6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 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 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. 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 all licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for one (Resident #27) of two residents reviewed for catheter care. LVN A inserted a foley catheter into Resident #27 urethra instead of re-inserting in his suprapubic stoma site and caused trauma and bleeding to the urethral region. This failure caused trauma and bleeding to the urethral region of Resident #27 and has the potential to affect all residents with catheters. Findings included: A record review of Resident #27's face sheet dated 6/27/2023 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of quadriplegia (paralyzed arms and legs), neuromuscular dysfunction of bladder (lack of bladder control), stage 4 pressure ulcer of sacral region (bedsore), depression, muscle wasting and atrophy (muscle breakdown), and non-compliance with medical treatment and regimen. A record review of Resident #27's MDS assessment dated [DATE] reflected a BIMS score of 14, which indicated no cognitive impairment. This assessment also reflected Resident #27 had an indwelling catheter and ostomy, and his primary reason for admission was traumatic spinal cord dysfunction. A record review of Resident #27's care plan last revised on 5/16/2023 reflected he had a suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow) due to quadriplegia (paralyzed arms and legs) with neuromuscular bladder dysfunction (lack of bladder control) and tendency to refuse catheter care at times. Resident #27's care plan goal reflected his suprapubic catheter would be maintained by nursing staff without complications. A record review of Resident #27's physician order dated 6/12/2022 reflected he had an order to have his catheter tubing and drainage bag changed as needed for indications of blockage, increased sediment, infection or displacement. A record review or Resident #27's discontinued physician orders dated 5/272023-6/27/2023 reflected no orders for a foley (transurethral) catheter. During an interview and observation on 6/26/2023 at 3:06 p.m., Resident #27 was observed lying in bed. Resident #27 stated one week ago (6/19/2023) LVN A put Resident #27's catheter in his urethra even though he needed a suprapubic catheter. Resident #27 stated the Wound Care Physician was there last Monday (6/19/2023) and he took out the catheter that LVN A inserted. Resident #27 stated he was concerned about getting a UTI after what had happened. Resident #27 stated LVN A still worked at the facility but that he did not work with Resident #27 anymore. Resident #27 stated on 6/19/2023 he had asked LVN A to change his suprapubic catheter. Resident #27 stated LVN A had done it before but that time instead of putting it in his belly LVN A put in his urethra. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 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 0690 Level of Harm - Actual harm Residents Affected - Few During an interview on 6/26/2023 at 3:47 p.m., Resident #27 provided more details about the incident with LVN A on 6/19/2023. Resident #27 stated LVN A had come into his room on 6/19/2023 to reposition him and give him medication. Resident #27 stated he told LVN A his suprapubic catheter was getting clogged. Resident #27 stated LVN A took out his suprapubic catheter and had syringes ready to go but when he tried to insert it the first time, LVN A put the catheter in his suprapubic region and blew up the balloon but the balloon was faulty-instead of inflating in his belly, Resident #27 stated the balloon inflated outside his belly. Resident #27 stated he told LVN A to just get another one but LVN A stated there was no more saline. Resident #27 stated LVN A left the room to retrieve more supplies, came back and did the balloon, and he felt something stinging but he thought he just had to pee. Resident #27 stated he could not see where LVN A was inserting the catheter because LVN A's gown was covering it up. Resident #27 stated LVA A did not explain to him where he was inserting the catheter. Resident #27 stated LVN A had changed his suprapubic catheter a few times and he did not know why LVN A inserted it through the urethra. Resident #27 stated on 6/19/2023 he found out the catheter was in his urethra when TCNA E came to him and asked what was wrong with his catheter. Resident #27 stated the Wound Care Physician was also in his room on 6/19/2023 and when he went to turn Resident #27 to provide wound care, the Wound Care Physician told Resident #27 his catheter was in his urethra. Resident #27 stated he asked the Wound Care Physician to put the catheter in his suprapubic region. Resident #27 stated on 6/19/2023 he told the DOR and Administrator about the incident. Resident #27 stated the DON came in and saw that he was bleeding on 6/19/2023 and he told he wanted to see how it goes instead of going to the hospital. Resident #27 stated he had some imaging of his pelvic region done on 6/22/2023 but he did not have the results yet. Resident #27 stated LVN A still came in his room to work with his roommate but he did not trust him at all. During an interview on 6/26/2023 at 4:08 p.m., the DOR stated she always went in Resident #27's room throughout the day to maintain him with preventing contractures. The DOR stated he did not have contractures then but he was stiff. The DOR stated on 6/19/2023 she went into Resident #27's room and he had a towel underneath his groin area with plenty of blood. The DOR stated it was not gushing but you could tell he bled and stated approximately 1/3 of the bath towel was covered with blood. The DOR stated Resident #27 had asked LVN A to change his catheter and since he did not have a lot of feeling, he could not tell that LVN A had put it [the catheter] through the urethra. The DOR stated Resident #27 reported he got the Wound Care Physician to correct it. The DOR stated Resident #27 wanted to wait to be cleaned up until the DON and Administrator came in. The DOR stated she went to get the DON, told her she needed to see Resident #27, and returned back to Resident #27's room with the DON. The DOR stated in front of Resident #27, the DON stated, we'll educate our staff and personally, if something happens to you as a patient, that was not what a patient would want to hear. The DOR stated she filed a grievance on 6/19/2023 on Resident #27's behalf. The DOR stated she did not know whether LVN A had received any disciplinary action. The DOR stated Resident #27 had an ultrasound of the pelvis on 6/22/2023. The DOR stated Resident #27 wanted a scan instead of going to the hospital because he believed he had trauma and just needed to wait it out. During an interview on 6/27/2023 at 8:46 a.m., TCNA E stated she oftentimes went into Resident #27's room with the Wound Care Physician to assist. TCNA E stated she was in Resident #27's room on 6/19/2023 around 11:00 a.m. helping the Wound Care Physician and she asked Resident #27 what had happened to his catheter because it was usually in his abdomen and she saw it was not in his belly. TCNA E stated when her and the Wound Care Physician pulled back Resident #27's sheet they discovered the catheter was inserted into his penis instead of the suprapubic area. TCNA E stated when the Wound Care Physician took out the foley catheter from Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 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 0690 Level of Harm - Actual harm Residents Affected - Few #27's penis, it squirted out blood and it was enough that it alarmed her. TCNA E stated a towel was placed to help soak up the blood. TCNA E stated the Wound Care Physician told her pass on the information if Resident #27 got a fever, chills, or kept bleeding. TCNA E stated she passed this information along to LVN B around 11:00 a.m. on 6/19/2023. TCNA E stated she went back to Resident #27's room around 1:00 p.m. to check on him and there was splattered blood on a bath towel and his penis was still leaking blood. TCNA E stated LVN B was passing medications around 11:00 a.m. on 6/19/2023 and she was not sure whether LVN B went into Resident #27's room between 11:00 a.m. - 1:00 p.m. that day. TCNA E stated she worked 6/20/2023 and Resident #27's bleeding has stopped. During an interview on 6/27/2023 at 8:49 a.m. the Wound Care Physician stated on 6/19/2023 he was going to have another nurse take out Resident #27's foley catheter but Resident #27 did not want LVN A to do it because he did not trust LVN A. The Wound Care Physician stated he removed the catheter from Resident #27's penis since it was in the wrong place and then inserted a fresh sterile suprapubic catheter. The Wound Care Physician stated no that LVN A should not have placed the catheter through Resident #27's penis. The Wound Care Physician stated inserting a suprapubic catheter was pretty easy but if a nurse was having trouble and could not advance the catheter through the suprapubic, that would be the time to send someone else to do it. The Wound Care Physician stated when he removed the catheter from Resident #27's penis, there was some blood that returned and that could indicate some kind of trauma to the urethra. The Wound Care Physician stated he did not know the anatomy of Resident #27's urinary and whether he had a stricture (narrowing of the urethra) or scarring but Resident #27's urologist would know. During an interview on 6/27/2023 at 4:07 p.m., the DON stated Resident #27 refused to be followed by a urologist. During an interview on 6/28/2023 at 8:31 a.m., LVN A stated Resident #27 was pretty rough sometimes. LVN A stated he entered Resident #27's room on 6/19/2023 to administer medicine and Resident #27 told him to cath me. LVN A stated Resident #27 reported the night shift had not done this. LVN A stated, I know how to do a suprapubic, I've been doing them for 20 years and stated there was no bleeding when he cathed Resident #27 in his penis. LVN A stated he had received training on suprapubic catheter insertion in 2003 and another nurse had shown him how to do it when he started working in the facility two months ago. LVN A stated he had changed Resident #27's suprapubic one time before. When asked why he did not insert a suprapubic catheter into Resident #27, LVN A stated, he was yelling at me, I guess I forgot he had a suprapubic, and he had an erection. LVN A stated, when I hear 'cath,' I think of penis catheter. LVN A stated no Resident #27 did not have an order for a foley (urethral) catheter. When asked why he inserted a catheter through Resident #27's penis without an order, LVN A stated, he was yelling and we wanted to meet his needs. LVN A stated hardly any nurses went back and read the orders. LVN A stated he read through the orders but probably sped through it too quick. LVA A stated the DON had trained him on suprapubic catheter insertion the previous week but not on foley (urethral) insertion because I've already been trained. LVN A stated Resident #27 had asked him to insert the catheter into his penis and when asked why Resident #27 would ask this of him when he had a suprapubic catheter, LVN A stated, he is really demanding. When asked if he explained the process to Resident #27 as he was inserting the foley (urethral) catheter, LVN A stated, no, he was barking orders at me. LVN A stated no he did not tell Resident #27 where he was inserting the catheter. During an interview on 6/28/2023 at 9:14 a.m., LVN B stated she started working at the facility on 5/16/2023 and she mostly worked on the opposite side of the facility from where Resident #27 resided but she had taken care of Resident #27 here and there. LVN B stated she worked the previous Monday (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 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 0690 Level of Harm - Actual harm Residents Affected - Few on 6/19/2023 and the only thing she knew was that TCNA E told her LVN A put Resident #27's catheter in his penis instead of suprapubic and LVN A asked her to take over Resident #27's treatments and medications that afternoon. LVN B stated TCNA E told her LVN A put Resident #27's catheter in the wrong place and Resident #27 was upset. LVN B stated she did not go into Resident #27's room because she got called down and she figured it was taken care of. LVN B stated she had not been trained on foley or suprapubic catheter insertion at that facility. During an interview on 6/28/2023 at 10:37 a.m., LVN A stated Resident #27's erection on 6/19/2023 had no significance other than that when he saw it, his first instinct was to put the catheter in the penis because the resident was saying cath me. During an interview on 6/28/2023 at 10:14 a.m., the DON stated there was no policy on following physician orders but she expected staff to follow orders. The DON stated licensed nurses were within their scope of practice to insert suprapubic catheters and that she had not trained LVN A on inserting suprapubic catheters. When asked how she ensured LVN A was competent, the DON stated, I will do in-services. The DON stated she had assessed LVN A on the floor and he's competent. The DON stated she had not assessed LVN A's competency on catheter insertion. During an interview on 6/28/2023 at 10:50 a.m., the DON stated Resident #27 refused to have a second ultrasound done because he did not like the x-ray technician. The DON stated Resident #27 refused to go to the hospital and he did not like the results of the first ultrasound because the results were normal. During an interview on 6/28/2023 at 2:39 p.m., the DON stated a doctor's order was needed in order to change a catheter. The DON stated she was not sure how Resident #27's suprapubic catheter came out. The DON stated there was a check off for catheter insertion and all nurses should have done it before she started working in the facility on 5/25/2023. The DON stated she believed nurses were assessed for their competency on inserting catheters annually. The DON stated she was not sure whether LVN A had done it but she would check. When asked what her expectation was for staff following orders, the DON stated LVN A should have called the physician for an order to insert the foley (urethral) catheter. The DON stated no there was not an order for Resident #27 to have a foley (urethral) catheter. When asked why LVN A inserted a foley catheter into Resident #27 without an order, the DON stated LVN A's side of the story was that [Resident #27] asked him to reinsert it into his penis instead of the suprapubic but [Resident #27] isn't the physician. The DON stated Resident #27 denied this. The DON stated it was never her understanding that LVN A tried to insert Resident #27's catheter into his suprapubic region. The DON stated LVN A's story was that when he went into Resident #27's room, the catheter was out of Resident #27's suprapubic site, Resident #27 did not know how it happened, and Resident #27 asked LVN A to put the catheter into his penis. The DON stated LVN A reported to her that he inserted the balloon into Resident #27's penis to inflate it but it did not work and at that point Resident #27's penis began to bleed so LVN A let some saline out and Resident #27 told LVN A to get out of his room. The DON stated to her knowledge, LVN A did not get anyone to help with the catheter insertion on 6/19/2023. The DON stated she was off on Monday 6/19/2023 but came to the facility later in the day. The DON stated Resident #27's suprapubic catheter was bloody and his penis was actively bleeding when she got to the facility but she did not say what time this was. When asked how Resident #27 was monitored after the incident, the DON stated she thought someone went in every hour to check on him but it was not documented. The DON stated she notified the PCP. The DON stated nursing staff were to communicate what they were doing during a catheter insertion by telling the resident step by step. When asked who was responsible for overseeing nursing staff to ensure they were changing catheter properly, the DON stated it had been the ADON but it will be me from now on. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 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 0690 Level of Harm - Actual harm Residents Affected - Few DON stated she had a conversation with LVN A on 6/19/2023 about the incident but it was not written down and she did not make him sign anything. The DON stated LVN A was not suspended. The DON stated she started an in-service with staff on 6/19/2023 but it covered catheter care and not catheter insertion. The DON stated, you would think LVNs would already know and be cleared to do that. The DON stated she reeducated LVN A verbally on following physician orders and inserting foley (urethral) catheters. The DON stated she was having the LVN Consultant come to the facility the following week to train nursing staff on inserting suprapubic catheters. The DON stated if nurses were not competent in changing catheters it could cause damage or harm to the resident, irritate the bladder, damage the urethra, tear the penis, or cause a UTI. The DON stated there was potential for bleeding any time a catheter was inserted but with Resident #27, there was more blood than she would expect from a catheter change. The DON stated she was not sure if Resident #27 tore something on the inside and that she thought he needed to go to the hospital but he would not go. The DON stated the PCP did not come to the facility because the bleeding stopped and he was assessed by the Wound Care Physician on 6/19/2023. The DON stated the PCP had not ordered a UA yet because Resident #27 had not had signs or symptoms of a UTI. During an interview on 6/28/2023 at 4:33 p.m., the Administrator stated he expected staff to follow physicians' orders. The Administrator stated the DON monitored nursing staff to ensure they followed orders. When asked how nursing staff were monitored to ensure they followed order, the Administrator stated, they look at it, during clinical meetings, by educating them on things, ADON delegation, and reeducation with the regional nurse consultant. The Administrator stated the DON and ADON ensured nurses were competent in caring for residents by completing return demonstrations, through education, and random audits. The Administrator stated he was not sure if the DON had completed a return demonstration with LVN A on catheter insertion. The Administrator stated Resident #27 called him on 6/19/2023 to tell him what had happened. The Administrator stated he went into Resident #27's room after the Wound Care Doctor had put Resident #27's catheter in the right place and he observed blood in the tube. When asked what a potential negative resident outcome was if nurses provided care without and order, the Administrator stated it could cause discomfort and bleeding. During an interview on 6/282023 at 5:32 p.m., the PCP stated Resident #27 did not have a urologist because he refused. The PCP stated Resident #27 refused transport out of the facility. The PCP stated the facility did report to him the incident on 6/19/2023. The PCP stated in his mind, Resident #27 probably had some scar tissue and stenosis (abnormal narrowing) due to the fact that he did not have use from the bladder down. When asked if inserting a foley catheter could cause trauma, the PCP stated yes, if someone was not knowledgeable about the anatomy there. A record review of Resident #27's progress note dated 6/19/2023 authored by LVN A reflected the following: Res asked me to change FC today and Res was very rude and abrasive talking to me and ordering me how to do new FC change and rushing me and going against the way I was doing the procedure and ended up cath-ing Res thru penis and inserting 10cc into bulb with no urine return. DON went into Res room to assess bleeding from Res' penis. Res conts. to have some bleeding from penis and DON asked Res if we could call non-emergency AMB to take him to the hospital and Res refused at that time. A record review of a Concern Form dated 6/19/2023 authored by the DOR reflected a concern was initiated by Resident #27. The documentation of the concern reflected the following: Patient very upset (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 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 0690 Level of Harm - Actual harm and reported that nurse (LVN A) placed catheter through his urethra instead of suprapubic. Aide (TCNA E) noticed the issue and wound care Dr. corrected the placement. Therapist seen blood on patient and reported to Admin and DON. Residents Affected - Few A record review of Resident #27's pelvic ultrasound results dated 6/22/2023 reflected the following: PELVIC ULTRASOUND LIMITED Results: Real time examination shows bladder catheter bladder now well visualized Conclusion: Normal limited pelvic ultrasound. A record review of the facility's document titled Competency Assessment dated 3/02/2023 reflected LVN A demonstrated competency to the Interim DON on suprapubic catheter replacement. A record review of the facility's in-services from June 2023 reflected nursing staff were trained on the facility's catheter care policy on 6/19/2023. There were no in-services on following physician's orders or inserting catheters. A record review of Resident #27's progress note dated 6/19/2023 authored by the Wound Care Physician reflected the following: Addendum: During course of visit was noted that the patient's urinary catheter was placed in his urethra instead of suprapubic position. Blood was noted from urethra and in catheter tubing. Patient was unaware of the placement due to his condition and paralysis. Patient requested that I replace suprapubic catheter with additional sterile catheter supplies in his room as I was a physician and he trusted me to perform the procedure after frustration of the error. The new catheter was placed in the suprapubic position through the present cystostomy with immediate return of urine and blood. Blood is likely result of traumatic insertion via urethra. A record review of the facility's policy titled Foley Catheter Insertion, Male Resident revised October 2010 reflected the following: Purpose The purpose of this procedure is to provide guidelines for the aseptic insertion of a urinary catheter. Preparation 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. Reporting 2. Notify the physician of any abnormalities (i.e., bleeding, obstruction, etc.). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 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 0690 3. Report other information in accordance with facility policy and professional standards of practice. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchens reviewed for sanitation. The Dietary Manager failed to ensure all foods were labeled and dated. The Dietary Manager failed to ensure the dish machine was functioning at the proper temperature to sanitize dishes. CK K failed to reheat or discard a food item measured to below the minimum temperature required for serving. These failures placed residents at risk of foodborne illness. Findings included: During an observation and interview on 6/26/2023 at 9:22 a.m., DA M was observed washing dishes in the dish room. DA M stated she had not tested the temperature of dish water and said she was almost done doing the dishes from breakfast. The dish machine's thermometer dial was observed to read about 111 degrees Fahrenheit. The Dietary Manager tested the dish water during a cycle using a bimetallic thermometer (non-digital thermometer) and the dish water was observed to be about 116 degrees Fahrenheit. DA M stated she did not check the chemical concentration of the dish water that morning because the dish machine was new and the process of testing it was new to her. DA M stated she had never used test strips to test the chemical concentration of sanitizer before. DA M stated the last time she measured the temperature of the dish water was two days ago (6/24/2023), the water was 120 degrees Fahrenheit at that time, and she did not know how long the dish machine had been running below the minimum required temperature, which she stated was 120 degrees Fahrenheit. During an interview on 6/26/2023 at 9:33 a.m., when asked how often she calibrated the bimetallic (non-digital) thermometers, the Dietary Manager stated dietary staff used digital thermometers to take food temperatures and they had never taken the temperature of the dish machine using the handheld thermometers. During observations of the walk-in refrigerator on 6/26/2023 from 9:36 a.m.-9:42 a.m., the following were noted: At 9:36 a.m., the walk-in refrigerated contained a container labeled chk Alfredo with no date. At 9:36 a.m., the walk-in refrigerator contained a container of tomato soup, labeled and dated 5-20. At 9:38 a.m., the walk-in refrigerator contained a plastic resealable bag of what appeared to be egg rolls with no label or date. At 9:39 a.m., the walk-in refrigerator contained an opened container of tartar sauce dated 6/9 with no opened date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many At 9:39 a.m., the walk-in refrigerator contained an opened container of mayonnaise dated 5-18 with no opened date. At 9:42 a.m., the walk-in refrigerator contained three packages of hamburger buns with no received date. During an observation and interview on 6/26/2023 at 9:42 a.m., CK K stated the plastic resealable bag contained the Dietary Manager's egg rolls that she brought for lunch that day. CK K then proceeded to date the bag of egg rolls with that day's (6/26/2023) date. CK K stated all items should be labeled and dated. CK K stated the dates written on the mayonnaise and tartar sauce were received dates and not opened dates. CK K stated the mayonnaise and tartar sauce were not labeled with opened dates and all items should be labeled with an opened date when they were opened. CK K stated the night cook should have discarded the tomato soup and should have discarded the undated chicken alfredo since she was the one who prepared those items. CK K stated the hamburger buns were received the previous Friday (6/23/2023) and said no they were not labeled with a received date. During an interview on 6/26/2023 at 10:01 a.m., the Dietary Manager stated there was a fridge in the break room for personal food items but it was all the way on the other side of the building. The Dietary Manager stated they did not usually store their personal food in the reach-in refrigerator. During an interview on 6/27//2023 at 9:15 a.m., the Dietary Manager stated, I think the thermometer thing is messed up. When asked if she meant the gauge on the dish machine, the Dietary Manager stated, yes. The Dietary Manager then ran the dish machine and measured the water using a digital thermometer and it read 112 degrees Fahrenheit. The Dietary Manager stated the water needed to be 120 degrees Fahrenheit and that was the first time she had noticed it was not reaching 120 degrees Fahrenheit. During an observation on 6/27/2023 at 9:58 a.m., the kitchen's Dishwashing Temperature/Sanitizer Record for June 2023 was observed posted on the wall of the dish room. The wash temperature for breakfast on 6/26/2023 recorded and initialed by DA M reflected 120 degrees Fahrenheit. The wash temperature for breakfast on 6/27/2023 recorded and initialed by CK L reflected 120 degrees Fahrenheit. During an observation and interview on 6/27/2023 at 9:59 a.m., the Dietary Manager stated, they turned up my water heater. Observed the Interim Maintenance Director in the dish room working on the dish machine. During an observation of the kitchen and interview on 6/27/2023 at 10:04 a.m., the production area was observed to have a container of white substance with no label or date. CK K stated it was food thickener and the label had come off when they were cleaning. During an interview on 6/27/2023 at 11:20 a.m., the Interim Maintenance Director stated he had turned up the hot water for the three-compartment sink by accident instead of the dish machine and that he was working on it. During an interview on 6/27/2023 at 11:20 a.m., the Dietary Manager stated no that dietary staff should not write in temperatures if they did not measure the temperature. When asked why DA M recorded a temperature of 120 on 6/26/2023 when she had not measured the water before doing breakfast dishes, the Dietary Manager stated she did not know but she could call DA M and ask. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm During an observation on 6/27/2023 at 11:25 a.m., CK K took the temperatures of all items on the service line before lunch. CK K measured the temperature of the alternate starch item (noodles) and it was 123 degrees Fahrenheit. CK K stated the Dietitian had told her the minimum temperature for serving was 127 degrees Fahrenheit and that she would need to reheat the noodles. CK K did not remove the noodles from the steam table. Residents Affected - Many During an interview on 6/27/2023 at 11:25 a.m., CK K stated she was going to start serving lunch. During an observation of meal service on 6/27/2023 at 11:47 a.m., CK K served the alternate starch (noodles) to one resident. During an interview on 6/27/2023 at 11:55 a.m., CK K stated, I forgot when asked why she had not heated up the noodles before serving them. CK K stated the steam table heated things up. During an interview on 6/27/2023 at 12:00 p.m., CK L stated she had checked the temperature of the dish machine that morning before doing the breakfast dishes and it was 100 degrees Fahrenheit. CK L stated the water was supposed to be 120 degrees Fahrenheit and the Interim Maintenance Director had come in to work on the dish machine after she finished doing the breakfast dishes. During an interview on 6/27/2023 at 11:59 a.m., the Interim Maintenance Director stated the temperature of the dish machine could not be too high otherwise the chemicals did not work. The Interim Maintenance Director stated the dish machine was 120-125 degrees that morning (6/27/2023). During an interview on 6/27/2023 at 12:05 p.m., when asked why she had recorded a temperature of 120 degrees Fahrenheit that morning on the temperature log if she had observed the temperature to be 100 degrees Fahrenheit, CK L stated, I wrote it down wrong. When asked why, CK L stated she did not know. During an interview on 6/28/2023 at 9:43 a.m., the RD stated he had started covering that facility one month ago. The RD stated he did not know the facility's food storage policy off the top of his head but stated foods should be dated with a received date when they were received. The RD stated foods should be labeled with an opened date and leftovers should be labeled with the date they were cooked. The RD stated he did not know the number of days leftovers were kept. The RD stated yes all opened items should be labeled and dated. The RD stated personal food items should not be stored with resident food items. The RD stated he thought the minimum temperature for serving food was 120 degrees Fahrenheit but he would need to double check. When asked what his expectation was for cooks if hot food items were measured to be in the temperature danger zone, the RD stated staff should reheat the food. The RD stated staff should measure the temperature of the dish machine before running it and it should be 120 degrees Fahrenheit. The RD stated whoever was doing the dishes should check the dish machine each time they ran it. The RD stated he did not know how the kitchen was monitored for sanitation but stated it should be the Dietary Manager who monitored. The RD stated he did a kitchen inspection once a month to make sure everything was okay and if I find something, I'll correct it. The RD stated he was pretty sure all kitchen staff had been trained on food storage and sanitation and he believed the Dietary Manager trained them. When asked what a potential negative outcome for residents was if the kitchen's food storage and sanitation policies were not followed, the RD stated, it can harm them in different ways. The RD stated it could range from different stuff and I don't' know if I'm able to answer that question. When asked if there was potential for foodborne illness, the RD stated, yeah that is one of the main ones if foods are not at the proper temperature. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 6/28/2023 at 4:33 p.m., the Administrator stated the Dietary Manager was out sick that day. The Administrator stated he did not know the facility's policy on food storage off the top of his head but stated there was a policy that specified and things needed an opened date. The Administrator stated there was no policy on storing employee food items but they had a break room where staff could store their items. The Administrator stated yes that all food items should be labeled and dated. The Administrator stated he did not know what the minimum temperature was for serving hot food items but stated no it was not appropriate to use the steam table to reheat foods and staff should follow the policy to reheat foods. When asked how the dish machine was monitored to ensure it was running at the proper temperature, the Administrator stated, we rely on information that staff are recording it properly. The Administrator stated the Dietary Manager monitored the dish machine by checking it at minimum weekly if not daily. When asked how the kitchen was monitored for sanitation, the Administrator stated they had monthly storage watch and checks. The Administrator stated himself and the Dietary Manager did walk throughs to check food storage and cleanliness monthly. The Administrator stated himself, the Dietary Manager and the RD monitored the kitchen for sanitation. The Administrator stated the RD monitored monthly. The Administrator stated the kitchen did not have any documented in-service trainings but the RD talked to the Dietary Manager monthly about any concerns. The Administrator stated kitchen staff were trained on food storage and sanitation by shadowing the Dietary Manager and he stated all staff had been trained. The Administrator stated foodborne illness of some sort was a potential negative outcome for residents if the kitchen's food storage and sanitation policies were not followed. A record review of the kitchen's Service Line temperature log dated June 2023 reflected no recorded temperature for the alternate starch (noodles) served for lunch on 6/27/2023. A record review of the facility's kitchen sanitation audit authored by the facility's previous dietitian (the RDN) dated 3/14/2023 reflected there were dry storage food items and refrigerated food items that were not covered, labeled and dated. A record review of the facility's kitchen sanitation audit authored by the facility's previous dietitian (the RDN) dated 4/13/2023 reflected food items were noted in the kitchen without an opened date, refrigerated items were noted without a label or date, and expired foods were found in the refrigerator. A record review of the facility's kitchen sanitation audit authored by the RD dated 6/16/2023 reflected the dish machine logs were not complete, up to date, and accurate. A record review of the facility's policy titled Preventing Foodborne Illness - Food Handling dated April 2022 reflected the following: Policy Statement Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. The Resident agrees to consult with Nursing and Dietary staff regarding food or beverages brought into the Center. Policy Interpretation and Implementation 1. This facility recognizes that the critical factors implicated in foodborne illness are: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 b. Inadequate cooking and improper holding temperatures Level of Harm - Minimal harm or potential for actual harm 2. With these factors as the primary focus of preventative measures, this facility strives to minimize the risk of foodborne illness to our residents. Residents Affected - Many 7. Potentially hazardous foods held in the danger zone (41°F to 135°F) for more than 4 hours (if being prepared from ingredients at room temperature) or 6 hours (if cooked and then cooled) will be discarded. 9. All food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendations. A record review of the facility's policy titled Food Storage dated 2018 reflected the following: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Procedure: 1. Dry storage rooms d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. 2. Refrigerators d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. A record review of the facility's policy titled Taking Temperatures dated 2018 reflected the following: Policy: The facility realizes the critical nature of serving foods at the correct temperatures to ensure the health of its residents. The facility will take and record the temperatures of all foods prior to service. Foods not at the correct temperature will be corrected or discarded, as necessary. Procedure: 7. If a potentially hazardous food is not at the proper temperature, further investigation is required to determine how long the food has been outside the safe temperature zone to determine if it is safe to restore the food to the correct temperature. If food has been outside the safe zone for over 2 hours, discard the food immediately. If food has been outside the safe zone for less than 2 hours, reheat per guidelines. A record review of the facility's policy titled Mechanical Cleaning and Sanitizing of Utensils and Portable Equipment dated 10/01/2018 reflected the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for mechanical cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. Procedure: Residents Affected - Many 1. Use only an approved dish machine that is properly installed and maintained. Operate the dish machine as instructed in the manufacturer's directions. Schedule and complete regular maintenance inspections. 7. If a machine that uses chemicals for sanitizing is in use, follow these guidelines: a. The temperature of the wash water must be at least 120°F. A record review of the 2017 Food Code reflected the following: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in [paragraph] (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. 3-401.13 Plant Food Cooking for Hot Holding. Plant FOODS that are cooked for hot holding shall be cooked to a temperature of 57°C (135°F). 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under [paragraph] (B) and in [paragraph] (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57°C (135°F) or above, except that roasts cooked to a temperature and for a time specified in [paragraph] 3-401.11(B) or reheated as specified in [paragraph] 3-403.11(E) may be held at a temperature of 54°C (130°F) or above; or (2) At 5ºC (41ºF) or less. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 If continuation sheet Page 22 of 22