Inspection·July 19, 2023

F 0577 responsibilities during the stay in the facility . Level of Harm - Potential for minimal harm . 8.A posting of names, addresses and phone numbers of all pertinent state client advocacy groups will be available in the facility. Residents Affected - Many 9.The facility prominently displays written information regarding how to apply for and use Medicare and Medicaid benefits. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675468 If continuation sheet Page 2 of 15 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 675468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hico Nursing and Rehabilitation 712 Railroad Ave Hico, TX 76457 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident within 48 hours of resident's admission that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 5 residents (Resident #90) reviewed for baseline care plan. The facility failed to ensure Resident #90's baseline care plan or comprehensive care plan that include the minimum healthcare information necessary to properly care for a resident was developed and implemented within 48 hours of her admission. This failure could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met. The findings were: Record review of Resident #90s face sheet, dated 07/17/23, reflected an admission date of 07/14/23 with diagnoses that included Congestive Heart Failure (low functioning heart), Alzheimer's disease, Hypertension (High blood pressure), Hypothyroidism (under active Thyroid gland), and Generalized Anxiety Disorder. Record review of Resident #90's admission MDS dated [DATE] revealed the resident's BIMS score was not assessed. Record review of Resident #90's care plan reviewed on 7/17/23 at 2:00PM revealed that there was no baseline or comprehensive care plan available. In an interview with the MDSC on 07/17/23 at 2:30PM, she stated at the facility, nurses at the time of the admission of new residents, develop the baseline care plan and later MDSC develops comprehensive care plan. She said, she was not sure what was the reason for the omission of Resident #90's baseline care plan. The MDSC stated she was responsible for ensuringe that a baseline care plan was developed within 48 hours of the admission of a resident. In an interview with the DON on 07/17/2023 at 3:45 p.m., she stated it was mandatory to develop a baseline care plan within 48 hours of the admission of the resident. The DON said a baseline care plan was essential as it provides information to the staff about initial goals based on admission orders, until a comprehensive careplan developed. Record review of the facility's policy titled, Baseline Care Plan dated 06/27/23, reflected, Policy: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Policy Explanation and Compliance Guidelines: 1. The baseline care plan will: a. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675468 If continuation sheet Page 3 of 15 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 675468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hico Nursing and Rehabilitation 712 Railroad Ave Hico, TX 76457 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 0655 Be developed within 48 hours of a resident's admission except on a weekend admission, it may then be completed on the first Monday following the admission by a supervising nurse. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675468 If continuation sheet Page 4 of 15 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 675468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hico Nursing and Rehabilitation 712 Railroad Ave Hico, TX 76457 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility failed to ensure the pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, in that. -medication room with OTC products contained two bottles of expired medication. This failure had the potential to place residents who receive medications from Medication Rooms at risk for not receiving the intended therapeutic benefit of their medication. The findings include: Observation of OTC (over the counter) Medication Room at 11:40 AM on 07/18/23 revealed the following: 2 bottles- Gas Ban (Simethicone 80 mg PO)- expired 06/2023 In an interview with RN A at 11:45 AM on 07/18/23, she stated that she was unaware of where expired medications were stored. RN A stated the DON was responsible for getting rid of medications. RN A stated that since she started working at the facility in January , she was not trained on medication storage of expired medication. RN A stated that if residents were given expired medication of Gas Ban, they would not get the full effect of medication. In an interview with the DON at 3:15 PM on 07/19/23, she stated there should not be any expired medication in the Medication room. She stated that she was responsible for checking expired medication and doesn't know how the medication got overlooked. DON stated that expired medication either go in her office or in a slot box in the overstock (prescribed meds not on floor) med room. Staff has not been trained on checking medication for expiration dates. She stated that all staff will be in serviced on storage of medications. The DON stated that administering expired medication to residents could pose a risk of liver, kidney damage to the residents. Record review of the Policy on medication storage dated 06/27/23 revealed: It is the policy of this facility to ensure all the medications housed on our premises will be stored in the pharmacy and/ or medication rooms according to the manufacturer. The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675468 If continuation sheet Page 5 of 15 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 675468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hico Nursing and Rehabilitation 712 Railroad Ave Hico, TX 76457 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to achieve a medication error rates are not 5 percent or greater. There were 22 errors out of 30 opportunities, resulting in a 73 percent medication error involving 4 of 5 residents. The facility were deficient in the following areas: Residents Affected - Some 1. LVN A Failed to provide medication to Resident # 28. 2. RN A Failed to administer medications within 1 hour before or after of physician's order for resident #17 and # 36 3. RN A failed to provide Dilantin according to physician orders to Resident # 05 Failure to achieve medication error rate below 5 percent can lead to potential outcome of residents at the facility not being adequately cared for. The findings included: Resident # 28 Record review of Resident #28's face sheet dated 07/19/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included altered mental status, unspecified symptoms and signs involving cognitive functions and awareness, pain in both wrist, pain in both joints of hands, and edema. Record review of MAR for July 2023 revealed: -Carbamazepine 200 mg tablet PO 4 times a day at 08:00 AM, 12:00 PM, 4:00 PM, 08:00 PM. - Missed doses noted in MAR ( on 07/16/2023 and 07/17/2023 at 4:00 PM and 08:00 PM). Record Review of the care plan dated 06/19/2023 revealed Resident # 28 to have seizures requiring her to be given medications by the facility. During an observation and interview on 7/18/23 at 09:45 AM, LVN A identified that Resident's #28 medication of carbamazepine 200 mg PO was empty. LVN A stated medication was ordered 07/16/2023. LVN A stated that Resident #28 medication has been out of stock since 07/16/2023 and pharmacy is currently in route to deliver. LVN stated that it was facility policy to always keep extra medication in the Emergency kit and phone pharmacy as soon as medication was running low. Resident #28 was in stable condition and did not appear to have any seizure during observation of med administration. Resident # 17 Record review of Resident #17's face sheet dated 07/19/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included schizoaffective disorder bipolar type, insomnia, hypothyroidism, and chronic fatigue. Record review dated 07/18/2023 of MAR revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675468 If continuation sheet Page 6 of 15 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 675468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hico Nursing and Rehabilitation 712 Railroad Ave Hico, TX 76457 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 - Metformin 1500 mg PO with meals at 08:00 AM Level of Harm - Minimal harm or potential for actual harm - Abilify 20 mg PO at 08:00 AM - Loratadine 10 mg PO at 08:00 AM Residents Affected - Some - Alprazolam 0.25 mg PO at 08:00 AM - Lisinopril 20 mg PO at 08:00 AM - Trihexyphenidyl 2 mg PO at 08:00 AM - Glipizide 5 mg PO at 08:00 AM During an observation on 7/18/23 at 09:45 AM, RN A administered Resident # 17's morning medications(Metformin, Abilify, Loratidine, Alprazolam, Lisinopril, Trihexyphenidyl, Glipizide) late. Resident # 36 Record review of Resident #36's face sheet dated 07/19/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included essential primary hypertension (high blood pressure), malignant neoplasm of left kidney (tumor on left kidney), hypokalemia (low potassium) and generalized muscle weakness. Record review dated 07/18/2023 of MAR revealed: - Aspirin low dose chewable PO at 08:00 AM: - Famotidine 20 mg PO at 08:00 AM - Gabapentin 300 mg PO at 08:00 AM - Hyzaar 100-12.5 mg PO at 08:00 AM - Potassium 20 meq 1 tab PO at 08:00 AM - Norco 10 mg- 325 mg PO at 08:00 AM During an observation on 7/18/23 at 09:57 AM, RN A administered Resident # 36's morning medications (Aspirin, Famotidine, Gabapentin, Hyzaar, Potassium, Norco.) Observation of Resident # 36 revealed no negative outcome. Resident # 05 Record review of Resident #5's face sheet dated 07/19/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included MAJOR depressive disorder (low mood), recurrent, severe with psychotic symptoms, muscle weakness, anemia (low blood), and anxiety. Record review of MAR for July 2023 revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675468 If continuation sheet Page 7 of 15 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 675468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hico Nursing and Rehabilitation 712 Railroad Ave Hico, TX 76457 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 - Gabapentin 300 mg PO at 08:00 AM Level of Harm - Minimal harm or potential for actual harm - Sucralfate 1 gm PO at 08:00 AM - Dilantin 125 mg/ 5 ml, 3 ml PO at 08:00 AM Residents Affected - Some - Multivitamin 1 tab PO at 08:00 AM - Famotidine 20 mg PO at 08:00 AM -Norco 7.5 - 325 mg PO 1 tab PO at 09:00 AM During an observation on 7/18/23 at 11:00 AM, RN A administered Resident # 05's (Gabapentin, Sucralfate, Dilantin, Multivitamin, Famotidine, Norco) medications. In addition, surveyor observed 6 ml of Dilantin being administered to resident. Surveyor did not observe any negative outcome from Dilantin administration. During an interview on 7/19/23 at 11:17 AM, RN A revealed the reason why Residents # 5, 17, and 36 received their medications late were because she was interrupted by needing to assist other residents in feeding for breakfast. RN A stated she needed more help with staffing. RN A initially stated that she administered 7 ml of Dilantin to Resident #5. RN A then stated that she drew up 7 ml of Dilantin and only administered 3 ml of the medication and threw the rest away. RN A did not give a response to if drawing up extra doses and throwing it away were facility policy. RN A stated that facility policies were to give medications within 1 hour before and 1 hour after med order time of administration. RN A stated that late medication administration for Residents #05, 17, and 36 were a violation of facility policy. During an interview on 7/19/23 at 11:17 AM, the DON revealed that since she has worked at the facility, med pass times were a concern for her. She stated that the current policy for meds to be given an hour before and an hour after needed to be modified. The DON could not give a reason for why med pass times being late beside the facility policies needing adjustment. DON stated that she and pharmacy were responsible for providing oversight during med aministration and monitoring for any deficient practice. The DON stated that medications were supposed to be delivered within 1 hour before or 1 hour after medication ordered time. The DON stated if meds were given outside of the window of time allowed then there was a violation of facility policy. The DON also stated that facility policy was not being followed regarding administration of Dilantin 7 ml to Resident # 5. The DON stated that medications were supposed to be administered according to physician orders to prevent harm from occurring to the resident. Record review of the facility policy and procedure titled, Medication Administration undated revealed in part, 1. All medications are administered by licensed medical or nursing personnel as ordered by the physician and in accordance with professional standards .2.Compare the medication source with the MAR to verify dose and time .3.administer medication within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician. Resident # 36 Record review of Resident #36's face sheet dated 07/19/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included essential primary hypertension (high blood pressure), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675468 If continuation sheet Page 8 of 15 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 675468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hico Nursing and Rehabilitation 712 Railroad Ave Hico, TX 76457 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 malignant neoplasm of left kidney (tumor on left kidney), hypokalemia (low potassium) and generalized muscle weakness. Level of Harm - Minimal harm or potential for actual harm Record review of MAR for July 2023 revealed: Residents Affected - Some - Aspirin low dose chewable PO at 08:00 AM: - Famotidine 20 mg PO at 08:00 AM - Gabapentin 300 mg PO at 08:00 AM - Hyzaar 100-12.5 mg PO at 08:00 AM - Potassium 20 meq 1 tab PO at 08:00 AM - Norco 10 mg- 325 mg PO at 08:00 AM During an observation on 7/18/23 at 09:57 AM, RN A administered Resident # 36's morning medications (Aspirin, Famotidine, Gabapentin, Hyzaar, Potassium, Norco.) Observation of Resident # 36 revealed no negative outcome. Resident # 05 Record review of Resident #5's face sheet dated 07/19/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included MAJOR depressive disorder (low mood), recurrent, severe with psychotic symptoms, muscle weakness, anemia (low blood), and anxiety. Record review of MAR for July 2023 revealed: - Gabapentin 300 mg PO at 08:00 AM - Sucralfate 1 gm PO at 08:00 AM - Dilantin 125 mg/ 5 ml, 3 ml PO at 08:00 AM - Multivitamin 1 tab PO at 08:00 AM - Famotidine 20 mg PO at 08:00 AM -Norco 7.5 - 325 mg PO 1 tab PO at 09:00 AM During an observation on 7/18/23 at 11:00 AM, RN A administered Resident # 05's (Gabapentin, Sucralfate, Dilantin, Multivitamin, Famotidine, Norco) medications. In addition, surveyor observed 6 ml of Dilantin being administered to resident. Surveyor did not observe any negative outcome from Dilantin administration. During an interview on 7/19/23 at 11:17 AM, RN A revealed the reason why Residents # 5, 17, and 36 received their medications late were because she was interrupted by needing to assist other residents in feeding for breakfast. RN A stated she needed more help with staffing. RN A initially stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675468 If continuation sheet Page 9 of 15 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 675468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hico Nursing and Rehabilitation 712 Railroad Ave Hico, TX 76457 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm that she administered 7 ml of Dilantin to Resident #5. RN A then stated that she drew up 7 ml of Dilantin and only administered 3 ml of the medication and threw the rest away. RN A did not give a response to if drawing up extra doses and throwing it away were facility policy. RN A stated that facility policies were to give medications within 1 hour before and 1 hour after med order time of administration. RN A stated that late medication administration for Residents #05, 17, and 36 were a violation of facility policy. Residents Affected - Some During an interview on 7/19/23 at 11:17 AM, the DON revealed that since she has worked at the facility, med pass times were a concern for her. She stated that the current policy for meds to be given an hour before and an hour after needed to be modified. The DON could not give a reason for why med pass times being late beside the facility policies needing adjustment. DON stated that she and pharmacy were responsible for providing oversight during med aministration and monitoring for any deficient practice. The DON stated that medications were supposed to be delivered within 1 hour before or 1 hour after medication ordered time. The DON stated if meds were given outside of the window of time allowed then there was a violation of facility policy. The DON also stated that facility policy was not being followed regarding administration of Dilantin 7 ml to Resident # 5. The DON stated that medications were supposed to be administered according to physician orders to prevent harm from occurring to the resident. Record review of the facility policy and procedure titled, Medication Administration undated revealed in part, 1. All medications are administered by licensed medical or nursing personnel as ordered by the physician and in accordance with professional standards .2.Compare the medication source with the MAR to verify dose and time .3.administer medication within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675468 If continuation sheet Page 10 of 15 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 675468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hico Nursing and Rehabilitation 712 Railroad Ave Hico, TX 76457 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were free of significant medication errors for one (Resident #05) of five residents reviewed for significant medication errors in that:. Residents Affected - Some RN A failed to administer the correct dose of Dilantin 125mg/ 5ml to Resident #05 according to physician's order. This deficient practice failure could affect residents who were receiving Dilantin by placing them at risk of confusion, extreme lethargy(tiredness), and coma. Based on observation, interview, and record review the facility failed to ensure residents were free of significant medication errors for one (Resident #5) of five residents reviewed for significant medication errors in that: RN A failed to administer the correct dose of Dilantin 125mg/ 5ml to Resident #5 according to physician's order. This failure could affect residents who were receiving Dilantin by placing them at risk of confusion, extreme lethargy(tiredness), and coma. The findings include: Record review of Resident #5's face sheet dated 07/19/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included major depressive disorder (low mood), recurrent, severe with psychotic symptoms, muscle weakness, anemia (low blood), and anxiety. Review of Annual Minimum Data Set (MDS) dated [DATE] for Resident #05 documented resident to have seizures and anxiety. Surveyor was not able to get a BIMS score for Resident #5. Review of Physician's Orders dated 03/12/2023 for Resident #5 documented in part: Dilantin 125 mg/ 5 ml, 3 ml PO at 08:00 AM for unspecified convulsion(seizures). Record Review of care plan dated revealed of care plan revealed Resident is to be given Dilantin QD per physician order and monitored for side effects with labs drawn every 3 months. Record Review of the MAR for July 2023 of Resident # 05 revealed adminstered doses of Dilantin Suspension125 MG/5ML at 08:00 AM Observation on 07/18/23 at 11:00 AM, revealed RN A administered 6 ml of Dilantin to resident #05. Observation on 07/18/23 at 11:10 AM, showed resident #05 was resting bed. Interview on 07/19/2023 at 2:30 PM, RN A reported that initially she gave 7 ml of Dilantin (125 mg/ 5 ml) to Resident #5. RN A later back tracked statement and said that she withdrew 7 ml of Dilantin and only administered 3 ml. When asked if throwing away extra doses was part of facility protocol (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675468 If continuation sheet Page 11 of 15 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 675468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hico Nursing and Rehabilitation 712 Railroad Ave Hico, TX 76457 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some RN A stated yes, it was normal to do that. RN A stated that if she did give 7 ml then it was deficient practice. When asked if it was against policy to give doses outside med order, RN A stated yes, it was a violation of facility policy. RN A stated that administering too much Dilantin can cause confusion and breathing problems with Resident #5. Observation on 07/18/23 at 11:10 AM, showed RN A Leave Resident #05 room. Surveyor did not witness any further observation of Resident #05 by RN A or communication to physician of the error by RN A. Interview on 07/19/2023 at 2:30 PM, the DON reported that RN A providing 7 ml of Dilantin (125 mg/ 5 ml) to Resident #5 was in violation of facility policies. The DON stated that it was not normal practice for a nurse to draw up extra doses to administer and throw away what's not used. The DON stated her and the consultant pharmacist are responsible for ensuring the staffs are providing the correct drug and amount to the residents. The DON stated if 5 ml of drug was required to be administer then nurses should only draw up 5 ml. The DON stated that RN A should have followed the doctor's order. The DON stated that by administering more doses than ordered of Dilantin can cause Resident # 5 to have severe sedation, lethargy, and confusion. Record Review of reference (Seizure Treatment | DILANTIN® (extended phenytoin sodium capsules, USP) | Safety Info)undated revealed high blood levels of Dilantin could cause confusion also known as delirium, psychosis, or a more serious condition that affects how your brain works (encephalopathy). Record review of the facility policy and procedure titled, Medication Administration undated revealed in part, .1. All medications are administered by licensed medical or nursing personnel as ordered by the physician and in accordance with professional standards .2.Compare the medication source with the MAR to verify dose and time . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675468 If continuation sheet Page 12 of 15 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 675468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hico Nursing and Rehabilitation 712 Railroad Ave Hico, TX 76457 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 maintain an effective pest control program so that the facility is free of pest and rodents in that : Residents Affected - Some The facility failed to ensure the facility was free from flies, crickets, and grasshoppers. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life. Findings Included: Observation on 07/18/23 at 12:00PM of the Dining hall, Hallways, and the Restrooms in the hallways, revealed there were dozens of crickets and grasshoppers roaming around. Observation of the kitchen on 07/18/23 at 2:00PM revealed, there were flies circling around in the kitchen and landing on various food products. There were crickets and grasshoppers on the floor on various locations. Observation of Resident # 35's room on 07/19/23 at 10:46 AM revealed, there were several crickets and grasshoppers on the floors. Record review of Resident #35's face sheet, dated 07/19/23, reflected an admission date of 04/14/22. He was a [AGE] year-old male diagnosed with Hypertension (High Blood pressure), Obesity, Hyperlipidemia (high fat level in blood), Repeated falls, Sleep Apnea, Retention of urine, Restless legs syndrome, Anxiety Disorder, Muscle Weakness, Lack of coordination, Chronic Obstructive Pulmonary Disease, Limitation of activities due to disability, Insomnia, Unsteadiness on feet and Abnormalities of gait and mobility. Record review of Resident #35's MDS dated [DATE] revealed the resident's BIMS score was 15, indicating he was cognitively intact. In an interview on 07/20/23 at 1:00PM with Resident#35 (was the Resident Council President), he stated there were crickets and grasshoppers in his room. He added that he had noticed lots of crickets and grasshoppers in the hallways as well and believed the insects were getting into residents' room from there. He said residents seems used to the insects at the facility so much so that they stopped complaining about it . Resident #35 said, he had seen pest control person spraying chemicals a month ago however, it did not seem to help. Record review of Resident #3's face sheet, dated 07/17/23, reflected an admission date of 07/08/20. She was an [AGE] year-old female diagnosed with Hypertension, Constipation, Major Depressive Disorder, Dysphagia, Gastrointestinal Hemorrhage, Anemia, Seizures, Need for assistance with personal care, Muscle weakness, Limitation of activities due to disability. Problems related to care provider dependency, Reduced mobility, hypokalemia (Low potassium level in blood) and Lack of coordination Record review of Resident #3's MDS dated [DATE] revealed the resident's BIMS score was 15, indicating she was cognitively intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675468 If continuation sheet Page 13 of 15 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 675468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hico Nursing and Rehabilitation 712 Railroad Ave Hico, TX 76457 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview with Resident#3 on 07/20/23 at 3:00PM, she stated, she had flies in her room. Resident #3 said there were crickets and grasshoppers as well. She stated she had complained about this many occasions however the insect issue still not resolved. The investigator observed no insects or flies during the visit for the interview. In an interview on 07/19/23 at 3:00PM with the Dietary Manager, she stated the number of flies in the kitchen were reduced after the installation of the electronic fly light however it could not totally stop them coming into the kitchen. She stated the pest control person had been at the facility; however, she did not think the treatment they were applying was working effectively. When the investigator asked about the consequences of flies and insects in the kitchen, she stated they spread diseases by landing on the food products and contaminating them. Interview on 07/20/23 at 10:50 AM with the HS revealed she had been working at the facility for more than 5 years. She stated she had seen flies, crickets, and grasshoppers everywhere at the facility. The HS stated at the beginning of this summer they have had a constant issue with flies, cricket, and grasshoppers. She said it was worse when summer started and had gotten better. The HS stated she had seen the pest control person doing the treatment however with little effect. In an interview on 07/20/23 at 3:23 PM with the MS, she stated she was working at a sister concern of the facility. After the sudden death of the MS at the facility, she temporarily had undertaken the MS tasks until further arrangement is done. When investigator asked about the consequences of flies and insects in the facility, she stated they spread diseases and could bite/sting residents. She added the presence of insects at the facility would not create a home like environment. The MS stated the facility planned to increase the frequency of pest control treatment more than once a month until the insect and flies' infestation is contained. In an interview on 07/20/23 at 4:00 PM with the DON, she stated flies, cricket and grasshoppers had been a constant issue. She said crickets and grasshoppers were big issue currently in the entire county and they were trying their level best to contain them at the facility. The DON said this year had been worse than, others. The DON stated they had contract with the pest control company for a monthly service with an additional treatment as and when needed. The DON stated the pest control person treated the facility on 06/13/23 and for the first week there were no insect activities and then the insects and flies slowly started to pick up. When the investigator asked if the pest control treatment was effective in the first week, why the facility had not increased the frequency more than a month, she stated the pest control person was scheduled to come in the next day and will use their service more than once a month in the summer. Record review of the pest control record since 01/01/23 revealed that the facility had a contract with the company PCC, and they visited at the facility once a month for the pest control treatment. The last visit for pest control was on 06/13/23. The target issues for the treatment during this visit was American Roaches, German Roaches and Little Black Ants and no treatment was evident for flies, crickets and grasshoppers. Review of the undated facility's policy Pest Control program, reflected the following: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675468 If continuation sheet Page 14 of 15 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 675468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hico Nursing and Rehabilitation 712 Railroad Ave Hico, TX 76457 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 0925 Level of Harm - Minimal harm or potential for actual harm 1.Facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis . . 3. Facility will maintain a report system of issues that may arise in between scheduled visits with the outside pest service and treat as indicated. Residents Affected - Some 4.Facility will utilize a variety of methods in controlling certain seasonal pests, i.e., flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675468 If continuation sheet Page 15 of 15