Health inspection·August 10, 2023

F 0607 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's medical notes dated 6/17/2023 at 12:35 PM, written by LVN B, indicated RP was notified. Record review of Resident #1's medical notes dated 6/17/2023 at 4:00 PM, written by LVN B, indicated X-ray was performed. Residents Affected - Few A review of Resident #1's medical notes dated 6/17/2023 at 7:14 PM, written by LVN B, indicated RP was not available to be informed of positive x-ray results. The facility medical director ordered Resident #1 to the ER for a second opinion of x-ray interpretation. A review of Resident #1's medical notes dated 6/17/2023 at 7:36 PM, written by LVN B, indicated EMS was notified to pick Resident #1 up from facility and transport to ER. A review of Resident #1's medical notes dated 6/17/2023 at 10:24 PM and written by MDS coordinator indicated: Received report from RN at Local Hospital ER that the resident (Resident #1) had a mild displacement with fracture to right humeral neck and is to keep sling in place until follow up with ortho of PCP choice. Floor nurse and DON made were made aware. During an interview and observation of Resident #1 on 7/20/2023 at 3:45 PM, she expressed no pain. Resident #1 was able to follow simple requests. Resident #1 was wearing socks on her feet and could not display a full range of motion when requested to move her feet. Resident #1 was unable to describe her injury, or how her injury occurred. Resident #1 was in no obvious distress. During an interview with Resident #1's daughter on 8/8/2023 at 10:40 AM she said the facility DON told her they did not know how her mother broke her arm and that her mother did not fall. During an interview with the DON on 7/21/2023 at 11:20 AM, she stated she did not want to assume anything and therefore did not reach a conclusion as to what probably happened with the resident. When asked why the bruise looked elongated, as if Resident #1 had banged her arm on a table or bar, she said she did not know. No conclusion as to what happened or what probably happened was forthcoming. During an interview with CNA E on 8/8/2023 at 3:40 PM she said she worked from 2 to 10 on 6/16/2023. She said Resident #1 usually takes a nap after dinner and does not get out of bed again until breakfast. CNA E said she did not remember changing Resident #1, but probably changed her before 10 PM. CNA E said they always do a last round before leaving. CNA C said there was nothing out of the ordinary. During an interview with hospitality aid D on 8/8/2023 at 4:05 PM she said she probably interacted with Resident #1 but does not remember. Hospitality aid D said the next time she came to work, Resident #1 was a Hoyer lift. Record review of the facility's Provider Investigation Report #431171 included: Resident chart notes 6/16/2023 - 6/17/2023 in-service: abuse and neglect dated 6/17/2023 in-service: gait belt transfers dated 6/17/2023 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lone Star Ranch Rehabilitaion and Healthcare Cente 316 General Cavazos Blvd Kingsville, TX 78363 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 0607 Attestation form of gait belt requirement (all direct care staff) Level of Harm - Minimal harm or potential for actual harm Grievance log July, June, May, April, March: no trends Record review of Abuse Policy (5/01/01 Revised 5/28/2021) indicated: Residents Affected - Few The facility will thoroughly investigate all alleged violations and take appropriate actions. Investigations will be prompt, comprehensive and responsive to the situation and contain founded conclusions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lone Star Ranch Rehabilitaion and Healthcare Cente 316 General Cavazos Blvd Kingsville, TX 78363 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident needs, that include measurable objectives and time frames to meet residents' physical needs for 1 of 1 (Resident #1) residents reviewed for care plans. The facility failed to develop a care plan to address Resident #1's fractured Humerous, which is the largest bone in the upper arm. This failure could affect residents by placing them at risk of not having their needs met. Findings include: Record review of Resident #1's face sheet revealed an 85 y/o female with diagnoses of other specified disorders of bone density and structure (unspecified site), Alzheimer's disease, dementia , abnormal gait, and a Humerus fracture. Record review of Resident #1's Care Plan, accessed on 7/20/2023 at 3:30 PM indicated Resident #1 had limited physical mobility r/t muscle weakness. Interventions revealed Resident #1 was WEIGHT-BEARING with transfers. She required the assistance of one staff. Record review of the admission Minimum Data Set (MDS) dated [DATE] indicated Resident #1 experienced a significant change. Resident #1 had a documented BIMS score of 03 out of 15, indicating severe cognitive impairment. A review of Resident #1's medical notes dated 6/17/23 at 5:50 AM indicated: CNA C notified charge nurse that resident was complaining of right arm pain, charge nurse assessed arm and noted three discolorations to right arm on forearm 3.5cm x3.5cm, above elbow 8cm x2cm and on elbow2.5cm x1.5cm, PRN pain medication administered, communication note sent to physician, VS- 96%, 67-P, 106/61, 18-RR, will ask morning nurse to contact RP due to early morning hours. A review of Resident #1s medical notes from 6/17/2023 at 2200 (10:00 PM) indicated: Received report from RN at Local Hospital ER that the resident has a mild displacement with fracture to right humeral neck and is to keep sling in place until follow up with ortho of PCP choice. Floor nurse and DON made aware. During an interview and observation of Resident #1 on 7/20/2023 at 3:45 PM, she expressed no pain. Resident #1 was able to follow simple requests. Resident #1 was wearing socks on her feet and could not display a full range of motion when requested to move her feet. Resident #1 was unable to describe her injury, or how her injury occurred. Resident #1 was in no obvious distress. During an observation on 7/20/2023 at 3:45 PM all staff on hall had gait belts available. During an interview and observation of Resident #1 on 7/20/2023 at 3:45 PM with CNA E she said Resident #1 could not walk and used a Hoyer Lift to get from her bed to her wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lone Star Ranch Rehabilitaion and Healthcare Cente 316 General Cavazos Blvd Kingsville, TX 78363 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm During an interview with DON on 7/20/2023 at 3:50 PM, she said she thought there should be a care plan for that (using a Hoyer Lift). The DON said they could possibly be providing incorrect care. During an interview with the MDS coordinator on 7/20/2023 at 4:00 PM, she said they just changed Resident #1's transfer requirements to a Hoyer lift, and she just updated her care plan. Residents Affected - Few During an interview with the DON on 7/21/2023 at 9:00 AM, she said she thought they had 5 days once the incident investigation was done to do the care plan. The DON said the MDS coordinator had been on vacation and that is why the care plan was late. During an interview with CNA E and CNA B on 7/21/2023 at 4:25 PM, they said they received a turnover report and were told then Resident #1 was a Hoyer lift now because of her arm. Record review of Care Plan Policy (Nexion 10-2022; Reviewed [DATE]) indicated the comprehensive, person-centered care plan is developed within (7) days of the completion of the required comprehensive assessment (MDS). Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lone Star Ranch Rehabilitaion and Healthcare Cente 316 General Cavazos Blvd Kingsville, TX 78363 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one of (Resident #2) of five residents that were reviewed for infection control and transmission-based precautions policies and practices, in that: Residents Affected - Few NA A did not perform hand hygiene prior to commencement of perineal care. NA A proceeded to clean perineal area without performing hand hygiene and maintained usage of dirty gloves throughout care. These failures could place residents at risk for infection through cross contamination of pathogens. The findings included: Record review of Resident #2's Face Sheet dated 07/21/2023, admitted originally 03/28/2019, with readmission date, documented a [AGE] year-old female with the following diagnoses of: dementia, cognitive communication deficit, pain, bipolar disorder (serious mental illness that causes unusual shifts in mood, ranging from extreme highs (mania or manic episodes) to lows (depression or depressive episode), type two diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). Record review of Resident #2's MDS dated [DATE] documented 7 out of 15 BIMS score suggesting severe cognitive impairment. As well as extensive dependency of staff to assist in activities of daily living. Record review of Resident #2's Comprehensive Care Plan date initiated 03/01/2021 and revised 06/02/2023 stated, Focus: Resident #2 has episodes of bowel/bladder incontinence r/t Dementia and Impaired mobility. Goal: Resident #2 will remain free from skin breakdown due to incontinence and brief use. Interventions: brief use: Resident #2 uses disposable briefs. Change q 2 hours and prn. Clean peri-area with each incontinence episode. Incontinent: check q2 hours and as required for incontinence. Resident #2 requests not to be disturbed during hours of sleep. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. Observation on 07/21/2023 at 2:57 PM NA A knocked and entered Resident #2's room and was granted permission from Resident #2 to perform perineal care. NA A washed her hands for 40 seconds and proceeded to grab Resident #2's bed remote to reposition the resident's bed using their bare hands. NA A continued by pulling string from Resident #2s overhead light, removed Resident #2's blankets and unlatched Resident #2's brief that was visibly soiled, all bare handed. After touching the multiple surfaces with bare hands, NA A did not perform hand hygiene prior to applying clean gloves. NA A commenced the perineal care, once finished with the perineal area, NA A turned R#2 to the left side by grabbing Resident #2's right leg and lifting the right leg up and over to the left side of bed. NA A then proceed to remove her dirty gloves and applied a new pair of clean gloves without performing hand hygiene, followed by cleaning excrement from R#2's gluteal folds. During interview on 07/21/2023 at 3:12 PM with NA A, inquired about the procedural steps taken on Resident #2's perineal care. To which NA A responded, she should have performed hand hygiene after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lone Star Ranch Rehabilitaion and Healthcare Cente 316 General Cavazos Blvd Kingsville, TX 78363 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few touching the multiple surfaces prior to perineal care. NA A stated she was nervous and was overthinking in her head. NA A stated once she was done cleaning the perineum area, she should have removed her dirty gloves, performed hand hygiene, and applied a new pair of gloves prior to turning Resident #2. NA A stated by performing hand hygiene followed by applying a new set of gloves before performing rectum cleaning care, would be a preventative measure to promote infection control and minimize potential of cross contamination. NA A stated by touching the bed remote, light string, Resident #2's blanket and soiled brief, followed then by Resident #2's perineal area, could have exposed Resident #2 to infectious microorganisms. NA A stated she was in serviced about infection control and hand hygiene two weeks ago but was nervous and forgot her training. During interview on 07/21/2023 at 4:02 PM with the DON, she stated prior to the commencement of perineal care, NA A should have performed hand hygiene after touching the multiple surfaces as a preventative measure to assist in infection control. The DON stated by not performing hand hygiene and glove change prior to turning Resident #2, NA A potentially exposed Resident #2 to infectious microorganisms or potential spread of bacteria. When DON was asked the reasoning as to why these specific steps were necessitated, the DON replied to minimize risk of infection. The DON stated it is a standard of practice to clean from cleanest to dirtiest. The DON stated she facilitated an in-service on perineal/incontinent care not too long ago. The DON stated she will weekly select four to five random clinical staff members and request they perform skills check off. The DON stated each skill check off is focused on infection control. Record Review of Hand Hygiene Policy, revision date 10/2020 stated, 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; d. Before performing any non-surgical invasive procedures; h. Before moving from a contaminated body site to a clean body site during resident care; j. After contact with blood or bodily fluids; l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; m. After removing gloves; Record review of the facility's Hand Hygiene/ Infection Control In-service dated July 19, 2023 indicated that NA A was not in attendance Record Review of the CDC Guidelines regarding Hand Hygiene in Healthcare Settings, last reviewed January 8, 2021, stated, Healthcare providers should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lone Star Ranch Rehabilitaion and Healthcare Cente 316 General Cavazos Blvd Kingsville, TX 78363 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 immediately after glove removal. 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: 675494 If continuation sheet Page 8 of 8