Health inspection·April 25, 2024

F 0695 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #23's MDS dated [DATE] reflected continuous oxygen therapy. No BIM score was provided. Resident #23 was not able to answer questions appropriately when questioned. Record review of #23's physician orders dated 1/28/2024 stated change, label, and date oxygen tubing and clean filter weekly. Residents Affected - Some Record review of #23's care plan dated 08/5/2023 reflected Resident #23 had congestive heart failure and oxygen at 2 litters per minute continuously. Observation on 04/23/24 at 03:09 PM of Resident #23's oxygen tubing was in use and not dated. Observation on 04/25/24 at 11:25 AM of Resident #23's oxygen tubing was in use and not dated. 3.) Record review of Resident # 170's face sheet dated 4/25/2024 reflected a [AGE] year-old female with an admission date of 3/21/2024. Diagnoses included chronic obstructive pulmonary disease (chronic obstructed airflow from the lungs), type two diabetes (insufficient production of insulin in the body), and heart disease. Record review of Resident #170's MDS dated [DATE] reflected a BIMS of 14 (cognitively intact) oxygen therapy. Record review of Resident #170's physician orders dated 4/21/2024 stated change, label, date oxygen tubing weekly. Record review of Resident #170's care plan dated 4/3/2024 reflected Resident has oxygen therapy related to infective gas exchange from COPD due to smoking in the past. Observation on 04/24/24 at 02:03 PM of Resident #170's oxygen tubing was in use and not dated. Observation on 04/25/24 at 11:10 of Resident #170's oxygen tubing was in use and not dated. In an interview on 04/25/24 at 11:20 AM Resident #170 stated she believes her oxygen tubing is changed out every Sunday night. In an interview on 04/25/24 at 11:26 AM LVN B stated resident's oxygen tubing should be dated to ensure patency and cleanliness. LVN B stated oxygen tubing is changed every week on Sundays during night shift and it is the responsibility of the nurse changing out the oxygen tubing to ensure it is dated at the time of change as well as all charge nurses. In an interview on 04/25/24 at 11:29 AM, the DON stated resident's oxygen tubing should be dated to make sure that they are being changed weekly so staff would be aware of the date when the oxygen tubing was changed. The DON stated the charge nurses are responsible for making sure oxygen tubing was dated as it could lead to not knowing when the oxygen tubing needed to be replaced for being used longer than it should be. The DON stated she was could not recall when the last in-service on oxygen tubing was conducted but would conduct an in-service immediately. Record review of the Oxygen Administration policy dated 2/2023 stated: Purpose (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 2 of 14 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 04/25/2024 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 0695 The purpose of this procedure is to provide guidelines for safe oxygen administration.' Level of Harm - Minimal harm or potential for actual harm Preparation Residents Affected - Some 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 3 of 14 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 04/25/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide separately locked and permanently affixed compartments for Schedule II-V medications and/or other medications subject to abuse in two (B and C wing) of two medication rooms that contained emergency use narcotics boxes. The facility failed to ensure the emergency use narcotic boxes in B and C wing medication rooms were permanently affixed. These failures could place residents at risk for misappropriation and/or diversion of medication. Findings included: Observation on [DATE] at 10:20 AM, the medication storage room on the secured memory unit C wing revealed a key locked door into the medication room. LPN A had the key and unlocked the door. Inside the medication room, there was a red metal box with a numbered keypad on the front sitting on top of the mini refrigerator. This box was picked up without difficulty and could easily have been carried out of the room. Observation on [DATE] at 11:32 AM, the medication storage room in B wing revealed a locked door into the room. The ADON had the key and unlocked the door. Inside the medication room, there was a red metal box with a numbered keypad on the front sitting on top of the mini refrigerator. This box was picked up without difficulty and could easily have been carried out of the room. In an interview on [DATE] at 11:35 AM, the ADON stated the rules for storing narcotics were that the narcotics had to be double locked, logged, and expiration dates checked. The ADON stated narcotics stored in the refrigerator had to be at the correct temperature and in a separate locked, unmovable box. The ADON stated the red boxes came from the pharmacy and if something was expired or a medication was used, the pharmacy would take the whole box and replace it with another. The ADON stated she would call the pharmacy to see what they could do about a permanently affixed box. In an interview on [DATE] at 01:08 PM, the DON stated narcotics are to be double locked and secured. The DON stated the pharmacy brought the red boxes to the facility. The DON stated the pharmacist who checked the boxes never told the facility the boxes had to be permanently affixed and just made them double lock them. The DON stated the red boxes had been that way for years and no one had said anything about it. Record review of the facility's Medication Labeling and Storage Policy dated 2001 and revised February 2023 stated in part: 7. Controlled substances (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 4 of 14 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 04/25/2024 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 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 1 of 1 kitchen reviewed for sanitation in that: 1. The facility failed to ensure dry goods were sealed 2. The facility failed to ensure dry goods were labeled and dated 3. The facility failed to ensure equipment was clean and sanitized 4. The facility failed to refrain from having personal items in the prep areas 5. The facility failed to label and date items in the walk-in refrigerator 6. The facility failed to label and date items in the walk-in freezer 7. The facility failed to maintain temperature logs for refrigerators and the freezer 8. The facility failed to maintain temperature and sanitization logs for the 3-compartment sink 9. The facility failed to maintain proper lighting in the walk-in refrigerator 10. The facility failed to maintain the door latch in walk-in freezer These failures could place residents at risk of foodborne illnesses. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 5 of 14 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 04/25/2024 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 0812 Findings included: Level of Harm - Minimal harm or potential for actual harm Observation and initial tour of the kitchen on 04/23/24 beginning at 9:20 AM revealed 1, partially full, 5-gallon bucket of rice was open to the air with a large scoop inside. There were 8, 16-oz. containers of spices open to the air. There was a bag of 6 slices of white bread with an expiration date of 04/22/24, and a bag of 8 hamburger buns with an expiration date of 04/20/24 in the dry storage area. 5 of 5 steam table wells were heavily crusted on the sides and bottoms with a flaking, yellow-whitish substance. There were no covers on the plate warmers. The light in the walk-in refrigerator was very dim. The latch on the walk-in freezer did not lock and there was ice build-up on the wall. There was a large purse with personal items visible inside it on a prep table. There was an opened, unlabeled, and undated 16-oz. bottle of water on a beverage cart with resident's beverages. There was a set of keys on a lanyard, a personal phone, a plastic file of papers, an ink pen, and other papers on a different prep table (the beverage prep table). There was a purple personal cup of ice with no lid on the shelf in the dry storage room. The light in the walk-in refrigerator was very dim. In the walk-in refrigerator, there was an unlabeled, undated 5-pound bag of shredded cheese open to the air, 4 uncovered, unlabeled, and undated cups of desserts on a tray of 13 other desserts, all unlabeled and undated, and 40 cups of beverages unlabeled and undated. In the walk-in freezer, there was a 2-gallon bag of cinnamon rolls, a 2-gallon bag of enchiladas, a 10-pound bag of breaded fish, a 10-pound bag of tamales, and a 10-pound bag of breaded chicken breasts all open to the air, unlabeled and undated. Residents Affected - Many In an interview with the FSM on 04/23/24 beginning at 9:30 AM, he stated the bucket of rice should have been covered at all times and the scoop should not have been in there. The FSM stated the spices should have been closed because particles could fall into them and that would be cross contamination. The FSM stated the bread and buns were expired and should have been thrown out. The FSM stated the steam table wells were cleaned nightly and the pans were new; they should be shiny. The FSM stated the particles floating in the steam table wells could contaminate the food and make residents sick. The FSM stated the cleaning log had been filled out as if the steam table had been cleaned daily, but the steam table wells did not look like they had been cleaned very recently, if at all. The FSM stated he did not know why there were no plate covers on the plates in the plate warmer. The FSM stated the plates would lose their heat, and the plates could get contaminated from particles in the air dropping on them, causing cross contamination and make residents sick. The FSM stated he was unaware the freezer latch had been broken and without a good seal on the door, the food inside could become damaged. The FSM stated he had not noticed the ice on the wall of the walk-in freezer. The FSM stated he was aware of the dim light in the walk-in refrigerator but did not know how to change the bulb, did not pursue how to, nor follow up. Further, the light in the walk-in refrigerator had been dim like that for weeks. The FSM stated the purse belonged to one of the dietary aids and should not have been on the prep table because of cross contamination. The FSM stated the water bottle belonged to one of the dietary aids and should not have been on the beverage cart with the resident's beverages because of cross contamination The FSM stated the set of keys on a lanyard belonged to him and they should have been on a hook on the wall because of cross contamination. The FSM stated the personal phone on the beverage prep table should not have been there because of cross contamination. The FSM stated the file of papers, an ink pen, and other papers on the beverage prep table should not have been there because of cross contamination. The FSM stated the purple personal cup of ice with no lid on the shelf in the dry storage room should not have been there because of cross contamination and it could have spilled, creating more cross contamination. The FSM stated the items in the walk-in refrigerator and freezer should all have been sealed, labeled, and always dated. The FSM stated the uncovered, undated, and unlabeled cups of desserts in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 6 of 14 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 04/25/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many walk-in refrigerator were from yesterday. The FSM stated the items in the walk-in freezer that were open to the air were at risk for becoming freezer burned and should have been thrown out because they were no longer good and if it were used, it would taste bad and possibly make the residents sick. In an interview with DA-A on 04/23/24 at 9:35 AM, she stated the water bottle on the beverage cart was hers, and it was her personal phone on the beverage prep table, she said they should not have been there because cross contamination could occur and make the residents sick. DA-A stated she did not know why she put her personal belongings on the beverage prep table, and guessed it was ok because the other items were on the table. In an interview with DA-B, on 04/23/24 at 9:40 AM, she stated the purse and purple cup on the prep table belonged to her, and they should not have been there. DA-B stated her personal purple cup of ice was on the shelf in the dry storage room because she moved it from the prep table, and it should not have been there either because cross contamination could occur and make the residents sick. DA-B stated the cup should have always had a lid on it because it could have spilled and contaminated the prep table and/or items in the dry storage room. DA-B stated she did not sanitize the prep table after removing her personal belongings from it. DA-B stated all stored items, whether in dry storage or the refrigerator or freezer, should always be labeled, dated, and sealed. DA-B stated she was unaware of the unlabeled, undated, and open to the air items in the dry storage, the refrigerator, or the freezer. DA-B stated she was always having to clean extra water out of the milk refrigerator and did not know what was causing it, nor told anyone about it-she just did it. Record review of the cleaning log dated April 2024 documented the steam table wells had been cleaned daily from 04/01/24-04/23/24. Observation in the kitchen on 04/24/24 at 12:05 PM revealed in the walk-in refrigerator, 6 trays (20 cups per tray) of desserts and beverages all unlabeled and undated, the same items seen on day 1 (04/23/24) that were open to the air, now including 2, 2-gallon bags of salad that had a thick-like brown liquid inside the bag. The milk refrigerator had 24 1-gallon containers of milk inside. In an interview with the FSM on 04/24/24 at 12:10 PM, he stated he was responsible for checking the walk-ins and he did not do it today. The FSM stated the milk refrigerator was not holding temperature and they were having to wipe up condensation off the floor because of it. The FSM stated he was not sure why the milk refrigerator was not working properly. The FSM stated he did not know if he was responsible for the milk refrigerator and had mentioned it to the maintenance supervisor. Observation and record review in the kitchen on 04/25/24 at 11:00 AM, revealed a personal phone on a prep table next to a container of pureed yellow food. There was no temperature log for the milk refrigerator or the 3-compartment sink sanitation and temperature. In an interview with the FSM on 04/25/24 at 11:13 AM, he stated he did not have any temperature logs for the walk-ins, the milk refrigerator, or 3-compartment sink. The FSM stated he did not know he was supposed to have logbooks for temperatures and had no way of knowing if the equipment was operating within parameters. The FSM stated he had not informed the ADM about the milk refrigerator or the plate warmer covers. The FSM stated he had contacted the company to replace the milk refrigerator several times but they would not replace it and he stated he did not have a copy of the contract. The FSM stated there was a risk of slip/fall accidents due to the condensation on the floor. The FSM stated he was not aware of his responsibilities as a food service manager. The FSM stated he was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 7 of 14 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 04/25/2024 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 0812 aware of the facility policies regarding the kitchen but was aware there were policies. Level of Harm - Minimal harm or potential for actual harm In an interview with Cook-A on 04/25/24 at 11:15 AM, she stated it was her phone on the prep table, she needed to use the restroom, so she just set her phone down on the prep table, indicating she was using her phone in the work area of the kitchen. Cook-A stated she was sorry and could have easily dropped her phone in her pocket instead of putting it on the prep table and did not know why she did not. Cook-A stated she knew better and putting personal items on the prep tables was a source of cross contamination. Residents Affected - Many Return trip to the kitchen and interview with the ADM on 04/25/24 at 1:20 PM, revealed the steam table wells now had a black substance on the bottoms along with a flaking, yellow-whitish substance. There was an 80-oz. partially full bag of instant dry milk and a 5-pound box of breading that were unlabeled, undated, and unsealed in the dry storage room. In an interview with the ADM on 04/25/24 at 1:27 PM, she stated she was unaware of the milk refrigerator malfunctioning and did not know there had been no temperature or sanitization logs. The ADM stated she was unaware of the dim light in the walk-in refrigerator or the broken walk-in freezer latch. The ADM stated the MS was out, but he could be reached via phone. In an interview with DA-B on 04/25/24 at 1:30 PM, she stated she had been a kitchen worker for years and knew there was supposed to be temperature logs for all the refrigerators, the freezer, and the 3-compartment sink. DA-B stated she told the FSM about not having logs 6 months ago, but he did not do anything about it. DA-B stated she did not notify anyone else because it was the FSM's responsibility. In a phone interview with LSC, ADM, and the MS on 04/24/24 at 3:17 PM, the MS stated the milk cooler was rented and it was the FSM's responsibility to replace. The MS stated he replaced the bulb in the walk-in refrigerator with the only bulb he could find. LSC asked the MS if he looked online or contacted the manufacturer for the bulb and the MS stated he did not. LSC asked the MS if he was aware of the broken latch on the walk-in freezer and the MS stated he noticed it a couple of weeks ago when he was working on the freezer fan. The MS stated he knocked ice off the latch but needed to go back and check the latching mechanism to see if it needed a part or if it was just coated with ice. Record review of the FSM's certification revealed a certificate of completion for an 8-hour course dated 03/13/24 titled Food Safety Management Principles. Record review of the RD's certification revealed a licensed dietician with an expiration date of 05/31/24. Record review of the facility's undated position description for dietary department director revealed the FSM was to report to the ADM and/or the RD. The job summary revealed, This position will provide management for the facility dietary department, ensuring quality food. It will report directly to the facility administrator and/or the dietician. It will direct and assist the preparation and serving of regular meals and therapeutic diets, order food and dietary supplies, maintain area and equipment in sanitary condition. This individual will assume administrative authority, responsibility, and accountability of managing the dietary department. Job Responsibilities: .directs and manages all facility dietary functions and personnel, develops job descriptions, cleaning schedules, and other dietary management tools, assures that proper storage is available, and that handling of food and supplies complies with federal guidelines. Position Qualifications: .Minimum 5 years dietary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 8 of 14 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 04/25/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm experience in long term care or hospital setting, strong organizational skills with attention to detail, ability to manage and maintain a safe and operating kitchen . Record review of In-services: 01/19/24-Care and Services-employees cannot refuse reasonable requests from residents, 03/13/24-Dress code, Fostering Mutual Respect and Professionalism. Residents Affected - Many Record review of the facility's policy titled Food Preparation and Service dated 10/2022 documented under Policy Statement, Food and nutrition employees prepare and serve food in a manner that complies with safe food handling practices. Food Preparation Area 4. Appropriate measures are used to prevent cross contamination. Food Preparation, Cooking, and Holding Time/Temperatures 1. The danger zone for food temperatures is between 41 F and 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Record review of the facility's policy titled Refrigerators and Freezers dated 10/2022 documented under Policy Statement, This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. 1. Acceptable temperature ranges are 35 F to 40 F for refrigerators and less than 0 F for freezers. 2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. 3. Monthly tracking sheets will include time, temperature, initials, and action taken. 4. Food service supervisors or designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening. 5. The supervisor will take immediate action if temperatures are out of range. Actions necessary to correct the temperatures will be recorded on the tracking sheet, including the repair personnel and/or department contacted. 6. Information regarding acceptable storage periods for perishable foods will be kept in the supervisor's office. A condensed version will be posted by each refrigerator and freezer for reference. 7. All food shall be appropriately dated to ensure proper rotation by expiration dates. ·Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be comp let ed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 9 of 14 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 04/25/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many are not expired or past perish dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes. 9. Supervisors will inspect refrigerators and freezers monthly for gasket condition. fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs will be initiated immediately. Maintenance schedules per manufacturer guidelines will be scheduled and followed. Record review of the facility's police titled, Food Receiving and Storage dated 10/2022 documented under Policy Statement, Foods shall be received and stored in a manner that complies with safe food handling practices. Under policy interpretation and implementation: 7. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date). 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (' use by date). 9. Refrigerated foods must be stored below 41 F unless otherwise specified by law. 11. The freezer must keep frozen foods frozen solid. Wrappers of frozen foods must stay intact until thawing. 12. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements. 14. Food items and snacks kept . must be maintained as indicated below: a. All food items to be kept below 41 F must be placed in the refrigerator . and labeled with a use by date. e. Refrigerators must have working thermometers and be monitored for temperature according to late-specific guidelines. d. Beverages must be dated when opened and discarded after twenty-four (24 ) hours. e. Other opened containers must be dated and sealed or covered during storage. f. Partially eaten food may not be kept in the refrigerator. Record review of the facility's police titled, Sanitization revised Jan. 2024 documented under Policy Statement, The food service area shall be maintained in a clean and sanitary manner. Under Policy interpretation and implementation: 2. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair, and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 10 of 14 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 04/25/2024 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 0812 use or proper cleaning. Seals, hinges and fasteners will be kept in good repair. Level of Harm - Minimal harm or potential for actual harm 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. Residents Affected - Many 9. Manual washing and sanitizing will employ a three-step process for washing, rinsing and sanitizing: a. Scrape food particles and wash using hot water and detergent b. Rinse with hot water to remove soap residue; and c. Sanitize with hot water or chemical sanitizing solution. 12. Kitchen waste that are not disposed of by mechanical means shall be kept in clean, leakproof, nonabsorbent, tightly closed containers and shall be disposed of daily. 16. The Food Services Manager will be responsible for scheduling staff' for regular cleaning of the kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 11 of 14 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 04/25/2024 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 2 (Resident #2 and Resident # 122) of 5 residents and 4 of ( CNA C, CNA D, CNA E, and HA F) staff that were reviewed for infection control in that: Residents Affected - Few 1. CNA C and CNA D did not perform hand hygiene for 20 seconds or longer and did not remove contaminated gloves during peri care after changing Resident # 2's brief and prior to putting on a new brief. 2. CNA E and Hospitality Aide F did not perform hand hygiene prior to peri care and did not perform hand hygiene for 20 seconds or longer after peri care. CNA E and Hospitality Aide E did not remove contaminated gloves during peri care after changing Resident #122's brief and prior to putting on a new brief. These failures could place residents at risk for infection through cross contamination of pathogens. The findings include: 1. Record review of Resident # 2's face sheet dated 4/25/2024 reflected a [AGE] year-old female with an admission date of 1/19/2024. Diagnoses included chronic obstructive pulmonary disease (chronic obstructed airflow from the lungs), type two diabetes (insufficient production of insulin in the body), and heart failure. Record review of Resident #2's MDS dated [DATE] reflected a BIMS of 99 (Severe cognitive impairment) and was always incontinent and required total dependence. During an observation of peri care for Resident #2 on 04/23/2024 at 02:33 PM CNA C and CNA D did not change gloves after removing Resident #2's soiled brief and began to place a clean brief on using contaminated gloves. After peri care was performed, CNA C and CNA D performed hand hygiene for approximately 15 seconds. In an interview on 4/23/2024 at 02:50 PM, CNA C stated Resident #2's brief was wet but did not change her gloves after she removed the soiled brief because it was not a BM (bowel movement), and she did not see anything that was dirty on her gloves and did not think she had to change them. CNA C stated she did not count while she washed her hands and did not know how long she washed her hands for. CNA C stated hand washing should be around 30 seconds to prevent the spread of germs to residents and others. CNA C could not recall when the last in-service or training was. In an interview on 4/23/2024 at 02:52 PM CNA D stated gloves should be changed between a dirty and a clean procedure if there was feces or if gloves were visibly soiled. CNA D stated hand hygiene should be for about 20 to 30 seconds to prevent the spread of germs to residents. CNA D could not recall when the last in-service on hand washing, or infection control was. 2. Record review of Resident #122's face sheet dated 4/25/2024 reflected an [AGE] year-old-female (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 12 of 14 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 04/25/2024 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 with an original admission date of 12/22/2014. Diagnoses included cerebrovascular disease (disease that affects the blood vessels in your brain), cognitive communication deficit, and hypertension (high blood pressure). Record review of Resident #122's MDS dated [DATE] reflected a BIM score of 7 (severe cognitive impairment) and was always incontinent with partial to moderate assistance required. During an observation of peri care for Resident #122 on 04/25/24 at 02:11 PM, CNA E and Hospitality Aide F did not perform hand hygiene prior to putting on gloves and began to perform peri care. After peri care was performed and soiled brief was removed, CNA E and Hospitality Aide F did not remove contaminated gloves. Hospitality Aide F then began to open Resident #122's drawers with contaminated gloves looking for barrier cream. Hospitality Aide F then removed gloves, left Resident #122's room to get barrier cream and returned. Hospitality Aide F did not perform hand Hygiene before proceeding with care and put on new gloves. CNA E removed only one glove and did not perform hand hygiene and placed on one new glove prior to placing a clean brief on Resident #122. After peri care was performed, CNA E removed gloves and performed hand hygiene for approximately 5 seconds. In an Interview on 04/25/24 at 02:25 PM, both CNA E and Hospitality Aide F stated they were nervous and did not realize they had missed steps. CNA E stated it was important to wash hands for about 20 seconds or longer to stop the spread of germs and diseases to residents. Both CNA E and Hospitality Aide F stated they did not think they had to change their gloves after cleaning Resident #122 because her brief was not visibly soiled. Both CNA E and Hospitality Aide F stated the last infection control and hand hygiene in-service was done within the past month. In an interview on 04/25/24 at 02:32 AM, the DON stated hand washing should be 20 seconds or greater to prevent the spread of bacteria to residents and other surfaces. The DON stated all gloves should be changed between brief changes from a dirty to clean procedure to ensure effective infection control practices and stop the spread of germs to staff, residents, and other surfaces. The DON stated last hand hygiene/ infection control in-service was done within the last month and is also conducted on an as needed basis. In an interview on 04/25/24 at 02:46 PM, the ADON stated effective hand washing of 20 seconds or greater is important to prevent the spread of infection to residents, staff, and visitors. ADON stated hands should be washed prior to performing care and gloves should be changed after performing peri care to reduce the risk of cross contamination from a clean to dirty surface. ADON stated once a month in-service on infection control and hand washing is conducted with staff. Record review of Handwashing/Hand Hygiene policy dated 3/1/2020 stated: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 13 of 14 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 04/25/2024 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 (antimicrobial or non-antimicrobial) and water for the following situations: Level of Harm - Minimal harm or potential for actual harm b. Before and after direct contact with residents; d. Before performing any non-surgical invasive procedures; Residents Affected - Few i. After contact with a resident's intact skin; m. After removing gloves; 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine. Record review of Infection Prevention and Control Program revised on 10/2022 and reviewed on 1/2023 stated: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 14 of 14