Health inspection·June 19, 2025

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for 800 mcg of folic acid 1 time per day. LVN C stated she administered 0.4 mg of folic acid to Resident #45 earlier that day. LVN C stated there were no 0.8 mg tablets in the nurse's cart. LVN C stated she made an error in only administering 1 400 mcg folic acid tablet to Resident #45. LVN C stated she chose to hold the hydrochlorothiazide for Resident #133 because her blood pressure was low. LVN C stated Resident #133 had three other blood pressure medications that were all held as well because Resident #133's blood pressure was below the threshold for administering them. LVN C stated the order for hydrochlorothiazide stated it was used to treat hypertension, so it should have had the same parameters on it as the other blood pressure medications. LVN C stated it was important for residents to receive medications as ordered so their symptoms and conditions did not worsen and harm the resident. In an interview with ADON 1 on 06/19/25 at 1:28 PM, ADON 1 stated before administering medication, nurses and med aides should compare what was written in the MAR to what was written on the blister pack to ensure there were no inconsistencies. ADON 1 stated LVN C should have given 800 mcg of folic acid to Resident #45 during medication pass. ADON 1 stated LVN C should have administered the hydrochlorothiazide to Resident #133 because the order was correct as written. ADON 1 stated the order did not have hold parameters because it was being used primarily to treat edema (excess fluid in the body tissues). ADON 1 stated the administration of incorrect doses of medications or holding medications inappropriately could lead to unnecessary changes in the treatment plans of residents leading to harm. In an interview with the CCS on 06/19/25 at 2:02 PM, the CCS stated if LVN C had questions about whether to administer the hydrochlorothiazide to Resident #133, she should have called the doctor to confirm the order. The CCS stated the order did not have hold parameters because it was being used primarily to treat edema. The CCS stated holding medications when they were supposed to be administered could harm the residents because it was not what the doctor ordered. The CCS stated errors in medication administration could lead to unnecessary changes to the treatment plan of residents. Record review revealed the facility policy titled Medication Administration last reviewed 07/08/24 stated the following: .4. Medications are administered in accordance with prescriber orders, including any required time frame . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 2 of 13 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 06/19/2025 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 - Few 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 ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 (100-hall nurse cart) medication carts reviewed for medication storage. 1. The facility failed to write the open date on the vial of Resident #10's multidose Lantus insulin vial in the 100-hall nurse cart. 2. The facility failed to write the open date on the vial of Resident #133's multidose Lispro insulin vial in the 100-hall nurse cart. This deficient practice could place residents at risk of receiving expired insulin. The findings included: 1. Record review of Resident #10's face sheet dated [DATE] revealed a [AGE] year-old female with an admission date of [DATE]. Pertinent diagnosis included Type 2 Diabetes Mellitus (chronic condition where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels). Record review of Resident #10's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 (cognition intact). Further review revealed Resident #10 had received seven insulin injections in the past seven days. Record review of Resident #10's comprehensive care plan dated [DATE] revealed the focus The resident has Diabetes Mellitus initiated on [DATE]. An intervention listed for the focus stated [DATE] Lantus insulin added and will be administered per MD orders initiated on [DATE]. Record review of Resident #10's order summary revealed an active order dated [DATE] for Insulin Glargine Solution 100 UNIT/ML. Inject 55 unit subcutaneously at bedtime for diabetes related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. 2. Record review of Resident #133's face sheet dated [DATE] revealed a [AGE] year-old female with an admission date of [DATE]. Pertinent diagnosis included Type 2 Diabetes Mellitus. Record review of Resident #133's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 14 (cognition intact). Further review revealed Resident #133 had received seven insulin injections in the past seven days. Record review of Resident #133's comprehensive care plan had not been completed at the time of record review. Resident #133's baseline care plan indicated to administer medications as ordered by the physician. Record review of Resident #133's order summary revealed an active order dated [DATE] for Insulin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 3 of 13 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 06/19/2025 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 - Few Lispro Prot[[NAME]] & Lispro Subcutaneous Suspension (75-25) 100 UNIT/ML (Insulin Lispro Protamine & Lispro). Inject 150 unit subcutaneously two times a day for [diabetes mellitus] related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. During an observation on [DATE] at 2:40 PM of the 100-hall nurse cart, this state surveyor found two opened, undated vials of insulin in the top drawer of the cart inside their original box. The label on the first vial stated it was Humalog (brand name for lispro) mix 75/25 and was for Resident #133. The label on the second vial stated it was Lantus and for Resident #10. Neither vial had an opened-on date written on the vial or box. In an interview with LVN D on [DATE] at 4:38 PM, LVN D stated she wrote the date an insulin vial was opened on the vial and its box as well. LVN D stated she was currently the nurse in charge of the 100-hall. LVN D stated she was unable to find any opened-on date on either of the two insulin vials or boxes found in the 100-hall nurse cart. LVN D stated she always checked the expiration date on an insulin vial before administering any insulin to a resident. LVN D stated it was important to write the opened-on date on insulin vials because they expire after only 28 days. LVN D stated administering expired insulin to a resident may not be as effective and lead to an elevated blood sugar level. In an interview with ADON 1 on [DATE] at 1:28 PM, ADON 1 stated nurses write the date an insulin vial was opened on the sticker attached to the insulin vial. ADON 1 stated nurses checked the expiration date on the vial before administering insulin to any resident. ADON 1 stated if expired insulin was administered to a resident, it may not be as effective leading to hyperglycemia (elevated blood sugar) or it could have an unpredictable effect. In an interview with the CCS on [DATE] at 2:02 PM, the CCS stated nurses wrote the date the insulin vial was opened on the sticker on the vial. The CCS stated nurses checked the expiration date on the insulin vial before administering it to a resident. The CCS stated if a nurse found an opened insulin vial that was not dated, they should inform the DON and then get a new vial if the insulin was determined to potentially be expired. The CCS stated expired insulin may not have the intended effect on a resident, leading to possible harm. Record review revealed the facility policy titled Medication Administration last reviewed [DATE] stated the following: .12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 4 of 13 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 (X3) DATE SURVEY COMPLETED A. Building 06/19/2025 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews 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, and 2 of 2 nutrition rooms reviewed for storage, preparation, and sanitation. The facility failed to ensure the ice machine chute was clean. The facility failed to ensure the juice gun nozzle was clean. The facility failed to ensure the steam table wells were clean. The facility failed to ensure the underside of the shelf directly above the range was clean. The facility failed to ensure containers of spices were not left open to air. The facility failed to ensure items in the dry storage area were sealed properly. The facility failed to ensure items in the refrigerators were labeled and dated. The facility failed to ensure food in the walk-in freezer were sealed properly. The facility failed to ensure there were no personal items in the walk-in freezer. The facility failed to ensure the cleaning schedule was followed and monitored. The facility failed to ensure the dishwasher sanitation was correct. The facility failed to ensure all kitchen logs were recorded, maintained, and monitored. The facility failed to ensure items in the nutrition refrigerators were labeled, dated, and not expired. The facility failed to ensure there were no personal items in the nutrition rooms or refrigerators. These failures could place residents who received meals and/or snacks from the kitchen risk for food contamination and food borne illness. Findings included: During the initial tour and observation of the kitchen on 06/17/25 at 9:10 AM revealed the following: *chute inside the ice machine had a removable black-brown substance along the edge where the ice dumped out. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 5 of 13 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 06/19/2025 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 *The juice gun inner nozzle had a thick red and a thick black substance stuck in the holes of the inner nozzle and black round spots around the threads where the outer nozzle connects with the inner nozzle. *Four of four steam table wells had a thick, yellowish substance that was flaking and floating in all four wells. The substance covered the bottoms and all sides of the wells. Residents Affected - Some *The range top was covered in food particles and shiny with what appeared to be grease. *The underside of the shelf above the range, directly over cooking food, had a removable, gritty, brownish-red substance in clumps. *3 of 11, 15-ounce containers of spice were open to air. *an open and unsealed 35-ounce bag of cereal in the dry storage area. * 3, 6.4-ounce bags of powdered seasoning mix that was not sealed properly with one of the bags open inside the unsealed bag in the dry storage area. * a cut onion in the walk-in refrigerator in an unsealed, undated, and unlabeled bag. *3 undated and unlabeled trays of beverages in the walk-in refrigerator. * a beverage pitcher half full of a brown liquid that was undated and unlabeled. * an undated and unlabeled 16-ounce beverage cup from a local fast-food establishment on the shelf in the walk-in freezer. *a 9.84-pound box of frozen enchiladas that was open to air and had crystalized ice on the product in the walk-in freezer. *heavy ice build-up in the back left corner of the walk-in freezer. *an unsealed, undated, and unlabeled 1-gallon bag of an unidentifiable substance in the walk-in freezer. *The Low-Temp dishwasher chem strip read 10 ppm (parts per million) during the rinse cycle. *3 of three dumpsters had the lids open. 1 of the dumpsters' lids was broken. The open dumpsters could be seen through the windows of the main dining room. Observation of the B-wing nutrition room on 06/19/25 at 8:30 AM revealed the following: *1,16-ounce unopened bottle of water, *1,16-ounce half full bottle of water, *1 quart-size bag of green grapes, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 6 of 13 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 06/19/2025 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 *1, 1-liter container of unknown food, Level of Harm - Minimal harm or potential for actual harm *approximately 34 ice pops were unlabeled and undated, Residents Affected - Some *1, 8-ounce, near empty container of sour cream and 1 large container of unknown food were labeled with a resident's name, but not the contents and not dated, and *1 opened 20-ounce container of strawberry jam had an expiration date of 04/08/25, was unlabeled and undated. Observation of the secure unit nutrition room on 06/19/25 at 8:40 AM revealed the following: *1, 16.9-ounce unopened bottle of water in the refrigerator that was unlabeled and undated. *a large purse in the nutrition room. During a return visit and observations of the kitchen on 06/19/25 at 8:50 AM revealed the following: *the chute inside the ice machine had the same removable black-brown substance along the edge where the ice dumped out and the filter had visible dust on it. *The juice gun inner nozzle had the same thick red and a thick black substance stuck in the holes of the inner nozzle. *The underside of the shelf above the range, directly over cooking food, had the same removable, gritty, brownish-red substance in clumps. *a 5-pound bag of opened brownie mix and a 10-pound package of dry pasta that were open and unsealed in the dry storage area. In an interview with DA 1 on 06/17/25 at 9:15 AM, he said the juice gun was cleaned every 4 days and they used it a lot. He detached the outer nozzle from the inner nozzle of the juice gun exposing clogged holes where the juice came through. He said he did not know what that was (clogging the holes). He said they were not dispensing any black drinks through the juice gun. He said the black substance was removable. He said the black substance might be mold. He said the drinks were getting cross-contaminated and could make residents sick. In an interview with the DW on 06/17/25 at 9:20 AM, she said the chem strip (sanitation level) for the dishwasher should be purple. She said she marked it in the log every day she worked before she started her shift-it was the first thing she did. When asked to see the log where she documented the sanitation level, she said, I didn't do it. I didn't test it (the sanitation level). She said she did not know what ppm's were or why it was important to maintain a specific level in the dishwasher rinse cycle. She demonstrated a chem strip test during the rinse cycle, the test strip color matched 10 ppm on the container of test strips. She said she was unaware of the large, printed instructions for using and reading chem strips that were on the front of the dishwasher. She said the process of washing dishes was to place dishes in a bin, run the bin through the dishwasher, let them air dry, then put them on the clean rack. She did not understand un-sanitized dishes and utensils should not be used for service. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 7 of 13 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 06/19/2025 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 - Some In an interview with the DS on 06/17/25 at 9:25 AM, she said the juice gun inner nozzle had mold on it. She said the juice gun was cleaned after each shift. She said the steam table wells had hard water staining them. At this time, the DS began to look for the cleaning schedules and temperature logs. She said she could not find the cleaning schedules. She said all food should be sealed, labeled, and dated. She said she did not know why the foods, spices, and beverages in the refrigerator, freezer, and dry storage room were not sealed, labeled, or dated. She said the chem strip for the dishwasher should be 100 ppm (parts per million). She said she had in-serviced staff regarding the above issues. She said personal items were never allowed in the kitchen or freezer. She would not say who the cup from a local fast-food establishment belonged to in the walk-in freezer. She said nothing when asked about the shelf over the range and the range being dirty. She said the dishwasher was the low temp kind. She said she was responsible for everything in the kitchen. Policies for dry storage, refrigerated foods, cleaning schedules, dishwasher sanitation logs, chem logs, in-services/trainings, and the RD were requested at this time. In an interview with the IADM, on 06/18/25 at 2:32 PM, she said it was important to have logs for the kitchen for infection control purposes as well as knowing if equipment was in working order and regulations required them. She said cleaning was really important for the kitchen because it was very susceptible to bacteria growth-the utensils and everything in the kitchen could harbor bacteria and make the residents sick if it was not being cleaned regularly and thoroughly. Kitchen policies, logbooks, cleaning schedules, in-services, and the RD were re-requested at this time. In an interview with ADON 1 on 06/19/25 at 8:40 AM, she said there were two nutrition rooms and they each had a designated refrigerator for the residents. She said all staff were responsible for labeling and dating everything in the nutrition refrigerators. In an interview with LVN A on 06/19/25 at 8:42 AM, he said the grapes and one of the bottles of water in the B wing nutrition refrigerator belonged to him. He said the nutrition room refrigerator was designated for the residents. He said everything in the nutrition refrigerator was supposed to be labeled with the resident's name, dated, and initialed by the person who received the item. He said the items required names and dates to make sure the food was still good. He said if staff did not know how old the food was, it could make the residents sick if consumed. He said food was good for 2 or 3 days. He said all staff were responsible for labeling and dating all food in the nutrition refrigerators to protect the residents. He said cross contamination would occur if mingling staff personal items with resident items. He said he had no excuse for not putting his personal items in the break room refrigerator where it belonged and for not labeling and dating them. In an interview with CNA B on 06/19/25 at 8:47 AM, she said the purse in the secure unit nutrition room belonged to her and she should not have left it there. She said she should have put her purse in the break room, which just outside the secure unit double doors. She said personal items inside the nutrition room could cause cross contamination to the residents and make them sick. She said she did not have an excuse as to why she had her purse in the nutrition room. She said everything in the nutrition room refrigerator should be labeled with the resident's names and dated. In an interview with DA 2, DS, and the cook on 06/19/25 at 9:35 AM, DA 2 said she did not notice the spices were open because she was not looking in that direction. She said she put the brownie mix in the dry storage area without properly sealing it and did not know why. She said she knew she should have put the brownie mix away properly, so it did not go bad. The cook said she put the cut onion in the walk-in Tuesday because she was in a rush. She said not storing foods and beverages properly could be very dangerous because food could grow mold and bacteria and could poison people. The DS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 8 of 13 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 06/19/2025 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 - Some and the cook said it was everyone's responsibility to keep the kitchen clean and safe. The DS said it was her ultimate responsibility to make sure the kitchen was operating as it should (meaning the logs were up to date, tasks were monitored, as well as the staff). The DS said the kitchen staff, usually herself, wiped down the ice machine inside and out every two weeks. She said the MS cleaned the filters and the inner workings every two weeks, so that was the schedule she followed for cleaning the ice machine and she did it when the MS was there, doing his thing. The DS said she could only find the daily cleaning schedules for June 2025. The DS said she did not know why the temperature logs were not consistent. She said she did not check them like she should have. She said she did not know if the temperatures got mixed up with the refrigerator or what but would have known had she been checking them. In an interview with the MS on 06/19/25 at 9:40 AM, he said he did not know when the ice machine was last cleaned but it was well over a month ago. He said he inspected the ice machine and did maintenance (cleaned the filter and inner workings around the motor) on it when the electronic reporting system popped up the task for it every 3 months. He said he defrosted the ice machine and wiped everything down. He said he ran a chemical through the system that cleaned the water pipes. He said he was the only one that cleaned the ice machine and was not sure if kitchen staff had anything to do with cleaning the ice machine. He said the discoloration on the ice chute was a build-up of dust. He said he did not know how dust could get inside the ice machine. He said the discoloration on the ice chute could be mold. He said he did not know the manufacturer's instructions or the facility policy for cleaning the ice machine. He said he did not check the logs in the kitchen. He said he was unaware of the ice build-up in the walk-in freezer. He said he was not responsible for the kitchen. During a phone interview with the Regional Lead Dietician on 06/20/25 at 3:30 pm, he said he visited the facility twice a month and once remotely. He said he had been going to the facility since November 2024. He said the DS reached out to him once a week or every other week for advice about food substitutions. He said his visits in April and May 2025 revealed some issues. He said he initiated in-services for sanitation in general including hairnets, hand washing, dry food boxes on the ground, logs were not filled out such as refrigerator, and freezer logs-there were several weeks not recorded in April or March 2025. He said he needed to hold people more accountable and had stressed to the DS that everything had to be clean all the time. He said there was an issue with kitchen employees having drinks in the kitchen. He said he told them they could not have personal drinks anywhere at any time inside the kitchen. He said, evidently there was no follow up after he left, and he needed to do more. He said there was lack of accountability. He said he also spoke to kitchen staff about having the dumpster lids closed. He said he was going to the facility next week to address the issues. He said he could not explain why the logs we not completed. Cleaning Policy requested. Record review of the facility's Daily kitchen 21-item cleaning checklists dated 06/01/25-06/14/25 revealed a total of 294 opportunities: Refrigerator, Freezer, Dry Storage, Counters, Steamtable, Mixer (crossed out-did not have one), Microwave, Toaster, Food Processor/Blender, Juice Machine, Coffee/Tea Urns, Slicer (crossed out-did not have one), Can Opener, Trash Cans, Steamer (crossed out-did not have one), Carts, Range/Grill, Oven, Pot & Pan Sink, Sinks, Dish machine, Ice Machine, Ice Scoop & Holder, and Floors. All tasks were checked as having been done. Record review of the facility's Freezer Temp Logs for 2025 revealed the following: January *the log for the month of January was missing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 9 of 13 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 06/19/2025 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 February Level of Harm - Minimal harm or potential for actual harm *had no days recorded. March Residents Affected - Some *walk-in freezer temps for morning and evening recorded for days 1-11 at 37-38 degrees F, *freezer temp log for the same time period was recorded at 32 F the morning of the 4th and 10th, all other days (from 1-11) were recorded at 35-37 F. There were no other days or evenings recorded. April *walk-in freezer temps were recorded 37F for the 1st-5th, and the 10th and 11th. No other days or evenings were recorded. * Freezer Temp Log was identical to April walk-in freezer temps. May * Freezer Temp Log was recorded for days 1-12, evenings 1-14 and the 29th and 30th. There were no temps recorded for the days of 13th-30th. 32 F or less was recorded 15 times out of 60 opportunities. The other temps recorded were 34F-37F. There was no May Walk-in Freezer Temp Log. June *Freezer Temp Log was missing the morning and evening of the 1st and 16th, and the evening of the 15th. All other temps logged were 10-13F. Record review of the facility's Refrigerator Temp Logs for 2025 revealed the following: January, March, and April *the logs were missing. February *had no days recorded. May *1st-12th days and evenings were recorded, and the evenings of the 13th, 14th, 29th, and 30th. All other days and evenings were blank. All temps were recorded as 32 F-41F. June *The log was missing the morning and evening of the 1st, 15th , and 16th. All other recordings ranged from 35 F-37 F. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 10 of 13 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 06/19/2025 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 Record Review of the facility's Sink Temperature and Chemical logs for 2025 revealed the following: Level of Harm - Minimal harm or potential for actual harm January *the log was missing. Residents Affected - Some February *had no days recorded. March *days 1-11 had water temperatures ranging from 141-150F for breakfast and no sanitizer recorded. There were no temperature or sanitizer recorded for any days recorded for lunch. Days 1-15 had water temperature recorded that ranged from 147-152F. There were no days recorded for sanitizer. All other days were blank. April *days 1-5, 10, and 11 recorded at 150F for dinner only. There was no sanitizer recorded for any days or services in April. May *had temperatures recorded on days 1-13, 14 and 15, 29th and 30th. Temperature ranged from 122 F-130F for breakfast service, 125F-132F for lunch, and 120F-137F for dinner. Sanitizer was recorded as 160-180 ppm for days 1-13 for breakfast, 150-200 ppm for lunch, and 150-350 ppm for dinner service. June had no temperature or sanitizer recorded for days 1-16 breakfast and lunch services. Dinner service had temperatures recorded for 80 F-165 [NAME] days 1-13. There was no sanitizer recorded for dinner service on days 1-5. Days 6-13 had sanitizer recorded for dinner service as 100 ppm for each day. June *the 17th had water temperature recorded as 181 F and sanitizer as 100 ppm for breakfast service. Temperature for the 17th lunch service was 160F and 100 ppm sanitizer. There were no other dinner service recordings after the 15th of June. The 18th breakfast service recorded the water temperature at 125 F and sanitation at 000 ppm. Record Review of the facility's Dish Washer Temp and Chemical Log for 2025 revealed the following: January *the log was missing. February * there were no entries until days 11,12, and 13. Days 14,15, and 16 were blank. All recorded (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 11 of 13 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 06/19/2025 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 - Some temperatures ranged between 135F and 152F. All sanitizer recordings were 100ppm for breakfast, lunch, and dinner services. March *the log was missing day 15 for all three services. All other temps ranged from 140F-160F. All sanitizer entries for all services were 100ppm. April *was missing days 7 and 8. All other temperatures were recorded ranging from 130F-172F for all services. All sanitizer entries for all services were 100ppm. May * was missing days 1, 2, 6, 28 lunch and dinner services, and the 29th had no entries. All other temperatures ranged from 140F-170F. All sanitizer entries for all services were 100ppm. June *the 17th and 18th were missing entries. The 17th had didn't use marked through the entire day. All other temps ranged from 140 F-172F. All sanitizer entries for all services were 100ppm. Record review of the facility's kitchen in-services revealed: Undated- No phones are to be out at all in kitchen during shift, Maintain professional behavior and respect co-workers, 04/15/25- Temp. Logs, Labeling, Cleaning Schedule. 05/09/25- Temp. Logs, Labeling, Cleaning Schedule. Record review of the ice machine task from the electronic reporting system revealed Instructions Ice Machines: Check filters (if present), clean coils, sanitize interior, delime as necessary. Marked done on-time by MS on June 13, 2025. Record review of the dish machine invoice dated 06/18/25 at 8:50 AM-9:50 AM revealed performed a check on dispenser to see if sanitizing solution was dispensing properly. Checked solution, shows the proper amount is being dispensed per test strip reading-solution testing between 50-100ppm. Record review of the facility policy dated 10/2022, titled, Food Receiving and Storage revealed under the policy statement: Foods shall be received and stored in a manner that complies with safe hood handling practices. 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. 12. Functioning of the refrigerators 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 on the nursing units must be maintained as indicated below: a. All food items .must be placed in the refrigerator located at the nurses' station and labeled with a use by date. b. All foods belonging to residents must be labeled with the resident's name, the item, and the use by date. c. Refrigerators must have working thermometers and be monitored for temperature according to state-specific guidelines. d. Beverages must be dated when opened and discarded after twenty-four 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. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 12 of 13 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 06/19/2025 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 - Some Record review of the facility policy dated 10/2022, titled, Refrigerators and Freezers revealed the 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 35F to 40F for refrigerators and less than 0F for freezers. Record review of the facility policy revised 01/2024, titled, Sanitation revealed under policy statement: The food service area shall be maintained in a clean and sanitary manner. 1. All kitchens, kitchen areas, and dining areas shall be kept clean . 2. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair . 8. Dishwashing machines must be operated using the following specifications: Low-Temperature Dishwasher (Chemical Sanitation) a. Wash temperature (120F); b. Final rinse with 50 ppm chlorine for at least 10 seconds. 11. b. Fixed Equipment 2. Staff members will be trained in the cleaning and maintenance of all equipment. 3. Food contact equipment will be cleaned and sanitized after every use. 11. Ice machines will be drained, cleaned, and sanitized per manufacturer's instruction and facility policy. 16. The food services manager will be responsible for scheduling staff for regular cleaning of the kitchen. 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. Record review of the facility policy reviewed 01/2023, titled, Dry Storage revealed: 3. All items must be dated with the date that the food was delivered. 9. If an item is open, the food must be tightly sealed. It should be dated with the date that it was opened. If the product was removed from its original container, then the product should also have the name of the product. If the food is directly in the bag, the bag must be sealed. 10. Lids on spices should be closed. Record review of the facility policy dated 04/2017, titled, Job Description-Dietary Manager revealed: under Supervisory Responsibilities Carries out supervisory responsibilities in accordance with the organizational policies and applicable laws .Ensures that food is received, stored, prepared, held, and served under sanitary conditions to prevent the transmission of food borne illness. Completes and maintains all food and nutrition services department records .Participates in long term care survey process. Instructs staff in matters of con disclosure. Always maintains presence while surveyors are on-site and timely collection of information required by the survey team. Demonstrates identified problems and undertakes corrective action while survey is in progress. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675494 If continuation sheet Page 13 of 13