Health inspection·August 3, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #26's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under the physician's statement that the date, printed name and license number was blank. Resident #29 Record review of Resident #29's face sheet, dated [DATE], revealed an [AGE] year-old-female who was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Parkinson's disease (brain disorder), muscle weakness, dementia (cognitive loss), and hypertension (high blood pressure). The face sheet also revealed under the advance directive section - DNR. Record review of Resident #29's physician order summary dated [DATE] revealed the following order: DNR dated [DATE]. Record review of Resident #29's care plan, dated [DATE], revealed care plan for DNR. Record review of Resident #26's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under A. Declaration of the adult person that the date and printed name was blank. During an interview on [DATE] at 10:20 AM with the DON, she stated the social worker was responsible for completing the OOH DNR form. She stated a DNR was a do not resuscitate order. She stated the social worker does a monthly audit to make sure all DNR's were completed accurately. She stated an OOH DNR was not vailed unless the form was completely filled out. She verified Resident's #8, #26 and #29 had DNR orders in the EMR and verified the missing information on the OOH DNR. She stated the potential negative outcome could be not following through with not doing CPR and the residents wishes not being honored. She stated the DNR were no accurate due to human error. During an interview on [DATE] at 10:20 with the Regional Compliance Nurse, surveyor requested policy for DNR. During an interview on [DATE] at 10:37 AM with the SW, she stated she was responsible for completing OOH DNR accurately. She stated a DNR was a do not resuscitate order. She stated, I just did an audit of all OOH DNR in the facility a few days ago and they were all complete, unless I messed someone. She stated she has been trained on how to properly complete an OOH DNR. She verified Residents #8, #26 and #29 had missing information on their OOH DNR forms. She stated an OOH DNR was not vailed unless the form was completely filled out. She stated the reason why the OOH DNR was not complete was due to her not catching the missing information and human error. During an interview on [DATE] at 12:10 PM with the ADMIN, she stated the social worker was responsible for completing the OOH DNR form. She stated the DNR was a do not resuscitate order. She stated audits of EMR was done by the ADMIN and Regional Compliance Nurse. She stated the OOH DNR was not vailed unless it was completely filled out. She stated she has had no trained training on how to complete an OOH DNR. She stated all appropriated spaces should be filled in. She stated the potential negative outcome could be resuscitating someone who does not want to be or going against their wishes. She stated the missing information was an oversight. During an interview on [DATE] at 12:30 with the Regional Compliance Nurse, she stated they do not have a policy specific to OOH DNR but provided a policy for resident's rights. No additional guidance regarding the instructions in completing the DNR form within the policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 2 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 0578 Record Review of the Instructions for Issuing An OOH-DNR Order (Revised [DATE]) revealed the following: Level of Harm - Minimal harm or potential for actual harm INSTRUCTIONS FOR ISSUING AN OOH-DNR ORDER PURPOSE Residents Affected - Some IMPLEMENTATION: A competent adult person, at least [AGE] years of age, or the person's authorized representative or qualified relative may execute or issue an OOH-DNR Order. The person's attending physician will document existence of the Order in the person's permanent medical record. The OOH-DNR Order may be executed as follows: Section A - If an adult person is competent and at least [AGE] years of age, he/she will sign and date the Order in Section A . The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 3 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record, review the facility, failed to ensure sure each resident had a right to a safe, clean, comfortable, and homelike environment in the facility and failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in the central bath and 9 of 18 resident rooms (40, 42, 44, 46, 51, 52, 54, 56 and 62) reviewed for environment, The facility failed to ensure resident use common areas and rooms were clean and did not need repair, These failures could place residents at risk for living in an unsafe, unclean, uncomfortable, and unhomelike environment which could cause a decline in resident psychosocial well-being. The findings include: Observation on 8/2/23 at 9:08 AM in room [ROOM NUMBER], revealed one of two grab bars were loose in the restroom. One of two lights above the sink was out. One of two over bed light shields, at the bed B, had an approximate 2x 4section that was missing. The restroom was shared with room [ROOM NUMBER]. Observation on 8/2/23 at 9:18 AM, room [ROOM NUMBER] had a center 3 foot section of the restroom door that was missing and the door panels were loose. This restroom was shared with room [ROOM NUMBER]. Observation on 8/2/23 at 9:27 AM room [ROOM NUMBER]'s the wallboard surrounding the sink was swollen and peeling from the surface. It was an approximately 1.5' x 1'area to the side and approximately 1'x 8on the back of the sink. Observation on 8/2/23 at 9:34 AM in room [ROOM NUMBER], one of two over bed light shields, at the B bed, had a hole in the cover which was approximately 2x 2and one of two over bed lights at the sink was out. The string was missing from the call system in the restroom and one of two grab bars was loose. This restroom was shared with room [ROOM NUMBER]. Observation on 8/2/23 at 9:41 AM., in room [ROOM NUMBER], there was a lingering urine odor in the restroom and the sink was clogged and drained very slowly. Observation on 8/2/23 at 9:47 AM in room [ROOM NUMBER], the wallboard surrounding the sink was swollen and frayed. The sink was also clogged and drained extremely slowly . During a confidential interview with a resident regarding the sink, the resident stated they were on a list to get it repaired, but the facility had no drain cleaner. The resident stated they had been waiting a week, but the maintenance staff were working on other resident sinks. Confidential interview on 8/2/23 at 10:01 AM was conducted with another resident regarding the slow drain in room [ROOM NUMBER]. The resident stated, the sink did not drain very good and that it had been that way forever. The resident stated he had asked two weeks ago for it to be repaired. On 8/2/23 at 10:07 AM an observation and interview were conducted in the central bath with CNA A. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 4 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some There were three shower chairs in the central bath. The bariatric shower chair had a heavy accumulation of dirt and residue on the mesh back and underside. The underside was soiled with a brown buildup and hair buildup. There were also three areas on the padded seat top surface that were approximately 1 inch in diameter that were cracked and expose the interior of the padded seat. The lounge chair shower had a padded seat that was soiled with dried brown smears on the top surface. The regular shower chair (blue) had a buildup of brown residue/BM on the underside of the frame . On 8/2/23 at 10:12 AM, CNA A was interviewed. Regarding deep cleaning of the shower chairs, she stated, staff sprayed and cleaned the shower chairs after each use. She did not know if the shower chairs were deep cleaned. Regarding the cracked seat, she stated, the condition had been present for weeks. Regarding what could result from residents using the shower chair that was cracked on the seat. She stated skin tears. There was also no toilet tissue holder at the central bath toilet. On 8/2/23 at 10:42 AM an interview was conducted with the Housekeeping Supervisor regarding the cleaning of showers. She stated housekeeping staff sweep, mop, disinfect twice a day in the showers. Housekeeping, and nursing, cleaned the chairs. Housekeeping staff deep cleaned shower chairs Monday, Wednesday and Friday. She further stated the facility were to replace some of the shower chairs and that the bariatric shower chair was super old. Regarding what could result from the unclean shower chairs, she stated infection control problems could result. On 8/3/23 at 11:20 AM an interview and observations were conducted with the Maintenance Supervisor regarding maintenance issues found. Regarding his process for knowing when repairs were needed in the facility, he stated, the facility used the Maintenance Care online system and staff issue work orders. He also stated the system generated routine scheduled items. He stated that staff did not use the Maintenance Care system a whole lot, and that he received most request verbally from residents and staff. He added, he usually took notes on the verbal request. Staff were encouraged to use the online system. He stated that the notes that he made from verbal request did not go into the Maintenance Care system. He stated the Maintenance Care system had approximately four staff-initiated requests in the last 40 to 60 days. Regarding the drain problem, he stated had drain problems at the facility went to a new purchasing system which had delayed getting the drain cleaner. On 8/3/23 at 11:30 AM an interview and observations were conducted with the Maintenance Supervisor regarding repair issues observed in the facility: room [ROOM NUMBER] - the grab bar was still loose and there was still a hole in the light shield. room [ROOM NUMBER] - door still had loose and missing sections. The Maintenance Supervisor stated, he was surprised no one said anything about this. room [ROOM NUMBER] - the wall board was still swollen and frayed, and the Maintenance Supervisor stated the wallboard repair was on his list of things to do and was slowly replacing them. room [ROOM NUMBER] - still had a loose restroom grab bar and missing call system string. He was also shown the central bath cracked seat cushion on the bariatric shower chair. He stated the cracked areas were pinch points for the residents (causing skin to be pinched). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 5 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 8/3/23 at 12:20 PM an interview was conducted with the DON regarding observed issues. Regarding shower chairs, she stated that they should be cleaned between uses. On 8/3/23 at 12:57 PM interview was conducted with the Administrator regarding issues found in the facility. Regarding the maintenance and environmental issues, she stated she expected staff to call a plumber and she expected the maintenance staff to report and follow through on repairs. She further stated staff should clean the shower chairs after each use. Regarding the result of these environmental issues, she stated regarding the shower chairs it could cause infection control problems. Regarding repairs problems, she stated it could affect quality of life. Record review of the Maintenancecare.com Task documentation revealed there was only three documented maintenance requests from facility staff. All others were system generated for regular scheduled maintenance tasks. The documentation presented was between 6/27/23 and 8/1/23. All three requests came from the kitchen. Record review of the facility policy, titled Environment of Care Policy and Procedure Manual 2003, PM 03-1.0 revealed the following documentation, Preventive Maintenance. Preventive maintenance is an undeniable critical component to any maintenance strategy. It is key to lowering maintenance costs, reducing equipment downtime, improving asset lifespan, efficiency and increasing environmental safety. Maintenance employees will take the necessary precautions and actions to reduce equipment failures from occurring before they happen. For example, performing regular, business and equipment inspections, cleaning and lubricating essential equipment, tidying the facility grounds are such examples of preventative maintenance. Facility maintenance will ensure that they utilize (facility) comprehensive preventative maintenance program that is in place for essential operating equipment. Preventative maintenance will be completed routinely, and according to protocol by the maintenance supervisor, or a qualified designee. 1. Maintenance care is (the facility) preferred maintenance system. 3. Maintenance task will be accessed by facility staff via the kiosk or PC. 4. Maintenance will access the system daily to review preventative and compliance test due. 5. Maintenance task input by facility will be received via PC or cell phone. 6. Task will be completed and closed in a timely manner or paused. If not current. 7. Administrator to review system weekly to ensure completion of tasks. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 6 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the resident's environment remained as free of accident hazards as is possible; and that each resident received adequate supervision to prevent accidents for 1 of 1 resident (Resident #33) reviewed for supervision, 1)The facility failed to provide effective monitoring and interventions to reduce Resident #33's wandering which was intrusive to other residents' privacy and unsafe for Resident #33 and other residents, 2)The facility failed to maintain the facility as free of accident hazards as possible, in that; oxygen was not stored in a safe manner, chemicals were not stored in a manner to prevent contamination of resident use items, hot water temperatures were not maintained in a safe range, and hazardous areas were not secured. These failures could place residents at risk for injury and not receiving adequate supervision in order to reduce the risk of accidents and meet plan goals. The findings include: 1)Record review of the Order Summary Report for female Resident #33, dated 8/1/23, revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood, disturbance, and anxiety (cognitive disorder), and cognitive communication deficit (cognitive disorder). Record review of the admission MDS assessment for Resident #33 dated 5/18/23 revealed that the resident had a BIMS score of six, indicating the resident had severe cognitive impairment. No behavior issues were documented. A documented Active Diagnosis was non-Alzheimer's dementia. Record review of the current care plan for Resident #33 revealed the following Focus, The resident is at risk for wandering. Resident wanders aimlessly, significantly intrude on the privacy or activities of other residents at times. Date initiated: 6/28/23. Revision on: 6/28/23. The Goal for this, Focus was documented as, The resident's safety will be maintained through the review date. Date initiated: 6/28/23. Revision on: 7/13/23. Target date: 8/18/23. Interventions/tasks listed for this Focus were as follows, Distract resident from wandering by offering pleasant diversion, structured activities, food, conversation, television, book. Date initiated: 6/28/23. Revision on: 6/28/23. Redirect resident and help her find her room if she is entering other resident's rooms. Date initiated: 6/28/23. Resident has a sign outside of her door to assist her with finding her room when she is moving about the facility. Date initiated: 6/28/23. An additional cognitive related Focus was as follows, The resident has impaired cognitive function/dementia or impaired thought processes Dementia, Disease Process DX: CAD, impaired decision making, long term memory loss. Date Initiated: 05/15/2023. Revision on: 05/15/2023. The Goals listed were: Goal The resident will remain oriented to nursing home placement spatial time through the review date. Date Initiated: 05/15/2023. Revision on: 07/13/2023. Target Date: 08/18/2023. o The resident will maintain improve memory level of cognitive function through the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 7 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some review date. Date Initiated: 05/15/2023 Revision on: 07/13/2023 Target Date: 08/18/2023. o The resident will be able to communicate needs to staff on a daily basis through the review date. Date Initiated: 05/15/2023 Revision on: 07/13/2023 Target Date: 08/18/2023. o The resident will practice safety skills and cope with cognitive decline and maintain safety by the review date. Date Initiated: 05/15/2023 Revision on: 07/13/2023 Target Date: 08/18/2023. Interventions included, Administer meds as ordered. Date Initiated: 05/15/2023. o COMMUNICATION: Use the residents preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. Date Initiated: 05/15/2023 Revision on: 05/23/2023. o Engage the resident in simple, structured activities that avoid overly demanding tasks. Date Initiated: 05/15/2023. o Keep the resident's, routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Date Initiated: 05/15/2023. o Monitor/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Date Initiated: 05/15/2023. A record review was conducted of the Progress Notes for Resident #33 from 5/24/23 thru 7/20/23. There were no progress notes after 7/20/23 as of downloading of the document on 8/03/23 at 10:25 AM. Resident #33's behaviors and interactions were documented as follows: Effective Date: 05/24/2023 1:20 PM Type: Social Service Note. Note Text: Resident at SW office confused bit but upset about (Family Member) resident not being at home. Resident expressed 'You know my son. I need him the police. We need to straighten some shit out. I need to know where my house is. SW facilitated a phone call to residents son. Resident conversed with son. Resident expressed I need to get out I'm at the hospital. Resident handed phone off to SW . Then resident expressed I need a shot of whiskey. Resident oriented to notify her charge nurse. Per charge nurse resident asked for whiskey. Author: Social Worker [e-SIGNED] Effective Date: 05/25/2023 4:42PM Type: Social Service Note. Note Text: Resident confused in SW office asked Where my home. Will you call (son) tell him his mother has lost her . mind. I have can't remember. SW assist resident to her room. Effective Date: 05/25/2023 6:05 PM Type: Nursing Progress Note. Note Text: Resident appears to become increasingly verbally aggressive and angry. She is stating that she is not supposed to be here, she owns the place and needs to go home. She is constantly wandering and ignoring prompts to stay in her wheelchair. She is observed wandering into a resident's room telling the resident to be quiet. She has been offered snacks, staff have sat and talked with resident to calm her as well as offer activity however resident refuses. Author: RN A [e-SIGNED] Effective Date: 05/26/2023 1:16 AM Type: Nursing Progress Note. Note Text: Resident is noted to be getting out of bed and wandering in facility, nursing staff redirect back in to room. Moments later she is found doing the same behavior, she is also going into different resident rooms, she is continued to be redirected by nursing staff, she easily follows command, resident is also noted to have flight of ideas, loose of thought, and concentration, nurse unable to ask questions due to noticeable increased agitation during her thought process During the night she shows to be no threat to herself, others and staff. Nursing staff educated on ways to redirect without having resident show increase in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 8 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 0689 Level of Harm - Minimal harm or potential for actual harm agitation. She may also benefit to have her check by provider due to lack of sleep due to her repetitive behavior she displays at night. Author: RN B [e-SIGNED] Effective Date: 06/25/2023 7:42 AM Type: Nursing Progress Note. Note Text: resident has been going into other residents' room, residents have become very upset. Redirected resident to stay out of other Residents Affected - Some residents' room. will continue to monitor. Author: LVN A [e-SIGNED] Effective Date: 06/25/2023 4:19 PM Type: Nursing Progress Note. Note Text: resident kept pushing doors to get out and set off door alarms, resident was redirected. will monitor resident and pass on to oncoming shift. Author: LVN A [e-SIGNED] Effective Date: 06/26/2023 4:30 PM Type: Nursing Progress Note. Note Text: resident calling staff a bitch, explained to resident that she cannot be calling staff names. Resident then began to grab my arm with force, told resident let go, and talk calmly. will pass on to ADON. Author: LVN A [e-SIGNED] Effective Date: 07/04/2023 5:35 AM Type: Nursing Progress Note. Note Text: Resident was awake et wandering around the facility throughout the night. Resident redirected to her room several times. Wandering into other resident rooms et attempting to open multiple doors stating she needed to go home. Staff able to prevent resident from going to doors leading to outside. Resident extremely confused et agitated. Author: LVN B [e-SIGNED] Effective Date: 07/12/2023 9:49 PM Type: Behavior Note. Note Text: ATTEMPTED 4 DIFFERENT TIMES TO DRAW LABS FROM PATIENT. SHE WAS ALREADY AGITATED AS SHE SUNDOWNS HEAVILY WITH HER DEMENTIA. PATIENT BECOMING AGGRESSIVE. I WOULD LEAVE AND WAIT FOR 20 MINUTES OR SO AND TRY AGAIN, POSSIBLY DAY SHIFT TOMORROW WILL HAVE BETTER SUCCESS Author: ADON [e-SIGNED] Effective Date: 07/16/2023 9:07 PM Type: Activity. Note Text: patient continuously roams about both in her wheelchair and with ambulating. She will go into other resident's rooms and go through the drawers, closets, etc. (Resident #28) yelled at her this evening when she went into her room. This evening she is not having aggressive behaviors. Author: ADON [e-SIGNED] Effective Date: 07/19/2023 9:32 AM Type: Teaching with Resident/Family. Note Text: Resident oriented to not go into other resident rooms due to privacy for another resident. Resident expressed We've got to shower them. Resident oriented staff assist with resident showers. Reoriented resident not to go into another resident room. Resident appears to have understood to stay out of other resident rooms. Author: Social Worker [e-SIGNED] Effective Date: 07/20/2023 8:43 AM Type: Nursing Progress Note. Note Text: resident exit seeking going to all the doors and pushing and banging on doors, stated she is going to get out, one way or another. Redirected resident this is her home, resident stated she has a home, and this is not it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 9 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 0689 Will continue to monitor resident. Author: LVN A [e-SIGNED]. Level of Harm - Minimal harm or potential for actual harm Record review of the July 2023 MAR for Resident #33 revealed that the resident had documented behaviors on 21 of 31 day shifts and 27 of 31 night shifts. There were only three days where the resident did not exhibit behaviors. On the dayshift, the resident exhibited agitation five days, false beliefs four days, wandering nine days, anxiety two days, hallucinations/paranoia one day, restlessness one day, and pacing one day. On the night shift the resident exhibited agitation six days, false beliefs five days, wandering 15 days, anxiety two days, hallucinations/paranoia one day, restlessness one day, pacing one day and insomnia two days. Residents Affected - Some Record review of the MAR for August 2023 for Resident #33 regarding behaviors revealed documentation that on August 1st and 2nd the resident was documented as wandering on the day and night shifts. Record review of the Order Summary Report dated 8/3/23, which included discontinued medications, for Resident #33 revealed that the resident had an order for Xanax oral tablet 0.25 mg (alprazolam) give one tablet by mouth every eight hours as needed for anxiety related to unspecified, dementia, unspecified, severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety for 14 Days. Order status completed. Order date 5/12/23. Start date 5/15/23. End date 5/29/23. Further record review of the Order Summary Report revealed that the resident currently had no orders for any psychoactive medications, and there was no documentation of an order for any psychiatric intervention such as a psychiatric consult. Record review of the resident's current clinical record revealed no documentation of psychiatric intervention. On 8/01/23 at 2:05 PM the confidential Resident Council Meeting was held. A Resident stated that Resident #33, goes through the kitchen and curses residents. Resident #33 comes in resident rooms and turns on the lights at night. She likes to go through everybody's stuff. Another Resident stated, It happens all the time. Regarding the intrusive wandering, 6 of 7 residents stated that Resident #33 wanders daily and nightly. Another Resident stated Resident #33 came into her room two times last night (7/31/23). She added You cannot get a good night's rest. She turns on the lights. An additional Resident stated that Resident #33 had been in the facility approximately a month. She further stated that the resident tries to feed other residents. A Resident stated that When staff see her, they try to redirect her. She further stated that sometimes when residents are here (common areas), and staff are not; they don't see what she does. She added that the resident wandered vacant halls. One Resident added It's driving us nuts since she's been here. She tries to answer the facility phones. A Resident also stated, She wanders at night. She cusses you out. Regarding interventions for the wandering residents, residents were asked whether any physical deterrents had been used, such as Stop Signs placed across the resident doors. Residents stated they were not aware of any physical deterrents being tried to prevent room entry. They also stated that they were not aware of any other solutions being tried regarding the residents wandering except to redirect her. On 8/2/23 at 8:57 AM a confidential interview was conducted with a Resident regarding Resident #33. The resident stated there was one lady (Resident #33) that wandered every night. The resident added he had seen her going through Resident #18's room and going through her drawers. On 8/2/23 at 1:26 PM a confidential interview was conducted with another Resident regarding Resident #33. The Resident stated the night before, Resident #33 grabbed his roommate's foot. He stated that these intrusive issues did not happen daily to him. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 10 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 0689 Level of Harm - Minimal harm or potential for actual harm On 8/3/23 at 9:58 AM a confidential interview was conducted with one other Resident regarding Resident #33. She stated, Yesterday I saw her almost come to blows with another resident because the resident told her to stop doing something she should not do. They just cussed each other. I see her six or eight times a day in and out of rooms and sometimes walking without a wheelchair. Her cursing and being aggressive is about 4 to 5 times a day. It happens when residents stop to tell her not to do things or she will hurt herself. Residents Affected - Some On 8/1/23 at 6:13 PM Resident #33 was in the dining room, confused and wheeling herself in her wheelchair. She was reaching for other resident's food on the table after the meal and was redirected by staff. Observation on 8/2/23 at 11:40 AM Resident #33 was in the dining room and there was no staff present. She was in her wheelchair and confused and talking to random residents. When she spoke to them, she was very close and in their personal space. Observation on 8/2/23 at 1:19PM Resident #33 was in the front hallway in a wheelchair alone with no issues only wandering. Observation on 8/2/23 at 1:30 PM Resident #33 was in the dining room, wheeling herself and wandering. On 8/3/23 at 9:34 AM an interview was conducted with LVN A regarding interventions for Resident #33's wandering. She stated staff were to re-educate the resident and redirect; there were no other interventions. She added, the resident wandered as soon as she got up. She goes in resident rooms on this and the other (vacant) hall. She stated she documented the behaviors and told the Administrator. She added that the resident was exit seeking. Regarding what resulted from her reports to the Administrator about the residents wandering, she stated there was no changes in interventions. She further stated that Resident #33 had encounters with residents daily; taking their stuff and residents yell at her. Resident #33 would respond to them by telling them it was her room. Staff would show her to her room. Regarding how she became aware that the resident has had an encounter with a resident, she stated, staff would hear them yelling. Regarding how many yelling encounters were average for Resident #33, she stated approximately three times during the shift. She added, she worked days, but had worked Monday night (7/31/23). She stated the resident was up and down the halls and saying that she owned the place. The resident was going into rooms and saying she would call the cops. LVN A added the Monday night behaviors occurred between 10 PM and 12 AM. Regarding where staff documented the resident's behaviors, she stated the documentation was in the progress notes or EMAR. She further stated regarding Resident #33's behavior, that she cursed residents and would get in resident faces and staff faces too. She stated this behavior occurred a few times a shift. She added the resident's name was in large letters on her door so she could see it. During an interview on 8/3/23 at 9:35 AM, CNA A stated Resident #33 would go in the dining room and get into the countertop refrigerated milk dispenser. On 8/3/23 at 9:47 AM an interview was conducted with CNA B regarding Resident #33. She stated, the resident usually woke up before lunch and then would be all riled up. She added Residents would get upset with her and she would continually mess with people and their stuff. CNA B stated that the resident thought she worked in the facility and would bother the residents, and they would be mean to her. She further stated the resident tried to clean the dishes and could be sweet at times. She stated staff tried to keep her in her wheelchair to prevent falls. She stated she thought the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 11 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was a Sundowner (cognitively impaired resident that is more active at night). She added the resident tried to elope too. She further stated Resident #33 argued with everyone; staff and residents and exit sought on her very bad days. She stated the very bad days happened every few days. Regarding her very bad days, the CNA stated most days she was sweet, but she cursed people out and gets in their face and said she would fire all of us. She further stated the redirection was every day. She added the resident had moved rooms two times so maybe she did not remember her room. CNA B stated she redirected the resident at least four or five times herself per shift and others also do. On 8/3/23 at 12:26 PM an interview was conducted with LVN A regarding Resident #33. Regarding how often she had reported to the Administrator regarding the resident's behaviors, she stated, she reported to the Administrator and documented in the progress notes. She stated she reported approximately once each rotation about the resident's behavior. Regarding their discontinuation of Xanax, she stated, she did not know of any reason why it was discontinued. She also stated she had not seen any documentation of a psychiatric consult for the resident. On 8/3/23 at 12:20 PM an interview was conducted with the DON regarding Resident #33. She stated, staff conducted one-on-one monitoring for two or three days starting 7/20/23. She added after the two or three days she stopped trying to get out. She further stated the resident seemed to get confused after smoking. The DON stated the resident was sweet, but residents did not like her. She added there had been a previously discussion about possibly moving the resident to another facility where there was a secure unit. On 8/3/23 at 12:57 PM an interview was conducted with the Administrator regarding issues found in the facility. Regarding the wandering situation with Resident #33, she stated the Resident Council had mentioned she gets into things. She added she had seen Resident #33 in the dining room cleaning things, mostly in the common areas. Regarding this situation with wandering, she stated she expected staff to report to the DON and report to administration and try other interventions. Regarding whom was responsible for ensuring that the residents wandering was not harmful to her or others, she stated it was ultimately her, the charge nurse, and aids. Regarding what could result from this situation she stated, it could cause harm to Resident #33 or others. Regarding why the issue of Resident #33's invasive wandering happened, she stated she was trying to know residents better. She added that the behaviors for Resident #33 was due to her sundowning and she may be regressing cognitively. She stated, staff reported things to her about Resident #33; she gets in the dining room and gets into plates. She stated she was aware the resident went to the back hall, was aggressive and got into in drawers. She added the Activity Director stated in Resident Council that residents had mentioned Resident #33's behaviors. Record review of the facility policy titled Nursing Policy and Procedure Manual 2003, Revised February 1, 2007, MM TIW WA 03-1.0, revealed the following documentation, Wandering. Policy Statement. Every effort will be made to prevent wandering episodes while maintaining the least restrictive environment for residents who are at risk for elopement. Intervention strategies. 6. Use simple, clear language. Tell the resident what you want him/her to do, not what you don't want them to do. (e.g., Hey, come with me instead of a don't go outside). 7. Approach wanderer in a non-threatening manner. 8. Do not confront or argue with resident. Acknowledge the residents' concerns and gently redirect the resident. 9. Follow the resident to see where he/she goes. If the destination is safe, consider using a volunteer companion or family member as a suitable escort. 10. Give the resident something to do that makes him/her feel useful (e.g., [NAME] yarn or folding towels) . Environmental Modifications. 3. Use full length mirrors, black doormats, or black tap grid pattern on floor to discourage demented residents from approaching door. 4. Use signs with large letter stating a No/No Entry/Sorry Door (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 12 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 0689 Level of Harm - Minimal harm or potential for actual harm Closed. Stress During Admission. 6. consider teaming the new resident with another resident who is comfortable and oriented in the facility. (i.e., The buddy system). 2) During a confidential interview on 8/2/23 at 9:14 AM a resident stated that the water in room [ROOM NUMBER] was never hot. Residents Affected - Some Observation on 8/2/23 at 9:23 AM the hot water in room [ROOM NUMBER] was 116.1°F and was witnessed by Housekeeper A. On 8/2/23 at 10:07 AM an observation and interview were conducted in the central bath with CNA A. The lower shelf of the wall cabinet had a bottle of K Quat Plus Cleaner and Disinfectant lying on its side on top of a packet of resident use wipes. It was also under washcloths and next to the shampoos and body wash. The cabinet was unlocked. Record review of the label of the KQuat Plus Cleaner and Disinfectant revealed the following, Danger. Corrosive. Causes irreversible eye damage. On 8/2/23 at 10:12 AM, CNA A was interviewed. She stated staff were told they could place the cleaner in the wall cabinet as long as the cabinet was locked. She stated she had asked this yesterday (8/01/23) but could not remember who she had told her this. Observation on 8/2/23 at 10:29 AM, in the dining room, revealed the dining room heater closet door was unlocked. The facility had a wandering resident. Observations were made of Resident #33 wandering and confused in the dining room on 8/1/23 at 6:13 PM, 8/2/23 at 11:40 AM and 8/2/23 at 1:30 PM. Record review of the Order Summary Report for female Resident #33, dated 8/1/23, revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood, disturbance, and anxiety (cognitive disorder), and cognitive communication deficit (cognitive disorder). Record review of the admission MDS assessment for Resident #33 dated 5/18/23 revealed that the resident had a BIMS score of six, indicating the resident had cognitive impairment. No behavior issues were documented. A documented Active Diagnosis was non-Alzheimer's dementia. Observation on 8/2/23 at 11:28 AM revealed Floor Tech A was on the patio and supervising smokers. At the same time, there were two oxygen tanks in black bags with tubing and freestanding in the dining room. One was propped on top of an oxygen tank storage rack, leaning on the wall behind the public double door to the dining room. This tank was reading 1000 on the gauge (contained an amount of oxygen). The other oxygen tank was freestanding on the floor next to the wall and the tubing was on the floor. There were residents in the dining room at this time. On 8/2/23 at 11:33 AM an interview and observation were conducted with CNA A regarding the oxygen tanks in the dining room. She stated the tanks belonged to the residents smoking. She added residents left them there and then go outside to smoke with staff. She stated the tanks belonged to Residents #18 and #87. These residents were observed outside, smoking supervised by the Floor Tech A. Regarding what could result from that way the oxygen tanks were stored, she stated the tanks could fall over and blow up and the tubing should not be on the floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 13 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 8/2/23 at 11:37 AM, an interview was conducted with Floor Tech A. Regarding the oxygen storage in the dining room, he stated staff normally remove the oxygen from the wheelchairs, prior to residents smoking. He stated he and a CNA had stored the oxygen tanks in the dining room. Regarding what could result from the way the oxygen tanks were stored, he stated the tanks could fall and cause an explosion. On 8/3/23 at 11:20 AM an interview and observations were conducted with the Maintenance Supervisor regarding maintenance issues found. Regarding hot water he stated that he had issues with the water temperatures mostly in the shower room and it had been happening for approximately a month. He stated that he tried to maintain water temperatures at 110°F. He added complaints had been received about water temperatures in room [ROOM NUMBER]. He stated he took water temps one time a week. He stated the area in the facility from the showers to room [ROOM NUMBER] was the problem area. He stated that he usually conducted water temperature checks in the morning and that the water was usually 108 to 112°F. On 8/3/23 at 11:30 AM an interview and observations were conducted with the Maintenance Supervisor regarding repair issues observed in the facility: Regarding how oxygen tanks should be stored, he stated, oxygen had to be in a rack. Regarding why he felt these maintenance issues happened in the facility, he stated wear and tear overtime, past maintenance neglect, and staff not reporting. Regarding what could result from the maintenance issues mentioned, he stated it could be a safety issue. On 8/3/23 at 12:20 PM an interview was conducted with the DON regarding observed issues. Regarding oxygen storage, she stated oxygen should be secured. Regarding the cleaning items stored with washcloths and wipes, she stated cleaners should be locked separately. On 8/3/23 at 12:57 PM interview was conducted with the Administrator regarding issues found in the facility. Regarding the maintenance and environmental issues, she stated she expected staff to call a plumber and she expected the maintenance staff to report and follow through on repairs. Regarding oxygen storage, she expected it should be secured. Regarding chemical storage she stated chemicals should be properly stored (separate from resident items). Regarding repairs problems, she stated it could affect quality of life. On 8/3/23 at 1:33 PM the Maintenance Supervisor was interviewed regarding the facility water temperature documentation he presented, which included no documented temperatures only room numbers. He stated, in March he received the current form. The issues with the water temperature started on 6/19/23 and he documented issues in the comments area of the form. Record review of the Water Temperature Check log dated 3/14/23 through 7/31/23. Review of the following, documentation weekly temperature checks of the hot water. Outgoing, water temperature for the hot water faucet (should be at least 100 to 110°C). Record review of the weekly checks revealed that there was no documentation of individual temperatures in any of the rooms tested. There was documentation in the comment section on 6/19/23 which stated shower not up to temp. Another comment documented on 7/3/23 revealed the following, temp fluctuating adjustment made. Further documentation on 7/17/23 revealed the following, adjusted temp. Documentation on 7/24/23 revealed the following in the comment section, shower, hot adjusted temp. There was no documentation of any temperatures regarding the adjustment. Review of the current American Burn Association Scald Injury Prevention Educator ' s Guide provided the following information. The basis of the information is from research conducted by [NAME], AR, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 14 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Herriques, FC Jr. Studies of thermal injuries: II The relative importance of time and surface temperature in the causation of cutaneous burns. M J Pathol 1947; 23:695-720. and Stone, M, [NAME] J, [NAME] J. The continuing risk of domestic hot water scalds to the elderly. Burns 2000; 26:347-350.: .although scald burns can happen to anyone, .older adults and people with disabilities are the most likely to incur such injuries .High Risk groups .Older Adults .Older adults, .have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults . People With Disabilities or Special Needs .Individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds sensory impairments can result in decreased sensation especially to the hands .so the person may not realize if something is too hot. Changes in a person ' s perception, memory, judgment or awareness may hinder the person ' s ability to recognize a dangerous situation .or respond appropriately to remove themselves from danger . Further review of the Guide revealed that 100 degree F. water was a safe temperature for bathing. Water at 120 degrees F. would cause a third degree burn (full thickness burn) in 5 minutes and 124 degrees F. water would cause a third degree burn in 3 minutes. The Guide further documented that water at 127 degrees F. caused third degree burns in 1 minute and water at 133 degrees F. caused third degree burns within 15 seconds. Water temperatures at 140 degrees F. caused third degree burns within 5 seconds. Record review of the facility policy, titled Environment of Care Policy and Procedure Manual 2003, HM 03-1.0, revealed the following documentation, Hazardous Communications Program. Statement of purpose: hazardous chemicals and materials are used throughout the facility. The Occupational Safety and Health Administration require each employer to communicate information about hazardous materials in the workplace to each employee. The policy will establish, maintain, evaluate and communicate information concerning hazardous chemicals in an effort to reduce or prevent injury or illness to employees in a manner consistent with the requirements of OSHA 29 CFR 1910.1200 regulations. Definition: hazardous chemicals, and materials according to 29 CFR 1910.1200 include any chemical or material that presents either a health or physical hazard. These include chemicals and materials that are . irritants, corrosives. and agents that damage, the lungs, skin, eyes, or mucous membranes, . Policy. 22. The rec[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 15 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 1 of 1 facility kitchen. The facility failed to designate a person to serve as the Dietary Manager who met the required qualifications. The facility designated Dietary Manager had not completed any Dietary Managers certification course or had any other qualifying credentials. This failure could place residents at risk for the spread of foodborne illness and residents not having their nutritional needs met. The findings include: Record review of the personnel file for the Dietary Manager's Application for Employment revealed no documentation that she had completed the certified Dietary Manager course, had experience as a Dietary Manager or other qualifying credentials. She had a date of hire of 07/5/23. Record review of the personnel file for the Dietary Manager revealed that she had a Texas Food Handlers certificate of completion, dated 7/22/23 which was current. Record review of the facility's Dietician documentation revealed that the Dietician was on contract and not full-time. On 8/1/23 at 10:07 AM an interview was conducted with the Dietary Manager. She stated that she started the position of Dietary Manager three weeks ago and had not completed the certified Dietary Manager course. She stated she had a food handler certificate. She also stated that she had not been a Dietary Manager before this position. On 8/2/23 at 5:45 PM an interview was conducted with the Administrator, and she stated that the facility Dietitian was on contract and was not full-time. On 8/3/23 at 10:54 AM an interview was conducted with the Dietary Manager regarding her not being a qualified Dietary Manager. She stated this issue could result in not providing the correct food groups to residents and could affect their health. On 8/3/23 at 12:57 PM an interview was conducted with the Administrator regarding issues about the Dietary Manager qualifications. She stated the facility's procedure was to hire a Dietary Manager which would work on their Certified Dietary Manager credentials. The Dietary Manager would be required to complete the course in a year. Regarding what could result from this issue, she stated, the Dietary Manager may not understand the nutrition side of dietary. On 8/3/23 at 3:13 PM an interview was conducted with the Administrator regarding the Dietary Manager's qualifications. She stated, the Dietary Manager had not taken the Certified Dietary Manager course. She added that she and the Dietary Manager had talked about it, and she would now take the course. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 16 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the facility policy, titled Human Resources Manual 2014, JD 11.0, revealed the following documentation, Job Description. Dietary Service Manager. The following is a non-exhaustive criteria that relates to the job of a Dietary Service Manager, and it is consistent with the business needs of the facility. These are legitimate measures are the qualifications for a Dietary Service Manager and are related to the functions that are essential to the job of a Dietary Services Manager. Knowledge base: current certification by state as required. Event ID: Facility ID: 675496 If continuation sheet Page 17 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure menus were followed for 3 of 3 food forms (regular, mechanical soft and pureed) for 3 residents (Residents #20, #23 and #27) reviewed for during mealtime. The facility failed to ensure Resident's #20, #23 and #27 received their meals according to the menu. This failure could place residents at risk for unwanted weight loss and hunger. The findings include: 1. Record review of the diet Order Summary Report, dated 8/1/23, for Resident #23 revealed an [AGE] year-old female who was admitted to the facility on [DATE] . The resident had diagnoses which included mood disorder due to non-physiological condition with major depressive like episodes (mental disorder), dysphagia, oropharyngeal, phase (swallowing disorder), gastroesophageal reflux, disease, without esophagitis (heartburn), hyperlipidemia (high cholesterol), unspecified dementia, and other diseases classified elsewhere with behavioral disturbance, anxiety disorder, unspecified (cognitive disorder), unspecified protein - calorie, malnutrition (nutrition deficiency), Alzheimer's disease with late onset (cognitive disorder), dysphagia unspecified (swallowing disorder). Further record review of the Order Summary Report revealed the resident had a diet order documented as, Regular diet, puréed texture, regular consistency. Order date 2/7/22. Start date 2/7/22. 2. Record review of the Order Summary Report for Resident #20, dated 8/2/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. The resident had diagnoses which included major depressive disorder, recurrent, mild (mental disorder), Vitamin D deficiency, unspecified, hyperlipidemia (high cholesterol), unspecified iron deficiency, unspecified proteins - calorie malnutrition (nutrition deficiency), dysphagia, unspecified (swallowing disorder), type two diabetes mellitus with diabetic neuropathy, unspecified (blood sugar imbalance). Further record review of the Order Summary Report revealed the resident had a diet order documented as, Regular diet, purée, texture, regular consistency. Order date 8/22/22. Start date 8/22/22. 3. Record review of the Order Summary Report, dated 8/1/23, for Resident #27 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #27 had diagnoses which included mixed, hyperlipidemia (high cholesterol), abnormal weight loss, dental caries (tooth decay), unspecified, dysphagia, oropharyngeal, phase (swallowing disorder), gastroesophageal reflux disease with esophagitis (heart burn), unspecified protein-calorie malnutrition (nutrition deficiency), other vitamin B 12 deficiency, anemia, Alzheimer's disease with late onset (cognitive disorder). Further record review of the Order Summary Report revealed the resident had a diet documented as Regular diet, mechanical soft texture, regular consistency . Order date 12/2/20. Start date 12/2/20. -The following observations were made, and interviews conducted during a kitchen tour on 8/01/23 that began at 11:25 AM and concluded at 1:10 PM: Dietary staff C was observed placing milk and two fried apple pies into the wet processor and puréed. The results looked coarse and lumpy. She dispensed one #12 scoop (1/3 cup), in each of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 18 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 0803 two bowls of the purée. Level of Harm - Minimal harm or potential for actual harm Observation on 08/01/23 at 12:31 PM revealed the steam table with the following results: Baked beans served with a 4 ounce ladle. Residents Affected - Some Ham and cheese sandwich Potato salad on ice and served with a #16 scoop. Barbecue sauce serve with a 3 ounce ladle. Ground pork rib served with a #8 scoop. Puréed baked beans served with a #10 scoop. Purée potato salad served with a #20 scoop. Ribs served with a tongs. Puréed pork ribs were still heating in the oven. Rolls were placed on the steam table Pureed Fried Apple pie #12 scoop served in bowl (previously observed preparation) Dietary Staff A was observed, during meal service, serving one scoop of each food on the trays for the menus/diets. Regular and mechanical soft trays were served #16 scoop (1/4 cup) potatoes salad instead of a ½ cup as called for on the menu. Pureed diets received #10 scoop (3/8 cup) of baked beans instead of a #8 (1/2 cup) scoop and received a #20 scoop (1/5 cup) of pureed potato salad instead of a #8 (1/2 cup). Observation on 8/1/23 at 1:04 PM revealed the meal tray for Resident #20 was prepared and the resident received puréed beans, puréed ribs. There was no tomato juice or margarine served. Observation on 8/1/23 at 1:07 PM revealed the meal tray was served and prepared for Resident #27. She received a #16 scoop of potato salad and one 4 ounce serving of beans. Staff stated she only wanted vegetables. Observation on 8/1/23 at 1:11 PM revealed Resident #20 feeding herself in the dining room and the meal tray was served as previously prepared; and the resident received puréed beans, puréed ribs. There was no tomato juice or margarine served. Observation on 8/1/23 at 1:12 PM revealed Resident #23 in the dining room being fed by staff. The resident received puréed beans, purée pork rib, puréed bread, and purée potato salad. The resident did not receive any tomato juice or margarine. Observation on 8/1/23 at 1:18 PM revealed 14 of 14 resident trays in the dining room had not been served any margarine with their meal. It was also observed that 13 of 13 resident trays, that were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 19 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 0803 regular diets, had not been served the barbecue relish tray. Level of Harm - Minimal harm or potential for actual harm -The following observations were made during a kitchen tour on 8/01/23 that began at 4:30 PM and concluded at 5:35 PM: Residents Affected - Some Observation on 8/1/23 at 5:20 PM revealed the following: Puréed Chicken fried steak served in bowls. Puréed French fries served in a bowl. Puréed Cabbage served in a bowl on the steam table. Observation on 8/1/23 at 5:46 PM revealed Resident #23 in the dining room fed by staff. The resident received tea, purée cabbage, puréed chicken fried steak, puréed French fries and puréed Jell-O. The resident did not receive any puréed bread as documented on the menu. The resident tray card documented the following: regular/purée, Entrée - cream gravy puréed beef steak finger, Starch - puréed crinkle cut fries, soft cooked slaw, puréed Texas toast one each, Margarine and Gelatin. During an interview on 8/1/23 at 1:06 PM, Dietary Staff A stated he served each tray with one scoop of food and two ribs were a serving unless the ribs were small and he added additional ribs. During a confidential interview revealed It would be nice if the facility had butter for the rolls. The resident had not received any margarine with the regular diet meal. During observation and interview on 8/1/23 at 1:23 PM the Dietary Manager stated, she forgot to get the barbecue relish tray and margarine out of the refrigerator. Observation of the refrigerator revealed there were containers of pickles and onions that were to be used for a BBQ relish tray. During observation and interview on 8/1/23 at 1:34 PM with Resident #27 revealed her tray card documented the resident was on a mechanical soft diet. Resident #27 stated she could not eat the fried apple pie because she had no teeth. Observation of the resident's mouth revealed she had missing teeth. Further observation of the tray card revealed the resident should have received a soft fried pie. The resident then dropped the fried pie on the plate, and it made a hard clank. She broke it open, and it was noted that the interior was soft, but the exterior was hard. The fried pie was hard and not soft fried as called for on the menu. Interview on 8/1/23 at 4:35 PM with Dietary Staff A stated everyone in dietary was new. He stated he had his food handler's certificate. He stated he had general facility orientation on Wednesday (7/26/23) and came back Saturday (7/29/23) and worked breakfast and lunch and was left on his own at dinner. Regarding training on scoop sizes, he stated they had not gone over scope sizes or matching it to the diet spreadsheet. He stated residents not receiving the correct portions of food would not be following the physician's orders and could affect the residents weight. Observation and interview on 8/1/23 at 6:05 PM with Dietary Staff B revealed there were two bowls of puree bread observed left in the refrigerator. Dietary staff B stated the pureed bread was in the refrigerator in crystal bowls along with an extra serving; meaning two of the three residents with puréed diets received puréed bread, but one did not (Resident #23). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 20 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 8/3/23 at 10:54 AM with the Dietary Manager, she said she had done a little training regarding scoop and portion sizes. She added she was also working as a cook and did not have sufficient time to devote to staff training on following the menu. The Dietary Manager stated the issues happened because staff were not paying attention. The Dietary Manager stated she expected staff to have used the correct scoops and serve the correct foods. The Dietary Manager stated a result from not following the menu could be residents could choke and would not be provided the correct foods as required. Interview on 8/3/23 at 12:57 PM with the Administrator, she stated she expected the staff to serve the correct foods and portions. She stated not following the menu could result in residents experiencing nutritional imbalance. Record review of the Tuesday (facility) 2023, Week 3 Lunch menu for residents on regulars/puree diets revealed the residents should receive one #8 scoop (1/2 cup) puréed apple fried pie. Record review of the Tuesday (facility) 2023, Week 3 menu Lunch revealed for lunch residents on regular diets received 3 ounces barbecue ribs, half a cup potato salad, half cup baked beans, one each fluffy wheat roll, one each margarine, one serving barbecue, relish plate, and one each apple fried pie. Record review of the Tuesday (facility) 2023, Week 3 menu Lunch revealed residents on a regular/mechanical soft diet received for lunch, 3 ounces ground barbecue ribs with sauce, 1/2 cup potato salad, 1/2 cup baked beans, one each fluffy wheat roll, one each margarine, 1/2 cup tomato juice and one each soft fried apple pie. Record review of the Tuesday (facility) 2023, Week 3 Lunch menu for residents on regular/puree diets revealed the following: one #10 scoop, puréed, barbecue rib, one #8 scoop puréed, potato salad, one #8 scoop puréed baked beans, one #10 scoop, puréed, fluffy wheat roll, one each margarine, 1/2 cup tomato juice and one #8 scoop puréed apple fried pie. Record review of the Tuesday (facility) 2023, Week 3 Supper menu revealed residents on a regular puréed diet should have received, one #10 scoop of puréed beef steak fingers, two fluid ounces with cream gravy, one #8 scoop purée crinkle cut fries, one #10 scoop of puréed soft cooked slaw (substituted cabbage) and one #16 scoop purée Texas toast. Record review of the Resident Roster: for Tuesday, 8/1/23 list documented 9 residents in the facility had physician orders for mechanical soft diets, three residents had orders for pureed diets and 25 had orders for a regular diet. Record review of the facility policy, titled Dietary Services Policy and Procedure Manual 2012, FP 00-6.0, revealed, Resident Menus. We will strive to assure the residents nutritional needs are provided based on the Recommended Daily Allowances. The standard menu will ensure nutritional adequacy of all diets, offer a variety of food in adequate amounts at each meal, and standardize food production. Procedure . 4. If any meal served varies from the planned menu, the change and reason for the change shall be noted on the substitution log. 5. The menus will be prepared as written, using standardize recipes. The Dietary Service Manager (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 21 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 0803 and cooks are trained and responsible for the preparation and service of the therapeutic diets as prescribed Level of Harm - Minimal harm or potential for actual harm Record review of the facility's guidance document, dated 2014, revealed the following documentation, Training, Staff on Puréed Foods 9. Check the scoop sizes on the menu and serve the proper portions . 10. Be sure to include purée bread on the trays per menu Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 22 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual needs for 2 of 2 meals observe for 2 3 of 2 residents with orders for puréed diet (Residents #20 and 23 and 27 ) reviewed for nutrition services and one resident on a mechanical soft diet (Resident #27); in that: The facility failed to provide food that was in a form to meet resident needs for 2 of 2 meals observed (8/01/23 and 8/02/23 - Lunch) for 2 of 2 residents with the orders for puréed diets (Residents #20 and 23) and one resident on a mechanical soft diet (Resident #27). Foods were not in a pureed form and mechanical soft foods were not in the form called for on the menu. This failure could place residents at risk of decreased food intake and choking. The findings include: Resident #23 Record review of the diet Order Summary Report dated 8/1/23 for female Resident #23 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of mood disorder due to non-physiological condition with major depressive like episodes (mental disorder), dysphagia, oropharyngeal, phase (swallowing disorder), gastroesophageal reflux, disease, without esophagitis (heartburn), hyperlipidemia (high cholesterol), unspecified dementia, and other diseases classified elsewhere with behavioral disturbance, anxiety disorder, unspecified (cognitive disorder), unspecified protein - calorie, malnutrition (nutrition deficiency), Alzheimer's disease with late onset (cognitive disorder), dysphagia unspecified (swallowing disorder). Further record review of the Order Summary Report revealed the resident had a diet order documented as, Regular diet, puréed texture, regular consistency. Order date 2/7/22. Start date 2/7/22. Record review of the quarterly MDS assessment for Resident #23 dated 6/23/23 revealed that the resident had a BIMS score of 99 which indicated the resident had a short term and long term memory problems. It further documented that the resident was moderately impaired cognitively. Further record review of the MDS documented that the resident had an active diagnosis of Alzheimer's disease, dementia and malnutrition. There were no documented swallowing issues. Record review of the current care plan for Resident #23 included a Focus that documented, Resident has a diet order other than regular and is at risk for unplanned, weight loss or gain. Puréed. Date initiated: 2/7/22. Revision on: 2/15/22. Interventions documented included, Serve diet and snacks as ordered. Date initiated 2/7/22. Record review of the Nutritional Risk Assessment V3 for a Resident #23, dated 2/28/23, revealed the resident was on a regular puréed diet. Physical and mental functioning was documented as .supervision while eating, chewing, or swallowing problems, teeth in poor repair, ill fitting, dentures, or refusal to wear, dentures, and dentulous. 9. Relevant medical condition. 3. Palliative care. Additional documentation revealed the following, 14. Swallowing difficulties. Resident appears to have some swallowing difficulties. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 23 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 0805 Resident #20 Level of Harm - Minimal harm or potential for actual harm Record review of the Order Summary Report for female Resident #20 dated 8/2/23 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of major depressive disorder, recurrent, mild (mental disorder), Vitamin D deficiency, unspecified, hyperlipidemia (high cholesterol), unspecified iron deficiency, unspecified proteins - calorie malnutrition (nutrition deficiency), dysphagia, unspecified (swallowing disorder), type two diabetes mellitus with diabetic neuropathy, unspecified (blood sugar imbalance). Further record review of the Order Summary Report revealed that the resident had a diet order documented as, Regular diet, purée, texture, regular consistency. Order date 8/22/22. Start date 8/22/22. Residents Affected - Some Record review of the quarterly MDS assessment for Resident #20 dated 7/4/23 revealed that the resident had a BIMS score of zero indicating that the resident was cognitively impaired. Active diagnosis listed for the resident included malnutrition. Further record review revealed no documentation of a swallowing Issue. Record review of the Nutritional Risk Assessment, V3 dated 2/28/23 revealed that Resident #20 was on a regular puréed diet. It further documented Physical and Mental Functioning. Supervision while eating, chewing, or swallowing problems, teeth in poor repair, ill-fitting dentures or refusal to wear dentures, and dentulous. 9. Relevant medical condition. 3. Palliative care. It further documented, 14. Swallowing difficulties. Resident appears to have some swallowing difficulties. Resident #27 Record review of the Order Summary Report dated 8/1/23 for female Resident #27 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of mixed, hyperlipidemia (high cholesterol), abnormal weight loss, dental caries (tooth decay), unspecified, dysphagia, oropharyngeal, phase (swallowing disorder), gastroesophageal reflux disease with esophagitis (heart burn), unspecified protein-calorie malnutrition (nutrition deficiency), other vitamin B, 12 deficiency anemia, Alzheimer's disease with late onset (cognitive disorder). Further record review of the Order Summary Report revealed that the resident had a diet documented as Regular diet, mechanical soft texture, regular consistency Order date 12/2/20. Start date 12/2/20. Record review of the annual MDS assessment dated [DATE] revealed that Resident #27 had a BIMS score of 15 indicating that the resident was cognitively intact. Active diagnoses listed included Alzheimer's disease and malnutrition. There was no documentation of swallowing or dental issues for the resident. Record review the current care plan for Resident #27 revealed a Focus stating, Potential risk for malnutrition related to diagnosis of malnutrition and history of alcohol abuse. Date initiated: 10/29/19. Revision on: 6/7/21. Interventions listed included, Diet mechanical, soft. Date initiated: 12/3/20. Revision on 6/7/21. Offer diet as ordered by the physician. Date initiated: 10/29/19. Revision on 6/7/21. Record review of the Nutritional Risk Assessment V3 for Resident #27 dated 7/14/23 documented, The resident was on a regular mechanical soft diet and further documentation revealed the following, 8. Physical and mental functioning. 2. Supervision while eating, chewing, or swallowing problems, teeth in poor repair, ill-fitting dentures, or refusal to wear dentures, and dentulous. 14. Swallowing difficulties. 2. Resident appears to have some swallowing difficulties. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 24 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some -The following observations were made, and interviews conducted during a kitchen tour on 8/01/23 that began at 11:25 AM and concluded at 1:10 PM: Dietary staff C was observed preparing the pureed fried apple pie. She placed an unknow amount of milk and two fried apple pies into the processor and puréed the mixture. The results looked coarse and lumpy. She dispensed one scoop in each of the two bowls of the purée. On 8/1/23 at 11:50 AM a sample of the puréed fried apple pie was sampled and observed by the surveyor, and it was coarse with of apple bits. Dietary staff A was observed taking regular pork ribs (including bone and gristle) from the steam table and then placed them in the processor. He added chicken broth to the pork ribs and puréed the mixture. During the pureeing process the processor blade continued to jam and hard pieces of food could be heard hitting the sides of the processor during the purée. He then placed the purée in a pan. On 8/1/23 at 12:25 PM the Surveyor observed and sampled the puréed pork ribs, and there were whole bits of gristle and sharp bits and slithers of bone fragment tasted. The surveyor intervened and the staff did not to serve this food. During an interview on 8/1/23 at 12:28 PM Dietary staff A stated, he did not realize it was bone and gristle making the noise and hitting the sides of the processor; now knew it was. He further stated he understood the bones and gristle were why the blade jammed during processing. The Dietary Manager was observed reprocessing the puréed pork ribs without bones and gristle. On 8/01/23 at 12:31 PM temperatures and other observations were made of the steam table with the following results: Puréed baked beans Purée potato salad Puréed pork ribs On 8/1/23 at 12:39 PM the new puréed pork ribs were observed and sampled the surveyor, and the puréed pork ribs had to be chewed to be consumed. The purée was coarse. Observation on 8/1/23 at 1:04 PM, the meal tray for Resident #20 was prepared. The resident received puréed beans, puréed pork ribs, purée potato salad, and puréed bread which had a coarse appearance. Observation on 8/1/23 at 1:07 PM, the meal tray was prepared and served and prepared for Resident #27. She received a scoop of potato salad, fried apple pie and beans. (The resident only wanted vegetables). On 8/1/23 at 1:34 PM an interview and observation were was conducted with Resident #27. Observation of her tray card revealed that she was on a mechanical soft diet. She stated, she could not eat the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 25 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some fried apple pie because she had no teeth. Observation of the resident's mouth revealed she had missing teeth. Further observation of the tray card revealed that the resident should have received a soft fried apple pie. The resident then dropped the fried pie on the plate, and it made a hard clanking sound. She broke it open, and the interior with soft, but the exterior was hard. On 8/1/23 at 4:35 PM an interview was conducted with Dietary staff A regarding food form issues observed . Regarding training, he stated he worked in a couple of kitchens as a teen. He added everyone in dietary was new. He further stated he had his food handler's certificate. He stated he had not received any training on puree preparation. He stated he received general facility orientation on Wednesday (7/26/23) and came back Saturday (7/29/23) and worked breakfast and lunch and was left on his own at dinner . -The following observations were made, and interviews conducted during a kitchen tour on 8/02/23 that began at 12:27 AM and concluded at 12:29 PM: The puréed three foods were tested and 2 of the 3 were not in a pureed form: Pureed Hamburger patty was thin, flat on the plate and watery. Puréed cream corn was thinner than pudding consistency. On 8/2/23 at 12:28 PM an interview was conducted with a Dietary Manager regarding the puréed beef patty and pureed corn. She stated, this was Dietary staff B's second week of employment. She further stated the pureed beef patty was thin. On 8/3/23 at 10:54 AM an interview was conducted with the Dietary Manager regarding issues in the kitchen. Regarding food form, she stated that she had given training on purées. Regarding why the foods were not in a puree or mechanical soft form, she stated Dietary staff A had only worked two days and staff needed more practice and more monitoring . Regarding what she expected of staff related to purees, she stated they should have puréed the foods correctly. Regarding what could result from an incorrect food form, she stated residents could choke and could receive incorrect portions. Regarding the mechanically altered food that was not in the correct form, she stated residents could choke. On 8/3/23 at 12:20 PM an interview was conducted with the DON regarding the reason Residents #20 and #23 were ordered a puréed diet. She stated, more than likely it was due to their diagnoses of dysphagia (swallowing disorder). On 8/3/23 at 12:57 PM an interview was conducted with the Administrator regarding issues found in the facility. Regarding food form, she stated she expected staff not to purée bones and expected them to produce foods that were in the appropriate thickness. She added these issues could result in residents choking. Record review of the Resident Roster: Tuesday, 8/1/23 Breakfast list documented 9 residents in the facility had physician orders for mechanical soft diets, three residents had orders for pureed diets and 25 had orders for a regular diet. Record review of the facility guidance document dated 2014, revealed the following documentation: Training, Staff on Puréed Foods. Puréed diets should receive food that is according to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 26 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete the menus. It should taste the same as the regular food and should contain the same seasonings and ingredients as the food served to the regular texture diet. Only the texture should be altered. It is important that shortcuts not be taken because it will alter the calories and nutritional value of the product, as well as the color and the taste. 3. Blend product until smooth, adding additional liquid as needed to keep the product, moist and soft. There should be no lumps or texture when the blending is complete. If you have problems, process it longer, or have maintenance sharpen the blade. Event ID: Facility ID: 675496 If continuation sheet Page 27 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 in 1 of 1 kitchen reviewed for dietary services. 1. The facility failed to ensure foods were processed under sanitary conditions. 2. The facility failed to ensure dietary staff maintained quaternary sanitizer levels within acceptable ranges and sanitizing solutions were tested according to manufacturer guidelines. 3. The facility failed to ensure food and non-food contact surfaces were cleaned. 4. The facility failed to ensure food was protected from possible contamination. 5. The facility failed to ensure staff used good hygienic practices. These failures could place residents at risk for food contamination and foodborne illness. The findings include: -The following observations were made, and interviews conducted during a kitchen tour on 8/01/23 that began at 10:05 AM and concluded at 10:50 AM: During an observation and interview on 8/1/23 at 10:10 AM, Dietary Staff C stated the dishwasher was not dispensing any sanitizer. She stated they were rinsing and letting dishes dry until the dishwasher was repaired. She tested the dishwasher final rinse, and the test strip was a very light purple color. The test strips used had no color scale for comparison and no instructions. Observation revealed Dietary Staff A tested the three compartment sink quaternary sanitizer with quaternary test strips. The sanitizer level was less than 150 ppm after being tested twice. During an interview on 8/1/23 at 10:17 AM Dietary Staff A stated the quaternary sanitizer should be between 150 ppm and 200 ppm to be correct. Dietary Staff A did not correct the sanitizer level. Observation revealed Dietary Staff A rinsed a knife and placed it in the sanitizer in three compartment sink. He then set it to dry down on the drain board. This was the same sanitizing solution that was less than 150 ppm. Observation of the quaternary sanitizer label for the three compartment sink, reflected KQuat No Rinse, documented the correct level of sanitizer for the solution was 150 to 400 ppm. Observation revealed a grease buildup on the sides of the fryer. During an interview on 8/1/23 at 10:30 AM, Dietary staff A stated nothing was added to the sanitizer he tested, which was less than 150 ppm in the three compartment sink. Observation on 8/1/23 at 10:38 AM revealed the Dietary Manager tested the chlorine level in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 28 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 dishwasher with test strips had a color comparison and instructions included. She asked Dietary Staff A how long she should dip the strip into the final rinse to test it. Dietary staff C responded, 10 seconds. The final rinse sanitizer level for chlorine indicated 10 ppm. Record review of the Hydrion Chlorine test strips package revealed documentation that stated, When testing, dip and remove immediately. Observation revealed the Dietary Manager was observed washing pans in the three-compartment sink which had a sanitizer level of less than 150 ppm quaternary sanitizer as previously tested. -The following observations were made, and interviews conducted during a kitchen tour on 8/01/23 that began at 11:25 AM and concluded at 1:10 PM: Observation revealed the Dietary Manager picked up cooked rolls with her bare hands and placed them in another pan. The Dietary Manager had long nails that were approximately a quarter of an inch above the end of her finger. An interview on 8/1/23 at 11:40 AM with the Dietary Manager revealed she picked up the rolls with her bare hand because she thought staff could not use gloves. Observation of the interior of the processor pot revealed it was wet. Dietary staff C placed milk and two fried apple pies into the wet processor and puréed the mixture. Observation revealed Dietary staff A wiped his hands inside the clean processor pot that was drying on the drain board. Observation revealed Dietary staff A, after washing his hands, dried them on a paper towel and then placed the used paper towel on the prep table and then handle beans that were in bowls. He then puréed the baked beans with chicken broth and placed the mixture in pan. The underside of the upper shelves of the steam table and the stove had an accumulation of dried spills. The Dietary Manager was holding the processor blade with her bare hand and swinging it in the air to get the water off it and dry it after washing it in the 3 compartment sink. Dietary staff A picked up the processor blade with his bare hands and put it in the processor. He added potato salad and chicken broth and puréed the mixture. He then pulled the blade out of the processor with his bare hands then put the puréed potato salad in a pan. Observation revealed Dietary staff A scratching his back and then picking up the processer pot and swinging it in the air to dry it. He washed a spatula in the 3 compartment sink, then washed his hands and then returned to place the blade in the processor. Dietary staff A wiped his hands on his apron, then put on a pair of gloves. He then picked up pork ribs with his gloved hands from a pan on the steam table, and then placed them in the processor. He removed his gloves and then placed the blade in the process of pot with his bare hands. He then added chicken broth to the pork ribs and puréed the mixture. -The following observations were made, and interviews conducted during a kitchen tour on 8/01/23 that began at 4:30 PM and concluded at 5:35 PM: Interview on 8/1/23 at 4:35 PM with Dietary staff A revealed he wiped his hand inside the processor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 29 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 pot because he was checking to see if it was dry. He stated he was told by staff not to wear gloves unless staff were prepping food. He added all the staff were new. He stated he had his Food Handler's certificate. He further stated his experience was not like what he was tested on for his Food Handler's certificate and not like a restaurant. He stated he received general facility orientation on Wednesday (7/26/23) and came back Saturday (7/29/23) and worked breakfast and lunch and was left on his own at dinner Dietary Staff A stated the dietary sanitation issues that occurred could cause cross-contamination. Observation revealed eight sets of kitchen fluorescent lights, one set had one of four lights with no stabilizing caps. Three sets of lights had four of four lights with no stabilizing cap to prevent breakage. Interview on 8/3/23 at 10:54 AM with the Dietary Manager, she stated she had conducted in-services a week ago. She stated training for new employees lasted two weeks with monitoring. She stated none of the current employees had training before she came. The Dietary Manager stated she had not conducted any in-services on hygienic practices. She stated she had conducted in-services on handwashing and sanitizing. She stated staff should be changed every two hours. She stated some staff were not previously trained on the quaternary sanitizer. The Dietary Manager stated she expected staff to correct the problems and find a solution. The Dietary Manager stated these issues happened in the kitchen because of improper training. She stated the result of the issues in the dietary department regarding sanitation could cause sanitation problems and residents get sick germs. She further stated staff were cleaning and they would conduct cleaning of the steam table and stove shelves one time a week. Interview on 8/3/23 at 12:57 PM with the Administrator, she stated she expected staff to use gloves. she stated the issues related to dietary sanitation could cause the spread of contamination. Record review of the dietary department in-services for the last three months(May - July 2023) revealed there was an in-service conducted on 7/18/23 with the topic, wearing aprons, hairnets according to the in-service training attendance roster. The in-service was given by the Dietary Manager. Dietary staff C was present for this in-service and the in-service training was documented as one on one in-service. Record review of the Record of Departmental In-Service and Meetings revealed there was an in-service conducted on 7/29/23 by the Dietary Manager. The title of the in-service was Food Temps, Sanitation, Infection, Control, Dishwashing. The documented summary of the in-service was as follows, Educate on temps of food, sanitation, infection, control, dishwashing, and preparation. Dietary staff A attended this in-service. Record review of the facility policy titled, Dietary Services Policy and Procedure Manual 2012, IC 00-7.0, revealed, Dishwashing, Preparation, And Dishwashing. The facility will complete the dishwashing process in a sanitary manner to provide clean and sanitary dishes and utensils. Procedure . 10. Manual dishwashing of eating utensils will be used only in the event of dish machine failure . e. All equipment and utensils will be sanitized by one of the following methods . 2. Immersion for a period of at least one minute in a sanitizing solution containing . c. At least 150-400 ppm of a quaternary ammonium compound a temperature of around 70°F (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 30 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 Record review of the facility policy, titled, Dietary Services Policy and Procedure Manual 2012, IC 00-6.0, revealed, Equipment, Sanitation. We will provide clean and sanitized equipment for food preparation. Facility will clean all food service equipment in a sanitary manner. Procedure . 8. Blenders and the food processor. Bowls should be inverted after cleaning to drain dry on shelves or trays with vented slots or bar netting Record review of the facility policy, titled Dietary Services Policy and Procedure Manual 2012, IC 00-4.0, revealed the following documentation, Handwashing. We will ensure proper handwashing procedures are utilized. Employees are to frequently perform handwashing as outlined Record review of the facility policy, titled Dietary Services Policy and Procedure Manual 2012, IC00-5.0, revealed, Food Safety. We will ensure all food purchased shall be wholesome and manufactured, processed, and prepared in compliance with all State, Federal, and local laws and regulations. Food shall be handled in a safe manner. Procedures . 11. Gloves must be worn for preparation and service of foods that do not require further cooking. Record review of the facility policy, titled Dietary Services Policy and Procedure Manual 2012, IC00-1.0, revealed the following documentation, Infection Control. We will ensure that all employees practice infection control in the dietary service department and maintain sanitary food preparation. All dietary service employees will follow infection control policies as established and approved by the infection control committee. Procedure . 2. Careful handwashing by personnel will be done in the following situation. b. Between handling of soiled dishes, boxes, or equipment and handling clean food or utensils . e. After each instance of coughing, sneezing, touching face and/or hair . 5. Equipment Sanitation. a. All kitchenware and food contact used in the preparation and/or service serving of food are cleaned and sanitized before use and cleaned after each meal preparation. Sanitizing agents are used for cleaning all surfaces. b. After cleaning, equipment and utensils are stored so as to prevent contamination. 6. Food Preparation . c . There shall be no bare hand to food contact . 8. Sanitation of Food Preparation surfaces. a. All kitchen ware and food contact surfaces will be cleaned and sanitized after each use . d. Each dietary employee must be instructed on how to properly use and test the sanitizing solution. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 31 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 e. Random checks testing the PPM are to be done by the Dietary Service Manager. Level of Harm - Minimal harm or potential for actual harm Record review of the facility guidance document dated 2014, revealed the following documentation, Training, Staff on Puréed Foods . Residents Affected - Many 6. The food processor must be washed and sanitized before you purée the next food, and between each food thereafter. You must also allow some time for it to air dry and be sure there is no water inside when you begin to use it again FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 32 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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, interview and record review, the facility failed to 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 1 of 16 residents (Residents #32) and 1 of 1 staff (CMA A) reviewed for infection control. Residents Affected - Some 1. CMA A failed to properly clean multi-use equipment between each resident. 2. CNA A failed to perform hand hygiene between glove changes when providing wound care for Resident #32. These failures could place residents at risk for spread of infection and cross contamination during incontinent care and medication administration. Findings include: 1. During an observation of medication pass on 08/02/23 at 08:59 AM revealed CMA A took a wrist blood pressure device into resident #21's room and took his blood pressure on his right wrist. She then took the wrist blood pressure device and placed it on top of the medication cart. She prepared medications for Resident #9 and took the wrist blood pressure device to resident #9 who were outside smoking and took his blood pressure on right wrist. She took the wrist blood pressure device and placed on top of medication cart. She picked up the wrist blood pressure device off top of medication cart and went to resident #136 room and took his blood pressure on the right wrist. She then took wrist blood pressure device back to medication cart and placed it on top of cart . No observation of CMA A sanitizing the blood pressure device. During an interview on 08/02/23 at 11:44 AM with CMA A, she stated she did not clean the wrist blood pressure device between each resident. She stated she forgot. She stated there was no cleaning wipes on her medication cart and she was going to replace them but forgot. She stated the wrist blood pressure device was to be cleaned between each resident. She stated the potential negative outcome could be the transfer of germs between residents. She stated she was trained to clean the blood pressure device between residents. During an interview on 08/03/23 at 10:20 AM with the DON, she stated multi use equipment should be cleaned between each resident. She stated staff were trained to clean multi-use equipment. She stated they had Santi wipes or soap and water to clean equipment. She stated the potential negative outcome would be passing communicable diseases to each other, make someone sick or death. During an interview on 08/03/23 at 12:10 PM with the ADM, she stated multi-use equipment should be cleaned between each resident use. She stated the equipment should be cleaned with Santi-wipes. She stated the potential negative outcome could be spread of infectious disease. Record review of the facility's policy titled Fundamentals of Infection Control Precautions, dated 2018, revealed: . 6. Resident care equipment and articles . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 33 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 3. Non-invasive care equipment is cleaned daily or as need between use by the nursing assistant Level of Harm - Minimal harm or potential for actual harm 2. Record review of Resident #32's, undated, face sheet, reflected a [AGE] year-old-female who was admitted to the facility on [DATE] with diagnosis which included anxiety (feeling of fear, dread and uneasiness) , dysphagia (swallowing difficulties), depression (sadness and a loss of intrest), hypertension (high blood pressure) and chronic obstructive pulmonary disease (lung disease). Residents Affected - Some Record review of Resident #32's Comprehensive Minimum Data Set, dated [DATE], revealed she was cognitively intact. She required extensive assistance of one person for bed mobility, dressing and personal hygiene. She required total assistance with two-person assistance for transfers, and toilet use. Resident #32 was always incontinent of bowel and bladder. Record review of Resident #16's Comprehensive Care Plan, dated 05/30/23, revealed the resident had bladder and bowel incontinence and was provided incontinent care at least every 2 hours or assisted with toileting as needed. During an observation of incontinent care on 08/02/23 at 10:00 AM, CNA A provided incontinent care for Resident #32. CNA A cleaned the resident front side handing used wipes to CNA B. CNA B placed used wipes in a trash bag on the bed. After cleaning the front side, CNA A doffed gloves and donned new gloves and turned Resident #32 onto her side. CNA A cleaned the back side area handing used wipes to CNA B to throw in trash bag on bed. CNA A removed the soiled brief and doffed gloves and donned new gloves. CNA A handed clean brief to CNA B and CNA B held brief with dirty gloved hand. CNA B handed clean brief to CNA A and she placed brief under resident and completed incontinent care. CNA B doffed gloves and took trash down the hall to the yellow bin. CNA B went to the linen cart and touched several items on the bottom shelf. CNA B then pushed the yellow bin down the hall to CNA A. CNA B was then headed into a room across the hall when CNA A intervened and told CNA B to wash her hands . CNA B observed washing her hands after intervention. During an interview on 08/02/23 at 11:50 AM with CNA B, she stated she did not wash her hands after doffing gloves and should have. She stated she also contaminated the clean brief by touching it with the dirty glove. She stated she had been trained on incontinent care, handwashing and infection control. She stated she should have washed hands after glove changes and before touching clean brief. She stated she got nervous and forgot. She stated the potential negative outcome could be cross contamination . During an interview on 08/02/23 at 02:02 PM with CNA A, she stated she did not wash her hands between glove changes because she forgot. She stated she should have washed her hands between glove changes. She stated she was trained on proper incontinent care, handwashing and infection control. She stated the potential negative outcome could be cross contamination and spreading infection. During an interview on 08/03/23 at 10:20 AM with the DON, she stated her expectations during incontinent care was for CNA's to wash their hands between glove changes. She stated she monitored and trained the CNA's skills competences annually. She stated she was responsible for monitoring CNA's to ensure they were following infection control. She stated handwashing was monitored monthly and incontinent care was monitored annually and as needed. She stated there was no reason why any staff would be exempt from handwashing. She stated all staff were trained on handwashing and infection control. During an interview on 08/03/23 at 12:10 PM with the ADM, she stated hands should be washed after each glove change. She stated the DON/ADON monitored skills competences annually and handwashing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 34 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 - Some monthly. She stated the infection preventionist, ADM and DON/ADON were responsible for monitoring staff to ensure they were following proper infection control. She stated the DON/ADON monitored CNA's for proper incontinent care and infection control. She stated there was no reason any staff would be exempt from handwashing. Record review CNA Proficiency Audit provided by the facility, dated 01/20/23, for CNA B reflected skills completed in handwashing and incontinent care. Record review the Post-Test Infection Control and Universal Precautions provided by the facility dated 1/26/23 for CNA B revealed education on infection control and universal precautions. Record review CNA Proficiency Audit provided by the facility, dated 03/21/23, for CNA A , reflected skills completed in handwashing and incontinent care. Record review of the facility's policy titled Perineal Care, dated 5/11/22, reflected: Procedure Content . 10) perform hand hygiene 11) [NAME] gloves . 24) Doff gloves and PPE 25) Perform hand hygiene . 30) tie off the disposable plastic bag of trash and/or linen 31) Perform hand hygiene . Important points . Always perform hand hygiene before and after glove use FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 35 of 36 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 675496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slaton Care Center 630 S 19th Slaton, TX 79364 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure resident bedrooms measured at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms for 1 of 61 semiprivate rooms (room [ROOM NUMBER]) reviewed for useable living space. The facility failed to ensure Room # 7 (a semi-private room) provided 80 square feet per resident. The square footage was 153 instead of 160 square feet. This failure could place residents at risk of crowding in resident rooms and cause difficulty in providing resident care. The findings include: Observation on 8/02/23 at 10:37 AM of room [ROOM NUMBER] revealed the room measured 153 square feet instead of the 160 square feet for a semi-private room for 2 residents. Interview on 8/2/23 at 5:45 PM, the Administrator stated she wanted to apply for the room waiver for room seven. Interview on 8/3/23 at 12:57 PM with the Administrator revealed the result could be inadequate space, quality of life and depression, if residents had inadequate room square footage. Interview on 8/3/23 at 2:16 PM, with the Regional Compliance Nurse revealed the facility had no policy related to room square footage. Record review of current CASPER 3 report, dated 7/26/23, during preparation for survey revealed a waiver for room size requirements was granted on 6/22/22. Record review of Texas Health and Human Services Form 3740 (Bed Classifications [Numbers and Location]) dated 8/03/23, documented room [ROOM NUMBER] was listed as a Title 18 bed classification semiprivate room for two residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675496 If continuation sheet Page 36 of 36