Health inspection·November 30, 2022

F 0550 stated all CNAs and nurses knew to knock on the door for dignity and respect. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/30/2022 at 9:00 a.m., CNA N stated she did not make it a habit of not knocking on the door when she entered the resident's rooms. CNA N stated she knew to knock because this was the home of the residents. CNA N stated she was trained to knock on the door to provide respect for the residents. CNA N stated she just was not thinking when she entered the room without knocking. Residents Affected - Some During an interview on 11/30/2022 at 9:20 a.m., the MDS Coordinator stated she was busy talking to a resident and opened the door to the room without knocking to let Resident #23's roommate into the room. The MDS Coordinator stated it was important to knock before entering to not infringe on the residents right to privacy. The MDS Coordinator stated she knew to knock and normally did knock before entering the resident's room. The MDS Coordinator stated Resident #23 was not oriented and more than likely did not know someone was in the room. During an interview on 11/30/2022 at 1:15 p.m., the DON stated it was not acceptable to not knock on the door of any resident before entering. The DON stated any reasonable person would not agree to people entering their homes without knocking. The DON stated the staff had already been in serviced about the incident of not knocking that occurred this morning. During an interview on 11/30/2022 at 4:15 p.m., the Administrator stated the facility was the resident's home and all the doors should be knocked on prior to entering. The Administrator stated it was the resident's right to have privacy and the CNAs were trained in orientation to knock before entering the room. The Administrator stated it could make a resident anxious and make them feel unsafe if they did not feel their privacy was respected. 2. Record review of Resident #4's face sheet, dated 11/28/22, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included need for assistance with personal care, muscle weakness (a lack of strength in the muscles) and depressive disorder (a persistent feeling of sadness and loss of interest). Record review of the annual MDS, dated [DATE], revealed Resident #4 was usually understood and usually understood others. The MDS revealed Resident #4 had a BIMS of 15, which indicated intact cognition and the resident required extensive assistance for bed mobility, dressing, personal hygiene, toilet use and bathing. Record review of Resident #4's care plan, dated 11/16/22, revealed potential for decline in ADL function related to refusal in get out of bed and minimal movements. Interventions included bed mobility assist x 1-2 (uses trapeze bar to assist with mobility), personal hygiene assist x1, toilet assist x 1-2 and maintain dignity and provide privacy while providing care. Record review of Resident #4's complainant statement, dated 11/01/22, revealed I needed my bed changed. I asked [CNA E] to change me, and she had [CNA F] come to assist her. [CNA F] stated, 'We [CNA F and CNA E] aren't going to change you, you were just changed.' I said if you aren't going to do it then let CNA E .I feel like my right and body were violated. Record review of CNA E's witness statement, dated 11/01/22, revealed [Resident #4] wanted his sheets and shirt changed. I asked [CNA F] to help me change him. She stated she just changed him like 30 minutes ago. [CNA F] told me that the sheets didn't need to be changed but [Resident #4] said that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 2 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 0550 they did. [Resident #4] started cussing at her [CNA F] about this . Level of Harm - Minimal harm or potential for actual harm Record review of CNA F's witness statement, dated 11/01/22, revealed . [CNA E] asked me to help her change [Resident #4]. I had just changed him less than 30 minutes prior to this request . Residents Affected - Some During an interview on 11/28/22 at 10:29 a.m., Resident #4 said earlier this month (November) an incident happened with CNA's E and F and he was upset about how he was treated. He said he asked CNA E to change his sheet and when she went to get CNA F, she told him he did not need to be changed. He said being contradicted made him mad because he was in his right mind. He said some of the CNAs do not treat the residents with dignity and respect. During an interview on 11/30/22 at 11:53 a.m., CNA E said she was a witness to the incident between Resident #4 and CNA F. She said she asked CNA F for assistance and in front of Resident #4, told him he did not need to be changed. She said the incident became tense after CNA F contradiction. She said Resident #4 got upset and frustrated with CNA F. She said it was Resident #4's right to be changed and his sheets did need to be changed. She said CNA F should not have contradicted Resident #4. During an interview on 11/30/22 at 3:30 p.m., CNA F said she was involved in the incident with Resident #4. She said she should not have contradicted Resident #4 request to be changed. She said in doing so she probably hurt his dignity. She said hurting his dignity caused him to become angry and escalated the situation. She said contradicting Resident #4 asking for assistance could cause him to not ask for help when he should and could cause injuries. During an interview on 11/30/22 at 4:10 p.m., the DON said she expected the nursing staff to check residents when they asked to be changed. She said she expected the nursing staff to not tell the residents they did not need to be changed. She said contradicting the resident could make the resident feel unimportant and probably hurt Resident #4's dignity. She said hurting Resident #4's dignity could cause depression which could lead to malnutrition, loss of sleep and decreased desire in wanting to do things. During an interview on 11/30/22 at 4:40 p.m., the ADM said he did not approve of staff telling residents they did not need to be changed when the resident asked for assistance. He said he talked to CNA F about her inappropriate comment. He said her comment was a breach of Resident #4's dignity. She said hurting his dignity could have made Resident #4 question if his cognition was impaired or inaccurate. Record review of the facility's, undated, policy titled Quality of Life-Dignity revealed .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .Resident shall be groomed as they wish to be groomed Residents' private space and property shall be respected at all times. Staff will knock and request permission before entering residents' rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 3 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure notice was provided to residents, as soon as was possible, where changes in coverage were made to items and services by Medicare and/or by the Medicaid State plan, for 1 of 3 residents (Resident #11) who were provided skilled Medicare services, were discharged from services, and remained in the facility. Residents Affected - Few The facility failed to ensure Resident #11 was given a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk of not being aware of changes to provided services. The findings were: Record review of Resident #11's face sheet, dated 11/28/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses which included stroke (damage to the brain from interruption of its blood supply, diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired), and need for assistance with personal care . Record review of Resident #11's MDS, dated [DATE], indicated Resident #11 was usually understood and sometimes understands others. Resident #11 had a BIMS of 09, which indicated moderate impaired cognition. Resident #11 required supervision to extensive assistance with ADLs. Record review for Resident #11 revealed the Notice of Medicare Non-Coverage (NOMNC) had been initiated on 6/16/2022 with the effective end date of coverage being 06/20/2022, this document was signed by Resident #11, however it was revealed a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) was not completed which would have informed Resident #11 of the option to continue services at the risk of out-of-pocket cost. During an interview on 11/29/2022 at 9:45 a.m., the MDS Coordinator said she had never issued ABN letters to any residents. She said she was under the impression ABN letters were for notification when a resident would no longer receive skilled care. She said Resident #11 was no longer receiving skilled care because she had met her goals with therapy. She said she was under the impression a NOMNC letter was the notification that Part A was ending, and the skilled care was ending for Resident #11 . During an interview on 11/29/2022 at 11:00 a.m., the Administrator said the facility did not have a policy concerning notification of ending Part A Benefits or ABN/NOMNC letters . During an interview on 11/30/2022 at 12:04 p.m., the DON said she had nothing to do with issuing ABN letters. She said this was the MDS Coordinator's responsibility. During an interview on 11/30/2022 at 3:09 p.m., the Administrator said it is the responsibility of the MDS Coordinator to issue ABN letters to residents. He said he would have expected Resident #11 to have been notified by ABN letter that her part A benefits were ending . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 4 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of CMS guidelines Beneficiary Notice Guidelines, approved by CMS-10124-DENC December 31, 2011, revealed Scenario Part A stay will end because: SNF (Skilled Nursing Facility) determines the beneficiary no longer requires daily skilled services. Resident has days remaining in the benefit period. Resident will remain in the facility (custodial care) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) CMS-10055 (2018) and Notice of Medicare Non-Coverage (NOMNC) CMS-10123 (12/31/11)) to be completed. Event ID: Facility ID: 675755 If continuation sheet Page 5 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all alleged violations involving of mistreatment, neglect, abuse, or misappropriation of resident property were reported immediately, but not later than 24 hours after the allegation was made to other officials (including to the State Agency) for 3 of 13 residents (Resident #2, Resident#13, and Resident #21) reviewed for abuse and neglect. The facility failed to report alleged violations to State Agency reported from Resident #2, Resident #13, and Resident #21 during a safe survey. This failure could place residents at risk for continued alleged violations, diminished quality of life and harm. Findings included: Record review of the facility's, undated, Abuse Investigation and Reporting policy revealed all reports of resident abuse, neglect .shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management .role of the administrator .if an incident or suspected incident of resident abuse, mistreatment, neglect .the Administrator will assign the investigation to an appropriate individual .the administrator will endure that any further potential abuse, neglect, exploitation, or mistreatment is prevented .the individual conducting the investigation will, as a minimum .review the completed documentation forms, review the resident's medical record to determine events leading up to the incident, interview the person reporting the incident, interview any witness to the incident, interview the resident as medically appropriate 1. Record review Resident #2's face sheet, dated 11/8/22, revealed Resident #2 was [AGE] year old female who was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and muscle weakness. Record review of the quarterly MDS, dated [DATE], revealed Resident #2 was understood and understood others. The MDS revealed Resident #2 had a BIMS of 15, which indicated intact cognition and required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene but total dependence for transfers. Record review of Resident #2's care plan, dated 10/12/22, revealed the resident required extensive assistance of total dependence related to hemiplegia with most ADLs. Interventions included maintain dignity and provide privacy while providing care. 2. Record review of Resident #13's face sheet, dated 11/30/22, revealed Resident #13 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included multiple sclerosis (is a disease that impacts the brain, spinal cord and optic nerves, which make up the central nervous system and controls everything we do) and recurrent depressive disorder (depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of the quarterly MDS, dated [DATE], revealed Resident #13 was usually understood and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 6 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some usually understood others. The MDS revealed Resident #13 had BIMS of 06, which indicated severe cognitive impairment. Resident #13 required limited assistance for transfers, extensive assistance for bed mobility, dressing, toilet use and personal hygiene but total dependence for bathing. Record review of Resident #13's care plan, dated 10/12/22, revealed need for assistance with ADLs related to multiple sclerosis as evidence by weakness and debility (physical weakness, especially as a result of illness). Interventions included maintain dignity and provide privacy while providing care. 3. Record review of Resident #21's face sheet, dated 11/29/22, revealed Resident #21 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #21 had diagnoses which included Alzheimer's disease (is a type of dementia that affects memory, thinking and behavior), depressive disorder (is a mood disorder that causes a persistent feeling of sadness and loss of interest), and primary osteoarthritis (breakdown of cartilage in the joint. As the cartilage wears down, the bone ends may thicken and form bony growths [spurs]). Record review of the quarterly MDS, dated [DATE], revealed Resident #21 was understood and understood others. The MDS revealed Resident #21 had a BIMS of 09, which indicated mild cognitive impairment and only required supervision for bathing and walking in room and corridor. Record review of Resident #21's care plan, dated 09/21/22, revealed a diagnosis of unspecified recurrent depressive disorder. Interventions included encourage to verbalize feelings, concerns, fears, etc. Clarify misconceptions. Record review of an undated resident Safe Survey Questionnaire completed by the ADM revealed the following: *1. Does staff treat the resident with dignity and respect? If no, tell me some examples. A question mark was placed for Resident #2 and yes was answered for Resident #13 and Resident #21. *2. Have you ever seen another staff member treat a resident roughly? If yes, Who, When and What happened? Resident #2 and Resident #13 answered yes. Resident #2 said she reported it and Resident #13 said he had not reported it to somebody. *3. Have you ever seen a staff member yell or be rude to a resident? If yes, Who, When and What happened? Resident #2 and Resident #13 answered yes. Resident #2 said she reported it and Resident #13 said he had not reported it to somebody. Record review of an undated, Resident list associated with Safe Survey revealed the following: 1. Does staff treat the resident with dignity and respect? If no, tell me some examples. [Resident #2] said sometimes but not always . 2. Have you ever seen another staff member treat a resident roughly? If yes, Who, When and What happened? [Resident#2] said sometimes staff are too rough with her, saying she's too fat . 3. Have you ever seen a staff member yell or be rude to a resident? If yes, Who, When and What happened? [Resident#2] said to herself and others (i.e. Staff member yelled at a resident in the dining room, she told the old ADM's husband, who also was an ADM .) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 7 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 0609 Level of Harm - Minimal harm or potential for actual harm 2. Have you ever seen another staff member treat a resident roughly? If yes, Who, When and What happened? [Resident #13] said has been treated verbally roughly by a CNA on night shift . 4. Does staff treat the resident with dignity and respect? If no, tell me some examples. [Resident #21] said CNA J was very ugly to her one day in the shower but hasn't been that way since the one time. Residents Affected - Some During an interview on 11/28/22 at 1:00 p.m., the ADM said he performed the safe survey after Resident #4 reported CNA F being rough. He said during the safe survey Resident #2, Resident #13 and Resident #21 did make allegations against staff members and CNA J. He said he did not investigate the allegation because the allegations were not part of Resident #4's incident. He said after the safe survey, he had an informal customer service conservation with all the staff. He said he did not directly coach or question CNA J about Resident #21's allegation because he was afraid CNA J could treat her differently. He said he did not ask Resident #21 if she minded him directly mentioning her allegation when he spoke with CNA J. He said he did not feel CNAs constantly spoke or made Resident #2 feel bad or fat. During an interview on 11/30/22 at 4:10 p.m., the DON said safe survey were performed to make sure other residents were not experiencing the same problems but not reporting it. She said if allegations were reported during a safe survey, the allegation needed to be investigated and possible reported to the state. She said it was called a safe survey to ensure the safety of the residents. She said the ADM or designee investigated allegations of abuse and all staff are required to report abuse to the abuse coordinator. During an interview on 11/30/22 at 4:40 p.m., the ADM said if a resident told him about any of the mentioned allegation from Resident #2, Resident 13, and Resident #21, he would call the alleged perpetrator and start the investigation process. He said depending on the alleged allegation, he would do the investigation then decide if the incident needed to be reported to the State. He said sometimes the boundaries between resident and staff got blurred and crossed, primarily verbally due to familiarity. He said he probably should have investigated and possible reported all the allegations mentioned on the safe survey. He said he was the abuse coordinator, so it was his responsibility to investigate, and report alleged allegations. He said investigating and reporting alleged allegations created a safe environment and prevented the allegation from continuing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 8 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure all allegations of abuse, neglect, exploitation, or mistreatment had evidence that all alleged violations were thoroughly investigated for 3 of 13 residents (Residents #2, #13 and #21) reviewed for abuse and neglect. Residents Affected - Some The facility failed to investigate alleged violations reported from Resident #2, Resident #13 and Resident #21 during a safe survey. This failure could place residents at risk for continued alleged violations, diminished quality of life and harm. Findings include: 1. Record review Resident #2's face sheet, dated 11/8/22, revealed Resident #2 was [AGE] year old female who was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and muscle weakness. Record review of the quarterly MDS, dated [DATE], revealed Resident #2 was understood and understood others. The MDS revealed Resident #2 had a BIMS of 15, which indicated intact cognition and required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene but total dependence for transfers. Record review of Resident #2's care plan, dated 10/12/22, revealed the resident required extensive assistance of total dependence related to hemiplegia with most ADLs. Interventions included maintain dignity and provide privacy while providing care. 2. Record review of Resident #13's face sheet, dated 11/30/22, revealed Resident #13 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included multiple sclerosis (is a disease that impacts the brain, spinal cord and optic nerves, which make up the central nervous system and controls everything we do) and recurrent depressive disorder (depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of the quarterly MDS, dated [DATE], revealed Resident #13 was usually understood and usually understood others. The MDS revealed Resident #13 had BIMS of 06, which indicated severe cognitive impairment. Resident #13 required limited assistance for transfers, extensive assistance for bed mobility, dressing, toilet use and personal hygiene but total dependence for bathing. Record review of Resident #13's care plan, dated 10/12/22, revealed need for assistance with ADLs related to multiple sclerosis as evidence by weakness and debility (physical weakness, especially as a result of illness). Interventions included maintain dignity and provide privacy while providing care. 3. Record review of Resident #21's face sheet, dated 11/29/22, revealed Resident #21 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #21 had diagnoses which included Alzheimer's disease (is a type of dementia that affects memory, thinking and behavior), depressive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 9 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some disorder (is a mood disorder that causes a persistent feeling of sadness and loss of interest), and primary osteoarthritis (breakdown of cartilage in the joint. As the cartilage wears down, the bone ends may thicken and form bony growths [spurs]). Record review of the quarterly MDS, dated [DATE], revealed Resident #21 was understood and understood others. The MDS revealed Resident #21 had a BIMS of 09, which indicated mild cognitive impairment and only required supervision for bathing and walking in room and corridor. Record review of Resident #21's care plan, dated 09/21/22, revealed a diagnosis of unspecified recurrent depressive disorder. Interventions included encourage to verbalize feelings, concerns, fears, etc. Clarify misconceptions. Record review of an undated resident Safe Survey Questionnaire completed by the ADM revealed the following: *1. Does staff treat the resident with dignity and respect? If no, tell me some examples. A question mark was placed for Resident #2 and yes was answered for Resident #13 and Resident #21. *2. Have you ever seen another staff member treat a resident roughly? If yes, Who, When and What happened? Resident #2 and Resident #13 answered yes. Resident #2 said she reported it and Resident #13 said he had not reported it to somebody. *3. Have you ever seen a staff member yell or be rude to a resident? If yes, Who, When and What happened? Resident #2 and Resident #13 answered yes. Resident #2 said she reported it and Resident #13 said he had not reported it to somebody. Record review of an undated, Resident list associated with Safe Survey revealed the following: 1. Does staff treat the resident with dignity and respect? If no, tell me some examples. [Resident #2] said sometimes but not always . 2. Have you ever seen another staff member treat a resident roughly? If yes, Who, When and What happened? [Resident#2] said sometimes staff are too rough with her, saying she's too fat . 3. Have you ever seen a staff member yell or be rude to a resident? If yes, Who, When and What happened? [Resident#2] said to herself and others (i.e. Staff member yelled at a resident in the dining room, she told the old ADM's husband, who also was an ADM .) 2. Have you ever seen another staff member treat a resident roughly? If yes, Who, When and What happened? [Resident #13] said has been treated verbally roughly by a CNA on night shift . 4. Does staff treat the resident with dignity and respect? If no, tell me some examples. [Resident #21] said CNA J was very ugly to her one day in the shower but hasn't been that way since the one time. During an interview on 11/28/22 at 1:00 p.m., the ADM said he performed the safe survey after Resident #4 reported CNA F being rough. He said during the safe survey Resident #2, Resident #13 and Resident #21 did make allegations against staff members and CNA J. He said he did not investigate the allegation because the allegations were not part of Resident #4's incident. He said after the safe (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 10 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some survey, he had an informal customer service conservation with all the staff. He said he did not directly coach or question CNA J about Resident #21's allegation because he was afraid CNA J could treat her differently. He said he did not ask Resident #21 if she minded him directly mentioning her allegation when he spoke with CNA J. He said he did not feel CNAs constantly spoke or made Resident #2 feel bad or fat. During an interview on 11/30/22 at 4:10 p.m., the DON said safe survey were performed to make sure other residents were not experiencing the same problems but not reporting it. She said if allegations were reported during a safe survey, the allegation needed to be investigated and possible reported to the state. She said it was called a safe survey to ensure the safety of the residents. She said the ADM or designee investigated allegations of abuse and all staff are required to report abuse to the abuse coordinator. During an interview on 11/30/22 at 4:40 p.m., the ADM said if a resident told him about any of the mentioned allegation from Resident #2, Resident 13, and Resident #21, he would call the alleged perpetrator and start the investigation process. He said depending on the alleged allegation, he would do the investigation then decide if the incident needed to be reported to the State. He said sometimes the boundaries between resident and staff got blurred and crossed, primarily verbally due to familiarity. He said he probably should have investigated all the allegations mentioned on the safe survey. He said he was the abuse coordinator, so it was his responsibility to investigate alleged allegations. He said investigating alleged allegations created a safe environment and prevented the allegation from continuing. Record review of the facility's, undated, Abuse Investigation and Reporting policy revealed all reports of resident abuse, neglect .shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management .role of the administrator .if an incident or suspected incident of resident abuse, mistreatment, neglect .the Administrator will assign the investigation to an appropriate individual .the administrator will endure that any further potential abuse, neglect, exploitation, or mistreatment is prevented .the individual conducting the investigation will, as a minimum .review the completed documentation forms, review the resident's medical record to determine events leading up to the incident, interview the person reporting the incident, interview any witness to the incident, interview the resident as medically appropriate FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 11 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 13 residents (Resident #4) reviewed for accuracy of assessments. Residents Affected - Few The facility failed to code Resident #4's use of oxygen on his MDS. This failure could place residents at risk of not having individual needs met. Findings include: Record review of Resident #4's face sheet, dated 11/28/22, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (diseases that cause airflow blockage and breathing-related problems) and acute respiratory failure with hypoxia (don't have enough oxygen in your blood). Record review of the Resident #4's consolidated physician orders, dated 10/28/22-11/28/22, revealed oxygen at 2 liters via nasal cannula, twice daily (6:00 a.m.-6:00 p.m. and 6:00 p.m.-6:00 a.m.) ordered 02/11/22. Record review of Resident #4's MAR, dated 11/05/22 -11/11/22, revealed oxygen at 2 liters via nasal cannula, twice daily (6:00 a.m.-6:00 p.m. and 6:00 p.m.-6:00 a.m.) ordered 02/11/22 with oxygen saturation (is the amount of oxygen you have circulating in your blood) documented. Record review of the annual MDS, dated [DATE], revealed Resident #4 was usually understood and usually understood others. Resident #4 had a BIMS of 15, which indicated intact cognition. The resident required extensive assistance for bed mobility, dressing, personal hygiene, toilet use and bathing. The MDS did not document the use of oxygen while a resident. Record review of Resident #4's care plan, dated 11/16/22, revealed use of oxygen as needed for COPD (chronic obstructive pulmonary disease) and history of COVID Pneumonia (is a lung infection caused by SARS CoV-2, the virus that causes COVID-19. It causes fluid and inflammation in your lungs). Interventions included administer oxygen as ordered and ensure supply was always available. During an observation on 11/28/22 at 10:29 a.m., Resident #4 was laying in his bed with a nasal cannula on his face. The oxygen concentrator flow meter read 2.5 liters with a water filled reservoir. During an observation on 11/29/22 at 11:26 a.m., Resident #4 was laying in his bed with a nasal cannula on his face. The oxygen concentrator flow meter read 2.5 liters with a water filled reservoir. During an interview on 11/30/22 at 11:48 a.m., the MDS Coordinator said she was responsible for the accuracy of MDS's. She said she looked at progress notes and MAR's to gather information to complete the MDS. She said she looked 7 days prior to the completion of the MDS. She said she looked at Resident #4 progress notes and did not see documentation of oxygen use. She said she thought she looked at the MAR but after reviewing it again, she missed the oxygen saturation documented on the MAR. She said an inaccurate assessment could affect the resident care and services provided by the facility. She said inaccurate MDS information could be transferred to the resident's care plan, causing an inaccurate care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 12 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview with the Administrator on 11/30/2022 at 1:03 p.m., the Administrator said a policy for accuracy of assessment was not available. During an interview on 11/30/22 at 4:10 p.m., the DON said the MDS Coordinator was responsible for the accuracy of MDS's. She said she expected the coordinator to review all documents to obtain her assessment for the MDS. She said the MDS assessed important aspects of the resident and presented a medical picture of the resident. She said an inaccurate assessment could cause inaccurate care or services provided to the resident. She said it was important to maintain or improve a resident's quality of life and care. Event ID: Facility ID: 675755 If continuation sheet Page 13 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C, to the maximum extent practicable to avoid duplicative testing and effort and coordination which included incorporating the recommendations from a PASARR (level II determination and the PASARR evaluation report into a resident assessment, care planning, and transitions of care for 1 of 5 residents (Resident #11) reviewed for PASARR services. 1. The facility failed to implement any services recommended from the PASARR Evaluation, dated 9/1/2021. 2. The facility failed to hold an annual Interdisciplinary Team (IDT) meeting with the local mental health authority for Resident #11. These failures could place residents at risk of not receiving specialized PASARR services which would enhance their highest level of functioning and could contribute to residents' decline in physical, mental and psychosocial well-being. Findings include: Record Review of Resident #11' s face sheet, dated 11/28/2022, revealed the resident was a [AGE] year-old female and was admitted to the facility on [DATE] with diagnoses which included stroke (damage to the brain from interruption of its blood supply) , other recurrent depressive disorders (periods of depression), and bipolar disorder , current manic severe with psychotic features (a disorder characterized by periods of depression and periods of depression and periods of abnormally elevated mood associated with psychosis.) Record Review of Resident #11's MDS , dated 09/06/2022, indicated Resident #11 was usually understood and sometimes understands. Resident #11 had a BIMS of 09, which indicated moderate impaired cognition. Resident #11 required supervision to extensive assistance with ADLs. Record review of Resident #11's care plan, dated 09/14/2022, did not indicate Resident #11 received PASARR services for PASARR positive diagnosis of mental illness. Record review of a Pre-admission Screening and Resident Review (PASARR) Evaluation Summary report concerning Resident #11, dated 9/1/2022, indicated, Section IV, Recommended MI (mental illness) Specialized Services .Individual Skills Training Record review of Resident #11's PASARR Evaluation, dated 9/1/2021, indicated the evaluator was the PASARR Manager. The evaluation indicated Resident #11 met the PASARR definition of mental illness. The evaluation indicated specialized services determination/recommendations of self-monitoring of medications, self-monitoring of nutritional services, and individual skills training. Record review of Resident #11's electronic medical record did not indicate the resident received any of the recommended services or any form of counseling for her mental illness. There was no indication of Resident #11 refusing any services or counseling. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 14 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 0644 Level of Harm - Minimal harm or potential for actual harm Record review of an Informational Note concerning Resident #11, dated 12/21/2021, and was provided by the PASARR Manager, with the mental health local authority indicated, .spoke with [Resident #11's] RN who reports that she has a medication provider prescriber for her medications .she has access to counseling through Deer Oaks Notes from the IDT meeting held in September 2021 were requested from the PASARR Manager with the local mental health authority and were not received prior to exit. Residents Affected - Few During an interview on 11/29/2022 at 2:15 p.m., the MDS Coordinator said Resident #11 was PASARR positive. She said there was no documentation of any of the recommendations made on the PASARR Evaluation, dated 9/1/2021, being implemented into the care of Resident #11. She said there had not been an IDT (Interdisciplinary team) meeting since 9/2021. She said she had no idea if any of the services (Individual skills training, self-monitoring of medications, self-monitoring of nutritional status) were being provided because she had not heard from the PASARR Manager since 9/2021. She said the PASARR Manager was responsible for implementing any recommendations made during the PASARR Evaluation, dated 9/1/2021. During an interview on 11/30/2022 at 9:44 a.m., the MDS Coordinator said herself and therapy were the only ones involved in quarterly PASARR IDT meetings. She said if it was an annual meeting an RN attended, and this was usually the DON. She said IDT meetings were supposed to be held quarterly. She said the reason Resident #11 had not had a meeting in over a year was because the PASARR Manager with the local mental health authority had not set up a meeting. She said she had reached out to the PASARR Manager and had not had a response from her. She said she had not reached out to anyone else to try to set up a meeting. She said it was not her job to implement any services recommended during a PASARR IDT meeting. She said they had two contacts with the local mental health authority and as far as she knew it was their job to implement the services recommended. She said Resident #11 had been evaluated by the PASARR Manager. She said recommended services not being implemented could cause a resident to not receive the care they needed. During an interview on 11/30/22 at 10:40 a.m., the PASARR Manager, with the local mental health authority, said the last IDT meeting for Resident #11 was held in September 2021 and there had not been a meeting since. She said Resident #11 was due for her annual meeting at this time. She said recommended services were implemented with routine case management. She said the case manager would come out once a month to re-evaluate the resident and make sure her needs were being met. She said if the needs were being met the case manager would not visit again after 90 days. She said there were notes from 12/2021 where a case manager contacted the facility. She said a nurse 's note said the resident had access to Deer Oaks for counseling. She said the last time a case manager contacted the resident was in February 2022 and they felt all of her needs were being met. She said individual skills training was not the same thing as occupational therapy. She said the individual skills training and other recommendations were not agreed upon at the IDT meeting in September 2021. She said counseling for the resident's mental illness was not recommended during the PASARR Evaluation because she was under the impression, she was receiving counseling through the facility. She said the last contact with the resident was February 2022 and there were no issues and the resident told them she was receiving counseling at the facility. During an interview on 11/30/2022 at 12:04 p.m., the DON said the MDS Coordinator was responsible for making sure PASARR recommended services were implemented. She said there were annual and quarterly IDT meetings. She said she would have expected there to have been IDT meetings since September 2021 for Resident #11. She said the local authority, therapy, a family member and the MDS Coordinator attended the quarterly and annual IDT meetings. The DON said she attended all annual meetings. She said she did not know why there had not been any IDT meetings over this last year. She said she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 15 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few thought Resident #11 was receiving counseling. After checking documentation, she said Resident #11 had not received any counseling services. During an interview on 11/30/2022 at 2:52 p.m., a Licensed Psychologist with Deer Oaks said she was called on 11/20/2022 to see Resident #11 and she was able to come to the facility to evaluate the resident. She said she was told the resident refused to be evaluated after she was released from a behavioral facility in December 2020. She said she had never received a referral because the resident was not giving her consent. She said after the evaluation on 11/30/2022 she felt the resident was unable to give an informed consent because of her mental status. She said after the initial assessment she planned to see the resident for a session or two. She said she did normally see PASARR positive residents. She said anyone the facility felt needed to be seen, she would come to the facility and evaluate them a few times. She said this was the first time she saw the resident and could not say if she would have benefited from counseling over the last two years. During an interview on 11/30/2022 at 3:09 p.m., the Administrator said the DON was responsible for making sure PASARR recommended services were implemented for PASARR positive residents. He said there should be monthly IDT PASARR meetings for each PASARR positive resident. He said he would have expected Resident #11 to have had an IDT meeting since the last one was in September 2021. During an interview with the Administrator on 11/30/2022 at 1:03 p.m., the Administrator said a policy for specialized PASARR services was available. Record review of the Detailed Item by Item Guide for Completing the Authorization Request for PASRR Nursing Facility Specialized Services (NFSS) Form, from the Texas Health and Human Services Commission, dated April 30, 2021, revealed . The nursing facility has 20 business days from the date of the initial IDT or a specialized service review meeting to initiate all PASRR nursing facility specialized services (NFSS) for those with a positive PE for ID/DD recommended and agreed to at the meeting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 16 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 13 residents (Resident #22) reviewed for PASRR Level I screenings. Residents Affected - Few The facility failed to review Resident #22's PASRR level 1 assessment for accuracy. Resident #22 was diagnosed with Bipolar which was not indicated on his PASRR level 1. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care and specialized services to meet their needs. Findings include: Record review of Resident #22's face sheet, dated 11/28/22, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and hallucinations (a perception of having seen, heard, touched, tasted, or smelled something that wasn't actually there). Record review of Resident #22's prescription order, dated 10/24/22, revealed Quetiapine (is used to treat certain mental/mood conditions (such as schizophrenia, bipolar disorder, sudden episodes of mania or depression associated with bipolar disorder). Quetiapine is known as an anti-psychotic drug) tablet, 50 mg, 1 tablet, oral twice a day for bipolar disorder. Record review of the admission MDS, dated [DATE], revealed Resident #22 was not currently considered by state level II PASRR process to have serious mental illness and/or intellectual disability or related condition. The MDS did not indicated Resident #22 had serious mental illness, intellectual disability, or related conditions. The MDS revealed Resident #22 was understood and understood others. Resident #22 had a BIMS of 14, which indicated intact cognition. Resident #22 was independent for bed mobility and toilet use but required supervision for transfers, personal hygiene, and limited assistance for dressing, and extensive assistance for bathing. Resident #22 had hallucinations. Resident #22 had an active diagnosis of bipolar disorder and hallucinations. Record review of Resident #22's care plan, dated 11/09/22, revealed signs and symptoms of mood distress as evidence by verbalizing feeling down, depressed, or hopeless. Interventions included administer medications as ordered and obtain a psychological consult/psychosocial therapy as needed. Record review of Resident #22's care plan, dated 11/09/22, revealed at risk for adverse consequences related to receiving antipsychotic medication for diagnosis of bipolar disorder complains of hallucinations/delusions and hearing and talking voices in his head. Interventions included assess/record effectiveness of drug treatment, attempt to give lowest dose possible, assess if behavioral symptoms present a danger to himself and/or others. Record review Resident #22's PASRR Level I Screening, dated 10/24/22, completed by a local hospital revealed no evidence of mental illness, intellectual disability, or developmental disability. During an interview on 11/30/22 at 11:48 a.m., the MDS Coordinator said she was responsible for PASRR accuracy. She said Resident #22 did have bipolar disorder with hallucinations as an active (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 17 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few diagnosis. She said the PASRR Level I Screening was completed by the receiving hospital. She said she was only required to uploaded it in the local authority system. She said it was not her responsibility to make sure if another entity filled out the PASRR correctly. She said she assumed the transferring entity filled the PASRR out correctly. She said Resident #22's bipolar disorder diagnosis was obtained after the age of [AGE] years old, so she did not think his diagnosis qualified as a mental illness of the PASRR. She said she could not remember specifically where she learned the 23-age requirement for mental illness qualification. She said Resident #22 PASRR Level I Screening not completed correctly could cause him to not receive services he needed and not having the local authority involved in his care. During an interview with the Administrator on 11/30/2022 at 1:03 p.m., the Administrator said a policy for PASARR services was not available. During an interview on 11/30/22 at 3:09 p.m., the ADM said nursing services was responsible for PASRR screening and implementation of recommended services. During an interview on 11/30/22 at 4:10 p.m., the DON said the MDS Coordinator handled PASRR accuracy. She said Resident #22 had bipolar disorder but was obtained after age of [AGE] years old, so she did not think his diagnosis qualified as a mental illness of the PASRR. She said she could not remember specifically where she learned the 23-age requirement for mental illness qualification. She said she was going to locate the information related to the age requirement for mental illness and PASRR. She said the facility submitted whatever the transferring entity completed. She said she did not expect the MDS Coordinator to make sure other entities PASRR screenings were correct because if they were incorrect, they could not change the answers. She said if Resident #22 did qualify for PASRR service, then he was not receiving the care and service he was entitled to. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 18 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 3 of 12 residents (Residents #27, #5 and #11) reviewed for comprehensive person-centered care plans. 1. The facility failed to develop and implement care plans for Resident #27 for the triggered care area of psychotropic medications and current antipsychotic usage. 2. The facility failed to develop a care plan to address Resident # 5's hospice services. 3. The facility failed to develop a care plan to address Resident #11's PASSR (Preadmission Screening and Resident Review) services. These failures could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services. Findings include: 1. Record review of Resident #27's face sheet, dated November 2022, indicated Resident #27 was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), delusional disorder (a belief or altered reality that is persistently held despite evidence or agreement to the contrary, generally in reference to a mental disorder), and anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Record review of Resident #27's annual MDS assessment, dated 09/01/2022, indicated Resident #27 had a BIMS (brief interview of mental status) score of 03, which indicated a severe cognitive impairment. Resident #27 was usually understood and usually understood others. Resident #27 required supervision assistance with bed mobility, ambulation, transfer and toileting. The MDS indicated 7 days of antipsychotic medication usage. Record review of the CAAs (Care Area Assessment), dated 09/01/2022, indicated Resident #27 triggered for the care areas of psychotropic medication usage. The care area assessment for psychotropic medication use indicated a care plan would be created for the psychotropic medication usage. Record review of Resident # 27's physician orders indicated an order for Seroquel 100 mg once daily at bedtime was ordered on 03/21/2021. Record review of Resident #27's medication administration record for September, October and November 2022 indicated Seroquel 100 mg was administered nightly for September, October, and November of 2022. Interview with LVN G on 11/30/2022 at 10:00 a.m. revealed Resident #27 had a delusional disorder (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 19 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and took Seroquel for several years. LVN G stated it was the responsibility of the MDS nurse to care plan all medications. LVN G stated care plans were created so the staff knew how to take care of the residents and their individual needs. Interview with the MDS Coordinator on 11/30/2022 at 10:30 a.m. revealed Resident #27 had daily antipsychotic use and psychotropic medications triggered on the annual MDS dated [DATE]. The MDS Coordinator stated the care plan should have been updated with the 09/01/2022 assessment to reflect the usage of psychotropic medications. The MDS Coordinator stated the resident would not suffer an adverse effect from the Seroquel not being care planned. The MDS Coordinator stated she must have overlooked the triggered care area. During an interview on 11/30/2022 at 1:35 p.m., the DON stated she was unaware the triggered psychotropic medication for Resident #27 was not care planned. The DON stated all triggered areas should be care planned so the care plan reflected the individual needs of the residents. The DON stated no negative outcome would come to the resident by not having an accurate care plan. The DON stated it was the responsibility of the MDS Coordinator to ensure all care plans were accurate. The DON stated no one checked the care plans behind the MDS nurse. The DON stated it was expected the MDS nurse completed full comprehensive care plans when she completed and annual assessment. During an interview on 11/30/2022 at 2:21 p.m., the Administrator stated he expected the MDS to create a full comprehensive care plan and keep it revised and updated. The Administrator stated the care plan was important because it was the instruction manual for the care of each resident. 2. Record review of Resident #5's face sheet, dated 11/29/2022, revealed an 82-year- old female and was admitted to the facility on [DATE] with diagnoses which included congestive heart failure, high blood pressure, and history of brain cancer. The face sheet indicated Resident #5 was under the care of Hospice effective 10/4/2022. Record review of the consolidated physician orders, dated 11/29/2022, did not indicate an order for Resident #5 to be admitted to hospice care. Record review of Resident #5's MDS , dated 6/14/2022, indicated Resident #5 was usually understood and usually understood others. The MDS indicated a BIMS (Brief Interview for Mental Status) was not conducted due to Resident #5 being rarely never understood. The MDS indicated Resident #5 began receiving hospice care while a resident at the facility. Record review of Resident #5's care plan, dated 10/19/2022, did not indicate Resident #5 was receiving hospice care or services . 3. Record Review of Resident #11's face sheet, dated 11/28/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses which included stroke (damage to the brain from interruption of its blood supply) and other recurrent depressive disorders (periods of depression), and bipolar disorder, current manic severe with psychotic features (a disorder characterized by periods of depression and periods of depression and periods of abnormally elevated mood associated with psychosis.) Record Review of Resident #11's MDS, dated [DATE], indicated Resident #11 was usually understood and sometimes understands others. Resident #11 had a BIMS of 09, which indicated moderately impaired cognition. Resident #11 required supervision to extensive assistance with ADLs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 20 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #11's care plan, dated 09/14/2022, did not indicate Resident #11 received PASRR services for a PASRR positive diagnosis of mental illness. Record review of a PASRR Level 1 Screening indicated Resident #11 was positive for mental illness. Record review of a Pre-admission Screening and Resident Review (PASRR) Evaluation Summary report concerning Resident #11 and was dated 9/1/2022 indicated, Section IV, Recommended MI (mental illness) Specialized Services .Individual Skills Training . Record review of Resident #11's PASSR Evaluation, dated 9/1/2021, indicated Resident #11 met the PASRR definition of mental illness. The evaluation indicated specialized services determination/recommendations of self-monitoring of medications, self-monitoring of nutritional services, and individual skills training. During an interview on 11/30/2022 at 9:44 a.m., the MDS Coordinator said she was responsible for creating and updating care plans for residents. She said if there was a change with a resident such as a fall or in the orders it was discussed in the morning meetings and then she updated each care plan. She said she would have expected all PASSR positive residents to be care planned for being PASSAR positive. She said Resident #11 not being care planned for being PASSR positive and the services recommended by the local authority was an oversight on her part. She said any resident who received Hospice services should have been care planned for receiving Hospice services. She said residents being placed on Hospice was a topic discussed during morning meetings. She said Resident #5 was admitted to Hospice on 10/11/2022 . She said Resident #5 not being care planned was an oversight on her part and should have been caught during the resident's care plan meeting on 11/19/2022. She said a resident not having a complete care plan could cause the resident to not receive the care they needed. During an interview on 11/30/2022 at 12:04 p.m., the DON said they did care plans as a team and the MDS Coordinator was responsible for updating care plans. She said the week Resident #5 was placed on Hospice, herself and the MDS Coordinator missed the care plan meeting. She said hospice services being care planned for Resident #5 was just missed. She said she was not sure why Resident #11 being PASSR positive was not care planned. She said she expected both services to have been care planned for each resident. She said the care plan guided the resident's total care. She said PASSR and Hospice services not being care planned could cause the resident's needs to not be met. She said depression was an issue with Hospice residents. She said hospice needed to be care planned because the resident could be declining. During an interview on 11/30/2022 at 3:09 p.m., the Administrator said they had care plan meetings every Wednesday. He said the MDS Coordinator was responsible for updating care plans. He said he expected Resident #5 to have a care plan concerning her hospice services and he expected Resident #11 being PASSR positive to have been care planned. He said without a correct care plan, the resident might not receive appropriate care. Record review of the facility's, undated, Care Plans, Comprehensive Person-Centered policy indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident .The comprehensive, person-centered care plan will .describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .describe services that would otherwise be provided for the above FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 21 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 - Few 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, interviews, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents reviewed for transfers. (Resident #12) The facility failed to ensure CNA C and CNA D transferred Resident #12 safely by not locking the wheels of the mechanical (Hoyer) lift while performing a wheelchair to bed transfer. The facility failed to ensure CNA D provided adequate supervision of Resident #12 during a Hoyer lift/transfer from wheelchair to bed as CNA C operated the Hoyer lift. This failure could place residents at risk for injury during mechanical lifts/transfers. Findings include: Record review of Resident #12's face sheet, dated 11/30/22, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with the diagnoses which included muscle weakness, history of stroke with right side paralysis (non-use) and contracture of right hand, hypertension (high blood pressure), diabetes (too much sugar in the blood), colostomy (artificial opening for bowel elimination), osteoporosis (bones become weak and brittle) with history of pathological fracture (bone fracture not caused by force or impact), polyosteoarthritis (pain of 5 or more joints), atrial fibrillation (irregular rapid heartrate that causes poor blood flow), cardiomegaly (enlarged heart), history of urinary tract infections, depression (mood disorder that causes persistent feelings of sadness and loss of interest), and anxiety (intense, excessive, and persistent worry and fear about everyday situations). Record review of Resident #12's quarterly MDS, dated [DATE], indicated Resident #12 had a BIMS of 15, which indicated she was cognitively intact. Resident #12 was total dependent with transfers and required the assistance of two persons for transfers. She required extensive assistance of two persons for most other ADLs. Resident #12 was always incontinent (unable to control) of urine, and she had a colostomy for bowel elimination. Record review of Resident #12's care plan, dated of 8/31/ 22, revealed Resident #12's left breast was significantly larger than her right and caused her emotional distress; Resident #12 had limited range of motion to the right upper and lower extremities; Resident #12 required extensive assistance with most ADLs and required two person assist and use of Hoyer lift with transfers; Resident #12 had pain to her right side related to hemiparesis (partial paralysis) from a stroke; and Resident #12 was at risk for bleeding due to taking Eliquis (blood thinner). Record review of the order history report with a date range of 10/30/22-11/30/22, revealed Resident #12 was to take Eliquis 2.5 milligrams 1 tablet twice daily and aspirin 81 milligram 1 tablet daily (both used to thin the blood). During an observation on 11/28/22 at 3:10 PM, CNA C and CNA D performed a mechanical lift/transfer on Resident #12. Resident #12 was sitting in her wheelchair just inside the door of her room. CNA D pushed the mechanical lift up to and around the resident's wheelchair and did not lock the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 22 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 - Few mechanical lift wheels prior or during the actual lift of the resident. CNA D and CNA C proceeded to attach blue loops of the lift pad, that were already under the resident in the wheelchair, to the hooks of the mechanical lift. CNA D then proceeded to crank the mechanical lift and raised the resident up over the top of the wheelchair with CNA C standing beside the resident. CNA D then pulled the mechanical lift backwards across the room in front of Resident #12's bed and turned and pushed the lift and resident over the bed. CNA C did not stay with the resident to safely guide the resident during transfer from the wheelchair to the bed. CNA C was by the room door while CNA D maneuvered the lift with the resident suspended in the air to the bed. Resident #12 was inappropriately placed in the lift pad and was folded tightly in the lift pad with her head pushed forward and her chin was on her chest. CNA C then came to the bedside and assisted CNA D with positioning the resident in the bed. CNA D then lowered the mechanical lift and resident to the bed. Both CNA D and CNA C removed the transfer lift pad from under the resident. During an interview on 11/29/22 at 3:29 PM with CNA D, she said she was employed at the facility for six years as a CNA. She said while performing a mechanical lift/transfer, you should position the lift and lock the wheels of the lift and the wheelchair prior to lifting the resident to prevent the lift or wheelchair from moving, slipping, or falling over with the resident. She said resident positioning in the lift pad depended on which color loop was used. She said she could have used the blue and green loops to position Resident #12 better in the lift pad. She said Resident #12 tried very hard not to holler out in pain during the lift/transfer, because the lift hurts the resident's left side. She said Resident #12 usually hollered with pain during her lift/transfers. She said mechanical lifts/transfers always required two persons and should never be done alone. She said the second person should stay with the resident during the transfer, help guide the resident and help position the resident to prevent accidents. She said the second person was also a second set of eyes to ensure everything was done correctly/safely. She said she should have waited for CNA C to come back to the resident's side before continuing to maneuver the mechanical lift across the room. She said the resident could have potentially fell and there was no one else to help in an emergency if they were not close to the resident. She said she knew the proper way to perform a mechanical lift/transfer, but she was nervous. During an interview on 11/29/22 at 3:48 PM with CNA C, she said she worked at the facility for six years. She said while performing a mechanical lift/transfer, you should push the Hoyer lift to the resident and apply brakes on both the Hoyer lift and the resident's wheelchair. She said the lift pad was placed on under the resident and the loops of the lift pad hooked to the Hoyer lift. She said then the Hoyer lift would be pushed over to the bed and resident positioned properly in the bed and then lowered onto the bed. She said there had to be two persons to do a Hoyer lift. She said the second person was to supervise and assist with positioning the resident. She said it was very hot in Resident #12's room and she had sweat running down her face and had to step away from the resident during the lift/transfer to wipe her face and change gloves. She said the resident could fall and she could lose her license if the Hoyer lift was not done properly. During an interview on 11/29/22 at 4:35 PM with Resident #12, she said the mechanical lift/transfer was a typical lift/transfer process when she was transferred from her wheelchair back to bed. She said she felt the lift was okay. She said her left side of her body was very tender from her stroke and it hurts her some during the lift/transfer process. She said the lift pad was tight on her during the lift/transfer. She said she did not have anything bad to say about the care she received at the facility. During an interview on 11/30/22 at 11:39 PM with the DON, she said CNA D reported to her on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 23 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 - Few 11/28/22 that she knew better and should have locked the mechanical lift. She said all CNA staff were in-serviced in August 2022 on proper mechanical (Hoyer) lifts/transfers. She said the second CNA should always stay with the resident during the transfer to make sure nothing happens, such as a fall, the Hoyer tip over, and to guide the resident safely. She said a resident could be injured during an unsafe mechanical (Hoyer) lift/transfer. She said she already had a plan to observe mechanical transfers for safety and she would work with the CNAs to determine what needs to happen to ensure Resident #12 was transferred comfortably and safely. She said the resident could need a different size transfer pad and/or she may need to educate the CNAs on proper use of the color coding of the lift pad loops for positioning during transfers. During an interview on 11/30/22 at 3:30 PM with the Administrator, he said he would expect the CNAs to perform mechanical lifts/transfers safely for the safety of the residents. Record review of Performance Evaluations for CNA revealed CNA C showed satisfactory competency of Hoyer transfer on 3/30/22. Record review of Performance Evaluations for CNA revealed CNA D showed satisfactory competency of Hoyer transfer on 11/15/22. Record review of an in-service titled Transfer Training, dated 8/24/22, revealed . Hoyer lift . Safety!! . Locks and position of patient . during transfer make sure to help guide and steady patient Record review of the facility's, undated, policy titled Mechanical Lift revealed . it is the policy of this facility to move a resident by a mechanical means as needed . moving resident from chair to bed . place foot of lift under chair and attach sling to lift . raise lift until resident's buttocks clear chair . slowly move resident away from chair toward bed . second person should guide sling . lower sling while second person guides resident to position on bed . unhook sling from lift . move lift away from resident and bed . remove sling and position resident FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 24 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 3 of 13 residents (Residents #4, #15 and #30) reviewed for respiratory care. Residents Affected - Some The facility failed to ensure Resident #4, Resident #15 and Resident 30's oxygen concentrator filters were free of gray particles. This failure could place residents at risk of respiratory infections. Findings include: 1. Record review of Resident #4's face sheet, dated 11/28/22, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (diseases that cause airflow blockage and breathing-related problems) and acute respiratory failure with hypoxia (don't have enough oxygen in your blood). Record review of Resident #4's consolidated physician orders, dated 10/28/22-11/28/22, revealed change oxygen set up and clean concentrator filter weekly on Sunday, once a day, 06:15 p.m.-06:16 a.m. ordered on 02/09/22. Record review of Resident #4's MAR, dated 11/17/22-11/30/22, revealed change oxygen set up and clean concentrator filter weekly on Sunday, once a day with start date of 02/09/22. The MAR was documented on 11/27/22 (Sunday) by LVN M as completed. Record review of Resident #4's annual MDS, dated [DATE], revealed Resident #4 was usually understood and usually understood others. Resident #4 had a BIMS of 15, which indicated intact cognition. Resident #4 required extensive assistance for bed mobility, dressing, personal hygiene, toilet use and bathing. The MDS did not document use of oxygen while resident . Record review of Resident #4's care plan, dated 11/16/22, revealed use of oxygen as needed for COPD (chronic obstructive pulmonary disease) and history of COVID Pneumonia (is a lung infection caused by SARS CoV-2 , the virus that causes COVID-19. It causes fluid and inflammation in your lungs). Interventions included administer oxygen as ordered and ensure supply was always available. During an observation on 11/28/22 at 10:29 a.m., Resident #4 was laying in his bed with a nasal cannula on his face . The oxygen concentrator flow meter read 2.5 liters with a water filled reservoir and two black filters with a moderated amount of gray particles . During an observation on 11/29/22 at 11:26 a.m., Resident #4 was laying in his bed with a nasal cannula on his face . The oxygen concentrator flow meter read 2.5 liters with a water filled reservoir and two black filters with moderated amount of gray particles. During an interview and observation on 11/30/22 at 9:04 a.m., LVN G said the oxygen concentrator filters were cleaned Sunday on the night shift. She said the filters should not have gray particles. LVN G removed both filters from Resident #4's oxygen concentrator and verbally agreed a moderate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 25 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 number of gray particles was noted. LVN G said she would clean the filters herself . Level of Harm - Minimal harm or potential for actual harm 2. Record review of Resident #15's face sheet, dated 11/30/22, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included heart failure (the heart doesn't pump blood as well as it should) and chronic obstructive pulmonary disease (diseases that cause airflow blockage and breathing-related problems). Residents Affected - Some Record review of Resident #15's consolidated physician orders, dated 10/30/22-11/30/22, revealed change oxygen set up and clean concentrator filter weekly on Sunday, once a day, 06:15 p.m.-06:16 a.m. ordered on 10/14/22. Record review of Resident #15's MAR, dated 11/17/22-11/30/22, revealed change oxygen set up and clean concentrator filter weekly on Sunday, once a day with start date of 10/14/22. The MAR was documented on 11/27/22 (Sunday) by LVN M as completed. Record review of the admission MDS, dated [DATE], revealed Resident #15 was usually understood and usually understood others. Resident #15 had a BIMS of 09, which indicated moderate cognitive impairment. Resident #15 required supervision for ADLs. Resident #15 received oxygen therapy while a resident. Record review of Resident #15's care plan, dated 11/02/22, did not document a care area for oxygen therapy. During an interview and observation on 11/28/22 at 11:34 a.m., Resident #15 was sitting on the side of her bed with a nasal cannula on her face . The oxygen concentrator had a white filter with gray particles. She said she could not remember the last time a nurse cleaned the filter, but she used to clean the filter at home once a week . During an attempted interview on 11/28/2022 at 4:30 p.m., a call was placed to LVN M. There was no answer and the voice mail box was full. 3. Record review of Resident #30's face sheet, dated 11/30/2022, revealed an 85-year- old female and was admitted to the facility on [DATE]. Resident #30 had diagnoses which included age related cognitive decline, chronic obstructive pulmonary disease (lung disease), and kidney failure. Record review of Resident #30's physician's orders, dated 11/30/2022, revealed an open order, dated 12/19/2021, for oxygen at 3 L (liters) via nasal cannula PRN (as needed). There was an order, dated 11/7/2021, for change O2 (oxygen) setup and clean concentrator filter weekly on Sunday. Record review of Resident #30's care plan, dated 10/5/2022, indicated Resident #30 used oxygen therapy at times for a diagnosis of COPD (chronic obstruction pulmonary disease) and emphysema (both are lung diseases). There was an intervention to administer oxygen as ordered. Record review of the MDS , dated 9/30/2022, indicated Resident #30 was usually understood and usually understood others. Resident #30 had a BIMS (Brief Interview for Mental Status) of 8 which indicated Resident #30 was moderately cognitively impaired. Record review of a Medication Administration Record dated 11/1/2022 - 11/29/2022, for Resident #30 indicated an order to change O2 setup and clean concentrator filter weekly on Sunday. The MAR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 26 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 indicated this was last performed on 11/27/2022 . Level of Harm - Minimal harm or potential for actual harm During an observation on 11/28/2022 at 10:34 a.m. revealed an oxygen concentrator beside the bed of Resident #30. There was a nasal cannula attached to the concentrator. The filter on the back of the concentrator was covered with gray fuzzy particles. Residents Affected - Some During an observation on 11/29/22 at 9:12 a.m., revealed Resident #30 was resting in bed. An oxygen concentrator was running at the resident's bedside. The filter on the back of the concentrator was covered with gray fuzzy particles . During an observation on 11/30/22 at 8:20 am., revealed an oxygen concentrator beside the bed of Resident #30. The filter on the back of the concentrator was covered in gray fuzzy particles. During an interview on 11/30/22 at 8:32 a.m., LVN G said oxygen tubing was changed every Sunday night on the graveyard shift. She said filters should have been cleaned when the tubing was changed. She said this was documented on the MAR. She said dirty filters could lead to infection. During an interview on 11/30/2022 at 12:04 p.m. The DON said oxygen concentrator filters should be cleaned when the tubing was changed, and this was done on Sunday night shift . During an interview on 11/30/2022 at 3:09 p.m., the Administrator said the nursing team was responsible for cleaning dirty oxygen concentrator filters. He said he would have expected the filter to be cleaned when the oxygen tubing was changed . Record review of the facility's, undated, Oxygen Administration policy revealed no documentation that indicated how often oxygen concentrator filters should be changed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 27 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being, for 1 of 13 residents (Resident #11) reviewed for behavioral health services. 1. The facility failed to follow up on Resident #11's recommended counseling after discharge from the local mental hospital. 2. The facility failed to ensure Resident #11 received mental health treatment for her PASSR positive due to mental illness. 3. The facility failed to develop and implement interventions to address Resident #11 moderate depression. These failures could place residents at risk for emotional trauma, untreated depression, and a decreased quality of life. Findings include: Record review of Resident #11's face sheet, dated 11/28/22, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder), bipolar disorder (extreme mood swings that include emotional highs (mania or hypomania) and lows [depression]), current episode manic severe with psychotic features, and recurrent depressive disorder (depressed mood or loss of interest in activities). Record review of Resident #11's quarterly MDS, dated [DATE], revealed Resident #11 was married. Resident #11 was admitted from a psychiatric hospital. Last reentry to the facility was on 04/18/22. Resident #11 was sometimes understood and usually understood others. Resident #11 had BIMS of 09, which indicated mild cognitive impairment. Resident #11 required limited assistance for transfer, and walk in room, extensive assistance for bed mobility, dressing, toilet use and personal hygiene but total dependence for bathing. Resident #11 displayed periods of inattention and disorganized thought. Resident #11 had a mood total severity score (the score is useful for knowing when to request additional assessment by providers or mental health specialists for underlying depression) of 14 out 27. Resident #11 had symptoms of feeling down, depressed, or hopeless with a frequency of 7-12 days (half or more of the days); feeling tired or having little energy with a frequency of 2-6 days (several days); poor appetite or overeating with a frequency of 7-12 days (half or more of the days); feel bad about yourself-or that you are a failure or have let yourself or your family down with a frequency of 7-12 days (half or more of the days); trouble concentrating with a frequency of 7-12 days (half or more of the days); moving or speaking so slowly that other people could have noticed with a frequency of 7-12 days (half or more of the days); thoughts that you would be better off dead, or hurting yourself in some way with a frequency of 12-14 days (nearly every day). Resident #11 received antidepressants. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 28 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #11's quarterly MDS, dated [DATE], revealed Resident #11 was admitted from a psychiatric hospital. Last reentry to the facility was on 04/18/22. Resident #11 was sometimes understood and usually understood others. Resident #11 had a BIMS of 09, which indicated mild cognitive impairment. Resident #11 required supervision for toilet use and walk in room. Limited assistance for transfer, extensive assistance for bed mobility, dressing and personal hygiene but total dependence for bathing. Resident #11 displayed periods of inattention and disorganized thought. Resident #11 had a mood total severity score (the score is useful for knowing when to request additional assessment by providers or mental health specialists for underlying depression) of 14 out 27. Resident #11 had symptoms of feeling down, depressed, or hopeless with a frequency of 7-12 days (half or more of the days); feeling tired or having little energy with a frequency of 2-6 days (several days); poor appetite or overeating with a frequency of 7-12 days (half or more of the days); feel bad about yourself-or that you are a failure or have let yourself or your family down with a frequency of 7-12 days (half or more of the days); trouble concentrating with a frequency of 7-12 days (half or more of the days); moving or speaking so slowly that other people could have noticed with a frequency of 7-12 days (half or more of the days); thoughts that you would be better off dead, or hurting yourself in some way with a frequency of 12-14 days (nearly every day). Resident #11 received antidepressants. Record review of Resident #11's care plan, with problem start date of 02/13/20, revealed trauma informed care plan with trauma indicators and can become physically aggressive with staff and other residents at times. Interventions included redirected to quiet/calm place and maintain a calm environment and approach. The care plan with last care conference of 09/14/22 did not address Resident #11's moderate depression with prescribed medications and bipolar disorder with prescribed medication. Record review of Resident #11's care plan, dated 09/14/2022, did not indicate Resident #11 received PASARR services for PASARR positive diagnosis of mental illness. Record review of the progress note written by the social service worker dated 06/08/22 revealed .alert and able to communicate her needs .BIMS determined by staff .her PHQ9 score was 3 which indicated mild symptoms of depression .she receives Prozac for depression .indicators of past trauma . Record review of the progress note written by the social service worker dated 09/07/22 revealed .alert and able to communicate her needs .BIMS 9 which indicates moderate impairment . her PHQ9 score was 14 which indicated moderate symptoms of depression . she receives Prozac for depression . indicators of past trauma .she is PASRR positive . Record review of Resident #11's progress notes dated 03/03/22-11/25/22 did not indicate any form of counseling for her mental illness. There was no indication of Resident #11 refusing any services or counseling. Record review of the psychiatric physician progress notes dated 11/26/20 revealed admission date 11/25/20 .chief complaint behaviors .grabbed resident arm stated 'I will break it' .refused redirection .grabbing CAN arm and twisting it . Record review of the psychiatric physician progress notes dated 12/04/20 revealed criteria for continued stay .medical evaluation, psychopharmological evaluation and adjustment, evaluation of psychiatric status, positive for new medication prescribed .discharged date 12/09/20. The progress notes did not mention counseling service recommended post discharge. Record review of a Pre-admission Screening and Resident Review (PASARR) Evaluation Summary report (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 29 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few concerning Resident #11, dated 9/1/2021, indicated, Section IV, Recommended MI (mental illness) Specialized Services .Individual Skills Training Record review of Resident #11's PASARR Evaluation, dated 9/1/2021, indicated the evaluator was the PASARR Manager. The evaluation indicated Resident #11 met the PASARR definition of mental illness. The evaluation indicated specialized services determination/recommendations of self-monitoring of medications, self-monitoring of nutritional services, and individual skills training. Record review of an Informational Note concerning Resident #11, dated 12/21/2021, and was provided by the PASARR Manager, with the mental health local authority indicated, .spoke with [Resident #11's] RN who reports that she has a medication provider prescriber for her medications .she has access to counseling through Deer Oaks Notes from the IDT meeting held in September 2021 were requested from the PASARR Manager with the local mental health authority and were not received prior to exit. During an observation and interview on 11/28/22 at 11:52 a.m., Resident #11 was sitting in the main area of the secured unit. Resident #11 stated she was married to Resident #13, but he was not on the secure unit. She said she wanted to be in the same room with him and it made her sad to not be with him. She said she only got to visit him during activities. She said she took medication for depression but was not receiving counseling because the facility did not have a social worker. During an interview on 11/29/2022 at 2:15 p.m., the MDS Coordinator said Resident #11 was PASARR positive. She said there was no documentation of any of the recommendations made on the PASARR Evaluation, dated 9/1/2021, being implemented into the care of Resident #11. She said there had not been an IDT (Interdisciplinary team) meeting since 9/2021. She said the PASARR Manager was responsible for implementing any recommendations made during the PASARR Evaluation, dated 9/1/2021. She said Resident #11's mental illness should be addressed in the care plan and reflect medication changes and dose reductions. She said her care plan not addressing her depression was an oversight. She said a resident not having a complete care plan could cause the resident to not receive the care they needed. During an interview on 11/29/22 at 3:39 p.m., Resident #11 said she was tired and sad. She said she talked to the social service worker, but it did not help. During an interview on 11/30/22 at 9:04 a.m., LVN G said she worked at the facility for 14 years. She said Resident #11 left the secure unit for activities to be with her husband and he went back on the secure unit for activities. She said they were allowed to visit each other daily. She said Resident #11 seemed happier when she could visit her husband. She said Resident #11 had a history of depression. She said the doctor recently decreased one of her anti-depressant medications. She said Resident #11 needed to be looked at or seen by the counseling service. She said she did not know why she was not routinely seen by the counseling service but at one time Resident #11 could not voice her feelings. She said no one notified her, her nurse, about her emotional changes. She said Resident #11 was slow to get up last week. She said the facility provided adequate training of mental health and felt staff could recognize signs and symptoms of depression. She said Resident #11 had never mentioned her broken, missing teeth made her sad or hurt. During an interview on 11/30/22 at 9:46 a.m., the Social Service Worker said she also was responsible for medical records, the activity director, transportation supervisor, and made appointments. She said a referral for counseling service was sent if a staff member noticed mental or behavioral changes in a resident. She said based on Resident #11's last assessment, she was great. She said Resident #11 refused mental health services but did not document her refusals. She said some of Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 30 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 0742 #11 sadness and depression would be alleviated if she was with her husband. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/30/22 at 10:40 a.m., the PASARR Manager, with the local mental health authority, said the last IDT meeting for Resident #11 was held in September 2021 and there had not been a meeting since. She said Resident #11 was due for her annual meeting at this time. She said there were notes from 12/2021 where a case manager contacted the facility. A nurse said the resident had access to a local counseling service for counseling. She said the last time a case manager contacted the resident was in February 2022 and they felt all her needs were being met. She said counseling for the resident's mental illness was not recommended during the PASARR Evaluation because she was under the impression, she was receiving counseling through the facility. She said the last contact with the resident was February 2022 and there were no issues and the resident told them she was receiving counseling at the facility. Residents Affected - Few During an interview on 11/30/22 at 11:07 a.m., CNA H said she worked at the facility for 28 years and mostly on the secured unit. She said Resident #11 had not been acting sad lately. She said Resident #11 did get sad when she wanted to see her husband and was always happy when they were together. She said they visited each other daily during activities. During an interview on 11/30/22 at 1:30 p.m., the DON said she thought Resident #11 received counseling services. The DON checked some documentations and said Resident #11 had not received counseling services. She said the MDS Coordinator was responsible for making sure PASARR recommended services were implemented. The DON said all triggered areas should be care planned so the care plan reflected the individual needs of the residents. She said the care plan guided the resident's total care. The DON said it was expected the MDS nurse completed full comprehensive care plans when she completed and annual assessment. During an interview on 11/30/22 at 1:40 p.m., the ADM said the facility did not have a policy to address behavioral/mental health. During an interview on 11/30/22 at 2:52 p.m., the Licensed Psychologist said she was called today to see Resident #11. She said Resident #11 refused to be evaluated after she was released from a local behavioral hospital in12/20. She said she never received the recommended referral in 2020 because Resident #11 did not give her consent. She said after the evaluation on 11/30/2022 she felt the resident was unable to give an informed consent. She said after her initial assessment, she would have a session or two with Resident #11. She said Resident #11 told her she wanted to go home but did not want to harm herself in anyway. She said she did normally see PASARR positive residents. She said anyone the facility felt needed to be seen, she would evaluate the resident. She said best case scenario, Resident #11 would have been periodically asked if she wanted counseling services since she refused in 2020. She said because this was her first evaluation of Resident #11, she could not say if counseling would have benefitted her over the last 2 years. During an interview on 11/30/22 at 4:10 p.m., the DON said during Resident #11 PASSR IDT meeting, mental health services was not addressed. She said normally during the meeting it was decided, facility or local authority, who would provide the mental health service. During an interview on 11/30/22 at 4:40 p.m., the ADM said all staff should be monitoring the residents for abnormal behaviors which could indicated mental health issues. He said he expected the resident to receive the mental health care and services they needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 31 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 13 residents (Resident #21) reviewed for psychotropic medications. The facility failed to have an appropriate diagnosis or indication of use for Resident #21's Risperdal Consta injection (antipsychotic) and Zyprexa (antipsychotic). This failure could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings include: Record review of Resident #21's face sheet, dated 11/29/2022, indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease (a disease of the brain causing dementia, mood swings, loss of motivation, self-neglect, and behavioral issues), generalized anxiety disorder, and other recurrent depressive disorders (periods of depression). Record review of physician's orders dated 11/29/2022, for Resident #21 indicated an order, dated 2/10/2021, for Risperdal Consta suspension, extended release; 12.5 milligrams/ 2 milliliters; intramuscular injection to be given once a day every 14 days. There was an order, dated 5/16/2022, for Zyprexa tablet; 2.5 milligrams; 1 tab; oral; at bedtime. Record review of the MDS, dated [DATE], indicated Resident #21 was understood and understood others. The MDS indicated Resident #21 had a BIMS score of 9, which indicated the resident was moderately cognitively impaired. T Resident #21 did not have behaviors of hallucinations (seeing, hearing, touching something not really there), delusions (alter reality of what was real), rejection of care, or wandering. Resident #21 required supervision with ADLs. Resident #21 did not have a diagnosis of Huntington's Disease (a disease affecting the brain by breaking down the nerve cells in the brain), Tourette's Disease (a disease characterized by multiple motor tics and at least one phonic tic), or Schizophrenia. Record review of Resident #21's care plan, dated 9/21/2022, indicated Resident #21 was at risk for adverse consequences related to receiving antipsychotic medication for treatment of psychosis. Record review of a medication administration record dated 10/1/2022 - 11/29/2022, indicated Resident #21 was administered Risperdal Consta injection, 12.5 milligrams/2 milliliters on 10/05/2022, 10/19/2022, 11/02/2022 and 11/16/2022. Resident #21 was administered a Zyprexa 2.5 milligram tablet every day at bedtime. During an interview on 11/29/2022 at 4:30 p.m., the ADON said Resident #21 was admitted from a behavioral hospital with prescriptions for Risperadol and Zyprexa. She said when the Risperadol and Zyprexa were started for Resident #21 she had a new onset of hallucinations and paranoia. She said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 32 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #21 was very anxious and got upset. She said the plan was to decrease the dose and hopefully take her off the medications all together. She said the resident had greatly improved since the medications were first ordered. She said the physician had reduced the doses several times but had chosen to keep the resident on the medications. She said the resident was currently having some anxiety due to some family issues and she was given medications for the anxiety. She said she was no longer hallucinating or suffering from paranoia. During an interview on 11/30/2022 at 12:15 p.m., the Attending Physician said he did not order psychotropic medications for people that had dementia diagnosis unless their behaviors warranted something stronger than an antidepressant. He said he tried almost all the recommendations the pharmacy made. He stated appropriate diagnoses for antipsychotics were Huntington's, Tourette's, delusional disorder, and schizophrenia/bipolar disorder. He stated he was aware of the side effects these medications had on the elderly and tried to refrain from using them unnecessarily. He stated antipsychotics caused a decreased appetite, increased risk of falling and even death. During an interview on 11/30/2022 at 12:04 p.m., the DON said Schizophrenia, Tourette's Disease, and Huntington's Disease were all appropriate diagnosis for antipsychotics. She said Resident #21 had none of these diagnoses. She said GDRs (gradual dose reductions) were being done because she did not have any of those diagnoses. She said in 2020 Resident #21 was hallucinating, refused medications and would not eat. She said it was like Resident #21 was going crazy. She said Resident #21 had not recently hallucinated, that she was aware of. She said the resident did fixate on family issues. She said she asked the attending physician to remove at least one of the medications. She said the doctor said he wanted to do a slow reduction because he did not want her to revert to her behaviors in 2020. During an interview on 11/30/22 at 3:09 p.m., the Administrator said he did not know the correct diagnoses indicated for anti-psychotic medications. He said he was unaware Resident #21 was ordered antipsychotics without a proper diagnosis. He said he was surprised because the DON usually took care of issues with residents on antipsychotics. Record review of the facility's, undated, Psychotropic Medication Policy and Procedure facility policy indicated, .It is the policy of this facility to use psychotic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation, and monitoring .the facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long term care facility to include regular review for continued need, appropriate dosage, side effects, risk and/or benefits Record review of the facility's, undated, CMS Allowed Diagnoses for Antipsychotic Medications by the Texas Department of Aging and Disability Services indicated, Long-term Chronic Conditions Schizophrenia, Tourette's disorder, Huntington's disease, delusional disorder, Bipolar disorder, and severe depression refractory to other therapies with psychotic features .Short-term Acute Conditions, Psychosis in the absence of dementia, medical illness with psychotic symptoms and/or treatment related to psychosis or mania FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 33 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 2 errors out of 37 opportunities, resulting in a 5.41 percent medication error rate for 2 of 9 residents reviewed for medication error. (Resident #10, Resident #22) Residents Affected - Few The facility failed to ensure Resident #10 received correct dosage of ferrous sulfate (iron) medication. The facility failed to ensure Resident #22 received correct dosage of Vitamin D medication. These failures could place residents at risk for inaccurate drug administration. Findings included: 1. Record review of a face sheet dated 11/30/22 revealed Resident #10 was a [AGE] year-old male, and admitted to the facility on [DATE] with the diagnoses including iron deficiency anemia (not enough iron in the body), hypertension (high blood pressure), history of a heart attack, diabetes (too much sugar in the blood), Paroxysmal atrial fibrillation (irregular, rapid heart rate that causes poor blood flow), difficulty speaking, has a gastrostomy tube (a tube passed through the abdominal wall into the stomach to receive nutrition, also known as a feeding tube), dementia (impairment of a least two brain functions, such as memory loss and judgement), Alzheimer's (progressive disease that destroys memory and other important mental functions), and prostate cancer. Record review of an annual MDS dated [DATE] indicated Resident #10 was unable to perform the BIMS. Resident #10 was total dependent and required the assistance of one to two persons for all ADLs. Resident #10 had a gastrostomy tube. Record review of the physician order history report with a date range of 10/30/22-11/30/22 revealed Resident #10 was to receive 5 mL (milliliters) of ferrous sulfate (medication also known as iron, used to treat iron deficiency) 300 mg/5 mL daily in the morning with a start date of 2/06/22. Record review of Resident #10's care plan dated 6/21/22 revealed the resident had a history of anemia and was at risk for increased weakness and fatigue. His interventions included giving medications per the orders and monitoring for side effects. During an observation on 11/29/22 at 8:52 AM observed LVN A administer 5 mL of ferrous sulfate (iron) 220 mg/5 mL to Resident #10 through his gastrostomy tube. During an observation and interview on 11/29/22 at 11:30 AM with LVN A, she pulled the bottle of ferrous sulfate (iron) labeled 220 mg/5 mL and said she had given Resident #10 five (5) mL of iron from that bottle. Surveyor asked LVN A to review the order for the medication and she opened the physician order on her computer. She said the order read for 300 mg/5 mL. She said she did not notice the difference in the dosage on the order versus what was on the bottle. She said Resident #10 was getting less iron than what the physician had ordered. She said the bottle was getting close to being empty and it was the only liquid iron they had available in the facility. She said she would contact the physician to clarify the order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 34 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Record review of the face sheet dated 11/30/22 revealed Resident #22 was a [AGE] year-old male, and admitted to the facility on [DATE] with diagnoses including Vitamin D deficiency (not enough Vitamin D in the body), dysphagia (difficulty swallowing), history of a stroke (damage to the brain from an interruption of its blood supply), hypertension (high blood pressure), chronic obstructive pulmonary disease (constriction of the airways, difficulty and/or discomfort breathing), encephalopathy (disease in which the functioning of the brain was affected by some agent or condition), bipolar (excessive mood swings), and weakness. Record review of an admission MDS dated [DATE] revealed Resident #22 was understood and understood others. Resident #22.had a BIMS of 14, which indicated he was cognitively intact. Resident #22 was independent and required supervision to limited assistance of one person for most ADLs. Record review of Resident #22's order history report dated 10/30/22-11/30/22 revealed cholecalciferol (Vitamin D3) 5000 units 2 capsules daily with a start date of 10/31/22. During an observation on 11/29/22 at 9:09 AM, CMA B administered Resident #22 Vitamin D3 5000 units 1 tab. During an observation and interview on 11/29/22 at 11:45 AM, CMA B said he thought the order said 1 tablet of Vitamin D3. He reviewed the order and said he should have given 2 tablets of Vitamin D3 5000 units to Resident #22. He said he would give the second tablet at that time. He said he thought the MAR said one tablet, but he was human. He said when administering medicatioins, he should check the order, the medication, and the resident three times to ensure the correct medication was given to the correct resident. During an interview on 11/30/22 at 11:39 AM, the DON said LVN A had reported the medication error on Resident 10's iron dosage on 11/29/22 and they had already called the physician and received a clarification order to change the dosage to what was available, which was 220 mg/5 mL . She said she had researched the chart to figure out the root cause of the iron medication error and she determined the nurse that entered the original order had chosen the incorrect dosage on the electronic drop-down box when he was admitted . She said the nurses should have already discovered the discrepancy and questioned the dosage order and the iron bottle dosage that was available. She said giving the wrong dosage of medication could have been a serious issue if the resident was receiving the wrong dose of certain medications, such as a heart medication. She said Resident #10 had severe anemia and had even had to have blood transfusions in the past. She said if the resident was not receiving the correct dosage of iron, it could lead to increased fatigue, shortness of breath, increased anxiety (feeling of worry, nervousness, or unease), irregular heart rate, and could increase risk for falls. She said if a resident does not receive enough Vitamin D3, it could affect the resident's skin, mood, bone health, and their nutritional status. She said the facility used Vitamin D3 as part of their pressure ulcer/skin breakdown prevention. She said Resident #22 had a Vitamin D deficiency. She said Resident #22 could have increased fatigue, increased risk for infection, and changes in mood if he did not receive correct dosage of Vitamin D3. She said she had already devised a plan to review all orders, especially the over-the-counter medications, to ensure the correct medications were available and she would re-educate staff on proper medication administration. During an interview on 11/30/22 at 3:30 PM., the Administrator said he would expect the medication error rate to be less than 5% for the safety of the residents. Record review of the facility Administering Medication policy not dated revealed . medications are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 35 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete administered in a safe and timely manner, and as prescribed . only person licensed or permitted by this state to prepare, administer and document the administration of medications may do so . the DON will supervise and direct all nursing personnel who administer medications . medications must be administered in accordance with the orders . the individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . Event ID: Facility ID: 675755 If continuation sheet Page 36 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 refrigerator, 1 of 2 freezers (Main area), in the facility's only kitchen, observed reviewed for kitchen sanitation and storage. The facility failed to label and date all food items stored in the refrigerator and freezer. The facility failed to date all food items stored in the pantry. The facility failed to ensure lids on food storage containers were not cracked. The facility failed to maintain a clean drink dispenser. The facility failed to maintain clean storage containers for utensils. The facility failed to ensure the microwave was without dried yellow substance. The facility failed to discard pans with carbon build up. The facility failed to ensure the prep sink was in proper working order. These failures could place residents at risk of food-borne illness. Findings included: During an observation of the main freezer in the kitchen area on 11/28/22 beginning at 9:05 a.m., revealed the following items: *1 unopened bag of frozen vegetables with no received date; *1 cup of frozen sherbet with no label or date; *1 box of unknown food item with no label or date; *4 logs of unknown meat with no label or date; *2 packages of unknown meat with no label or date; and *1 box of opened frozen rolls with no date. During an observation of the refrigerator in the kitchen area on 11/28/22 at 9:12 a.m., revealed 1 opened box of bacon with no date. During an observation of the drink dispenser machine in the kitchen area on 11/28/22 at 9:15 a.m. revealed small amount of brown fuzzy particle on the inside edge of the area that holds the juice cartridges. Below the drink dispenser, a medium sized plastic container with three drawers holding (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 37 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 utensils, had dried splatters of red and brown substance. Level of Harm - Minimal harm or potential for actual harm During an observation of the dry storeroom on 11/28/22 beginning at 9:18 a.m., revealed the following: *2 large pots with carbon build up on the bottom; Residents Affected - Many *2 muffin pans with carbon build up on the sides and bottom; *1 blue lid with a crack on the container with rice; *2 unopened boxes of cereal bars with no received date; *1 box with 3 packages of cereal with not received date; *4 unopened bags of potato chips with no received date; *1 unopened box of crackers with no received date; *4 unopened bags of dark brown sugar with no received date; and *1 bag of pasta with no date. During an observation of the main kitchen area on 11/28/22 beginning 9:25 a.m., revealed the following: *dried yellow substance in the microwave on the turning table; *5 flat cooking pans with carbon build up on the sides and bottom; and * bucket under prep sick sink filled with water. During an interview on 11/30/22 at 12:38 p.m., [NAME] K said her duties included cooking, preparing puree and mechanical soft diets, doing internal temperatures on food items, labeling/dating food items, and cleaning. She said it was all the kitchen staff's responsibility to label and date food items in the refrigerator, freezer, and dry storeroom. She said it helped you know what goes first and prevented residents from getting sick which could cause hospitalization or death. She said the dietary aides were responsible for the drink dispenser. She said there should not be brown fuzzy material in the holding area or stains on the utensil storage container. She said this could produce bacteria and get residents sick which could cause hospitalization or death. She said the cooks were responsible for the removal of carbon buildup on pots and pans. She said carbon buildup caused fires and could burn down the facility and leave residents with no home. She said everyone was responsible for ensuring food storage containers did not have cracked lids. She said the cracked lid introduced moisture, bugs, and bacteria which could make residents sick and alter the taste of the food causing weight loss. She said the cooks were responsible for cleaning the microwave. She said the microwave should be cleaned daily and as needed. She said an unclean microwave could grow bacteria. She said the prep sink had been leaking for a while. She said the maintenance man was aware it needed to be fixed. She said everyone should be emptying the water out of the bucket catching the leaking water. She said the leaking sink and bucket underneath with standing water was fall hazard and could air borne (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 38 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 bacteria. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/30/22 at 12:45 p.m., Kitchen aide L said she had worked at the facility since November 2021. She said her duties included cleaning, washing dishes, performing, and logging temperatures for the dishwasher, preparing drinks and desserts, making sanitation water for buckets, label and date food items, and rotating can goods. She said kitchen aides were responsible for the labeling and dating of dry goods. She said labeling and dating helped staff know when things expired so residents would not get food poison. She said food poisoning could cause residents hospitalization. She said the kitchen aides were responsible for the cleanliness of the drink dispenser. She said the dispenser should be wiped down daily but believed it was three times a week on the schedule. She said the bacteria could get into the resident's drinks causing sickness. She said the cleanliness of the utensil storage container was the responsibility of the evening kitchen aide. She said it was important to place cleaned utensils in a clean storage container to prevent cross contamination. She said she did not know about the cracked lid on the rice container in the dry storeroom. She said it was the kitchen aide's responsibility to make sure lids were secured on containers. She said outside chemicals could get in the rice and make resident sick. She said the prep sink had been broken for at least 6 months. She said the standing water could become contaminated and produce mold spores making everyone sick. She said the bucket of water was a fall hazard too. Residents Affected - Many During an interview on 11/30/22 at 1:00 p.m., the Dietary Manager said the refrigerator and freezer label/dating was the cook's responsibility and dry storage was the dishwashers. He said this ensured expired food was not served, making residents sick. He said the drink dispenser was the kitchen aide's responsibility. He said the nozzles were scheduled to be cleaned every 2 weeks, but the rest of the machine was supposed to be cleaned daily. He said this prevented cross contamination because dirty equipment introduced pathogens in the drinks. He said this could make residents sick causing adverse health issues or aggravating current health issues. He said the utensil storage container was a place to put clean dishes and should prevent cross contamination or introducing old stuff in new foods. He said carbon buildup on pots and pans was a fire hazard and should be cleaned off once a month. He said it was his responsibility because the chemicals the facility used were corrosive. He said the cleanliness of the microwave was the cook's responsibility. He said cleaning the microwave prevented cross contamination and introducing old stuff with new foods. He said the leaking prep sink with the bucket underneath catching water could have bacteria growth, attract pest, and fall hazard. He said it was his responsibility to tell the maintenance man to fix it and he did. During an interview on 11/30/22 at 4:40 p.m., the ADM said he expected the kitchen staff to label and date food items. He said kitchen sanitation should be performed daily for infection control. He said carbon buildup on pots and pans did not look good and did not want it to get in the food served to the residents. He said he did not know about the prep sink being broken. He said the dietary manager should be ensuring labeling, dating, and kitchen sanitation. He said the dietary manager should have notified him the sink was broken. During an interview on 11/30/22 at 5:00 p.m., the maintenance man said he did not know the prep sink in the kitchen was broken. He said staff normally verbally told him maintenance issues. He said he did not recall the dietary manager telling him about a broken sink. Record review of an employee in-service/educational attendance record dated 09/10/22 revealed topics discussed .dietary department mail, taking items out of boxes, storage, and tray tickets .signed by 4 dietary staff and Dietary Manager (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 39 of 40 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 675755 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare of Daingerfield 507 E W M Watson Blvd Daingerfield, TX 75638 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of an employee in-service/educational attendance record dated 10/10/22 revealed topics discussed .spoke with staff about minor issues and new attempt to put 200 and 300 hall trays on same cart .encouraged to do good .spoke about writing on chalkboard .spoke on cleaning habits Record review of a facility preventing foodborne illness dated 07/14 revealed .food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized .critical factors implicated in foodborne illness are .contaminated equipment .unsafe food sources .all food service equipment and utensils will be sanitized according to current guidelines . Event ID: Facility ID: 675755 If continuation sheet Page 40 of 40