Health inspection·December 28, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of Resident #4's baseline care plan dated 5/28/23 indicated his cognition was alert and cognitively intact and required one person assist with bed mobility, transfers walking in toileting . The care plan indicated the resident had a club foot, a new colostomy, and an abdominal incision. He had a new colostomy with interventions to teach the resident proper changing techniques and monitor site of colostomy. Record review of a Provider Investigation Report dated 5/28/23 at 9:59 p.m., indicated on the morning of 5/28/23 around 1:30 a.m. to 3:30 a.m. Resident #4 alleged LVN D verbally abused him. The report contained a letter from the Administrator that stated he first heard of the incident on Sunday, 5/28/23 at 7:30 p.m. Resident #4 said LVN D verbally abused him. The LVN continued to agitate and provoke Resident #4 to the end of his shift at 6:00 a.m. He said they flagged LVN D (an agency nurse) to no longer work for the facility. The investigation indicated Resident #4 was interviewed on 5/30/23 and said LVN D came to his room to help change his colostomy bag and did not bring the appropriate tools. Resident #4 said he felt LVN D did not want to help him. Resident #4 said he told LVN D to get his A out of his room. The Resident said LVN D responded with, I will mop you with the floor. Resident #4 responded. I'll beat your A. Resident #4 said he did not feel safe with LVN D in the building as his nurse. When asked Resident #4 said he did not have a knife. He said he felt he needed to bluff LVN D to ensure his safety. The resident's room was searched and there was no knife found. Interview with LVN D indicated Resident #4 had asked him to help him change his colostomy, in his room and then came to the nurse's station to ask again. LVN D said he told Resident #4 he would assist him when he finished his rounds. LVN D said when he went to the room Resident #4 was rude and talked harshly to him. LVN D said Resident #4 told him, To get his A out of his room. He said the resident continued to give him attitude the rest to the night. The resident told one of the aides he had a knife. The LVN D denied he had harassed the resident. The report indicated a statement from one of the aides indicated LVN D did try and provoke Resident #4 during the night. Record review of a statement that accompanied the Provider Investigation Report for Resident # 4 indicated on 5/28/23 [They (CNA C and CNA E) heard LVN D arguing loudly with Resident # 4. Resident #4 was saying if you are going to hit me then hit me. We (CNA C and CNA E) walked down the hall and LVN D was coming out the room. LVN D said if he was not a professional, he would have whopped Resident #4's A. After that, every time LVN D walked by Resident #4 he would giggle at him and smacked the wall like he was trying to intimidate Resident #4. LVN D really upset Resident #4 to the point he did not feel safe and wanted to leave. LVN D did tell us he told the resident if he was not a professional, he would whip his A.] the statement was signed by CNA C. Record review of the Provider Report Post Action Investigation indicated [ LVN D should have never allowed the situation to get out of hand. He should have been more patient with Resident #4 and never made Resident #4 feel he needed to protect himself. Resident #4 should have shown LVN D more patience as he was seeing other residents during his rounds. Both individuals should have conducted themselves more professionally to ensure a healthy exchange of information and services to be achieved. I feel both men were at fault and this situation could have easily ben avoided. I am finding this inconclusive because both men conducted themselves inappropriately. Neither one were at risk of injury or injured. They obviously do not get along with each other. I do not agree how LVN D conducted himself at the facility and we have taken measures for him not to return to the facility as he is not employee. He is an agency employee and will not be allowed to work another shift at this facility.] The form was signed by the Administrator on 5/31/23. During an interview on 12/18/23 at 2:20 p.m. CNA C said she and CNA E were working in another resident room and came into the hallway and heard loud voices coming from Resident #4's room on morning (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 2 of 29 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 12/28/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some of 5/28/23. She said the LVN D came out of the room and was hollering back, I would whip your A if you were not a resident. She said Resident # 4 was very upset and wanted to leave the facility. He tried to exit through several of the doors. She said she spent the night trying to keep him from leaving and watching LVN D try and aggravate the resident. She said every time LVN D would pass by the Resident #4. He would giggle and hit on the wall or the side rails as if he was hitting someone. She said the nurse's behavior was not professional at all, in fact he acted like a child. She said she did not remember if she called anyone to report the incident or not. She spent the night trying to keep the peace and trying to keep Resident#4 from leaving. She said at one point they were outside in the smoking area, and Resident#4 said he would throw himself on the ground, throw his wheelchair down the steps, crawl down the steps and get back in his wheelchair and leave. During an interview on 12/18/23 at 2:25 p.m., the Administrator said he did not remember who notified him about the incident that happened on 5/28/23. He said he was told it happened on that morning around 1:30 a.m. or 2:00 a.m. he said it was not reported to him until 5/28/23 at 7:30 p.m. and he called it into the state around 9:00 p.m. He said in the defense of the resident he was very independent. He said the resident told the nurse he had a knife because he tried to intimidate him when he walked by. The Administrator said the resident did not have a knife and he could not find one. He said the resident admitted he just felt he needed some type of protection from the LVN D. During an interview on 12/18/23 at 3:30 p.m., CNA E said when they rounded the corner on the night of 5/28/23, LVN D and Resident #4 were arguing. The nurse was LVN D was hollering at the Resident #4. We (CNA C and CNA E) tried to deescalate the situation. CNA E said Resident #4 tried to leave through two different doors. She said the nurses' behavior was not professional, he was hollering and talking smart. Resident #1 Record review of Resident #1's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were Alzheimer's, disease, anxiety disorder, and history of falling. Record review of Resident #1's quarterly MDS dated [DATE] indicated she had no cognitive impairment. The resident used mobility devices of a walker and a wheelchair. She required partial assistance with hygiene, and partial assistance with chair to bed transfer, and partial assist with toilet transfer. Record review of Resident #1's care. Plan indicated she had a problem of ADL function. She required two people assist with bathing, two people assist with toileting, and two people assist with bed mobility. Record review of a Complaint/Concern form dated 7/3/23 indicated Resident #1 was filing a complaint against CNA A. Resident #1 said CNA A was rough in the way that she handled her care, causing her pain and discomfort when she was turning her, placing her in the chair and any other physical contact. Resident #1 said CNA A spoke to her in a rude and hurtful manner. Resident #1 said she refused to put up with it any longer. CNA A said Resident # 1, was always complaining about something and making notes to tell on me. Resident #1 disagreed with that statement. Resident #1 said that she refused to be spoken to or treated to rudely any longer. The resident said she asked CNA A to stop on several occasions, but it continued. Resident #1 said it had become harassment. The resident did not want CNA A to be associated with her care any longer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 3 of 29 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 12/28/2023 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 0600 Resident #3 Level of Harm - Immediate jeopardy to resident health or safety Record review of a face sheet for Resident #3 with no date indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were stroke, removal of the right breast, acute kidney failure, stiffness in the right knee, need for assistance with personal care, abnormal posture Disorder of the bone upper arm, and muscle weakness. Residents Affected - Some Record review of Resident #3's quarterly MDS dated [DATE] indicated she had no cognitive impairment. Her functional status was she used a wheelchair for mobility. She had impairment on her upper extremity shoulder, elbow, wrist, and hand, and she had impairment on her lower extremity hip knee, ankle, and foot. Record review of Resident #3's care plan dated 11/15/23 indicated a problem of limited range of motion to the right upper and lower extremities. Resident # 3 required assistance with active and passive range of motion in a splint applied to the right hand. Resident # 3 had problems of ADL function and required a lift for transfers. The resident required one or two people to aid turn and reposition in bed frequently to prevent skin breakdown. The resident required one person assist for dressing, and two people for a transfer by Hoyer lift. Record review of a Complaint/Concern Form dated 7/3/23 indicated Resident# 3 filed a complaint against CNA A. The Complaint indicated the aide was rough in the way she handled Resident #3's care, causing her pain and discomfort when she was turning Resident #3, placing her in the chair and other physical contact. Resident #3 said the way CNA A spoke to her was rude, hurtful, and she refused to put up with it any longer. The resident said CNA A told her that turning her hurt her because she was a big woman, and she was doing it by herself. Resident # 3 said she told CNA A she should ask for help. Resident # 3 said CNA A told her she stunk after Resident # 3 had breast surgery. The Resident # 3 said the CNA told her the smell coming from her breast stinking up the room. The form indicated CNA A said she and Resident #3 were friends and that was just the way they talked to each other. Resident #3 disagreed with that statement, and she said she did comment back to the aide but in self-defense. Resident #3 said they were not friends and she refused to be spoken to or treated rudely any longer. Resident # 3 said asked CNA A to stop on multiple occasions, but her attitude continued. Resident #3 said it had become harassment. The resident did not want CNA A to be associated with her care any longer. When talking to CNA A about the event, she said that she and the resident joked all the time, and she was unaware that it bothered the resident. CNA A stated, verbally that she would not joke like that again, and would have a more professional manner when interacting with residents. The investigation finding indicated, Resident # 3 said she did not have an issue with CNA A but was embarrassed by the event. The steps taken to correct the action was a counseling form on how to keep a professional manner. The steps taken to correct the issue was CNA A was removed from her care and could only provide care when assisting other staff. A counseling will be provided to CNA A on treating residents in a professional manner. Record review of a Counseling/Disciplinary note for CNA A dated 7/18/23 (15 days later) indicated the reason for the counseling was multiple complaints on CNA A for being verbally, aggressive, and short with Residents. The corrective actions were to speak with the aid about how to approach residents in a more professional manner and it was signed by the DON and CNA A on 7/19/23. There was no Inservice attached. Record review of a Complaint/Concern form dated 9/5/23 indicated Resident #1 reported that she continued to have problems with CNA A. She stated that on 8/30/23 CNA A continuously interrupted her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 4 of 29 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 12/28/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some shower to talk to the shower aid, making her uncomfortable. The resident stated CNA A's language was profane. Resident #1 said on the following day, 8/31/23 CNA A and another aide came into the room going through her roommates closet and cursing very loudly. Resident #1 said they were gossiping about other employees and used an extreme amount of profanity. Resident #1 said that she was very offended. Resident #1 said on the following morning she was sleeping when CNA A came into her room, and said loudly, Your breakfast is served. Wake up and eat it. Resident #1 said it was very rude, so she refused acknowledge her. Resident #1 said, I feel targeted . Resident #1 said she spoke to the nurse on the weekend about her concerns ( no statement from the nurse) Resident #1 said she felt CNA A used the excuse of taking care of her roommate, as an opportunity to antagonize an aggravate her . The allegation was investigated, and the IDT meeting was held. The findings were CNA A was guilty of the events, and will be given the option of quitting or resigning from her position. Signed by the Administrator Record review of a Counseling/Disciplinary note for CNA A dated 9/8/23 indicated CNA A was discharged and her last day at work was 9/8/23. The form indicated this would serve as termination. Corrective actions had already been taken and misconduct continued. The employee comments were, Do not understand what the reason. Signed by CNA A. During an interview on 12/14/23 at 11:00 a.m., the DON said she had determined Resident #1's allegations were true. She did not have statements from the shower aide, nurse, or CNA A. She said they had gotten multiple complaints regarding the aide and felt it was time to let her go. When asked about the statement on the grievance dated 9/5/23 that said CNA A was guilty of the allegations made by Resident #1. The DON said she did not remember how she verified the events that occurred were true regarding Resident #1's allegations. During an interview on 12/14/23 at 11:50 p.m., the DON and the Administrator said because of her previous behaviors with residents, CNA A was terminated, on 9/8/23. The DON said there was another resident on the same hall as Resident #1 who did not want CNA A in her room. That resident changed her details of the occurrence several times so they could not validate her allegations. However, the resident said she did not like CNA A and did not want her back in her room. The DON and Administrator said Resident #1 and Resident #3's issues bordered on abuse but neither resident said they were abused. The Administrator and the DON said they did not know that CNA A continued to go into Resident #1's room. During an interview on 12/18/23 at 11:58 a.m., the Administrator said CNA A worked at a fast pace and the former DON loved her (the former DON left 6/30/23). He said he tried to work with CNA A. He felt her actions would get right up to the line of abuse and then she would pull back. The Administrator said he did not think CNA A was a nice person. The Administrator said one issue with CNA A was that she had a foul mouth. The Administrator said he had tried to encourage her not to use foul language around residents. He said CNA A did not have much respect for authority, and she did what she wanted to do. The Administrator said they had to let her go because warnings did not help, and she had gone past the point respecting the residents. During an interview on 12/18/23 at 12:50 p.m., Resident #3 said the things CNA A did to her could have been abuse. Resident # 3 stated it started out as joking, and she would never have called CNA A her friend. Resident # 3 said CNA A took the snide comments to a whole different level. Resident #3 said CNA A was rough when she provided care to her. Resident#3 said would tell CNA A she was rough and hurting her. She said CNA A knew she was hurting her and did not care. Resident# 3 said on one occasion when she complained to aide about her being rough, CNA A told her, Well you are not light. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 5 of 29 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 12/28/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Resident # 3 asked her to get some help if she was too heavy and the aide refused. Resident #3 said she had a stroke on her right side, and it hurt when she was moved around roughly. Resident#3 said some of the things the aide said were hurtful and hurt her feelings. cane said when CNA A provided care to her, the aide knew she was rough, and hurt her but did not care. Resident#3 said complained after she could not take anymore. Resident #3 said CNA A was not allowed back in her room and did not speak to her in the hallway. Residents Affected - Some During an interview on 12/18/23 at 12:55 p. m. Resident #2 said CNA A had been unkind to her on several occasions. When she finally told the staff, she felt threatened when the aide came in the room. She said she might have confused the events some, but the aide was mean, and she did not want her in her room. She said she heard they terminated her because she was mistreated another resident. During an interview on 12/18/23 at 2:10 p.m., Resident #1 said she remembered CNA A quite well. She had been rude and mean to her. She had requested she not be allowed in her room. She said on several occasions when she was in the shower room getting assistance with a shower. She said CNA A would come in and take a seat and try to intimidate her. She said CNA A would talk, and all kinds of filthy language would come out of her mouth. She asked her to leave the shower room on at least two occasions because she did not feel comfortable with her there. She said on several occasions she would come into her room and move her walker around in the room or come in to care for the roommate and use filthy language. She had complained back in September, and she was finally let go. Resident #1 said she felt the aide was trying to intimidate her because she had complained of her attitude and treatment towards her in the past. During an interview on 12/18/23 at 2:25 p.m., the Administrator he was not aware of any furniture being moved in Resident #1's room. He said there was a dresser she complained had been moved and he moved it back. It was only moved a few inches. He was not aware of any allegation that CNA A had been in Resident #1's room. He said he thought he had statements from staff regarding the issues with CNA A but could not find any. He said he did conduct in services after each episode of possible abuse. During an interview on 12/18/23 at 3:00 p.m., the DON said she did not remember Resident #1 saying anything about her things being moved around in her room. During a telephone interview on 12/18/23 at 3:38 p, CNA B (former shower aide) said CNA A did come in a few times when she was giving Resident #1 a shower. She said she had only come in to get a basin of warm water or something like that. She did not remember her cursing but she did remember Resident #1 asking CNA A to leave the shower room and she left. During an interview on 12/27/23 at 11:20 a.m. , the Administrator said they had a QA meeting scheduled for tomorrow, 12/28/23. He said they had not QA the event between Resident #4 and LVN D after reviewing his QA book. During an interview on 12/27/23 at 12:30 p.m. the Administrator said he said something about Abuse and Neglect during every in service. He did not have any additional content for the for the 6/9/23 after the incident with Resident #4. The administrator there was no in-service regarding Resident Behaviors or deescalating agitation or aggressive situations. During an interview on 12/27/23 at 1:55 p.m. Administrator said CNA A was guilty of using foul language in the shower room. He said CNA A admitted to using foul language in the shower room. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 6 of 29 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 12/28/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Administrator said CNA A never admitted to giving care to Resident #1 or doing anything with #1. He said CNA A was not allowed to give care to Resident #1. He said they had written on the grievance form she was guilty but not of all of the allegations made. He said they did not interview other staff or get statements about the incident, so they could not verify that Resident #1's allegations were true or not. They were aware CNA A continued to receive complaints about her behaviors and they could not allow her to continue to work for the facility. He said they had not taken statements from the aide or the aides that may have witnesses the behaviors. The Administrator said what was he supposed to do with the LVN D. He said if he sent the nurse home, they would have only had one nurse in the building that night. The Administrator said at that time if they called the former DON, she would not have answered the phone and she sure would not have come to the facility to fill for the LVN. He said he was between a rock and a hard place. If he sent the nurse home, he would not have had sufficient nursing coverage for the facility, what was he supposed to do? During an interview on 12/27/23 at 2:07 p.m., CNA A said Resident #1 asked her to leave the shower room a couple of times when she was getting a shower. CNA A said she had gone to the shower room to get hot water. CNA A said she may have said a curse word or two while in the shower, she was not sure. She said she may have delivered a breakfast tray to Resident #1 if she was passing trays and had one for her roommate. She said she was not told to not go in Resident #1's Room, she was told not to provide care to Resident #1. She said Resident #1 had a roommate and she provided care to her. CNA A said Resident #1 may have heard her cursing. CNA A said the Kiosk that they used to input resident care information was right outside of Resident #1's room and she often cursed while using it. CNA A said she was told not to go into Resident #3's room, and she had not been back in her room. She said Resident #3 was upset and it could have been something that she said. CNA said Resident #3 took what she said out of context. The aide said when she provided care to Resident #3 who was a two person assist, there was always at least one other person in the room with her. CNA A said she never provided care to Resident #3 without assistance. She said she told Resident #3 told her there was something wrong with her breast, it smelled. She said she even went to get the nurse ( can not remember who) to look at it. She said the nurse came in and told Resident #3 something was wrong or needed to take the bra off and it had a smell to it. CNA A said CNA O was the aide that was with her that day. CNA A said she may let a [NAME] word slip sometimes when she walked out of a room. She said the Administrator told her was not obligated to tell her why they terminated her. She said she had in services on abuse and knew what abuse was. CNA A said if cursing close to a resident was abuse, then Yes she did abuse residents. CNA A said she knew they wrote several things up on her about residents complaining. She said the Administrator told her that if he turned the write ups into the state his job would be on the line. CNA A said she had about 3 residents that complained about her on that hall and did not want her providing care to them but the facility never moved me from that hall. CNA A said when complaints started coming in the Administrator and DON brought her in to talk about the same things that happen back in July. She said she no longer worked at the facility and these things all happened a long time ago. CNA A wanted to know why the incidents with Resident #1 and Resident # 3 were being questioned about today. She said the Administrator told her they were not called into the State. During an interview on 12/27/23 at 2:12 p.m., Administrator said told CNA A on the incident in July if they continued to get complaints on her she would be terminated. The Administrator said CNA A had a very foul mouth he said he had heard her curing and had reprimanded her on several occasions to stop curing in the facility. He said Resident #1 was very dedicated to her religion and CNA A cursing would have been very offensive to Resident #1. He said CNA A knew that and that is probably why she cursed outside (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 7 of 29 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 12/28/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the resident's door or whenever Resident #1 could hear her. He said CNA B and CNA O were CNA A's friends and they would not say anything bad about CNA A. He said CNA O was terminated and she and CNA A work at the same place. The Administrator said when they worked at this facility they would team up and work with new aides, most of which would quit. He said it was not good for the business at all. During an interview on 12/27/23 at 2:31 p.m., the ADON said she had worked at the facility for 15 years. She said she took the position of ADON about June 2023. She said CNA A seemed to be very kind and caring to the residents in front of administrative staff. However, CNA A came across rough and plan speaking. The ADON said sometimes it appeared that CNA A was playing or joking. The ADON said CNA A told her Resident #3's breast smelled told to come down and because the breast smelled like death. She said Resident #3 did not want to get people in trouble and was kind of laughing at the time. The ADON said Resident #3's breast did smell and had dried blood and the nurses should have been washing a surgical wound. She said she knew they called CNA A in to talk to her after the two complaints were voiced by Resident #1 and Resident #3. She said she did not know where it went from there. The ADON said with the complaint on 9/5/23 they pulled CNA A in the office and told her had too many complaints on her and we needed to let her go. The ADON said she had heard CNA A curse on the hallway. The ADON said after reviewing the schedule and the time sheets. The only thing she could tell was the incidents with Residents #1 and #3 did not happen on 7/3/23. She said she did not work that day and neither did CNA A. she said she could not figure out when the incident happened, but it was before 7/3/23. Record review of the facilities, abuse and neglect protocol with no date indicated abuse is defined as the willful inflection of injury, unreasonable, confinement, intimidation, or punishment with resulting physical harm, pain of mental anguish. Abuse also included the derivation by an individual, included caregiver, goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. The policy statement, a resident, have a right to be free from abuse, neglect. This includes but not limited to freedom from corporal, punishment, involuntary, seclusion, verbal, mental, physical abuse, the development, an implementation, and policy development, and implement policies and procedures in preventing abuse, neglect, or mistreatment of resident to identifying all possible incidence of abuse to protect resident during abuse investigations. Establish and implement a QAIP review and analysis abuse and implement changes to prevent future currencies of abuse . Each interview will be conducted separately in a private location. Witness reports will be obtained in writing either witness will write his or her statement, sign, and date. Or the investigator may obtain a statement read it back to the member and have him sign and date it. Reporting an alleged violation of abuse or neglect will be reported immediately, but not later than: Two hours if the alleged volition involves abuse or has resulted in serious bodily injury or 24 hours if the alleged violations involved abuse and had not resulted in serious bodily injury. This was determined to be an Immediate Jeopardy (IJ) on 12/27/23 at 3:00 p.m. The facility Administrator, and ADON were notified. The Administrator was provided with the IJ template on 12/27/23 at 3:00 p.m. Plan of Removal for [Tag F-600: The employee responsible for abuse to Resident 1 and 3 has been terminated on 9/8/2023. The shift key employee responsible for abuse on resident 4 has been red flagged and is no longer able to pick up shifts or return to this facility effective 5/28/2023. Administrator and DON followed up with residents after incidents to ensure no psychological impact was made. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 8 of 29 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 12/28/2023 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 0600 An immediate in-service has been started for all staff with the subject of De-escalating Resident Behaviors. Level of Harm - Immediate jeopardy to resident health or safety Conduct a safe survey with all current interviewable residents. (See attachment 1 below). This will establish residents, individuals, or clients are no longer at a high risk of serious injury, harm, impairment, or death. o Residents Affected - Some Surveys will be completed by 12:00pm 12/28/2023. o Surveys will be completed by the following department heads: Social Services BOM Dietary Supervisor MDS Coordinator Director of Rehabilitation ADON o Non-interviewable residents will have skin assessment completed once a week, for 3 months to be reviewed monthly in QA. Documented daily rounds to determine if non-interviewable residents are free from abuse to be completely 3 times a week for 3 months and reviewed in monthly QA. Create a new policy for Abuse which will include the following: o Definitions o Screening o Training o (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 9 of 29 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 12/28/2023 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 0600 Prevention Level of Harm - Immediate jeopardy to resident health or safety o Residents Affected - Some o Identification Investigation o Protection o Reporting The new Policy was completed by Administrator. Policy[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 10 of 29 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 12/28/2023 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure they implemented their abuse policy to ensure residents had the right to be free from abuse or neglect for 4 of 7 residents reviewed for abuse. (Resident #1, Resident #2, Resident #3, and Resident #4) Residents Affected - Some The facility failed to follow their policy and ensure Resident #4 was not verbally abuse by LVN D and mental abused and harassed for the remainder of the night on 5/28/23. The facility failed to follow their policy and identify harassment, and intimidation for Resident #1, Resident #2, and Resident #3 when they reported CNA A had intentionally tried to intimidate them. The facility failed to follow their policy when Resident #3 said CNA A intentionally caused her pain. An Immediate Jeopardy (IJ) situation was identified on 12/27/23 at 3:00 p.m. while the IJ was removed on 12/28/23 at 8:18 p.m., the facility remained out of compliance at a potential for actual harm with a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of physical harm and or emotional abuse. Findings included: Record review of Resident #4's face sheet with no date indicated he was admitted to the facility on [DATE] and discharge 6/2/23. Resident #4 was a [AGE] year-old male with admitting diagnoses of need for assistance with personal care, history of falling, colostomy status, mood disturbance, anxiety, and lack of coordination. Record review of Resident #4's admission MDS dated [DATE] indicated the resident had moderate cognitive impairment. His functional status indicated he required extensive assist of one person with transfers, toilet use and dressing. The resident was unable to stand and stabilize himself. He did not walk. He was unable to move himself off the toilet, and he was not steady with transfers from surface to surface. Review of Resident #4's baseline care plan dated 5/28/23 indicated his cognition was alert and cognitively intact and required one person assist with bed mobility, transfers walking in toileting . The care plan indicated the resident had a club foot, a new colostomy, and an abdominal incision. He had a new colostomy with interventions to teach the resident proper changing techniques and monitor site of colostomy. Record review of a Provider Investigation Report dated 5/28/23 at 9:59 p.m., indicated on the morning of 5/28/23 around 1:30 a.m. to 3:30 a.m. Resident #4 alleged LVN D verbally abused him. The report contained a letter from the Administrator that stated he first heard of the incident on Sunday, 5/28/23 at 7:30 p.m. Resident #4 said LVN D verbally abused him. The LVN continued to agitate and provoke Resident #4 to the end of his shift at 6:00 a.m. He said they flagged LVN D (an agency nurse) to no longer work for the facility. The investigation indicated Resident #4 was interviewed on 5/30/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 11 of 29 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 12/28/2023 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some and said LVN D came to his room to help change his colostomy bag and did not bring the appropriate tools. Resident #4 said he felt LVN D did not want to help him. Resident #4 said he told LVN D to get his A out of his room. The Resident said LVN D responded with, I will mop you with the floor. Resident #4 responded. I'll beat your A. Resident #4 said he did not feel safe with LVN D in the building as his nurse. When asked Resident #4 said he did not have a knife. He said he felt he needed to bluff LVN D to ensure his safety. The resident's room was searched and there was no knife found. Interview with LVN D indicated Resident #4 had asked him to help him change his colostomy, in his room and then came to the nurse's station to ask again. LVN D said he told Resident #4 he would assist him when he finished his rounds. LVN D said when he went to the room Resident #4 was rude and talked harshly to him. LVN D said Resident #4 told him, To get his A out of his room. He said the resident continued to give him attitude the rest to the night. The resident told one of the aides he had a knife. The LVN D denied he had harassed the resident. The report indicated a statement from one of the aides indicated LVN D did try and provoke Resident #4 during the night. Record review of a statement that accompanied the Provider Investigation Report for Resident # 4 indicated on 5/28/23 [They (CNA C and CNA E) heard LVN D arguing loudly with Resident # 4. Resident #4 was saying if you are going to hit me then hit me. We (CNA C and CNA E) walked down the hall and LVN D was coming out the room. LVN D said if he was not a professional, he would have whopped Resident #4's A. After that, every time LVN D walked by Resident #4 he would giggle at him and smacked the wall like he was trying to intimidate Resident #4. LVN D really upset Resident #4 to the point he did not feel safe and wanted to leave. LVN D did tell us he told the resident if he was not a professional, he would whip his A.] the statement was signed by CNA C. Record review of the Provider Report Post Action Investigation indicated [ LVN D should have never allowed the situation to get out of hand. He should have been more patient with Resident #4 and never made Resident #4 feel he needed to protect himself. Resident #4 should have shown LVN D more patience as he was seeing other residents during his rounds. Both individuals should have conducted themselves more professionally to ensure a healthy exchange of information and services to be achieved. I feel both men were at fault and this situation could have easily ben avoided. I am finding this inconclusive because both men conducted themselves inappropriately. Neither one were at risk of injury or injured. They obviously do not get along with each other. I do not agree how LVN D conducted himself at the facility and we have taken measures for him not to return to the facility as he is not employee. He is an agency employee and will not be allowed to work another shift at this facility.] The form was signed by the Administrator on 5/31/23. During an interview on 12/18/23 at 2:20 p.m. CNA C said she and CNA E were working in another resident room and came into the hallway and heard loud voices coming from Resident #4's room on morning of 5/28/23. She said the LVN D came out of the room and was hollering back, I would whip your A if you were not a resident. She said Resident # 4 was very upset and wanted to leave the facility. He tried to exit through several of the doors. She said she spent the night trying to keep him from leaving and watching LVN D try and aggravate the resident. She said every time LVN D would pass by the Resident #4. He would giggle and hit on the wall or the side rails as if he was hitting someone. She said the nurse's behavior was not professional at all, in fact he acted like a child. She said she did not remember if she called anyone to report the incident or not. She spent the night trying to keep the peace and trying to keep Resident#4 from leaving. She said at one point they were outside in the smoking area, and Resident#4 said he would throw himself on the ground, throw his wheelchair down the steps, crawl down the steps and get back in his wheelchair and leave. During an interview on 12/18/23 at 2:25 p.m., the Administrator said he did not remember who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 12 of 29 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 12/28/2023 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 0607 Level of Harm - Immediate jeopardy to resident health or safety notified him about the incident that happened on 5/28/23. He said he was told it happened on that morning around 1:30 a.m. or 2:00 a.m. he said it was not reported to him until 5/28/23 at 7:30 p.m. and he called it into the state around 9:00 p.m. He said in the defense of the resident he was very independent. He said the resident told the nurse he had a knife because he tried to intimidate him when he walked by. The Administrator said the resident did not have a knife and he could not find one. He said the resident admitted he just felt he needed some type of protection from the LVN D. Residents Affected - Some During an interview on 12/18/23 at 3:30 p.m., CNA E said when they rounded the corner on the night of 5/28/23, LVN D and Resident #4 were arguing. The nurse was LVN D was hollering at the Resident #4. We (CNA C and CNA E) tried to deescalate the situation. CNA E said Resident #4 tried to leave through two different doors. She said the nurses' behavior was not professional, he was hollering and talking smart. Resident #1 Record review of Resident #1's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were Alzheimer's, disease, anxiety disorder, and history of falling. Record review of Resident #1's quarterly MDS dated [DATE] indicated she had no cognitive impairment. The resident used mobility devices of a walker and a wheelchair. She required partial assistance with hygiene, and partial assistance with chair to bed transfer, and partial assist with toilet transfer. Record review of Resident #1's care. Plan indicated she had a problem of ADL function. She required two people assist with bathing, two people assist with toileting, and two people assist with bed mobility. Record review of a Complaint/Concern form dated 7/3/23 indicated Resident #1 was filing a complaint against CNA A. Resident #1 said CNA A was rough in the way that she handled her care, causing her pain and discomfort when she was turning her, placing her in the chair and any other physical contact. Resident #1 said CNA A spoke to her in a rude and hurtful manner. Resident #1 said she refused to put up with it any longer. CNA A said Resident # 1, was always complaining about something and making notes to tell on me. Resident #1 disagreed with that statement. Resident #1 said that she refused to be spoken to or treated to rudely any longer. The resident said she asked CNA A to stop on several occasions, but it continued. Resident #1 said it had become harassment. The resident did not want CNA A to be associated with her care any longer. Resident #3 Record review of a face sheet for Resident #3 with no date indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were stroke, removal of the right breast, acute kidney failure, stiffness in the right knee, need for assistance with personal care, abnormal posture Disorder of the bone upper arm, and muscle weakness. Record review of Resident #3's quarterly MDS dated [DATE] indicated she had no cognitive impairment. Her functional status was she used a wheelchair for mobility. She had impairment on her upper extremity shoulder, elbow, wrist, and hand, and she had impairment on her lower extremity hip knee, ankle, and foot. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 13 of 29 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 12/28/2023 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #3's care plan dated 11/15/23 indicated a problem of limited range of motion to the right upper and lower extremities. Resident # 3 required assistance with active and passive range of motion in a splint applied to the right hand. Resident # 3 had problems of ADL function and required a lift for transfers. The resident required one or two people to aid turn and reposition in bed frequently to prevent skin breakdown. The resident required one person assist for dressing, and two people for a transfer by Hoyer lift. Residents Affected - Some Record review of a Complaint/Concern Form dated 7/3/23 indicated Resident# 3 filed a complaint against CNA A. The Complaint indicated the aide was rough in the way she handled Resident #3's care, causing her pain and discomfort when she was turning Resident #3, placing her in the chair and other physical contact. Resident #3 said the way CNA A spoke to her was rude, hurtful, and she refused to put up with it any longer. The resident said CNA A told her that turning her hurt her because she was a big woman, and she was doing it by herself. Resident # 3 said she told CNA A she should ask for help. Resident # 3 said CNA A told her she stunk after Resident # 3 had breast surgery. The Resident # 3 said the CNA told her the smell coming from her breast stinking up the room. The form indicated CNA A said she and Resident #3 were friends and that was just the way they talked to each other. Resident #3 disagreed with that statement, and she said she did comment back to the aide but in self-defense. Resident #3 said they were not friends and she refused to be spoken to or treated rudely any longer. Resident # 3 said asked CNA A to stop on multiple occasions, but her attitude continued. Resident #3 said it had become harassment. The resident did not want CNA A to be associated with her care any longer. When talking to CNA A about the event, she said that she and the resident joked all the time, and she was unaware that it bothered the resident. CNA A stated, verbally that she would not joke like that again, and would have a more professional manner when interacting with residents. The investigation finding indicated, Resident # 3 said she did not have an issue with CNA A but was embarrassed by the event. The steps taken to correct the action was a counseling form on how to keep a professional manner. The steps taken to correct the issue was CNA A was removed from her care and could only provide care when assisting other staff. A counseling will be provided to CNA A on treating residents in a professional manner. Record review of a Counseling/Disciplinary note for CNA A dated 7/18/23 (15 days later) indicated the reason for the counseling was multiple complaints on CNA A for being verbally, aggressive, and short with Residents. The corrective actions were to speak with the aid about how to approach residents in a more professional manner and it was signed by the DON and CNA A on 7/19/23. There was no Inservice attached. Record review of a Complaint/Concern form dated 9/5/23 indicated Resident #1 reported that she continued to have problems with CNA A. She stated that on 8/30/23 CNA A continuously interrupted her shower to talk to the shower aid, making her uncomfortable. The resident stated CNA A's language was profane. Resident #1 said on the following day, 8/31/23 CNA A and another aide came into the room going through her roommates closet and cursing very loudly. Resident #1 said they were gossiping about other employees and used an extreme amount of profanity. Resident #1 said that she was very offended. Resident #1 said on the following morning she was sleeping when CNA A came into her room, and said loudly, Your breakfast is served. Wake up and eat it. Resident #1 said it was very rude, so she refused acknowledge her. Resident #1 said, I feel targeted . Resident #1 said she spoke to the nurse on the weekend about her concerns ( no statement from the nurse) Resident #1 said she felt CNA A used the excuse of taking care of her roommate, as an opportunity to antagonize an aggravate her . The allegation was investigated, and the IDT meeting was held. The findings were CNA A was guilty of the events, and will be given the option of quitting or resigning from her position. Signed by the Administrator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 14 of 29 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 12/28/2023 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of a Counseling/Disciplinary note for CNA A dated 9/8/23 indicated CNA A was discharged and her last day at work was 9/8/23. The form indicated this would serve as termination. Corrective actions had already been taken and misconduct continued. The employee comments were, Do not understand what the reason. Signed by CNA A. During an interview on 12/14/23 at 11:00 a.m., the DON said she had determined Resident #1's allegations were true. She did not have statements from the shower aide, nurse, or CNA A. She said they had gotten multiple complaints regarding the aide and felt it was time to let her go. When asked about the statement on the grievance dated 9/5/23 that said CNA A was guilty of the allegations made by Resident #1. The DON said she did not remember how she verified the events that occurred were true regarding Resident #1's allegations. During an interview on 12/14/23 at 11:50 p.m., the DON and the Administrator said because of her previous behaviors with residents, CNA A was terminated, on 9/8/23. The DON said there was another resident on the same hall as Resident #1 who did not want CNA A in her room. That resident changed her details of the occurrence several times so they could not validate her allegations. However, the resident said she did not like CNA A and did not want her back in her room. The DON and Administrator said Resident #1 and Resident #3's issues bordered on abuse but neither resident said they were abused. The Administrator and the DON said they did not know that CNA A continued to go into Resident #1's room. During an interview on 12/18/23 at 11:58 a.m., the Administrator said CNA A worked at a fast pace and the former DON loved her (the former DON left 6/30/23). He said he tried to work with CNA A. He felt her actions would get right up to the line of abuse and then she would pull back. The Administrator said he did not think CNA A was a nice person. The Administrator said one issue with CNA A was that she had a foul mouth. The Administrator said he had tried to encourage her not to use foul language around residents. He said CNA A did not have much respect for authority, and she did what she wanted to do. The Administrator said they had to let her go because warnings did not help, and she had gone past the point respecting the residents. During an interview on 12/18/23 at 12:50 p.m., Resident #3 said the things CNA A did to her could have been abuse. Resident # 3 stated it started out as joking, and she would never have called CNA A her friend. Resident # 3 said CNA A took the snide comments to a whole different level. Resident #3 said CNA A was rough when she provided care to her. Resident#3 said would tell CNA A she was rough and hurting her. She said CNA A knew she was hurting her and did not care. Resident# 3 said on one occasion when she complained to aide about her being rough, CNA A told her, Well you are not light. Resident # 3 asked her to get some help if she was too heavy and the aide refused. Resident #3 said she had a stroke on her right side, and it hurt when she was moved around roughly. Resident#3 said some of the things the aide said were hurtful and hurt her feelings. cane said when CNA A provided care to her, the aide knew she was rough, and hurt her but did not care. Resident#3 said complained after she could not take anymore. Resident #3 said CNA A was not allowed back in her room and did not speak to her in the hallway. During an interview on 12/18/23 at 12:55 p. m. Resident #2 said CNA A had been unkind to her on several occasions. When she finally told the staff, she felt threatened when the aide came in the room. She said she might have confused the events some, but the aide was mean, and she did not want her in her room. She said she heard they terminated her because she was mistreated another resident. During an interview on 12/18/23 at 2:10 p.m., Resident #1 said she remembered CNA A quite well. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 15 of 29 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 12/28/2023 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some had been rude and mean to her. She had requested she not be allowed in her room. She said on several occasions when she was in the shower room getting assistance with a shower. She said CNA A would come in and take a seat and try to intimidate her. She said CNA A would talk, and all kinds of filthy language would come out of her mouth. She asked her to leave the shower room on at least two occasions because she did not feel comfortable with her there. She said on several occasions she would come into her room and move her walker around in the room or come in to care for the roommate and use filthy language. She had complained back in September, and she was finally let go. Resident #1 said she felt the aide was trying to intimidate her because she had complained of her attitude and treatment towards her in the past. During an interview on 12/18/23 at 2:25 p.m., the Administrator he was not aware of any furniture being moved in Resident #1's room. He said there was a dresser she complained had been moved and he moved it back. It was only moved a few inches. He was not aware of any allegation that CNA A had been in Resident #1's room. He said he thought he had statements from staff regarding the issues with CNA A but could not find any. He said he did conduct in services after each episode of possible abuse. During an interview on 12/18/23 at 3:00 p.m., the DON said she did not remember Resident #1 saying anything about her things being moved around in her room. During a telephone interview on 12/18/23 at 3:38 p, CNA B (former shower aide) said CNA A did come in a few times when she was giving Resident #1 a shower. She said she had only come in to get a basin of warm water or something like that. She did not remember her cursing but she did remember Resident #1 asking CNA A to leave the shower room and she left. During an interview on 12/27/23 at 11:20 a.m. , the Administrator said they had a QA meeting scheduled for tomorrow, 12/28/23. He said they had not QA the event between Resident #4 and LVN D after reviewing his QA book. During an interview on 12/27/23 at 12:30 p.m. the Administrator said he said something about Abuse and Neglect during every in service. He did not have any additional content for the for the 6/9/23 after the incident with Resident #4. The administrator there was no in-service regarding Resident Behaviors or deescalating agitation or aggressive situations. During an interview on 12/27/23 at 1:55 p.m. Administrator said CNA A was guilty of using foul language in the shower room. He said CNA A admitted to using foul language in the shower room. The Administrator said CNA A never admitted to giving care to Resident #1 or doing anything with #1. He said CNA A was not allowed to give care to Resident #1. He said they had written on the grievance form she was guilty but not of all of the allegations made. He said they did not interview other staff or get statements about the incident, so they could not verify that Resident #1's allegations were true or not. They were aware CNA A continued to receive complaints about her behaviors and they could not allow her to continue to work for the facility. He said they had not taken statements from the aide or the aides that may have witnesses the behaviors. The Administrator said what was he supposed to do with the LVN D. He said if he sent the nurse home, they would have only had one nurse in the building that night. The Administrator said at that time if they called the former DON, she would not have answered the phone and she sure would not have come to the facility to fill for the LVN. He said he was between a rock and a hard place. If he sent the nurse home, he would not have had sufficient nursing coverage for the facility, what was he supposed to do? (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 16 of 29 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 12/28/2023 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During an interview on 12/27/23 at 2:07 p.m., CNA A said Resident #1 asked her to leave the shower room a couple of times when she was getting a shower. CNA A said she had gone to the shower room to get hot water. CNA A said she may have said a curse word or two while in the shower, she was not sure. She said she may have delivered a breakfast tray to Resident #1 if she was passing trays and had one for her roommate. She said she was not told to not go in Resident #1's Room, she was told not to provide care to Resident #1. She said Resident #1 had a roommate and she provided care to her. CNA A said Resident #1 may have heard her cursing. CNA A said the Kiosk that they used to input resident care information was right outside of Resident #1's room and she often cursed while using it. CNA A said she was told not to go into Resident #3's room, and she had not been back in her room. She said Resident #3 was upset and it could have been something that she said. CNA said Resident #3 took what she said out of context. The aide said when she provided care to Resident #3 who was a two person assist, there was always at least one other person in the room with her. CNA A said she never provided care to Resident #3 without assistance. She said she told Resident #3 told her there was something wrong with her breast, it smelled. She said she even went to get the nurse ( can not remember who) to look at it. She said the nurse came in and told Resident #3 something was wrong or needed to take the bra off and it had a smell to it. CNA A said CNA O was the aide that was with her that day. CNA A said she may let a [NAME] word slip sometimes when she walked out of a room. She said the Administrator told her was not obligated to tell her why they terminated her. She said she had in services on abuse and knew what abuse was. CNA A said if cursing close to a resident was abuse, then Yes she did abuse residents. CNA A said she knew they wrote several things up on her about residents complaining. She said the Administrator told her that if he turned the write ups into the state his job would be on the line. CNA A said she had about 3 residents that complained about her on that hall and did not want her providing care to them but the facility never moved me from that hall. CNA A said when complaints started coming in the Administrator and DON brought her in to talk about the same things that happen back in July. She said she no longer worked at the facility and these things all happened a long time ago. CNA A wanted to know why the incidents with Resident #1 and Resident # 3 were being questioned about today. She said the Administrator told her they were not called into the State. During an interview on 12/27/23 at 2:12 p.m., Administrator said told CNA A on the incident in July if they continued to get complaints on her she would be terminated. The Administrator said CNA A had a very foul mouth he said he had heard her curing and had reprimanded her on several occasions to stop curing in the facility. He said Resident #1 was very dedicated to her religion and CNA A cursing would have been very offensive to Resident #1. He said CNA A knew that and that is probably why she cursed outside the resident's door or whenever Resident #1 could hear her. He said CNA B and CNA O were CNA A's friends and they would not say anything bad about CNA A. He said CNA O was terminated and she and CNA A work at the same place. The Administrator said when they worked at this facility they would team up and work with new aides, most of which would quit. He said it was not good for the business at all. During an interview on 12/27/23 at 2:31 p.m., the ADON said she had worked at the facility for 15 years. She said she took the position of ADON about June 2023. She said CNA A seemed to be very kind and caring to the residents in front of administrative staff. However, CNA A came across rough and plan speaking. The ADON said sometimes it appeared that CNA A was playing or joking. The ADON said CNA A told her Resident #3's breast smelled told to come down and because the breast smelled like death. She said Resident #3 did not want to get people in trouble and was kind of laughing at the time. The ADON said Resident #3's breast did smell and had dried blood and the nurses should have been washing a surgical wound. She said she knew they called CNA A in to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 17 of 29 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 12/28/2023 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some talk to her after the two complaints were voiced by Resident #1 and Resident #3. She said she did not know where it went from there. The ADON said with the complaint on 9/5/23 they pulled CNA A in the office and told her had too many complaints on her and we needed to let her go. The ADON said she had heard CNA A curse on the hallway. The ADON said after reviewing the schedule and the time sheets. The only thing she could tell was the incidents with Residents #1 and #3 did not happen on 7/3/23. She said she did not work that day and neither did CNA A. she said she could not figure out when the incident happened, but it was before 7/3/23. Record review of the facilities, abuse and neglect protocol with no date indicated abuse is defined as the willful inflection of injury, unreasonable, confinement, intimidation, or punishment with resulting physical harm, pain of mental anguish. Abuse also included the derivation by an individual, included caregiver, goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. The policy statement, a resident, have a right to be free from abuse, neglect. This includes but not limited to freedom from corporal, punishment, involuntary, seclusion, verbal, mental, physical abuse, the development, an implementation, and policy development, and implement policies and procedures in preventing abuse, neglect, or mistreatment of resident to identifying all possible incidence of abuse to protect resident during abuse investigations. Establish and implement a QAIP review and analysis abuse and implement changes to prevent future currencies of abuse . Each interview will be conducted separately in a private location. Witness reports will be obtained in writing either witness will write his or her statement, sign, and date. Or the investigator may obtain a statement read it back to the member and have him sign and date it. Reporting an alleged violation of abuse or neglect will be reported immediately, but not later than: Two hours if the alleged volition involves abuse or has resulted in serious bodily injury or 24 hours if the alleged violations involved abuse and had not resulted in serious bodily injury. This was determined to be an Immediate Jeopardy (IJ) on 12/27/23 at 3:00 p.m. The facility Administrator, and ADON were notified. The Administrator was provided with the IJ template on 12/27/23 at 3:00 p.m. The Plan of Removal for: [Tag F-607: The employee responsible for abuse to Resident 1 and 3 has been terminated on 9/8/2023. The shift key employee responsible for abuse on resident 4 has been red flagged and is no longer able to pick up shifts or return to this facility effective 5/28/2023. Administrator and DON followed up with residents after incidents to ensure no psychological impact was made. An immediate in-service has been started for all staff with the subject of De-escalating Resident Behaviors. Conduct a safe survey with all current interviewable residents. (See attachment 1 below). This will establish residents, individuals, or clients are no longer at a high risk of serious injury, harm, impairment, or death. o Surveys will be completed by 12:00pm 12/28/2023. o (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 18 of 29 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 12/28/2023 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 0607 Surveys will be completed by the following department heads: Level of Harm - Immediate jeopardy to resident health or safety Social Services Residents Affected - Some Dietary Supervisor BOM MDS Coordinator Director of Rehabilitation LVN, ADON If concerns arise from safe survey, statements will be taken from residents. If an allegation of abuse is noted, statements will be taken from all possible sources. In-service has already been provided targeting the importance of reporting as soon as possible and NOT allowing the abuse to continue. An in-service will be provided on behavior training for staff on how to deescalate resident behaviors. This in-service will be completed by DON/Admin by the end of 12/29/2023. An in-service will be provided for treating residents with dignity and respect. To be completed by DON/Admin by the end of 12/29/2023. Create a new policy for Abuse which will include the following: o Definitions o Screening o Training o Prevention o&nbsp[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 19 of 29 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 12/28/2023 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 - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to have evidence violations were thoroughly investigated to prevent further abuse for 4 of 7 residents reviewed for abuse. (Resident #1, Resident #2, Resident #3, and Resident #4) Residents Affected - Some The facility failed to ensure a thorough investigation when Resident #4 was not verbally abuse by LVN D and mental abused and harassed for the remainder of the night on 5/28/23. The facility failed to ensure a thorough investigation was conducted when residents complained of harassment, and intimidation for Resident #1, and Resident #3 when they reported CNA A had intentionally tried to intimidate them. The facility failed to complete a thorough investigation on abuse when Resident #3 said CNA A intentionally caused her pain. An Immediate Jeopardy (IJ) situation was identified on 12/27/23 at 3:00 p.m. while the IJ was removed on 12/28/23 at 8:18 p.m., the facility remained out of compliance at a potential for actual harm with a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of physical harm and or emotional abuse. Findings included: Record review of Resident #4's face sheet with no date indicated he was admitted to the facility on [DATE] and discharge 6/2/23. Resident #4 was a [AGE] year-old male with admitting diagnoses of need for assistance with personal care, history of falling, colostomy status, mood disturbance, anxiety, and lack of coordination. Record review of Resident #4's admission MDS dated [DATE] indicated the resident had moderate cognitive impairment. His functional status indicated he required extensive assist of one person with transfers, toilet use and dressing. The resident was unable to stand and stabilize himself. He did not walk. He was unable to move himself off the toilet, and he was not steady with transfers from surface to surface. Review of Resident #4's baseline care plan dated 5/28/23 indicated his cognition was alert and cognitively intact and required one person assist with bed mobility, transfers walking in toileting . The care plan indicated the resident had a club foot, a new colostomy, and an abdominal incision. He had a new colostomy with interventions to teach the resident proper changing techniques and monitor site of colostomy. Record review of a Provider Investigation Report dated 5/28/23 at 9:59 p.m., indicated on the morning of 5/28/23 around 1:30 a.m. to 3:30 a.m. Resident #4 alleged LVN D verbally abused him. The report contained a letter from the Administrator that stated he first heard of the incident on Sunday, 5/28/23 at 7:30 p.m. Resident #4 said LVN D verbally abused him. The LVN continued to agitate and provoke Resident #4 to the end of his shift at 6:00 a.m. He said they flagged LVN D (an agency nurse) to no longer work for the facility. The investigation indicated Resident #4 was interviewed on 5/30/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 20 of 29 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 12/28/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Some and said LVN D came to his room to help change his colostomy bag and did not bring the appropriate tools. Resident #4 said he felt LVN D did not want to help him. Resident #4 said he told LVN D to get his A out of his room. The Resident said LVN D responded with, I will mop you with the floor. Resident #4 responded. I'll beat your A. Resident #4 said he did not feel safe with LVN D in the building as his nurse. When asked Resident #4 said he did not have a knife. He said he felt he needed to bluff LVN D to ensure his safety. The resident's room was searched and there was no knife found. Interview with LVN D indicated Resident #4 had asked him to help him change his colostomy, in his room and then came to the nurse's station to ask again. LVN D said he told Resident #4 he would assist him when he finished his rounds. LVN D said when he went to the room Resident #4 was rude and talked harshly to him. LVN D said Resident #4 told him, To get his A out of his room. He said the resident continued to give him attitude the rest to the night. The resident told one of the aides he had a knife. The LVN D denied he had harassed the resident. The report indicated a statement from one of the aides indicated LVN D did try and provoke Resident #4 during the night. Record review of a statement that accompanied the Provider Investigation Report for Resident # 4 indicated on 5/28/23 [They (CNA C and CNA E) heard LVN D arguing loudly with Resident # 4. Resident #4 was saying if you are going to hit me then hit me. We (CNA C and CNA E) walked down the hall and LVN D was coming out the room. LVN D said if he was not a professional, he would have whopped Resident #4's A. After that, every time LVN D walked by Resident #4 he would giggle at him and smacked the wall like he was trying to intimidate Resident #4. LVN D really upset Resident #4 to the point he did not feel safe and wanted to leave. LVN D did tell us he told the resident if he was not a professional, he would whip his A.] the statement was signed by CNA C. Record review of the Provider Report Post Action Investigation indicated [ LVN D should have never allowed the situation to get out of hand. He should have been more patient with Resident #4 and never made Resident #4 feel he needed to protect himself. Resident #4 should have shown LVN D more patience as he was seeing other residents during his rounds. Both individuals should have conducted themselves more professionally to ensure a healthy exchange of information and services to be achieved. I feel both men were at fault and this situation could have easily ben avoided. I am finding this inconclusive because both men conducted themselves inappropriately. Neither one were at risk of injury or injured. They obviously do not get along with each other. I do not agree how LVN D conducted himself at the facility and we have taken measures for him not to return to the facility as he is not employee. He is an agency employee and will not be allowed to work another shift at this facility.] The form was signed by the Administrator on 5/31/23. During an interview on 12/18/23 at 2:20 p.m. CNA C said she and CNA E were working in another resident room and came into the hallway and heard loud voices coming from Resident #4's room on morning of 5/28/23. She said the LVN D came out of the room and was hollering back, I would whip your A if you were not a resident. She said Resident # 4 was very upset and wanted to leave the facility. He tried to exit through several of the doors. She said she spent the night trying to keep him from leaving and watching LVN D try and aggravate the resident. She said every time LVN D would pass by the Resident #4. He would giggle and hit on the wall or the side rails as if he was hitting someone. She said the nurse's behavior was not professional at all, in fact he acted like a child. She said she did not remember if she called anyone to report the incident or not. She spent the night trying to keep the peace and trying to keep Resident#4 from leaving. She said at one point they were outside in the smoking area, and Resident#4 said he would throw himself on the ground, throw his wheelchair down the steps, crawl down the steps and get back in his wheelchair and leave. During an interview on 12/18/23 at 2:25 p.m., the Administrator said he did not remember who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 21 of 29 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 12/28/2023 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 - Immediate jeopardy to resident health or safety notified him about the incident that happened on 5/28/23. He said he was told it happened on that morning around 1:30 a.m. or 2:00 a.m. he said it was not reported to him until 5/28/23 at 7:30 p.m. and he called it into the state around 9:00 p.m. He said in the defense of the resident he was very independent. He said the resident told the nurse he had a knife because he tried to intimidate him when he walked by. The Administrator said the resident did not have a knife and he could not find one. He said the resident admitted he just felt he needed some type of protection from the LVN D. Residents Affected - Some During an interview on 12/18/23 at 3:30 p.m., CNA E said when they rounded the corner on the night of 5/28/23, LVN D and Resident #4 were arguing. The nurse was LVN D was hollering at the Resident #4. We (CNA C and CNA E) tried to deescalate the situation. CNA E said Resident #4 tried to leave through two different doors. She said the nurses' behavior was not professional, he was hollering and talking smart. Resident #1 Record review of Resident #1's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were Alzheimer's, disease, anxiety disorder, and history of falling. Record review of Resident #1's quarterly MDS dated [DATE] indicated she had no cognitive impairment. The resident used mobility devices of a walker and a wheelchair. She required partial assistance with hygiene, and partial assistance with chair to bed transfer, and partial assist with toilet transfer. Record review of Resident #1's care. Plan indicated she had a problem of ADL function. She required two people assist with bathing, two people assist with toileting, and two people assist with bed mobility. Record review of a Complaint/Concern form dated 7/3/23 indicated Resident #1 was filing a complaint against CNA A. Resident #1 said CNA A was rough in the way that she handled her care, causing her pain and discomfort when she was turning her, placing her in the chair and any other physical contact. Resident #1 said CNA A spoke to her in a rude and hurtful manner. Resident #1 said she refused to put up with it any longer. CNA A said Resident # 1, was always complaining about something and making notes to tell on me. Resident #1 disagreed with that statement. Resident #1 said that she refused to be spoken to or treated to rudely any longer. The resident said she asked CNA A to stop on several occasions, but it continued. Resident #1 said it had become harassment. The resident did not want CNA A to be associated with her care any longer. Resident #3 Record review of a face sheet for Resident #3 with no date indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were stroke, removal of the right breast, acute kidney failure, stiffness in the right knee, need for assistance with personal care, abnormal posture Disorder of the bone upper arm, and muscle weakness. Record review of Resident #3's quarterly MDS dated [DATE] indicated she had no cognitive impairment. Her functional status was she used a wheelchair for mobility. She had impairment on her upper extremity shoulder, elbow, wrist, and hand, and she had impairment on her lower extremity hip knee, ankle, and foot. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 22 of 29 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 12/28/2023 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 - Immediate jeopardy to resident health or safety Record review of Resident #3's care plan dated 11/15/23 indicated a problem of limited range of motion to the right upper and lower extremities. Resident # 3 required assistance with active and passive range of motion in a splint applied to the right hand. Resident # 3 had problems of ADL function and required a lift for transfers. The resident required one or two people to aid turn and reposition in bed frequently to prevent skin breakdown. The resident required one person assist for dressing, and two people for a transfer by Hoyer lift. Residents Affected - Some Record review of a Complaint/Concern Form dated 7/3/23 indicated Resident# 3 filed a complaint against CNA A. The Complaint indicated the aide was rough in the way she handled Resident #3's care, causing her pain and discomfort when she was turning Resident #3, placing her in the chair and other physical contact. Resident #3 said the way CNA A spoke to her was rude, hurtful, and she refused to put up with it any longer. The resident said CNA A told her that turning her hurt her because she was a big woman, and she was doing it by herself. Resident # 3 said she told CNA A she should ask for help. Resident # 3 said CNA A told her she stunk after Resident # 3 had breast surgery. The Resident # 3 said the CNA told her the smell coming from her breast stinking up the room. The form indicated CNA A said she and Resident #3 were friends and that was just the way they talked to each other. Resident #3 disagreed with that statement, and she said she did comment back to the aide but in self-defense. Resident #3 said they were not friends and she refused to be spoken to or treated rudely any longer. Resident # 3 said asked CNA A to stop on multiple occasions, but her attitude continued. Resident #3 said it had become harassment. The resident did not want CNA A to be associated with her care any longer. When talking to CNA A about the event, she said that she and the resident joked all the time, and she was unaware that it bothered the resident. CNA A stated, verbally that she would not joke like that again, and would have a more professional manner when interacting with residents. The investigation finding indicated, Resident # 3 said she did not have an issue with CNA A but was embarrassed by the event. The steps taken to correct the action was a counseling form on how to keep a professional manner. The steps taken to correct the issue was CNA A was removed from her care and could only provide care when assisting other staff. A counseling will be provided to CNA A on treating residents in a professional manner. Record review of a Counseling/Disciplinary note for CNA A dated 7/18/23 (15 days later) indicated the reason for the counseling was multiple complaints on CNA A for being verbally, aggressive, and short with Residents. The corrective actions were to speak with the aid about how to approach residents in a more professional manner and it was signed by the DON and CNA A on 7/19/23. There was no Inservice attached. Record review of a Complaint/Concern form dated 9/5/23 indicated Resident #1 reported that she continued to have problems with CNA A. She stated that on 8/30/23 CNA A continuously interrupted her shower to talk to the shower aid, making her uncomfortable. The resident stated CNA A's language was profane. Resident #1 said on the following day, 8/31/23 CNA A and another aide came into the room going through her roommates closet and cursing very loudly. Resident #1 said they were gossiping about other employees and used an extreme amount of profanity. Resident #1 said that she was very offended. Resident #1 said on the following morning she was sleeping when CNA A came into her room, and said loudly, Your breakfast is served. Wake up and eat it. Resident #1 said it was very rude, so she refused acknowledge her. Resident #1 said, I feel targeted . Resident #1 said she spoke to the nurse on the weekend about her concerns ( no statement from the nurse) Resident #1 said she felt CNA A used the excuse of taking care of her roommate, as an opportunity to antagonize an aggravate her . The allegation was investigated, and the IDT meeting was held. The findings were CNA A was guilty of the events, and will be given the option of quitting or resigning from her position. Signed by the Administrator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 23 of 29 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 12/28/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of a Counseling/Disciplinary note for CNA A dated 9/8/23 indicated CNA A was discharged and her last day at work was 9/8/23. The form indicated this would serve as termination. Corrective actions had already been taken and misconduct continued. The employee comments were, Do not understand what the reason. Signed by CNA A. During an interview on 12/14/23 at 11:00 a.m., the DON said she had determined Resident #1's allegations were true. She did not have statements from the shower aide, nurse, or CNA A. She said they had gotten multiple complaints regarding the aide and felt it was time to let her go. When asked about the statement on the grievance dated 9/5/23 that said CNA A was guilty of the allegations made by Resident #1. The DON said she did not remember how she verified the events that occurred were true regarding Resident #1's allegations. During an interview on 12/14/23 at 11:50 p.m., the DON and the Administrator said because of her previous behaviors with residents, CNA A was terminated, on 9/8/23. The DON said there was another resident on the same hall as Resident #1 who did not want CNA A in her room. That resident changed her details of the occurrence several times so they could not validate her allegations. However, the resident said she did not like CNA A and did not want her back in her room. The DON and Administrator said Resident #1 and Resident #3's issues bordered on abuse but neither resident said they were abused. The Administrator and the DON said they did not know that CNA A continued to go into Resident #1's room. During an interview on 12/18/23 at 11:58 a.m., the Administrator said CNA A worked at a fast pace and the former DON loved her (the former DON left 6/30/23). He said he tried to work with CNA A. He felt her actions would get right up to the line of abuse and then she would pull back. The Administrator said he did not think CNA A was a nice person. The Administrator said one issue with CNA A was that she had a foul mouth. The Administrator said he had tried to encourage her not to use foul language around residents. He said CNA A did not have much respect for authority, and she did what she wanted to do. The Administrator said they had to let her go because warnings did not help, and she had gone past the point respecting the residents. During an interview on 12/18/23 at 12:50 p.m., Resident #3 said the things CNA A did to her could have been abuse. Resident # 3 stated it started out as joking, and she would never have called CNA A her friend. Resident # 3 said CNA A took the snide comments to a whole different level. Resident #3 said CNA A was rough when she provided care to her. Resident#3 said would tell CNA A she was rough and hurting her. She said CNA A knew she was hurting her and did not care. Resident# 3 said on one occasion when she complained to aide about her being rough, CNA A told her, Well you are not light. Resident # 3 asked her to get some help if she was too heavy and the aide refused. Resident #3 said she had a stroke on her right side, and it hurt when she was moved around roughly. Resident#3 said some of the things the aide said were hurtful and hurt her feelings. cane said when CNA A provided care to her, the aide knew she was rough, and hurt her but did not care. Resident#3 said complained after she could not take anymore. Resident #3 said CNA A was not allowed back in her room and did not speak to her in the hallway. During an interview on 12/18/23 at 12:55 p. m. Resident #2 said CNA A had been unkind to her on several occasions. When she finally told the staff, she felt threatened when the aide came in the room. She said she might have confused the events some, but the aide was mean, and she did not want her in her room. She said she heard they terminated her because she was mistreated another resident. During an interview on 12/18/23 at 2:10 p.m., Resident #1 said she remembered CNA A quite well. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 24 of 29 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 12/28/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Some had been rude and mean to her. She had requested she not be allowed in her room. She said on several occasions when she was in the shower room getting assistance with a shower. She said CNA A would come in and take a seat and try to intimidate her. She said CNA A would talk, and all kinds of filthy language would come out of her mouth. She asked her to leave the shower room on at least two occasions because she did not feel comfortable with her there. She said on several occasions she would come into her room and move her walker around in the room or come in to care for the roommate and use filthy language. She had complained back in September, and she was finally let go. Resident #1 said she felt the aide was trying to intimidate her because she had complained of her attitude and treatment towards her in the past. During an interview on 12/18/23 at 2:25 p.m., the Administrator he was not aware of any furniture being moved in Resident #1's room. He said there was a dresser she complained had been moved and he moved it back. It was only moved a few inches. He was not aware of any allegation that CNA A had been in Resident #1's room. He said he thought he had statements from staff regarding the issues with CNA A but could not find any. He said he did conduct in services after each episode of possible abuse. During an interview on 12/18/23 at 3:00 p.m., the DON said she did not remember Resident #1 saying anything about her things being moved around in her room. During a telephone interview on 12/18/23 at 3:38 p, CNA B (former shower aide) said CNA A did come in a few times when she was giving Resident #1 a shower. She said she had only come in to get a basin of warm water or something like that. She did not remember her cursing but she did remember Resident #1 asking CNA A to leave the shower room and she left. During an interview on 12/27/23 at 11:20 a.m. , the Administrator said they had a QA meeting scheduled for tomorrow, 12/28/23. He said they had not QA the event between Resident #4 and LVN D after reviewing his QA book. During an interview on 12/27/23 at 12:30 p.m. the Administrator said he said something about Abuse and Neglect during every in service. He did not have any additional content for the for the 6/9/23 after the incident with Resident #4. The administrator there was no in-service regarding Resident Behaviors or deescalating agitation or aggressive situations. During an interview on 12/27/23 at 1:55 p.m. Administrator said CNA A was guilty of using foul language in the shower room. He said CNA A admitted to using foul language in the shower room. The Administrator said CNA A never admitted to giving care to Resident #1 or doing anything with #1. He said CNA A was not allowed to give care to Resident #1. He said they had written on the grievance form she was guilty but not of all of the allegations made. He said they did not interview other staff or get statements about the incident, so they could not verify that Resident #1's allegations were true or not. They were aware CNA A continued to receive complaints about her behaviors and they could not allow her to continue to work for the facility. He said they had not taken statements from the aide or the aides that may have witnesses the behaviors. The Administrator said what was he supposed to do with the LVN D. He said if he sent the nurse home, they would have only had one nurse in the building that night. The Administrator said at that time if they called the former DON, she would not have answered the phone and she sure would not have come to the facility to fill for the LVN. He said he was between a rock and a hard place. If he sent the nurse home, he would not have had sufficient nursing coverage for the facility, what was he supposed to do? (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 25 of 29 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 12/28/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Some During an interview on 12/27/23 at 2:07 p.m., CNA A said Resident #1 asked her to leave the shower room a couple of times when she was getting a shower. CNA A said she had gone to the shower room to get hot water. CNA A said she may have said a curse word or two while in the shower, she was not sure. She said she may have delivered a breakfast tray to Resident #1 if she was passing trays and had one for her roommate. She said she was not told to not go in Resident #1's Room, she was told not to provide care to Resident #1. She said Resident #1 had a roommate and she provided care to her. CNA A said Resident #1 may have heard her cursing. CNA A said the Kiosk that they used to input resident care information was right outside of Resident #1's room and she often cursed while using it. CNA A said she was told not to go into Resident #3's room, and she had not been back in her room. She said Resident #3 was upset and it could have been something that she said. CNA said Resident #3 took what she said out of context. The aide said when she provided care to Resident #3 who was a two person assist, there was always at least one other person in the room with her. CNA A said she never provided care to Resident #3 without assistance. She said she told Resident #3 told her there was something wrong with her breast, it smelled. She said she even went to get the nurse ( can not remember who) to look at it. She said the nurse came in and told Resident #3 something was wrong or needed to take the bra off and it had a smell to it. CNA A said CNA O was the aide that was with her that day. CNA A said she may let a [NAME] word slip sometimes when she walked out of a room. She said the Administrator told her was not obligated to tell her why they terminated her. She said she had in services on abuse and knew what abuse was. CNA A said if cursing close to a resident was abuse, then Yes she did abuse residents. CNA A said she knew they wrote several things up on her about residents complaining. She said the Administrator told her that if he turned the write ups into the state his job would be on the line. CNA A said she had about 3 residents that complained about her on that hall and did not want her providing care to them but the facility never moved me from that hall. CNA A said when complaints started coming in the Administrator and DON brought her in to talk about the same things that happen back in July. She said she no longer worked at the facility and these things all happened a long time ago. CNA A wanted to know why the incidents with Resident #1 and Resident # 3 were being questioned about today. She said the Administrator told her they were not called into the State. During an interview on 12/27/23 at 2:12 p.m., Administrator said told CNA A on the incident in July if they continued to get complaints on her she would be terminated. The Administrator said CNA A had a very foul mouth he said he had heard her curing and had reprimanded her on several occasions to stop curing in the facility. He said Resident #1 was very dedicated to her religion and CNA A cursing would have been very offensive to Resident #1. He said CNA A knew that and that is probably why she cursed outside the resident's door or whenever Resident #1 could hear her. He said CNA B and CNA O were CNA A's friends and they would not say anything bad about CNA A. He said CNA O was terminated and she and CNA A work at the same place. The Administrator said when they worked at this facility they would team up and work with new aides, most of which would quit. He said it was not good for the business at all. During an interview on 12/27/23 at 2:31 p.m., the ADON said she had worked at the facility for 15 years. She said she took the position of ADON about June 2023. She said CNA A seemed to be very kind and caring to the residents in front of administrative staff. However, CNA A came across rough and plan speaking. The ADON said sometimes it appeared that CNA A was playing or joking. The ADON said CNA A told her Resident #3's breast smelled told to come down and because the breast smelled like death. She said Resident #3 did not want to get people in trouble and was kind of laughing at the time. The ADON said Resident #3's breast did smell and had dried blood and the nurses should have been washing a surgical wound. She said she knew they called CNA A in to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 26 of 29 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 12/28/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Some talk to her after the two complaints were voiced by Resident #1 and Resident #3. She said she did not know where it went from there. The ADON said with the complaint on 9/5/23 they pulled CNA A in the office and told her had too many complaints on her and we needed to let her go. The ADON said she had heard CNA A curse on the hallway. The ADON said after reviewing the schedule and the time sheets. The only thing she could tell was the incidents with Residents #1 and #3 did not happen on 7/3/23. She said she did not work that day and neither did CNA A. she said she could not figure out when the incident happened, but it was before 7/3/23. Record review of the facilities, abuse and neglect protocol with no date indicated abuse is defined as the willful inflection of injury, unreasonable, confinement, intimidation, or punishment with resulting physical harm, pain of mental anguish. Abuse also included the derivation by an individual, included caregiver, goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. The policy statement, a resident, have a right to be free from abuse, neglect. This includes but not limited to freedom from corporal, punishment, involuntary, seclusion, verbal, mental, physical abuse, the development, an implementation, and policy development, and implement policies and procedures in preventing abuse, neglect, or mistreatment of resident to identifying all possible incidence of abuse to protect resident during abuse investigations. Establish and implement a QAIP review and analysis abuse and implement changes to prevent future currencies of abuse . Each interview will be conducted separately in a private location. Witness reports will be obtained in writing either witness will write his or her statement, sign, and date. Or the investigator may obtain a statement read it back to the member and have him sign and date it. Reporting an alleged violation of abuse or neglect will be reported immediately, but not later than: Two hours if the alleged volition involves abuse or has resulted in serious bodily injury or 24 hours if the alleged violations involved abuse and had not resulted in serious bodily injury. This was determined to be an Immediate Jeopardy (IJ) on 12/27/23 at 3:00 p.m. The facility Administrator, and ADON were notified. The Administrator was provided with the IJ template on 12/27/23 at 3:00 p.m. The Plan of Removal for: [Tag F-610: The employee responsible for abuse to Resident 1 and 3 has been terminated on 9/8/2023. The shift key employee responsible for abuse on resident 4 has been red flagged and is no longer able to pick up shifts or return to this facility effective 5/28/2023. Administrator and DON followed up with residents after incidents to ensure no psychological impact was made. An immediate in-service has been started for all staff with the subject of De-escalating Resident Behaviors. Conduct a safe survey with all current interviewable residents. (See attachment 1 below). This will establish residents, individuals, or clients are no longer at a high risk of serious injury, harm, impairment, or death. o Surveys will be completed by 12:00pm 12/28/2023. o (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 27 of 29 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 12/28/2023 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 Surveys will be completed by the following department heads: Level of Harm - Immediate jeopardy to resident health or safety Social Services Residents Affected - Some Dietary Supervisor BOM MDS Coordinator Director of Rehabilitation ADON o Non-interviewable residents will have skin assessment completed once a week, for 3 months to be reviewed monthly in QA. Documented daily rounds to determine if non-interviewable residents are free from abuse to be completely 3 times a week for 3 months and reviewed in monthly QA. Create a new policy for Abuse which will include the following: o Definitions o Screening o Training o Prevention o Identification o Investigation o Protection (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 28 of 29 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 12/28/2023 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 o Level of Harm - Immediate jeopardy to resident health or safety Reporting Residents Affected - Some Policy was completed 12/28/2023 at 10:00am The new Policy was completed by Administrator. N[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675755 If continuation sheet Page 29 of 29