Health inspection·June 22, 2023

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation of Resident #7 on 06/21/23 at 01:30 PM revealed Resident #7 was lying in bed. Resident #7 had a hospital bed with a half bed rail on the left. Resident #14 Record review of Resident #14's electronic face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia (a condition the impairs the ability to remember, think, or make decisions that interferes with doing everyday activities), weakness, broken right arm, and kidney disease. Record review of Resident #14's quarterly MDS, dated [DATE] Section C. Brief Interview of Mental Status assessment revealed a score of 11 out of 15 which indicated moderate mental impairment and Section P. Restraints and Alarms P0100 Physical Restraints A. Bed Rail 0. Not Used was selected as the answer. Record review of Resident #14's comprehensive care plan, revised 05/15/2023, revealed the resident was at risk for falls due to unsteady gait (walking), decreased balance, medications, and poor safety awareness. Resident #14's care plan noted the resident required supervision and limited assistance with bed mobility. Interventions listed did not include placement and/or use of bed rails. Record review of Resident #14's electronic physician orders revealed no order for the use of bed rails. Record review of Resident #14's Occupational Therapy Treatment Encounter Notes, dated 03/27/2022, revealed no documentation on assessment and training for siderail use for independence with transfers. Record review of Resident #14's electronic records revealed no documentation of an attempt to use alternatives to bed rails or assessment for the risk of entrapment. Observation of Resident #14's room on 06/20/23 at 11:30 AM revealed the bed had half bed rails in place. During an interview on 06/22/23 at 10:15 AM, Resident #14 stated she used her bed rail to assist in transferring. Resident #18 Record review of Resident #18's electronic face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE] with an initial admission date of 09/23/2022. Resident #19 had diagnoses which included dementia, weakness, broken right hip, and repeated falls. Record review of Resident #18's discharge - return anticipated MDS, dated [DATE], revealed Section C. Brief Interview of Mental Status assessment revealed a score of 14 out of 15, which indicated no mental impairment and Section P. Restraints and Alarms P0100 Physical Restraints A. Bed Rail 0. Not Used was selected as the answer. Record review of Resident #18's comprehensive care plan, revised 10/12/2022, revealed the resident was at risk for falls due to an unsteady gait, decreased balance and medications. Resident #18's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675832 If continuation sheet Page 2 of 12 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 675832 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rising Star Nursing Center 411 S Miller Rising Star, TX 76471 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some care plan noted the resident required assistance with transfers. Interventions listed did not include placement and/or use of bed rails. Record review of Resident #18's electronic physician orders revealed no order for the use of bed rails. Record review of Resident #18's Occupational Therapy Treatment Encounter Notes, dated 06/21/2023, revealed no documentation on assessment and training for siderail use for independence with transfers. Record review of Resident #18's electronic records revealed no documentation of an attempt to use alternatives to bed rails or assessment for the risk of entrapment. Observation of Resident #18's room on 06/20/23 at 11:22 AM revealed the bed had half bed rails in place. Resident #20 Record review of Resident #20's electronic face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included weakness and dementia. Record review of Resident #20's significant change in status MDS, dated [DATE], revealed Section C. Brief Interview of Mental Status assessment revealed a score of 9 out of 15 which indicated moderate mental impairment and Section P. Restraints and Alarms P0100 Physical Restraints A. Bed Rail 0. Not Used was selected as the answer. Record review of Resident #20's comprehensive care plan, reviewed 04/28/2023, revealed the resident was at risk for falls due to weakness, unsteady gait, decreased balance, medications, and poor safety awareness. Resident #20's care plan noted the resident required assistance with bed mobility. Interventions listed did not include placement and/or use of bed rails. Record review of Resident #20's Occupational Therapy Treatment Encounter Notes, dated 06/13/2023, revealed no documentation on assessment and training for siderail use for independence with transfers. Record review of Resident #20's electronic records, accessed 06/21/2023, revealed no documentation of an attempt to use alternatives to bed rails or assessment for the risk of entrapment. Observation of Resident #20's room on 06/20/23 at 12:10 PM, the bed had one half bed rail in place on the right. Resident #22 Record review of Resident #22's electronic face sheet revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included weakness and gout (a condition that affects the joints.) Record review of Resident #22's significant change in status MDS, dated [DATE], revealed Section C. Brief Interview of Mental Status assessment revealed a score of 15 out of 15, which indicated no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675832 If continuation sheet Page 3 of 12 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 675832 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rising Star Nursing Center 411 S Miller Rising Star, TX 76471 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some mental impairment and Section P. Restraints and Alarms P0100 Physical Restraints A. Bed Rail 0. Not Used was selected as the answer. Record review of Resident #22's comprehensive care plan, revised 05/23/2023, revealed the resident was at risk for falls due to unsteady gait and decreased balance. Resident #22's care plan noted the resident required assistance with bed mobility. Interventions listed did not include placement and/or use of bed rails. Record review of Resident #22's electronic physician orders revealed no order for the use of bed rails. Record review of Resident #22's Occupational Therapy Treatment Encounter Notes, dated 03/02/2023, revealed no documentation on assessment and training for siderail use for independence with transfers. Record review of Resident #22's electronic records revealed no documentation of an attempt to use alternatives to bed rails or assessment for the risk of entrapment. Observation of Resident #22 on 06/20/23 at 10:58 AM revealed the resident was lying in bed, eyes closed, respirations even and unlabored. Resident #22's bed had one bed rail in place on the left. Resident #232 Record review of Resident #232's electronic face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included fainting, weakness, and difficulty walking. Record review of Resident #232's quarterly MDS, dated [DATE], revealed Section C. Brief Interview of Mental Status assessment revealed a score of 14 out of 15, which indicated no mental impairment and Section P. Restraints and Alarms P0100 Physical Restraints A. Bed Rail 0. Not Used was selected as the answer. Record review of Resident #232's comprehensive care plan revealed the resident was at risk for falls due to an unsteady gait, decreased balance, medications, poor safety awareness. Interventions listed did not include placement and/or use of bed rails. Record review of Resident #232's electronic physician orders revealed no order for the use of bed rails. Record review of Resident #232's electronic records revealed no documentation of an attempt to use alternatives to bed rails or assessment for the risk of entrapment. Observation of Resident #232 on 06/20/23 at 11:10 AM, revealed the resident sitting in a wheelchair in her room watching TV. Resident #232's bed had one bed rail in place on the right. During an interview on 06/22/23 at 10:10 AM, the DON stated bed rails were usually installed when a resident requested to use as enabler bars. The DON stated assessments were not performed prior to installing bed rails on beds for Resident #7, Resident #14, Resident #18, Resident #20 Resident #22, or Resident #232. She stated obtaining a physician's order was not specified in the facility policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675832 If continuation sheet Page 4 of 12 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 675832 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rising Star Nursing Center 411 S Miller Rising Star, TX 76471 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The DON stated bed rails should be addressed on the care plan and did not know why bed rails were not included on the care plan. During an interview and record review on 06/22/23 at 10:51 AM, LVN A stated the nurses had a list of 6 residents who had bed rails. Review of the list provided by LVN A revealed Resident #4, Resident #16, Resident #18, Resident #20, Resident #133, and Resident #232 were listed. LVN A stated she did not know why the failure to obtain a physician's order or include the bed rails on the care plan occurred. During an interview on 06/22/23 at 10:53 AM, LVN B stated effect on residents of not having a physician's order for bed rails or including bed rails on the care plan could affect residents' mobility, or ability to transfer in and out of bed. LVN B stated residents who were not used to having bed rails may get confused and could get hurt. During an interview on 06/22/23 at 02:15 PM, the Maintenance Director stated he inspected bed rails when they were installed. He stated he inspected the bed rails the day before. The Maintenance Director stated if staff noticed a problem with a bed rail it was logged in the maintenance book for him to fix. During an interview on 06/22/23 at 03:27 PM, the ADON stated she was responsible for entering data for the MDS. She stated bed rails were not selected on the MDS because the facility did not consider them restraints. The ADON stated they were a restraint free facility. She explained the consequences to a resident of failing to document bed rails on the MDS was because bed rails were the wording made it confusing on where to put data in the MDS. The ADON described her training for the position as trained by the former MDS nurse, and the facility paid for her to attend a Resource Utilization Group (RUG) course. The RUG is a system that groups residents based on health status and care needs. The ADON stated she was confused on how to enter the bed rail used as mobilization equipment on the MDS. Record review of the facility's, undated, policy titled Bed Rails revealed To ensure the appropriate use of Bed or Side rails at all times. Procedure: The facility will attempt the use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility will ensure correct installation, use, and maintenance of bed rails, including but not limited to the following: 1. Assessing the resident for risk of entrapment from bed rails prior to installation with the TMF Side Rail Assessment form. 2. Review the risks and benefits of bed rails with the cognizant resident or resident representative and obtain informed consent prior to installation. 3. Ensure that the bed's dimensions are appropriate for the resident's size and weight. 4. Follow the manufacturer's recommendations and specifications for installing and maintaining be rails. 5. Utilizing the TMF Side Rail Utilization Assessment to comply with state regulations for safety. 6. Consult with Therapy regarding assessment and training for siderail use for independence with transfers. 7. The maintenance director will supervise the maintenance of all bed siderails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675832 If continuation sheet Page 5 of 12 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 675832 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rising Star Nursing Center 411 S Miller Rising Star, TX 76471 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for one of one facility reviewed for RN services. Residents Affected - Some The facility failed to provide evidence a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week for 6 days (1/1/23, 1/14/23, 1/15/23, 1/28/23, 1/29/23, and 2/12/23) of the FY Quarter 2 (January1- March31) out of 4 Quarters. This failure could place residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff. Findings include: Record review of the facility's Staffing Data Report for FY Quarter 2 revealed no RN coverage on 1/1/23, 1/14/23, 1/15/23, 1/28/23, 1/29/23, and 2/12/23. During an interview on 06/22/23 at 1:34 PM the DON stated her expectation was there should have been an RN at least 8 hours per day in the facility. The DON stated she was responsible for making the RN schedule and the ADMN and herself were responsible for monitoring the RN coverage. The ADMN was responsible to make the staffing report. The DON stated that schedules and when they did not have RN coverage the DON or ADON would work, the DON and the ADON did clock in when they worked. The DON stated she was not sure of the dates on staffing report were not covered. One of the weekend RN's was on leave and the DON and the ADON split their schedules. The DON stated she only thought there were 2 days that were not covered . During an interview on 06/22/23 at 1:47 PM the ADMN stated his expectation was to have 8 hours RN coverage daily. The ADMN stated he did not think there was a negative impact on residents for not having an RN in the building because nursing staff had access to an on-call RN who could be at the facility within 30 minutes. The ADMN stated LVNs were trained and licensed, so no one suffered from lack of quality of care. The ADMN stated what led to the failure was the weekend RN called in or did not show up and it was hard to locate an RN to work weekends. The ADMN stated the DON and ADMN monitored RN coverage but it ultimately landed on the ADMN. Record review of the facility's, undated, policy titled, RN Coverage revealed, The facility will make every effort to assign registered nurse coverage at least eight (8) hours per day, seven (7) days per week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675832 If continuation sheet Page 6 of 12 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 675832 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rising Star Nursing Center 411 S Miller Rising Star, TX 76471 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen surveyed for kitchen sanitation. 1. The facility failed to ensure food items were disposed after the use by or expiration date. 2. The facility failed to ensure dinnerware was stored in a way to prevent contamination. These failures could place residents at risk of foodborne illness and a decline in health status. The findings included: Observation in the kitchen area on 06/20/23 between 09:30 AM and 10:15 AM, revealed the following: -One 35.3 oz. plastic jar of dry coffee creamer in a cabinet did not have an opened date and had an expiration date of 10/21/21. -One 1 gallon 2% milk approx. 1/3 full in the door of the refrigerator with an expiration date of 06/18/23. -Two stacks of dinner plates above the steam table were turned right side up without a cover. -Several small plastic bowls and plastic storage containers on a shelf to the right of the sink were turned right side up without a cover. -In the commercial freezer, one opened clear plastic bag tied in a knot contained slices of garlic bread with no date opened or expiration date. -Three 5 lb. bags labeled pancake mix did not have an expiration date. During an interview on 06/22/23 at 10:46 AM, the DC did not have a reason the 2% milk was in the refrigerator past the expiration date. She stated usually milk was used too fast for it to come close to the expiration date. The DC stated when the big refrigerator went out, items had to be moved to another refrigerator and that may have been part of the problem. She stated she routinely checked for expired and past use by date food items and the dishwasher monitored the drinks. The DC explained she was initially trained by a night cook. She stated she also completed the food handlers' course, and her certification was current. The DC stated the DM did frequent face-to-face trainings to refresh the staff on procedures or to pass on new information. She stated the effect receiving out of date food on the residents was that it could make them sick. During an interview on 06/22/23 at 01:37 PM, the DM stated she was ultimately responsible for checking for expired food stock and past use by dates. She stated the staff were very good about checking frequently but occasionally items were missed. She attributed the issue with the gallon of 2% milk to the refrigerator going out and having to transfer refrigerated foods to a residential refrigerator and it was missed. The DM did not have an explanation for why coffee creamer had not been disposed of. She explained training was done at hire and monthly. The DM stated the effect on residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675832 If continuation sheet Page 7 of 12 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 675832 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rising Star Nursing Center 411 S Miller Rising Star, TX 76471 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 receiving an expired food item was that the resident(s) could get sick. Level of Harm - Minimal harm or potential for actual harm Record review of the dietary staff's certifications revealed all certificates were current. Residents Affected - Some Record review of the facility's, undated, policy titled Storage of Food in Refrigerators, revealed: Procedure 4. All containers must be labeled with the contents and date food item was placed in storage. Record review of the Federal Food Code, dated 2002 Chapter 4 Equipment, Utensils, and Linens section 4-903.11.(B)(2) revealed: Clean equpment and utensils shall be stored . covered or inverted. Record review of the Federal Food Code, dated 2022, Annex 6: Food Processing Criteria (2) (K) Disposition of Expired Product at Retail, revealed .foods that exceed the use-by date or manufacturer's pull date . must be disposed of in a proper manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675832 If continuation sheet Page 8 of 12 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 675832 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rising Star Nursing Center 411 S Miller Rising Star, TX 76471 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 (CNA-C) staff observed for infection control. Residents Affected - Few The facility failed to ensure CNA-C performed proper hand hygiene while providing incontinent care. These failures could place residents at risk for unnecessary infections. Findings include: During observation on 06/21/23 at 02:09 PM, CNA C performed peri care on Resident 29. CNA C entered the room without performing hand hygiene. CNA C pulled the privacy curtain and donned gloves without performing hand hygiene. CNA C unfastened brief and pushed the front in between the residents' legs. CNA C wiped the front center peri-area from front to back and placed the wipe in the brief between the residents legs. CNA C wiped the front center peri- area from front to back with another wipe and placed it in the brief. CNA C rolled the resident on her left side. CNA C wiped the residents right buttocks with BM from front to back and placed the wipe in the brief. CNA C grabbed a new wipe and wiped center buttock crack from front to back then folded wipe and wiped back to front in a zig-zag motion then discarded wipe into brief. CNA C removed brief and placed it in a plastic bag that had fallen on the floor. CNA C doffed gloves and did not perform hand hygiene. CNA C looked in two drawers opening them with her bare hands then when into the hall and returned with moisture cream. CNA C did not perform hand hygiene and donned gloves. CNA C placed a clean brief under the resident and applied moisture cream. CNA C placed moisture cream on her gloved hand and wiped all over the residents' buttocks in a zig-zag motion and then wiped the cream on the clean brief. CNA C rolled resident onto her back and fastened the clean brief. CNA C doffed gloves and did not perform hand hygiene. CNA C repositioned the resident and exited the room with the plastic bag which contained the dirty brief and walked down the hall to place it in the trash. In an interview on 06/22/23 at 03:35 PM, CNA C explained how to perform Peri care and stated he would go to the linen closet to get his supplies (basin, washcloth, brief peri wash and creams). Go to the resident's room, knock and explain what he was doing. Put water in basin (check for water temperature), Setup basin and supplies. CNA C then stated he would put his gloves on and begin peri care using the four corners method with his washcloth (he said also calls it flowering). CNA C stated he received his training by the DON. He stated she taught the four corners method in peri care training. In an interview on 06/22/23 at 04:41 PM, the DON stated she did most all trainings for nursing services. The DON stated the ADON did trainings for the CNA's. The DON stated she started doing their trainings beginning in early April. The DON stated she did audits and observed the CNA's techniques after their training was completed. The DON stated all the retraining for CNA's were done by the ADON. The DON stated the washcloths were hygiene wipes. The DON described them as a premoisten disposable cleaning wipes. The DON stated there were some CNAs that were originally trained by her utilizing an actual cloth, washcloths. The DON stated staff could use the hygiene wipes if they folded and used a clean side. The DON stated the four corners method was not appropriate with the hygiene wipes. Most especially because of the size and consistency they were not designed for the fold four corner method. The DON stated the effect of improper peri care on a resident would depend on where the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675832 If continuation sheet Page 9 of 12 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 675832 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rising Star Nursing Center 411 S Miller Rising Star, TX 76471 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm deficient practice was within the process. The DON stated the failure to perform hand washing or hand sanitizer hygiene had the potential to lead to cross contamination. The DON stated the effect could expose the residents to opportunist pathogen with associated with potential infection. Record review of the facility policy titled Perineal Care reflected the following: Residents Affected - Few 2. Assemble the equipment and supplies as needed. Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure: 1. Incontinence product such as brief or underwear 2. Barrier cream or moisturizer as directed by the nurse 3. Incontinence cleanser (as needed) 4. Under pad 5. Plastic trash bag 6. Gloves Step in Procedure 1. Arrange the supplies as they can be easily reached. 2. Wash and dry your hands thoroughly or use hand sanitizer. Record review of the facility policy titled Hand Washing reflecting the following: Section 12-Infection Control (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675832 If continuation sheet Page 10 of 12 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 675832 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rising Star Nursing Center 411 S Miller Rising Star, TX 76471 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Purpose: Hand washing will be regarded by this facility as the single most important means of preventing the spread of infections. Level of Harm - Minimal harm or potential for actual harm Procedure: Residents Affected - Few 1. All personnel will follow the facility's established handwashing procedures using current CDC Hand Hygiene Guidance protocols to prevent the spread of infections and disease to other personnel, residents, and visitors. 2. Hands should be washed 20 seconds under the following conditions . c. Before performing invasive procedures . e. Before handling clean or soiled dressings, gauze pads, etc f. After handling used dressings, contaminated equipment, etc g. After contact with blood, body fluids, excretions, secretions, mucous membranes, or nonintact skin h. After handling items potentially contaminated with blood,. body fluids, excretions, or secretions i. After using the toilet, blowing or wiping the nose, smoking, combing the hair, etc j. After removing gloves Record review of the facility policy labeled Hand Hygiene Guidance, (CDC Centers for Disease Control and Prevention) reflected the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675832 If continuation sheet Page 11 of 12 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 675832 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rising Star Nursing Center 411 S Miller Rising Star, TX 76471 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 The core infection prevention and control practices in All . Level of Harm - Minimal harm or potential for actual harm 2. All personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors Residents Affected - Few .7. Use of an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .b. Before and after direct contact with residents; c. Before preparing or handling medications .k. After handling used dressings, contaminated equipment, etc .9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675832 If continuation sheet Page 12 of 12