Health inspection·September 29, 2022

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few left the dining room. Resident #15 stated that it makes him feel belittled, made him feel bad. Resident #15 stated that he could not believe that the activity director was talking to them like that and it made him feel angry when she yelled. During an interview on 09/15/2022 at 9:36 am with Resident #19. Resident #19 stated that he was bothered by the way that the activity director had yelled at the group like that. Resident #19 stated that this is not the first time that the activity director has yelled at the residents like this. Resident #19 stated that it makes him feel like not even wanting to talk at all and made him feel like a child being scolded. Resident #19 stated that all they were doing was talking to each other and stated that he thought they were adults and could do that. Resident #19 stated, I did not feel like we were doing anything wrong. During an interview with activity director on 09/15/2022 at 10:39 am. Activity director immediately stated, I'm sorry, I'm sorry, I just get frustrated and lose my cool sometimes when the residents won't listen to me. I know that I should not have talked to them like that. That will not happen again, I'm sorry. Activity director stated that she is aware that talking to residents like that is not acceptable. Activity director stated that instead of getting so upset at the residents she should have asked them to listen to her instead of yelling at them. Activity director stated that the negative potential outcome for yelling at the residents that it could make them feel worthless and like children. During an interview with DON on 09/16/2022 at 8:07 am. DON stated that the behavior of the activity director while performing activities was unacceptable and uncalled for. DON stated that she did visit with the activity director and made her aware that this behavior will not be tolerated. DON stated that she expects if a staff member gets frustrated to take a cooling off period and come to her for advice if they are unsure how to handle the situation. DON stated that an in-service will be completed for dignity with the activity director. DON stated that the negative potential outcome for yelling at residents is that it could potentially make them feel like they do not want to live in the facility, make them feel depressed and change their attitude and the way that they feel and look at life for them. During an interview with administrator on 09/16/2022 at 2:33 pm. Administrator stated that she is aware of the situation that happened with the activity director yelling at the residents in the dining room and it does call for disciplinary action and will be taken immediately. Administrator stated that she expects all staff members to have respect for all residents at all times. Administrator stated that the negative potential outcome for the residents getting yelled at by the activity director could make the residents embarrassed, loss of self-respect about themselves and others, loose trust and safety in the staff. Record review of the facility provided policy titled Dignity, date revised on February 2021, revealed: Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation: 1). Residents are treated with dignity and respect at all times. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 2 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 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 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 8). Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his/her room number, diagnosis, or care need. Record review of the facility' provided information sheet by the Texas Health and Human services titled Resident's Rights, dated on April 2019, revealed, Under section Dignity and Respect: You have the right to: Be treated with dignity, consideration, courtesy, and respect. Under the section Freedom of Choice: Participate in activities inside and outside the facility. Record review of the facility provided in-service titled Please treat our residents with dignity and respect. Freedom of choice. Privacy and confidentiality. Participation in care. Complaints, dated on 07/29/2022. Record review of the facility provided in-service titled Just a reminder to care for these residents like they are your own family. Be kind and smile, they are going through a lot and kindness and a smile goes a long way. Provide them with the care that you were trained to give and show compassion, dated on 08/12/2022. Record review of the facility provided in-service titled Treat residents with dignity and respect. They can have what food and drink that they want. If there is a question about thickness of dining and diet of food nurse can be asked. Residents can ask for meds and if they have a question, they can have a copy of their MARS. Facial expressions, body language tells a lot about you, please watch how you talk to residents. They can sense your mood. No yelling down the hall. Residents have rights to showers, right to refuse care or meds. Knock on doors and wait for them to answer before entering. Please do not be rude to our residents since this is their home and usually live out their lives in the facility, dated on 07/29/2022. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 3 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accommodate the needs and preferences of 4 of 16 residents (Residents #6, #15, #24, #43) reviewed for accommodation of needs. Residents Affected - Some The facility failed to place Resident # 6, #15, #24, #43 call-light within reach. These failure could place residents at risk of not having their needs and preferences met and a decreased quality of life. Findings include: Resident #6 Record review of Resident #6s face-sheet revealed a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included: dementia, anxiety, essential hypertension, muscle weakness, lack of coordination, age-related physical disability, feeding difficulties, fracture of unspecified part of neck of left upper thigh. Record Review of Resident #6s admission MDS dated on 06/27/2022 revealed Resident #6 has a BIMs Summary Score (Brief Interview for Mental Status) of 4 meaning that the resident is severely impaired. Under section G: Functional Status (a). Bed mobility listed as 3: extensive assistance (i). toilet use listed as 4: total dependence. Under Section G: Balance during Transition and Walking, (a). Moving from seated to standing position listed as 8: activity did not occur, (c). Turning around listed as 8: activity did not occur (d). Moving on and off toilet listed as 8: activity did not occur Under section H: Bladder and Bowel: urinary continence: always incontinent. Bowel continence: Always incontinent. Observation and interview on 09/13/2022, at 9:05 AM, resident #6 was observed lying in bed, call-light was tied on the side of the bed and was dangling down towards the floor. Resident #15 Record review of Resident #15 face sheet revealed an admission date of 03/02/2022 and diagnoses that included: quadriplegia, alcohol dependence, major depressive disorder, anxiety disorder, intermittent explosive disorder, muscle weakness, personal history of transient ischemic attack (TIA) and cerebral infarction. Record Review of Resident #15s admission MDS dated on 03/09/2022 revealed Resident #15 has a BIMs Summary Score (Brief Interview for Mental Status) of 14 meaning that the resident is cognitively intact. Under section G: Functional Status (a). Bed mobility listed as 3: extensive assistance (i). toilet use listed as 3: extensive assistance. Under Section G: Balance during Transition and Walking, (a). Moving from seated to standing position listed as 2: not steady but able to stabilize with staff assistance, (c). Turning around listed as 2: not steady but able to stabilize with staff assistance. (d). Moving on and off toilet listed as 2: not steady but able to stabilize with staff assistance. Under section H: Bladder and Bowel: urinary continence: occasionally incontinent. Bowel continence: Always incontinent. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 4 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an observation on 09/15/2022 at 6:32 am revealed that Resident #15 in bed at 06:32AM with call light out of reach on his dresser next to his bed. Resident #24 Record review of Resident #24s face sheet revealed an admission date of 02/18/2022. With a diagnosis that included: senile degeneration of brain, depression, anxiety disorder, insomnia, heart failure, peripheral vascular disease, acid reflux, overactive bladder, dysphagia, dementia. Record Review of Resident #24s admission MDS dated on 02/25/2022 revealed Resident #24 has no BIMs Summary Score (Brief Interview for Mental Status) listed. Under section G: Functional Status (a). Bed mobility listed as 4: total dependence (i). toilet use listed as 4: total dependence. Under Section G: Balance during Transition and Walking, (a). Moving from seated to standing position listed as 2: not steady but able to stabilize with staff assistance, (c). Turning around listed as 8activity did not occur. (d). Moving on and off toilet listed as 2: not steady but able to stabilize with staff assistance. Under section H: Bladder and Bowel: urinary continence: always incontinent. Bowel continence: Always incontinent. Observation on 1/23/18 at 9:20 AM, Resident #24 was observed sleeping in bed and observed call light across the other side of the room where there were no other resident. Resident #43 Record review of Resident #43 face-sheet revealed a [AGE] year-old female, admitted to the facility on [DATE], with a diagnosis included: type 2 diabetes, cystitis, feeding difficulties, depression, paranoid schizophrenia, vitamin D deficient, anxiety, edema, lack of coordination, dysphagia, muscle weakness, gait abnormalities, aphagia, age-related physical disability. Record Review of Resident #43s admission MDS dated on 08/12/2022 revealed Resident #43 has a BIMs Summary Score (Brief Interview for Mental Status) of 3 meaning that the resident is severely impaired. Under section G: Functional Status (a). Bed mobility listed as 3: extensive assistance (i). toilet use listed as 4: total dependence. Under Section G: Balance during Transition and Walking, (a). Moving from seated to standing position listed as 8: activity did not occur, (c). Turning around listed as 8: activity did not occur. (d). Moving on and off toilet listed as 8: activity did not occur. Under section H: Bladder and Bowel: urinary continence: always incontinent. Bowel continence: Always incontinent. In an observation on 09/15/2022 at 6:28 am revealed that Resident #43 sleeping in her bed at 06:28 AM with call light sitting out of reach in her recliner. Interview on 09/14/2022 at 4:29 pm, with LVN B. LVN B stated that it is the responsibility of all the staff on the floor to make sure that the residents call lights are in place. LVN B stated that she is not sure why some residents call lights were not in place and would make sure to correct this issue. LVN B stated that normally the staff check the call lights every 2 hours. LVN B stated that she had been trained to make sure that call lights are in place and does know to make sure that they are in place. LVN B stated that she just gets busy and sometimes forgets to check. LVN B stated that the negative potential outcome for the residents not having the call light in place would be that the resident could fall and become injured. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 5 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 09/14/2022 at 4:35 pm, with CNA H. CNA H stated that all aides are responsible for making sure that call lights are in resident's reach. CNA H stated that she has been trained to place call lights within resident's reach. CNA H stated that usually after aides provide care, they would have placed the call light next to the resident. CNA H stated that she was not aware that Resident #6, #15, #24, and #43 had no call light in reach. CNA H stated that she has not personally made sure that the call lights were in place. CNA H stated that she did not have a specific reason for why the call lights were not in place. CNA H stated that the negative potential outcome if the resident could not reach the call light would be that they could fall or if the resident became disoriented and could not call for help they could get hurt badly. CNA H stated that the outcome of that would not be good. Interview on 09/14/2022 at 4:48 pm, with administrator. Administrator stated that if the resident needed to use the call light and could not reach it then it could cause the resident to get hurt. Administrator stated that she expects the staff to make sure that all resident's call lights are within their reach. Administrator stated that the facility makes a promise to the residents that they would be able to keep them safe and it will become a trust issue if the facility fails to comply with these standards. Administrator stated that it is the responsibility of all staff to make sure that all residents have their call lights within reach. Interview on 09/14/2022 at 5:00 pm, with DON. DON stated that it is the responsibility of all staff to ensure that the resident is in reach of their call light. DON stated that she would make sure to do another in-service for call lights. DON stated that she expects all staff to make sure that the residents are safe by making sure they have their call light in reach. DON stated that the negative potential outcome for a resident not being able to reach their call light would be that the resident could fall, not able to notify staff when they need help, and could potentially end up in death. Record review of facility provided in-service, labeled, Make sure call lights are in reach before you leave a resident's room. Dated 08/08/2022 Record review of facility provided policy, labeled, Answering call lights, dated revised on March 202, Under general guidelines: (5). When a resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 6 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, including the State Survey agency, in accordance with State law through established procedures for 2 of 2 residents (#44 and 60); in that : 1)The facility failed to report two allegations of neglect involving Resident #60 to the State Survey Agency, and 2) The facility failed to report an allegation of abuse involving Resident #44 to the State Survey Agency. This failure could place additional residents at risk for abuse and neglect that resulted in injury. The findings include: 1)Record review of the Order Summary Report dated 9/15/22 for Resident #60 revealed that the resident was male and admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Major Depressive Disorder, Recurrent, Unspecified, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety, Muscle Weakness (Generalized), Cognitive Communication Deficit, Unsteadiness on Feet, Major Depressive Disorder, Recurrent Severe Without Psychotic Features, Anxiety Disorder Due To Known Physiological Condition and Hypothyroidism, Unspecified. Record review of the Progress Notes for Resident #60 revealed that on 8/18/22 the resident was discovered missing from the facility at 4:45 PM. The resident was not found and returned to the facility until 6:37 PM. Further record review of the Progress Notes for Resident #60 revealed that on 9/3/22 the resident was reported missing from the facility at 9:15 AM. The resident was found by his son at 11:43 AM (approximately .6 miles from the facility) on 82nd and Quaker Ave. The resident was returned to the facility at 12:00 PM. On both occasions the police were called, and facility staff search for the resident. The resident was discharged from the facility after the incident on 9/03/22 at 4:30 PM. Record review of the Incident-by-Incident Type list for the facility dated 9/13/22 revealed that there were one resident listed as having an elopement incident. The date range for the list was 3/13/22 to 9/13/22. Resident #60 was not listed on this document as eloping from the facility. On 9/16/22 at 11:14 AM, an interview was conducted with the DON. She stated Resident #60 wandered and was confused and had dementia. She added the first time he eloped; she was not sure how far he was from the facility. The second time he was found outside a new restaurant on 82nd street. She added that the Administrator was responsible for reporting incidents to the State. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 7 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 9/16/22 at 11:29 AM, an interview was conducted with the Administrator regarding elopement protocols. Regarding Resident #60 she stated, he was a dementia resident from another nursing home. She believed the first time he was found was on 76th and Salem Avenue (approximately 0.3 miles from the facility). She added both times the resident was gone an hour or less. The second time was on a Saturday (9/03/22). She further stated she did not report either incident of elopement to the State survey agency. She added that she thought the incidents were reportable if the resident was gone more than two hours. She stated the resident was discharged to a secure nursing facility (9/03/22). 2) Resident #44 is a [AGE] year old female admitted on [DATE] with diagnoses of Encephalopathy (disease affecting the brain), Neuromuscular Dysfunction Of Bladder (brain causes lack of bladder control), Anemia (lack of red blood cells), Type 2 Diabetes Mellitus Without Complications, Unspecified Atrial Fibrillation (irregular heart beat that can cause clots), Gastro-Esophageal Reflux Disease Without Esophagitis (stomach acid goes up into esophagus), Chronic Kidney Disease, and Dysphagia (difficulty swallowing). According to the MDS completed on 08/25/22, Resident 44 has a BIMS of 12 (moderately impaired cognition) According to record review of Resident 44's chart, a progress note dated 9/15/2022 at 5:20 pm, Resident 44's family member reported to this nurse that res has bruise on her forehead and that when she asked her what happened, res reported to her that the night shift girls got angry at her for calling so much that they repositioned her too rough and hit her head into the bedrail. This nurse reassured family member that this would be reported to ADON/administrator. In an interview on 9/16/22 at 10:43 am Resident 44 was observed lying in bed with a sheet over her; she had a bruise in the middle of her forehead, near the hair line. She stated she had pain in her head. When asked how it occurred she stated she fell trying to go to the restroom and had to get a stitch above her left eye. A healed spot above the left eye was visible. In an interview on 9/16/22 at 5:10 pm with the Administrator, she stated that she was notified on 9/15/22 around 5:00 pm of the family member's allegation of abuse reported to a nurse. She stated she had started an internal investigation, but Resident 44 often has confusion. She stated she had not reported the allegation to any authorities because she had not completed her investigation. When asked what the potential outcome for residents of not reporting abuse allegations to authorities, the Administrator stated it could cause harm to the residents if abuse occurred or continued to occur. Record review of the document titled Policy and Procedure Freedom From Abuse or Neglect, revised 9/13/11 revealed the following documentation, It is the policy of this facility that each resident has the right to be free from mistreatment, neglect, abuse, and misappropriation of property by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Definitions . Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The facility shall 7. Report all alleged violations and all substantiated incidents to the state survey agency and to all other agencies as required and take all necessary corrective actions depending on the results of the investigation The administrator of this facility is responsible for the initial reporting, investigation of alleged violations and reporting of results to the proper authorities. In the event the administrator is unavailable, the Director of Nurses shall assume such responsibility. In the event both the Administrator and the Director of Nurses are unavailable, the social worker shall assume such responsibility. Record review of the facility policy titled Abuse Investigations, revised June 2005, revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 8 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few following documentation, Policy Statement. All reports of resident abuse, neglect and injuries of unknown origin shall be promptly and thoroughly investigated by the facility management. Policy Interpretation and Implementation. NFs (nursing facilities) must report abuse allegations immediately, but not later than two hours after the allegation is made, if the event that caused the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and do not result in serious bodily injury. Record review at the facility policy titled Reporting Resident Abuse, Revised September 2003 revealed the following documentation, Policy Statement. All employees of this facility must immediately report any incident or suspected incident of resident neglect, abuse, or misappropriation of resident property. Such incidents will be investigated and any findings of abuse will be reported to the state agency responsible for recording such data in the abuse registry FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 9 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 3 of 13 residents (Resident #22, Resident #12, Resident #9) reviewed for accuracy of MDS assessments. Residents Affected - Some -The MDS assessment of Resident #22 had errors in ADLs and Falls. -The MDS assessment of Resident #12 had errors in ADLs, Nutrition, and Medications. -The MDS assessment of Resident #9 had errors in assessment of continence. This failure could place residents at risk for not receiving the correct care to meet their physical, mental, and psychosocial needs. Findings include: Resident 22 Record review of Resident 22's face sheet revealed an [AGE] year old female admitted [DATE] with diagnoses including: Fracture of right clavicle (collar bone) on 3/11/22, feeding difficulties, hypothyroidism (thyroid underperforming), type 2 diabetes, hyperlipidemia (high cholesterol), dementia, Alzheimer's, heart failure, angina (chest pain from blocked blood vessels), osteoarthritis, cognitive communication deficit, dysphagia (trouble swallowing), and pain in unspecified joint. Record review of Resident 22's Care Plan, last reviewed on 08/30/22 showed that under the focus of Activities of Daily Living (ADL's), for eating - the resident requires (supervision to limited assistance x1 person physical assist) for setup/cleanup. Further along in the ADL section, it showed transfer: the resident requires (limited assistance x 1 person physical assist) moving between surfaces including to or from: bed, chair, wheelchair, standing position. In addition, the care plan showed a focus of actual fall on 05/15/22, actual fall with no injury which was added to the care plan on 05/19/22. Record review of MDS that was the last annual assessment, dated 05/12/22, showed in section J - Health Conditions, for J1800 has the resident had any falls since admission/entry or reentry or the prior assessment (whichever is more recent? And the answer is 0 which equates to the answer no. The newest MDS assessment of Resident #22, a quarterly MDS dated [DATE], indicated in section G Functional Status, letter B. Transfer was marked 3 (two+ persons physical assist). In the same section, question letter H. Eating was marked 3 (two+ persons physical assist), but the care plan referenced above stated 1 person assist for both activities, eating and transfers. In addition, in section J - Health Conditions, question J1900 Any falls since admission/entry or reentry or prior assessment, whichever is more recent, the facility marked no falls since prior assessment, however a fall was documented as occurring on 5/15/22 in the care plan and the prior MDS was dated prior on 5/12/22. Resident 12 Record review of Resident 12's face sheet revealed a [AGE] year old female admitted [DATE] with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 10 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm diagnoses including: Huntington's Disease (genetic disease that destroys the nerve cells in the brain), dyskinesia (abnormal movements), body mass index (BMI) of 19.9 or less (below healthy), dementia, major depressive disorder, functional urinary incontinence (brain is talking to bladder, but decisions or environment prevent continence), fracture of the right arm, dysphagia (trouble swallowing), and cognitive communication deficit. Residents Affected - Some Record review of Resident 12's active orders as of 09/13/22 showed an order for Aspirin 81 mg by mouth 1 time a day for anagesic (should be analgesic - pain relief). No other orders reflect any blood or platelet altering medications. Record review of Resident 12's care plan last reviewed 06/07/22 showed a focus of nutrition management with a goal of maintaining a weight of 88 to 98, and interventions of inviting her to activities to promote intake, reporting to MD signs of malnutrition, emaciation (cachexia - defined as weakness and wasting of the body due to severe illness). Under the ADL's focus for Resident 12, the care plan stated in the locomotion on/off unit section: the resident requires (limited to extensive assistance x1 person physical assist) moving between locations in her room, corridor, and distant areas of the facility. The MDS assessment of Resident #12 dated 07/05/22, which was an annual assessment, indicated in Section G - Functional status question C. Walk in room a number 2, which represents one-person physical assist. In the same section, question D. Walk in corridor was marked as a 1, which represents setup help only. In section I - active diagnoses, question I5600 Malnutrition (protein or calorie) or at risk for malnutrition, the box is not checked despite the care plan addressing the resident being at risk for this issue. In addition, according to her face sheet, she has a diagnosis of BMI 19.9 or less. In Section N Medications, question N0410 Medications Received, indicate how many days of the last 7 days were administered, question letter E is anticoagulant and is marked 7 days, but no prescription for an anticoagulant was present, only aspirin which is an antiplatelet (see below for delineation of antiplatelet and anticoagulant). In an observation on 09/13/22 at 10:16 am, Resident #12 was observed pacing in her room stating, there's an alarm over and over again; staff was found and informed, they stated this is normal behavior for her. In a further observation on 09/15/22 at 5:00 pm, Resident #12 was seated on her bed when surveyor entered and then she stood up and paced in her room for 10 minutes while surveyor and resident chatted. Record review of an article on Medline Plus titled Blood Thinners, last updated 01/31/22, accessed 09/27/22, found at this link: https://medlineplus.gov/bloodthinners.html#:~:text=Anticoagulants%2C%20such%20as%20heparin%20or,a%20heart%20a The article defines blood thinners as medicines that prevent blood clots for forming and it listed two types of blood thinners: anticoagulants, such as heparin or warfarin that slow down the process of making clots, and antiplatelets such as aspirin and clopidogrel prevent cells called platelets from clumping together. Resident 9 Record review of Resident 9's face sheet revealed a [AGE] year old female admitted [DATE] with diagnoses including: Parkinson's (disease affecting nerves in the brain and through the body), cognitive communication deficit, major depression, myopia (near sighted), chronic obstructive pulmonary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 11 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm disease (lungs can't spread oxygen), emphysema (sacs in the lung can't switch oxygen and carbon dioxide leaving person breathless), schizoaffective disorder bipolar type (mood disorder that varies by person but has mania and depression), generalized anxiety, history of falling, post-traumatic stress disorder (PTSD), pain in unspecified joint, bilateral cataract (cloudiness in both eyes), benign neoplasm of left choroid (abnormal cells in the left eye), and insomnia. Residents Affected - Some Record review of Resident 9's care plan, last reviewed 07/14/22, stated in the focus of bladder/bowel management that Resident 9 is incontinent of bladder and at risk for fecal incontinence, initiated on 05/07/18 and revised on 04/14/22. It shows a goal of remaining free from skin breakdown due to incontinence and brief use through the review date; this goal was initiated 05/07/18, revised on 09/07/22 and has a target date of 10/28/22. In another focus section of the care plan titled bowel/bladder management, initiated on 09/19/19 and revised on 04/10/22, it stated that Resident 9 has bowel incontinence and one intervention/task is provide pericare after each incontinent episode (entered 09/19/19). Record review of the most recent quarterly MDS assessment, dated 07/05/22, of Resident #9 Section H Bladder and Bowel, question H0300 Urinary Continence was marked as a 0, which corresponded to always continent. Question 0400 Bowel Continence was marked as 0, which corresponded to always continent. During an interview with the ADON on 09/16/22 at 11:25 AM, she explained the process for creating the MDS. She stated the responsibility rests with the MDS Coordinator, who is relatively new to the position. She stated that some of the diagnoses come from the electronic health record, but that the MDS Coordinator may pull some from the admission paperwork or hospital discharge paperwork. From the MDS that is created, there is a care plan team that meets daily and consists of the DON, Social Worker, MDS Coordinator, Administrator, and each specialty area such as Dietary and Therapies. She stated that the care plan is developed from the active diagnoses, the orders, and from the MDS results. She stated that inaccurate MDS information can lead to improper care plans and improper care plans can lead to improper care for a resident, which would be harmful to that resident. During an interview with the MDS Coordinator on 09/16/22 at 11:43 am, I stated I had found errors in the MDS and Care Plans, and I asked what was the process for creating the MDS and Care Plan, and there was a corporate MDS advisor present, as the MDS Coordinator was new. The MDS Coordinator stated that the electronic health record automatically takes the diagnoses entered for the residents and auto populates the MDS worksheets. She stated that there is a team, the interdisciplinary team (IDT) that meets daily and includes MDS Coordinator, DON, ADON, Social Work, Dietary, Therapy, Activities, and the Administrator to discuss issues for each patient that may need to be updated on the MDS or the Care Plan for the resident. She stated that the nurses discuss skin issues and other direct care issues at these meetings. She said the nurses are responsible for most of the resident assessments, the Braden weekly assessment. If there is a significant change the DON or ADON will bring this up and it will get updated in the MDS and then the care plan. She stated that certain care areas in section V they automatically trigger for every resident, such as dehydration, since all are at risk for these issues. She stated they use the worksheets for the MDS to make sure all major diagnoses, medications, falls, hydration, and pacemaker are added the MDS within 7 days and then discussed at the care plan IDT meeting. She stated that inaccuracies or omissions from MDS lead to inaccurate care planning and services for the resident. Record review of the facility policy MDS Completion and Submission Timeframes, published in 2001 and revised in July 2017 revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 12 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 .Assessment Coordinator or designee is responsible for assuring MDS is submitted in required times Level of Harm - Minimal harm or potential for actual harm . based on Resident Assessment Instrument Manual Residents Affected - Some Record review of the facility policy Goals and Objectives, Care Plans, Published in 2001 and revised in April 2009, revealed the following documentation: Policy Statement Care Plan shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Policy Interpretation and Implementation 1. Care plan goals and objectives are defined as the desired outcome for a specific resident problem . 3. objectives are derived from information in the resident's assessment . 5. goals and objectives are reviewed and/or revised: a.significant change b.outcome had not been achieved c.readmit from hospital/rehab stay d. at least quarterly FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 13 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I screening accurately reflected the resident's status for 4 of 6 residents (Residents #37, #43, #48, and #50) reviewed for PASRR services. Residents Affected - Some The facility failed to ensure the accuracy of the PASRR Level 1 screening for Residents #37, #43, #48, and #50, which resulted in the residents not receiving a PASRR Level II evaluation. This failure could place residents who have a mental illness at risk of not receiving individually specialized services to meet their needs. Findings included: Resident #43: Record review of Resident #43's face sheet, dated 9/14/2020, revealed an [AGE] year-old female originally admitted on [DATE], with diagnoses including paranoid schizophrenia (onset date 6/27/2020), disorganized schizophrenia (onset date of 6/27/2020), schizophrenia unspecified (onset date 6/27/2020), schizoaffective disorder - bipolar type (onset date of 6/27/2020), major depressive disorder (onset date of 1/27/2020), and psychotic disorder with delusions due to know physiological condition (onset date of 6/27/2020). Record review of Resident #43's MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15 indicating she was severely cognitively impacted. Record review of Resident #43's PASRR Level 1 screen dated 05/5/2020, with an Effective and Entered date listed in the electronic medical records system of 6/29/2020, revealed the following in part, .C0100. Mental Illness: Is there evidence or an indicator this is an individual that has a mental illness . The answer was No. During an interview with the MDS Coordinator on 09/14/22 at 2:43 PM, she was asked if she could provide a more current PASRR Level screening or level 2 evaluation and she said she would look for one. During an interview with the MDS Coordinator on 09/15/22 at 07:50 AM, I asked if she was ever able to locate the requested PL1 or PL2 for Resident #43 and she said they did not have one. She said she had contacted the Local Mental Health Care Authority to come to the facility today to reevaluate Resident #43. No evidence of an updated or accurate PASRR Level 1 screening was provided prior to exit date of 9/16/2022. During an interview on 09/15/22 at 11:14 AM with the MDS Coordinator, she said PASRR Level 1 screening is usually already done when a resident is admitted to the facility. She said if the PASRR Level 1 was not already completed, like if a resident came from home for example, then the social worker was supposed to get it done and the MDS coordinator was responsible for reviewing and documenting the information into the electronic medical records system. She said the information should be entered within about two days of resident admission. She then clarified the social worker completes the PASSAR level 1 screening, and the MDS nurse enters information into SimpleLTC. When asked who was responsible for checking that PASRR Level 1 screening was documented correctly, she said she usually (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 14 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 Level of Harm - Minimal harm or potential for actual harm makes sure they are done correctly or her supervisor. When asked if diagnoses of bipolar disorder, schizophrenia or major depressive disorder are conditions that should have triggered a level 2 evaluation, she said yes, they would be marked as a yes under section C0100 which screens for mental illnesses and triggered a PASRR Level 2 screening for services. She said if the PASRR Level 1 was not accurate related to mental illness diagnoses, then the resident may not receive specialized services needed. Residents Affected - Some During an interview with the Social Worker on 09/15/22 at 11:24 AM, she said PASRR Level 1 screenings should be done when a resident admits to the facility, and they would like to get it before if the resident transferred from another facility. She said if a resident came from home, she is responsible for completing it. She said she thought the MDS Coordinator's supervisor was responsible for verifying accuracy of PASRR Level 1 screening forms. When asked if schizophrenia or major depressive disorder are conditions that should have triggered a level 2 evaluation, she said yes, they would be under mental illness and should have been indicated as a yes for C0100. She said the risk to the resident was that the resident would have missed out on needed services. Resident #50: Record review of the face sheet and Order Summary Report dated 9/13/22 for Resident #50 revealed that he was admitted to the facility on [DATE] and readmitted on [DATE]. The resident was [AGE] years old and had diagnoses of Schizoaffective Disorder, Bipolar Type(F25.0), Bipolar Disorder, Unspecified, Acute Kidney Failure, Unspecified, Generalized Anxiety Disorder, Hemiplegia and hemiparesis Following Unspecified Cerebrovascular Disease Affecting Unspecified Side (paralysis), Peripheral Vascular Disease, Type 2 Diabetes Mellitus Without Complications, Other Specified Mental Disorders Due To Known Physiological Condition, Bipolar Disorder, Current Episode Depressed, Severe, With Psychotic Features, Major Depressive Disorder, Single Episode, Unspecified, Other Chronic Pain, Essential (Primary) Hypertension (high blood pressure), Chronic Obstructive Pulmonary Disease, Unspecified (lung disorder), Alcoholic Cirrhosis Of Liver Without Ascites(liver disease), Unspecified Convulsions, and Human Immunodeficiency Virus Disease (HIV). Record review of the facility submitted list of PASRR positive residents, dated 9/13/22, revealed that there were seven residents listed, but Resident #50 was not on this list. Record review of the PASRR Level 1 Screening for Resident #50 dated 9/16/21 revealed that the resident was negative for mental illness, intellectual disability and developmental disability. This PASRR screening was conducted by the resident's previous facility. On 9/13/22 at 1:40 PM an interview and observation were made of Resident #50. He stated he had been in the facility since November 2021. The resident was obese, was seated in a wheelchair and the room was dark. The resident had depressive appearance/affect. On 9/14/22 at 1:10 PM an interview was held with the MDS Coordinator regarding the PASRR assessment for Resident #50. She stated, the PASRR Level 1, completed by the hospital and previous nursing home, were both negative. She added that their facility had missed his diagnosis of Schizoaffective Disorder, Bipolar Type and Bipolar Disorder. She further stated the PASRR representative said that he was not eligible for services due to the negative MI, ID and DD from the 9/16/21 assessment. She added that she became the MDS Coordinator in April 2022. On 9/15/22 at 3:48 PM an interview was conducted with the MDS Coordinator regarding the incorrect (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 15 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some PASRR assessment for Resident #50. She stated the incorrect assessment occurred because she went by the negative assessment from the previous nursing home and failed to check the resident's diagnosis. She added that she did not know she needed to check the accuracy of the assessments. She stated that she was responsible ensuring that the assessments were correct regarding PASRR. She added if residents received incorrect assessments, they may not receive the services they needed or correct placement. She stated that she had not observed any schizophrenic or bipolar behavior with Resident #50. She further stated she had heard the resident gets upset but she had not seen it. On 9/15/22 at 4:01 PM an interview was conducted with the Administrator. Regarding incorrect PASRR assessments, she stated she expected staff to work with corporate to have the proper training. She added staff must be aware of resident diagnoses and PASRR mistakes and not take for granted the PASRR assessments were correct. she stated that incorrect PASRR assessments could result in resident needs not being met. Resident 48: Based on record review of the face sheet, accessed 09/14/22, Resident 48 is an [AGE] year old female admitted to the facility 03/17/2016 with diagnoses including: schizoaffective disorder, bipolar type (severe mental illness), other specified anxiety disorders, metabolic encephalopathy (brain problems), Alzheimer's disease with late onset, psychotic disorder with hallucinations due to known (mental illness, seeing things that are not there), major depressive disorder, recurrent severe without psychotic (mental illness makes you sad due to brain chemical imbalance), psychotic disorder with delusions due to known physiological (mental illness, believing things that are not true), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of the brain), and hallucinations (seeing things that are not there). In an interview on 09/14/22 with MDS Coordinator, Resident #48's Level II PASRR was requested and the facility informed surveyors that there was no Level II PASRR for Resident #48. In addition, based on record review, on her annual MDS done on 10/14/2021, Section A, question 1500 Preadmission Screening and Resident Review (PASRR) which asks if the resident is considered by the state level II process to have a serious mental illness and/or intellectual disability or related condition, the answer is no despite the resident having a diagnosis of schizoaffective disorder, bipolar type; psychotic disorder with hallucination and delusions, and an anxiety disorder. Record review of Resident 48's PASRR I revealed a negative screening, with question C0100. Mental Illness marked as 0, which is a no, despite the resident admissions diagnosis of multiple mental illnesses including schizoaffective disorder, bipolar type. Resident 37: Based on record review of Resident 37's face sheet, accessed 09/14/22, Resident 37 was a [AGE] year old female admitted to the facility 01/21/2019 with diagnoses including Generalized Anxiety Disorder, Bipolar Disorder (severe mental illness with mood swings), and Anxiety Disorder, Unspecified. In an interview on 09/14/22 with MDS Coordinator, Resident #37's Level II PASRR was requested and the facility informed surveyors that there was no Level II PASRR for Resident #37. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 16 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record Review of Resident 37's Level I PASRR revealed a negative screening, with question C0100. Mental Illness was marked as 0, which is a no. Resident #37 was admitted to the facility with a diagnosis of Bipolar Disorder and Generalized Anxiety Disorder. Record review of the transfer-discharge return anticipated note in Resident 37's medical record, Resident #37 was transferred to the hospital for Cognitive impairment possible mental health crisis according to the transfer form section 1 in her medical chart, which also states relevant diagnosis of bipolar. Section II of the transfer form states resident's husband is concerned that the resident is experiencing a mental health crisis. Stated, 'this has happened before and she had to get treatment from covenant's mental health hospital.' Record review of Form 1012, Texas Health and Human Services Mental Illness/Dementia Resident Review found at https://www.hhs.texas.gov/regulations/forms/1000-1999/form-1012-mental-illnessdementia-resident-review (accessed on 09/21/2022) read in part, .Examples of MI (mental illness) are: a schizophrenic, mood disorder (bipolar, major depression, or other mood disorder), paranoid disorder; somatoform disorder; schizoaffective disorder; panic or other disorder that may lead to a chronic disability diagnosable under the current Diagnostic and Statistical Manual of Mental Disorders . Record review of the facility's undated current policy titled, Policy and Procedure for PL1 (PASRR Level 1 Screening)/PASRR/ . Revised 1/16/2019 revealed the following documentation, Rationale: The facility will ensure compliance with all Phase I and II guidelines of the PASRR process for long-term care. Responsibilities: MDS coordinators, marketing/admissions team members/social worker/administrator/DON/IDT members. Procedures: 1. Submit a PL1 form for every person entering your facility regardless of payer source within 72 hours of admission. A. The LTC facility is only allowed to complete/submit the PL1 form for LTC facility to LTC facility transfer, all other PL1 forms are completed by the referring entity or family, if the person is coming from home, staff may assist the family with completing the PL1 information and fax in to the local authority. The local authority must submit PL 1 forms prior to admission to the facility and facility must certify they can care for the resident. Additional record review of facility's undated policy titled Policy and Procedure for PL1/PASRR/NFSS/1012/PCSP read in part, . If at any time a resident has a significant change, admits to Hospice, discharging to another facility, or you receive information that might indicate the resident may have a MI/ID/DD (mental illness/ intellectual disability/ developmental disability) diagnosis or condition not contained in the medical record, please submit a PL1 form for the resident to be evaluated by the Local Authority . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 17 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial needs for 3 of 13 residents (Residents #'s 5, 29, 48) reviewed for care plans as follows: Resident 5 did not have a care plan for BiPAP, back injury, nor for Urinary Incontinence. Resident 29 did not have a care plan for pain, indwelling urinary catheter, oxygen, pressure ulcers, diabetes mellitus, atrial fibrillation, arthritis, hyperlipidemia, and vision with corrective lenses used. Resident 48 did not have a care plan for pain, communication, osteoarthritis, schizoaffective disorder (bipolar type), nor correct assistance with toileting. This failure could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings include: Resident 5 Record Review of Resident 5's face sheet revealed an [AGE] year old female admitted [DATE] for diagnoses that included the following : Chronic Respiratory Failure Whether With Hypoxia Or Hypercapnia (failure of lungs to provide oxygen), Cerebrospinal Fluid Leak, Unilateral Primary Osteoarthritis Knee (inflammation in knee joint), Spondylosis Without Myelopathy Or Radiculopathy, Lumbar Region (narrowing of the spine in the lower back), Other Intervertebral Disc Degeneration, Lumbosacral Region (breakdown of cushion between discs of spine in lower back), Dorsalgia (back pain), Post laminectomy Syndrome, Not Elsewhere Classified (pain in back after surgery to remove part of the spinal bone called the lamina), Arthrodesis Status (fusion of 2 bones in a joint), Radiculopathy, Site Unspecified (pain or tingling caused by damage to a spinal nerve). Record Review of Resident 5's comprehensive MDS (Minimum Data Set) dated 06/01/22 documented the following: Section C - Cognitive Patterns - C0500. BIMS (Brief Interview for Mental Status) Summary Score = 15, no cognitive deficit. Section O - Special Treatments, Procedures, and Programs - O0100. C. Oxygen Therapy = Yes while a resident. G. Non-Invasive Mechanical Ventilation (BiPAP/CPAP) was left blank. Section V - Care Area Assessment (CAA Summary) triggered for 06. Urinary Incontinence. Record Review of Resident 5's Active Orders showed an order dated 01/28/22 for BIPAP SETTINGS INSPIRATORY PRESSURE 5 WITH 02 BLEED IN OF 2-3LPM, VERIFIED BY RT. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 18 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 09/13/22 at 10:06 AM revealed Resident 5 had a BiPAP machine on the small table next to the head of the bed. Record Review of Resident 5's active care plan, last reviewed on 08/30/22, did not reveal a care plan for a BiPAP, for Urinary Incontinence, nor for multiple injuries to her back listed on her face sheet as current diagnoses (including CSF leak, abscess of the back, spondylosis of the lumbar region, intervertebral disc degeneration in the lumbo-sacral region, dorsalgia, and post-laminectomy syndrome). Resident 29 Record review of Resident 29's face sheet revealed a [AGE] year old female admitted [DATE] with the following diagnoses: Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; pain in unspecified joint; muscle weakness; unspecified lack of coordination; cognitive communication deficit; age-related physical debility; COVID-19; type 2 diabetes without complications; other hyperlipidemia (high cholesterol); metabolic encephalopathy (problems in the brain); secondary hypertension (high blood pressure); unspecified atrial fibrillation (irregular heart rhythm); other specified arthritis, unspecified joint; and altered mental status, unspecified. Record review of Resident 29's comprehensive MDS (Minimum Data Set) dated 08/12/22 documented the following: Section B - Hearing, Speech, and Vision - B1200 Corrective Lenses is marked 1 (yes). Section C - Cognitive Patterns - C0500. BIMS (Brief Interview for Mental Status) Summary Score = 07, severe cognitive deficit. Section H - Bladder and Bowel - H0100 Appliances. A. Indwelling Catheter = checked indicating device present. Section I. Active Diagnoses. I0300 Atrial fibrillation was marked, I2900 Diabetes Mellitus is marked, I 3300 Hyperlipidemia is marked, and I3700 Arthritis was marked, Section V - Care Area Assessment (CAA Summary) triggered for 06. Urinary Incontinence and Indwelling Catheter and 16. Pressure Ulcer. Record review of Resident 29's active orders showed an order entered on 08/23/22 for 02 continuous 2Lpm via NC to keep sats above 90%; an order placed on 08/15/22 for CATHETER CARE EVERY SHIFT FOR INFECTION PREVENTION MAINTENANCE every shift ENSURE EACH SHIFT THE CATHETER IS ANCHORED PER PROTOCOL AND THE PRIVACY/DIGNITY COVER IS IN PLACE every shift; an order on 08/05/22 for Atorvastatin Calcium Tablet 10 MG Give 1 tablet by mouth one time a day related to OTHER HYPERLIPIDEMIA; Tylenol Tablet 325 MG (Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for pain, fever. An observation of Resident #29 on 9/15/22 at 8:48 am revealed that there was an indwelling urinary catheter present, and the catheter bag was over full and bulging; urine that was present in the tubing of the catheter bag was cloudy and chunky looking. A record review of Resident 29's active care plan, initiated on 08/09/22 with some updates 08/20/22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 19 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and one update 08/23/22 lacked the following: a care plan for pain, despite a diagnosis of pain in unspecified joint and an order for pain medicine as needed; a care plan for the indwelling urinary catheter; a care plan for oxygen despite an order for oxygen; a care plan for pressure ulcers despite it triggering on the MDS Section V; a care plan for diabetes mellitus, atrial fibrillation, arthritis, and hyperlipidemia despite the active diagnoses on the list and being marking on the MDS; and there is no care plan for the resident's vision that requires corrective lenses as marked in the MDS. The care plan had a section stating the resident has bladder incontinence r/t Confusion and Dementia and a goal of the resident will remain free from skin breakdown due to incontinence and brief use through the review date. The activities to address the focus were notify nursing if incontinent during activities and check the resident every two hours and as needed and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. The resident has an indwelling urinary catheter, so there can't be any bladder incontinent issues. Resident 48 Record review of Resident 48's face sheet revealed an [AGE] year old female admitted [DATE] who had diagnoses including: Schizoaffective Disorder Bipolar Type, Other Specified Anxiety Disorders, Hereditary And Idiopathic Neuropathy, Polyosteoarthritis, Alzheimer's Disease With Late Onset, Psychotic Disorder With Delusions Due To Known Physiological Condition, Unspecified Dementia with Unspecified Severity Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety; Hallucinations, Age-Related Physical Debility, Pain In Unspecified Joint, Shortness Of Breath, Overactive Bladder, and Other Chest Pain. Record review of Resident 48's comprehensive MDS (Minimum Data Set) dated 10/14/21 documented the following: Section C - Cognitive Patterns - C0500. BIMS (Brief Interview for Mental Status) Summary Score = 03, severe cognitive deficit. Section I - Active Diagnoses - I3700 Arthritis is marked Section V - Care Area Assessment (CAA Summary) triggered for 04. Communication Record Review of Resident 48's abbreviated update to the MDS dated [DATE] documented the following: Section G - Functional Status - I Toilet Use - Requires 2 person assist Section I - Active Diagnoses - I6000 Schizophrenia (e.g., schizoaffective and schizophreniform disorders) is marked Record review of Resident 48's active orders revealed an order for Norco Tablet 7.5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth three times a day related to PAIN IN UNSPECIFIED JOINT entered on 04/19/22. Record review of Resident 48's active care plan, last reviewed 07/05/22, stated TOILET USE: The resident requires (extensive assistance x 1-person physical assist) to use toilet or bedpan despite the 8/16/22 MDS stating 2 persons are required to assist. In addition, the care plan states the resident requires psychotropic medications for diagnosis of psychosis, delusions and hallucinations, Seroquel Tablet (Quetiapine Fumarate), however there is no active order for Seroquel for Resident 48. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 20 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Further review of the active care plan revealed no care plan for communication existed despite it triggering in Section V of the latest complete MDS. The care plan also failed to address Resident 48's pain and nor did it address the use of the narcotic hydrocodone for her pain. The care plan did not address Resident 48's active diagnosis of osteoarthritis that was marked on the MDS active diagnoses list. There was no care plan present for the active diagnosis of schizoaffective disorder (bipolar type) which was also marked on the MDS active diagnoses list. During an interview with the ADON on 09/16/22 at 11:25 AM, she explained the process for creating the MDS. She stated the responsibility rests with the MDS Coordinator, who is relatively new to the position. She stated that some of the diagnoses come from the electronic health record, but that the MDS Coordinator may pull some from the admission paperwork or hospital discharge paperwork. From the MDS that is created, there is a care plan team that meets daily and consists of the DON, Social Worker, MDS Coordinator, Administrator, and each specialty area such as Dietary and Therapies. She stated that the care plan is developed from the active diagnoses, the orders, and from the MDS results. She stated that inaccurate MDS information can lead to improper care plans and improper care plans can lead to improper care for a resident, which would be harmful to that resident. During an interview with the MDS Coordinator on 09/16/22 at 11:43 am, I stated I had found errors in the MDS and Care Plans, and I asked what was the process for creating the MDS and Care Plan, and there was a corporate MDS advisor present, as the MDS Coordinator was new. The MDS Coordinator stated that the electronic health record automatically takes the diagnoses entered for the residents and auto populates the MDS worksheets. She stated that there is a team, the interdisciplinary team (IDT) that meets daily and includes MDS Coordinator, DON, ADON, Social Work, Dietary, Therapy, Activities, and the Administrator to discuss issues for each patient that may need to be updated on the MDS or the Care Plan for the resident. She stated that the nurses discuss skin issues and other direct care issues at these meetings. She said the nurses are responsible for most of the resident assessments, the Braden weekly assessment. If there is a significant change the DON or ADON will bring this up and it will get updated in the MDS and then the care plan. She stated that certain care areas in section V they automatically trigger for every resident, such as dehydration, since all are at risk for these issues. She stated they use the worksheets for the MDS to make sure all major diagnoses, medications, falls, hydration, and pacemaker are added the MDS within 7 days and then discussed at the care plan IDT meeting. She stated that inaccuracies or omissions from MDS lead to inaccurate care planning and services for the resident. Record review of the facility policy Goals and Objectives, Care Plans, Published in 2001 and revised in April 2009, revealed the following documentation: Policy Statement Care Plan shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Policy Interpretation and Implementation 1. Care plan goals and objectives are defined as the desired outcome for a specific resident problem . 3. objectives are derived from information in the resident's assessment . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 21 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 5. goals and objectives are reviewed and/or revised: Level of Harm - Minimal harm or potential for actual harm a.significant change b.outcome had not been achieved Residents Affected - Some c.readmit from hospital/rehab stay d. at least quarterly Record review of the facility policy MDS Completion and Submission Timeframes, published in 2001 and revised in July 2017 revealed the following: .Assessment Coordinator or designee is responsible for assuring MDS is submitted in required times . based on Resident Assessment Instrument Manual FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 22 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident receives adequate supervision to prevent elopement for 1 of 7 residents who wandered (Resident #60). The facility further failed to ensure that the resident environment remained as free of accident hazards on 2 of 2 Halls (Hall1/Central and Hall2), in that: 1). The facility failed to adequately supervise Resident #60 to prevent him from eloping from the facility on 8/18/22 and 9/03/22. The facility failed to develop and implement interventions to prevent elopement after multiple verbalizations by Resident #60 of wanting to leave the facility which resulted in him eloping. 2) The facility failed to store chemicals in a safe manner and were left accessible to residents in common areas on 2 of 2 Halls (Hall 1/Central and Hall 2). An immediate jeopardy (IJ) was identified on 9/28/22 at 5:25 PM. While the IJ was removed, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not Immediate Jeopardy and a scope of pattern. These failures related to adequate supervision could place residents at risk for wandering into unsafe environments outside of the facility and sustaining serious injury, harm, impairment or death. Failures related to chemical storage could place residents at risk for chemical injuries. The findings include: 1) Resident #60 Record review of the face sheet and Order Summary Report for male Resident #60 dated 9/15/22 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnosis of Hypothyroidism, Unspecified, Major Depressive Disorder, Recurrent, Unspecified, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Muscle Weakness (Generalized), Cognitive Communication Deficit, Unsteadiness on Feet, Major Depressive Disorder, Recurrent Severe Without Psychotic Features, and Anxiety Disorder Due to Known Physiological Condition. Record review of the admission MDS assessment for Resident #60 dated 8/19/22 revealed that the resident had a BIMS score of 4 , indicating he was cognitively impaired. Further record review of the MDS revealed the resident had a behavior of rejecting care. This behavior occurred every one to three days. The resident was also documented as wandering and this behavior occurred daily. It was further documented that the residents wandering did not place the resident at significant risk of getting to a potentially dangerous place, such as stairs, outside of the facility. Record review of the current undated care plan for Resident #60 revealed that there was a Focus titled, The resident is an elopement risk r/t dementia. ***Patient has a (electronic monitoring device) *** *(Electronic monitoring device) checks 3 times each shift. *Staff will round to lay eyes on patient every 1 to 2 hours and as needed. Patient eloped on 08/18/2022* WAS FOUND SAFE AND RETURNED TO (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 23 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some BUILDING Date Initiated: 08/10/2022 Revision on: 08/19/2022. The documented Goal for this Focus was documented as follows, The resident's safety will be maintained through the review date. Date Initiated: 08/10/2022 Revision on: 09/07/2022. Target Date: 11/30/2022. o The resident will not leave facility unattended through the review date. Date Initiated: 08/10/2022 Revision on: 09/07/2022 Target Date: 11/30/2022. The Approach for this Focus was documented as, o Assess for fall risk. Date Initiated: 08/10/2022 o Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: Date Initiated: 08/10/2022 . Record review of the Elopement Risk Assessment for Resident #60 conducted on 8/09/22 by LVN D revealed that the resident made statements and or threats to leave the facility and made frequent request to go home. It also documented that the resident had confused expressions related to tasks to complete. It further documented that the resident verbalized anger and frustration related to his placement. The document stated that the resident had restless behavior such as wandering. Additional information listed on the form revealed that the resident did not recognize stoplights and signs, did not know precautions when crossing streets and did not know the location of his current residence. It was further documented that the resident does not recognize all needs but some. Related to physical capacity it documented that the resident ambulates independently or with device. Cognitive skills for daily decision-making were listed as modified independence - some difficulty in new situation only. Record review of the Progress Notes (8/10/22 thru 9/03/22) for Resident #60 revealed: -On 8/18/22 at 4:45 PM the resident could not be found in the facility. He was found and returned to the facility at 6:37 PM. The nurse on duty was LVN C (agency). The police were called, and facility staff searched for the resident in the facility and surrounding areas. Family and department heads were informed. On his return it was determined he had no injury and an electronic monitoring device was placed on the resident on his return. -On 8/28/22 the resident removed his electronic monitoring device and staff placed another one on his ankle. -On 8/30/22 the resident's wife discovered his electronic monitoring device amongst the resident's possessions and staff placed another one on the resident's right wrist. -On 9/3/22 at 9:15 AM Resident #60 could not be found in the facility again. He was found by family at 11:43 AM and returned to the facility at 12:00 PM. The LVN on duty was LVN D (agency). The police were called, and facility staff searched for the resident in the facility and surrounding areas. Family and department heads were informed. The resident had no injuries. -On 9/03/22, 12:00 PM - Upon entrance to facility, door alarm sounded d/t resident being noted to have electronic monitoring device on wrist. How resident got out of facility with electronic monitoring device on is TBD ADON requested Q 30 min checks for a couple areas then hrly (hourly) until further notice . The resident was discharged from the facility on 9/03/22. Record review of the Incident-by-Incident Type list for the facility dated 9/13/22 revealed that there was one resident listed as having an elopement incident. The date range for the list was 3/13/22 to 9/13/22. Resident #60 was not listed on this document as eloping from the facility. Record review of the MAR/TAR for Resident #60 for August 2022 revealed that the facility started ordered electronic monitoring device checks on 8/11/22 on the night shift. The electronic monitoring (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 24 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some device was checked Q shift. On 8/17/22 there was no documentation that the electronic monitoring device was checked on the dayshift. On 8/18/22 it was documented that the resident had his electronic monitoring device on during the day and night shift. On 8/19/22 at 4:00 PM the residents electronic monitoring device monitoring order changed from Q shift to Q4 hours. Further documentation on the TAR revealed that on 8/25/22 there was no documentation that the electronic monitoring device had been checked at (4:00 AM). The resident's electronic monitoring device was documented as being off him on the following dates and times: 8/28/22 at (8:00 PM) 8/30/22 at (4:00 PM and 8:00PM) 8/31/22 at (12:00 AM and 8:00 AM) On 8/31/22 there was no documentation of the electronic monitoring device being checked at (4:00 AM). Record review of the September 2022 MAR/TAR for Resident #60 revealed an order for electronic monitoring device checks Q4 hours. There was no documentation on 9/1/22 at (4:00 PM) that the electronic monitoring device was checked. Further record review of this MAR/TAR for Resident #60 revealed that the electronic monitoring device documentation for his right ankle and left wrist on 9/2/22 ( 8:00 AM and 12:00 PM) was documented as Other and to see the nurses notes for an explanation. The resident was documented as having the electronic monitoring device on starting 9/02/22 at (4:00 PM) through (12:00 PM) on 9/3/22. The electronic monitoring device checks on 9/03/22 revealed that the resident had his electronic monitoring device on for the 8:00 AM and 12:00 PM checks. Record review of the Progress Notes for Resident #60 revealed no documentation as to why there was no on or off electronic monitoring device documentation on 9/2/22 at (8:00 AM) and (12:00 PM). On 9/16/22 at 10:11 AM, an interview and record review was conducted with LVN C (agency) regarding Resident #60's wandering and eloping from the facility. He stated the resident was a wanderer but could converse and state his needs. He added that he would hang around at the exit door near room [ROOM NUMBER]. He was definitely a wanderer. Regarding the day the resident eloped, he stated, on 8/18/22 it was a normal day. Dinner was served. LVN C was in the dining room helping out. Staff report to him at approximately 4:45 PM that they could not find the resident. LVN C searched every room, outside and surrounding areas including businesses. He also called local hospital ERs. Family and law enforcement were called, and the resident was located by police at 82nd street and returned at approximately 6:50 PM. Upon the resident's return, he was assessed, and an electronic monitoring device was placed on him. He further stated the resident had a history of asking for scissors to cut off his electronic monitoring device. The LVN stated he was on duty the next day and monitored him closely. He added he double checked him every hour or two for his whereabouts. There were no other interventions to prevent him from eloping. The LVN stated he was told by staff the resident would remove his electronic monitoring device and ask for scissors to cut it off. He added that the resident never asked him for scissors. LVN C was then asked about their procedures related to electronic monitoring devices. He stated he visually checked the electronic monitoring devices and documented it in the MAR. He added that if a resident wanders to the front of the facility, the electronic monitoring device alarms. He added staff used harder zip type ties to keep the electronic monitoring device on once they knew he could take it off. LVN C then checked the electronic incident documentation system to see if an incident report had been developed for the elopements on 8/18/22 and 9/03/22 and found none. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 25 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety LVN C also stated that he contacted the Administrator, DON and ADON about the 8/18/22 elopement but did not contact the physician. He added that it was not OK not to inform the physician. Regarding the missing incident reports, he stated if there is no documentation it is not done. He further stated he was not sure if the facility had an elopement protocol and did not know what the facility elopement protocol was. He stated, I'm just agency. He also added that there was no documentation of his monitoring of the resident every one or two hours. He stated that his monitoring documentation was only in the nurses' notes . Residents Affected - Some On 9/16/22 at 11:14 AM, an interview was conducted with the DON. Regarding Resident #60 she stated he was tall, had dementia, confusion, was a wanderer and was admitted from a secure facility . Regarding wandering intervention for the resident, she stated after the first elopement they increased electronic monitoring device checks and checked the room daily. Staff checked every shift and more often. The second time he eloped, staff implemented checks every 2 hours. She added, the last time he eloped, he still had his electronic monitoring device on. Staff did not know if someone let him out. She was unsure how far he was from the facility the first time he eloped. The second time he eloped he was found outside a new restaurant on 82nd street. Regarding their elopement protocol, she stated nurses are to check each room. Some staff checked the parameters. Within an hour we called the police. Regarding any orientation provided to agency nurses prior to assuming duties in the facility, she stated, staff conduct a quick one. Staff familiarize them with the charting system. Contact information is given to them for the DON and ADON. Regarding residents, agency staff know what to do. They are informed of resident tendencies. On 9/16/22 at 11:29 AM, an interview was conducted with the Administrator. Regarding elopement protocols, she stated, if residents are not found they look in-house. The administrator is informed, and the administrator informs staff by group text and the department heads look for the resident. She stated the second elopement was handled this same way. Regarding Resident #60 she stated, he was a dementia resident admitted from a secure nursing home. He did not do any wandering there. He was here two weeks and then was found outside. He was gone about 45 minutes . He was not exit seeking. She added that after meals his dementia tells him to go to work. Staff knew to monitor him after meals. He thought he was trying to get to work when he was found at a restaurant on 82nd and Quaker Avenue (Approximately 0.6 miles from the facility). He was found quickly. She believed, the first time he was found on 76th and Salem Avenue (approximately 0.3 miles from the facility). She further stated, both times he was gone an hour or less . The second time was on a Saturday. On 9/16/22 at 11:54 AM, an interview was conducted with the Maintenance Supervisor regarding the electronic monitoring device system. He stated there are two doors with the electronic monitoring device system; the front and the dining room that are exits are alarmed. He added he checks the doors weekly on Mondays. During the generator test it deactivates the electronic monitoring device system and the test lasts 30 minutes . He further stated to test the electronic monitoring devices, he uses an electronic monitoring device and goes to the door to check if it alarms. He also stated that he has a resident, with a monitoring device, go by the door and see if it locks. Regarding Resident #60, he stated the resident got out two times. The first time, staff say he cut off the electronic monitoring device. The second time only thing he could think of was the resident went out with a visitor. He added he did not know if anyone heard the electronic monitoring device alarm go off, but staff should have. Record review of the facility documentation on Door Alarm checks revealed that weekly checks were made. Between 8/01/22 and 9/12/22 all door alarms were documented as passing and had no issues (8/01/22, 8/08/22, 8/15/22, 8/23/22, 8/29/22, 9/05/22 and 9/12/22). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 26 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some On 9/16/22 at 12:45 PM, an interview was conducted with the ADON regarding Resident #60's elopement. Regarding why the incidents happened, she stated, some family may have let him out. He may have been gone out before staff saw him. It's hit and miss who's around the exit door. LVN D told her she did not hear an alarm. Agency staff was at station one. She added that the first elopement he said he was going to work. It was something all staff knew. These were suggestions of what he was thinking. She stated they ensured residents do not elope outside of the facility by conducting hourly checks , frequent checks. She added if staff hear the alarm, they go straight to the door. She further stated there were no documentation of the (hourly) checks. She added, staff make sure they make rounds. She stated, everyone is responsible to ensure that residents do not elope from the facility. She added, she expected that staff are in the building working and others are out searching for any eloped residents. She stated that if residents were not appropriately monitored and eloped, others could elope from the facility. She also stated that there was no paper documentation of the monitoring that they conducted on Resident #60. On 9/16/22 at 2:40 PM, an interview was conducted with the Administrator. Regarding Resident #60 elopements she stated, the staff did not think he would leave prior to the first elopement . She added that staff were supposed to monitor the resident after dinner . She also stated that someone may have let him out. She stated caregivers, charge nurse, nursing and administrator were responsible for ensuring that residents do not elope from the facility. She added she expected staff to provide a better monitoring system to prevent elopements. She further stated she made it clear to staff and they should have taken Resident #60 to his room after his meals. She was asked how an elopement could affect residents. She responded by stating that the facility makes sure residents are in a safe environment, experiencing no harm. On 9/16/22 at 3:06 PM, an interview was conducted with agency LVN E (agency). She stated she worked in the facility approximately three times a month. She stated that she was not oriented by the facility regarding missing residents and the elopement protocol prior to working in the facility. She stated that she had been oriented at other facilities. She stated if residents elope from the facility they could be in danger, run over, or multiple things happen to them. On 9/19/22 at 7:50 PM an interview was conducted with LVN D (agency at the time of elopement). She stated Resident #60, was a roamer and walked all day and night. He was super confused. Sometimes he would layer his clothes wearing seven or eight shirts at a time. All day he would say he was going somewhere. She stated she was not told specifically to take the resident back to his room after meals, but felt it was a given fact. Regarding the 9/03/22 elopement, she stated, it was an hour and a half after breakfast . She had been looking for him for him for something and then discovered he was missing. She added staff started checking and he was not found. Staff did not hear an alarm; no one did. She stated, if the door is held, it should have alarmed. She added that she did not know what exit he may have gotten out of. She stated she did not develop an incident report but documented the incident in the nurse's notes. She stated the incident occurred on her second day at work and she called the family, ADON and DON. She added that family brought the resident back and she assessed him. She was asked what could result from an elopement of a resident. She stated if residents were to elope from the facility they could be hit by a car and be led to do things they should not do. She added that the resident talked well and presented himself well if you were not aware he had dementia . She stated that she had not call the doctor about the incident. She stated when she started working in the facility, nothing special was told to her about Resident #60, but she was made aware that he removed his electronic monitoring device. She added that she placed it back on him a couple of times and that he would pull real hard and could pull it off. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 27 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During an interview conducted on 09/29/2022 at 9:42 AM with the Administrator , she said she did not recall if they had reviewed camera footage once she was notified the facility had been searched, they started searching outside. She said she was out of town during Resident #60's second elopement. She said it was her understanding that both elopements were through the front door of the facility. She was not sure if an alarm went off, she was told Resident #60 was out on the porch outside of the facility, seen by another visitor, then later found at a restaurant. She said the first time Resident #60 eloped; he was found about a block from his house, which she said was in the area of the facility, talking to the neighbors who called the police while they were at the facility with the Administrator. She further stated the electronic monitoring device alarm on the door goes off until the keypad code is entered by staff. Observation made on 09/28/2022 at 8:16 AM showed a camera to be in the lobby facing the entrance to the facility. Observation made on 09/28/2022 at 8:45 AM showed a camera facing the first nurses' desk nearest the entrance to the facility (Hall1). Observation on 09/28/2022 at 8:47 AM showed a camera facing the facility's dining hall and back door entrance. Observation made on 09/28/2022 at 8:48 AM showed a camera facing the break room. Observation made on 09/28/2022 at 8:50 AM showed a camera facing the south side door at the end of the east hall (Hall 2). Observation made on 09/28/2022 at 8:35 AM showed a camera to be facing the north side door at the end of the east hall (Hall 2). During an interview conducted on 09/28/2022 at 8:59 AM with the Administrator, she said all the cameras were working. She said the monitors were in the central supply room in the beauty shop. During an observation and interview on 9/28/22 at 9:58 AM with the Maintenance Supervisor, he was asked if it would be possible to check camera footage from specific dates. He was not sure if the cameras saved footage. Observation of the central supply closet inside the beauty salon room with the Maintenance Supervisor revealed a monitor could be seen with several viewing panels for all cameras showing no footage being taken currently on any camera as indicated by a blank black screen. Using the search feature found on the monitor, the Maintenance Supervisor typed in the dates in question (08/18/2022, 09/03/2022) and no footage was found. Observation of the cameras in the Dietary Manager's office showed live footage from only the temperature-scanning camera located in the lobby could be seen. He was unable to show footage of the dates in question (08/18/2022, 09/03/2022). During an interview conducted on 09/28/2022 at 9:28 AM with the DON. When asked about the cameras and whether they had ever reviewed camera footage after Resident #60's elopements. She said she did not know how to access them and has never reviewed camera footage. During an interview conducted on 09/28/2022 at 10:33 AM, the Maintenance Supervisor stated he had spoken with the facility's IT (Information Technology) department and was told the cameras send footage to the Administrator's computer with storage only for the last 30 days. He said the Administrator did not know that though, and he was going to her office next to see if it was set up on her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 28 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some computer. Based on the time frames of stored footage, he was asked to provide footage from 09/03/2022 for the hours leading up to Resident #60's noted absence from the facility at 9:15 AM. During an interview conducted on 09/28/2022 at 11:36 AM with the Administrator, she said they had made progress on finding camera footage from 09/03/2022 and said: they are looking at it right now. During an interview conducted on 09/28/2022 at 11:37 AM, the ADON was asked if they had found the footage from 09/03/2022 pertaining to Resident #60 and the elopement from 09/03/2022. She said they were still looking. Observation made on 09/28/2022 at 11:37 AM showed staff members in the Business Office Manager's office looking at camera footage on the computer. During an interview conducted on 09/29/2022 at 10:39 AM with the Business Office Manager concerning footage that she and the ADON had reviewed the previous day, she said they were not able to see any footage of the resident exiting the building. She said they had reviewed footage from all the cameras in the facility yesterday, and that not all doors exiting the facility had a camera facing them that adequately captured the view of the door. On 9/28/22 at 9:10 AM, an interview was conducted LVN A. Regarding Resident #60 she stated, she remembered him. Staff were told to basically watch him and keep an eye on him; Every 30 minutes. She had to check his wander guard four times a day because he would take it off. His roommate was Resident #40. Their room was near the nurse's station. Regarding Resident #60's electronic monitoring device removal, she stated she did not know what he cut it off with. She never witnessed the removal. Staff placed a type of zip tie on it to keep it on. The band looked like it was cut when she saw it. She thought he may have got a butter knife to cut it off. She stated she never checked the resident for a knife and she only kind of looked around his room for an item that could have been used to cut it off. She added, he could get aggressive. She stated Resident #60 mostly watched TV. It seemed lunchtime he might get up. Regarding training about elopements and wandering residents she stated, she had not had any since being in the facility, which was approximately 2 months. She stated she learned from other facilities to keep an eye on them. The other places (facilities) staff saw them and where they were. Regarding any documentation of the 30-minute checks that she conducted on wandering residents, she stated she recently started documenting the checks and added that her weak point in nursing was documentation. She further stated, she could not recall staff asking her to document the one- or two-hour checks on Resident #60's whereabouts. Regarding any interventions told to her after the 8/18/22 elopement, she stated, she was told to make sure to keep an eye on him; her and the CNAs. He was always dressed and ready to go. He mainly stayed in his room. She further stated she never had anything to write on the nurse communication sheets about Resident #60. She stated the nurse communication sheets were placed in the box and then given to the ADON. Record review of the Nurse Communication Sheets for 8/18/22 and 9/03/22 - 9/04/22 revealed no documentation related to Resident #60. On 9/28/22 at 9:45 AM LVN A was interviewed and stated, sometimes Resident #60 ate in his room and she tried to be in the dining room to feed her residents during meals. She added, because he was an elopement risk, she kept her eyes on him. She further stated that no one had told her that Resident #60 needed to be taken to his room after meals. On 9/28/22 at 9:53 AM an interview was conducted with CNA I. She stated staff did one-hour checks (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 29 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some on Resident #60 and documented it on their POC (CNA electronic resident documentation kiosk). Staff just checked that he had not wandered off and that his electronic monitoring device was on. He was known to take it off. She stated she never figured out how he got it off. He would tear it off. He was strong. Regarding the 8/18/22 elopement, she stated she was the one that noticed he was gone. Staff searched inside and outside. Staff would see him wandering. He walked with Resident #40. She noticed she had not seen him at her hourly check . It was at supper, and she had not seen him. After he returned, staff was instructed to conduct 30-minute checks. They changed where his wander guard was applied. She added, there was no documentation of the 30-minute checks, it was just every day and it continued. She stated, she received training regarding wandering residents and elopement weeks or months ago. She further stated staff were told Resident #60 should go back to his room after meals by LVN A. On 9/28/22 at 10:40 AM, an interview was conducted with the DON. Regarding interventions implemented after the elopement on 8/18/22, she stated, electronic monitoring devices were checked frequently, and redirection using activities. The nurse was to report abnormal behaviors. The nurse also made rounds. Staff were rounding different hours for the electronic monitoring devices. On 8/19/22 they checked the wander guard three times and then later every four hours. Regarding interventions for the resident removing his electronic monitoring device, she stated, place a new one on and provide education to the resident which was not very effective. Staff changed the positions of the electronic monitoring device. Staff made sure the electronic monitoring devices was comfortable. The main intervention was rounding every four hours. She stated that she would check him when she saw him. The Resident spent a lot of time in common areas. Regarding how he got the electronic monitoring devices off, she stated there was nothing in his room to remove it. Staff thought he was just pulling it off. The resident made comments about scissors. Staff checked everywhere they could for something he used to take the electronic monitoring devices off. The DON stated she thought it was irritating to him and he pulled it off. Regarding if staff had been instructed to take the resident to his room after meals, she stated, she instructed staff to conduct more rounding. She further stated she did not instruct staff to take Resident #60 back to his room after meals. Regarding in-services or training provided for wandering residents and elopements, she stated, staff were provided verbal education. She added more attention was given to station two since Resident #60 resided there. She stated she talked to LVN D, who was the charge nurse. LVN A and agency staff. She added she started the verbal education when the electronic monitoring device was placed on him. Regarding the screening process to determine if referred residents were appropriate for admission, she stated, they reviewed the referrals with a whole team. If there were unresolved issues with the referral, the DON was responsible for addressing the issues. She stated that she did not see Resident #60 prior to admission. She added that the referrals for admission for Resident #60 were received by the Administrator. The DON stated she ensured the nurses were competent in their skills in caring for residents that wandered by the DON and ADON talking to them. She added staff do rounds and check on the residents. Regarding what type of plan was in place for wanderers, she stated, the facility has electronic monitoring devices and an electronic monitoring device system. It locks the door. Staff check doors weekly. Staff try to provide activities for wanderers. Regarding any type of in-services provided on wanderers and elopement since admitting residents with those issues, she stated, staff were provided a lot of verbal instruction. The most recent documented in-service was 6/16/22. She stated, she did not think the facility was secure enough for Resident #60. She added that the facility was secure to a certain extent. On 9/28/22 at 11:24 AM an interview was conducted with the DON regarding why there was no incident report done for Resident #60's two elopements. She stated, no incident report was done (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 30 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 since staff found him within two hours. She stated she was told that by the Administrator. Level of Harm - Immediate jeopardy to resident health or safety During an interview conducted on 9/28/2022 at 1:47 PM with the DON , she was asked if notification to Resident #60's physician regarding his elopement had been made. She said that notification to the resident's physician would be documented in a progress note in the EMR (Electronic Medication Record). She said she would verify with the ADON as well and ask if there is anywhere else that would be documented. This documentation was never provided. Residents Affected - Some During an observation and interview on 9/28/22 at 11:28 AM, CNA I demonstrated where the resident monitoring documentation was located in the POC system for CNAs. The dates range checked was 8/19/22 through 9/03/22. There was no documentation in this system of hourly monitoring checks. At this time CNA I stated, she guessed their instructions to monitor were just verbal. Staff were verbally told to do it. She confirmed that there was no documentation on any of those days that one hour or 30 minutes or any resident checks were conducted for Resident #60. The only documentation that she found was on 9/02/22. There was a note that stated, walk with supervision. On 9/28/22 at 11:45 AM an interview was conducted with the Administrator. Regarding monitoring documentation, she stated, staff would not be documenting unless he was one-on-one supervision or mandated. She stated, It was just known, especially after meals, that he wandered. There was nothing written. Regarding any viewing of the cameras footage for Resident #60's elopements. She stated, they cannot find anything on camera so far. Regarding in-services offered on wanderers and elopement, she [TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 31 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 1 of 1 facility kitchen. The facility failed to designate a person to serve as the Dietary Manager who met the required qualifications. The facility designated Dietary Manager had not completed the state dietary managers course or had any other qualifying credentials. This failure could place residents at risk for the spread of foodborne illness and residents not having their nutritional needs met. The findings include: Record review of the personnel file for the Dietary Manager revealed she had a date of hire of 4/02/18 and there was no documentation of completion of the state required dietary managers course or documentation which indicated she met any of the other qualifying education levels/credentials ( certified dietary manager: certified food service manager: has similar national certification for food service management and safety from a national certifying body; has an associates or a higher degree in food service management or in hospitality, if the core study includes food service or restaurant management, from an accredited institution of higher learning; and in states that have establish standards for food service managers or dietary managers, meets state requirements for food service managers or dietary managers). Record review of the facility's Dietician documentation revealed that the Dietician was contract and not full-time. Record review of the Food Handler Certificate of Completion for the Dietary Manager revealed that it was issued on 6/13/22 and was valid through 6/13/24. On 9/13/22 at 10:26 AM, the Dietary Manager was interviewed regarding her qualifications. She stated, she had been promoted to Dietary Manager in June 2022. She stated that she had recently enrolled in the required Dietary Manager courses yesterday. Record review of facility Rates of Pay documentation for the Dietary Manager revealed that she was promoted to Dietary Supervisor on 6/8/22. Record review of the document titled Food Handler Card Online, Order Confirmation revealed that the Dietary Manager was enrolled in the Texas Certified Food Manager Training Program and Texas Certified Food Managers Exam on 9/16/22. On 9/15/22 at 4:01 PM an interview was conducted with the Administrator regarding the Dietary Manager not being qualified. She stated she was appointed to the position of Dietary Manager prior to the Administrator taking her position in the facility. She stated residents could be affected by this situation because the Dietary Manager would not have the proper education tools to do her job. Record review of facility provided documentation titled F tag Help - F801 Qualified Dietary Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 32 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm dated 9/16/22 revealed the following documentation, . Staffing. If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the Director of food and nutrition services who is a a. Certified dietary manager, or Residents Affected - Few b. Certified food service manager; or c. Has similar national certification for food service management and safety from a national certifying body; or d. Has an associates or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; and III. In states that have establish standards for food service managers or dietary managers, meets state requirements for food service managers or dietary managers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 33 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: Residents Affected - Many 1)The facility failed to ensure the kitchen was free of insect infestations (roaches), 2) The facility failed to ensure food and non-food contact surfaces were clean, and 3) The facility failed to ensure foods and food contact equipment were protected from possible contamination during processing, storage and service. These failures could place residents at risk for food contamination and foodborne illness. The findings include: ~ The following observations were made during a kitchen tour that began on 9/13/22 at 9:19 AM and concluded at 10:36 AM: The spout had a buildup of residue and dirt on the drink dispensing machine drink gun. Observation of 1 of 2 ovens, right side, revealed that there were too numerous to count adult, nymph (pre adult), and adult roaches with egg cases crawling in the oven. There was also a heavy accumulation of roach specs/feces. On 9/13/22 at 9:33 AM the Dietary Manager stated regarding the roaches that the pest control operator sprayed for roaches last week. She added that the section of the oven, with roaches, was not used. She stated that the roach population had worsened recently, and she reported it to the administrator. Then the pest control came. The plastic food bin exteriors were gummy and soiled. The small plastic scoop storage cabinets had a buildup of dirt on the exterior and had a gummy feel. There was one roach crawling on the floor when a large pot was moved on the floor under the convection oven. There was a buildup of gummy grease on the convection oven top and sides. There was a dead roach on the cart where the toaster oven was stored next to the steam table. There was a heavy accumulation of roach specs (feces) on the piping behind the steam table. There was an area of wallboard that was buckled at the steam table. The interior of the gap revealed there was a heavy accumulation of roach specs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 34 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 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 The drink gun/drink dispensing area table had buckling paint and a sticky buildup. Level of Harm - Minimal harm or potential for actual harm The pump type drink carafes had a gummy exterior. Residents Affected - Many There was a heavy accumulation of roach specs on the encased electrical outlet next to the three-compartment sink. There were five dead roaches observed stuck to the wall behind the fire extinguisher sign near the three-compartment sink. Inside the Dietary Manager's office in the kitchen, there was a box of thickened water next two containers of Avistat-D spray disinfectant labeled, . If swallowed: call a poison control center or doctor immediately. Caution. Causes moderate eye irritation. There were also boxes of Nepro supplement and 5 large cans of coffee stored on the same shelf. On 9/13/22 at 10:06 AM Dietary Manager stated the cans of coffee were used for residents. These five large cans of coffee were also on the shelf next to Champion Oven Cleaner labeled, Danger: contains sodium hydroxide. Avoid contact with skin. Injurious if sprayed in eyes. There was a box of teabags on top of this box of oven cleaner. Also on the shelf was Handy Klenz Lime Descaler which was labeled, Danger. Causes serious eye damage. Causes severe skin burns and eye damage. May be corrosive to metals There were bottles of steak sauce, coffee filters, hot sauces and oven bags next to the chemicals. There were chemicals on the top shelf above the cans of coffee and other foods which included Pro Power Heavy Duty Oven and Grill Cleaner, labeled, Danger: causes severe skin burns and serious eye damage. There was a can of Enforcer Flea Spray stored on the same shelf. An adult roach was crawling on the floor of the water heater closet inside the Dietary Manager's office. T his closet had holes in the ceiling and around the pipes entering the ceiling and wall. Observation of a cart at the front of the kitchen revealed that the cart had Champion Oven Cleaner stored next to apple juice and a backpack on the same shelf. The oven cleaner was also stored above boxes of coffee filters that were on a lower shelf. The refrigerator and freezer storage area, adjacent to the assist dining room, had an icemaker in which the interior flashing needed cleaning. There were two of two unshielded ceiling fluorescent lights in the refrigerator and freezer storage area. Observation on 9/13/22 at 10:35 AM the Dietary Manager stated previously roaches come out continuously and were worse at one time. She added that the roaches were wherever you turned your head. ~ The following observations were made during a kitchen tour that began on 9/13/22 at 11:35 AM and concluded at 12:45 PM: The exterior of the large mixer had an accumulation of hardened splattered food. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 35 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 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 Dietary staff A was observed preparing purées. Prior to putting the food in the processor, the surveyor asked to see the interior and blade of the processor. The blade had a sudsy film and was wet and the interior of the processor was wet. She then placed scoops of pot roast and milk into the processor and pureed it. She then placed it in a pan to be placed on the steam table. Residents Affected - Many On 9/13/22 at 11:48 AM Dietary staff A was observed washing the processor parts in the dishwasher. On 9/13/22 at 11:50 AM the dishwasher cycle ended, and the processor parts were wet (blade and interior of the processor pot). On 9/13/22 at 11:51 AM Dietary staff A placed scoops of carrots into the processor and puréed it while the interior and parts were still wet. Record review and observation of the Auto Chlor System Super 8 chlorine sanitizer, used in the dishwasher, revealed the following, .Sanitizing Food Contact Surfaces. 5. Drain and allow equipment or utensils to air dry. There were two sets of soiled keys stored on the prep table. On 9/13/22 at 12:14 PM an adult roach was observed crawling on the floor near the steam table during meal service. The following observations were made during a kitchen tour that began on 9/13/22 at 4:35 PM and concluded at 5:56 PM: There were 2 bottles of blue colored personal drinks stored on the lower shelf of the prep table next to pans. On 9/15/22 at 3:05 PM, an interview was conducted with a Dietary Manager. Regarding the roaches she stated they were pretty much there in the facility. Regarding not allowing the processor to air dry she stated Dietary staff A, felt under pressure. Regarding cleaning of equipment, she stated staff were responsible and they clean as they go. She added that she knew chemicals had to be stored away from food but did not know coffee was an issue. She added that staff conduct deep cleaning on Sundays which included cleaning the fryers and soaking the cups for coffee stains. She stated that she ensured staff follow proper food service procedures and protocols by going by the cleaning schedule and monitoring staff. She further stated that she expected Dietary staff A to let the processor air dry as she normally does. She stated that the problems found in the dietary department could result in residents getting chemicals in their food and residents becoming ill. She stated that staff and the dietary manager were responsible for ensuring staff follow all appropriate food service policies and procedures. On 9/15/22 at 4:01 PM, an interview was conducted with the Administrator . Regarding dietary sanitation issues, she stated that residents could be affected by toxics in the food. She added that she expected dietary staff to ensure toxics were stored properly. She further stated she expected the Dietary Manager to check staff and ensure that they do what they are supposed to. She stated she did not know what to do about the roaches. She added the German cockroaches were only treated every six months. She further stated she would take the oven out and fumigate it. She stated the increase in roaches could cause infection control issues. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 36 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Record review of the facility policy titled Sanitization, Revised October 2008 revealed the following documentation, Policy Statement. The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation. 1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning. 3. All equipment, food contact surfaces and utensils shall be washed to remove or clean completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. 10. Food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical. 11. For fixed equipment or utensils that do not fit in the dishwashing machine, washing shell consist of the following steps: a. Equipment will be disassembled as necessary to allow access of detergent/solution to all parts; b. Removable components will be scraped to remove food particle accumulation and washed according to manual or dishwashing procedures. 12. Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy. 16. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. 17. The food services manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Record review of the facility policy titled Food Receiving and Storage, Revised October 2017, revealed the following documentation, Policy Statement. Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation. 15. Pesticides and other toxic substances and drugs will not be stored in the kitchen area or in store rooms for food or food preparation equipment and utensils. 16. Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage and labeled clearly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 37 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement an infection prevention and control program (IPCP) that included a system for COVID-19 screening for visitors, proper use of masks, regular changing of bed linens, and proper hand hygiene. Residents Affected - Some The facility failed to ensure that visitors, including the survey team, were adequately screened for signs and symptoms of COVID-19. The facility staff failed to maintain a safe environment by not wearing a mask or wearing masks improperly during activities. The facility failed to change Resident #2's soiled bed linens. The facility failed to perform proper hand hygiene when providing wound care for Resident #10 and Resident #54. These failures could place residents at risk of exposure to COVID-19 and other types of infection. Findings included: Observations made upon facility entrance on 9/13/2022 at 8:15 AM showed none of the survey team members were asked the screening questions. Survey team members were prompted to stand on the X on the ground and to look at the temperature camera to have temperatures checked. Masks were available as well as hand sanitizer. Observation made on 9/14/2022 around 8:35 AM during entrance into the facility showed no screening questions were asked of the surveyor. No staff member was present to ask screening questions and surveyor took temperature, used hand sanitizer, and wore mask unprompted. Observation made on 9/15/2022 around 6:25 AM during entrance into the facility showed no screening questions were asked of the surveyor. No staff member was present to ask screening questions and surveyor took temperature, used hand sanitizer, and wore mask unprompted. On 09/15/22 between 5:45 and 6:30 PM, observation was made of two visitors who entered the facility without being screened for Covid-19. The Administrator asked them to stand on the X to get their temperatures taken and then asked who they were visiting and told them to proceed to the nurse's station. Observation made on 9/16/2022 around 8:50 AM during entrance into the facility showed no screening questions were asked of the surveyor. No staff member was present to ask screening questions and surveyor took temperature, used hand sanitizer, and wore mask unprompted. On 09/16/22 at 12:11 PM, observation was made of a visitor entering the facility who walked through the lobby without being stopped by anyone or screened upon entrance. The DON happened to be walking by when the visitor was near the dining area and asked him to go back to screen. She followed him and then asked him screening questions, took his temperature, and asked him to wear a mask. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 38 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 09/16/22 at 12:13 PM, observation was made of two visitors entering the facility without being screened. The Administrator was made aware, and she asked them to come back and get a mask, but no screening questions were asked. During an interview with the DON (also the infection preventionist for the facility) on 09/16/22 at 11:59 AM, she said they try to stop visitors at the entrance and screen them as well as ask them to wear masks. She said she thought the Business Office Manager was responsible for stopping visitors to screen them as her office was at the front of the building near the entrance. She said that if she personally saw a visitor enter the facility, she tried to stop them and screen them. She said the risk to the resident would be possible exposure if visitors are not screened correctly. During an interview with the Business Office Manager on 09/16/22 at 12:06 PM, she said it is part of her responsibility to screen visitors for signs and symptoms of COVID-19 upon entrance to the facility. She said she stopped visitors and asked them to check their temperature by standing on the X on the floor and looking at the temperature camera. She also said she asks them to wear masks, she said it is her understanding that she only needs to ask screening questions if the temperature detector's alarm goes off, indicating a temperature above 100.4-degree Fahrenheit. During an interview with the Administrator on 09/16/22 at 12:10 PM, she was asked what her expectations are concerning the COVID-19 screening process for visitors. She said they had been lowered to only making sure hand sanitizer is available, masks available, and making sure visitors read the sign indicating temperature limitations (which was posted in English only outside of the facility entrance). She said no one is specifically responsible for screening visitors. She said her understanding was that they only were required to ask visitors the screening questions if they had a high temperature. She said she thought CDC had lessened guidelines and they were not required to ask everyone screening questions. She further stated that she is not asking everyone those questions (referring to the screening questions which include questions regarding exposure, travel, symptoms of COVID-19, and recent test results). She said she was told or read somewhere that they cannot screen surveyors but was unsure where this information came from and did not provide it to me. Record review of one of the facility's undated policies on COVID-19 visitation screening which was provided and titled Coronavirus Disease (COVID-19) - Visitors read in part .Core principles and best practices to reduce COVID-19 transmission are adhered to at all times, including: screening of all who enter the facility for signs and symptoms of COVID-19 and denial of entry of those with signs and symptoms or those who have had close contact with someone with COVID-19 infection in the prior 14 days (regardless of visitor's vaccination status) . Record review of an additional undated policy provided which was titled Visitation - Pandemic read in part Core Principles- utilized during visitation: Screening of all individuals who enter the facility for signs and symptoms of COVID-19. See active screening sheet questions: Obtain body temperature check, question regarding recent temperature above 100.4 in past 72 hours Have you traveled outside of the United States in the last 14 days? (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 39 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 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 Have you experienced any signs of symptoms of resp. infection, fever, chills, shortness of breath, fatigue, muscle or body aches, headache, congestion or runny nose, cough, sore throat, vomiting, diarrhea, upset stomach, loss of smell or taste? Residents Affected - Some Have you been exposed to anyone with or suspected of COVID-19 in the last 14 days? Have you been exposed to anyone with or suspected of a respiratory illness in the last 14 days? Have you had a positive COVID-19 test result in the last 10 days? Any questions that pose an increased temperature or an answer of Yes will not be allowed to enter. Review of the CDC (Centers for Disease Control and Prevention) Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes read in part .Indoor visitation during an outbreak response: Facilities should follow guidance from CMS about visitation . (accessed on 09/22/2022 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html). Review of CMS's memorandum summary related to COVID-19 and visitation guidance dated 9/17/2020 and revised on 03/10/2022 read in part . Core Principles of COVID-19 Infection Prevention. Visitors who have a positive viral test for COVID-19, symptoms of COVID-19, or currently meet the criteria for quarantine should not enter the facility until they meet the criteria used for residents to (quarantine). Facilities should screen all who enter for these visitation exclusions . (accessed on 9/22/2022 from https://www.cms.gov/files/document/qso-20-39-nh-revised.pdf). Observation was made on 09/13/2022 at 12:29 pm of the activity director not properly wearing her mask. While conducting observations of residents during lunch in the dining room, the activity director was observed wearing her mask under her chin, exposing her entire nose and mouth while closely engaging in conversations with multiple residents during lunch. During an interview with the activity director on 09/13/2022 at 12:53 pm., the activity director was informed of the error of improperly wearing her mask. The activity director stated, I took down my mask because the residents have a hard time hearing what I say. The activity director stated that she is aware that the facility requires a mask to be worn at all times. The activity director stated that what she should have done to avoid this error was to keep her mask on and repeated herself to the residents or waited for a time that would have been less loud. The activity director stated that she has been trained in PPE and how to properly wear masks. The activity director stated that the negative potential outcome for the residents and other staff would be that she could possibly spread infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 40 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with the DON on 09/16/2022 at 8:13 am., the DON was informed of the error of the activity director wearing her mask under her chin while closely engaging in conversations with the residents during lunch. The DON stated that she expects all staff members to wear a mask at all times to help prevent the spread of infection. The DON stated that the activity director has been trained in how to properly wear PPE and should not have had her mask down under her chin. The DON stated that she would expect the activity director to always wear her mask and if the residents could not hear her then she would expect the activity director to repeat herself to the residents. The DON stated that the negative potential outcome for the residents and other staff members would be that the activity director could possibly spread infection to them. DON stated that she expects the staff to protect the residents by taking precautions to keep them safe such as wearing a mask properly. DON stated that masks are required in the facility. During an interview with the administrator on 09/16/2022 at 2:18 pm., the administrator was informed that the activity director was observed not wearing her mask properly while closely engaging in conversation with residents during lunch. The administrator stated that she expects all of her staff to always wear masks in the facility at all times and there is no reason that she should have had her mask down. The administrator stated that all staff had been trained on how to properly wear a mask. The administrator stated that the negative potential outcome for residents and other staff members would be that the activity director could potentially spread illnesses such as covid, strep, flu, etc. Record Review conducted on 09/16/2022 at 10:53 am of picture stating, MASKS ARE REQUIRED, posted on front glass by the front door of the facility. Record Review conducted on 09/14/2022 at 1:17 pm of facility policy reviewed labeled, Face Masks, revised date on July 2009. Policy Statement: Facility personnel must wear face masks when performing any task that may involve the splashing of blood or body fluids into the nose or mouth. Policy Interpretation and Implementation: (1). Facility personnel must wear a mask when performing any task that may involve the splashing of blood or body fluids into the nose or mouth and when the use of eyewear is indicated. Record Review on 09/14/2022 at 1:28 pm of facility in-service labeled, Applying Face Masks, dated on 07/07/2022 revealed how to apply and remove face masks. 3. Determine which side of the mask is the top. The side of the mask that has a stiff bendable edge is the top and is meant to mold to the shape of your nose. 4. Determine which side of the mask is the front. The colored side of the mask is usually the front and should face away from you, while the white side touches your face. 5. Follow the instructions below for the type of mask you are using. a). Face mask with ear loops: hold the mask by the ear loops only. Place a loop around each ear. Record Review from the Centers for Disease Control at https://www.cdc.gov labeled, CDC Mask Recommendations, stated: Wearing a mask is one effective way to reduce the spread of covid variants. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 41 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record Review of Resident #2's face sheet indicates that Resident #2 is a [AGE] year-old male with a diagnosis of muscle weakness, age-related physical disability, high blood pressure, chronic pain, dependence on oxygen, chronic kidney disease, major depression, type 2 diabetes, morbid obesity, difficulty swallowing, feeding difficulties, heart attack, a condition in which there is gradual thickening and tightening of the tissue under the skin in the hand, blood has too many fats such as high cholesterol or high triglycerides, hypertensive retinopathy, atherosclerosis, COPD Observation with Resident #2 on 09/14/2022 at 10:18 am. Observation was completed during the initial tour during the survey process. Observed Resident #2 with dirty bed linens and what looked to be spilled coffee on the bed sheets on top and on the side of the bed sheet. Observations indicated that at the foot of resident #2 bedding, there were what looked to be a couple of spots of blood. During an interview with Resident #2 on 09/14/2022 at 10:22 AM, Resident #2 stated that he hardly ever gets his bed sheets changed unless he asks and sometimes not even then. Resident #2 stated that there are times that he will have to just change the sheets and covers himself and that is sometimes weeks after asking. Resident #2 stated that he is very weak and would rather the staff just change the bed linens because he does not want to fall while doing it, but they will not change the sheets. Resident #2 stated that he has made several attempts to tell staff, and nothing gets done about the situation. During an interview with DON on 09/16/2022 at 8:08 am., the DON was informed about observations of Resident #2's sheets/bedding not being changed. DON stated that she expects staff to change bed linens on the day's showers are given or if a resident has an accident or something is spilled on the sheets and/or blankets. DON stated that the negative potential outcome for the residents not having sheets changed would be the resident left to feel dirty, not having a homelike feeling, and spread of infection. DON stated that she will do an in-service and speak to the staff about changing the bed linens. During an interview with CNA F on 09/16/2022 at 11:25 am., CNA F stated that the staff usually changes the bed linens on the resident's designated shower day, at the resident's or family's request, or if the bedding is soiled or wet. CNA F stated that she was unaware that Resident #2's bed linens had not been changed. CNA F stated that they had been busy and that they just had not gotten to it that day. CNA F stated that the bed linens will be changed. CNA F stated that the negative potential outcome for the residents not getting their bed linens changed would be bed sores, body lice, feeling unclean, and the spread of bacteria. During an interview with CNA G on 09/16/2022 at 11:37 am., CNA G stated that she is an agency CNA but is in this facility often. CNA G stated that they are to change the resident's bed linens when the resident takes a shower unless they need the linens changed before that. CNA G stated that she is not sure if any of the other CNAs have changed the linens and she can only speak for herself. CNA G stated that she is in the process of changing linens now. CNA G stated that the negative potential outcome for residents not having their bed linens changed is there would be dead skin on the linens, residents could get bed sores, and bacteria. During an interview with the administrator on 09/16/2022 at 2:25 pm., the administrator stated that bed linens are supposed to be changed on the resident's designated shower days. The administrator stated that either the resident's shower days would be on Monday, Wednesday, and Friday or they would be Tuesday, Thursday, and Saturday. The administrator was informed of the error that bedding had not been changed in at least the first three days that the survey team was in the building. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 42 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some administrator stated that she expects her staff to be diligent about getting the bed linens changed and there is no excuse why they would not have changed them. The administrator stated that it is the responsibility of the aids, nurses, and DON to make sure that the aids are completing all their tasks. The administrator stated that the negative potential outcome for the residents not having their bed linens changed is that it would make the resident feel dirty, not sleep comfortably, not a homelike environment, and spread of infection. Record Review of facility policy: During an interview with the ADON on 09/16/2022 at 4:07 PM., about the policy for clean bed linens, she stated that the facility did not have anything that indicated clean bed linens and that she would say that they did not have a policy on this. Resident #10: Record review of Resident #10 face sheet revealed an admission date of 03/15/2022 with a BIMs of 12 and diagnoses that included: displaced intertrochanter fracture of right femur, muscle weakness, feeding difficulties, malignant neoplasm of the right female breast, facial weakness, rheumatoid arthritis, COPD, hypokalemia, dysphagia, need for assistance with personal care. Record Review of resident #10 orders dated 09/01/2022 stated: Wound care: Clean coccyx with normal saline, pat dry, apply calcium alginate, secure with a foam dressing, one time a day for wound healing. During an Observation of wound care with ADON on 09/14/2022 at 10:41 am with Resident #10. ADON failed to wash hands or use hand sanitizer during wound treatment going from dirty to clean. ADON had removed her gloves after taking off the dirty bandage and placed clean gloves on without using hand sanitizer or washing her hands beforehand. During an interview with the ADON on 09/16/2022 at 2:21 pm., the ADON was informed of the error to wash hands during wound care. The ADON said she understood the importance of making sure to wash her hands during wound care. The ADON stated that she was nervous. The ADON stated that she had been trained in wound care. The ADON stated that it is the responsibility of the DON to make sure to complete skills checks with staff for wound care. The ADON stated that the potential negative outcome of not washing hands during wound care would be the spread of infection. Resident #54: Record review of Resident #54 face sheet revealed an admission date of 08/09/2022 with a BIMs of 15 and diagnoses that included: hemiplegia and hemiparesis following cerebral infarction, hypothyroidism, hyperlipidemia, insomnia, cataract, atherosclerotic heart disease, pulmonary hypertension, nonrheumatic tricuspid (valve) insufficiency, atrial fibrillation, dysphagia, peripheral vascular disease, type 2 diabetes, cardiac pacemaker, hypertensive heart disease. Record review of resident #54 orders dated 09/07/2022 stated: Left lower leg: cleanse with wound cleanser or NS, pat dry with gauze, apply Santyl, cover up with calcium alginate, and cover with a silicone dressing one time a day for wound healing. Observation of wound care with LVN B on 09/14/2022 at 11:38 pm with Resident #54. LVN B failed to wash hands prior to gathering clean supplies to perform wound care on Resident #54. LVN B failed to clean the bedside table on which she was placing clean supplies. LVN B failed to clean the scissors (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 43 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that she used to cut the old bandage off of Resident #54. LVN B failed to wash hands or change gloves after removing the old bandage when cleaning Resident #54's wound and placing on a new bandage. During an interview with LVN B on 09/14/2022 at 12:18 pm., LVN B stated that she was nervous and that she was new to this position with this facility. LVN B stated that she was caught off guard and is usually not this nervous. LVN B stated that she has been trained in hand washing and wound care. LVN B stated that it is the responsibility of the DON to ensure that skills checks are completed. LVN B stated that the potential negative outcome of not washing hands, using hand sanitizer, or using proper cleaning of wound care tools for the resident would be contamination and spread of infection. During an interview with the DON on 09/16/2022 at 9:10 am., the DON was informed of the observed error of staff not washing hands either before and during wound care for resident #10 and resident #54. The DON stated that she expects staff to always wash their hands or use hand sanitizer, especially with wound care. The DON stated that her staff should know when to wash their hands with wound care and that they all have been trained in wound care. DON stated that her staff has frequent skills checks on things like hand washing and infection control practices. The DON stated that the negative potential outcome for the resident when staff failed to wash their hands before, during, or after is that the staff could potentially spread infection or make the resident wound worse. During an interview with the administrator on 09/16/2022 at 2:42 pm., the administrator was informed of errors observed during wound care of not washing hands before and during wound care for resident #10 and resident #54. The administrator stated that she expects her staff to thoroughly wash their hands before, during, and after wound care. The administrator stated that staff members have been trained in hand washing and should already know how to do that. The administrator stated that it is the responsibility of the DON to ensure that training for hand washing and wound care is provided. The administrator stated that the negative potential outcome of not washing hands before, during, and after wound care is that it could spread infection to the resident. Record Review of facility provided policy for wound care, labeled, Wound Care, date revised on October 2010 stated: Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 3. Assemble the equipment and supplies as needed. Date and initial all bottles and jars upon opening. Wipe nozzles, foil packets, bottles tops, etc. with alcohol wipe before opening, as necessary. (Note: this may be performed at the treatment cart.) Steps and Procedures: 2. Wash and dry your hands thoroughly. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 16. Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard into (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 44 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 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 designated container. Wash and dry your hands thoroughly. Level of Harm - Minimal harm or potential for actual harm 23. Wash and dry your hands thoroughly. Residents Affected - Some Record Review of facility provided policy for hand washing, labeled, Handwashing/Hand Hygiene. Revision date of August 2019 stated: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: b.) Before and after direct contact with resident d.) Before performing any non-surgical invasive procedures. i.) After contact with a resident's intact skin l.) After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. m.) After removing gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 45 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in the kitchen and 1 of 2 corridors (Hall 2 (east)), in that: Residents Affected - Many 1)Live roaches were observed crawling in the kitchen and Hall 2, and 2) The pest control program was further compromised due to unclean surfaces and unsealed gaps and crack that provided harborage areas in the facility. These failures could place residents at risk for foodborne illness and infections. The findings include: ~ The following observations were made during a kitchen tour that began on 9/13/22 at 9:19 AM and concluded at 10:36 AM: The drink dispensing machine drink gun spout was soiled and had a buildup of residue. Observation of 1 of 2 ovens (right side) revealed that there were too numerous to count adult, nymph (pre adult), and adult roaches with egg cases crawling in the oven. There was also a heavy accumulation of roach specs/feces. On 9/13/22 at 9:33 AM the Dietary Manager stated regarding the roaches that the pest control operator sprayed for roaches last week. She added that the section of the oven, with roaches, was not used. She stated that the roach population had worsened recently, and she reported it to the Administrator. Then the pest control came. The plastic food bin exteriors were dirty with gummy feel. The small plastic drawers where scoops were stored had a buildup of dirt on the exterior and had a gummy feel. There was one roach crawling on the floor when a large pot was moved under the convection oven. There was a buildup of gummy grease on the side of the convection oven on and the top. There was a dead roach on the toaster oven cart next to the steam table. There was a heavy accumulation of roach specs on the piping behind the steam table. There was an area of wallboard that was buckled at the steam table. The interior of the gap revealed that there was a heavy accumulation of roach specs. The drink gun/drink dispensing area table had buckling paint and was sticky with dried spills. The pump drink carafes had a gummy exterior. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 46 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 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 0925 Level of Harm - Minimal harm or potential for actual harm The covered electrical plug/outlet had a heavy accumulation of roach specs on the outlet and the casing next to the three-compartment sink. There were five dead roaches observed stuck to the wall behind the fire extinguisher sign near the three-compartment sink. Residents Affected - Many An adult roach was observed crawling on the floor of the water heater closet inside of the dietary manager's office. This closet had holes in the ceiling and around the pipes entering the ceiling and wall. The assist dining room had one of the three cabinets, unlockable, with sticky and soiled shelves. The assist dining room also had an electrical outlet that had half of the face plate missing and the interior of the wall was exposed. Observation on 9/13/22 at 10:35 AM the Dietary Manager stated that previously, roaches came out continuously and were worse at one time. She added that the roaches were wherever you turned your head. Observation on 9/13/22 at 11:15 AM revealed was an adult roach crawling on the Hall 2 corridor floor and into room [ROOM NUMBER]. ~ The following observations were made during a kitchen tour that began on 9/13/22 at 11:35 AM and concluded at 12:45 PM: On 9/13/22 at 12:14 PM an adult roach was observed crawling on the floor near the steam table during meal service. On 9/13/22 at 3:08 PM a confidential interview was conducted with a resident regarding roaches in the facility. The resident stated, roaches were all over - in rooms, bathroom, dining room, and hallways. The resident stated roaches were last sighted a couple of days ago. The resident further stated he found the roach situation disgusting and hoped they do not get in his food. On 9/14/22 at 10:30 AM a confidential interview was conducted with another resident regarding roaches in the facility. The resident stated the roach situation was upsetting. The resident further stated he was unable to kill them due to a disability with his leg. The resident added that roaches were seen in the restroom and on the floor every day. On 9/14/22 at 9:53 AM residents voiced concerns related to roaches in the facility during the confidential Resident Council Meeting. Residents stated roaches were in the dining room especially in the cabinet in the back underneath the coffee storage area. They stated that area was constantly kept wet and there are roaches constantly there. They added that now and then the roaches were also seen in resident rooms. On 9/14/22 at 2:21 PM, an interview was conducted with the Maintenance Supervisor regarding pest control and roaches. He stated that staff report roach sightings to him. He added that the facility had a roach problem prior to his hiring. He added that a pest control operator visits the facility monthly and as needed. He stated the pest control operator came to the facility last week and their monthly visits consists of spraying each room, halls and dietary. He added, the pest control operator conducted an invasive treatment previously. He stated the pest control operator had not mention anything to them about sealing areas that could be a harborage area. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 47 of 48 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 9/14/22 at 4:35 PM, the Maintenance Supervisor was interviewed regarding interventions related to the roaches. He stated he tries to coordinate with housekeeping to clean more. On the exterior, staff try to prevent things from piling up. An over-the-counter insect spray was used on the exterior of the facility. He added that the big thing was cleaning on the inside. He stated that it was hard to determine what caused the increase in roaches. He added that the previous grease trap leaked and rusted out. Then the facility got a new grease trap. When they installed the grease trap, they tunneled from the outside. He thought that when the old grease trap leaked, it could have caused the increase in roaches. He stated the increase in roaches could result in the facility being unsanitary. On 9/14/22 at 5:33 PM an observation was made of the kitchen and the pest control operator was spraying during meal service. He stated that he was treating for German roaches today. He added that a monthly general spray is conducted in the facility. He stated his plan of treatment was using more chemicals today and doing bait stations. He added he was using transference chemicals and insecticidal dust. On 9/15/22 at 4:01 PM an interview was conducted with the Administrator regarding roaches. She stated she did not know what to do. She added the German cockroaches were only treated every six months. She further stated she would take the oven out and fumigate it. She stated the increase in roaches could cause infection control issues. Record review of the pest control service forms/invoices revealed that the facility had visits from the Pest Control Operator on 6/08/22, 7/12/22, 8/4/22, 9/08/22 9/14/22. Documentation on the service form for 6/8/22 revealed that it was a general monthly treatment. It was also documented that the facility was treated for German cockroaches on 6/10/22. Documentation on the invoice stated, This is a progressive treatment and can take multiple treatments to gain full control. Please give chemical time to work and continue to deep clean degreasers and kitchen. Record review of the 9/14/22 pest control visit revealed that the targeted pest for the visit was German roaches. Further record review of the invoice documented, This is a very progressive treatment and can take multiple treatments to gain full control. Please give chemical time to work and continue to deep clean greasers and kitchen. Record review of the facility policy titled Pest Control, Revised May 2008, revealed the following documentation, Policy Statement. Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation. 1. This facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. 4. Only approved FDA and EPA insecticides and rodenticide are permitted in the facility and also supplies are stored in areas away from food storage areas 6. Maintenance services assist, when appropriate and necessary, in providing pest control services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675853 If continuation sheet Page 48 of 48